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REVIEW
The Medical Consultant’s Role in Caring for Patients with Hip Fracture
R. Sean
Morrison, MD; Mark R. Chassin, MD, MPP, MPH; and
Albert L. Siu, MD, MSPH
15 June 1998 | Volume 128 Issue 12_Part_1 | Pages
1010-1020
Background: Hip fractures are an important cause of
death andfunctional dependence in the United States.
Purpose: To review the evidence for clinical decisions that
medical consultants make for patients with hip fracture andto
develop recommendations for care.
Data Sources: Published reports of clinical studies were found
by searching MEDLINE and selected bibliographies.
Study Selection: Studies were included if data were presented
on clinical interventions to improve care of conditions typically
encountered by medical consultants in the care of patients with
hip fracture. Such conditions include timing of surgery, infection
prophylaxis, thromboembolic prophylaxis, postoperative nutritional
management, urinary tract management, prevention and management
of delirium, application and timing of rehabilitation services,
and prevention of subsequent falls. Meta-analyses; randomized,
controlled trials; or other controlled studies were includedif
possible. If no such trials were identified, the best evidencefrom
studies with other designs was included.
Data Extraction: Interventions were selected on the basis of
their efficacy or potential efficacy in improving functional
outcome. Trials with positive and negative results were compared
for differences in intervention and strength of study methods.
Data Synthesis: Strong evidence supports medical recommendations
for decisions about timing and duration of prophylactic antibiotics,
selection of thromboembolic prophylaxis, urinary tract and
nutritionalmanagement, and rehabilitative services. Many case series
supportearly surgical repair, although patients who would benefit
fromdelay and further medical work-up have not been well
identified.Evidence for decisions about assessment of subsequent
risk forfall and risk for and management of delirium is based
largelyon data from patients without hip fracture but is probably
applicable.Future research should target optimal duration of
thromboembolicprophylaxis, cost-effectiveness of
low-molecular-weight heparincompared with that of other
thromboembolic prophylactic regimens,management of delirium,
rehabilitative services, and efficacyof assessment of risk for later
falls.
Conclusions: The data suggest that evidence-based medical care
can improve hip fracture outcomes. The medical consultant hasa
key role in providing this care and managing the preoperative
conditions and postoperative complications that may affect optimal
functional recovery.
Hip fractures are an
important cause of death and functionaldependence. Approximately 250
000 hip fractures occur annuallyin the United States, and this
number is expected to increaseseveral fold in the coming decades [1].
The mortality rate forpersons in the U.S. Medicare population who
sustain a hip fractureis 7% at 1 month, 13% at 3 months, and 24% at
12 months [2].
For patients who survive to 6 months, 60% recover their prefracture
walking ability, half recover their prefracture ability to perform
activities of daily living, and about 25% recover their prefracture
ability to perform instrumental activities of daily living [3].
However, after 1 year, only 54% of surviving patients can walk
unaided and only 40% can perform independently all physical
activities of daily living [3].
Although surgical repair of the fractured extremity is the cornerstone
of therapy, available data suggest that the factors crucialto
optimal functional recovery in hip fracture are independentof
fracture repair and are instead related to prefracture conditionsand
postfracture complications [4].
Thus, successful care andoutcome of patients with hip fracture
require an active partnershipbetween the orthopedic surgeon and
others, including the medicalconsultant.
The medical consultant’s role includes medical evaluation and
stabilization of the patient before surgery, prevention and
management of postoperative complications (such as delirium),
and follow-up after increasingly shorter hospital visits. Despite
the involvement of medical consultants in the care of most patients
with hip fracture (in one large series of patients with hip
fracture, 81% had a presurgical medical consultation [Magaziner
J. Personal communication]), many internists have no formal
training in this condition and may be unfamiliar with the optimal
management of its complications.
We review the clinical evidence to support decisions that internists
are often asked to make for patients with hip fracture, develop
evidence-based recommendations, and identify areas requiring
further research. Medical decisions include decisions about
timing of surgery, infection prophylaxis, thromboembolic prophylaxis,
postoperative nutritional management, urinary tract management,
prevention and management of delirium, application and timing
of rehabilitation services, and prevention of subsequent falls.
We excluded preoperative risk assessment and fracture prevention
because extensive literature on these subjects already exists.
