Hip Fractures Increase One-Year Mortality in Older Women

From Medscape Multispeciality, 09/29/2011 Hip fractures are a major public health problem, with more than 300,000 annually reported in the United States. By 2050, 6.3 to 8.2 million hip fractures will occur annually worldwide. Studies and meta-analyses have indicated that mortality rate is increased 1 year after hip fractures in women, but health status is not always taken into account.  A longitudinal prospective cohort study of women 65 years and older examines mortality in the short term (1 year), intermediate term (> 1 to 5 years), and long term (> 5 to 10 years) associated with hip fractures in women. Women who break a hip at age 65 years or older face double the risk of dying within the coming year compared with those without a hip fracture, even if they have an otherwise excellent bill of health, according to an analysis of osteoporotic fractures published online September 26 in the Archives of Internal Medicine. "Our study suggests it is hip fracture, and not just poor health, that puts these women at higher risk of dying," said Teresa Hillier, MD, coauthor of the study and senior investigator at the Kaiser Permanente Center for Health Research in Portland, Oregon, in a written statement. She hypothesized that "hospitalization, surgery and immobility lead to other complications that ultimately result in their death." In addition, age makes an important difference, with fractures occurring between the ages of 65 and 69 years conferring a 5-fold mortality risk within a year of fracture compared with a doubling of risk in the 70- to 79-year-old age category, and a tripling of risk in octogenarians, but only those who are in excellent health. "Women who are younger than 80 years or who are 80 years or older and healthy have the highest risk of dying in the first year compared with women of similar age and health status," concluded lead author Erin LeBlanc, MD, also from the Kaiser Permanente Center for Health Research, and colleagues. "Those who are younger and/or healthier have a low risk of dying from other causes," the authors explain. "Therefore, experiencing a hip fracture may increase their mortality risk.... In contrast, octogenarians generally have a relatively high risk of dying from other causes; therefore, experiencing a hip fracture does not result in an increased risk of death during the next year compared with other women their age, unless they are exceptionally healthy." The study included 5580 women from the Study of Osteoporotic Fractures, aged 65 years or older, who were followed prospectively for a mean of 14.4 years until December 2005. Included in this cohort was a subset of 960 healthy octogenarians.  During the study period, 1116 women had a hip fracture, 192 within the healthy octogenarian subset. Each fracture patient was age-matched with 4 control participants without hip fracture.

The study looked at short-term mortality (≤1 year) after fracture, but also intermediate-term (>1 to ≤5 years) and long-term (>5 to ≤10 years) mortality. The investigators adjusted their results for age, bone mineral density, smoking status, self-reported health status, clinical site, Mini-Mental State Examination scores, the ability to stand from a chair at baseline, and a history of diabetes, hypertension, stroke, or Parkinson's disease. Overall, across age groups, mortality risk was highest in the first year after fracture, with 16.9% of patients with fracture dying compared with 8.4% of control patients (multivariable adjusted odds ratio [OR], 2.3). Although deaths in the control group were evenly spaced across the first year, 52.4% of deaths in the fracture group occurred within 3 months of the injury, and 72.5% occurred within 6 months. When examined according to age and underlying health, women with fractures who were aged 65 to 69 years had a short-term mortality rate of 16.3% compared with 3.7% in control patients (OR, 5.0), and fractures in the 70- to 79-year-old age category were associated with a 16.5% mortality rate compared with 8.9% in control patients (OR, 2.4). Overall, fractures in women aged 80 years or older were not linked to an increased short-term mortality rate (20.3% in those with fracture vs 16.8% in those without; OR, 1.1). However, among the healthy octogenarian subset, there was an increased mortality risk associated with fracture (15.1% vs 7.2%; OR, 2.8). For intermediate and long-term mortality rates after fracture, risk returned to nonfracture levels for women aged 70 years and older, but persisted in women aged 65 to 69 years (17.2% vs 11.3% [OR, 1.9] for years 1 through 5; 12.1% vs 5.9% [OR, 3.2] for years 5 through 10). "This is a wake-up call that the first year after a hip fracture is a critical time for all elderly women, but especially for younger women, ages 65-69, who face a much higher death rate compared to their peers," said Dr. LeBlanc in a written statement. "We need to do more to prevent hip fractures from occurring, and we need to study how best to care for women after fracture to prevent these deaths."