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a Department of Epidemiology and Preventive Medicine, University of Maryland, Baltimore
b School of Social Work, University of North Carolina at Chapel Hill
c Managed EDGE/EURO RSCG, New York, New York
d Sinai Rehabilitation Center, Baltimore, Maryland
e Division of Orthopedic Surgery, University of Maryland Medical System, Baltimore
Jay Magaziner, Department of Epidemiology and Preventive Medicine, University of Maryland Medical System, Division of Gerontology, 660 West Redwood Street, Suite 200, Baltimore, MD 21201-1596 E-mail: jmagazin{at}epi.umaryland.edu.
Decision Editor: John E. Morley, MB, BCh
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Abstract |
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Methods. Community-residing hip fracture patients (n = 674) admitted to eight hospitals in Baltimore, Maryland, 1990–1991, were followed prospectively for 2 years from the time of hospitalization. Eight areas of function (i.e., upper and lower extremity physical and instrumental activities of daily living; gait and balance; social, cognitive, and affective function) were measured by personal interview and direct observation during hospitalization at 2, 6, 12, 18, and 24 months. Levels of recovery are described in each area, and time to reach maximal recovery was estimated using Generalized Estimating Equations and longitudinal data.
Results. Most areas of functioning showed progressive lessening of dependence over the first postfracture year, with different levels of recovery and time to maximum levels observed for each area. New dependency in physical and instrumental tasks for those not requiring equipment or human assistance prefracture ranged from as low as 20.3% for putting on pants to as high as 89.9% for climbing five stairs. Recuperation times were specific to area of function, ranging from approximately 4 months for depressive symptoms (3.9 months), upper extremity function (4.3 months), and cognition (4.4 months) to almost a year for lower extremity function (11.2 months).
Conclusions. Functional disability following hip fracture is significant, patterns of recovery differ by area of function, and there appears to be an orderly sequence by which areas of function reach their maximal levels.
MORE than 300,000 persons over age 65 will fracture a hip in the United States during the coming year (1) at an estimated annual cost of over $5 billion (2)(3)(4); by 2040, over 650,000 hip fractures will occur annually in this group (5). Between 18%–33% of older hip fracture patients die within 1 year of their fracture, depending upon the specific population studied (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). Most surviving hip fracture patients experience reduced mobility and lose their ability to function independently. As many as 45% of those who are community dwelling at the time of their fracture are discharged to institutions after hospitalization, and 15%–25% remain institutionalized for a year postfracture (20). Depending upon the population studied and function being assessed, an estimated 25%–75% of those who are independent before their fracture can neither walk independently nor achieve their previous level of independent living within 1 year following their fracture (6)(20)(21)(22)(23).
Research on the functional sequelae of hip fracture has been limited by several factors. Hip fractures may affect many different areas of functioning, including mobility, physical and instrumental task performance, cognition, affect and social functioning; all are important aspects of the quality of life. Most previous studies of the functional sequelae of hip fracture have concentrated on mobility and physical and instrument functioning (20)(21)(24)(25)(26)(27)(28)(29)(30); few have considered affective (22)(23)(31)(32)(33) and social function (19)(22)(32)(34)(35). Information contrasting patterns of recovery in different functional domains is lacking due to the limited number of domains examined in any single study. With few exceptions (19)(27)(30), most studies of postfracture functioning do not follow patients for more than 1 year. Although it appears that maximal recovery in the functions evaluated to date occurs by 6 months following the fracture (20)(21)(22), there is evidence to indicate that recovery continues to at least 1 year in some physical and instrumental functions (21)(22) and beyond that in physical activities of daily living (36). Additional evidence indicates that a subgroup of patients who recover by 6 months subsequently decline (20)(37). Previous studies are limited in other ways as well. With few exceptions (20)(23)(34)(37), previous studies included patients admitted to a single hospital, thereby limiting generalizability; previous studies also relied on self- and proxy reports of functioning and not on measures of performance.
The present study reports on the sequelae of hip fracture in eight areas of functioning using data obtained from community-dwelling hip fracture patients entering eight Baltimore area hospitals, 1990–1991, and followed prospectively for up to 2 years. The objectives of this report are to describe changes in different aspects of functioning following a hip fracture, identify the point at which maximal levels of functioning are reached in each area, and evaluate the sequence of recuperation across multiple functional domains.