We also excluded topics not usually under the purview of the
medical consultant, such as choice of anesthesia and type of
surgical repair.
Methods
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Info  References |
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We did a
systematic review of processes related to the medicalcare of
patients with hip fracture, concentrating on processesthat could
lead to improved functional outcome (Table
1). Wesearched the MEDLINE database, using the MeSH terms
femoralfractures, hip fractures, or femoral neck fractures and
thekeywords or text words given in Table
1, for English-languagearticles published from January 1966
through June 1997. If nostudies were identified, we repeated the
search with only thekeywords or text words. Articles were reviewed
to determinetheir relevance to patients with hip fracture (for
example,elderly persons or patients undergoing lower-extremity
orthopedicprocedures, such as total hip arthroplasty). To identify
additionalstudies, we searched the reference lists of the selected
articles.Within each subject area, we included meta-analyses;
randomized,controlled trials; or other controlled studies wherever
possible.If no such trials were identified, we included the best
availableevidence from studies with other designs. Articles were
reviewedindependently by two of the authors, the evidence was
summarized,and recommendations were drafted. If the reviewers
disagreedabout a recommendation, the underlying assumptions leading
tothe recommendation were discussed until consensus was
reached.Summaries were subsequently reviewed by a panel of content
expertsin orthopedics, internal medicine, geriatrics,
rehabilitation,nursing, and nutrition and were revised on the basis
of thepanel’s recommendations. Final summaries were prepared,
andthe quality of evidence was rated by using ratings adapted
fromthe U.S. Preventive Services Task Force [5].
Meta-analysis wasbeyond the scope of this paper given the multiple
domains, theheterogeneity of study populations, and the wide
variation inquality and design of the studies.
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Summary of Evidence
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A
summary of the studies and the strength of the evidence isgiven in
Table
2.
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Timing of Surgery
The timing of surgical repair of hip fracture may affect patient
outcomes in two ways. Delay in surgical repair, which causes
delay in return to weight bearing, may affect functional recovery.
Conversely, failure to stabilize medical problems before surgery
may increase risk for perioperative complications. Althoughthe
orthopedist schedules surgery, the rate-limiting step inthis process
is often the internist’s preoperative medical evaluation.
We identified 9 cohort studies [6,7,9,10,54-58];
1 randomized,controlled trial of anesthetic techniques that included
surgicaldelay as an independent variable [8];
and 1 autopsy series [59]
that examined the effects of operative timing on post-operative
outcome. The results of these 11 studies suggest that early
surgical repair (within 24 to 48 hours) is associated with a
reduction in 1-year mortality. However, most of the studies
either did not control for the presence and severity of comorbid
conditions or excluded patients with complicating medical conditions;
thus, these data are difficult to interpret. Of the 5 studies
that attempted to control for comorbid conditions [6-10],
4reported lower mortality rates and 1 [6]
reported a lower incidenceof confusion and pressure ulcers in
patients who underwent surgicalrepair within 48 hours.
Evidence from cohort studies indicates that for medically stable
patients who do not have active comorbid illness (such as unstable
angina), surgical repair of hip fracture within the first 24to
48 hours of admission is associated with a decrease in 1-year
mortality. Patients who would benefit from delay and further
medical evaluation have not been well characterized.
Prophylactic Antibiotics
Prophylactic antimicrobial agents are often administered to
prevent postoperative wound infections. We reviewed the literature
to identify the benefit of antibiotic use for postoperative
infections and to identify the optimal timing of administration
and duration of use. Three meta-analyses examined prophylactic
antibiotic use in patients with hip fracture [11]
(Table
3).The first compared antibiotic use with placebo, the second
comparedsingle doses of antibiotics with multiple doses, and the
thirdcompared 3 doses of antibiotics with multiple doses. We
foundno randomized trials that examined the timing of
antibioticadministration, but we found one large case series
involvingpatients undergoing elective surgery [12]
(Table
3).
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Meta-analysis of seven studies [60-66]
that compared antibioticuse with placebo showed a 44% risk reduction
in postoperativeinfection for the antibiotic group. Four studies [64,67-69]
compared multiple doses (range, 2 to 10 doses) with a single
dose of antibiotics given immediately before surgery. Therewas
a trend toward a reduction in postoperative infection inthe
multiple-dose group. A third meta-analysis summarized twostudies [68,70]
that compared 3 doses of antibiotics with multipledoses. No
significant differences were seen in infection ratesbetween the two
groups. First- and second-generation cephalosporinswere used in most
of the studies.
