Recovering From Hip Fracture Jay Magaziner, PhD, MSHyg and Nancy Chiles, BS University of Maryland School of Medicine Baltimore, Maryland 2016 Symposium for State and Local Commissions on Aging September 22, 2016

Acknowledgements The many investigators and staff in the Baltimore Hip Studies Program The patients and hospitals that participated in studies over the past 30 years The National Institute on Aging, which has funded this work on hip fracture recovery for the past 30 years

Disclosures During the past year, Dr. Magaziner has consulted or served on advisory boards for: American Orthopaedic Association; Ammonett; Novartis; Pluristem; Scholar Rock; Viking Therapeutics

Overview of Presentation Magnitude of the Problem 30 Years of Evidence from the Baltimore Hip Studies Program: From Observation to Intervention Consequences Recovery Patterns How This Information Informs Intervention Targets

Magnitude of Problem Estimated 3.9 million hip fractures worldwide annually Three-quarters of hip fractures are in women Despite advances in surgical procedures, post-operative care, and long term rehabilitation, hip fractures rank in the top ten worldwide in terms of disability and functional decline.

Hip Fractures Worldwide, n Hip Fractures Are Common: Number Projected to Increase 0.5 1.0 1.5 2.0 2.5 3.0 3.5 1990 2000 2010 2020 2030 2040 2050 Men Women Year Hip Fractures Worldwide, n (million) Projected Data Gullberg B, et al. Osteoporos Int. 1997;7:407–413.

Assessing the Risk for Hip Fracture1,2 Strength of Bone Fall-Related Trauma Risk of Fall Neuromuscular Function Environmental Hazards Time Spent at Risk Bone Turnover Bone Mass Force of Impact Type of Fall Protective Responses Energy Absorption Bone Quality 1. Kanis JA. Osteoporosis. Blackwell Healthcare Communications Ltd; 1997. 2. Cumming RG, et al. Epidemiol Rev. 1997;19:244–257.

FALLS PREVALENCE IN OLDER PERSONS (percentage of men and women falling each year) Community 33 percent Institution 50 percent

THE BALTIMORE HIP STUDIES

Goals of Baltimore Hip Fracture Studies To identify, develop, and evaluate strategies to optimize recovery from hip fracture.

The Baltimore Hip Studies (BHS) Over the past 30 years, the BHS have enrolled and followed more than 4,000 hip fracture patients admitted to 25 Baltimore area hospitals. Outcomes studied include mortality, functional recovery, and changes in bone mineral density, muscle mass and composition, bone and muscle strength. Studies have progressed from observational to interventional. BHS Investigators have collaborated on many single and multi-center studies of hip fracture outcomes outside Baltimore

Consequences of Hip Fracture Selected Finding From Baltimore Hip Studies

Some Consequences of Hip Fracture Death 18-33% die within 1 year Hospitalization 3-8 days, regional variation Disability and Dependency 15-25% to institution for 1+ years 25-75% do not regain pre-fracture functioning Burden Patients Family Health care systems

Mean Percent Loss From Baseline Consequences of Hip Fracture: Increased Hip Bone Loss (BMD) Over 1 Year Hip fracture patients Expected in non-hip fracture population Total Hip Femoral Neck 1 1 –1 –1 –2 –2 Mean Percent Loss From Baseline –3 –3 –4 –4 –5 –5 –6 –6 –7 –7 2 4 6 8 10 12 2 4 6 8 10 12 Months Post-Fracture Error bars represent standard error of the mean. Expected values based on interpolated data obtained over a 42.3-month period, Study of Osteoporotic Fractures. Magaziner J, et al. Osteoporos Int. 2006;17:971-977.

Lean Body Mass Average Mass (grams) Days Post-fracture 40000 39500 39000 38500 Average Mass (grams) 38000 37500 Fox, K.M., Magaziner, J., Hawkes, W.G., YuYahiro, J., Hebel, J.R., Zimmerman, S.I., Holder, L., Michael, R. Loss of bone density and lean body mass after hip fracture. Osteoporos Int, 11, (1), 2000, 31-35. 37000 36500 36000 3-10 60 120 180 240 300 360 Days Post-fracture Fox KM, et al. Osteoporos Int. 2000;11:31-35.

