TY - JOUR
AU - Siu, Albert L.
AB - Abstract Hip fracture is a potentially devastating condition for older adults. Hip fracture leads to pain and immobilization with complications ranging from delirium to functional loss and death. Although a mainstay of treatment is orthopedic repair, a multidisciplinary comanagement approach, including medical specialists and rehabilitation, may maximize patient recovery. Using the case of Mr W, an older man who sustained a fall and hip fracture, we present evidence-based components of care both in the hospital and outpatient settings. Preoperatively, clinicians should correct medical abnormalities and consider the appropriateness, timing, and type of surgical repair in the context of the patient's life expectancy and goals of care. Perioperative care should include prophylaxis with antibiotics, chemoprophylaxis for venous thromboembolism, and correction of major clinical abnormalities prior to surgery. Pain control, delirium, and pressure ulcer prevention are important inpatient care elements. Multidisciplinary models incorporating these care elements can decrease complications during inpatient stay. Rehabilitation strategies should be tailored to patient needs; early mobilization followed by rehabilitation exercises in institutional, home, and group settings should be considered to maximize restoration of locomotive abilities. Attention to care transitions is necessary and treatment for osteoporosis should be considered. The road to recovery for hip fracture patients is long and most patients may not regain their prefracture functional status. Understanding and anticipating issues that may arise in the older patient with hip fracture, while delivering evidence-based care components, is necessary to maximize patient recovery. The patient's story Mr W, an 89-year-old veteran, arrived in the emergency department after falling. He had a history of congestive heart failure, chronic kidney disease, obstructive sleep apnea, asthma, gastroesophageal reflux disease, benign prostatic hyperplasia with urinary incontinence, sensorineural hearing loss, depression, and mild cognitive impairment. He also had a vitamin D deficiency and chronic low back pain from lumbar spinal stenosis, despite a laminectomy. Prior to his hip fracture, he ambulated with a 4-wheel walker and had no history of falls. At the occurrence of the hip fracture, Mr W was standing—he twisted suddenly and subsequently lost his balance. He fell onto a hard floor, landing on his left hip and was brought to the hospital by his family. His medications at that time included furosemide, bupropion, citalopram, trazodone, finasteride, terazosin, oxybutynin, albuterol inhaler, loratidine, omeprazole, vitamin D, calcium, senna, acetaminophen, and acidophilus. Prior to the hip fracture, Dr H, his geriatrician, tried on several occasions to reduce the number of medications, but Mr W resisted. On admission, a radiograph of his left hip revealed a minimally displaced femoral neck fracture. The next morning, following medical optimization, Mr W underwent a pinning, in situ while under spinal anesthesia, with 4 screws placed under fluoroscopic guidance. On postoperative day 1, he had escalating pain in his left hip and was administered morphine intravenously and oxycodone orally. Over the next few hours, he became delirious and was transferred to the intensive care unit for bradycardia and hypotension. Mr W continued to have a fluctuating level of alertness for several days. By postoperative day 4, he was able to participate in physical therapy. On day 6, he was discharged to a skilled nursing facility for continued therapy. One month later, he returned home and received several weeks of in-home occupational and physical therapy, twice weekly. Because he still was not fully weight bearing at the conclusion of home rehabilitation, he received another 2 months of outpatient physical therapy. Approximately 4 months after the hip fracture, Mr W developed severe pain over his left greater trochanter. He was seen the following day in the orthopedics clinic, was diagnosed with trochanteric bursitis, and treated with an injection of triamcinolone into the bursa. Afterwards, his pain quickly abated. Six months following the hip fracture, Mr W was walking well with his 4-wheel walker and had minimal hip pain. He regularly rode a stationary bicycle for exercise. He continued taking oral calcium and vitamin D but was not given zoledronic acid due to renal insufficiency. Dr H felt that he had regained the level of mobility experienced prior to his hip fracture and that his major problems were his chronic diseases. Throughout his course of treatment, Dr H was in close contact with Mr W and his family through hospital visits, weekly phone calls and e-mail messages, and close outpatient follow-up. A Care of the Aging Patient series editor interviewed Mr W, his wife Mrs W, and Dr H, in the spring of 2011. Perspectives Mr W: I don't know if I’ll ever be [back to my full strength], but I’m pretty good. . . . It took time to do that. Mrs W: It's very important to have follow-up come to the home [giving him exercises]. Dr H: He is a very determined person. He has a very good social support system. Overview In many ways, hip fracture is a prototypical geriatric illness. Older adults are most commonly affected; patients with hip fracture often have multiple comorbidities and geriatric problems. Because a fall, which is a geriatric syndrome, often precipitates hip fracture, it shares many risk factors with other geriatric syndromes. Treatment course after hip fracture is prolonged and recovery is variable and requires extensive support from multiple disciplines. Because of the patient population affected by hip fracture and its effect on mobility and function, understanding geriatric principles and anticipating issues in the aging patient can further enhance care. In this article, we will discuss care components applicable to the patient with hip fracture based on lessons learned from studies of patients with hip fracture and also aging patients. While drawing on the experience of Mr W, we present these essential care elements by time and setting as the patient with hip fracture transitions through inpatient acute care (including preoperative, perioperative, and postoperative periods), rehabilitation, and recovery. Methods We searched MEDLINE and the Cochrane database for peer-reviewed English-language articles from 1980 to April 2012 to identify effective hip fracture treatment elements under the subject heading of hip fracture, limiting types of study to clinical trials, randomized controlled trials (RCTs), comparative studies, or systematic reviews. We also performed specific searches on effective inpatient care models for hip fracture patients; and effective rehabilitation strategies to restore mobility. We synthesized the database