Hip Fractures and Alzheimer's Disease by gjjur4356

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									Hip Fractures and Alzheimer’s Disease
People with Alzheimer’s disease have a higher incidence of hip fractures than other elderly
people. Unfortunately, patients with dementia are also less likely to recover their previous
functional status following a hip fracture, are more likely to require institutionalization, and
have a higher mortality rate.

By Susan Freter, MSc, MD, FRCPC; and Kata Koller, MD, FRCPC



                                        Classification
H     ip fractures are common and
      often devastating in the elder-
ly population. Annually, there are
                                        of Hip Fractures
                                        Hip fractures can be classified by
                                                                                  a poorer health status. They had
                                                                                  decreased functional recovery at
                                                                                  two and six months, as well as
more than 35,000 hip fractures in       the location of the fracture line         longer hospital stays.8
Canada and more than 270,000 in         along the femur, into intracapsular
the United States, and most occur       or extracapsular. Intracapsular frac-     Outcomes
in individuals older than 60 years.     tures include femoral head and neck       After Hip Fracture
Overall incidence is anticipated to     fractures, and extracapsular frac-        Hip fractures in older adults have
double by the year 2040.1,2 In          tures can be subdivided into              potentially serious consequences,
Canada alone, the current annual        intertrochanteric or subtrochanteric.     resulting in increased morbidity,
cost of hip fractures has been esti-    The femoral neck is the most com-         mortality, functional impairment,
mated at $650 million and is            mon location for a hip fracture,          and healthcare costs.3 By global
expected to increase to $2.4 billion    accounting for 45% to 53%.                estimates, there were 1.31 million
by 2041. Lifetime incidence of hip      Approximately 38% to 49% of hip           new hip fractures in 1990 and the
fracture at age 50 is 17% to 22%        fractures are intertrochanteric, and      prevalence of individuals with hip-
for women, and 6% to 11% for            5% to 15% are subtrochanteric.7           fracture-related disability was 4.48
men.3 Amongst Caucasian women,          Most of the blood supply to the           million with 1.75 million disability-
one in six will suffer a hip fracture   femoral head is supplied by the pos-      adjusted life-years (DALYs) lost.9
in her lifetime.4                       teromedial and lateral femoral cir-       The mortality rate associated with
                                        cumflex arteries, which wrap              hip fracture is estimated at 10% at
Susan Freter, MSc, MD, FRCPC
Attending Geriatrician,
                                        around the neck of the femur.             one month, 20% at four months, and
Queen Elizabeth II Health               Intracapsular fractures can cause         30% one year after.10 Complications
Sciences Centre                         disruption of this arterial system,       relating to restricted mobility, such
Associate Professor of Medicine,        potentially resulting in avascular        as pneumonia, deep vein thrombo-
Dalhousie University
Halifax, Nova Scotia
                                        necrosis of the femoral head and/or       sis, pulmonary embolism, decondi-
                                        nonunion.5,6 One large study fol-         tioning and poor rehabilitation out-
Kata Koller, MD, FRCPC                  lowed more than 900 elderly inpa-         comes correlate with increased mor-
Fellow in Geriatric Medicine,           tients with hip fractures and found       tality rates postoperatively.2
Dalhousie University,
Special interest in Palliative Care
                                        that patients with intertrochanteric          Functional decline commonly
Halifax, Nova Scotia                    fractures tended to be older and had      follows hip fracture, with rates of


                                                        The Canadian Review of Alzheimer’s Disease and Other Dementias • 15
 AD and Concomitant Conditions


