OBJECTIVES: To examine whether an effect on muscle mass or strength explains the association between interleukin‐6 (IL‐6) and lower extremity function in the year after hip fracture.
DESIGN: Analysis ...of data from a longitudinal cohort study.
SETTING: Two Baltimore‐area hospitals.
PARTICIPANTS: Community‐dwelling women aged 65 and older admitted to one of two hospitals in Baltimore with a new, nonpathological fracture of the proximal femur between 1992 and 1995.
MEASUREMENTS: At 2, 6, and 12 months postfracture, serum IL‐6, appendicular lean muscle mass (aLM), and grip strength were measured, and the Lower Extremity Gain Scale (LEGS), a summary measure of performance of nine lower extremity tasks was calculated. Generalized estimating equations were used to model the longitudinal relationship between IL‐6 tertile and LEGS. Whether muscle mass or strength explained the relationship between IL‐6 and LEGS was examined by adding measures of aLM, grip strength, or both into the model.
RESULTS: Subjects in the lowest IL‐6 group performed better on the LEGS than those in the highest tertile by 4.51 (95% confidence interval (CI)=1.50–7.52) points at 12 months postfracture. Adjusting for aLM and grip strength, this difference was 4.28 points (95% CI=1.14–7.43) and 3.81 points (95% CI=0.63–7.00), respectively. Adjusting for both aLM and grip strength, the mean difference in LEGS score was 3.88 points (95% CI=0.63–7.13).
CONCLUSION: In older women, after hip fracture, reduced muscle strength, rather than reduced muscle mass, better explains the poorer recovery of lower extremity function observed with higher levels of the inflammatory marker IL‐6.
Background. Vitamin D, known for its role in calcium homeostasis, may also regulate immune function. Whether vitamin D deficiency at the time of hip fracture is associated with the inflammatory ...response postfracture is not known. Methods. In a cohort from the Baltimore Hip Studies, women aged ≥65 years were evaluated at baseline and 2, 6, and 12 months after hip fracture repair. Serum at baseline was analyzed for 25-hydroxyvitamin D 25(OH)D, and serum from all time points was analyzed for interleukin-6 (IL-6). Participants were divided into two groups based on their baseline 25(OH)D levels. Vitamin D deficiency was defined as a 25(OH)D level of ≤15 ng/mL (< 37.5 nmol/L). We examined IL-6 level as a function of vitamin D status using generalized estimating equations, adjusting for covariates. Results. Women deficient in vitamin D at baseline had higher IL-6 levels in the year postfracture (p =.02). On average, participants with low 25(OH)D levels had adjusted serum IL-6 levels that were 6.0 pg/mL (95% confidence interval CI: −6.7, 18.7 pg/mL), 11.9 pg/mL (95% CI: 3.5, 20.4), 13.1 pg/mL (95% CI: 4.6, 21.6), and 13.4 pg/mL (95% CI: 2.3, 24.5) higher at baseline, 2, 6, and 12 months after hip fracture, respectively. Conclusions. Women with vitamin D deficiency at the time of hip fracture had higher serum IL-6 levels in the year after hip fracture. Whether the proinflammatory state of vitamin D deficiency explains the association of this deficiency with adverse outcomes in older adults warrants further study.
OBJECTIVE: As part of a larger study to describe indices of recovery during the year after hip fracture, the current prospective study investigated longitudinal changes in serum and urine markers of ...bone metabolism for the year after hip fracture and related them to bone mineral density (BMD).
DESIGN: A representative subset of participants provided serum and urine samples and had bone density measured at 3, 10, 60, 180, and 365 days postfracture.
SETTING: Two Baltimore hospitals.
PARTICIPANTS: The subjects were 205 community‐dwelling, white women age 65 and older with fresh proximal femur fractures.
MEASUREMENTS: Samples were assayed for specific bone‐related proteins and bone turnover markers, including serum osteocalcin (OC), procollagen type 1 carboxy‐terminal extension peptide (PICP), bone‐specific alkaline phosphatase (BAP), and urinary deoxypyridinoline (DPD) cross‐links. Selected hormonal regulators of bone metabolism, including parathyroid hormone (PTH), calcitonin (CT), 1,25‐dihydroxy vitamin D3 (1,25 (OH)2D), and estrone (E1) were measured from serum samples. Repeated measures analyses were used to evaluate postfracture changes in each of the markers.