on the time and setting of treatment elements pertaining to hip fracture treatment, and our recommendations are based on the evidence and clinical experience caring for patients with hip fracture. Based on authors' reviews, levels of evidence include classes 1A (for 2 or more RCTs), 1B (for 1 RCT or meta-analysis), 2 (for nonrandomized trials), 3 (for cohort studies), and 4 (for expert opinion).1,2 Details of the specific searches are included in the eAppendix. Additional resource websites are also available (see “Resources” in Author Information section below). Epidemiology Quiz Ref IDMore than 1.6 million older adults worldwide sustain hip fractures annually, with 320 000 of these in the United States; numbers are expected to increase as the population ages.3,4 Three-quarters of all hip fractures occur in women.4 Hip fracture risk increases as people age—adults aged 85 years and older are more than 10 times more likely to sustain hip fracture than are those aged 65 to 69 years.5 Osteoporosis and falls are major risk factors for hip fracture; consequently, risk factors for falls, such as polypharmacy, use of assistive devices, and cognitive impairment, also increase the risk of hip fracture.6 Mr W, as is common with the typical hip fracture patient, had multiple risk factors. Older adults who experience hip fractures often have poor outcomes, including functional decline, institutionalization, and death.Quiz Ref ID Among older adults who sustain hip fractures, approximately 13.5% die within 6 months and 24% within 1 year.7,8 The increase in mortality risk persists beyond 10 years after hip fracture, with higher excess mortality risk among men than women.9 Among those who survive 6 months, only 50% recover their prefracture ability to perform activities of daily living (ADLs) and only 25% recover their ability to perform instrumental ADLs.10 Following a hip fracture, older adults are 5 times more likely than age-matched controls without hip fracture to be institutionalized at 1 year.11 Mr W belongs to the minority of hip fracture patients who had an excellent outcome with good recovery of function. Given the potential for devastating consequences of hip fracture, it is important that patients with hip fracture receive care that integrates effective elements of care throughout the course toward recovery. Inpatient care Patients with hip fracture are often heterogeneous in their baseline functional and comorbid status12; it is important to assess prefracture status when considering an overall approach. Because the goal of hip fracture surgery is to return patients to their preinjury level of functioning, the goals of care for patients with life-limiting comorbid illnesses (eg, advanced dementia), poor baseline functional status (eg, being bedridden), or both should be determined. This, in turn, should inform the discussion on the decision for operative vs nonoperative management. Surgical risk should also be considered in determining whether nonoperative management may be more appropriate. For surgical risk stratification, the American Society of Anesthesiologists (ASA) Physical Status Classification System is often applied; the assignment of the categories is based on the presence of comorbid illnesses and their severity.13 Patients with significant systemic disease and those in whom the systemic disease is a constant threat to life (ASA classification, 3-4) demonstrated 1-year mortality rates that were 9 times higher than rates in patients classified as ASA 1 to 2 (normal healthy patients to those with mild systemic disease).13 Surgical Management Quiz Ref IDSurgery should proceed as soon as the patient's clinical status is deemed medically optimized. Major clinical abnormalities including coagulopathy, respiratory failure, electrolyte disturbances, and heart failure should be addressed prior to surgery.14 Beneficial effects of early surgery include decreased pain, shorter length of stay, and fewer major postoperative complications.15 In a cohort study of 367 hip fracture patients, a surgical delay of more than 2 days from admission approximately doubled the risk of 1-year mortality; however, the mortality excess is no longer present after controlling for comorbid conditions delaying surgery.16 Thus, most excess in-hospital mortality risk associated with surgical delays is partially related to the medical reasons for the delays rather than the delays alone.17 Mr W sustained an impacted femoral neck fracture, which placed his fracture in the minimally displaced category. For nondisplaced or minimally displaced fractures of the femoral neck, operative management most commonly consists of placement of screw alone or plate and screw fixation. If a nondisplaced or impacted femoral neck fracture is treated without fixation, there is a 12% to 33% risk of fracture displacement prior to healing.18,19 To prevent the complications associated with fracture displacement and to allow the patient to mobilize early and prevent the complications of prolonged recumbency, fixation with screws is the standard of care20 (class 3). Conversely, patients with intertrochanteric fractures should be treated with fixation using a sliding hip screw or intramedullary screw depending on stability of the fracture, and there is insufficient evidence to recommend replacement arthroplasty over internal fixation.21 The treatment of choice for displaced femoral neck fractures includes either a partial hip replacement or a total hip arthroplasty. Most of these patients (85%) can expect 9-year survivorship of the hemiarthroplasty or partial replacement implant before requiring revision surgery.22 Some studies have demonstrated improved functional outcomes for those who receive a total hip arthroplasty compared with a hemiarthroplasty.23 Therefore, patients who are expected to live longer and are healthy and active may benefit from total hip arthroplasty. Hemiarthroplasty is still reserved for less active patients with shorter life expectancy.24 Comparisons of regional (spinal/epidural) and general anesthetic techniques have not demonstrated any significant differences in mortality and functional outcomes following hip fracture.25 A Cochrane review suggested that regional anesthesia may be associated with a reduction in postoperative confusion from 19.2% to 9.4%, which represents a 50% decrease in risk (class 1B).25 Other evidence-based elements include perioperative administration of first-generation cephalosporin for 24 hours (single or multiple dose), which reduces risk of surgical wound infection by 60% (class 1A)26; and venous thromboembolic prophylaxis using fondaparinux, low-molecular-weight heparin, low-dose unfractionated heparin, or adjusted-dose vitamin K antagonist, which reduces incidence of venous thromboembolism by 40% or more (class 1A).27,28 When compared with indwelling urinary catheter for 48 hours