Bone to Pick

Without proper care, hip fractures can drastically increase mortality rates.

Back Longreads Jul 31, 2013 By Jeff Wilser

(istockphoto.com)

(istockphoto.com)

Eighty percent of women say they’d rather be dead than in a nursing home.

December 1st is AIDS day. February 4th is World Cancer Day. Millions of yellow bracelets — worn by everyone from Ashley Olsen to John Kerry — boost awareness for testicular cancer. Michael J. Fox sheds light on Parkinson’s Disease, Katie Couric does the same for colon cancer and Maria Shriver champions the fight against Alzheimer’s.

These are all noble causes. They save lives and better the world. Conspicuously absent from the list, however, is a mundane, unglamorous and misunderstood health issue that can work as a silent assassin: the hip fracture.

“Hip fractures kill,” said orthopaedic trauma specialist Dr. Erika Mitchell at the annual meeting of the Clinical Orthopaedic Society, where she discussed sober new research that links hip fractures to mortality rates. “The 30-day mortality rate after a hip fracture is about 9 percent. It rises to 17 percent if the patient already has an acute medical problem. … Far more people will have a fragility fracture than will have a heart attack, cancer or stroke.”

So in lieu of a splashy celebrity endorsement, here are some grim, unsettling facts:

  • Twenty percent of elderly people who break a hip die within one year.
  • Each year in the U.S., hip fractures send about 300,000 elders to the hospital.  
  • If someone has pneumonia after a hip fracture, the 30-day mortality rate climbs to 43 percent.
  • According to at least one study, the mortality rate after a hip fracture is higher than the mortality rate after breast cancer. 

The risks begin earlier than you might think. A study published in the Archives of Internal Medicine found that a hip fracture, paradoxically, triggers the highest spike of mortality rates in younger seniors. If you’re 65 to 69 and break your hip, your mortality rates increase by a factor of 5, compared to a factor of 2 for those in their seventies. The logic? In other respects, younger people are relatively healthier, so the hip fracture dramatically tips the scales. For women 65 and older, hip fractures double their risk of dying within a year.

“Our study suggests that it is the hip fracture — not just poor health — that puts these women at higher risk of dying,” says the co-author of the research, Dr. Teresa Hillier.

So why the hip?  “Let’s say you’re 30 years old and get in a car accident. Your body has to repair everything. It’s a stress on your system — the adrenal glands are putting out cortisol and epinephrine, and your heart is pumping harder to give blood to all of the tissues that are trying to heal,” says Dr. Harry Khasigian at Sacramento’s Methodist Hospital. He often treats seniors for hip fractures. “But if this trauma happens to a 75 or 80 year old, the heart is weaker. It doesn’t pump as strong as it used to. It can’t do all these extra things the body is asking it to do.”

Then, the kicker: hip fracture surgery, which can be a necessary evil. “Hip fracture is a major trauma, and then you have a second major trauma — surgery. So you have two major insults to a weakened system,” says Dr. Khasigian. This can lead to immobility, blood clots, cardiac problems, urinary track infections, pneumonia and something called pulmonary embolism, the blockage of arteries in the lungs. The hip fracture is a toppled domino that ripples through the body.

Bones aren’t static. Every day, your body creates tiny bits of bone and flushes out the old, just like it does with skin, hair and finger nails. When we’re young and growing, the body creates more bone than it purges. Calcium fuels this growth. As adults, every year we lose some of our precious stock of calcium, which makes our bones more brittle and more likely to crack. This is especially true for women, who, thanks to menopause, will eventually lose 30 percent to 50 percent of their bone density. If unchecked, this can lead to osteoporosis, a bone-thinning disease that’s a leading cause of hip fractures. This is why 80 percent of hip fractures occur in women.

So to avoid a hip fracture, the trick is to avoid osteoporosis by strengthening bones. The steps are simple but important:

  • Consume enough calcium — 1,500 milligrams a day, according to the National Institute of Health. (This varies with your age and other factors, so ask your doctor.)
  • Get tested. People often don’t know that they have osteoporosis until there’s a fracture.
  • Curb the smoking and drinking, which are both risk factors.

As for preventing the fall itself, you can trim the risk. Check for poor vision (a leading cause of accidents amongst the elderly), fall-proof the home (handrails on stairs, nonslip rugs, etc.) and, most of all, exercise.

In a fascinating, decade-long study in Finland, 160 elderly women were split into two groups: 84 women exercised daily, and 76 didn’t. For three years, the exercisers learned balance drills and strengthened their legs. The findings should cheer the hearts of fitness junkies everywhere: Seven years later, the nonexercisers had a total of five hip fractures. The exercisers? Zero. In those same seven years, eight of the nonexercisers passed away (more than 10 percent) and only one of the exercisers died. The researchers noted that, “life-long physical activity was associated with reduced risk of fractures.”

So the lessons we learn as children — stay active, consume calcium — still serve us in our 70s and 80s, and they can, quite literally, mark the difference between life and death.

AFTER THE BREAK

If there’s a fracture, immediate action is key. Surgery. ASAP.

