Fractures in the Elderly

Prevalence and Effects on

Quality of Life

Joe Dan Metcalf II, M.D. Hospital Medicine Medical Director of Palliative Care Director of Best Practices

Objective

– State short-term and long-term effects of long bone and spinal fractures in the geriatric patient

How serious is the problem?

Falls with Fractures- Outcomes

• 20-30% percent of people who fall suffer moderate to severe injuries: lacerations, hip fractures, or head trauma (Sterling, O’Connor & Bonadies, 2001).

• These injuries impact the patient’s functional capacity and increase their risk of early death (Alexander, Rivara & Wolf, 1992).

Location of Falls (65 years and older)

Home 60% Public Places 30%

Nursing Home 10%

Unintentional Fall Death Rates by Gender, Age 65 +, U.S. 1996

National Center for Health Statistics, Vital Statistics

0

20

40

60

80

100

120

140

Per

100,0

00

65-74 75-84 85+

Men

Women

Unintentional Fall Age-Adjusted Death Rates, Age 65 +, gender and race U.S.

0

5

10

15

20

25

30

35

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

White, Men

Black, Men

White, Women

Black, Women

National Center for Health Statistics, Vital Statistics

Intrinsic (Personal) factors for Falls

• Aged (over 65 years) • Female • Low mobility or fragility – lower extremity

weakness, and poor grip strength • Functional impairments - limited Activities

of Daily living (ADL) • Poor gait and balance • Low body weight

Risk Factors

• Cognitive impairment or dementia

• Chronic illness

- Parkinson disease, visual difficulties, stroke, hypertension, or urinary incontinence

• Psychoactive medication

- tranquilizers or antidepressants

• Previous falls

• Heavy drinking

Fragile Bone

Osteoporosis, or brittle bones

Fall induced fractures

Normal Bone Osteoporotic Bone

Dempster et al., JBMR 1986

Most Common Fractures in Older Adults

• Spine • Hip • Forearm • Leg • Ankle • Pelvis • Humerus • Hand Scheffer AC, Schuurmans MJ, Van Dijk N, Van Der Hoof T. Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age and Ageing 2008;37:19–24. Bell AJ, Talbot-Stern JK, Hennessy A. Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis. Medical Journal of Australia 2000;173(4):176–7.

Falls and fractures (Colledge, 2007)

Type of fracture Percentage attributed to

falls by older women

Wrist

Proximal Humerus

Hip

Ankle

Pelvis

Face

Tibia / fibula

Face

Vertebral

96

95

92

88

80

77

65

59

<25

HIP FRACTURES

• Hip fracture 2nd leading cause of hospitalization.

• 300,000 annually in US- 90% from falls. • Women sustain 75% of all hip fractures. • People age 85 years or older are 10-15x more

likely to sustain hip fractures than age 60-65 [National Hospital Discharge Summary,2011].

• Age –adjusted incidence is increasing : frail elderly at risk for hip fracture will double; in US by 2040 to 840,000 annually. [Marks et.al.,2002].

Epidemiology and Demographics

• 50% hip fractures patients lose ability to function independently [Gantz et.al.,2007].

• 1 in 3 remain in nursing home for at least a year after their injury [Liebson et.al., 2005].

• 1 out 5 hip fracture patient dies within a year of injury [Farahmand, BY et.al., 2005].

Epidemiology and Demographics

Epidemiology and Demographics

• Fastest growing US population: over 65 (20% by 2025)

• Life expectancy at age 65: 18.9 years; 75=11yrs; 85=7 yrs

• 10% people over age 90 will live to 100 • Increased incidence with increased age

– 4% in men age 64-69, 31% risk in men over age 90

• Women over age 50: 15% lifetime risk hip fracture

Bynum, DL. Care of the hip fracture patient: An evidence-based review. Division of geriatric medicine, University of North Carolina. PP Retrieved November 8, 2013.

Epidemiology and Demographics

• Bad Predictor – Increased mortality

• No significant decline in mortality since 1980s

• 20% mortality over first year

– Decreased functional status • 30% survivors discharged to skilled

nursing facility

Bynum, DL. Care of the hip fracture patient: An evidence-based review. Division of geriatric medicine, University of North Carolina. PP Retrieved November 8, 2013.

Hip Fractures Classified by Location

Model of Key Risk Factors in HIP FRACTURE (Marks et.al., 2003)

MUSCLE WEAKNESS in Hip Fracture Disability

[Marks et.al., 2003]

Typical Hip Fractures Have Changed

At present, we face not only an increasing number of fractures of the hip, but more demanding and complex fractures in older patients than a decade ago

Lakstein, D ; Hendel, D ; Haimovich, Y ; Feldbrin, ZE. (2013). Changes in the pattern of fractures of the hip in patients 60 years of age and older between 2001 and 2010: A radiological review. Bone & Joint Journal, 95 (9), 1250-54. Retrieved November 8, 2013.