postsurgery, intermittent urinary catheterization for urinary retention reduced the time of return to satisfactory voiding by 4 days (class 1B).29 Regarding the use of nutritional supplementation, no benefits on survival or functional recovery have been demonstrated.30 Nevertheless, small studies have demonstrated a 29% reduction in medical complications, particularly with the use of protein supplementation, which should therefore be considered in patients with malnutrition (class 1B).30 Regarding transfusion strategies to manage anemia, there is little evidence that liberal transfusion to maintain a hemoglobin level of more than 10 g/dL has additional benefit beyond a more restrictive strategy of maintaining a hemoglobin level of more than 8 g/dL in the absence of symptoms of anemia (class 1B).31 The Table and Box summarize specific interventions and the evidence supporting their use throughout the course of hip fracture care. Box. Checklist of Important Care Elements Throughout Treatment Course of Patients With Hip Fracture Preoperative and Perioperative Care Surgical team (with support of geriatric consultant, medical consultant, and primary care physician) □ Consideration of operative vs nonoperative management Emergency and surgical team (with support of geriatric and medical consultants) □ Adequate pain control: femoral nerve block, scheduled pain regimen, and as-needed pain regimen □ Correction of medical abnormalities prior to surgery □ Timing of surgery: early surgery, but treat medical problems first Surgical team and anesthesia □ Regional vs general anesthesia Surgical team and nursing □ Prophylaxis against venous thromboembolism □ Perioperative antibiotic prophylaxis □ Pressure ulcer prevention using pressure-redistributing support surfaces, and heel elevation device Inpatient Postoperative Care Inpatient primary team (with support of geriatric and medical consultants) □ Adequate pain control: scheduled pain regimen, preemptive pain medications □ Delirium prevention: structured protocols □ Anemia management □ Oxygen support □ Multidisciplinary inpatient care Rehabilitation services □ Early ambulation Nutrition and primary team □ Consideration for nutrition support, particularly for patients with malnutrition Nursing □ Urinary catheter management □ Pressure ulcer prevention Discharging team □ Transitions management Rehabilitation Postdischarge Care Rehabilitation services □ Rehabilitation exercises in facilities, home, and outpatient settings Primary care clinicians and surgical team □ Secondary fracture prevention: bisphosphonates and fall prevention □ Monitor recovery of function □ Pain monitoring Primary care □ Depression monitoring and treatment □ Consideration for other modalities of care eg, palliative care □ Communication: review trajectory of recovery and caregiver expectations Pain Control Mr W: I was in quite a bit of pain. They gave me medicine to ease the pain. Patients with hip fracture often have undertreated pain during their hospitalization. In a cohort study of 411 patients in the postoperative inpatient setting, 50% experienced moderate to severe pain at rest, 83% when getting out of bed, and 91% when receiving physical therapy. Only 13% of these patients received standing orders for analgesics during their hospitalization.43Quiz Ref IDUndertreated pain in patients with hip fracture is associated with longer length of stay in the hospital, missed physical therapy sessions, delayed ambulation, and poorer locomotion at 6 months.44 A common concern is that analgesics, opioids in particular, may increase the risk of delirium; however, a large cohort study of 541 patients with hip fracture showed that severe pain increases the risk of delirium among patients with hip fracture. Those receiving a very low dose of opioids (<10 mg/d of parenteral morphine equivalents) were 5.4 times more likely to develop delirium compared with those receiving a higher dose (>30 mg/d of morphine equivalents).43 Therefore, the concern for risk of delirium should not be a deterrent to adequate pain treatment. In addition to systemic opioids, preliminary data support the use of femoral nerve block45; however, more definitive trials are needed. A sensible approach would be to adopt a regimen of standing, as needed, and preemptive (prior to physical therapy) opioid administration (class 2).33 As an example, for an 89-year-old patient like Mr W, the starting regimen would have been a standing order of 3 mg of oxycodone administered orally every 4 hours, 1.5 mg of oxycodone every hour as needed, 1.5 mg of oxycodone 1 hour prior to physical therapy sessions, and subsequent administration titrating to effect.33 Delirium Dr H: Many things . . . in the hospital . . . can make older people delirious . . . A hip fracture is a pretty big insult to the body. Delirium occurs frequently in patients with hip fracture while hospitalized—incidence estimates from prospective cohorts range from 10% to 65%.46-48 As many as one-third of delirium episodes persist after hospital discharge.46,48 Delirium upon hospital admission is associated with poorer physical and cognitive functioning at 6 months after hip fracture.49 Delirium during hospitalization for hip fracture is associated with mobility and functional decline, death, and nursing home placement 1 month after discharge.48 Quiz Ref IDTwo RCTs have demonstrated that a significant proportion of delirium episodes can be prevented by using geriatric consultation or ward teams delivering targeted interventions (class 1A). In one trial, proactive geriatric consultation using targeted recommendations such as fluid and electrolyte balance, pain management, elimination of unnecessary medications, early removal of urinary catheters, and early mobilization reduced delirium episodes from 50% to 28% (risk reduction, 0.64).34 In another trial, a specialized geriatric ward with staff applying comprehensive geriatric assessment led to a 20% absolute risk reduction in delirium incidence and a 5-day reduction in duration of delirium episodes compared with usual care.47 Mr W had several risk factors for developing delirium including advanced age, cognitive impairment, hearing loss, and polypharmacy including psychoactive medications. He would benefit from a multicomponent intervention while in the hospital including reduction of unnecessary medications; provision of hearing assistance, frequent orientation, and adequate pain control; and assistance with early mobilization. Pressure Ulcer Prevention Due to long periods of immobility, patients with hip fracture are at high risk of developing pressure ulcers. Pressure ulcer formation is associated with poor patient outcomes.50 In a cohort of 658 patients with hip fracture, 16% developed a new pressure ulcer (≥stage 2) at 7 days after initial hospitalization, 28% at 14 days, and 36% at 32 days.51 To prevent pressure ulcers, current