Fat Mass Average Mass (grams) Days Post-fracture 18000 17500 17000 16500 Fox, K.M., Magaziner, J., Hawkes, W.G., YuYahiro, J., Hebel, J.R., Zimmerman, S.I., Holder, L., Michael, R. Loss of bone density and lean body mass after hip fracture. Osteoporos Int, 11, (1), 2000, 31-35. 16000 15500 3-10 60 120 180 240 300 360 Days Post-fracture Fox KM, et al. Osteoporos Int. 2000;11:31-35.

Lower Extremity Activities of Daily Living Percentage of Those Unimpaired Pre-Fracture 10 20 30 40 50 60 70 80 90 100 Put on Pants In/Out Bed Walk 10 Feet Rise From Chair Walk 1 Block On/Off toilet Bath Climb 5 Stairs Percentage New Impairment at 12 Months With Impairment at 12 Months Post-Fracture Magaziner, J., Hawkes, W., Hebel, J.R., Zimmerman, S.I., Fox, K.M., Dolan, M., Felsenthal, G., Kenzora, J. Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci, 55A, (9), 2000, M498-M507. Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507.

Other Functional Consequences of Hip Fracture Loss of Neuromuscular Function (gait/balance) More Difficulties with Instrumental Tasks (Shopping/housework) Increase in Cognitive Deficits (50% in hospital; 25% at 2 months) Increase in Depressive Symptoms (50% in hospital; 25% at 2 months) Changes in Social Function (visiting with others/participating in activities) Magaziner, J., Hawkes, W., Hebel, J.R., Zimmerman, S.I., Fox, K.M., Dolan, M., Felsenthal, G., Kenzora, J. Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci, 55A, (9), 2000, M498-M507. Magaziner, J., Simonsick, E.M., Kashner, T.M., Hebel, J.R., Kenzora, J.E. Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol, 45, (3), 1990, M101-M107. Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507. Magaziner J, et al. J Gerontol. 1990;45:M101-M107.

Patterns Of Recovery

Recovery In Lower Extremity ADLs 10 20 30 40 50 60 70 80 2 6 12 18 24 Get In/Out of Bed Walk 10 Feet Rise From Chair Walk 1 Block Months Unpublished data from Baltimore Hip Studies Cohort 2

Time to Recuperation Following Hip Fracture Summary Measures of Functioning Upper Extremity ADL 2 4 6 8 10 12 14 16 Depression Cognition Balance Gait Social Instrumental ADL Lower Extremity ADL Time (Months) Magaziner, J., Hawkes, W., Hebel, J.R., Zimmerman, S.I., Fox, K.M., Dolan, M., Felsenthal, G., Kenzora, J. Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci, 55A, (9), 2000, M498-M507. Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507.

Hip Fracture Recovery Process RECOVERY FROM IMPAIRMENTS RECOVERY IN FUNCTIONAL LIMITATIONS Neuromuscular gait/balance Cognitive Affective Strength RECOVERY IN DISABILITY Lower Extremity ADLs Instrumental ADLs Social Activities PATHOLOGY Osteoporsis Sarcopenia Chronic Conditions Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507.

Interventions and Their Timing

Hip Fracture Recovery Process RECOVERY FROM IMPAIRMENTS RECOVERY IN FUNCTIONAL LIMITATIONS Neuromuscular gait/balance Cognitive Affective Strength RECOVERY IN DISABILITY Lower Extremity ADLs Instrumental ADLs Social Activities PATHOLOGY Osteoporsis Sarcopenia Chronic Conditions Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507.

Hip Fracture Treatments Suggested By Deficits and Recovery Sequence Recovery Process Possible Treatments Treat Pathology Osteoporosis Bone strengthening medications Sarcopenia Pharmacalogic agents Chronic conditions Stabilize exacerbations, control complications Vitamin D, Calcium, Protein, other nutrition Treat Impairment Hip fracture Surgical management , anesthesia, transfusion Reduce Functional Limitations Neuromuscular Gait training, balance training, strength training Cognitive Medical stabilization, orientation therapy Affective Medication, psychological therapy Minimize Disability ADLs Physical therapy IADLs Occupational therapy Social activity Social engagement strategies

Conclusion

The Future Multidisciplinary/multi-component interventions have the potential to improve long term outcomes Need to design programs using effective components that target individual patient need, and evaluate their combined effect Packages of interventions need to be tested and translated for use in practice Need strategies for delivering these interventions in a coordinated manner

Hip fracture is a multi-faceted problem which requires multiple treatments/interventions