Residential care and risk of proximal femur fracture

Fracture incidence in nursing homes in Japan

We conducted the first study to determine fracture incidence in institutionalized elderly people in East Asia. Fracture incidence was generally higher than in the general population but was not for all fracture types. Specific fracture prevention strategies for institutionalized people are needed. Ethnic differences in fracture incidence are also discussed.

INTRODUCTION

The aim of this study was to determine the incidence of fractures in nursing homes in Japan, where fracture is becoming an increasingly problematic health issue.

METHODS

We conducted a cohort study with a 1-year follow-up. Subjects were 8,905 residents (average age, 84.3 years) in nursing homes. Caregivers assessed activities of daily living levels using Barthel's index, and we collected demographic data of each resident. Fracture diagnosis was based on medical records from the hospitals where patients were admitted.

RESULTS

Incidence of hip fracture was 14.9 per 1,000 person-years for women and 9.7 for men. Incidence of forearm and upper-arm fractures was 1.9 and 5.1 for women and 0.5 and 2.1 for men, respectively. Hip and upper-arm fracture rates were higher than in the general population, but forearm fracture rates were lower. Hazard ratio of fracture incidence in totally dependent to partially dependent or independent subjects was 0.14 (95%CI 0.05-0.33) for hip fracture and 0.34 (95%CI 0.23-0.50) for all fractures.

CONCLUSIONS

Fracture incidence in institutionalized elderly people is generally higher but is not higher for all types of fractures than the general population. In addition, totally dependent persons had a much lower risk of hip fracture.

Hip fracture incidence in nursing home residents and community-dwelling older people, Washington State, 1993-1995

OBJECTIVES

To establish and validate a method of linking data from the Minimum Data Set (MDS) and Medicare hospital claims, to estimate hip fracture incidence rates for Medicare beneficiaries aged 65 and older in Washington State, and to compare the incidence rates of hip fractures in nursing home and non-nursing home residents.

DESIGN

Retrospective analysis of Medicare population-based enrollment, hospital claims, and nursing home administrative data sets.

SETTING

Nursing home and non-nursing home setting.

PARTICIPANTS

Medicare beneficiaries in Washington State residing in the community or in skilled nursing facilities.

MEASUREMENTS

Crude age- and sex-specific and standardized age- and sex-adjusted hip fracture incidence for persons residing and not residing in nursing homes.

RESULTS

From October 1, 1993, through September 30, 1995, 7,812 Medicare beneficiaries aged 65 or older were hospitalized for hip fractures (6,566 fractures for 1,155,234 person-years of exposure in non-nursing home residents and 1,246 fractures for 42,986 person-years of exposure in nursing home residents). The standardized age- and sex-adjusted hip fracture rate of nursing home residents (23.0 per 1,000 person-years) substantially exceeded that of non-nursing home residents (5.7 per 1,000 person-years) (incidence rate ratio = 4.0, 95% confidence interval = 3.7-4.5).

CONCLUSION

The incidence of hip fracture in nursing home residents far exceeds that in noninstitutionalized older people. Linkage of MDS and Medicare hospital claims data is a useful tool for epidemiological surveillance regarding events in nursing homes that are likely to result in hospitalization.

Clinical outcomes and mortality after hip fracture: a 2-year follow-up study

The aim of this study was to evaluate the burden of hip fractures, which occurred in the French region of Picardie, in 1992, among 1103 women and 356 men, whether the fractures occurred at home or in a community (i.e., patients who depended on a collective service). The data are part of the PICAROS study, which was designed to assess prospectively the outcome of patients as judged by clinical, economical, and quality of life factors. Patients and/or proxies were questioned during the 2nd or 3rd week following the fracture, and again at 3, 6, 12, and 24 months after the fracture. The survey was conducted by home interview. Recruitment criteria were: 1) all patients with a hip fracture as defined by the International Classification of Disease (ICD); 2) 20 years of age and over; 3) admitted to one of the 34 surgical units from the region, public and private, and had an operation or not. Patients with metastatic or myelomatous fractures or fractures on prothesis device were not included. For the present analysis, patients under 50 years of age were excluded. Among people aged 50 years and over, 3% of the general population lived in a community; 32% of hip fractures were from a community. Patients in a community, aged 60-69, had 15 times more risk of having a hip fracture than subjects of the same age at home. The excess risk decreased with age and stabilized over 85 years of age at two to threefold. During the 24 month follow-up, 394 women and 173 men died. Among those surviving, 87% were interviewed at 2 years. We analysed seven classes of complications, according to the ICD: (1) pressure sores and blisters; (2) pulmonary infections; (3) urinary infections; (4) surgical complications; (5) orthopedic complications; (6) thrombosis and embolisms; and (7) secondary hip fractures. Patients coming from a community had a higher risk of mortality, pressure sores, surgical complications, and pulmonary and urinary infections. From an economical perspective, the institutionalized population would seem to be a profitable target for the prevention of fractures and their complications.

Influence of age and body mass on the effects of vitamin D on hip fracture risk

The role of vitamin D in the prevention of hip fracture is controversial and protective effects appear to be confined to the institutionalized and elderly population. The aim of this study was to assess the interaction of age and body mass index (BMI) on the effects of vitamin D on the risk of hip fracture in the community. We studied 1634 women with low-energy fractures of the hip aged 50 years or older, and 3532 age-matched controls from 14 centres in six Mediterranean countries (the MEDOS study), with a structured retrospective questionnaire. The use of vitamin D supplements was associated with a modest and non-significant decrease in the risk of hip fracture (RR = 0.74; 95% confidence interval (CI) 0.53-1.03; p = 0.07). The risk reduction was influenced by age and body mass. Women aged above 80 years had a significant decrease in the relative risk of hip fracture (RR = 0.63; 95% CI 0.40-0.98) as did women with a BMI below 20 kg/m2 (RR = 0.45; 95% CI 0.24-0.84). Elderly women were more likely to have a low BMI but the elderly did not appear to benefit from vitamin D where their BMI was 20 kg/m2 or higher. The findings could not be explained by differences in sun exposure or in physical exercise. We conclude that the use of vitamin D for the prevention of hip fracture might usefully be targeted to the frail and elderly.