“Orthopaedic studies have shown that treatment of the hip fracture within 48 hours results in a lower rate of mortality and morbidity,” says Dr. Rajiv Rajani, a spokesperson for the American Academy of Orthopaedic Surgeons. “Early stabilization of the fracture leads to improved pain control, along with the ability to mobilize earlier. This leads to fewer bed sores, urinary tract infections and blood clots.”

But here’s where it gets tricky. After the surgery, once the patient is back in the comforts of home, the natural inclination of caregivers is to help the patient rest. We want to nurture. We want to pamper. We want to let them nap and bring them soup.

But rest can be the enemy of recovery. Too much rest can mean immobility, and that can trigger blood clots and a chain reaction of further complications. “Often times, family members want their loved ones to lay in bed after surgery to allow them to recover. However, surgeons recommend physical therapy on the first day after surgery if the patient is stable,” Dr. Rajani says.

Huh? Last week, Aunt Edna walked two miles a day and danced the Foxtrot at a wedding. Now she’s going to a nursing home?!  The prospect can be jarring. According to one survey, 80 percent of women said they’d rather be dead than in a nursing home.

Even though it sounds uncomfortable and might prick the ego, the first few weeks are critical, even for otherwise healthy patients.

“From our perspective, going to a rehab center is much better than doing it at home,” says Dr. Khasigian at Sacramento’s Methodist Hospital. Nursing homes have lifts to assist people out of bed, focused therapy and a staff that can handle the icky stuff. “If you’re a family, it’s really hard to take care of someone who can’t get out of bed on their own, who can’t put full weight on their legs and can’t go to the bathroom by themselves.”

After those first crucial weeks of therapy, the physical therapist will decide when the patient can head home. They need to be able to walk freely, get in and out of bed without help, have a healed incision and go to the bathroom alone. “That’s a big one,” Dr. Khasigian says.

Then what? The answer can be hard for some to swallow. Even if the patient feels spry, she might not be fully out of the hip-fracture woods. “Usually after a hip fracture, it can take a while to get back to 100 percent, even if they feel good,” Dr. Khasigian says, noting that is not surprising when the healing process takes a year or more.

“In my experience, many patients and their families do not realize the seriousness of a hip fracture. Their expectations are often that the bone should simply heal and that they will return to their previous level of activity.” Dr. Rajani says. Assisted living after a hip fracture is often the best option.

But there is some good news. About a year after the hip fracture, mortality rates return to normal. So the hip fracture should be viewed with healthy concern, but not a sense of doom. Eventually it can heal, but it doesn’t happen on its own and it doesn’t happen through rest. Sometimes it can’t even happen at home. But to live a long and healthy life, it must happen thoughtfully and carefully, even without a colored wrist band. 
     
Jeff Wilser is the author of “The Maxims of Manhood.” His work has appeared in print or online in GQ, Esquire, Glamour, mental_floss, and VH1. On Twitter at @jeffwilser.  


Which nursing home is best?

If you are looking for a rehabilitation facility for yourself or for an older person you are caring for, the search may be daunting. But you don’t have to do it in the dark. Carole Herman established the Foundation Aiding the Elderly after her aunt passed away as the result of poor rehabilitative care following a hip fracture 31 years ago. She has since established herself as one of the area’s foremost experts on elder care and says these steps will help you find a facility that is safe and reputable:

Find a rehabilitation center that is conveniently located. To keep a close watch on your elderly family members, it is a good idea to choose a nursing home that is near you so you can have quick access to it. The convenience will limit undue stress and allow you to keep a closer eye on things, Herman says. “You can get there quickly, stop by before work, after work, any time during the day.”

Request a complete facility profile from the State Licensing and Certification Department office that licenses these facilities. You may have to go the extra mile to ensure the facility is doing its job, but the effort is worth the time. According to Herman, California has the most punitive citations in the country. You can look at public records of the facility to see how many complaints have been filed. You can also see which ones were unsubstantiated and see any fines given. Herman says online resources do not always carry all of the data, so getting the information in person is best. Additionally, every nursing home has to post annual certification results. See what they were in violation of.

Watch the drugs. “Know that certain drugs cannot be given without informed consent. And my experience is that a lot of antipsychotics are being given to nursing home patients and rehab patients, too, for behavioral control — without consent,” Herman says. If your family member is taking a mind-altering drug or any other prescriptions, it will behoove you to monitor their administration. Family members can consult pharmacists or the Internet about dangerous drugs side effects and combinations.

Know your rights. Family members have the right to choose their own facilities and visit their family members 24/7.

Take a tour. Look around the facility. If it is dirty or has an odor, it probably is not the best option. Check out the kitchen at mealtime and see what kind of food is being served to the residents, Herman says. “A lot of times, I’ve gone into nursing homes and said, ‘Well that’s mystery meat; it’s mystery food,” Herman says. So be wary of food that might be a discomfort to an elderly individual.

Speak to other family members. Approach visiting family members and ask them about the person they are watching over. What is their experience with the facility? Follow up with any information they share that sounds disconcerting.

— Isabel Ward


 

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