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Methods |
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Study personnel trained in medical record abstracting, interviewing, and evaluation of neuromuscular performance obtained information on demographic and medical characteristics of patients from medical records in each of the study hospitals, and then invited patients to enroll in the prospective study. After obtaining informed consent, interviews were conducted during the hospital stay and again at 2, 6, 12, 18, and 24 months postfracture. Interviews were conducted directly with all patients who were able to provide information for themselves [Mini-Mental State Examination (MMSE) score >16] (39); for those unable to provide information, a proxy was interviewed. In most cases, the proxy was a spouse or caregiver of the patient. Previous studies indicate that proxies can provide reliable estimates for areas of function evaluated in this study (40)(41)(42). Interviews were conducted during the hospital stay to obtain information about demographic characteristics and prefracture medical and functional status; cognitive and affective status were evaluated postsurgery. Information about comorbidity and surgical procedure were obtained through medical chart review. Follow-up evaluations were conducted in the patient's place of residence (i.e., home, nursing home, extended care facility) and consisted of interviews about medical and functional status, as well as observation of neuromuscular function.
Of the 804 patients identified at the time of their hospitalization, 674 (83.8%) agreed to provide information during the hospital stay and to be followed prospectively. A comparison of the 674 patients enrolling in the follow-up study with the 130 patients identified but not enrolled revealed that those enrolled were less likely to have had subcapital fractures (45.7% vs 57.4%, p < .05) and arthroplasty surgery (36.4% vs 37.5%, p < .05). No statistically significant differences (p < .05) were detected between the groups on age, gender or race, or comorbidity as measured by the presence of 19 conditions. Of the 674 enrolled patients, 531 (84.3% of 2-month survivors) were interviewed at 2 months, 490 (83.6% of 6-month survivors) at 6 months, 461 (82.5% of 12-month survivors) at 12 months, 405 (74.6% of 18-month survivors) at 18 months, and 389 (74.2% of 24-month survivors) at 24 months.
Measures
Physical activities of daily living (PADLs)..--
PADLs were assessed using questions structured like those on the Functional Status Index (43). Information about 15 tasks was obtained to determine whether patients used no assistance, equipment or human assistance, or if they did not perform the task for health or other reasons during the past week. The compilation of 15 items represents activities requiring specific lower and upper extremity functions. These were divided into two groups: lower extremity physical activities of daily living (LPADLs) and upper extremity physical activites of daily living (UPADLs). LPADLs were measured as a count of the number of activities requiring lower extremity function in which the person was dependent (i.e., used either human or equipment assistance or both, or did not perform the activity due to health problems). The 11 lower extremity activities included were as follows: walking 10 feet; walking 1 block; climbing 5 stairs; getting into a car; getting in or out of bed; rising from an armless chair; putting on pants; putting socks and shoes on both feet; getting in or out of a bath or shower; taking a bath, shower, or sponge bath; and getting on or off the toilet. The LPADL scale ranges from 0 to 11, with higher scores representing greater dependency. In a like manner, disability in UPADLs was measured. The four activities included were putting on a shirt or blouse, buttoning a shirt or blouse, feeding self after food is readied, and grooming (brushing hair, teeth). The UPADL scale ranges from 0 to 4, with higher scores representing greater disability.
Instrumental activities of daily living (IADLs)..-- Information on IADLs was obtained using a modified version of the Older Americans Resources and Services Instrument, or OARS (44), which asks about performance of seven tasks of daily living during the preceding 2 weeks. IADLs were measured as a count of the number of activities in which the person was dependent, (i.e., required human assistance or was completely unable to perform). The seven activities included were as follows: using the telephone, getting to places out of walking distance, shopping for groceries or clothes, preparing meals, housecleaning, handling money, and taking medications. The scale ranges from 0 to 7, with higher scores representing greater disability.
Neuromuscular function..-- Neuromuscular function was represented by summary measures of gait and balance, based on observations of performance of a series of neuromuscular tasks in the patient's place of residence (30)(45). In addition, walking speed and time to rise from a chair were examined separately. If patients were not contacted directly or could not perform tasks, no score was obtained.
Social functioning..-- Social functioning was measured by report of the number of social activities the patient participated in during the 2 weeks prior to interview. The items selected derive from a measure of social functioning developed by House (48) and included the following: going to movies, concerts, plays, or sporting events; going to fairs, museums, or exhibits; attending meetings, appointments, classes, or lectures; going to church or temple services; going on pleasure drives or picnics; playing cards, bingo, and so forth with other people; going to family's or friends' homes for a meal; participating in active sports or swimming; working in the garden or yard, or at a hobby; and doing community or volunteer work. The scale ranges from 0 upwards, with higher scores indicating greater frequency of social contact.
