Hip fracture is a major public health problem with significant consequences for the older patients, their families, and the health-care system. In 2003, there were 310,000 hospital admissions for hip fracture in the United States alone. Recent worldwide estimates are in the order of 1.6 million hip fractures annually. By the middle of this century, the number is expected to more than double. As seen in Figure 118-1, hip fracture incidence increases exponentially in both men and women with advancing age. The average age of a patient with hip fracture is 82 years. Although hip fractures are thought to be a condition faced primarily by older white women, approximately 20% of hip fractures occur in men, and, in the United States, 8% occur in nonwhites. Prominent risk factors for hip fracture are osteoporosis and propensity to fall. Underlying these essential conditions for having a hip fracture are the reduced bone strength and quality that are characteristic of osteoporosis and the multiplicity of medical, psychosocial, and environmental factors that lead to falls.
Age-specific incidence rates of hip fracture (per 1000 person-years): the Framingham study. (Samelson et al. Am J Public Health. 2002;92(5):858–862.)
The direct medical and indirect nonreimbursed costs (e.g., unpaid caregiving services and lost wages of patients and caregivers) of hip fracture have been estimated at more than $15 billion annually in the United States. Of those who have a hip fracture, approximately 18% of women and 36% of men are expected to die within the first year of their fracture, with the most dramatic increases in mortality seen within the first few months of a fracture among those who are in the poorest health. Comparison of survival in women with hip fracture to similarly impaired women without fractures indicates that the fracture itself is responsible for nine extra deaths per 100 patients during the first 4 years following the fracture. There also is suggestion from epidemiological data on women that even in those with the fewest medical comorbidities and best functioning at the time of fracture, the mortality attributable to hip fracture continues to increase well beyond the first year post fracture. Causes of death in women and men are similar and approximately four times greater than their nonfracture counterparts for heart disease, three times greater for cerebrovascular disease, and three times greater for chronic obstructive pulmonary disease. Interestingly, one recent study showed that men are far more likely than their nonfracture counterparts to die from infectious causes such as septicemia and pneumonia, in the first 2 years following hip fracture.
The intent of this chapter is to provide information about the medical and psychosocial status of the older patient who presents with a hip fracture and to discuss strategies for care and the role of the geriatrician in providing that care during the hospital stay and for the subsequent year ...