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Hip Fracture in the Elderly and Assisted Care

Last updated: April 4, 2014

Hip fractures in the elderly are critical ailments, with possible life-endangering complications. Surgeries to fix breaks are common and consistently effective, while healing can take an entire year. And once a senior suffers from a broken hip, his or her health can take a downward spiral as the break can trigger other problems and affect the elderly immune system.

Here is a scenario:

When Teresa Lang remembered a last-minute item she needed for her trip to Europe, she jumped up from her couch. She tumbled over a small suitcase on the floor, right into a wall. "The instant I did this, before I hit the wall, I knew what had happened," says the 88-year-old Lang. She had broken her left hip.

Hip fractures in the elderly are common. In fact, for every 10 hip fractures, about nine occur in people over the age of 60. "Hip fractures double with every five-year increase in age [after age 50]," says Sandy B. Ganz, PT, DSc, GCS, the director of rehabilitation at Amsterdam Nursing Home in New York City. By 90 years of age, one in four women and one in eight men will have fractured a hip, according to a study done by the Center for Disease Control and Prevention.

Causes and Risk Factors

Elderly people are at a high risk for falling, the usual traumatic event that leads to hip fractures. "They fall because they lose their coordination. They have difficulty with their eye sight and they have difficulty with their balance, and they become weak," says Dr. Charles A. Peterson, an orthopedic surgeon at Seattle Orthopaedic and Fracture Clinic. "When they fall, they tend to have a higher frequency of fractures due to osteoporosis and weaker bones."

The risk factors for suffering a broken hip are numerous, including:

  • Osteoporosis: This disease causes bones to become weaker, making them more susceptible to fracture. In the U.S., an estimated 10 million individuals already have osteoporosis, and 80% of those affected are women. In this population, hip fractures can occur during simple weight-bearing activities.
  • Gender: Women lose bone density more quickly than men due to a decrease in estrogen levels after menopause begins.
  • Heredity: Small-boned, slender-framed people; Caucasians; and Asians have an increased risk of suffering from osteoporosis.
  • Nutrition: Poor nutrition in childhood increases hip-fracture risk. Eating disorders such as anorexia nervosa and bulimia damage bones.
  • Tobacco and alcohol use: Smoking and drinking too much can lead to bone loss.
  • Medications: Taking four or more medications at a time or taking any psychoactive medications are risk factors for falling.
  • Home environment: Throw rugs and electrical wires are tripping hazards, as are a lack of stair railings and grab bars, unstable furniture, and poor lighting.
  • Medical conditions: The following conditions can increase the risk of hip fractures, either through bone loss or by increasing the risk of falling: endocrine disorders, such as type 1 diabetes; gastrointestinal disorders; rheumatoid disorders; prolonged bed rest or immobility; nervous system disorders such as Parkinson's disease or multiple sclerosis; dementia; and depression.

Signs and Symptoms

Most often, an individual knows right away that she has broken her hip. For example, Lang was unable to stand up and was discovered by her son who happened to stop by that day. Usually severe pain is felt in the hip or groin areas and the person cannot walk. Other symptoms include stiffness, contusions, or inflammation in the hip area; the leg on the broken hip side is shorter or turns outward. If the head of the hip bone is impacted onto the neck of the hip bone, the person might not know he has a broken hip, as this break can be less painful, according to Peterson.

Because hip fractures in the elderly are life-threatening, make sure your loved one heads to a hospital immediately. Surgery to fix the fracture is usually done within 24 hours. The examining doctor can diagnose a broken hip simply from symptoms, but an x-ray or MRI will verify the break and display the fracture type.

Treatment: Surgery for Hip Fractures in the Elderly

There are two main types of hip fractures, and older people almost always undergo surgery to repair these breaks:

Femoral Neck Fracture
The femoral neck is right below the ball (or head) of the ball-and-socket hip joint. Because this type of fracture diminishes and can sometimes stop the flow of blood to the broken part of the bone, surgery is almost always done to correct it. Partial hip replacement, called hemiarthroplasty, replaces the ball and femoral neck with a metal prosthesis, usually made from stainless steel or chrome cobalt alloy. While the patient is under general or spinal anesthesia, the surgeon makes an incision. The broken head is removed, and the surgeon clears out cartilage and damaged bone from the hip socket. The new socket, which includes a ball and stem, is cemented in place. Muscles and tendons are positioned around the prosthesis and the incision is closed.If the patient has arthritis or a previous injury that has damaged the joint and they are physiologically sound, a total hip replacement may be done for a femoral neck fracture.

Intertrochanteric Region Fracture
Just below the femoral neck, this is where the thigh bone juts out. The fracture runs between two bumps called trochanters. While the patient is under general or spinal anesthesia, the surgeon makes an incision on the side of the thigh. The patient's bones are manipulated to correct their position. A large screw called a hip nail is placed along the break and up into the femoral head. This screw is held to a metal plate that is attached to the outside of the thigh using several smaller screws. This plate and screw helps the bones heal, compressing them so they grow together.

