We’ve known for a long time
that breaking a hip can be devastating for an older person. It often leads to
a loss of independence and it's associated with a substantial increase in the
risk of both nursing home placement and death. While the rate of hip fractures declined in the US between 1990 and 2010, it remains stubbornly high: every
year, 300,000 people fall and fracture a hip. A new study suggests the
consequences of a hip fracture are especially severe in people who live in
nursing homes. In light of the high rate of
disability and death in the 6 months after a hip fracture, an accompanying
editorial recommends that breaking a hip in the nursing home signal the
need for palliative care. Absolutely—but many of the patients reported in the new study should have been
getting palliative care long before their fateful fall.
The authors of the study in JAMA Internal Medicine identified
725,000 Medicare fee-for-service patients who broke a hip during a 4-year period between
2005 and 2009; just over 60,000 of them, or 8%, lived in a nursing home prior
to sustaining a hip fracture. It was these 60,000 who were the basis of the study: the vast majority were women (75%),
white (92%) and demented (91%). They also tended to have multiple chronic
diseases and to have difficulty with many basic daily activities, which is hardly
surprising, as their illnesses and their impairments were precisely why they
lived in the nursing home.
After their hip fractures,
many patients went downhill quickly. Fully 36% were dead within 6 months. Among
those who survived to the 6 month mark, over a quarter had become totally
dependent in walking. By the time a year had elapsed, just under half of the
residents who had fractured their hip had died. Only 1 in 5 of those who started out
being fairly independent in walking had regained their previous level of
function. Risk factors for death or disability included male sex, advanced age,
white race, multimorbidity, cognitive impairment, and dependence in
basic activities. Of note, patients treated non-operatively (11.8% of the sample)
did particularly poorly in terms of physical functioning and survival.
These findings fit with the
results of earlier, smaller studies. But I couldn’t help asking, as I read this
dismal portrait of life-after-hip-fracture-in-the-nursing-home, what happens to
people who live in a nursing home who don’t break a hip? How many of them decline? The study in JAMA
Internal Medicine had no control group, no nursing home residents with a
comparable degree of physical and mental impairment, cared for during the same
time period, who happened not to sustain a hip fracture.
I turned up another study also published this year entitled “Natural course of
dependency in residents of long-term care facilities: prospective follow-up
study.” The study was carried out in
Dutch nursing homes and it included both people who had hip
fractures along with those who did not. The population was
reasonably similar to the US nursing home Medicare population: 75% were women
and their mean age was 84. The Dutch have a system for reporting dependency
that is different from (and more sophisticated than) the American approach: they
report on the “Care Dependency Scale (CDS),” a 15-item scale that grades patients
from 15 (totally dependent) to 75 (almost independent in eating, dressing,
walking, and dressing). What they found was that among
890 Dutch nursing home residents, just under 15% had died at 6 months and
another 18% had died by one year. But the degree of dependency at baseline was
strongly predictive of the outcome, with higher dependency leading to greater
likelihood of death, even after correcting for gender, age, and the presence of
diagnoses such as cancer or dementia. Among residents in the low CDS group
(that is, the most independent people), 20% actually improved over a 12-month
period and the vast majority (80%) remained unchanged. Among residents in the
highest CDS group (the most dependent people), no one improved, 64% remained
stable over 6 months, and 36% got worse. The middle group, not surprisingly,
fell between these extremes.
How did the nursing
home residents in the Dutch study (some unknown fraction of whom fell and broke a hip) compare to
the nursing home residents in the American study (who were selected based on their having
fallen, broken a hip, and been hospitalized)? Those with hip fracture did
worse: over the course of a year, 80% deteriorated markedly in their independence, compared to only 36% of
the worst-off Dutch residents; and by 6 months, 36% had died, compared to about
20% of the worst-off Dutch.
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