Cognitive functioning..-- Cognitive functioning was assessed using the MMSE (39). This instrument assesses orientation, registration, recall, attention, calculation, and language. Scores range from 0 to 30, with higher scores representing better cognitive status. Scores below 17 indicate severe cognitive impairment; scores between 17 and 24 indicate mild cognitive impairment. To include patients whose mental status could not be evaluated with the MMSE during their hospital stay, cognitive impairment during the acute hospitalization was also considered present if there was a history of dementia or postsurgical confusion.
Affective functioning..-- Depressive symptoms were measured using the Center for Epidemiological Studies–Depression (CES-D) Scale (49), which consists of items that describe behaviors and feelings, such as feeling fearful, lonely, and sad. Patients were asked how often within the past week they behaved or felt this way (rarely, sometimes, occasionally, most of the time). This scale ranges from 0 to 60, with higher scores indicating more depressive symptomatology. Patients with scores greater than 16 were considered to have depressive symptomatology.
Analysis
To identify the point at which the maximal level of recuperation had occurred for each aspect of function, longitudinal data were analyzed using the system of Generalized Estimating Equations (GEEs) developed by Liang and Zeger (50). The fixed effect of time was modeled as Ln (Y) = a + b(1/t), where Ln (Y) is the natural logarithm of the given outcome variable (or the odds of that outcome for dichotomous variables), and t is time measured in months. This model enabled the use of a straight line equation in which the intercept was indicative of the eventual recuperation level. The recuperation described by the equation is an exponential curve that approaches the recuperation level asymptotically with increasing time. To test the adequacy of the GEE modeling strategy, the observed proportions of dependent patients and the proportions predicted by the GEE modeling were compared. This model fit the actual recuperation trajectory very well (see Fig. 1). Because the recuperation level predicted by the curve could not (theoretically) be reached in a finite time span, the estimated recuperation time was defined as occurring at that point in time where the instantaneous slope of the curve became less than 1% of 1 standard deviation of the outcome measure. The estimated recuperation level was determined as the antilog of the intercept. In fitting the GEE models, an identity link function was used for continuous variables and a logit link function for dichotomous dependent variables; an exchangeable covariance matrix was specified in both.
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Results |
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Postfracture Dependency Levels
The degree of prefracture and subsequent disability in specific physical and instrumental ADLs is summarized in Table 2 . Prefracture disability levels ranged from as low as 11.8% (putting on pants) to as high as 64.9% (doing housework). New dependency at 12 months postfracture, for those who required no assistance prefracture, ranged from as low as 20.3% for putting on pants to as high as 89.9% for the task of climbing 5 stairs. Similar levels of new impairment were observed among survivors at 24 months. Greater than 50% of previously nondependent patients were dependent in 5 of 11 lower extremity tasks and 2 of 7 instrumental tasks 1 year after the fracture.
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Fig. 3 shows postfracture recuperation times for separate areas of functioning as generated by the longitudinal analyses using GEE modeling, displayed in the order in which recovery occurs. Summary measures (scales) are presented separately from individual items that are components of those summary scales. Recuperation times were specific to area of functioning, ranging from approximately 4 months for depressive symptoms (3.9 months), UPADLs (4.3 months), and cognitive status (4.4 months) to almost 1 year for performance of LPADLs (11.2 months). Considering individual tasks, recuperation times ranged from approximately 10 months for the two neuromuscular performance tasks, chair rise speed (9.9 months) and walking speed (10.8 months), to slightly over 14 months for the ability to walk 10 feet without assistance (14.1 months).
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Discussion |
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The extent of new disability in ADLs also is task specific. Among those not relying on other people or equipment for assistance in physical activities involving lower extremities prior to their fracture, between 20% and 90% required this type of assistance (or did not perform the task due to their health) for as much as 1 year postfracture, depending on the task evaluated. Similarly, between 22% and 62% of patients experienced new postfracture dependency in instrumental tasks using this definition. Previous studies, although limited in some important ways (i.e., small samples of patients, admissions to a small number of hospitals, evaluation of a limited number of functional areas, relatively short follow-up periods), also reported increased levels of disability in physical and instrumental (20)(21)(24)(25)(26)(27)(28)(29)(30), cognitive, and affective (22)(23)(31)(32)(33) areas of function, and similar (although not identical) patterns of recovery following a fracture (20)(21)(22)(31)(33). With the exception of previous reports from this cohort (30)(45)(51)(52), we are not aware of other studies that have evaluated gait and balance with performance-based measures, which provide additional information about the recovery process.