increased dependence in activities           one-year mortality following a           Aside from bone quality, the like-
of daily living (ADLs) approach-             second hip fracture is 24%.14            lihood that a fall will result in
ing 50%.10 By six months post-                                                        fracture depends on the point of
fracture, only 50% of patients will          Risk Factors                             impact and the energy of the fall.
have recovered their prefracture             The two principle determinants of        Elderly individuals tend to fall
walking ability. By one year post-           hip-fracture risk are low bone min-      with relatively low velocity, but
fracture, less than 50% of patients          eral density (BMD) and falls.15 It is    directly onto their hips and with-
can walk without aids and only               generally accepted that the vast         out putting their arms out to slow
40% are independent in all ADLs.             majority of hip fractures in the geri-   their fall.4
Hip fractures are associated with            atric population are “fragility frac-       The multifactorial nature of
subsequent institutionalization in           tures,” occurring in the setting of      hip-fracture risk is reflective of
10% to 20% of individuals.11                 underlying bone weakness stressed        general frailty, fall risk and bone
Several studies have shown that              to a breaking point.3 History of         fragility.5,18 Table 1 organizes risk
delay in surgery is correlated with          either vertebral compression frac-       factors for hip fracture by factors
higher mortality, longer hospital            ture or distal radial fracture doubles   associated with osteoporosis and
stays and a higher complication              the risk of hip fracture. History of     those raising the risk of falls.
rate.12 In one large study, a signif-        previous hip fracture increases the
                                                                                      Hip Fractures and
Falls are the causal mechanism for 95% of all hip                                     Alzheimer’s Disease (AD)
fractures. One in every three individuals older than 65                               People with AD have a higher inci-
sustains a fall each year.                                                            dence of hip fractures than other
                                                                                      elderly people. Unfortunately,
icant increase in short-term and             risk for second hip fracture by six-     patients with dementia are also
one-year mortality was seen in               fold.16 There is an exponential risk     less likely to recover their previ-
patients who waited for surgery              increase with age, particularly after    ous functional status following a
more than four days, when com-               age 70.17 This likely relates to the     hip fracture, and are more likely
pared to those who had surgery               age-associated decline in BMD, as        to require institutionalization, and
within two days.13                           well as an increase in number of         have a higher mortality rate. One
   For those patients who survive            comorbid conditions and risk of          study found that institutionalized
their hip fracture and regain some           falls.4                                  patients with AD were approxi-
independence in ambulation,                      Falls are the causal mechanism       mately twice as likely to have sus-
there is an increased risk of suf-           for 95% of all hip fractures. One in     tained a hip fracture over a 12 month
fering a second hip fracture.                every three individuals older than       period as nursing-home residents
Older age and a low body mass                65 sustains a fall each year.            without dementia.19 There may be a
index (BMI) are predictive of a              Individuals in residential and long-     number of reasons for this associa-
second hip fracture, as is having            term care facilities have a three-       tion, including a higher rate of falls
regained a higher functional sta-            fold risk of hip fracture, as com-       and osteoporosis in patients with
tus after the first hip fracture,            pared to the general population.         AD. Weller et al found that there is a
presumably because of increased              Having sustained one fall increas-       relationship between AD and frac-
opportunities for suffering a sec-           es the probability of having anoth-      tures which is independent of falls
ond devastating fall. Whereas the            er fall by three-fold.3 In elderly       and osteoporosis. They suggest that
risk of death following an initial           women, approximately 1% of               low BMI, weight loss, decreased
hip fracture is around 16%, the              falls will result in hip fracture.       muscle mass, nutritional deficien-


16 • The Canadian Review of Alzheimer’s Disease and Other Dementias
                                                                                                         Hip Fractures


cies, and sideways direction of           bidities. Average cost increases               counterparts.24 It is concerning
falling may be more common in             with the number of comorbid ill-               that this post-fracture decline in
patients with AD and might help           nesses, but the specific type of               ambulation and functioning is
explain the increased risk of sustain-    associated illness has also been               actually associated with a shorter
ing a hip fracture.19                     found to be important, with                    length of hospital stay, reflecting a
    Community-dwelling people             dementia topping the list by                   tendency to send these patients
with dementia who are prescribed          adding the largest amount to total             back to their nursing homes as
antipsychotic drugs are at an             costs.22 Cost-containment solu-                soon as they are medically stable,
increased risk of having a hip frac-      tions could include efforts at                 rather than having access to inpa-
ture, and this association holds for      reducing length of stay, by reduc-             tient rehabilitation.
atypical and conventional antipsy-        ing wait times before surgery, and                Individuals with dementia are at
chotics.20 Interestingly, apolipopro-     further exploring how dementia                 greater risk of developing delirium
tein E4, which is associated with a       contributes to length of stay and              during hospitalization for hip frac-
higher risk of developing AD, may         cost.                                          ture, with published incidences
also be a marker for hip-fracture            Concerns about quality of hos-              ranging from 15% to 60%, depend-
risk.21 The relationship between          pital care for patients with AD and            ing on the specific criteria used.
AD and hip fracture needs fur-            hip fractures have been raised, in             Hip-fracture patients with delirium
ther exploration, as in some              part because of the greater odds of            have worse outcomes, including
instances the onset of AD fol-            death during index hospitaliza-                longer hospitalizations, decreased
lows the hip fracture, implying           tion, compared to individuals                  recovery of functional abilities and
that either the hip fracture              without AD.23 The situation is                 ambulation, and increased risk of
brought the patient’s cognitive           more complex in patients from                  institutionalization and death.
deficits to medical attention or          chronic-care facilities. Although              Cognitive impairment and dementia
that the hip fracture and surgery         patients from chronic-care set-                have been cited as the best predic-
may have precipitated the cogni-          tings generally have lower pre-                tors of post-orthopedic surgery
tive decline.                             fracture function, the decline in              delirium.25-27 As delirium can
    Hospitalization for hip fracture      level of functioning and mobility              potentially be prevented and treat-
is costly, and the cost goes up with      after a hip fracture is much greater           ed,28,29 this may be an important
longer length of stay and comor-          than in their community-dwelling               starting point for improving the care