LTC Admission and Falls

• People age 75 and older who fall are four to five

times more likely than those age 65 to 74 to be admitted to a long-term care facility for a year or longer.

• One in three adults who lived independently before their hip fracture remains in a nursing home for at least a year after their injury.

Liebson, Toteson, Gabriel, Ransom, and Melton, 2002

SPINAL FRACTURES

BURST FRACTURE WEDGE FRACTURE

Risk Factors for Spinal Fractures

Non-modifiable risk factors

1. Age and female gender 2. Caucasian race 3. Dementia 4. History of falling 5. History of fractures in adulthood 6. History of fractures in a first-degree relative Old JL and Calvert M. (2004). Vertebral compression fractures in the elderly. American Family Physician, 69(1), 111-116.

Risk Factors for Spinal Fractures

Modifiable 1. Abusive situation 2. Alcohol/tobacco use 3. Osteoporosis and/or estrogen deficiency 4. Early menopause 5. Frailty 6. Impaired eyesight 7. Insufficient physical activity 8. Low body weight 9. Deficiency of calcium and/or Vitamin D in diet Old & Calvert, 2004

Etiology of Spinal Fractures in the Elderly

• Weight of the upper body exceeds the ability of the bone of the vertebral body to support the load

• 30% of compression fractures occur when in bed

• Minor trauma (stepping out of the bathtub, vigorous sneeze, picking up a small object, misstep)

• Fall or other trauma

Old & Calvert, 2004

Complications of Spinal Fractures in the Elderly

• Constipation

• Bowel obstruction

• Prolonged inactivity

• DVT

• Increased osteoporosis

• Progressive muscle weakness

• Loss of independence

• Kyphosis and reduced height

• Crowding of internal organs

• Atelectasis and pneumonia

• Prolonged pain

• Low self-esteem

• Emotional and social problems

• Increased nursing home admissions

• Mortality

(Old & Calvert, 2004)

References

• Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall–related injuries in older adults. American Journal of Public Health 1992;82(7):1020–3.

• ASRT Essential Education. (2013). Radiologic Technology, Jan/Feb 2013. American Society of Radiological Technologists.

• Bell AJ, Talbot-Stern JK, Hennessy A. Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis. Medical Journal of Australia 2000;173(4):176–7.

• Bynum, DL. Care of the hip fracture patient: An evidence-based review. Division of geriatric medicine, University of North Carolina. PP Retrieved November 8, 2013.

• Colledge, N. (2007). Falls and Fracture Prevention. Liberton Hospital and Royal Infirmary, Edinburgh. Retrieved November 13, 2013 from

https://www.google.com/search?sourceid=ie7&q=powerpoint+fractures+and+nursing+home+admission&rls=com.microsoft:en-us:IE-

SearchBox&ie=UTF-8&oe=UTF-8&rlz=1I7LENP_en

• Deprey SM, Descriptive analysis of fatal falls of older adults in a Midwestern counting in the year 2005. Journal of Geriatric Physical Therapy 2009;32(2):23–28.

• Farahmand BY, Michaelsson K, Ahlbom A, Ljunghall S, Baron JA. Swedish Hip Fracture Study Group. Survival after Hip Fracture. Osteoporosis International. 2005;16(12):1583-90.

• Kiss, J. (2013). Osteoporotic fractures of the proximal humerus – conservative vs. surgical solutions. St. John’s Hospital, Budapest, Hungary. Powerpoint retrieved November 8, 2013.

• Lakstein, D ; Hendel, D ; Haimovich, Y ; Feldbrin, ZE. (2013). Changes in the pattern of fractures of the hip in patients 60 years of age and older between 2001 and 2010: A radiological review. Bone & Joint Journal, 95 (9), 1250-54. Retrieved November 8, 2013.

• Leibson CL, Toteson ANA, Gabriel SE, Ransom JE, Melton JL III. Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. Journal of the American Geriatrics Society 2002;50:1644–50.

• Marks R, Allegrante JP, MacKenzie CR, Lane JM. Hip fractures among the elderly: causes, consequences and control. Aging Research Reviews. 2003;2:57-93.

• National Hospital Discharge Survey (NHDS), National Center for Health Statistics. Available at: http://205.207.175.93/hdi/ReportFolders/ReportFolders.aspx?IF_ActivePath=P,18 Accessed August 29, 2013

• Old JL and Calvert M. (2004). Vertebral compression fractures in the elderly. American Family Physician, 69(1), 111-116. Retrieved from http://www.aafp.org/afp/2004/0101/p111.html

• Scheffer AC, Schuurmans MJ, Van Dijk N, Van Der Hoof T. Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age and Ageing 2008;37:19–24.

• Sterling DA, O'Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. Journal of Trauma–Injury, Infection and Critical Care 2001;50(1):116–9.