Pertrochanteric hip fracture is associated with mobility decline and poorer physical performance 4 to 6 months post-hip fracture.

BACKGROUND: To study the effect of hip fracture type on physical performance, functional ability and change in mobility four to six months after the injury. METHODS: A total of 1331 patients out of consecutive 2052 patients aged ≥ 65 years who underwent hip fracture surgery were included in the study. Patient information was collected on admission, during hospitalization, by phone interview and at the geriatric outpatient clinic 4 to 6 months after the fracture. Of the 1331 eligible patients, Grip strength, Timed Up and Go -test (TUG), Elderly Mobility Scale (EMS), mobility change compared to pre-fracture mobility level, Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL) were used to determine physical performance and functional ability. Logistic regression was used for the analyses which was adjusted for gender, age, American Society of Anesthesiologists score, diagnosis of cognitive disorder, pre-fracture living arrangements, mobility and need of mobility aid. RESULTS: Patients with pertrochanteric hip fracture had an EMS lower than 14 (Odds Ratio (OR) 1.38, 95% confidence intervals (CI) 1.00-1.90), TUG time ≥ 20 s (OR 1.69, 95% CI 1.22-2.33) and they had declined in mobility (OR 1.58, 95% CI 1.20-2.09) compared to femoral neck fracture patients 4 to 6 months post-hip fracture in multivariable-adjusted logistic regression analyses. Grip strength and functional ability (IADL, BADL) 4 to 6 months after hip fracture did not differ between fracture types. There were no statistically significant differences in physical performance in patients with a subtrochanteric fracture compared to patients with a femoral neck fracture. CONCLUSIONS: Pertrochanteric hip fracture independently associated with poorer physical performance 4 to 6 months post hip fracture compared to other hip fracture types. Pertrochanteric hip fracture patients should be given special attention in terms of regaining their previous level of mobility.

Factors associated with and 1-year outcomes of fear of falling in a geriatric post-hip fracture assessment.

BACKGROUND: Hip fracture causes not only physical injury but also psychological trauma. Fear of falling (FoF) is related to poor recovery, loss of mobility and mortality. There is limited data on the clinical factors affecting post-hip fracture FoF and its consequences. OBJECTIVE: To investigate the factors associated with and 1-year outcomes of post-hip fracture FoF. METHODS: An observational prospective cohort study. Data were collected on hospital admission, at a geriatric outpatient assessment 4-6 months post-hip fracture and by telephone interviews 1 year after the index fracture. FoF was assessed with a dichotomous single-item question. Logistic regression analyses were conducted to examine the age, gender and multivariable-adjusted association between baseline and the geriatric assessment domains with FoF. Follow-up outcomes included changes in mobility, living arrangements and mortality. RESULTS: Of the 916 patients included, 425 (49%) had FoF at the time of their geriatric assessment. These patients were predominantly female and were living alone in their own homes with supportive home care. They scored lower on tests of physical performance. Less FoF was documented in patients with diagnosed cognitive disorders before the index fracture and in those with Clinical Dementia Rating ≥ 1. After adjusting for age and gender, no association was observed between FoF and any of the 1-year follow-up outcomes. CONCLUSION: Post-hip fracture FoF is common and associated with female gender, polypharmacy, poor daily functioning, poor physical performance and depressive mood. Patients with cognitive disorders have less FoF than those without. FoF appears to have no impact on the follow-up outcomes.

Prevalence and prognostic significance of depressive symptoms in a geriatric post-hip fracture assessment.

OBJECTIVES: To investigate the prevalence and prognostic significance of post-hip fracture depressive symptoms. METHODS: A naturalistic clinical cohort study. Data were collected on admission to hospital, geriatric assessment 4-6 months post-fracture and by telephone interview one-year post fracture. Depressive symptoms were assessed at the geriatric assessment using the 15-item Geriatric Depression Scale (GDS-15). Logistic regression analyses with multivariable models were conducted to examine the association of depressive symptoms with changes in mobility and living arrangements and Cox proportional hazards models for mortality between the geriatric assessment and one-year follow-up. RESULTS: Of the 1070 patients, 22% (n = 238) had mild and 6% (n = 67) moderate to severe depressive symptoms. Patients with depressive symptoms had poorer nutritional status at baseline, lower scores on the cognitive and physical performance tests and poorer functional abilities in the geriatric assessment than those without. No association was observed between depressive symptoms and any of the outcomes at one-year follow-up. Poor nutritional status and physical functioning remained significant prognostic indicators. CONCLUSION: Post-hip fracture depressive symptoms are common and deserve attention during post-hip fracture recovery and rehabilitation. Nonetheless, depressive symptoms have no impact on the change in mobility or living arrangements or mortality. These latter outcomes are mainly explained by poor nutritional status and functioning.

In-Hospital Delirium as a Prognostic Factor for New Cognitive Disorder in a 1-Year Post-Hip Fracture Follow-Up.

BACKGROUND: Older hip fracture patients are at high risk of delirium during acute hospital care. Pre-fracture dementia is known to increase the risk of in-hospital delirium. Data on the development of new cognitive disorders in patients with delirium are scarce. OBJECTIVE: The objective of this study is to evaluate the prognostic significance of in-hospital delirium on the development of new cognitive disorders in a 1-year follow-up in older hip fracture patients. MATERIAL AND METHODS: Data consisted of 476 hip fracture patients aged 65 years or more with no known cognitive disorder on admission. Delirium was assessed using the Confusion Assessment Method (CAM). Cognitive disorders were diagnosed following the national guidelines. Information on the new diagnoses of cognitive disorders (NDCD) at 1-year follow-up was elicited in a telephone interview and confirmed from the electronic patient files. Logistic regression analyses were conducted to examine the association of delirium with NDCDs. RESULTS: Of the 476 patients, 87 (18%) had delirium during hospital stay. Patients with delirium were older, they had poorer nutritional status, lower mobility level, and more supported living arrangements than did patients without delirium. At the 1-year time point, 205 (43%) had NDCDs or were strongly suspected of this. CAM result was statistically significantly associated with development of NDCD in multivariable-adjusted analysis (odds ratio [OR] 2.29; 95% confidence interval [CI]: 1.39-3.79). Also, poor nutritional status continued to be associated with NDCDs (multivariable-adjusted OR 1.58; 95% CI: 1.03-2.43). CONCLUSION: Delirium during hospitalization and poor nutritional status on admission are independent prognostic factors for development of subsequent cognitive disorders in older hip fracture patients.