The only study that addressed optimal timing of antibiotic
administrationwas a cohort study of 2847 elective procedures [12].
In thisstudy, wound infection rates were lowest when antibiotics
wereadministered 0 to 2 hours before surgery.
Considerable evidence from 11 randomized trials [60-70]
supportsthe use of prophylactic antibiotics (first- and
second-generationcephalosporins) in patients with hip fracture.
Antibiotics seemto reduce the risk for deep-wound infections by
approximately44%, and therapy should probably be continued for 24
hours (thatis, about 3 doses should be given). Published data
suggest thatantibiotics should be administered 0 to 2 hours before
surgery.
Thromboembolic Prophylaxis
Venous thromboembolism is a substantial cause of postoperative
morbidity and mortality in patients with hip fracture. Despite
a clear rationale for prophylaxis and clinical evidence of efficacy,
use of prophylaxis is not universal, largely because of questions
about which agent is the safest and most effective [71].
We identified three meta-analyses [13,14,23]
in which patientswith hip fracture were examined and an additional
10 randomized,controlled trials in which prophylactic thromboembolic
agentsin hip fracture were examined (Table
4). One of the meta-analysescompared low-dose heparin with
placebo, one compared low-molecular-weightheparin with placebo or
low-dose heparin, and the third comparedaspirin with no treatment [23].
We found no data on the durationof prophylaxis.
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The studies reviewed strongly support the use of thromboembolic
prophylaxis, but which agent is optimal is less clear. Low-dose
heparin has been the agent most frequently studied in hip fracture
and was associated with a reduction of about 60% in deep venous
thromboses in one meta-analysis [13]
(Table
4). Low-molecular-weightheparin has also been evaluated by
meta-analysis and was shownto produce a similar reduction in deep
venous thrombosis [14]
(Table
4). The latter meta-analysis also pooled data from fourstudies
that compared low-molecular-weight heparin with low-doseheparin and
found no significant differences between the twoagents for
development of deep venous thrombosis. Low-dose heparinseems to
proportionately increase the risk for major bleedingepisodes by
about 30% compared with placebo, but the actualpercentage increase
is small (overall rates, 3.5% in the heparingroups compared with
2.9% in the placebo groups) [13].
In moststudies, heparin therapy was initiated on hospital
admission.
The use of aspirin as prophylaxis was examined in one meta-analysis
of 10 orthopedic trauma trials, 9 of which included only patients
with hip fracture and 1 of which included patients with hipand
pelvic fractures [23]
(Table
4). Aspirin was found to significantlyreduce the risk for deep
venous thrombosis and pulmonary embolism.However, when aspirin was
compared with low-molecular-weightheparin for prevention of deep
venous thrombosis in one recenttrial [15],
low-molecular-weight heparin resulted in a relativerisk reduction of
37% and no significant difference in bleedingcomplications was
seen.
Several other prophylactic agents have been evaluated (Table
4).Low-dose warfarin (prothrombin time 1.5 times that of
control)was compared with placebo in two studies [16,72]
and with low-molecular-weightheparin in one study [17].
Warfarin seems to confer a reductionin risk for deep venous
thrombosis similar to that conferredby heparin, although the one
study that compared low-molecular-weightheparin and warfarin
directly suggests that low-molecular-weightheparin may be more
efficacious [17].
The use of dextran fordeep venous thrombosis prophylaxis was
evaluated in five trials[18-22],
and this agent seems to be as efficacious as low-doseheparin [18,20]
or aspirin [19]
but is probably less efficaciousthan low-molecular-weight heparin [19,21,22].
Pneumatic compressiondevices seem to reduce the incidence of deep
venous thrombosiscompared with no treatment [24].
Strong evidence supports the use of low-dose heparin or
low-molecular-weightheparin as prophylaxis for deep venous
thrombosis starting athospital admission. The latter agent is
probably slightly moreeffective but is more expensive. Aspirin seems
to have somebenefit (but to a lesser extent) and may be considered
in patientsat high risk for hemorrhagic complications. Several
studiessupport the use of low-dose warfarin; however, the
requiredinternational normalized ratio [INR] monitoring and risk
forover- or underanticoagulation are potential drawbacks.