guidelines suggest pressure ulcer risk assessment, frequent repositioning, and the use of pressure redistributing support surfaces.52 A recent review from the Cochrane collaboration supports the use of pressure-relieving overlays in the operating room and the use of foam alternatives rather than standard hospital foam mattresses, which can reduce pressure ulcer incidence by 60% (class 1A).53 Another RCT showed that patients with hip fracture experienced a 73% reduction in the incidence of heel ulcers when heel protectors were used.54 Early Ambulation To return patients to their preinjury level of function, patients should be mobilized soon after surgery, often during the next morning following surgery. Early ambulation improves patient outcomes, including functional recovery and mortality rate.35 Delayed ambulation is associated with the development of new-onset delirium, postoperative pneumonia, and increased length of stay.55 Depending on fracture stability achieved by surgery, rehabilitation may commence with unrestricted weight bearing. This should progress each day, ideally leading to stair climbing by postoperative day 4. These goals are to be taken as general guidelines; each rehabilitation program must be tailored to the individual's physical, psychological, and social situation. Poor pain control is associated with delayed ambulation, making attentive pain control a priority both for the patient's comfort as well as to improve locomotion during hospitalization.33,44 Transitions of Care Patients with hip fracture often experience multiple hand-offs during care transitions across settings, such as from hospital to rehabilitation facility, rehabilitation facility to home, and rehospitalization; the average number of transitions for a patient with hip fracture is 3.5.56 Transitions of care represent vulnerable points in the trajectory toward recovery, because medication errors and adverse events are prone to occur.57 As clinicians, it is important to ensure that hand-offs are accurate and complete and services are adequate when patients are transitioned to a less intensive level of care. Approximately one-third of patients with hip fracture are readmitted to the hospital within 6 months.58 Most rehospitalizations (89%) are for nonsurgical causes—infectious and cardiac causes being most common.58 Readmissions are associated with increased risk of mobility dependence (total assistance with ambulation) and death at 6 months.58 Although not studied directly in patients with hip fracture, interventions targeted at improving care transitions among older patients can reduce hospital readmissions.37 Mr W experienced transitions from the hospital to a skilled nursing facility to receive rehabilitation, and subsequently home. Ensuring that he received correct medications at every transition, follow-up appointments and means to attend them (including negotiating stairs at the house or physician's office), and information about indications that his medical conditions were worsening were all keys to successful transitions. The National Transitions of Care Coalition provides information to help address transitions of care (see Resources). Models of Care for Inpatient Management Incorporating the elements of care described in this article requires the involvement of multiple disciplines including, but not limited to, orthopedics (for surgical and perioperative management), geriatrics or internal medicine (for delirium, pain, and medical management), rehabilitation, social work, and nursing. Models of inpatient care, such as orthogeriatric units, have been developed to meet patient needs. We reviewed studies of these inpatient models of care (eTable 1, eTable 2, and eTable 3) and found that the studies vary in design, setting, and outcomes. By organizing these studies by outcomes—long-term, short-term, process, or administrative outcomes, we were able to draw certain conclusions. First, there is a lack of evidence that inpatient multidisciplinary models by themselves improve long-term clinical outcomes such as function59; studies that have found improvement in long-term outcomes have included coupled rehabilitation interventions in rehabilitation units or after hospital discharge.60,61 Second, the incidence of medical complications during hospital stay, including delirium, is reduced with multidisciplinary care, mostly when a geriatrician or internist is involved. Two studies reported a reduction in hospital mortality.62,63 Third, multidisciplinary models have variable effects on length of stay (6 shortened, 2 with no effect, 1 prolonged). With the limited evidence, the strongest benefit of multidisciplinary care is the reduction of hospital complications including delirium, urinary retention, infection, and pneumonia.34,62 Including these elements of care into the protocol may improve adherence to evidence-based practices.34,62 Future studies should focus on adherence to evidence-based elements of care and include clinically relevant short- and long-term outcomes. Posthospital discharge care Rehabilitation After Repair Mrs W: They started him out gradually and then they had him walking in [with the help of the parallel] bars. A mainstay of posthospital care for the patient with hip fracture is rehabilitation to restore mobility. Although multiple RCTs have evaluated rehabilitation strategies after hip fracture, rehabilitation in clinical settings is often guided by the trajectory of rehabilitation, patient's capability and motivation, and the availability of social support. Also, similar to the evidence on multidisciplinary models of care, studies on rehabilitation strategies vary in design, length, setting, and outcomes, limiting our ability to determine the best single strategy, an observation also noted in a recent Cochrane review.64 Examining the evidence by setting and intensity of treatment (eTable 4) showed that home-based rehabilitation programs may improve locomotive and functional performance at 1 to 12 months,65-67 but 1 program only improved gait performance at 6 months but not at 12 months.68 For patients who can tolerate physical therapy at an outpatient clinic, facility-based (in outpatient rehabilitation gyms or clinics) higher-intensity treatment may lead to improved physical performance, functional status, and quality of life when compared with home-based programs.69,70 Including other modalities of rehabilitation, such as occupational therapy, may lead to improved quality of life and ability to perform instrumental ADLs at 2 months.71 Optimal duration of rehabilitation programs is unclear—1 study reported improvement in function in a 6-month program,69 but a 12-month program only yielded increased physical activity level but no effect on functional performance.72 Mr W underwent rehabilitation in a skilled nursing facility followed by continued physical and occupational therapy at home