A third type of break, called asubtrochanteric fracture, occurs in the thigh bone or femur, and is quite rare. The surgical repair is similar to the plate and screw system used in intertrochanteric fractures, although the recovery period is much longer.

In rare instances, people who have hip fractures do not have surgery. If someone is too sick for surgery to occur, traction or other methods are used to repair the break.

Recovery and Therapy

Although surgeries to repair fractures are straightforward and relatively simple fixes, complications after surgery can be dangerous. Mortality rates in the year following a hip fracture are about 25 percent. Complications include blood clots, infection, and pneumonia. With a partial hip replacement, the patient can also dislocate the prosthesis before it stabilizes. If an individual has fragile bones, the hip nail or screw may pull out of the bone. Post-surgery complications more often lead to death if a patient already suffers from another serious medical condition.

Recovery after hip surgery is a lengthy process. The typical hospital stay lasts four days to a week, but a longer stay isn't unusual. Lang remained in the hospital for about a week, and then moved to a sub-acute rehabilitation center for a month. Now she is at home, receiving assisted care from her family, and two therapists work with her twice a week. After a hospital stay, patients can follow many different routes, depending on insurance, age, and complications. According to Ganz:

  • Some live in acute rehabilitation centers, which offer a minimum of three hours of physical and occupational therapy each day;
  • Some patients live in a skilled nursing facility for sub-acute rehabilitation, which offers a minimum of 30 minutes per day of therapy;
  • Others go straight home and receive in-home assisted care and therapy;
  • Others go home with no home care, but receive therapy as an out-patient in a private practice or hospital.

Up to 25% of community-dwelling seniors who sustain hip fractures remain in an institutional assisted care setting such as a nursing home for at least a year.

Physical and occupational therapists begin to work with recovering patients right at the hospital, helping them begin walking with assistance usually the day after surgery. "Physical therapy intervention for a hip fracture usually consists of muscle re-education, strengthening exercises, balance retraining, bed mobility, and transfer and gait training," says Ganz. "Occupational therapy focuses on the activities of daily living: dressing, grooming, bathing, as well as balance retraining and strengthening exercises."

The amount of therapy a patient receives depends on insurance. "Unfortunately, right about the time therapy typically ends, about four to six months post operatively, is when the patient is first physically and physiologically able to receive more intensive therapy," says Ganz.

While a patient may recover from surgery quickly, there is a difference between healing and recovery. "After recovery, they can continue doing everything on their own to get stronger," says Jill Heitzman, PT, DPT, GCS, FCCWS, a physical therapist at Mary Greely Rehab and Wellness in Ames, Iowa. "When they are actually healed, they are back to doing everything they want to do." Healing, she says, typically takes nine months to a year.

About 25% of people with hip fractures will experience a full recovery and return to a semblance of their post-fall life. However, 50% will need to use a cane or walker, and about 20% of individuals who break their hip will permanently live in a nursing home. Caregivers can help ensure the best outcome by helping their loved ones adhere to their therapy regimens and taking some preventive measures such as fall-proofing their homes.

Prevention

Ideally, one can prevent hip fractures in the elderly in the first place. People who have broken a hip also have a good chance of falling again. You can help by making sure your loved one's home environment is safe, as well as seeing that she stays as healthy as possible.

Homes, rehabilitation centers, and nursing homes all need to be fall-proofed. Ganz includes the following recommendations in a recently published home-hazards guide:

  • Lighting should not be too dim or too direct, and light switches should be accessible.
  • Carpets and rugs should be tacked down.
  • Bathrooms should have a chair for bathing or skid-resistant mats, grab bars should be placed where needed and the toilet seat needs to be tall enough for easy transferring.
  • Chairs need to be stable (without wheels) and have arm rests.
  • Kitchen items that are frequently used should be at waist level or on low shelves, a rubber mat should be placed in front of the sink and non-slip wax should be used on the floor.
  • Stairways need handrails and steps should not be slippery.

There are several other simple suggestions that can help prevent falls and hip fractures. People need to have regular eye-checkups; wear sensible, hard-soled flat shoes; and be mindful of medication's side effects. Individuals can also wear hip padding to minimize the impact of a fall. A doctor can talk with your loved one about how to increase her bone density through taking supplements, including bisphosphonates for osteoporosis sufferers, calcium, vitamin D, or starting estrogen or hormone replacement therapy, says Ganz.

Exercise is imperative for preventing falls. Heitzman recommends that a regimen includes:

  • an aerobic workout that elevates heart rate and increases breathing capacity;
  • a strength-training program that involves lifting against resistance;
  • exercising on different surfaces-such as carpets, stairs, and gravel-to challenge one's balance.

Healing from a hip fracture takes time and patience. Seven weeks after her fall, Lang uses a walker to move around her apartment and the world outside. Before her accident, she occasionally used a cane for outings, saying she found it elegant. Now she looks forward to just using her cane. "They say you'll never be exactly how you were, but you will be a pretty good facsimile of that!" says Lang.

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