 Table 1

 Risk Factors for Hip Fractures
 Osteoporosis-associated             Increased Risk of Falls                                           Both
 Low bone mineral density (BMD)      Polypharmacy                     Diabetes                        Age
 High bone turnover                  Sedative medication use          Peripheral neuropathy           Frailty
 Calcium deficiency                  Orthostatic hypotension          Sensory impairment              Previous falls/fractures
 Low body mass index (BMI)           Deconditioning                   Balance problems                Vitamin D deficiency
 Weight loss                         Dementia                         Foot disorders                  Physical inactivity
 European or Asian ancestry          Parkinson’s disease              Urinary urgency                 Anticonvulsant use
 Female gender                       Stroke                           Environmental hazards           Thyroid disorders
 Caffeine intake                     Arthritis                                                        Alcohol intake
 Cigarette smoking                                                                                    Certain medications
 Family history



                                                               The Canadian Review of Alzheimer’s Disease and Other Dementias • 17
 AD and Concomitant Conditions


of elderly dementia patients with hip        ing, against which later cognitive        poor rehabilitation outcomes.
fractures. Targeting patients who are        changes can be compared.                  Undernutrition may also contribute
at greatest risk of developing post-             Uncontrolled pain is itself a risk    to delayed wound healing and
operative delirium with delirium-            factor for developing delirium, in        impaired functioning of the immune
prevention strategies may help to            addition to being inhumane. Pain          system. Early medical complica-
improve quality of care and postop-          medications are frequently pre-           tions and dementia have been shown
erative outcomes, and reduce costs.          scribed on an as-needed basis, but        to be major risk factors for inade-
More research on delirium preven-            patients with cognitive impairment        quate postoperative nutritional
tion and management is needed in             may not be able to effectively com-       intake.32 Strategies to improve nutri-
this population, as many research            municate their needs. This increases      tion in high risk groups may include
trials have excluded patients with           the likelihood of relatively severe       reducing fasting time preoperatively,
dementia.                                    postoperative hip pain, which may         reducing opioid load, and nutrition-
                                             then result in the administration of      al supports. Patients with dementia
Improving Care of Hip                        higher opioid doses. Regular admin-       who are at increased risk of compli-
Fracture In Patients with                    istration of non-narcotic analgesics,     cations may benefit from further
Dementia (Table 2)                           such as acetaminophen, may help to        intensification of nutritional sup-
Delirium Prevention and Manag-               reduce uncontrolled severe pain and       port.32 Another innovative approach
ement. Having sustained a hip frac-          the total amount of opioid that is        may include providing one-on-one
ture is an independent risk factor for       needed.5,28                               attention from dietary assistants, in
developing delirium and this risk is             Unfortunately, environmental          high-risk patients, to help with meal
increased several-fold in patients           strategies, such as limiting changes      choices and actual food consump-
with pre-existing dementia.27 There          in staff and involving relatives in re-   tion, if needed.33
may be ways to improve the periop-           orientation, are frequently over-             Rehabilitation. A multidiscipli-
erative care of frail elderly hip-frac-      looked.31 Delirium-prevention stud-       nary approach to rehabilitation after
ture patients, with the goal of              ies have, by and large, been fully        hip fracture can help to optimize
decreasing the incidence of deliri-          funded research studies in tertiary       recovery of mobility and functional
um. Work by Marcantonio28 has                referral centres and it is unclear        capacity.34,35 Rehabilitation in
demonstrated that combined med-              whether their results can be repli-       patients with dementia can be more
ical and nursing interventions, aug-         cated in everyday practice. A chal-       challenging and may require spe-
mented by proactive geriatric con-           lenge in delirium research is to dis-     cialized geriatric rehabilitation
sultation, can potentially reduce the        cover ways in which good practice         teams. However, research has
incidence and severity of delirium           can be disseminated widely, so that       shown that pre-morbid ambulatory
complicating postoperative hip-frac-         permanent improvements in quality         status is more important than the
ture care. Another intervention              of care for vulnerable elderly peo-       presence or absence of dementia at
study, involving systematic cogni-           ple can be achieved and appropriate       predicting who will reach motor
tive screening, regularly scheduled          interventions become part of rou-         independence and safe gait, follow-
pain medications, and education of           tine care.                                ing rehabilitation efforts.36,37
nursing staff, resulted in decreased             Nutrition. Malnutrition is com-       Functional status at discharge from
severity and shorter duration of             mon amongst elderly hip-fracture          rehabilitation after hip fracture does
delirium in hip-fracture patients.36         patients. This, in addition to the        depend, to some extent, on pre-oper-
Routine cognitive screening on               catabolic response to surgery, can        ative cognitive status and functional
admission can be helpful in estab-           contribute to muscle wasting and          ability, but nonetheless, the ability to
lishing baseline cognitive function-         weakness and may contribute to            perform functional activities is


