Medico-Social Impact of Fragility Fracture Dr David Dai Consultant Geriatrician Prince of Wales Hospital 24 th January, 2014 2014 Policy Agenda As Hong Kong moves steadily to an ageing society (with the number of elderly people aged 65 and above rising from 1.02 million or 14% of the population in 2012 to a hefty 2.56 million or 30% in 2041), elderly care ranks high on the current-term Government s policy and action agenda. Our objective is to enable our senior citizens to live in dignity and to provide the necessary support for them to promote their sense of belonging, security and worthiness. We will continue to implement a host of measures and initiatives to enhance elderly care on all fronts. We will step up our efforts in promoting active ageing. Our aim is to facilitate the elderly to lead a more fulfilled life in their golden years and harness their wealth of experience, knowledge and expertise through continued learning, volunteer service and participation in social and economic activities. For the frail elderly, we strive to provide quality and cost-effective long-term care services in line with our policy of promoting ageing in place as the core, institutional care as back-up. In this respect, we will strengthen and expand community and home care services whilst at the same time increase and enhance subsidised residential care services. Hong Kong: Age of Ageing Aging of the Aged % of whole population Hong Kong Census & Statistics Department: Translating dementia http://www.censtatd.gov.hk research into practice DCRC/Brodaty 2011 1
The Fragility Fracture Syndrome Old Age Frailty (Reserve) and Vulnerability Osteopenia Sarcopemia Falls Premobid multiple comorbidities Pre-operative medical instability (metabolic, CVS, resp) Hospitalisation syndrome (Delirium, infection, polypharmacy) Post-operative instability (CVS, neurological, metabolic, respiratory, fever) Functional decline Psychosocial issues Post-discharge support Fragility Fracture Syndrome Hip Fracture Mean age= 85 Post discharge period I year Declining Physiological Reserves ( Crit Care Med 2004; 32(suppl): S92-S101) Cardiac Respiratory Renal GI Hepatobiliary Body composition and energy use CNS and pain Immune function Haemopoietic Medical Social Frailty Fracture Staff in LTC 2
Fatigue Frailty, Falls and Fracture ( J Morley JAMDA 2013; 149-151) Resistance (can you walk up one flight?) Aerobic ( can you walk more than a block?) Illness ( > 5) Loss of weight (> 5% in 6 months) Frailty predict increased risk of falls and fractures ( Ost Int 2013, 24: 2397-2403) LASA ( Longitudinal Aging Study Amsterdam) Frailty markers: low body wt low peak expiratory flow impaired cognitive function impaired visual acuity or hearing impairment incontinence low mastery depressive symptoms low physical activity Associated with falls ( > 3 or more falls) and fractures ( > 2 or more fractures ) especially in age > 75 yrs Prevention of falls targeted in this group Effect of Hospitalization Acute illness Mobility Frailty Function Social Activity Incontinence Dementia Gait/Falls Hospitalization Complications: Restraints Medications Functional decline BPSD Bladder Infections Fail Osteopenia Hip Fracture Fear of Falling Hospitalization Institutionalization Death Stroke 3
Excess Mortality ( Bone 2013; 56: 23-29) From 60 yrs, remaining life time risk of hip fracture for men ( 5%), women ( 10%); higher than breast cancer 20% women with hip fracture died within 1 yr In men 37% ( 1.8 fold higher than women) Bone 2013;56:23-29 >85 yrs: a unique subset ( Geri Orth Surg 2011, 2(4): 123-127) Excess mortality within the first 5 years Particularly, the first year is the ideal time for intervention to reduce risk of mortality 30 day and 1 yr mortality significantly higher: >85 yrs: 10% and 30% <85 yrs: 5% and 9% LOS higher: > 85 yrs: 20 days < 85 yrs: 16 days Cognitive impairment higher: > 85 yrs: 34% < 85 yrs: 19% Return to original residence: > 85 yrs: 60% < 85 yrs: 72% 4
Sernbo score predicts survival ( Ann R Coll Surg Engl 2013; 95: 29-33) Geri Orth Surg & Rehab 2011;2(4):123-127 Sernbo score identifies patients at high risk of death in first 30 days Extra early multidisciplinary input on admission Ann R Coll Surg Engl 2013;95:29-33 5
