Hip fracture in older adults: Epidemiology and medical management

INTRODUCTION — As the population ages, the number of hip fractures continues to increase. Older patients have weaker bones and are more likely to fall due to poorer balance, medication side effects, and difficulty maneuvering around environmental hazards. Clinicians in many fields are involved in caring for patients with hip fractures and should be familiar with the basic assessment and management of these injuries. This topic will discuss the epidemiology and risk factors for hip fractures and the timing of surgery for older adults. Related concerns are discussed in more depth separately, including:

●Perioperative thromboprophylaxis (see "Prevention of venous thromboembolism in adults undergoing hip fracture repair or hip or knee replacement")

●Perioperative delirium (see "Delirium and acute confusional states: Prevention, treatment, and prognosis")

●Postoperative treatment of osteoporosis (see "Bisphosphonate therapy for the treatment of osteoporosis", section on 'Use immediately after fracture')

Preoperative evaluation, risk assessment, and risk management are discussed in multiple other UpToDate topics:

●(See "Preoperative evaluation for anesthesia for noncardiac surgery".)

●(See "Overview of the principles of medical consultation and perioperative medicine".)

●(See "Evaluation of perioperative pulmonary risk".)

●(See "Management of cardiac risk for noncardiac surgery", section on 'For urgent or emergency surgery'.)

●(See "Evaluation of cardiac risk prior to noncardiac surgery".)

Anatomic considerations, initial management, and the types of hip fractures are discussed separately. (See "Overview of common hip fractures in adults".)

EPIDEMIOLOGY

Incidence — Hip fractures are common and likely to increase as the population ages. Worldwide, the total number of hip fractures is expected to surpass six million by the year 2050 [1]. Fracture rates vary by country, with the highest age- and sex-standardized incidence rates per 100,000 population observed in Denmark (315.9), Singapore (314.2), and Taiwan (253.4) and the lowest rates in Brazil (95.1), Thailand (95.2), and the United Kingdom (134.0) [2]. A total of 310,000 individuals were hospitalized with hip fractures in the United States alone in 2003, according to data from the United States Agency for Healthcare Research and Quality [3]. Approximately one-third (101,800) of fracture patients go on to receive a hip replacement. From 1996 to 2010, there was a decline in the incidence of hip fractures in the United States, with a total of 258,000 recorded for hospitalized patients. While the reasons are not entirely clear, possible explanations include the release of several bisphosphonates, as well as lifestyle changes that include an increased focus on calcium and vitamin D supplementation, avoidance of smoking, moderation of alcohol use, awareness of falls, and regular weightbearing exercise [4,5]. Data from multiple countries reveal that this decreasing trend has continued across multiple countries from 2005 until 2018 [2].

A large review of hip fractures in the United States found that femoral neck and intertrochanteric fractures occur most commonly among women and among patients ages 65 and over [6]. Intracapsular (ie, femoral neck) fractures occurred approximately three times more often in women. Intertrochanteric extracapsular fractures also occurred in a 3:1 female to male ratio. Subtrochanteric fractures show a bimodal distribution (20 to 40 years and over 60 years), with older patients experiencing fragility fractures [7,8].

Isolated trochanteric fractures occur often in young, active adults [9,10]. Trochanteric fractures in older patients usually result from direct trauma (eg, fall) but can be associated with pathologic injury (eg, fracture through bone metastases). (See "Clinical presentation and evaluation of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma".)

Morbidity and mortality — Hip fractures substantially increase the risk of major morbidity and death in older patients [11,12]. These risks are especially high among nursing home residents, particularly men, patients over age 90, those with cognitive impairment and other comorbidities, individuals treated nonoperatively, and those who cannot ambulate independently [13-15]. Approximately one-half of patients are unable to regain their ability to live independently [16].

In-hospital mortality rates range from approximately 1 to 10 percent depending upon the location and patient characteristics, and rates are typically higher in men, although this discrepancy appears to be declining in some areas [17-22]. In a global study, one-year mortality rates differed across countries, ranging from 12.1 to 25.4 percent in females and from 19.2 to 35.8 percent in males [2]. Mortality may be declining in some regions [2,4]. In a meta-analysis of prospective studies, the mortality risk in older patients (age ≥80 years) was elevated during the first three months following a hip fracture, with a higher risk in men compared with women (hazard ratio [HR] 7.95, 95% CI 6.13-10.30 and HR 5.75, 95% CI 4.94-6.67, respectively) [23]. Although it decreases over time, the increased risk of death likely persists [22-24]. However, one large prospective case-control study found no increased risk of mortality after the first year following a hip fracture among women 70 years or older [25].