Nonetheless,some patients may prefer weekly monitoring of the INR to
twice-dailyinjections of heparin or low-molecular-weight heparin.
Compressionstockings seem to impart benefit with negligible risk and
shouldbe used. Future research should determine the optimal
durationof prophylactic anticoagulation and the cost-effectiveness
oflow-molecular-weight heparin compared with that of other
prophylacticthromboembolic regimens.
Nutritional Management
Malnutrition is associated with increased surgical morbidityand
mortality [73].
It has been reported that as many as 20%of patients experiencing hip
fracture are severely malnourished[74].
Interventions that improve nutritional status may thereforeimprove
outcome and decrease complications.
We identified four randomized, controlled trials of nutritional
supplementation in patients undergoing surgery for hip fracture.
Three examined oral protein supplementation [25-27],
and oneexamined nocturnal nasogastric tube feeding [28].
Stableforth [27]
compared patients with hip fracture randomlyallocated to protein
supplementation with those allocated tousual care; significantly
improved nitrogen and calorie balancewas reported in the group that
received supplementation. Delmi[26]
and Tkatch [25]
and their associates randomly assignedpatients with hip fracture to
receive protein supplementationor usual care [26]
or placebo [25]
on admission to the orthopedicservice. Patients who received protein
supplementation had significantlymore favorable long-term outcomes
at 6 months (none or onlyone minor complication), significantly
higher albumin levels,and significantly shorter overall lengths of
stay than patientswho did not receive supplementation.
Bastow and coworkers [28]
examined the effect of nocturnal nasogastrictube feeding in 122
patients at increased risk for nutritionalcompromise (arm and
trifold skin circumference <1 SD belowthe mean for home and
hospitalized elderly patients [75]).
Patientswere randomly assigned to receive usual care or nocturnal
tubefeedings within 5 days of admission. Mortality in the two
groupsdid not differ significantly, but the study lacked
statisticalpower to detect this difference. Very thin patients had a
significantreduction in overall length of stay and had significant
increasesin weight (mean gain, 4.2 kg; P < 0.01) compared with
controls.Patients who received tube feedings achieved independent
mobilitysignificantly faster than patients who did not receive
tubefeedings. One fifth of patients could not tolerate the
nocturnalfeedings.
Oral protein supplementation seems to be beneficial in reducing
minor postoperative complications, preserving body protein stores,
and reducing overall length of stay. Patients with evidenceof
moderate to severe malnutrition may benefit from nocturnalenteral
tube feeding if they can tolerate it.
Urinary Tract Management
Urinary retention, incontinence, and urinary tract infectionsare
commonly seen after surgery in patients with hip fracture[76].
Because of the frequency of postoperative bladder problems,
successful strategies to reduce voiding problems may decrease
morbidity.
We identified two randomized, controlled trials of urinary bladder
management in patients undergoing orthopedic surgery [29,30].
One study included patients with recent hip fracture, and the
other included patients undergoing hip or knee replacement.
Michelson and colleagues [30]
randomly assigned 100 patientswith knee or hip replacement to have
their indwelling urinarycatheters removed immediately after surgery
or the morning aftersurgery. The group that had the catheter removed
the morningafter surgery had significantly lower rates of urinary
retention.Skelly and associates [29]
randomly assigned 67 patients withhip fracture to receive an
indwelling catheter for 48 hoursafter surgery followed by scheduled
intermittent straight catheterizationor scheduled intermittent
straight catheterization immediatelyafter surgery. Spontaneous
voiding occurred significantly earlierin the group that received
intermittent catheterization immediatelyafter surgery. The incidence
of urinary tract infections didnot significantly differ between the
control and interventiongroups in either study.
Few studies have examined the management of urinary cathetersin
hip fracture. The management of catheters may be affectedby previous
level of continence, mobility, and availabilityof nursing staff.
Whenever possible, indwelling catheters shouldprobably be removed
within 24 hours of surgery, and patientsshould be managed with
scheduled intermittent straight catheterization.
Delirium
Delirium occurs in up to 61% of patients with hip fracture [77].
Despite its prevalence, delirium is often unrecognized or
misdiagnosed[78].
Delirium in hospitalized patients has been shown to increaselength
of stay, risk for complications, mortality, and institutionalization
[79-83].
