OBJECTIVES: To study the association between amount of social contact and mortality after hip fracture in elderly participants.
DESIGN: Prospective cohort.
SETTING: Community residents of Baltimore, ...Maryland.
PARTICIPANTS: Six hundred seventy‐four elderly participants.
MEASUREMENTS: Amount of telephone and direct personal contact between participants and their relatives and friends and mortality up to 2 years after fracture.
RESULTS: No social contact with friends during the 2 weeks before the fracture was associated with a five times greater risk of death over 2 years than daily contact with friends during the 2 weeks before the fracture (hazard ratio (HR)=5.04, 95% confidence interval (CI)=2.75–9.23). Participants with less than daily contact were also at greater risk of dying, although the CI spanned 1 (HR=1.76, 95% CI=0.99–3.13). Participants who had no contact with family members prefracture were more than twice as likely to die as those who communicated daily during the 2 weeks before fracture (HR=2.26, 95% CI=1.36–3.77). Participants who had less than daily contact were also more than twice as likely to die (HR=2.55, 95% CI=1.65–3.94).
CONCLUSION: This study suggests that lower social contact before hip fracture is associated with poorer survival after 2 years.
Objectives
To identify care‐related factors associated with hospital‐acquired pressure ulcers (HAPUs).
Design
Prospective cohort study.
Setting
Nine hospitals in Baltimore Hip Studies network.
...Participants
Six hundred fifty‐eight individuals aged 65 and older who underwent surgery for hip fracture.
Measurements
Skin examinations at baseline and on alternating days until hospital discharge. Participants were deemed to have a HAPU if they developed one or more new Stage 2 or higher pressure ulcers (PUs) during the hospital stay.
Results
Longer emergency department stays were associated with lower HAPU incidence (>4–6 hours: adjusted incidence rate ratio (aIRR) = 0.68, 95% confidence interval (CI) = 0.48–0.96; >6 hours: aIRR = 0.68, 95% CI = 0.46–0.99, both vs ≤ 4 hours). Participants with 24 hours or longer between admission and surgery had a higher postsurgery HAPU rate than those with less than 24 hours (aIRR = 1.62, 95% CI = 1.24–2.11). Surgery with general anesthesia had a lower postsurgery HAPU rate than surgery with other types of anesthesia (aIRR = 0.66, 95% CI = 0.49–0.88). There was no significant association between HAPU incidence and timing of transport to the hospital, type of transport to the hospital, or surgery duration.
Conclusion
Most of the factors hypothesized to be associated with higher PU incidence were associated with lower incidence or were not significantly associated, suggesting that HAPU development may not be as sensitive to care‐related factors as commonly believed. Rigorous studies of innovative preventive interventions are needed to inform policy and practice.
OBJECTIVES: To identify care settings associated with greater pressure ulcer risk in elderly patients with hip fracture in the postfracture period.
DESIGN: Prospective cohort study.
SETTING: Nine ...hospitals that participate in the Baltimore Hip Studies network and 105 postacute facilities to which patients from these hospitals were discharged.
PARTICIPANTS: Hip fracture patients aged 65 and older who underwent surgery for hip fracture.
MEASUREMENTS: A full‐body skin examination was conducted at baseline (as soon as possible after hospital admission) and repeated on alternating days for 21 days. Patients were deemed to have an acquired pressure ulcer (APU) if they developed one or more new stage 2 or higher pressure ulcers after hospital admission.
RESULTS: In 658 study participants, the APU cumulative incidence at 32 days after initial hospital admission was 36.1% (standard error 2.5%). The adjusted APU incidence rate was highest during the initial acute hospital stay (relative risk (RR)=2.2, 95% confidence interval (CI)=1.3–3.7) and during re‐admission to the acute hospital (RR=2.2, 95% CI=1.1–4.2). The relative risks in rehabilitation and nursing home settings were 1.4 (95% CI=0.8–2.3) and 1.3 (95% CI=0.8–2.1), respectively.
CONCLUSION: Approximately one‐third of hip fracture patients developed an APU during the study period. The rate was highest in the acute setting, a finding that is significant in light of Medicare's policy of not reimbursing hospitals for the treatment of hospital‐APUs. Hip fracture patients constitute an important group to target for pressure ulcer prevention in hospitals.
Hip fracture is an important problem for older adults with significant functional consequences. After hip fracture, reduced muscle loading can result in muscle atrophy.
We compared thigh muscle ...characteristics in the fractured leg with those in the nonfractured leg in participants from the Baltimore Hip Studies 7th cohort using computed tomography (CT) scan imaging.
