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Abstract title: Risk of Hip Fracture in Disabled Community-Living Older Adults

Author(s):
LC Walter - San Francisco VA Medical Center and University of California, San Francisco
L Lui - University of California, San Francisco
C Eng - University of California, San Francisco, and On Lok Senior Services, San Francisco
KE Covinsky - San Francisco VA Medical Center and University of California, San Francisco

Objectives: To determine the rate of hip fracture and the risk factors associated with hip fractures in disabled elderly persons who choose to live in the community rather than a nursing home.

Methods: We assessed potential risk factors in 5,187 persons who enrolled 1/90-12/97 in 12 nationwide sites of the Program of All-Inclusive Care for the Elderly (PACE), which provides comprehensive care to nursing-home-eligible men and women living in the community (mean age=79, 71% women, 49% white, 47% with dementia). Functional status on enrollment was assessed by each site's nursing staff and included degree of dependence in walking and 5 activities of daily living: bathing, dressing, toileting, transferring and eating. Cognitive status was assessed using a 10-item mental status questionnaire (SPMSQ). Demographics and comorbidities were also recorded on enrollment. The main outcome measure was time to hospitalization for a new hip fracture.

Results: During the follow-up period (1,058 person-years), 238 individuals (4.6%) had a new hip fracture for an incidence rate of 2.2% per person-year. Four independent predictors of hip fracture were identified using Cox proportional hazard analysis: age>=75years (adjusted hazard ratio (HR)=2.0, 95% CI 1.4-2.8); Caucasian race (HR=2.1, 95% CI 1.6-2.8); ability to transfer independently from bed to chair (HR=3.0, 95% CI 1.2-7.2); and SPMSQ errors>=5 (HR=1.6, 95% CI 1.3-2.1). Several risk factors, including sex and history of stroke, were not independently associated with hip fracture after adjustment for the above risk factors. The incidence of hip fracture ranged from 0.5% per person-year among persons with 0-1 independent risk factors, to 4.7% per person-year among those with all four risk factors.

Conclusions: This cohort of disabled community-living older adults showed a high rate of hip fractures (2.2% per person-year), but this is lower than reported for nursing home cohorts (4.4% per person-year). Older age, Caucasian race, ability to transfer, and cognitive impairment were independent predictors of hip fracture in this population.

Impact statement: These four risk factors were able to identify a subgroup of people at particularly high risk for hip fracture (4.7% per person-year) to whom aggressive prevention strategies should be targeted.