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Slide 1-

Recovering From Hip Fracture Jay Magaziner, PhD, MSHyg and Nancy Chiles, BS University of Maryland School of Medicine Baltimore, Maryland 2016 Symposium for State and Local Commissions on Aging September 22, 2016
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Acknowledgements The many investigators and staff in the Baltimore Hip Studies Program The patients and hospitals that participated in studies over the past 30 years The National Institute on Aging, which has funded this work on hip fracture recovery for the past 30 years
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Disclosures During the past year, Dr. Magaziner has consulted or served on advisory boards for: American Orthopaedic Association; Ammonett; Novartis; Pluristem; Scholar Rock; Viking Therapeutics
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Overview of Presentation Magnitude of the Problem 30 Years of Evidence from the Baltimore Hip Studies Program: From Observation to Intervention Consequences Recovery Patterns How This Information Informs Intervention Targets
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Magnitude of Problem Estimated 3.9 million hip fractures worldwide annually Three-quarters of hip fractures are in women Despite advances in surgical procedures, post-operative care, and long term rehabilitation, hip fractures rank in the top ten worldwide in terms of disability and functional decline.
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Gullberg B, et al. Osteoporos Int. 1997;7:407–413. Hip Fractures Are Common: Number Projected to Increase
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Assessing the Risk for Hip Fracture1,2 Strength of Bone Fall-Related Trauma Bone Turnover Bone Mass Bone Quality Risk of Fall Neuromuscular Function Environmental Hazards Time Spent at Risk Force of Impact Type of Fall Protective Responses Energy Absorption 1. Kanis JA. Osteoporosis. Blackwell Healthcare Communications Ltd; 1997. 2. Cumming RG, et al. Epidemiol Rev. 1997;19:244–257.
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FALLS PREVALENCE IN OLDER PERSONS Falls (percentage of men and women falling each year) Community 33 percent Institution 50 percent
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THE BALTIMORE HIP STUDIES
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Goals of Baltimore Hip Fracture Studies To identify, develop, and evaluate strategies to optimize recovery from hip fracture.
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The Baltimore Hip Studies (BHS) Over the past 30 years, the BHS have enrolled and followed more than 4,000 hip fracture patients admitted to 25 Baltimore area hospitals. Outcomes studied include mortality, functional recovery, and changes in bone mineral density, muscle mass and composition, bone and muscle strength. Studies have progressed from observational to interventional. BHS Investigators have collaborated on many single and multi-center studies of hip fracture outcomes outside Baltimore
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Consequences of Hip Fracture Selected Finding From Baltimore Hip Studies
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Some Consequences of Hip Fracture Death 18-33% die within 1 year Hospitalization 3-8 days, regional variation Disability and Dependency 15-25% to institution for 1+ years 25-75% do not regain pre-fracture functioning Burden Patients Family Health care systems
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1 –7 –6 –5 –4 –3 –2 –1 0 0 2 4 6 8 10 12 1 Mean Percent Loss From Baseline –7 –6 –5 –4 –3 –2 –1 0 Months Post-Fracture 0 2 4 6 8 10 12 Hip fracture patients Expected in non-hip fracture population Total Hip Femoral Neck Error bars represent standard error of the mean. Expected values based on interpolated data obtained over a 42.3-month period, Study of Osteoporotic Fractures. Magaziner J, et al. Osteoporos Int. 2006;17:971-977. Consequences of Hip Fracture: Increased Hip Bone Loss (BMD) Over 1 Year
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Lean Body Mass 36000 36500 37000 37500 38000 38500 39000 39500 40000 0 60 120 180 240 300 360 Days Post-fracture Average Mass (grams) 3-10 Fox KM, et al. Osteoporos Int. 2000;11:31-35.
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Fat Mass 15500 16000 16500 17000 17500 18000 Average Mass (grams) 0 60 120 180 240 300 360 3-10 Days Post-fracture Fox KM, et al. Osteoporos Int. 2000;11:31-35.
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Percentage of Those Unimpaired Pre-Fracture With Impairment at 12 Months Post-Fracture Lower Extremity Activities of Daily Living Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507.
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Other Functional Consequences of Hip Fracture Loss of Neuromuscular Function (gait/balance) More Difficulties with Instrumental Tasks (Shopping/housework) Increase in Cognitive Deficits (50% in hospital; 25% at 2 months) Increase in Depressive Symptoms (50% in hospital; 25% at 2 months) Changes in Social Function (visiting with others/participating in activities) Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507. Magaziner J, et al. J Gerontol. 1990;45:M101-M107.
Slide 19-

Patterns Of Recovery
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Recovery In Lower Extremity ADLs
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Summary Measures of Functioning Time to Recuperation Following Hip Fracture Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507.
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RECOVERY IN DISABILITY Lower Extremity ADLs Instrumental ADLs Social Activities RECOVERY IN FUNCTIONAL LIMITATIONS Neuromuscular gait/balance Cognitive Affective Strength Hip Fracture Recovery Process RECOVERY FROM IMPAIRMENTS Hip Fracture PATHOLOGY Osteoporsis Sarcopenia Chronic Conditions Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507.
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Interventions and Their Timing
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RECOVERY IN DISABILITY Lower Extremity ADLs Instrumental ADLs Social Activities RECOVERY IN FUNCTIONAL LIMITATIONS Neuromuscular gait/balance Cognitive Affective Strength Hip Fracture Recovery Process RECOVERY FROM IMPAIRMENTS Hip Fracture PATHOLOGY Osteoporsis Sarcopenia Chronic Conditions Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507.
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Recovery Process Possible Treatments Treat Pathology Osteoporosis Bone strengthening medications Sarcopenia Pharmacalogic agents Chronic conditions Stabilize exacerbations, control complications Vitamin D, Calcium, Protein, other nutrition Treat Impairment Hip fracture Surgical management , anesthesia, transfusion Reduce Functional Limitations Neuromuscular Gait training, balance training, strength training Cognitive Medical stabilization, orientation therapy Affective Medication, psychological therapy Minimize Disability ADLs Physical therapy IADLs Occupational therapy Social activity Social engagement strategies Hip Fracture Treatments Suggested By Deficits and Recovery Sequence
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Conclusion
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The Future Multidisciplinary/multi-component interventions have the potential to improve long term outcomes Need to design programs using effective components that target individual patient need, and evaluate their combined effect Packages of interventions need to be tested and translated for use in practice Need strategies for delivering these interventions in a coordinated manner
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Hip fracture is a multi-faceted problem which requires multiple treatments/interventions