At 2 months postfracture, a single 10-mm axial CT scan was obtained at the midthigh level in 47 participants (26 men and 21 women) with a mean age of 80.4 years (range 65-96), and thigh muscle cross-sectional area (CSA), CSA of intermuscular adipose tissue (IMAT), as well as mean radiological attenuation were measured. Total thigh muscle CSA was less on the side of the fracture by 9.2 cm(2) (95% CI: 5.9, 12.4 cm(2)), whereas the CSA of IMAT was greater by 2.8 cm(2) (95% CI: 1.9, 3.8 cm(2)) on the fractured side. Mean muscle attenuation was lower on the side of the fracture by 3.61 HU (95% CI: 2.99, 4.24 HU).
The observed asymmetry is consistent with the effect of disuse and inflammation in the affected limb along with training effects in the unaffected limb due to the favoring of this leg with ambulation during the postfracture period.
Objectives
To determine whether interleukin (IL)‐6 or soluble tumor necrosis factor alpha receptor 1 (sTNF‐αR1) is associated with depressive symptoms in the year after hip fracture.
Design
...Prospective cohort.
Setting
Three Baltimore‐area hospitals.
Participants
Community‐dwelling women aged 65 and older admitted with a new, nonpathological fracture of the proximal femur (N = 134).
Measurements
Two, 6, and 12 months after fracture, serum was analyzed for IL‐6 and sTNF‐αR1, and depressive symptoms were measured using the 15‐item Geriatric Depression Scale (GDS). Generalized estimating equations were used to model the longitudinal relationship between IL‐6, sTNF‐αR1, and GDS score. Whether lower extremity function, as measured according to the Lower Extremity Gain Scale (LEGS), explained the relationship between IL‐6, sTNF‐αR1, and GDS score was also examined.
Results
Participants in the highest categories of IL‐6 (≥5.14 pg/mL) and sTNF‐αR1 (≥2,421 pg/mL) had the highest GDS scores in the year after fracture (P = .09 for both). Twelve months after fracture, those in the highest IL‐6 and sTNF‐αR1 categories had GDS scores that were on average 1.9 (95% confidence interval (CI) = 0.4–3.4, P = .01) and 1.4 (95% CI = −0.1–3.0, P = .07) points higher than those in the lowest category, respectively. Adjusting for LEGS score, the mean difference in GDS scores for highest versus lowest IL‐6 categories was 1.6 (95% CI = 0.2–3.0, P = .02) points at 12 months.
Conclusion
Results from these exploratory analyses support a role for inflammation in the pathophysiology of depressive symptoms after hip fracture. Depressive symptoms in the context of high cytokine levels may represent a sickness syndrome that is chronic in some individuals. Further research should establish the cause and effect of this relationship, as well as long‐term correlates.
Background: although the majority of hip fractures are the result of a fall, whether repeated falls in the year post-fracture adversely influence recovery of social participation is not known. ...Design: analysis of data from a longitudinal cohort study. Subjects: community-dwelling women aged ≥65 years, admitted to one of two hospitals in Baltimore with a new, non-pathological fracture of the proximal femur between 1992 and 1995. Methods: information on falls was collected from a falls diary. At the baseline, 6- and 12-month evaluations, subjects were asked about the number of times in the 2 weeks prior to the evaluation they had participated in 10 categories of social activities. We examined the association of repeated falls with social participation using generalized estimating equations. The effect of physical and psychological functions was examined by including measures of lower extremity functional performance and depressive symptoms into the model. Results: the analyses included 196 women, mean age = 80.2 years. Eighty-one subjects fell. The subjects with >1 fall between evaluations participated in a mean (95% CI) of 3.5 (0.12, 6.9) and 4.3 (0.9, 7.7) fewer social activities at 6 and 12 months post-fracture, respectively, compared to those who did not fall (P = 0.0003). These results were attenuated by adjustment for depressive symptoms, but not by lower extremity functional performance. Conclusions: in the year post-fracture, repeated falls in women were associated with decreased social participation independent of lower extremity function. Depressive symptoms in repeated fallers may partly explain this association.
OBJECTIVES: To evaluate the association between pressure‐redistributing support surface (PRSS) use and incident pressure ulcers in older adults with hip fracture.
DESIGN: Secondary analysis of data ...from prospective cohort with assessments performed as soon as possible after hospital admission and on alternating days for 21 days.
SETTING: Nine hospitals in the Baltimore Hip Studies network and 105 postacute facilities to which participants were discharged.
PARTICIPANTS: Six hundred fifty‐eight people aged 65 and older who underwent surgery for hip fracture.
MEASUREMENTS: Full‐body examination for pressure ulcers; bedbound status; and PRSS use, recorded as none, powered (alternating pressure mattresses, low‐air‐loss mattresses, and alternating pressure overlays), or nonpowered (high‐density foam, static air, or gel‐filled mattresses or pressure‐redistributing overlays except for alternating pressure overlays).