Most patients who develop delirium have some persistentsymptoms up
to 6 months later. In patients with hip fracture,delirium may have
an additional effect on functional outcomeby interfering with
rehabilitation activities and delaying returnto weight bearing.
For this review, we focused on three types of investigations.
First, we identified studies in which multivariate methods were
used to identify risk factors that, if modified, may prevent
delirium; 13 studies met these criteria [31-36,77,83-88].
Second,because treatment of the underlying cause is a cornerstone
ofthe management of delirium, we identified studies that
systematicallydescribed the frequency of different causes of this
syndrome.We found three case series [32,89,90].
Finally, we identifiedstudies that focused on the prevention and
management of deliriumin patients with hip fracture. We found two
nonrandomized studiesthat examined supportive treatment of delirium
[37,38].
With regard to baseline risk factors for delirium, the findings
seem fairly consistent across most studies. Advanced age, history
of cognitive impairment, greater severity of illness, and history
of alcohol use seem to increase the risk for confusion in
hospitalizedmedical and surgical patients. In the two studies of
patientswith hip fracture, only age, dementia, and prefracture
functionalstatus predicted development of delirium [37,77].
Precipitatingrisk factors have been more difficult to identify and,
withfew exceptions, a clear understanding of the iatrogenic
conditionsthat increase risk for delirium in elderly patients has
notyet emerged. Although many risk factors have been proposed
(suchas metabolic disturbances, dehydration, alcohol
withdrawal,urinary retention, changes in environment, psychosocial
factors,and medications [91],
only electrolyte imbalances and some classesof medication (opioids,
sedative-hypnotics, and anticholinergics)have been consistently
identified as precipitating factors inprospective trials, and even
these factors are not consistentacross studies. No precipitating
factors were identified inthe two studies of patients with hip
fracture, but these studieshad limited power to identify such
factors [37,38].
As for the cause of delirium, we could not identify any studies
that focused exclusively on patients with hip fracture. We identified
three case series [32,89,90]
that examined this issue in medicaland surgical patients; only one
had specific criteria for assigningcauses. These studies suggest
that the most common causes ofdelirium are fluid and electrolyte
imbalances, infection, metabolicdisorders, drug toxicity, and
sensory and environmental problems.
Management of delirium has been based largely on clinical experience
because few systematic and controlled studies have been done[91].
We identified two nonrandomized studies involving patientswith hip
fracture. Williams and coworkers [37]
did a time-sequencetrial of pre- and postoperative nursing
interventions (suchas environmental manipulation, reorientation, and
reassurance)in patients with hip fracture. The incidence of delirium
was44% in the treatment group and 52% in the control group.
Gustafsonand associates [38]
compared 103 patients who received treatmentwith 111 historical
controls admitted 2 to 5 years before theintervention cohort. The
intervention in this study consistedof pre- and postoperative
geriatric assessments, oxygen therapyfor hypoxia, early surgery
(done as soon as patients were medicallystable), and aggressive
treatment of perioperative decreasesin blood pressure. The incidence
of delirium was 61% in thecontrols and 48% in the treatment group.
Patients in the treatmentgroup were less likely than controls to be
confused for morethan 7 days (9% compared with 28%) and had a
shorter lengthof stay (11.6 days compared with 17.4 days). The
individualcontributions of each component of the intervention to
reductionin delirium are not known.
In summary, although many cohort studies have examined the risk
factors for delirium, most analyses have not specifically focused
on patients with hip fracture and many studies have lacked adequate
statistical power. Nevertheless, the assembled studies indicate
numerous recurring, potentially modifiable risk factors for
delirium, including electrolyte and metabolic laboratory
abnormalities,medications with psychoactive properties, and
infection. Studiesthat have systematically examined causes of
delirium have beensmall. However, their findings indicate several
common causes,including fluid and electrolyte abnormalities,
infection, drugtoxicity, metabolic disorders, and low cerebral
perfusion. Environmentalmanipulation and supportive reorientation
seem to reduce theincidence of delirium and benefit acutely
delirious patients.More research on the optimal management of
delirium is needed.
