Identifying risk factors for and preventing hip fractures in elderly patients

AORN Journal, Oct, 1997 by Ellice Mellinger

The incidence of hip fractures worldwide in 1990 was 1.6 million, with a projected incidence in 2050 of 6.26 million.(1) Twenty-five percent of all people 65 to 74 years of age fall each year, and 3% to 5% of these falls result in serious injuries.(2) Each year in the United States, more than 200,000 people sustain hip fractures that require surgery.(3) The role of perioperative nurses, therefore, has expanded to include more patient education and preparation for surgery. For perioperative nurses dealing with elderly patients, this expanded role requires them to increase their knowledge of risk factors for and prevention of hip fractures.

Only 16.7% of patients who sustain hip fractures regain their overall functional mobility one year after surgery.(4) In 1990, life expectancy of patients 65 years of age or older one year after surgery for their hip fractures was seven years. This is compared to an average life expectancy range of 16 to 20 years for a person of 65 years of age or older who has not had a hip fracture. This difference in life expectancy may be a result of poor underlying health status and the acute effects of the fracture.(5)

In the late 1980s, a national strategy for significantly improving Americans' health was developed by the US Public Health Service in conjunction with thousands of health care professionals from many disciplines, as well as consumers.(6) This group of health care professionals set measurable targets for health promotion and disease prevention to be achieved before the year 2000. Their goals included

* decreasing the number of hip fractures in individuals 65 years of age and older and

* decreasing the number of deaths from falls and fall-related injuries.(7) A 1995 review of this initiative reported that the rate of hip fractures had increased in the five years since the goal was established from a baseline of 714 per 100,000 hospitalizations for hip fractures to 841 per 100,000 hospitalizations in 1993. The review, however, found that although the number of hip fractures had increased, the death rate from falls and fall-related injuries had begun to decrease.(8)

RISK FACTORS

A review of the literature identifies many risk factors that may lead to hip fractures in elderly patients. These risk factors include

* age,

* gender (ie, female),

* body mass,

* race (ie, Caucasian),

* history of falls, prior hospitalization within the past 12 months,

* poor nutrition,

* osteoporosis,

* decreased physical activity,

* chronic dehydration,

* impaired neuromuscular condition,

* impaired vision,

* barbiturate and psychotropic medication use,

* gait disorders,

* low bone density,

* low body weight,

* poor self-rated health,

* history of hyperthyroidism, and

* caffeine use.(9)

In addition, smokers have twice the risk for hip fractures as nonsmokers. Inherited characteristics of the femur and bone density also may account for familial predisposition (eg, a Caucasian woman whose mother fractured her hip before the age of 80 is twice as likely to sustain a hip fracture as a woman with no maternal history of hip fractures). Following is a discussion of physiologic, environmental, and psychosocial factors that increase elderly patients' risks for hip fractures. Patients with a combination of these risk factors and decreased bone density are at particularly high risk for hip fractures.(10)

Age. Although reduced bone mass secondary to osteoporosis often causes many types of fractures, hip fractures result in higher mortality and morbidity rates among elderly patients." Any type of postmenopausal fracture in elderly women increases their risk for hip fractures.(12) In the mid-1980s, more than 10 billion dollars were spent in acute hospitalization for osteoporotic fractures.(13) Aging and decreased estrogen levels have been identified as causes of osteoporosis in Caucasian and Asian women with small frames.(14) Elderly women also are at increased risk for osteoporosis because of their low calcium intake and malabsorption of dietary calcium.(15) In both men and women, calcium absorption declines after 60 years of age, with an average calcium loss of 30% to 50% by 90 years of age.(16)

Falls. Ninety percent of all elderly patients hip fractures are the result of falls.(17) In a cyclical pattern, falls may lead to elderly patients fear of falling, and medications and cardiovascular disease may lead to failure of their protective responses to falls.(18) In addition, lower limb dysfunction, visual impairment, and the use of ambulatory aids contribute to elderly patients risks of falling.(19) Environmental factors were identified one third of the time as the cause of elderly patients falls that resulted in hip fractures (ie, 76% of falls occurred indoors in the kitchen, living room, or bedroom).(20)

Nutritional status. More than other patient population groups, elderly patients are likely to suffer from poor nutrition due to financial constraints, physical limitations, loneliness, inadequate nutrition information, and inadequate skills in preparing and purchasing food.(21) Elderly patients who are malnourished often have postoperative complications (eg, low serum albumin, recent myocardial infarction, decompensated congestive heart failure(22)). Malnourishment in elderly patients also can result in poor wound healing and increased lengths of hospital stay. Moderate to severe protein deficiencies in elderly patients who undergo hip surgery lead to more postoperative complications that consume more health care dollars and lower these patients probability of survival.(23) Decreased serum albumin also is associated with increased mortality.