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: 4.57). 09/2008; 56(10):1887-92. DOI: 10.1111/j.1532-5415.2008.01918.x
Source: PubMed


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.

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    • "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). "
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    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.
    Full-text · Article · Jan 2012 · The Tohoku Journal of Experimental Medicine
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    • "The vast majority of hip fractures thus occur in elderly individuals, many of them in residential care where the risk of hip fracture is 2-fold to 11-fold that of individuals living in the general community [4–8]. Within a year of sustaining a hip fracture, an elderly nursing home resident has a 40% risk of death and a 6% to 12% risk of further hip fracture [9, 10] This high incidence of re-fracture is likely related to a very high risk of falls in such individuals: 98% of hip fractures are the result of fall, the proportion of vertebral fractures is lower [11, 12]. The risk of fracture seems to be determined by a balance between bone strength and propensity for falls, which in term are determined by the frailty of the patient [13]. "
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    ABSTRACT: Hip fracture is associated with high morbidity, mortality, and economic burden worldwide. It is also a major risk factor for a subsequent fracture. A literature search on the management of osteoporosis in patients with hip fracture was performed on the Medline database. Only one clinical drug trial was conducted in patients with a recent hip fracture. Further studies that specifically address post-fracture management of hip fracture are needed. The efficacy of anti-osteoporosis medication in older individuals and those at high risk of fall is reviewed in this paper. Adequate nutrition is vital for bone health and to prevent falls, especially in malnourished patients. Protein, calcium, and vitamin D supplementation is associated with increased hip BMD and a reduction in falls. Fall prevention, exercise, and balance training incorporated in a comprehensive rehabilitation program are essential to improve functional disability and survival. Exclusion of secondary causes of osteoporosis and treatment of coexistent medical conditions are also vital. Such a multidisciplinary team approach to the management of hip fracture patients is associated with a better clinical outcome. Although hip fracture is the most serious of all fractures, osteoporosis management should be prioritized to prevent deterioration of health and occurrence of further fracture.
    Preview · Article · Dec 2010 · Osteoporosis International
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    • "Similar results were reported in other studies [15, 16]. In addition, almost all fractures after the initial hip fracture were caused by low-energy traumatic accidents (eg, fall from standing height or less, fall from a chair, or fall out of bed) [12, 13•, 14••, 15, 16]. "
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    ABSTRACT: A prior fracture is a well-documented risk factor for a subsequent fracture and it doubles the risk of subsequent fractures. Few studies have investigated the time that elapses between the initial and subsequent fracture. These studies show that the subsequent fracture risk is not constant, but fluctuates over time. The risk of subsequent vertebral, hip, and nonvertebral non-hip fractures is highest immediately after initial hip, clinical, and radiographic vertebral fractures and nonvertebral fractures and declines afterward, regardless of gender, age, and initial fracture location. These studies indicate the need for early action after an initial fracture with medical interventions that have an effect within a short term to reduce the preventable risks of subsequent fractures.
    Full-text · Article · Sep 2010 · Current Osteoporosis Reports
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