Rehabilitation
Rehabilitative services for patients with hip fracture may include
limb and joint mobilization and progressive exercises, physical
and occupational therapy to regain mobility and independencein
activities of daily living, physician supervision of therapy,
psychological counseling, social work, restorative nursing services,
and recreational services. For this review, we focused on selected
aspects of rehabilitation that are particularly salient to the
internist; we recognize that rehabilitation is a responsibility
shared with the surgeon who, depending on the fracture and type
of surgery, may have specific recommendations about mobilization
and weight bearing. We address the value of early mobilization,
intensified interdisciplinary rehabilitation approaches, and
intensity and frequency of therapy.
We identified several reports of programs that used early mobilization
or early weight-bearing policies. From these reports, we excluded
studies, primarily from the 1960s and 1970s, that reviewed the
effects of “early weight-bearing” initiated many days or weeks
after the perioperative period; we focused instead on studies
that reported on mobilization in the first 24 to 48 hours. We
identified one randomized trial [39]
that included early mobilizationas part of a larger program of
accelerated rehabilitation; wealso identified many trials in which
all patients received earlymobilization (in the first 24 to 48
hours) [40-45,92-97].
Inthe case of intensified interdisciplinary rehabilitation
programs,we identified four randomized trials [46,47,98,99].
For theintensity and frequency of physical therapy, we identified
twosmall randomized trials [45,99]
and two cohort studies thatattempted to control for potential
confounding between patientcharacteristics and receipt of services
[3,48].
The randomized trial that evaluated early mobilization (usually
within 24 hours of surgery) did so as part of a program that
included early discharge from the hospital and a comprehensive
rehabilitation program during and after hospitalization [39].
Although that trial found no differences in the physical independence
of the 252 patients at 4 months, it showed that so-called accelerated
rehabilitation could reduce health care costs. Other studies[40-45,92-97]
showed that policies on early mobilization fromthe first day after
surgery can be implemented with acceptablerates of complications [40-42],
discharge destination [40,44],
functional outcome [40,43,45],
and mortality [42,44].
Of the four relatively small randomized trials that evaluatedthe
benefits of geriatric interdisciplinary rehabilitation [46,47,98,99],
two found no differences in functional outcome [99],
mortality,or placement [98].
However, two studies found positive effectsassociated with these
programs. In a study of 112 patients,Kennie and colleagues [46]
reported improved functional statusand found that patients were more
likely to be discharged totheir own homes than to a nursing home
after interdisciplinaryrehabilitation. In addition, a randomized
trial of geriatricassessment and rehabilitation in which hip
fracture was themost common diagnosis (occurring in 18% of the
patients) foundthat geriatric rehabilitation improved the patient’s
likelihoodof returning to the community [47].
Two randomized trials evaluated intensified physical therapy(that
is, therapy sessions twice per day rather than once perday or
supplemental individualized educational sessions) [45,99].
Both trials failed to show a benefit in functional outcomes;
however, both were small. Therefore, we sought additional evidence
of efficacy from cohort studies that attempted to control for
potential confounding between patient characteristics and receipt
of services. In a cohort study of 162 hospitalized patients,
Guccione and associates [48]
found that more than one physicaltherapy session per day was
associated with improved functionaloutcome after adjustment for age,
prefracture ambulation, andlength of stay. In a study of 536
patients, Magaziner and coworkers[3]
reported that the number of physical therapy sessions (after
adjustment for prefracture and other hospital care variables)
was associated with improved physical independence at 1 year
but did not affect walking ability or ability to perform instrumental
activities of daily living.
In summary, the data suggest that early mobilization is safein
selected patients. However, data are lacking on the potential
benefits of early mobilization. In the case of interdisciplinary
rehabilitation featuring geriatric assessment, randomized trials
suggest that these programs can improve functional outcome and
increase the likelihood that patients will return to the community.
These trials, however, were small and were limited to programs
with personnel who have a special interest in orthogeriatrics.
For physical therapy services, cohort studies that have adjusted
for potential confounders suggest that the frequency of physical
therapy probably has an important effect on outcome and that
more than one session per day is probably beneficial.
Assessment of Falls
Patients with hip fracture have an increased risk for subsequent
fracture [100].
Interventions to reduce the likelihood and numberof subsequent falls
may therefore have beneficial effects onoutcome.
