Hip fractures among nursing home residents are associated with high mortality rates, functional decline

The frequently poor outcomes of nursing home residents who have a hip fracture were quantified by a new study.

The retrospective cohort study included more than 60,000 Medicare beneficiaries who were living in nursing homes when they were hospitalized for hip fracture between 2005 and 2009. Outcomes were evaluated at 180 days after fracture and included death from any cause, dependence in locomotion, and changes in function on activities of daily living (ADL). Results were published by JAMA Internal Medicine on June 23.

In total, 36.2% of the patients had died by 180 days. Mortality risk was higher among men, as 46% of them had died. Among a healthier subset of patients, those who were not totally dependent in locomotion at baseline, more than half (53.5%) were dead or totally dependent at 180 days, and only about 1 in 5 regained their prefracture level of independence. Overall, function declined substantially after fracture in all ADL domains. The researchers did identify some predictors of death and total dependence, including nonoperative fracture management (relative risk [RR] for combined outcome compared to internal fixation, 1.48; P<0.001) and older age (RR for patients >90 years vs. those ≤75 years, 1.42; P<0.001). The strongest predictor of death and total dependence was very severe cognitive impairment at baseline.

This study confirms and extends prior research showing that survival and functional outcomes are poor in nursing home residents who have a hip fracture, the study authors concluded. The finding of worse outcomes with nonoperative management could result from the sickest patients not undergoing surgery, but it may also suggest that more patients could benefit from surgery, the authors concluded. The other predictors could be used in care planning, and the results should encourage clinicians to counsel patients about their prognoses, goals of care, and options to treat distressing symptoms. Specialized inpatient geriatric fracture programs may also be helpful for nursing home residents.

According to an accompanying commentary, the study highlights the importance of offering palliative care to elderly, vulnerable hip fracture patients. Palliative care should be implemented immediately after the fracture and include “effective communication, care planning and coordination, symptoms management, psychosocial, spiritual and bereavement support, and end-of-life care,” the commentary said. Surgery should also be considered, but its benefits should be balanced with potential risks and patients' life expectancy.