Acta chir belg, 2006, 106, 393-396
Quality of Life after Hip Fracture Surgery in the Elderly J. Fierens* and P. L. O. Broos** Departments of Surgery* and Traumatology and Emergency Surgery**, UZ Gasthuisberg, Leuven, Belgium.
Key words. Hip fracture ; quality of life ; elderly. Abstract. As the world population ages, the prevalence of osteoporosis and the incidence of hip fractures will increase dramatically, being responsible for an increase of the health expenditure. On the other hand, there is the inescapable fact of scarcity creating the necessity of making difficult choices with regard to the allocation of human resources. So the question remains : should we carry on investing an important part of our health expenditure for the treatment of hip fractures in elderly people ? To answer this statement, we compared 384 hip fracture patients of 70 years and older treated in our department between 1978 and 1983 with 1102 patients treated between 1998 and 2003. Both groups had a prospective follow-up of at least one year. There were no statistically significant differences : mortality rate 24% vs. 23% ; good functional outcome 82% vs. 73% ; and home going rate 60% vs. 66%. The factors influencing these results were studied. So we can conclude : – The number of hip fractures treated nowadays has increased compared with twenty years ago ; – There is no significant improvement in mortality, nor in quality of life ; – Age is not a contraindication for hip fracture surgery.
Introduction The incidence of hip fractures is increasing due to the ageing population. The world-wide annual number is estimated to rise from 1,7 millions in 1990 to 6,3 millions in 2050 (1). Most hip fractures are related to osteoporosis (2) and are perhaps the most dramatic consequence of it in the elderly, as it is associated with excess mortality (3) and morbidity that usually results in costly hospital and lengthy rehabilitation procedures (4) ; patients experience considerable difficulties in returning to their pre-fracture living situation and in achieving full recovery of function (5-6). These fractures are thus responsible for an increase of the health expenditure, in an era where as a result of scarcity, choices with regard to the allocation of human resources have to be made. The authors wish to evaluate the quality of life after hip fracture surgery in the elderly, in proportion to the costs for the society, to answer the question whether or not old age is a contraindication for hip fracture surgery. Health expenditure As mentioned above, more attention has recently been attached to the economic consequences of hip fractures in the elderly. The Belgian Hip Fracture Study Group made a prospective study to assess the costs of the initial hospitalization for a first hip fracture and evaluate the
excess costs attributable to the hip fracture during the one year period following hospital discharge (7). The mean cost of the initial hospitalisation for the fracture was $ 9,534. The mean costs of the medical services during the one year follow-up period were $ 13,470 for the hip fracture patients and $ 6,170 for a matched control group. Thus, the one year excess cost after hospital discharge averaged $ 7,300. BRAINSKY et al. showed that the costs after a hip fracture increased for the first six months and then decreased, so that they approached levels as before fracture by the end of the first year (8). These results confirm that the economic burden associated with hip fracture is substantial, taking the increasing incidence into account. Quality of life We compared mortality, functional outcome and home going rate of 384 consecutive hip fracture patients of 70 years and older treated in the University Hospitals Gasthuisberg, Leuven between 1978 and 1983 with 1102 patients treated between 1998 and 2003. Both
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Presented at the 6th Belgian Surgical Week, Quality of life and trauma outcome (Belgian Trauma Society), Ostend, April 28th, 2005.
394 groups had a prospective follow-up of at least one year. The factors influencing these results were studied and compared to recent literature. Mortality The mortality during the year after hip fracture surgery of the patients treated between 1978 and 1983 was 24% (9). No significant difference was found as compared to the group treated between 1998 and 2003 (23%). The mortality rate was influenced by age, gender and cardio-pulmonary status (p < 0,05). Mental state and pre-fracture functional status was found to be more important (p < 0,01). According to recent literature, in hip fracture patients, mortality in the first year after discharge may be as high as 5-36%, a rate several times higher than the corresponding age- and sex-specific mortality rates in the population at large (3). BOONEN et al. found, in a prospective controlled study, a mortality rate of 13% of the hip fracture patients during the year after hospital discharge, as compared to only 3% of the age- and neighbourhood-matched controls (p < 0,001) (10). The hip fracture group showed a significantly greater proportion of women with neuropsychiatric disorders and a greater proportion of women with two or more coexisting illnesses. Compared to patients who survived the first year after hospital discharge, patients who died were older (mean age 85 years, as compared to 78 years, p = 0,002) and suffered from more pre-fracture comorbidities (p = 0,038). VAN BALEN et al. reported a mortality of 20% at 4 months follow-up after hip fracture (11). The patients were on average 83-year old and nearly 70% had two or more diagnosis in addition to the hip fracture ; 34% of the patients had dementia. Nearly 40% of the patients with dementia died within these 4 months of follow-up. The mortality during the post-fracture year in the studied population of RÖDER et al. with normal mental status, as verified on admission by Mini Mental State Examination, was 11,7% (12). These findings are in agreement with the earlier reported relationship between poor cognitive state and mortality after hip fracture surgery (13). In a cohort of 7512 elderly ambulatory women, the EPIDOS prospective study group reported that the 338 women who suffered a first hip fracture during the 4 years of follow-up had twice the risk to die than women who did not have any fracture, even after accounting for age and baseline health state (14). This increased risk appeared more pronounced in the first 6 months after the fracture but persisted for three years. Earlier reports, suggesting the long-term effect of hip fractures on mortality, noted that the effect was most pronounced in the least impaired patients (15). They hypothesized that there are two groups of hip fracture patients. One group