RESULTS: BAP, OC, and PICP were most active during the early postfracture period (3–60 days). BAP and OC remained elevated at 365 days compared with 3 days. DPD rose 48% from 3 days to 60 days, but this difference was not statistically significant. PTH and 1,25 (OH)2D increased steadily and significantly from 3 to 365 days. E1 was highest at baseline and decreased at each time point, whereas CT showed no significant changes. When subjects were stratified into high‐, medium‐, and low‐BMD groups based on their measurement at 3 days, both osteoclastic and osteoblastic markers in the low‐BMD group displayed exaggerated and different patterns over time compared with the other groups.
CONCLUSION: Currently, the standard treatment of care for hip fractures still results in high morbidity and mortality and failure to regain prefracture quality of life. Gaining an understanding of bone cell activity in these patients after hip fracture, derived by measuring markers longitudinally during recovery, provides a baseline by which to measure the effectiveness of new interventions to improve recovery from hip fracture.
Mobility After Hip Fracture Predicts Health Outcomes Fox, Kathleen M.; Hawkes, William G.; Hebel, J. Richard ...
Journal of the American Geriatrics Society (JAGS),
February 1998, Letnik:
46, Številka:
2
Journal Article
Recenzirano
OBJECTIVES: Balance and gait are essential to physical functioning and the performance of activities of daily living. The objective of this study was to determine the predictive value of a balance ...and gait test on subsequent mortality, morbidity, and healthcare utilization among older hip fracture patients.
DESIGN: A prospective study of hip fracture recovery.
SETTING: Patients with a new hip fracture admitted from the community to one of eight Baltimore hospitals and followed in their homes for 2 years postfracture.
PARTICIPANTS: A total of 306 patients with hip fracture, 65 years of age and older, who completed a gait and balance assessment at 2 months postfracture.
MEASUREMENTS: The relationship between gait and balance test performance at 2 months postfracture and mortality, physician visits, rehospitalizations, nursing home placement, and falls up to 24 months postfracture was assessed by Cox proportional hazards and least squares regression.
RESULTS: After adjusting for age, sex, race, and comorbidity, the balance score and the summary mobility score predicted mortality. A 17% increase in the risk of mortality was demonstrated for each unit decrease in the balance score (range 0–17), and a 10% increase was demonstrated for each decrease in the summary score (range 0–26). Unsteady balance during immediate standing, turning, sitting down, and rising from a chair were associated significantly with increased mortality. Poor balance, but not poor gait, was associated with an increase in hospitalizations up to 24 months postfracture. Both poor balance and poor gait were associated with nursing home placement, with 20% and 17% increased odds, respectively. Mobility did not predict future physician visits or falls.
CONCLUSIONS: These findings demonstrate that balance and gait are predictive of future health outcomes for older hip fracture patients.
Hip fracture patients are at increased risk of confusion or delirium due to the trauma associated with the injury and the rapid progression to hospitalization and surgery, in addition to the pain and ...loss of function experienced. Hip fracture patients who develop delirium may require longer hospital stays, are more often discharged to long-term care, and have a generally poor prognosis for returning home or regaining function in activities of daily living (ADL).
The present study examines the impact of delirium present on hospital admission in a sample of 682 non-demented, aged hip fracture patients residing in the community at the time of their fracture. In-hospital assessments designed to assess both prefracture and postfracture functioning, as well as follow-up interviews at 2, 6, 12, 18, and 24 months postfracture, were obtained from participants.
Analyses indicate that baseline or admission delirium is an important prognostic predictor of poor long-term outcomes in persons without known cognitive impairment, after controlling for age, gender, race, comorbidity, and functional status. Delirium at admission (i.e., prior to surgery) was associated with poorer functioning in physical, cognitive, and affective domains at 6 months postfracture and slower rates of recovery. Impairment and delays in recovery may be further exacerbated by increased depressive symptoms in confused patients over time. Delirium on hospital admission was not a significant predictor of mortality after adjustment for confounding factors.
The present findings further emphasize the significance of immediate detection and treatment of delirium in hip fracture patients to ameliorate the short and long-term effects of acute confusion on functional outcomes.
