Hip fractures are common, especially if you are old, female and live in Northern Europe and Scandinavia. You might be out doing some shopping or getting up to open the door to a neighbour and, in a moment your life changes. You fall to the ground and are unable to get up. Thus starts weeks, perhaps months of treatment and rehabilitation, but first you have to be admitted to the unfamiliar hospital environment where you will have an operation and be at risk of infections, delirium and isolation. You may die, around 6% do, but even if you survive you may struggle to make it back home.
Hip fractures are fragility fractures. That means they are sustained after a fall from standing height. In the UK around 80000 hip fractures are treated every year and this is predicted to rise. Those experiencing hip fracture now are different, even compared to those with the same condition 20 years ago. They are older. They are increasingly frail with other illnesses like diabetes, heart disease and kidney problems. They are on many, sometimes interacting, medicines. They often live alone.
Hip fractures are not new. Cases have been observed by archaeologists investigating ancient Egypt and Rome. In the case of a skeleton excavated in Eraculum, Italy they were able to conclude that the man had been elderly and that he had lived sometime after this fracture, judging by the extent of healing. Generally though, this fracture meant certain death with the loss of mobility causing susceptibility to problems such as chest infections. Surgery was considered unfeasible. Sir Astley Cooper, an eminent 19th century surgeon advised: ‘treat the patient and let the fracture go’. Fortunately, in the 20th century successful interventions were developed and by the 1940s the famous orthopaedic surgeon, Austen T Moore, in collaboration with Harold Bohlman, had inserted the first metal prosthesis to replace the upper femur.
Today, orthopaedic surgeons repair hip fractures on a daily basis. Even the frailest patient will be considered for surgery so they have the best chance of surviving and to manage the significant pain the break causes. Efforts are being made to make sure that the best treatment is available for these often vulnerable people, wherever they might live.
In Scotland, like other countries, we are trying to make sure that our care is world class. To do that Standards have been developed to cover not only the operation but factors such as the time in the emergency department, the active involvement of the multidisciplinary team (physiotherapists, occupational therapists, geriatricians) and assessment for osteoporosis (to try to prevent further fractures). Compliance with the standards is audited, with recent research showing better outcomes when more standards are met. Areas of good practice and innovative approaches to care are shared across the country.
Our district general hospital serves an area with oldest population in Scotland. We want to make sure our patients survive, but not only that, we want them, as far as possible, to be back to their pre fall level of mobility and function and back at home at 30 days. We want to avoid acute confusion or delirium, which can affect 25-40% of hip fracture patients. We need to be aware of it and take measures to avoid it and screen for it using reliable tests.
Delirium is awful – its increases the chances of dying, it slows recovery, accelerates dementia and can even cause post-traumatic stress disorder. It is incredibly distressing for patients and their loved ones. Some simple measures can help avoid it such as paying attention to fluid intake and providing a supportive environment. Interest groups have grown up around identifying, clarifying and sharing knowledge of the factors that help prevent delirium (www.hospitalelderlifeprogram.org). If delirium develops it needs to be recognised and treated quickly.
We cared for a lady of 90 who lived alone in a rural village, distant from the hospital. She had been crossing the road to the post office, tripped on the kerb, fell and broke her hip. Surgery was straightforward but she was very sleepy the day after. She was settled and uncomplaining so no concerns about her condition were raised. When I went to see her I was immediately concerned, not because I’m an amazing diagnostician but because I knew the lady before the fall. I knew that, despite her 90 years, she was generally bright, alert and totally orientated. She was barely rousable, didn’t recognise me and could not remember where she was. Some rapid checks revealed she was anaemic after the operation and was on some medications that were likely to interact and cause problems in an older person. The medicines were stopped, she had a blood transfusion and the next morning was back to her usual self with no memory of the previous day at all. She went home, with extra support, five days later.
