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Long-term Care

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Unsteadiness and falls often lead to hip fracture and subsequent functional decline in the elderly

Weakened bones, gait imbalance, and use of multiple medications predispose many elderly people to unsteadiness, falls, and hip fracture. These individuals often end up in the hospital to undergo total hip replacement surgery, and many decline in functioning while in the hospital. Three recent studies on these issues that were supported in part by the Agency for Healthcare Research and Quality are described here.

Mahomed, N.N., Barrett, J.A., Katz, J.N., and others (2003, January). "Rates and outcomes of primary and revision total hip replacement in the United States Medicare population." (AHRQ grant HS09775). Journal of Bone and Joint Surgery 85A, pp. 27-32.

These investigators used 1995 and 1996 Medicare claims data to identify 61,568 patients who had total hip replacement for a reason other than a fracture and those who had revision total hip replacement (13,483 patients). They examined the association between patient characteristics and surgical rates with rate of occurrence of five complications within 90 days of surgery. They adjusted for hospital and surgeon volume, which have been shown to affect patient surgical outcomes.

The rates of primary total hip replacement were three to six times higher than the rates of revision total hip replacement. The rates of both primary and revision total hip replacement increased with age until the age of 75 to 79 years and then declined. Rates were higher for women, whites, and individuals with higher income than for men, blacks, and those with lower income. The overall rates of adverse outcomes were relatively low, but except for pulmonary embolism, they were at least twice as common after revision than after primary total hip replacement.

Ninety-day postoperative complication rates after primary total hip replacement versus revision surgery were 1 vs. 2.6 percent for mortality, 0.9 vs. 0.8 percent for pulmonary embolus, 0.2 vs. 0.95 percent for wound infection, 4.6 vs. 10 percent for hospital readmission, and 3.1 vs. 8.4 percent for hip dislocation. Elderly people who were older, male, black, or low-income, and those who had other medical conditions were at greater risk than other elderly patients of having adverse outcomes.

Morrison, R.S., Magaziner, J., Gilbert, M., and others (2003). "Relationship between pain and opioid analgesics on the development of delirium following hip fracture." (AHRQ grant HS09459). Journal of Gerontology 58A, pp. 76-81.

From 13 to 61 percent of hip fracture patients develop delirium which, in turn, slows their recovery rate and reduces functioning after surgery. Undertreated pain and inadequate analgesia appear to be risk factors for delirium in frail older adults, concludes this study. The researchers found that avoiding opioids or using very low doses of opioids increased the risk of delirium among elderly hip fracture patients. Cognitively intact patients with undertreated pain were nine times more likely to develop delirium than patients whose pain was adequately treated.

A major barrier to the treatment of pain in older adults has been the fear that opioids cause delirium. But this study found that, with the exception of meperidine, opioids did not precipitate delirium in patients with acute pain. Patients at risk for developing delirium can be identified at hospital admission using a few risk factors, such as elevated blood pressure or congestive heart failure, note the researchers. They studied 542 patients from four hospitals with hip fracture and without delirium; 16 percent of the patients became delirious.

Lindenberger, E.C., Landefeld, C.S., Sands, L.P., and others (2003). "Unsteadiness reported by older hospitalized patients predicts functional decline." (AHRQ grant K02 HS00006). Journal of the American Geriatrics Society 51, pp. 621-626.

Unsteadiness, a common complaint among older men and women with dizziness, has been associated with increased falls and restricted activity. Asking elderly patients a simple question about their steadiness when they are admitted to the hospital can identify those who are more likely to decline in their ability to carry out activities of daily living (ADLs), such as bathing and dressing, while in the hospital, according to this study. Targeting these at-risk patients early during hospitalization could lead to interventions aimed at improving functional outcomes, suggest the researchers. They studied 1,557 elderly hospitalized medical patients at two hospitals.

The researchers asked the patients to report their steadiness walking and whether they could independently perform each of five basic ADLS at two points in time—at baseline (2 weeks prior to admission) and at admission—to determine decline in ADL function prior to admission. Overall, 25 percent of patients were very unsteady at admission; 22 percent of very unsteady patients declined in ADL functioning during hospitalization compared with 17 percent, 18 percent, and 10 percent for slightly unsteady, slightly steady, and very steady patients, respectively.

After adjusting for other factors such as age and coexisting illness, unsteadiness remained significantly associated with ADL decline. Those who were very unsteady had 2.6 times the likelihood of functional decline during their hospital stay than the very steady. Also, 44 percent of very unsteady patients failed to recover preadmission functioning compared with 35 percent, 36 percent, and 33 percent for each successively higher level of steadiness, respectively.

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