18 • The Canadian Review of Alzheimer’s Disease and Other Dementias
                                                                                                        Hip Fractures


 Table 2                                                                                and sun exposure are unpre-
 Improving Care of Hip Fracture Patients with Dementia                                  dictable in nursing-home popula-
 Perioperative Care                                                                     tions. A number of studies have
                                                                                        found that oral calcium and vita-
 Multidisciplinary team approach
 Education of healthcare team
                                                                                        min D supplementation reduced
 Routine cognitive screening
                                                                                        falls and fractures in nursing-
 Delirium prevention strategies                                                         home patients.45 However, a sub-
 Regularly scheduled non-opioid analgesia                                               sequent study failed to replicate
 Nutritional support                                                                    these findings,49 so the jury is still
 Geriatric rehabilitation                                                               out on this issue.
                                                                                            Patients with dementia may be
 Prevention Strategies                                                                  less likely to engage in regular exer-
 Fall prevention                                                                        cise, which can contribute to muscle
 Exercise programs in the community and nursing home                                    weakness from deconditioning, and
 Osteoporosis treatments                                                                may increase their risk of falls and
                                                                                        fractures. Rolland et al50 imple-
improved by the rehabilitation              based rehabilitation programs,43            mented a twice-weekly exercise
process in cognitively impaired             and body-weight-supported tread-            program in nursing-home patients
patients.38,39 Indeed, the greatest         mill techniques, which may be use-          with dementia. Over the course of a
benefit by specialized geriatric reha-      ful in more severe dementia.44              year, they noted an increase in walk-
bilitation programs may be derived              Prevention. Hip-fracture pre-           ing speed and significantly less
by hip-fracture patients with mild-         vention starts with efforts at fall         decline in ADLs in the exercise
to-moderate dementia.40,41                  prevention, for which multifactori-         group. There were too few frac-
    Taking this one step further, it        al programs in certain settings may         tures in either group to allow any
may be beneficial to introduce a            be effective. Not all falls, of course,     insight into fracture prevention,
multidisciplinary approach even             can be prevented. There has been            but it is thought-provoking that it
earlier in the postoperative course.        some interest in hip-protector use          was possible to implement a regu-
In one study, a multidisciplinary,          to prevent fractures resulting from         lar exercise program in this popu-
multi-factorial intervention pro-           falls. Meta-analysis on this ques-          lation. Preliminary work in people
gram was implemented in the                 tion is inconclusive, but there may         with dementia living in the com-
acute-care and rehabilitation phas-         be a small reduction in rates of hip        munity showed that it is possible
es of hip-fracture patients, resulting      fracture in care homes with the use         to successfully train caregivers to
in a significant reduction in falls         of hip protectors.45                        implement a home exercise pro-
during the inpatient stay, related at           There is good evidence for the          gram, which may have a persistent
least in part to a reduction in post-       pharmacologic treatment of osteo-           effect on physical health and func-
operative delirium in the interven-         porosis, with outcomes including            tioning .51
tion group. Dementia patients, who          fracture reduction in post-
are at highest risk of delirium and         menopausal women, including                 Conclusions
further falls after hip-fracture sur-       those with a previous fracture his-         As the population ages, the preva-
gery, seemed to benefit the most            tory.3,46,47 Risedronate has been           lence of Alzheimer’s disease and
from this intervention program.42           found to reduce the risk of hip             other dementias, as well as the inci-
Future directions in hip fracture           fracture in elderly women with              dence of hip fractures, will continue
rehabilitation may include home-            AD.48 Dietary intake of calcium             to rise. Outcomes after hip fracture


                                                              The Canadian Review of Alzheimer’s Disease and Other Dementias • 19
  AD and Concomitant Conditions


tend to be poor in patients with                                plines will have to become comfort-                              period, which will include delirium
dementia, and much can be done to                               able with managing frail elderly                                 recognition and management, as
improve the care of this group.                                 patients, with or without cognitive                              well as a multifactorial approach to
Health care providers from all disci-                           impairment, in the perioperative                                 optimizing outcomes.




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20 • The Canadian Review of Alzheimer’s Disease and Other Dementias

								
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