RISK FACTORS — Major risk factors for hip fractures among older patients include osteoporosis and falls. It is estimated that approximately 30 to 60 percent of community-dwelling older adults fall each year [26]. Approximately 90 percent of hip fractures in older patients occur from a simple fall from the standing position [27]. Women sustain hip fractures more often due to their higher rates of osteoporosis. The lifetime risk of hip fracture is 17.5 percent for women and 6 percent for men [28]. On average, women who sustain a femoral neck fracture are 77 years old and men are 72 years old [27]. Risk factors for falls and for osteoporosis are discussed separately. (See "Falls in older persons: Risk factors and patient evaluation" and "Falls: Prevention in community-dwelling older persons" and "Osteoporotic fracture risk assessment".)

Patients with a low body mass index (BMI; <22) appear to be at higher risk of hip fracture compared with those with a higher BMI (22 to 25) [29]. While fracture risk levels off at BMIs of 25 or more in younger individuals, among women age 70 to 79, the risk of hip fracture continues to decrease with increasing BMI.

Other associations include low socioeconomic status [30-32], cardiovascular disease [33], some endocrine disorders (eg, diabetes, hyperthyroidism), and certain medications that increase the likelihood of falling (eg, benzodiazepines, opioids, antidepressants) or weaken bone [34-37]. (See "Bone disease with hyperthyroidism and thyroid hormone therapy", section on 'Fracture risk' and "Bone disease in diabetes mellitus", section on 'Bone fracture' and "Drugs that affect bone metabolism", section on 'Drugs that may have adverse effects'.)

Patients with hip fractures are at increased risk for a second fracture; the risk of a second fracture is greater for older patients and patients who have a higher functional level [13,38].

PREVENTION — Preventing hip fractures is of great importance in older adult patients. These strategies, including fall prevention and the treatment of osteoporosis, are discussed separately. (See "Falls: Prevention in community-dwelling older persons" and "Osteoporotic fracture risk assessment" and "Overview of the management of low bone mass and osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men".)

INDICATIONS FOR SURGERY — Most hip fractures require surgical repair [39]. Nonoperative management may be considered in patients with severe frailty, immobility prior to injury, or very limited lifespan due to severe medical comorbidities. Although data are limited, one multi-site cohort study found that health-related quality of life and overall quality of life were similar in frail, institutionalized older adults undergoing operative and nonoperative management. Those undergoing surgical repair were noted to have lower pain in the first week following fracture and lower mortality rates. Treatment satisfaction was high in both groups [40]. For these patients, a goals-of-care discussion should be undertaken with patients and/or their surrogates, including tangible prognostic information, specifically the overall poor rates of survival and functional recovery associated with hip fracture in this population (see 'Morbidity and mortality' above). The decision to pursue operative management needs to be carefully considered in the context of benefits and risks of orthopedic surgery, symptom management, and the patient's life expectancy. In patients with life-limiting diseases, such as advanced dementia, patient-centered comprehensive interdisciplinary palliative and hospice care without concurrent operative management may be a more suitable model of care [41].

In addition, the specific fracture type (eg, femoral neck and intertrochanteric versus trochanteric fractures) may influence the need for surgical intervention. (See "Overview of common hip fractures in adults", section on 'Femoral neck fractures' and "Overview of common hip fractures in adults", section on 'Intertrochanteric fractures' and "Overview of common hip fractures in adults", section on 'Trochanteric fractures'.)

The benefit of surgery was suggested by a single center retrospective study of 340 patients ≥60 years of age who were offered surgical treatment for a hip fracture [42]. Mortality in patients who chose nonoperative treatment was four-fold higher at one year and three-fold higher at two years than patients who had the fracture repaired. All patients were mobilized early and received mechanical prophylaxis for deep vein thrombosis.

TIMING OF SURGICAL INTERVENTION — The timing of surgery depends on the medical stability of the patient and whether there are treatable comorbid illnesses that can be efficiently optimized prior to surgical treatment. The timing of surgical intervention may have an important impact upon patient outcomes [39]. We advise:

●In patients who are medically stable, surgery can be performed promptly (ie, within 24 hours of hospitalization).

Delay in surgical repair will result in postponement of full weightbearing status, leading to delayed functional recovery. In addition, prolonged bed rest may increase the risk of medical complications, including deep vein thrombosis, pneumonia, urinary tract infection, and skin breakdown.