J. Fierens and P. L. O. Broos consists of frail elderly subjects who have a number of comorbid conditions and older age and who die rapidly after the fracture. In this group, a hip fracture is simply one of a series of events in the cascade of late-life illness that accelerates an older person’s chance of dying. The other group consists of healthier elderly individuals without significant disease or disability and may be better able to withstand the initial insult of the fracture owing to their better health and coping capabilities. In this second group the hip fracture may signal or induce a progressive decline in health and may translate into an increased risk of death only after a couple of years. The results of a large short-term effect of hip fracture on mortality and a smaller but persistent long-term effect are consistent with the hypothesis of two groups of hip fracture patients. A recent controlled study of FRANSEN et al. found that the increased risk of death after hip fracture was markedly greater for men than for women (16). Male gender was a risk factor for sustaining a postoperative complication as well as higher mortality at one year post hip fracture (17). Several elements suggest that men who suffer a hip fracture are in worse health than women who suffer such a fracture, as evidenced by a higher American Society of Anaesthesiologists rating of preoperative risk. A study by ALEGRE-LOPEZ et al. identified predictors of mortality at one year after hip fracture (18). Mortality was observed to be independently associated with poor mental status (relative risk [RR] = 6,96), pre-fracture limited functional ability (RR = 4,35), institutionalized disposition at discharge (RR = 2,92), and male gender (RR = 2,44). Elderly operated within 5 days of the hip fracture have increased survival time (p < 0,05) and better functional outcome (p < 0,05) than those operated after the fifth day of admission (19). A delay of more than four days in patients who are fit for surgery significantly increases mortality and must be avoided (20). Patients with medical comorbidities that delayed surgery, such as a chest infection, had 2,5 times the risk of death within thirty days after the surgery compared with patients without comorbidities delaying surgery. Functional outcome Of the 384 patients treated between 1978-1983 and of the 1102 patients treated between 1998-2003, respectively 241 and 632 patients were living independently before the injury. Excellent or good results were achieved in 82% of these independent patients in the first group, and in 73% of the patients treated twenty years later (p > 0,05). Functional status upon hospital discharge, type of fracture and age were factors influencing the functional outcome (9).
Quality of Life after Hip Fracture Patients surviving a hip fracture still suffer from substantial functional impairment one year after the fracture. According to BOONEN et al., fracture patients needed, over 12 months of follow-up, significantly less assistance with activities of daily living (ADL) (p < 0,001), reflecting their functional recovery (10). Despite a significant recovery in the year following fracture, the functional outcome scores (including activities of daily living, degree of dependence and cognitive impairment) at one year still showed a marked difference (p < 0,001) between the hip fracture group and the control group. After adjusting for potential confounders (age, pre-fracture comorbidities, mental impairment and place of residence), the functional decline due to hip fracture occurrence over the year following acute treatment was 24%. They also reported that almost one-third of patients (30%) less than 80 years old were still unable to walk independently at one year, compared to only 7% of control women (p < 0,001). In women older than 80 years, 56% of patients needed assistance to walk (or were even unable to walk) at 12 months, compared to 15% of control women of the same age (p < 0,001). Functional status upon hospital discharge appeared to be the best prognostic marker of long-term functional outcome after hip fracture, according to several prospective studies (6). Other important predictors, according to BOONEN et al., are pre-fracture comorbidities and living in a nursing home prior to the fracture (10). VAN BALEN et al. found that walking ability and activities of daily living improved significantly between follow-ups (p < 0,001), but only 43% of patients had reached the same level of walking ability as before at 4 months, and only 17% of patients had achieved the same level of ADL as before fracture (11). Home going rate Of the independently living patients of the first and second group treated in our centre, respectively 60% and 66% were discharged at home (p > 0,05). Age, functional status pre-injury, postoperative general complications and the functional status upon hospital discharge were factors influencing the home going rate (p < 0,05) (9). Studies of hip fracture recovery have shown that 1525% of patients who were independent and living at home before the fracture spend at least 1 year after the fracture institutionalized in long-term care facilities (6). A prospective study of VAN BALEN et al. with 102 patients of which 42% were admitted from an institution, reported that only 47% of patients were discharged to the same type of residence they had before fracture (11). At 4 months, this percentage had increased to 57%. Nearly 2/3 of patients were discharged from the hospital to a nursing home and 27% were still staying in a nursing home at 4 months follow-up (21). Of the
395 patients who came from home, 63% were back home at 4 months after fracture. In multivariate analysis age, cognitive status and number of comorbidities were predictive factors for being back home at 4 months. Is old age a contraindication for hip fracture surgery ? Hip fractures in the elderly are associated with excess mortality and morbidity resulting in costly hospitalization and rehabilitation programmes. Beyond the age of 65 years, the cost-benefit advantages of the treatment of hip fracture patients are lost (22). From that point of view old age is a contraindication. A more appropriate answer was formulated by SMITH in 1907 : “First, because they are old, we must not consider that it is time for them to die. We should endeavour to prolong life, and prolong it in comfort. Second, we must realize that surgery is appropriate in emergencies which threaten life and in conditions which destroy the peace and comfort of the elderly”. From that point of view, age is not a contraindication and hip fracture patients deserve optimistic and compassionate doctors. Conclusion The number of hip fractures treated nowadays has increased compared with twenty years ago, resulting in a substantial economic burden. The results after hip fracture surgery show no significant improvement as compared with twenty years ago : high mortality rate, functional impairment and low home going rates. The functional status upon hospital discharge is one of the most powerful factors influencing the quality of life after hip fracture surgery in the elderly. Although these negative results, age is not a contraindication for hip fracture surgery. The issue remains improving the quality of life and maintaining dignity. Surgeons should not be involved in the allocation of scarce resources in the situation of an individual patient.
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J. Fierens UZ Gasthuisberg B-Leuven, Belgium E-mail :
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