Hip Fractures in Patients With Advanced Dementia: What Treatment Provides the Best Palliation?

Nursing home residents sustaining a hip fracture have poor outcomes both in terms of survival and ambulation. Using US Medicare data on nursing home residents from 2005 through 2009, Neuman and colleagues1 found that by 6 months after the fracture, 36.2% had died; moreover, among residents who were not totally dependent in prefracture locomotion, 54% had either died or developed new total dependence. Nonetheless, unless patients are imminently dying, conventional wisdom suggests that the advantages of repairing hip fractures in terms of managing pain and facilitating mobility usually outweigh the disadvantages. These issues are particularly pertinent for nursing home residents with advanced dementia for whom a goal of maintaining comfort is often the predominant preference of their proxy decision maker.2 However, the literature contains limited information to guide proxy decision makers regarding shortand long-term outcomes of operative or nonoperative management of hip fracture in these patients. In this issue of JAMA Internal Medicine, Berry and colleagues3 use Medicare claims and nursing home Minimum Data Set (MDS) data to report on several outcomes of nursing home residents with advanced dementia whose hip fractures were treated operatively (85%) or nonoperatively (15%).3 By 6 months after fracture, deaths occurred in 31.5% of those treated surgically and 53.8% of those treated without surgery. One might have expected an even higher figure for the nonoperative group. Although we are not presented exact figures for earlier mortality, including in-hospital mortality, the survival curve in the nonoperative cohort drops much more steeply in the first few months following the fracture. Consistent with this, the adjusted median survival is only 0.4 years in the nonoperative group. Among survivors, MDS assessments between 120 and 240 days following the fracture showed that 29% and 31% of residents reported pain among those treated operatively and nonoperatively, respectively. Antipsychotic use was more common in the operative group (29.5% vs 20.4%), and pressure sores were more common in the nonoperative group (19% vs 11%); however, neither of these results was statistically significant. There are many methodological strengths in this study3; however, as with all observational studies of treatment, there are issues in interpreting the results. Residents treated nonoperatively were much more impaired at baseline than those in the operative group, which likely influenced both the choice not to operate and their poor outcomes. For example, 26% of residents in the nonoperative group were completely dependent in their activities of daily living, as opposed to 5% in the surgical group. Similarly, only 10.5% of those in the nonoperative group were fully ambulatory prior to the fracture compared with 31.8% in the operative group. The authors used a multivariable Related article page 774 Research Original Investigation Surgical Repair of Hip Fracture in Nursing Home Residents With Advanced Dementia