Another lady, a fit and active 78 year old came to our attention rather more quickly. She had tripped and fallen in her garden. Again, surgery was straightforward but 48 hours after she demanded that she be allowed to go home immediately. She was very vocal in her complaints and insistent that she be allowed to go. It transpired she was convinced the nurses were trying to kill her. We persuaded her to stay until some tests were done. The first task was to call her next of kin, a friend who confirmed she was usually the gentlest, least aggressive person one could meet. Then we arranged some routine blood and urine tests. We found she had a urine infection. Although suspicious she agreed to antibiotics and to staying in hospital a further 24 hours. The next day she was transformed. Her paranoia had gone but she was so upset at the bother she felt she had caused as she could remember shouting, complaining and being convinced she was going to be murdered.
For some a hip fracture comes at the end of a long life, often on a background of declining mobility and loss of independence. Elsie was a very frail lady in her late 80s when she tripped getting out of her daughter’s car to go for lunch. She had been managing to live alone with carers twice a day and her devoted daughter helping out with shopping, cleaning and sometime staying overnight. She had heart, lung and kidney problems that her GP was keeping under control. We discussed with her and her daughter the risks of the operation but she understood that the alternative was to die, likely with significant pain. Twenty-four hours after the operation she developed a chest infection that was quickly diagnosed and treated by the ward doctor. She was struggling to drink so we continued to give her fluids by a drip. Her kidneys started to fail and we talked with her and her daughter again about what we should do. Elsie did not want dialysis. She wanted to ‘slip away’. No longer in any pain since the operation, we made sure any medication that might be required were prescribed, that we cared for her skin and mouth and that she had a space where her family could visit. Her daughter stayed with her most of the time from that moment until her death. She made sure Elsie’s grandchildren visited at a time when she could talk with them and say goodbye. She rubbed cream into her mother’s skin. She told her what a great mum she had been. When a place in the palliative care unit was available it was quietly declined –‘we know all the staff here’. Elsie died peacefully with her daughter and son and law at her side in an orthopaedic ward.
Increasingly, people suffering hip fractures are isolated. Irene fell at home and broke her hip after getting up to the bathroom in the night. Unfortunately, she had left her ‘Carecall’ button that would have enabled her to call for help, on the bedside table. In pain and unable to move, she could only pull a blanket over herself for warmth and wait for her carers to arrive in the morning. By the time she was found she was cold and distressed. She had suffered a heart attack. A very elderly lady, she had moved to the area in retirement with her husband. When he had died 10 years before, she had stayed on because of ‘good friends’. They had died. She had no family or friends left. A sensible woman, she had spoken to a solicitor in her home town and arranged for her to be her Power of Attorney. In hospital, aware she may not survive, she asked us to contact the solicitor and let her know the situation. That evening, the solicitor drove the two hours from Irene’s home town to visit. Irene was overjoyed. A few days later, following another heart attack, she died. The solicitor called to make arrangements to pick up the necessary paperwork. She thanked us most sincerely for looking after Irene and we thanked her for the joy she had brought with her visit, for going beyond the call of duty.
Worldwide it is estimated that the incidence of hip fracture will rise from 1.66 million in 1990 to 6.26 million in 2050. In northern Europe most of us will be touched in some way by this injury suffered by some of our most vulnerable elderly. Increasing our knowledge about prevention through avoiding risk factors, improved nutrition, falls avoidance and osteoporosis treatment could help attenuate this. Being aware of the potential complications could help us advocate for friends and relatives too frail to do so for themselves, thereby improving outcomes. Ultimately, as Irene’s solicitor showed, we may all have a role in reducing the suffering caused by this devastating condition.
Living into advanced old age can bring new possibilities but also risks and challenges. Hip fractures were sentinel moments, often harbingers of death. Today they have been transformed into treatable problems, allowing life expectancy and quality of life to be restored. They can even be undertaken for palliative purposes. At the same time we are intrigued by their causation and prevalence. No longer seen only in narrow orthopaedic terms, they have become another vector along which good care can be delivered – restoring wellbeing and continuing to extend the horizon of healthy ageing, even in the face of death.
Fiona Graham is a GP with an interest in the care of the frail elderly, palliative and end of life care. She works in a rural general practice and in ortho-geriatrics and oncology at her local hospital. She is involved in the establishment of a graduate entry medical school for Scotland (ScotGEM)