Hip Fracture in Nursing Home Residents with Advanced Dementia: An Opportunity for Palliative Care

Overall, 21.5% of NH residents utilized comfort-focused care within 6 months after hip fracture, with a mean time to utilization of hospice care of 56 ± 49 days. In those who were managed surgically, 19.3% utilized hospice care, as compared with 33.8% in those who did not receive surgical intervention. In NH residents who survived 6 months after hip fracture, only 1.1% in both groups acquired a DNH directive.

Conclusion. In older long-stay NH residents with advanced dementia and hip fracture, surgical repair was associated with lower all-cause mortality, less documented pain, and fewer pressure ulcers compared to nonsurgical management. However, adverse clinical outcomes such as pain, physical restraint use, pressure ulcers, and antipsychotic drug use were common regardless of treatment modality. The high incidence of these adverse outcomes and hazardous interventions, coupled with low utilization of comfort-focused care and DNH directive, highlight an opportunity to improve the quality of care in this vulnerable population.

Commentary

Hip fracture is very common in NH residents, with an overall incident rate of 2.3 per 100 person years and is associated with a high mortality rate of 36.2% by 6 months after fracture.^1,2 Moreover, Neuman and colleagues have recently reported that among NH residents who have some degree of functional independence in locomotion prior to hip fracture, 54% either die or develop new total dependence in locomotion within 6 months of fracture and that severe cognitive impairment is a risk factor highly associated with these adverse outcomes.³ Despite this emerging knowledge, surgical repair of hip fracture remains the mainstay treatment in many NH residents in the hope of alleviating pain and improving mobility, and palliative care is considered only when patients are imminently dying or have deteriorated past the point of meaningful recovery. In cases of NH residents with advanced dementia whose life expectancy is limited and whose care goals may favor maintaining comfort, the health care proxies are frequently challenged with a difficult choice of either pursuing or foregoing surgical management—a complex medical decision to be made in the absence of sufficient evidence in this uniquely frail patient population.

The study reported by Berry and colleagues provides an important and timely investigation in examining associations of adverse clinical outcomes (mortality, pain, pressure ulcer) and hazardous interventions (physical restraint and antipsychotic drug use) in long-stay NH residents with advanced dementia and hip fracture who underwent surgical repair or nonsurgical management. The authors reported a 6-month mortality rate of 31.5% in NH residents who underwent surgical repair, an event rate similar to that reported by Neuman and colleagues. While surgical repair after hip fracture was associated with a decreased risk of death compared to nonsurgical management, high incidences of pain (29.0% to 30.9%) and pressure ulcers (11.2% to 19.0%), and frequent physical restraint use (11.1% to 13.0%) and antipsychotic drug use (20.4% to 29.5%) were noted in NH residents who survived 6 months after fracture regardless of treatment modality. These findings are consistent with the high rate of post-hip fracture functional disability previously reported by Neuman and colleagues, and highlight the trajectory of decline, frequent distressing symptoms, and prevalent use of pharmacologic and nonpharmacologic restraints in long-stay NH residents after hip fracture. Taken together, the low utilization of comfort-focused care (21.5%) and DNH directive (1.1%) in NH residents who survived 6 months suggest a missed opportunity to integrate palliative care in a patient population that stands to benefit from this intervention.

This study is the first to report the associations between hip fracture surgery and a reduction in adverse outcomes such as pain and pressure ulcer that commonly affect vulnerable NH residents with advanced dementia. This study was well designed and leveraged strengths of Medicare claims data linked with MDS assessments to capture outcome measures including pain, pressure ulcer, and restraint use that would otherwise be difficult to ascertain. However, as in all retrospective cohort design, there were limitations in this study. For instance, secondary outcomes were determined from a single time point (ie, first MDS assessment completed between 120 to 240 days following hip fracture) and thus data capture may be incomplete. Additionally, other conditions important to complex decision making in the care of frail older adults including postoperative complications (eg, delirium, infections, cardiac complications) and in-hospital mortality were not examined. Despite these limitations, this study has enhanced our understanding of the clinical course of long-term care NH residents with advanced dementia who endured hip fracture.