●For patients who require stabilization of comorbid illness (eg, unstable angina, heart failure, or poorly controlled obstructive lung disease), we suggest proceeding with surgery within 72 hours rather than immediate surgery or additional delay for further optimization. However, if the patient is not medically stabilized within this timeframe, it may be necessary to defer surgery beyond 72 hours. Failure to stabilize coexisting medical conditions prior to surgery may increase the risk of postoperative complications [43]. (See "Evaluation of perioperative pulmonary risk" and "Management of cardiac risk for noncardiac surgery", section on 'For urgent or emergency surgery' and "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Management based on risk'.)

●Unless contraindicated, thromboembolic prophylaxis should be instituted in patients who are awaiting surgery. (See 'Thromboembolic prophylaxis' below.)

●Aggressive pressure ulcer prevention measures should be employed in patients in whom surgery is delayed beyond 24 to 48 hours. (See 'Prevention of pressure ulcers' below.)

A number of studies have examined the association of operative timing on postsurgical outcome [44-58]. Interpretation of these data is complicated by the fact that many early studies were small and underpowered and most did not control for the presence or severity of comorbidities or excluded patients with complicating medical conditions. Subsequent studies that did attempt to control for comorbidities had variable outcomes [51-58].

●Surgical repair within 24 hours is associated with reduced pain and a decreased length of stay compared with delayed surgery (>24 hours) [56].

●In a randomized trial including almost 3000 patients with hip fracture, there was no reduction in mortality or the rate of major complications among those undergoing accelerated surgery (surgery within six hours) compared with standard care (surgery within 24 hours) [59].

●In a meta-analysis of five prospective studies controlling for comorbidities, risk of mortality was lower among patients undergoing earlier surgery (within 72 hours) compared with delayed surgery (relative risk [RR] 0.81, 95% CI 0.68-0.96) [60].

●In a retrospective, population-based cohort study of 42,230 patients, those who had surgery within 24 hours of admission had lower 30-day mortality compared with patients who had surgery >24 hours after admission (5.8 versus 6.5 percent, absolute risk reduction 0.79 percent, 95% CI 0.23-1.35 percent) [61]. This study was notable for the fact that the number of hours from admission to surgery was available for each patient, allowing the investigators to identify an inflection point at which risk of mortality increased (ie, 24 hours). The absolute risk reduction in this study was relatively small, and the observational design makes it possible that residual confounding exists, likely attenuating the risk reduction.

●However, two large studies that also controlled for comorbid conditions suggested that the time to surgery is primarily a marker of comorbidity [55,58]. In a retrospective study of 8383 patients, mortality rates were not different among patients who had surgery more than 96 hours after admission compared with patients who had surgery 24 to 48 hours after admission after adjusting for demographic characteristics and underlying medical problems [55]. The risk of decubitus (pressure) ulcer was associated with delayed surgery (odds ratio [OR] 2.2, 95% CI 1.6-3.1). A subsequent prospective cohort study of 2250 patients also found no association of in-hospital mortality or complications with surgical delays of ≤120 hours after adjusting for demographic characteristics and comorbid conditions [58]. However, higher rates of mortality and medical complications were associated with surgical delays >120 hours, despite adjustment for these factors.

MEDICAL MANAGEMENT

All patients — The clinician should determine the reason for any fall (eg, syncope, stroke), assess for additional orthopedic and internal injuries (eg, intracranial hemorrhage, cervical spine fracture), and initiate management as indicated.

Multidisciplinary management may be beneficial after hip fracture, particularly in older patients. This issue is discussed separately. (See "Hospital management of older adults", section on 'Multidisciplinary team'.)

Pain management — Pain management is important for all patients. The majority of persons undergoing hip fracture will experience moderate to severe pain, and a substantial number of persons (both operative and nonoperative management) will continue to experience moderate to severe pain for a least a month following fracture. Inadequately treated acute pain may increase the risk of chronic pain syndromes. Acetaminophen remains the standard therapy for those with mild pain. Judicious use of opioids should be undertaken for those with moderate to severe pain with doses adjusted based upon patient's self-reported pain scores and interference with function [40,62,63].

Osteoporosis assessment and treatment — Hip fractures in older patients are fragility fractures and thus a manifestation of osteoporosis. All patients with a recent hip fracture should be treated for their underlying osteoporosis [64]. Bone densitometry is indicated to establish a baseline to monitor treatment response but not to determine whether to initiate treatment.

Treatment of osteoporosis and the timing of treatment of osteoporosis with bisphosphonates relative to an acute fracture is discussed separately. (See "Bisphosphonate therapy for the treatment of osteoporosis", section on 'Use immediately after fracture' and "Overview of the management of low bone mass and osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men".)

