Subsequent fracture in nursing home residents with a hip fracture: A competing risks approach

Hebrew SeniorLife, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts 02131, USA.
Journal of the American Geriatrics Society (Impact Factor: 4.22). 09/2008; 56(10):1887-92. DOI: 10.1111/j.1532-5415.2008.01918.x
Source: PubMed

ABSTRACT To determine the incidence and predictors of subsequent fracture in nursing home residents with a hip fracture, accounting for the competing risk of death.
Dynamic cohort study.
Hebrew Rehabilitation Center, a 725-bed, long-term care facility in Boston, Massachusetts.
Long-term care residents with a surgically repaired hip fracture (1999-2006) followed through June 30, 2007, for the occurrence of subsequent fracture at any skeletal site.
Information on age, sex, anatomic location, type of repair, body mass index (BMI), comorbidities, functional status, cognitive status, and medication use were evaluated as potential risk factors for subsequent fracture.
The study included 184 residents with a baseline hip fracture. Thirty-nine residents (7 men, 32 women) experienced a subsequent fracture over a median follow-up of 1.1 years. After the baseline hip fracture, 6% of residents experienced a subsequent fracture within 6 months, 12% within 1 year, and 21% within 5 years. In addition, 23% of residents died within 6 months, 31% within 1 year, and 60% within 5 years. High functional status was associated with a five times greater risk of subsequent fracture (high vs low functional status, hazard ratio=5.10, P<.005). Age, sex, BMI, comorbidities, cognitive status, and medication use were not associated with subsequent fracture.
Hip fractures are a sentinel event in nursing home residents, with a high incidence of subsequent fracture and death occurring within 1 year. Identification of prefracture characteristics and postfracture complications associated with mortality should help guide secondary prevention efforts in nursing home residents.

  • Source
    • "In addition to the aforementioned risk factors, we observed that patients with only a single hip fracture had a higher incidence of comorbid conditions, which limited their daily activity. This decreased their propensity toward a subsequent fracture as the patient was more likely to be stationary, with fewer opportunities for forthcoming falls and fractures (Berry et al. 2008). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Little is known about the effect of a subsequent osteoporotic vertebral compression fracture on the survival rate of patients with a previous hip fracture. In this study, we aimed to compare the survival rates of hip fracture patients with and without subsequent osteoporotic vertebral compression fractures and determine the risk factors associated with subsequent fracture. During 2000-2008, 933 initial hip fracture patients were reviewed and divided into two groups: subsequent fracture group (160 patients) and single hip fracture group (i.e., no subsequent fracture; 773 patients). All information pertaining to their most recent fracture event(s), including mortality causes/rates, were recorded. Differences in mortality rates and hazard ratios (HRs) between the two groups were also analyzed. The 1-year and 1-to-5-year mortality rates were 1.3% and 1.9%, respectively, in the subsequent fracture group, and 4.7% and 1.4%, respectively, in the single hip fracture group, with no significant differences observed. Interestingly, the HR for mortality was significantly higher in the single hip fracture group than in the subsequent fracture group (p < 0.05). The significant risk factors for subsequent fractures were identified as knee osteoarthritis, neurological disease, and an initial hip fracture with intertrochanteric involvement. Our findings indicate that the occurrence of a vertebral compression fracture after an initial hip fracture does not greatly impact patient survival. Conversely, patients presenting with a single hip fracture have a significantly higher mortality-HR, indicating that single hip fracture patients without subsequent fracture should be provided with the same standard of care as patients with subsequent fractures.
    The Tohoku Journal of Experimental Medicine 01/2012; 226(2):129-35. DOI:10.1620/tjem.226.129 · 1.28 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: SummaryThis review article on musculoskeletal rehabilitation after hip fractures summarizes current scientific evidence concerning prevention, treatment and post-fracture surveillance of patients who sustained a low-trauma hip fracture due to osteoporosis. IntroductionWith increasing longevity, hip fractures become more and more a serious burden not only for societies in developed civilization, but also for emerging countries. According to world-wide projections 1.5 million people are affected each year. Although a lot of research has been performed over the last decade, there is still a lack of standardized and evidence-based approaches for prevention, treatment and rehabilitation of this worst complication of osteoporosis. Therefore, the evidence base for this article was synthesized in accordance with SIGN methodology. Databases searched include Medline, Embase, CINAHL and the Cochrane Library between January 1996 and March 2010. The following terms are used: osteoporosis, hip fracture, rehabilitation, falls, muscle strength, nutrition, exercise, balance, sway, and hip protectors. Moreover, reference lists from included studies were checked and author’s names were searched for additional studies. Possibly, the best approach to rehabilitation after hip fracture is a multi-disciplinary team co-ordinating medical, social, educational and vocational measure for training or retraining the individual to the highest possible level of function. In order to prevent thromboembolism fondaparinux should be used for 28days starting 6h after surgery. This should be accompanied by a daily nutritional intake of at least 20-g protein, 1,200mg of elemental calcium and 800IU of vitamin D; whereas in severe vitamin D insufficiencies, recommendations may be certainly higher. After surgical repair of the hip fracture, an anti-resorptive medication should be started. While balance training and performing of Tai Chi has been shown to reduce fall risk and thereby also decrease hip fracture risk, the use of hip protectors is still under evaluation and cannot be generally advocated. KeywordsOsteoporosis–Hip fracture–Rehabilitation–Nutrition–Muscle strength–Exercise–Falls–Hip protectors
    Archives of Osteoporosis 12/2010; 5(1):49-59. DOI:10.1007/s11657-010-0050-8
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVES: Previous fracture prediction models have been based on the assumption of a stable risk of subsequent fractures over time. The aim of the present work was to develop a nomogram for prediction of 5-year and 10-year individualised absolute fracture risks for postmenopausal women taking into account the time relation between fractures. METHODS: A population-based prospective study was performed in 23 general practice centres located in the southern part of The Netherlands. At baseline (1992-1994), 4203 postmenopausal women between 50 and 80 years participated and 2372 of them also participated 10 years later. Baseline measurements included lumbar spine bone mineral density (BMD) and clinical risk factor evaluation. The incidence of fractures was ascertained. Bayesian model averaging and Cox's proportional hazards model were used. RESULTS: After enrolment, 382 (16.1%) women had a clinical fracture. Fracture risk was associated with advancing age (HR 1.09 per SD (5 years); 95% CI 1.01 to 1.17), lumbar spine BMD (HR 1.23 per -1 SD; 95% CI 1.10 to 1.37) and a prior fracture, with HR 3.27 (95% CI 2.50 to 4.30) for a recent prior fracture (</=5 years previously) and HR 1.97 (95% CI 1.43 to 2.71) for a non-recent prior fracture after menopause (>5 years previously). Women with a recent prior fracture had 66% higher risk of an incident fracture than those with a non-recent prior fracture (HR 1.66; 95% CI 1.15 to 2.40). CONCLUSIONS: The nomogram developed can help doctors to inform patients more effectively and thus better manage patient care by providing an individualised fracture risk taking into account the time relationship for fractures.
Show more


Available from