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

2. 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

3. 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

4. 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

5. 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.

6. 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.

7. 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.

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

9. THE BALTIMORE
HIP STUDIES

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

11. 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

12. Consequences of Hip Fracture Selected Finding From Baltimore Hip Studies

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

14. 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:

15. 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,
37000
36500
36000
3-10 60
120
180
240
300
360
Days Post-fracture
Fox KM, et al. Osteoporos Int. 2000;11:31-35.

16. 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,
16000
15500
3-10 60
120
180
240
300
360
Days Post-fracture
Fox KM, et al. Osteoporos Int. 2000;11:31-35.

17. 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.

18. 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.

19. Patterns Of Recovery

20. Recovery In Lower Extremity ADLs10 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

21. 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.

22. 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.

23. Interventions and Their Timing

24. 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.

25. 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

26. Conclusion

27. 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

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