Patients undergoing surgery

Analgesia — Pain is often undertreated in older patients, which is not only inhumane but impairs functional recovery and increases the risk of delirium, length of hospital stay, and the risk of the development of chronic pain syndromes [65].

Using a multimodal analgesic strategy that includes nonopioid analgesics (eg, acetaminophen), neuraxial anesthesia, and peripheral nerve blocks, when possible, may reduce the need for opioids. Single-injection or continuous blocks can be used preoperatively in patients awaiting surgery and can be continued for postoperative analgesia [66-72]. (See "Anesthesia for orthopedic trauma", section on 'Peripheral nerve blocks for hip fracture'.)

Older adults are generally more sensitive to opioids than younger persons and require lower starting doses of opioids to achieve appropriate analgesia. Intravenous opioids provide faster relief, but oral medications may also be used. (See "Anesthesia for the older adult", section on 'Impact of age-related physiologic changes on anesthetic care'.)

A systematic review concluded that neither skin nor skeletal traction prior to surgery provides any benefit in reducing pain or improving the ease or quality of hip fracture reduction [73]. Eleven studies involving 1654 patients who were primarily older were included.

Thromboembolic prophylaxis — Patients with hip fracture are at high risk of venous thromboembolism. The decision to administer pharmacologic prophylaxis or mechanical prophylaxis depends on the patient-specific risk of bleeding. These issues are discussed in detail separately. (See "Prevention of venous thromboembolism in adults undergoing hip fracture repair or hip or knee replacement".)

For patients who receive pharmacologic deep vein thrombosis prophylaxis, the choice of antithrombotic medication and timing of administration may affect the options for neuraxial anesthesia, due to the risk of spinal epidural hematoma. Thus, thromboembolic prophylaxis should be coordinated with the surgeon and anesthesia clinician. (See "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication".)

Infection prophylaxis — Antibiotic prophylaxis for surgical site infection is indicated for any patient who undergoes surgery for hip fracture. The rationale, efficacy, choice of antibiotic, and timing of administration are discussed separately. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Hip fracture repair'.)

Delirium prevention — Delirium is a common complication in hospitalized older adults and occurs in as many as 61 percent of patients with hip fracture [74]. The risk factors, precipitating factors, and preventive measures for delirium, as well as evaluation, treatment, and prognosis for patients with delirium, including patients with hip fracture, are all discussed separately. (See "Diagnosis of delirium and confusional states" and "Delirium and acute confusional states: Prevention, treatment, and prognosis".)

Constipation — Care should be taken to prevent constipation, especially in patients who receive opioid analgesics. Although stool softeners are widely prescribed prophylactically, there is limited evidence of efficacy. (See "Constipation in the older adult", section on 'Stool softeners, suppositories, and enemas'.)

For patients who are already taking a laxative (not a stool softener), we continue the laxative or prophylactically start a stimulant laxative such as senna or bisacodyl. (See "Constipation in the older adult", section on 'Stimulant laxatives'.)

If constipation develops in a hip fracture patient, we manage it as follows:

●For patients who are eating and have not had a bowel movement in two days, we evaluate them for ileus or fecal impaction (see "Postoperative ileus" and "Constipation in the older adult", section on 'Fecal impaction'). If neither is present:

•For those patients not taking a stimulant laxative (eg, senna or bisacodyl), we begin one. If there is no response (bowel movement) in two days, we add an osmotic laxative (eg, polyethylene glycol or lactulose). (See "Constipation in the older adult", section on 'Osmotic laxatives'.)

•For those patients already taking a stimulant laxative, we add an osmotic laxative (eg, polyethylene glycol or lactulose).

●For all patients, if there is no response to the osmotic laxative and still no evidence of ileus or fecal impaction, we treat with a tap water enema. (See "Constipation in the older adult", section on 'Stool softeners, suppositories, and enemas'.)

In addition, peripherally active mu opioid receptor antagonists (alvimopan or methylnaltrexone) may be helpful in managing patients with opioid-related constipation [75].

Nutrition — In older patients, oral nutritional supplementation (eg, one can three times daily between meals) may be beneficial for reducing minor postoperative complications in patients with hip fracture, preserving body protein stores, and reducing the overall length of stay [76-78], although a systematic review found only weak evidence based on trials with methodologic flaws [77]. Nocturnal enteral feeding should be considered for patients with moderate to severe malnutrition [79]. (See "Enteral feeding: Gastric versus post-pyloric" and "Nutrition support in intubated critically ill adult patients: Enteral nutrition".)