RESULTS: Incident pressure ulcers (IPUs), Stage 2 or higher, were observed at 4.2% (195/4,638) of visits after no PRSS use, 4.5% (28/623) of visits after powered PRSS use, and 3.6% (54/1,496) of visits after nonpowered PRSS use. The rate of IPU per person‐day of follow‐up did not differ significantly between participants using powered PRSSs and those not using PRSSs. The rate also did not differ significantly between participants using nonpowered PRSSs and those not using PRSSs, except in the subset of bedbound participants (incidence rate ratio=0.3, 95% confidence interval=0.1–0.7).
CONCLUSION: PRSS use was not associated with a lower IPU rate. Clinical guidelines may need revision for the limited effect of PRSS use, and it may be appropriate to target PRSS use to bedbound patients at risk of pressure ulcers.
Background. Although substantial decrements in bone, muscle, and functional ability have been reported to follow the occurrence of hip fracture in elderly women, little is known about the ...interrelation of these consequences. The authors evaluated the associations among physiologic and functional factors during recovery from hip fracture to determine whether any consistent sequence of events followed and whether markers of functional outcomes could be identified. Methods. Two hundred five community-dwelling women aged 65 years and older who sustained hip fracture between 1992 and 1995 and were admitted to one of two acute care hospitals in metropolitan Baltimore, Maryland, participated in a 1-year prospective cohort study. Bone mineral density, lean mass, and fat mass were measured by dual-energy X-ray absorptiometry during the hospitalization and 2, 6, and 12 months later. Functional limitations were self-reported and grip strength was measured during interviews at the same time points. Correlation coefficients were calculated for all possible pairs of measures and time points. Results. Losses of femoral neck bone mineral density and lean body mass and gains in fat mass were observed. Grip strength showed early improvement but declined by 1 year to levels close to those seen during hospitalization. Functional outcomes showed minimal correlation with bone or body composition and only moderate correlation with strength. Conclusions. Physiologic and functional declines follow hip fracture in elderly women. These are largely independent of one another and suggest that interventions to maximize recovery must simultaneously target multiple areas, including bone, muscle, strength, and function.
Background. A hip fracture often heralds a period of functional decline in elderly persons. Although an inflammatory reaction would be expected following a hip fracture, whether the degree of this ...response is associated with adverse functional outcomes is unknown. Methods. In a cohort from the Baltimore Hip Studies, women aged 65 years or older with a hip fracture were evaluated at 3 or 10 days (baseline) and 2, 6, and 12 months (follow-up) postfracture. Serum was analyzed for interleukin-6 (IL-6) level. A score of timed performance of 9 tasks, the Lower Extremity Gain Scale (LEGS) was calculated at each evaluation. We divided participants into tertiles based on their cytokine levels at 2, 6, and 12 months, and examined the LEGS score trajectories as a function of IL-6 tertile using generalized estimating equations, adjusting for age, prefracture function, body fat, pain, cognitive function, type of surgical repair, the number of in-hospital complications, and the number of comorbid medical conditions. Results. At baseline, 2, 6, and 12 months, respectively, 149, 95, 101, and 82 participants provided serum samples; of these participants 65, 78, and 59 also provided a LEGS measure at 2, 6, and 12 months, respectively. At 12 months postfracture the median (interquartile range) of serum IL-6 levels was 7.4 (4.0, 15.9) pg/mL. Participants in the lowest tertile of IL-6 level performed better on the LEGS than did those in the highest tertile (p =.008). At 12 months postfracture, participants in the lowest tertile scored 5.3 points better (95% confidence interval, 2.0-8.6) on the LEGS than did those in the highest tertile (p =.002). Conclusions. Higher IL-6 levels are adversely associated with recovery of lower extremity function after hip fracture. Factors that predict cytokine response and the potential mechanisms by which this effect is mediated warrant further study.
To develop and determine the reliability and validity of a sensitive observational measure to assess recovery in clinically meaningful areas of function after hip fracture.
Used survey data to ...identify activities difficult to perform after fracture; conducted focus groups; interviewed patients; and developed a standardized protocol to prospectively test the highest ranking activities.
Evaluations conducted in 8 Baltimore hospitals or the patients' residence.
Patients 2 to 24 months postfracture, 65 years and older, and community-dwelling.
Not applicable.
The Lower Extremity Gain Scale (LEGS).
Nine performance-based activities were appropriate for administration in clinical and research settings: (1) walk 3m (10ft); put on a (2) sock and (3) shoe on the fractured side; (4) rise from an armless chair; step (5) up and (6) down 4 stairs; get (7) on and (8) off the toilet; and (9) reach for an item on the ground from a sitting position. Reproducibility is good and measures of internal consistency and content, concurrent, and construct validity are high.
The LEGS can be easily administered by clinicians in a short time as part of care. Research and clinical scoring methods and performance norms can track recovery in activities that are most relevant in the lives of patients.
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