The Recovery Process
Study data suggest a sequence by which functional areas recover, with affective function, cognition, balance, and gait reaching their maximal levels before social, instrumental, and lower extremity physical function. This pattern parallels the process of functional decline described by the World Health Organization's International Classification of Impairments, Disability, and Handicaps, or ICIDH (53)(54), and elaborated by Nagi (55) and by Verbrugge and Jette (56), who refer to the process of decline as the disablement process. Using the terminology of functional limitations and disability described by Nagi and by Verbrugge and Jette, these models of loss articulate a process of decline, which begins with an underlying pathology or disease that produces impairment characterized by dysfunction and structural abnormalities in specific body systems. Impairment then leads to functional limitations or restrictions in basic physical and mental actions that ultimately result in disability or inability to perform activities of daily life (see Fig. 4).
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This recovery process may be superimposed on disabling processes already progressing at the time of the fracture, which may explain why a secondary loss occurs in some areas of functioning after reaching their peak (e.g., LPADLs), an observation that also can be made from information presented elsewhere (20)(22). Consistent with this, one recent report provides evidence of continued mortality in some hip fracture patients up until 4 years postfracture (61). Here, it is possible that the fracture alters other disabling processes in a way that has a detrimental outcome several years after recuperation from the fracture itself has peaked. Further study is needed to chart these and other losses and to develop strategies for understanding the role of hip fracture in the larger disablement process.
Social function appears to recover to a level beyond that of prefracture, and IADLs have additional improvement beyond 18 months (see Fig. 2 and Fig. 2). Social function may increase as patients engage in different (and possibly more restrictive) social activities as substitutes for activities they engaged in before their fracture. Social function also may increase as a result of family and friends initiating more contact and caregiving activities, which is consistent with results from other studies showing that acute illness and hospitalization lead to mobilization of social and emotional support for many patients (35)(62). The late improvement in IADLs is consistent with some longitudinal observations of IADLs in which IADL function improves in some subjects, most notably in those who are at the highest levels initially (63)(64). Following a hip fracture, this apparent improvement may reflect willingness on the part of patients to carry out tasks more independently and recognition by caregivers that this is possible. It also is possible that the healthiest individuals have survived to 18 months, and this is the group that continues to improve.
The design of the present study provides new opportunities to examine the recovery process in greater detail. Multiple areas of function were examined simultaneously in the same cohort of patients so that function-specific patterns could be evaluated; patients were followed for 2 years, which permitted evaluation of most recovery and identification of an initial recovery plateau for each functional area, and a new method for modeling the plateau and recovery level was applied. In addition, sequential admissions to eight facilities were followed, which improves generalizability over studies of patient series in a single hospital.
Among the study's limitations are that subjects came from only eight Baltimore hospitals. Although demographically similar to hip fracture patients treated in other hospitals (38), caution is required when generalizing beyond this group. Second, the least healthy patients dropped out earlier, and although the analytic methods account for missing information, the potential for bias from healthier survivors needs to be considered. Last, lack of a comparison group restricts the ability to determine how much of the loss in function is attributable to the hip fracture and how much other disabling processes affect the peak level and recovery time. Additional studies with similarly impaired persons who do not fracture, serving as comparisons, are required to address this limitation. It also is noteworthy that the present study relied on an inclusive definition of dependency that was based on the use of assistive devices, human assistance, or nonperformance for a health reason. Alternative definitions permitting the use of equipment to be viewed as independent, for example, would yield lower estimates of postfracture disability.
Despite these limitations and caveats, the present study provides new information on differential levels and patterns of recovery in several important areas of function and has identified a recovery sequence that parallels the process by which function is lost. Consideration of this sequence for hip fracture, and possibly other suddenly disabling conditions, in older persons may provide valuable clues for designing interventions and developing postfracture management and rehabilitation pathways that extend beyond the acute and immediate postacute care period.
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Acknowledgments |
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Received January 21, 2000
Accepted March 23, 2000
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