We identified seven randomized trials [50-53,101-103]
and onepreplanned meta-analysis [49]
of clinical and social interventionsto reduce falls. None of the
studies specifically targeted patientswith hip fracture. Two of the
seven studies [51,52]
focusedon patients at risk for falling on the basis of other
factors.Four [50,53,102,103]
focused on older persons in the communitywho were otherwise not
screened for risk for falls, and onefocused on frail nursing home
residents [101].
A meta-analysis[49]
included eight trials, two of which are cited above [51,101],
and examined the effect of exercise and balance on fall prevention.
The five studies [50,53,101-103]
that focused on persons previouslyunscreened for risk for falling
randomly assigned nursing homeresidents [101],
senior centers, or households to such interventionsas low-intensity
exercises, counseling on risk-factor reduction,and efforts to
identify and correct environmental hazards. Twoof the studies [50,53]
showed that the intervention slightlyreduced the risk for falling
but not the risk for fracturesor falls requiring medical attention.
Interventions that targetedolder persons at risk for falling were
more efficacious. Rubensteinand colleagues [52]
randomly assigned ambulatory nursing homeresidents to receive usual
care or detailed clinical and environmentalassessments within 1 week
of the fall. The intervention didnot significantly reduce the risk
for subsequent falls, butthe intervention group was hospitalized
less frequently overthe next 2 years. Tinetti and coworkers [51]
identified community-dwellingolder persons with specific risk
factors for falling (such aspostural hypotension or difficulty in
transferring) and randomlyassigned them to receive social visits or
a multifactorial interventionthat featured medication adjustment,
behavioral instruction,and exercise activities targeted to the
person’s risk factors.This intervention reduced the risk for falling
(relative risk,0.69 [95% CI, 0.52 to 0.90]) and the prevalence of
targetedrisk factors. Province and associates [49]
did a meta-analysisof eight trials involving diverse patient
populations and severaldifferent interventions, all of which
included an exercise component.Treatment arms that included the
exercise component showed anadjusted incidence rate for falls of
0.90 (CI, 0.81 to 0.99),and an adjusted incidence rate for falls of
0.83 (CI, 0.70 to0.98) was seen for groups receiving treatment that
includedbalance training compared with controls. No exercise
componentwas significant for injurious falls, but power was low to
detectthis outcome.
These studies suggest that interventions to reduce the incidence
of falls are more likely to be beneficial if they focus on persons
at risk for falls and target specific risk factors or behaviors.
Exercise and balance training also seem somewhat effective in
decreasing risk for falls. Because persons who have sustained
hip fractures are at higher risk for subsequent falls, these
findings may be generalizable to this population.
Conclusions
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Hip
fracture is a common condition that results in death orsubstantial
loss of function for more than 150 000 persons annuallyin the United
States. Furthermore, the annual number of hipfractures is expected
to double by the year 2040 [104,105].
Our literature review suggests that evidence-based medical care
can improve clinical outcomes of patients with hip fracture(Table
2). We identified processes of medical care for whichthe data
are unambiguous (such as prophylactic antibiotics andthromboembolic
prophylaxis) and others for which the data areless clear and for
which more research is needed (such as managementof delirium,
prevention of falls, duration of thromboembolicprophylaxis, and the
cost-effectiveness of low-molecular-weightheparin compared with that
of other agents). We believe thatour recommendations will enhance
the ability to predict andmanage the common complications of hip
fracture, improve functionand quality of life, and improve the
quality of medical careafforded to patients with hip fracture.
Acknowledgment: The authors thank Jay Magaziner, PhD, MSHyg,for
permission to cite unpublished data from the Baltimore HipFracture
Study.
Grant Support: In part by no. U18HS09459-0 from the Agency for
Health Care Policy and Research. Dr. Morrison is a Brookdale
National Fellow.
Requests for Reprints: R. Sean Morrison, MD, Department of Geriatrics,
Box 1070, The Mount Sinai School of Medicine, One Gustave L.
Levy Place, New York, NY 10029; e-mail .
Current Author Addresses: Dr. Morrison: Department of Geriatrics,
Box 1070, Mount Sinai School of Medicine, One Gustave L. Levy
Place, New York, NY 10029.
Drs. Siu and Chassin: Department of Health Policy, Box 1077,Mount
Sinai School of Medicine, One Gustave L. Levy Place, NewYork, NY
10029.
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Ann Intern Med.
1998;128:1010-1020.
From Mount Sinai School of Medicine, New York, New York.
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