after discharge. As Mr W was motivated in his rehabilitation efforts, he received additional physical therapy in the outpatient rehabilitation facility. The higher-intensity treatment may have contributed to his good recovery. Trajectory of Functional Recovery and Follow-up Mr W: [On things that were most instrumental to making a terrific recovery] First of all, time. It took time. All patients with hip fracture should be followed up at standard intervals to assess fracture healing. Expert opinion on optimal care includes follow-up with hip radiographs at 6 weeks if fixation was performed and every 6 weeks thereafter, until bony union occurs. For patients who received arthroplasty, follow-up with radiograph occurs at 3 months and then yearly to assess the integrity of the implant. Patients who have undergone arthroplasty are cautioned to limit certain physical positions for 3 months, such as flexion with internal rotation, to prevent hip dislocation. At each follow-up, the extent of functional recovery, including mobility and ADL performance, should be assessed. Understanding the time course of expected functional recovery helps clinicians to advise patients. Patients with hip fracture represent heterogeneous groups of individuals with variable baseline status, including some with ongoing physical decline that has culminated in hip fracture.12 Data from a cohort of 674 patients with hip fracture who were followed up for 24 months showed that function in 8 areas recovered progressively over the first postfracture year, with different levels of recovery and time to maximum levels of function observed.73 Recuperation times to maximal recovery were specific to area of function, ranging from 4 months for depressive symptoms, upper extremity function, and cognition, to 9 months for gait and balance, and to 11 months for lower extremity function. New dependency in specific areas includes 20% with difficulty putting on pants, 66% getting on or off the toilet, 83% getting in or out of the bath or shower, and 90% for climbing 5 stairs.73 Risk Reduction of Subsequent Fracture Dr H: He has a lot of [comorbid conditions] . . . I try to manage those without making him fall. Approximately 10% to 20% of patients with hip fracture have a subsequent hip fracture, representing a 2.5-fold increase in risk74; thus, secondary prevention of subsequent fracture is an important aspect of care. This is often overlooked because it is not part of the acute care management of hip fracture. Current guidelines suggest assessment of osteoporosis if not previously diagnosed, calcium and vitamin D supplementation, and bisphosphate use. Vitamin D supplementation, with calcium supplementation, increases bone mineral density and reduces falls.75,76 Bisphosphonates, including zoledronic acid, can reduce rates of clinical fractures among patients who have had a hip fracture (class 1A).38 Bisphosphonate treatment should be initiated within 90 days postsurgery for patients without contraindications, and should be on the checklist of all physicians providing follow-up care. Fall-prevention strategies may consist of risk factor assessment and multifactorial targeted intervention, as discussed in a prior article in the Care of the Aging Patient series.1 Mr W's renal insufficiency limited bisphosphonate use; instead, he was prescribed calcium and vitamin D supplementation. For fall prevention, Mr W would benefit from a comprehensive fall-risk assessment, which may result in elimination of unnecessary medications, especially psychoactive and anticholinergic medications, continued physical therapy for gait and balance training, and a home safety assessment. Pain and Psychological Issues Dr H : [I make] sure that he has support at home. His caregiver is a big part of why he's doing well. Persistent, residual pain after hip fracture is common—40% to 50% of patients report moderate to severe pain at 3 to 6 months.44,77 Thus, continuing assessment of pain at follow-up is necessary. Chronic pain management may include a regimen of opioid or nonopioid analgesics titrated to maintain mobility and ability to participate in rehabilitation exercises. Sudden-onset or worsening pain should prompt evaluation because it may indicate associated hip problems such as trochanteric bursitis or loss of fixation, dislocation, infection, or osteonecrosis (a late complication) of the hip. Clinically significant depression develops in 14% to 20% of patients with hip fracture78,79 and postoperative pain and anxiety symptoms are potentially modifiable factors associated with depression. Clinicians should continue to monitor for signs of depression during follow-up. Also, 50% or more of patients with hip fracture experience fear of falling, which is associated with poor rehabilitation outcomes, mobility loss, and institutionalization.80 Although educational programs such as coaching to improve self-efficacy expectations show promise, current evidence is insufficient to support practice changes.81 Caregivers often experience frustration with communication in health care delivery and in caregiving-related activities.82 Clinicians should proactively and sensitively communicate with patients' caregivers. Dr H communicated frequently to support to the patient and his family, which may have helped ease patient and caregiver frustration during this prolonged recovery process. Patients both with and without caregivers may be referred for additional nursing and homemaking services depending on individual needs; alternative living arrangements such as assisted living may be explored. Role of Palliative Care Dr H: When I heard [Mr W] had a hip fracture, I thought this was going to be it. Discussion of management goals and choices with patients and proxies should be initiated early in the course of treatment of patients with hip fracture.83 In patients with life-limiting diseases such as advanced dementia,84 it is particularly important that alternatives to surgical treatment, including palliative management, are explored. Aspects of palliative care applicable to the hip fracture include symptom management and assisting patients and caregivers in coping with this difficult condition. For patients with poor functional recovery, significant worsening of comorbid conditions, and multiple readmissions, discussion of goals of care should include consideration of alternative models of care both in institutions and at home, to best serve their needs.85 Palliative care consultation both in the hospital and after discharge may be helpful for patients with significant symptoms and difficulty coping with illness. Conclusions Hip fracture has a prolonged treatment course with potentially devastating consequences. The patient's overall status and goals should be used to tailor care and optimize patient outcomes. Patients with hip fracture require care that integrates surgical, geriatric, rehabilitative, and psychosocial principles throughout its course. This condition also requires physicians to anticipate problems that may arise during recovery, whether the complications are from hip fracture and immobility, exacerbations of chronic diseases, or problems with social and psychological support. As illustrated in Mr W's case, it takes a team of dedicated professionals working together seamlessly to deliver care appropriate for patient goals and to maximize recovery. Back to top Article Information Corresponding Author: William W. Hung, MD, MPH, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1070, New York, NY 10029 (william.hung@mssm.edu). Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Egol reports receipt of consultancy fees and royalties from Exactech; grants or pending grants from the Orthopaedic Research & Education Foundation and the Orthopaedic Trauma Association; and holding stock/stock options with Johnson & Johnson. The other authors report no disclosures. Funding/Support: Dr Hung is currently supported by the New York Academy of Medicine Hoar Fellowship. This article was supported in part by the Claude D. Pepper Older Americans Independence Center at Mount Sinai School of Medicine (P30-AG028741). The Care of the Aging Patient series is made possible by funding from The SCAN Foundation. Role of the Sponsor: The funders had no role in the collection, management, analysis, and interpretation of the data or the preparation, review, or approval of the manuscript. Additional Contributions: We thank the patient, his family, and his physician for sharing their stories and providing permission to publish them. Call for Patient Stories: The Care of the Aging Patient editorial team invites physicians to contribute a patient story to inspire a future article. Information and submission instructions are available at http://geriatrics.medicine.ucsf.edu/agingpatient/. Care of the Aging Patient: From Evidence to Action is produced and edited at the University of California, San Francisco, by Seth Landefeld, MD, Louise Walter, MD, Louise Aronson, MD, MFA, and Anna Chang, MD; Amy J. Markowitz, JD, is managing editor.Box Reference Online-Only Resources: eResources for Care of the Older Patient General Resources Centers for Disease Control and Prevention http://www.cdc.gov/HomeandRecreationalSafety/Falls/adulthipfx.html#reference This website contains general information about hip fracture with recent data and statistics. Agency for Healthcare Research and Quality http://www.effectivehealthcare.ahrq.gov This website contains reviews of evidence for effectiveness and comparative effectiveness research for clinicians, consumers, and policy makers with a searchable index for information related to falls and hip fracture. National Rehabilitation Information Center (NARIC) http://www.naric.com/public/readyref/ This website contains links to resources related to disability and rehabilitation-oriented information, including information on aging and on choosing rehabilitation facilities. American Academy of Orthopaedic Surgeons http://orthoinfo.aaos.org/topic.cfm?topic=A00392 This website contains information about orthopedic treatment for hip fracture including radiographic depictions of hip fracture repair. Care Transitions National Transitions of Care Coalition http://www.ntocc.org This website provides information to address problems associated with transitions of care. It is a non-profit organization that provides tools to help health care professionals, patients, and caregivers establish safer transitions; and resources for practitioners and policy makers to improve transitions throughout the health care system. Delirium Prevention Hospital Elder Life Program (HELP) http://www.hospitalelderlifeprogram.org This website provides information about recognition and prevention of delirium in hospitalized older adults. Osteoporosis Treatment National Osteoporosis Foundation http://www.nof.org The National Osteoporosis Foundation is dedicated to the prevention of osteoporosis and broken bones, the promotion of strong bones for life, and the reduction of human suffering through programs of public and clinician awareness, education, advocacy, and research. References 1. Tinetti ME, Kumar C. The patient who falls: “it's always a trade-off.” JAMA. 2010;303(3):258-26620085954PubMedGoogle ScholarCrossref 2. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ. 1999;318(7183):593-59610037645PubMedGoogle ScholarCrossref 3. Cummings SR, Rubin SM, Black D. The future of hip fractures in the United States: numbers, costs, and potential effects of postmenopausal estrogen. Clin Orthop Relat Res. 1990;(252):163-1662302881PubMedGoogle Scholar 4. Centers for Disease Control and Prevention. Injury prevention & control: hip fractures among older adults. http://www.cdc.gov/HomeandRecreationalSafety/Falls/adulthipfx.html. Accessed September 1, 2011 5. Samelson EJ, Zhang Y, Kiel DP, Hannan MT, Felson DT. Effect of birth cohort on risk of hip fracture: age-specific incidence rates in the Framingham Study. Am J Public Health. 2002;92(5):858-86211988460PubMedGoogle ScholarCrossref 6. Stolee P, Poss J, Cook RJ, Byrne K, Hirdes JP. Risk factors for hip fracture in older home care clients. J Gerontol A Biol Sci Med. Sci. 2009;64(3):403-41019196903PubMedGoogle ScholarCrossref 7. Hannan EL, Magaziner J, Wang JJ, et al. Mortality and locomotion 6 months after hospitalization for hip fracture: risk factors and risk-adjusted hospital outcomes. JAMA. 2001;285(21):2736-274211386929PubMedGoogle ScholarCrossref 8. Lu-Yao GL, Baron JA, Barrett JA, Fisher ES. Treatment and survival among elderly Americans with hip fractures: a population-based study. Am J Public Health. 1994;84(8):1287-12918059887PubMedGoogle ScholarCrossref 9. Haentjens P, Magaziner J, Colón-Emeric CS, et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152(6):380-39020231569PubMedGoogle ScholarCrossref 10. Magaziner J, Simonsick EM, Kashner TM, Hebel JR, Kenzora JE. Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol. 1990;45(3):M101-M1072335719PubMedGoogle ScholarCrossref 11. Cumming RG, Klineberg R, Katelaris A. Cohort study of risk of institutionalisation after hip fracture. Aust N Z J Public Health. 1996;20(6):579-5829117962PubMedGoogle ScholarCrossref 12. Penrod JD, Litke A, Hawkes WG, et al. Heterogeneity in hip fracture patients: age, functional status, and comorbidity. J Am Geriatr Soc. 2007;55(3):407-41317341244PubMedGoogle ScholarCrossref 13. Michel JP, Klopfenstein C, Hoffmeyer P, Stern R, Grab B. Hip fracture surgery: is the pre-operative American Society of Anesthesiologists (ASA) score a predictor of functional outcome? Aging Clin Exp Res. 2002;14(5):389-39412602574PubMedGoogle ScholarCrossref 14. McLaughlin MA, Orosz GM, Magaziner J, et al. Preoperative status and risk of complications in patients with hip fracture. J Gen Intern Med. 2006;21(3):219-22516390507PubMedGoogle ScholarCrossref 15. Orosz GM, Magaziner J, Hannan EL, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004;291(14):1738-174315082701PubMedGoogle ScholarCrossref 16. Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995;77(10):1551-15567593064PubMedGoogle Scholar 17. Vidán MT, Sánchez E, Gracia Y, Marañón E, Vaquero J, Serra JA. Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med. 2011;155(4):226-23321844548PubMedGoogle ScholarCrossref 18. Bentley G. Treatment of nondisplaced fractures of the femoral neck. Clin Orthop Relat Res. 1980;(152):93-1017438625PubMedGoogle Scholar 19. Holmberg S, Kalén R, Thorngren KG. Treatment and outcome of femoral neck fractures: an analysis of 2418 patients admitted from their own homes. Clin Orthop Relat Res. 1987;(218):42-523568494PubMedGoogle Scholar 20. Parker MJ, Myles JW, Anand JK, Drewett R. Cost-benefit analysis of hip fracture treatment. J Bone Joint Surg Br. 1992;74(2):261-2641544965PubMedGoogle Scholar 21. Parker MJ, Handoll HH. Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2006;(2):CD00008616625528PubMedGoogle Scholar 22. Obrant KJ, Carlsson AS. Survival of hemiarthroplasties after cervical hip fractures. Orthopedics. 1987;10(8):1153-11563628104PubMedGoogle Scholar 23. Blomfeldt R, Törnkvist H, Eriksson K, Söderqvist A, Ponzer S, Tidermark J. A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. J Bone Joint Surg Br. 2007;89(2):160-16517322427PubMedGoogle ScholarCrossref 24. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty: treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am. 2006;88(2):249-26016452734PubMedGoogle ScholarCrossref 25. Parker MJ, Handoll HH, Griffiths R. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev. 2004;(4):CD00052115494999PubMedGoogle Scholar 26. Gillespie WJ, Walenkamp GH. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev. 2010;(3):CD00024420238310PubMedGoogle Scholar 27. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3):(suppl) 338S-400S15383478PubMedGoogle ScholarCrossref 28. Handoll HH, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Milne AA, Gillespie WJ. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev. 2002;(4):CD00030512519540PubMedGoogle Scholar 29. Skelly JM, Guyatt GH, Kalbfleisch R, Singer J, Winter L. Management of urinary retention after surgical repair of hip fracture. CMAJ. 1992;146(7):1185-11891555145PubMedGoogle Scholar 30. Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev. 2010;(1):CD00188020091525PubMedGoogle Scholar 31. Carson JL, Terrin ML, Noveck H, et al; FOCUS Investigators. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365(26):2453-246222168590PubMedGoogle ScholarCrossref 32. Handoll HH, Parker MJ. Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev. 2008;(3):CD00033718646065PubMedGoogle Scholar 33. Morrison RS, Flanagan S, Fischberg D, Cintron A, Siu AL. A novel interdisciplinary analgesic program reduces pain and improves function in older adults after orthopedic surgery. J Am Geriatr Soc. 2009;57(1):1-1019054187PubMedGoogle ScholarCrossref 34. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49(5):516-52211380742PubMedGoogle ScholarCrossref 35. Siu AL, Penrod JD, Boockvar KS, Koval K, Strauss E, Morrison RS. Early ambulation after hip fracture: effects on function and mortality. Arch Intern Med. 2006;166(7):766-77116606814PubMedGoogle ScholarCrossref 36. Huang TT, Liang SH. A randomized clinical trial of the effectiveness of a discharge planning intervention in hospitalized elders with hip fracture due to falling. J Clin Nurs. 2005;14(10):1193-120116238765PubMedGoogle ScholarCrossref 37. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-182817000937PubMedGoogle ScholarCrossref 38. Lyles KW, Colón-Emeric CS, Magaziner JS, et al; HORIZON Recurrent Fracture Trial. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357(18):1799-180917878149PubMedGoogle ScholarCrossref 39. Wells G, Cranney A, Peterson J, et al. Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008;(1):CD00452318254053PubMedGoogle Scholar 40. Wells GA, Cranney A, Peterson J, et al. Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008;(1):CD00115518253985PubMedGoogle Scholar 41. Wells GA, Cranney A, Peterson J, et al. Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008;(1):CD00337618254018PubMedGoogle Scholar 42. Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev. 2010;(10):CD00125520927724PubMedGoogle Scholar 43. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003;58(1):76-8112560416PubMedGoogle ScholarCrossref 44. Morrison RS, Magaziner J, McLaughlin MA, et al. The impact of post-operative pain on outcomes following hip fracture. Pain. 2003;103(3):303-31112791436PubMedGoogle ScholarCrossref 45. Fletcher AK, Rigby AS, Heyes FL. Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med. 2003;41(2):227-23312548273PubMedGoogle ScholarCrossref 46. Brauer C, Morrison RS, Silberzweig SB, Siu AL. The cause of delirium in patients with hip fracture. Arch Intern Med. 2000;160(12):1856-186010871981PubMedGoogle ScholarCrossref 47. Lundström M, Olofsson B, Stenvall M, et al. Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study. Aging Clin Exp Res. 2007;19(3):178-18617607084PubMedGoogle ScholarCrossref 48. Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc. 2000;48(6):618-62410855596PubMedGoogle Scholar 49. Dolan MM, Hawkes WG, Zimmerman SI, et al. Delirium on hospital admission in aged hip fracture patients: prediction of mortality and 2-year functional outcomes. J Gerontol A Biol Sci Med Sci. 2000;55(9):M527-M53410995051PubMedGoogle ScholarCrossref 50. Berry SD, Samelson EJ, Bordes M, Broe K, Kiel DP. Survival of aged nursing home residents with hip fracture. J Gerontol A Biol Sci Med Sci. 2009;64(7):771-77719414511PubMedGoogle ScholarCrossref 51. Baumgarten M, Margolis DJ, Orwig DL, et al. Pressure ulcers in elderly patients with hip fracture across the continuum of care. J Am Geriatr Soc. 2009;57(5):863-87019484841PubMedGoogle ScholarCrossref 52. Agency for Healthcare Research and Quality. Guideline synthesis: prevention of pressure ulcers. National Guideline Clearing House website. http://www.guideline.gov/syntheses/synthesis.aspx?id=25078&search=pressure+ulcer. Accessed October 24, 2011 53. McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2011;(4):CD00173521491384PubMedGoogle Scholar 54. Donnelly J, Winder J, Kernohan WG, Stevenson M. An RCT to determine the effect of a heel elevation device in pressure ulcer prevention post-hip fracture. J Wound Care. 2011;20(7):309-312, 314-30821841719PubMedGoogle Scholar 55. Kamel HK, Iqbal MA, Mogallapu R, Maas D, Hoffmann RG. Time to ambulation after hip fracture surgery: relation to hospitalization outcomes. J Gerontol A Biol Sci Med Sci. 2003;58(11):1042-104514630887PubMedGoogle ScholarCrossref 56. Boockvar KS, Litke A, Penrod JD, et al. Patient relocation in the 6 months after hip fracture: risk factors for fragmented care. J Am Geriatr Soc. 2004;52(11):1826-183115507058PubMedGoogle ScholarCrossref 57. Boockvar K, Fishman E, Kyriacou CK, Monias A, Gavi S, Cortes T. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med. 2004;164(5):545-55015006832PubMedGoogle ScholarCrossref 58. Boockvar KS, Halm EA, Litke A, et al. Hospital readmissions after hospital discharge for hip fracture: surgical and nonsurgical causes and effect on outcomes. J Am Geriatr Soc. 2003;51(3):399-40312588585PubMedGoogle ScholarCrossref 59. Naglie G, Tansey C, Kirkland JL, et al. Interdisciplinary inpatient care for elderly people with hip fracture: a randomized controlled trial. CMAJ. 2002;167(1):25-3212137074PubMedGoogle Scholar 60. Shyu YI, Liang J, Wu CC, et al. Two-year effects of interdisciplinary intervention for hip fracture in older Taiwanese. J Am Geriatr Soc. 2010;58(6):1081-108920722845PubMedGoogle ScholarCrossref 61. Adunsky A, Lerner-Geva L, Blumstein T, Boyko V, Mizrahi E, Arad M. Improved survival of hip fracture patients treated within a comprehensive geriatric hip fracture unit, compared with standard of care treatment. J Am Med Dir Assoc. 2011;12(6):439-44421450210PubMedGoogle ScholarCrossref 62. Pedersen SJ, Borgbjerg FM, Schousboe B, et al; Hip Fracture Group of Bispebjerg Hospital. A comprehensive hip fracture program reduces complication rates and mortality. J Am Geriatr Soc. 2008;56(10):1831-183819054201PubMedGoogle ScholarCrossref 63. Vidán M, Serra JA, Moreno C, Riquelme G, Ortiz J. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc. 2005;53(9):1476-148216137275PubMedGoogle ScholarCrossref 64. Handoll HH, Sherrington C. Mobilisation strategies after hip fracture surgery in adults. Cochrane Database Syst Rev. 2007;(1):CD00170417253462PubMedGoogle Scholar 65. Sherrington C, Lord SR. Home exercise to improve strength and walking velocity after hip fracture: a randomized controlled trial. Arch Phys Med Rehabil. 1997;78(2):208-2129041904PubMedGoogle ScholarCrossref 66. Sherrington C, Lord SR, Herbert RD. A randomized controlled trial of weight-bearing versus non-weight-bearing exercise for improving physical ability after usual care for hip fracture. Arch Phys Med Rehabil. 2004;85(5):710-71615129393PubMedGoogle ScholarCrossref 67. Zidén L, Kreuter M, Frändin K. Long-term effects of home rehabilitation after hip fracture—1-year follow-up of functioning, balance confidence, and health-related quality of life in elderly people. Disabil Rehabil. 2010;32(1):18-3219925273PubMedGoogle ScholarCrossref 68. Tinetti ME, Baker DI, Gottschalk M, et al. Home-based multicomponent rehabilitation program for older persons after hip fracture: a randomized trial. Arch Phys Med Rehabil. 1999;80(8):916-92210453768PubMedGoogle ScholarCrossref 69. Binder EF, Brown M, Sinacore DR, Steger-May K, Yarasheski KE, Schechtman KB. Effects of extended outpatient rehabilitation after hip fracture: a randomized controlled trial. JAMA. 2004;292(7):837-84615315998PubMedGoogle ScholarCrossref 70. Carmeli E, Sheklow SL, Coleman R. A comparative study of organized class-based exercise programs versus individual home-based exercise programs for elderly patients following hip surgery. Disabil Rehabil. 2006;28(16):997-100516882639PubMedGoogle ScholarCrossref 71. Hagsten B, Svensson O, Gardulf A. Health-related quality of life and self-reported ability concerning ADL and IADL after hip fracture: a randomized trial. Acta Orthop. 2006;77(1):114-11916534710PubMedGoogle ScholarCrossref 72. Orwig DL, Hochberg M, Yu-Yahiro J, et al. Delivery and outcomes of a yearlong home exercise program after hip fracture: a randomized controlled trial. Arch Intern Med. 2011;171(4):323-33121357809PubMedGoogle ScholarCrossref 73. Magaziner J, Hawkes W, Hebel JR, et al. Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci. 2000;55(9):M498-M50710995047PubMedGoogle ScholarCrossref 74. Colón-Emeric C, Kuchibhatla M, Pieper C, et al. The contribution of hip fracture to risk of subsequent fractures: data from two longitudinal studies. Osteoporos Int. 2003;14(11):879-88314530910PubMedGoogle ScholarCrossref 75. Grant AM, Avenell A, Campbell MK, et al; RECORD Trial Group. Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium Or vitamin D, RECORD): a randomised placebo-controlled trial. Lancet. 2005;365(9471):1621-162815885294PubMedGoogle ScholarCrossref 76. Harwood RH, Sahota O, Gaynor K, Masud T, Hosking DJ.Nottingham Neck of Femur (NONOF) Study. A randomised, controlled comparison of different calcium and vitamin D supplementation regimens in elderly women after hip fracture: the Nottingham Neck of Femur (NONOF) study. Age Ageing. 2004;33(1):45-5114695863PubMedGoogle ScholarCrossref 77. Herrick C, Steger-May K, Sinacore DR, Brown M, Schechtman KB, Binder EF. Persistent pain in frail older adults after hip fracture repair. J Am Geriatr Soc. 2004;52(12):2062-206815571543PubMedGoogle ScholarCrossref 78. Lenze EJ, Munin MC, Skidmore ER, et al. Onset of depression in elderly persons after hip fracture: implications for prevention and early intervention of late-life depression. J Am Geriatr Soc. 2007;55(1):81-8617233689PubMedGoogle ScholarCrossref 79. Voshaar RC, Banerjee S, Horan M, et al. Predictors of incident depression after hip fracture surgery. Am J Geriatr Psychiatry. 2007;15(9):807-81417698601PubMedGoogle ScholarCrossref 80. Visschedijk J, Achterberg W, Van Balen R, Hertogh C. Fear of falling after hip fracture: a systematic review of measurement instruments, prevalence, interventions, and related factors. J Am Geriatr Soc. 2010;58(9):1739-174820863333PubMedGoogle ScholarCrossref 81. Crotty M, Unroe K, Cameron ID, Miller M, Ramirez G, Couzner L. Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people. Cochrane Database Syst Rev. 2010;(1):CD00762420091644PubMedGoogle Scholar 82. Nahm ES, Resnick B, Orwig D, Magaziner J, Degrezia M. Exploration of informal caregiving following hip fracture. Geriatr Nurs. 2010;31(4):254-26220682403PubMedGoogle ScholarCrossref 83. Sudore RL, Fried TR. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010;153(4):256-26120713793PubMedGoogle ScholarCrossref 84. Morrison RS, Siu AL. Mortality from pneumonia and hip fractures in patients with advanced dementia. JAMA. 2000;284(19):2447-244811074771PubMedGoogle ScholarCrossref 85. Coventry PA, Grande GE, Richards DA, Todd CJ. Prediction of appropriate timing of palliative care for older adults with non-malignant life-threatening disease: a systematic review. Age Ageing. 2005;34(3):218-22715863407PubMedGoogle ScholarCrossref
TI - Hip Fracture Management: Tailoring Care for the Older Patient
JF - JAMA
DO - 10.1001/jama.2012.4842
DA - 2012-05-23
UR - https://www.deepdyve.com/lp/american-medical-association/hip-fracture-management-tailoring-care-for-the-older-patient-6lePPD0L8z
SP - 2185
EP - 2194
VL - 307
IS - 20
DP - DeepDyve
ER -