Prevention of pressure ulcers — Pressure ulcers occur in 10 to 40 percent of older adult patients hospitalized for hip fracture and increase nosocomial infection rates and lengths of stay [80]. In a prospective study including 650 patients over age 65 who underwent hip fracture surgery, the incidence of pressure ulcers was greater during the acute hospital period than in the subsequent rehabilitation or nursing home setting over a period of 32 days [81]. Use of foam or alternating pressure mattresses, compared with usual care, may reduce the incidence of pressure ulcers [80]. (See "Prevention of pressure-induced skin and soft tissue injury".)

Bladder catheterization — Short-term use of indwelling urinary catheters appears to reduce the incidence of urinary retention and bladder overdistention compared with intermittent catheterization alone, without increasing the rate of urinary tract infection [82]. Catheters should be removed within 24 hours of surgery to prevent iatrogenic urinary infection; patients can be managed subsequently with intermittent catheterization if needed [82-84]. (See "Catheter-associated urinary tract infection in adults", section on 'Prevention'.)

Blood transfusion — Approximately one-quarter of older adults will require postoperative blood transfusion [85]. Indications and hemoglobin thresholds for transfusion after surgery are discussed separately. (See "Indications and hemoglobin thresholds for RBC transfusion in adults", section on 'Orthopedic surgery'.)

Rehabilitation after hip fracture surgery — Rehabilitation after hip fracture surgery is discussed separately. (See "Overview of geriatric rehabilitation: Patient assessment and common indications for rehabilitation", section on 'Hip fracture'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hip fracture in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Hip fracture (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Epidemiology and impact – Hip fractures are common among older adults, although the incidence has been decreasing over the past decades. Major risk factors are osteoporosis and falls. Hip fractures are associated with substantial risk of death and major morbidity in older adults. (See 'Epidemiology' above and 'Morbidity and mortality' above and 'Risk factors' above.)

●Indications for surgery – Hip fracture repair surgery is indicated for most patients with hip fracture. Nonoperative management may be considered in patients with severe frailty, immobility prior to injury, or very limited lifespan due to severe medical comorbidities. (See 'Indications for surgery' above.)

●Timing of surgery – We perform hip fracture surgery within 24 hours of hospitalization for patients who are medically stable and without significant comorbid illness. For patients who require stabilization of comorbid illness (eg, unstable angina, heart failure, or poorly controlled obstructive lung disease), we suggest proceeding with surgery within 72 hours rather than immediate surgery or additional delay for further optimization (Grade 2C). However, if the patient is not medically stabilized withing this timeframe, it may be necessary to defer surgery beyond 72 hours. (See 'Timing of surgical intervention' above.)

●Pain management – Pain management is indicated for all patients. Using a multimodal analgesic strategy that includes nonopioid analgesics (eg, acetaminophen), neuraxial anesthesia, and peripheral nerve blocks, when possible, may reduce the need for opioids. For patients who require opioids, lower starting doses may be appropriate since older adults are generally more sensitive to opioids compared with younger persons. (See 'Analgesia' above and 'Pain management' above and "Anesthesia for orthopedic trauma", section on 'Hip fracture'.)

●Osteoporosis treatment – All hip fracture patients should be treated for osteoporosis, if present. Patients with a fragility hip fracture should be evaluated with bone densitometry to establish a baseline to monitor treatment response. Treatment of osteoporosis in hip fracture patients is similar to other osteoporotic patients. (See 'Osteoporosis assessment and treatment' above and "Overview of the management of low bone mass and osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men".)

●Further management of operative patients – Other aspects of medical management for patients with hip fracture include prevention of constipation, nutrition, prevention of pressure ulcers, management of bladder catheterization, and blood transfusion as necessary. In addition:

•Patients with hip fracture are at high risk of venous thromboembolism. The decision to use pharmacologic or mechanical venous thromboembolism prophylaxis depends on the patient-specific risk of bleeding. (See "Prevention of venous thromboembolism in adults undergoing hip fracture repair or hip or knee replacement".)

•Antibiotic prophylaxis is indicated to prevent surgical site infection in patients who undergo surgery for hip fracture. (See 'Infection prophylaxis' above and "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

•Patients with hip fracture are at high risk for postoperative delirium. Prevention and treatment of delirium is similar to that in other hospitalized patients. (See 'Delirium prevention' above and "Delirium and acute confusional states: Prevention, treatment, and prognosis".)