Ortho-geriatric Co-management at PWH since 2003 Expected benefits of acute orthogeriatric care (Curr Anae & Critical Care 2005, 16:2-10) Superior medical care Optimal scheduling of fracture surgery Better communication with patients and their relatives Better communication within the multidisciplinary team Initiation of research, education and audit Reduction in adverse events Earlier initiation of rehabilitation and more effective use of discharge resources 6
Probability of patient survival after hip fracture according to geriatric and medical intervention Ambulatory Status at 3 months Cumulative survival free of patient after hip fracture 1.0 0.8 0.6 0.4 0.2 Log-rank: P < 0.0001 Geriatric Intervention Conventional Care without Medical Consultation Conventional Care with Medical Consultation 0.0 0 50 100 150 200 250 Time, days P value <0.01 Ambulatory Status at 12 months Maintain rehabilitation achievements (Disability & Rehab 2012; 34(4): 304-310) > 50% unable to maintain rehabilitation achievements 1 year post discharge More favourable functional achievements and lower education level more prone to decline Continuous physical training after discharge to preserve function Motivate participation P value <0.01 7
Informal support facilitates social participation and active lifestyle ( Arch Geron & Geri 2013; 56: 457-465) Help with ADL by family members, neighbours, friends Social participation ( social activities, cultural activities, leisure activities) On-line Hip Fracture Resource Center ( Nur Res 2012; 61( 6): 413-422) Nursing Research 2012;61(6):413-422 Nursing Research 2012;61(6):413-422 8
Public perceptions Appendix 1 Patient information leaflet Hip Fractures in the Elderly: Patient Information Introduction The hip is a ball and socket joint, situated at the top end of the thigh (femur) bone. It was estimated that 70,000 people over 60 years of age would suffer a hip fracture (fractured neck of femur) in the UK in 2008. Hip fractures commonly occur in elderly people and are most common in women over the age of 80 years. Hip fractures usually result from a simple fall from a standing position in such patients The scope of the problem Hip fractures can result in significant medical complications. This is because an untreated hip fracture will lead to prolonged bed rest. Many patients are already very frail and have other medical problems. Thus a hip fracture poses a serious upset to the patient as a whole. For many patients with other such medical problems, a hip fracture may signal an event which leads to the end of their lives. Treatment The primary goal of treatment is to get the patient back on their feet again as soon as possible and, therefore, avoid the complications of prolonged bed rest. Surgery is usually the only way to achieve this. The operation will normally either involve fixing the fracture with a plate and screws or some form of hip joint replacement. As with any surgery there are risks to take into account, these include the risk of the anaesthetic, bleeding, infection and blood clots. However, it is clear that in most cases the benefits of surgery far outweigh the risks. Prior to surgery it may be necessary to stabilise and optimise a patient. Rehabilitation Many patients will require at least 2 weeks in hospital. Many patients may not be as confident or as able as they were on their feet prior to this injury. Some patients may require institutional care, e.g. a residential home. Ann R Coll Surg Engl 2011;93:67-70 Fracture type on QOL ( Arch Phys Med Rehabil 2012, 93: 512-519) Quality of life 9
Hip fractures result in the smallest improvement in physical domain and greatest decline in the psychological, social and environmental domains during the first year Need for rehabilitation programmes to consider nonphysical aspects of health Programmes to be modified for elderly women who have suffered fractures at different sites Fig 3. Standard difference scores (s-scores) of HRQOL and GQOL at one- and two-year follow-up, compared with baseline for patients with hip fracture (n = 61) and controls (n = 61) with valid HRQOL and GQOL change-scores BMC musculoskeletal Disorders 2010;11:226 After Aftercare and Rehabilitation ( Crit Rev Physical and Rehab Med 1998; 10(1): 1-13) Long-term outcome adverse factors: Over 80 Lack family involvement Disoriented Assistance in transfers, walking, ADL, bowel incontinent 4 or more of these, permanent institutionisation 10
