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Habitus and hip fracture revisited: skeletal size, strength and cognition rather than thinness?

Age and Ageing, Nov, 1995 by N. Bean, K.M. Bennett, A.B. Lehmann

Summary

In a prospective study, 50 consecutive women with fractured hips were compared for body mass, skeletal size, handgrip strength and the 12-point information/orientation CAPE score with 50 age-matched women who had never broken their hips. Women were excluded from both groups if they lived in institutions or were severely disoriented.

Although weight and skeletal size were significantly lower in the patients than in the controls, weights when corrected for skeletal size were not significantly different. Handgrip was significantly lower in the cases than in the controls. Both handgrip strength and CAPE score were significant correlates of hip fracture in multiple regression analysis.

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After exclusion of heavily dependent patients, hip fracture may be associated with reduced muscle strength rather than reduced body mass or fat.

Introduction

Past studies have reported associations between thinness, dementia and fractured femur [1-6]. The directness and nature of these, associations however remain unclear and controversial. In people with dementia there are contradictory findings of reduced calcium absorption, but bone density is not reduced [7, 8]. There have been several studies of thinness in dementia describing different mechanisms: inadequate feeding time [9]; reduced absorption [6-8]; and conflicting reports about the role of metabolism [10, 11]. The findings relating thinness to hip fracture have not been challenged hitherto with data and several mechanisms have been proposed including susceptibility to cold [2, 12] and reduced oestrogen production [4, 13].

In Nottingham, 50 unselected consecutive women admitted with fractured hip were compared for body mass, skeletal size and handgrip strength with a representative randomly-selected age-matched control group of women who had never broken their hips. Subjects who were very dependent (defined here as living in institutional care or having severe dementia) were excluded for the purposes of this investigation. The present study aimed to reassess the role of body mass, skeletal size and handgrip strength in the osteoporotic syndrome at the point of hip fracture.

Method

Hip fracture patients: All hip fracture patients in Nottingham go to the only local casualty department. Consecutive patients with trochanteric or subcapital fracture admitted between December 1990 and June 1991 were interviewed and measured by one observer (N.B.) and all measurements apart from weight were carried out within 72 hours of admission. This formed part of a prospective study of nutritional supplementation. Ethical permission was obtained from the Hospital Ethical Committee and patients'consent was sought. In the parent study 86% of the patients had complete data sets [reasons for exclusion included refusal, severe disorientation (a CAPE score of <6/12) and previous hip fracture]. For the present study, 50 patients living at home and not in institutions were randomly chosen. The average length of stay of these patients on the acute orthopaedic ward was 27.9 days (SD 20.1, range 7-99). None of these patients died during admission: 34 returned home, six went to residential homes and ten went to rehabilitation wards (of these, four then went to nursing homes and six to their own homes).

Control group: The control group was drawn from female respondents who participated in the first survey of the Nottingham Longitudinal Study of Activity and Ageing (NLSAA) in 1985. The NLSAA was set up in 1983 to assess the role of lifestyle and customary physical activity in promoting and maintaining psychological well-being in later life. The first population survey was conducted between May and September 1985 during which time 1042 people randomly sampled from Family Practitioner Committee lists, and demographically representative of the British elderly population were interviewed in their homes. The interview questionnaire contained a total of 318 items and covered aspects of health, lifestyle,demographic and socioeconomic status. The details of this study and the subjects have been previously described [14-16]. Ethical approval was obtained from the University of Nottingham Medical School Ethical Committee and respondents who consented were included. Subjects with CAPE information/orientation scores <7/12 had either proxy interviews or their interviews discontinued.

For the present study, 50 cases of this sample were randomly selected and age-matched ([+ or -]3 years) with a respondent from the hip fracture study. Medical records were checked and only those who did not have a history of fractured hip were included. The mean age of the hip-fracture subjects was 79.5 (SD 8.4), and the mean age of the control group was 79.6 (SD 7.7). There was no significant difference between the two groups for age (t = -0.19, df = 98, p < 0.846).

Measurements: Body mass was measured in the fractured-hip patients as soon as possible after hip fixation and subsequent radiography, approximately 48 hours after operation, wearing only nightclothes and without footwear. Operations are usually performed 36-72 hours after admission. The scales used were sitting scales (Avery 3307ABW, weighing up to 120 kg), calibrated and checked regularly by weighing known weights. The controls were weighed similarly without shoes in light indoor clothing, standing on bathroom scales (Krups, Ireland) calibrated and checked regularly against Roman arm scales (Avery 3306 ABV) by duplicate weighing of at least two individuals of different sizes (precise and accurate to [+ or -]O.5 kg up to 150 kg) as previously described [15].

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Habitus and hip fracture revisited: skeletal size, strength and cognition rather than thinness?

Age and Ageing, Nov, 1995 by N. Bean, K.M. Bennett, A.B. Lehmann

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