Objectives: To compare proxy perceptions about change over 6 months in physical, instrumental, affective, and cognitive functioning of older persons with computed change in patient self‐report and ...performance and patient's own perceptions about change.
Design: Prospective study.
Setting: Recovery from hip fracture that occurred in community‐dwelling persons in Baltimore, Maryland, in 1990–91. The recovery from the sixth to the 12th month postfracture was observed.
Participants: One hundred forty‐one hip fracture patients aged 65 and older and a self‐designated proxy for each.
Measurements: For specific tasks of physical and instrumental functioning, proxy perception of change over the previous 6 months asked in the 12th month postfracture was compared with change in criterion measures (subject self‐report and observed performance) from the sixth to the 12th month postfracture. For global change over the previous 6 months in each area of functioning, proxy perception was compared with the subject's own perception in the 12th month postfracture.
Results: Agreement between proxy perceptions of change and change in criterion measures was poor. There was a general pattern for proxies to overstate improvement and understate deterioration in comparison with change observed in criterion measures for specific tasks of physical and instrumental functioning. Proxies' global perceptions reported subjects improving less and deteriorating more than patients' own perceptions.
Conclusion: Proxy perceptions about task‐specific and global changes in subjects' functional health over a short period of time are systematically different from patient report and observed performance.
More than 1/3 of the 300,000 hip fractures that occur each year among the elderly in the US occur in men, with a rate in white men of approximately 19 per 1,000 person-years. Colon-Emeric et al ...hypothesized that men with hip fractures would have a significantly greater rate of subsequent skeletal fractures than men of the same age without hip fracture.
Hip fracture affects more than 1.6 million persons worldwide and causes substantial changes in body composition, function, and strength. Usual care (UC) has not successfully restored function to most ...patients, and prior research has not identified an effective restorative program. Our objective was to determine whether a yearlong home-based exercise program initiated following UC could be administered to older patients with hip fracture and improve outcomes.
A randomized controlled trial of 180 community dwelling female patients with hip fracture, 65 years and older, randomly assigned to intervention (n = 91) or UC (n = 89). Patients were recruited within 15 days of fracture from 3 Baltimore-area hospitals from November 1998 through September 2004. Follow-up assessments were conducted at 2, 6, and 12 months after fracture. The Exercise Plus Program was administered by exercise trainers that included supervised and independently performed aerobic and resistive exercises with increasing intensity. Main outcome measures included bone mineral density of the contralateral femoral neck. Other outcomes included time spent and kilocalories expended in physical activity using the Yale Physical Activity Scale, muscle mass and strength, fat mass, activities of daily living, and physical and psychosocial functioning. The effect of intervention for each outcome was estimated by the difference in outcome trajectories 2 to 12 months after fracture.
More than 80% of participants received trainer visits, with the majority receiving more than 3 quarters (79%) of protocol visits. The intervention group reported more time spent in exercise activity during follow-up (P < .05). Overall, small effect sizes of 0 to 0.2 standard deviations were seen for bone mineral density measures, and no significant patterns of time-specific between-group differences were observed for the remaining outcome measures.
Patients with hip fracture who participate in a yearlong, in-home exercise program will increase activity level compared with those in UC; however, no significant changes in other targeted outcomes were detected.
clinicaltrials.gov Identifier: NCT00390741.
This observational study compared the outcomes of 271 cases of hip osteoarthritis receiving primary total hip replacement (patients 65 years of age and older) from numerous surgeons in 12 Baltimore ...region hospitals from 1991–1993. The independent variables studied were: (a) totally non-cemented prostheses (non-cemented femoral component, non-cemented acetabular component) versus hybrid prostheses (cemented femoral component, non-cemented acetabular component), and (b) lateral or anterolateral surgical approach versus posterior surgical approach. Outcomes included complications during the initial hospitalization, hospital length of stay, hospital cost, readmission, and reported and/or observed physical, instrumental, neuromuscular and affective functioning and pain at 2, 6, and 12 months post surgery.
Results indicated that, while the totally non-cemented prosthesis was more costly, there were no statistically significant differences in clinical or functional outcomes between the non-cemented and the hybrid prostheses up to 12 months post surgery. Also, while the posterior surgical approach was associated with a non-statistically significant higher rate of dislocation, overall, there was improved function and reduced pain in the first 12 months post-surgery associated with this approach.
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