2 or 3 of these, 72% after rehabilitation can be discharged home Modifiable factors: rehabilitation therapy cognition and mental state mood co-morbidities motivation and cooperativeness social support Better recovery: Large social network Married Cervical hip fracture Interdisciplinary intervention improves QOL (BMC Mus Dis 2010, 11: 225-235) Geriatric consultation Rehabilitation programme ( early post-op and in-home: exercise protocol by nurse once per week in first month; once every 2 weeks in 2 nd and 3 rd month) Discharge planning: geriatric nurse made home visit before discharge and phone calls to remind follow-up visits Fig 3. Changes in Physical function (PF) and regression coefficient (p-value) of intervention effect. Physical function (PF) at different time points and regression coefficients (p-value) for intervention effect on physical function. BMC Musculoskeletal disorders 2010;11:225 11
Residential Care in Hong Kong Fig 4. Changes in Role physical (RP) and regression coefficient (p-value) of intervention effect. Role physical limitations due to physical health problems (RP) at different time points and regression coefficients (p-value) for intervention effect on role physical BMC Musculoskeletal disorders 2010;11:225 Countries Institutionalization rate Hong Kong 6.8% China 1% Tai Wan 2% Japan 3% Singapore 2.3% Australia 5.4% UK 4.2% US 3.9% Canada 4.2% Predictors for old age home placement in HK: (24% discharged to OAH) older age ( 1.6 risk for 10 yrs increase age) dementia low mobility scores low basic and instrumental ADL ( Asian J Gerontol Geriatr 2007; 2: 69-77) 12
Hiu Kwong Fractures in a HK residential home Total no of residents: 979 M/F: 2/3 Level of care: mild ( self ambulatory but frail) 19.5% moderate ( assisted ambulation) 58.2% severe ( chair or bed bound) 22.3 % Mean stay: 32.58 months Lower limb fracture: 38% Stroke in preceding 12 months: 1.43% Hip fracture and residential home Substantial loss of functional independence (33%), ambulation and HRQL. Little recovery after first 3 months and 50% mortality within 12 months. ( JAGS 2012; 60: 1268-73) Risk of hip fracture 1.5 times (female) and 4.3 times ( male) higher than community dwelling; oldest residents, risk in men> women ( J Aging Res 2010) 6-12% another hip fracture ( JAGS 56(10): 1887-1892) NICE on care home patients ( June 2011) 30% of all hip fracture patients Frailer, more functionally dependent and higher prevalence of cognitive impairment Higher mortality esp 30 days (RR1.9); 25% died by 96 days ( ANZ J Surg 2010 (80): 447-450) Pressure sore and pneumonia associated with mortality ( J Geron 2009; 64A( 7): 771-777) More frequent readmissions after discharge within 3 months Early supported discharge with multidisciplinary rehabilitation based in residential facility 13
Current research in LTC sparse about the rehabilitation care ; research needed to determine the most effective rehabilitation interventions following hip fracture for residents of LTC with dementia ( J Geriatr Psy Ther 2013 (36): 39-46) Prevention in LTC The oldest and frailest in LTC are neglected in clinical trials,falls in LTC 50-75% of residents per yr, studies directly targeting this population needed ( JAGS 2010 (58): 738-745) Strongest evidence for reduction of hip fractures in LTC is Vitamin D (Scoping Review PLoS ONE 2010) All nursing home residents routinely supplemented with (at minimun) 2000iu D3 daily ( Mol, Nutr,. Food Res 2010(54): 1072-1076) Delirium Dementia Depression 14
Rehabilitation of the Very Old > 90 yr old:16/18 survived at 1 yr; all needed assistive devise for ambulation; 63% attained independent ambulation; 44% returned home ( Ach Phys Med Rehab 1887; 68: 369-371) >95 yr old: higher mortality, unlikely to recover independence at 30months; 96% required permanent institutionalization ( J Bone and Joint Surgery 2006; 88(8): 1060-1064) Aging in Place and Continuum of Care Social investment and capacity building Multipartite partnership and collaboration Social enterprise Capacity and network building Innovation to drive service delivery Family and district-based approach Research-based planning and assessment Cost 15
Economic Analysis Illustration of the transition possibilities in the Markov model Arch Ostopporos 2013;8:126 Arch Ostopporos 2013;8:126 Arch Ostopporos 2013;8:126 16
Arch Ostopporos 2013;8:126 17