Does cognitive/physical screening in an outpatient setting predict institutionalization after hip fracture?

BACKGROUND: Institutionalization after hip fracture is a socio-economical burden. We examined the predictive value of Instrumental Activities of Daily Living (IADL) and Mini Mental State Examination (MMSE) for institutionalization after hip fracture to identify patients at risk for institutionalization. METHODS: Fragility hip fracture patients ≥65 years of age (n = 584) were comprehensively examined at a geriatric outpatient clinic 4 to 6 months after surgery and followed 1 year postoperatively. A telephone interview with a structured inquiry was performed at 1, 4, and 12 months after hip fracture. RESULTS: Age-adjusted univariate logistic regression analysis revealed that IADL and MMSE scores measured at the outpatient clinic were significantly associated with living arrangements 1 year after hip fracture. Multivariate logistic regression analysis established that institutionalization 1 year after hip fracture was significantly predicted by institutionalization at 4 months (odds ratio [OR] 16.26, 95 % confidence interval [CI] 7.37-35.86), IADL <5 (OR 12.96, 95 % CI 1.62-103.9), and MMSE <20 (OR 4.19, 95 % CI 1.82-9.66). A cut-off value of 5 was established for IADL with 100 % (95 % CI 96 %-100 %) sensitivity and 38 % (95 % CI 33 %-43 %) specificity and for MMSE, a cut-off value of 20 had 83 % (95 % CI 74 %-91 %) sensitivity and 65 % (95 % CI 60 %-70 %) specificity for institutionalization. During the time period from 4 to 12 months, 66 (11 %) patients changed living arrangements, and 36 (55 %) of these patients required more supportive accommodations. CONCLUSION: IADL and MMSE scores obtained 4 to 6 months after hospital discharge may be applicable for predicting institutionalization among fragility hip fracture patients ≥65 years of age at 1 year after hip fracture. An IADL score of ≥5 predicted the ability to remain in the community. Changes in living arrangements also often occur after 4 months.

Surgical procedures in femoral neck fractures in Finland: a nationwide study between 1998 and 2011.

PURPOSE: For femoral neck fractures, recent scientific evidence supports cemented hemiarthroplasty (HA) over uncemented HA and suggests that total hip arthroplasty (THA) should be performed more frequently. We report the current surgical trends in treating femoral neck fractures in Finland. METHODS: The study was conducted using the Finnish National Hospital Discharge Register and included all Finns at least 50 years of age who underwent surgery for femoral neck fractures from 1998 through 2011. Age- and sex-specific incidence rates and annual proportion of each treatment method were calculated. RESULTS: During 1998-2011, a total of 49,514 operations for femoral neck fracture were performed in Finland. The proportion of uncemented HA increased from 8.1% in 2005 to 22.2% in 2011. During the same time, the proportion of cemented HA decreased from 63.9 to 52.5%, internal fixation decreased from 23.2 to 16.1% and THA increased from 4.9 to 9.2%. CONCLUSIONS: Between 2005 and 2011, the proportion of uncemented HA for femoral neck fractures increased markedly in Finland, while cemented HA and internal fixation declined. During this time, the use of THA nearly doubled. The current evidence-based guidelines for treatment of femoral neck fractures were mainly followed, but the increase in uncemented HA procedures contradicts recent scientific evidence.

Delay to Surgery of Less Than 12 Hours Is Associated With Improved Short- and Long-Term Survival in Moderate- to High-Risk Hip Fracture Patients.

INTRODUCTION: The effect of delays before surgery of 24 hours, 48 hours, and 72 hours on short- and long-term survival has been investigated comprehensively in hip fracture patients, but with controversial results. However, there is only limited evidence for how a threshold of 12-hour delay before hip fracture surgery affects survival. MATERIALS AND METHODS: A prospective observational study of 884 consecutive hip fracture patients (age ≥ 65 years) undergoing surgery was carried out in terms of 30- and 365-day survival. A Cox hazard regression survival model was constructed for 724 patients with American Society of Anesthesiologists score ≥3 with adjustments of age, gender, cognition, number of medications on admission, hip fracture type, and prior living arrangements. RESULTS: Patients who underwent surgery within 12 hours had better chances of survival than did those with 12 to 24 hours (hazard ratio [HR]: 8.30; 95% confidence interval [CI]: 1.13-61.4), 24 to 48 hours (HR: 7.21; 95% CI: 0.98-52.9), and >48 hours (HR: 11.75; 95% CI: 1.53-90.2) delay before surgery. Long-term survival was more influenced by nonadjustable patient features, but the adverse effect of >48 hours delay before surgery was noticed with HR: 2.02; 95% CI: 1.08-3.80. Increased age and male gender were significantly associated with worse short- and long-term survival. DISCUSSION/CONCLUSIONS: Early hip fracture surgery within 12 hours of admission is associated with improved 30-day survival among patients with ASA score ≥3. Delay to surgery of more than 48 hours has an adverse effect on 365-day survival, but factors related to patients' comorbidities have a great influence on long-term survival.