Mortalität, gesundheitsbezogene Lebensqualität und Funktionalität nach proximaler Oberschenkelfraktur und ihre Einflussfaktoren in der 5-Jahres-Nachuntersuchung

Hip fractures grow in importance due to an expanding and aging population. It is associated with a high mortality as well as a decreased outcome in health-related quality of life and functionality. 402 patients were included in a prospective, single center study. Mean age of the mostly female cohort at inclusion was 81 years. Follow-up surveys were retrospectively before fracture at admission to the hospital, at discharge from hospital, 6 and 12 months after fracture. This data was added by the present 5-year-follow-up study. The aim of this study was to identify mortality rate, health related quality of life and functionality after hip fracture with its predicting and affecting factors. Of 402 included patients 7 were lost to follow-up and 152 patients (38%) survived the study period of five years. Mortality was more than 25% in the first year after surgery and between 7 to 9% in the following years. Significant independent risk factors for death were male gender (p = 0,002), higher age (p < 0,001), lower Charlson Comorbidity Score (p = 0,033), lower Barthel-Index (p = 0,024), lower Mini-Mental State Examination (p = 0,002) and occurrence of delirium during hospitalization (p = 0,008). The results confirm a high mortality rate after hip fracture. To provide best results aims should be obtaining functionality and independence in the fragile group of patients. Delirium needs to be prevented and in case of occurrence it should be diagnosed as soon as possible to provide early treatment. Patients should be discharged into rehab and discharge management initiated immediately to optimize the individual aftercare. Of 152 surviving patients 134 patients were examined in the 5-year follow-up. Average age at time of follow-up was 83 years while most patients were female (81%). Added data by the 5-year follow-up included functional status and health-related quality of life which allows conclusions to affecting factors by correlating to before fracture status. Using EQ5D-Index the health-related quality of life among the cohort was evaluated. Results showed poorer status even 5 years after hip fracture (0,66; CI 0,61-0,72) compared to general german population older than 65years (0,87; CI 0,86-0,89). It was significantly lower in patients with cognitive (MMSE p = 0,050) and functional (Barthel-Index p = 0,001) impairment, older age (p = 0,023) and multiple diseases (ASA-Score p = 0,049; CCS p = 0,048). Possible depression (GDS p = 0,022) or delirium (DRS p = 0,049) were associated with lower EQ5D-Index, while total hip arthroplasty showed a positive influence (p = 0,048). Functionality is an explicable independent factor affecting HRQOL, which should be preserved to maintain a higher level of health-related quality of life. Functionality is at the lowest level at time of discharge from hospital and increases during the following 6 to 12 months to almost reach the level before fracture. A decrease in long-term observation is mostly due to increased age and concomitant multimorbidity. The course of functionality pointed out by this study highlights the importance of rehabilitation since the highest potential of recovery is in the first months following surgery. Functional outcome is significantly lower in nursery home residents (p < 0,001), those who were discharged into a nursery home (p < 0,001), older patients (p = 0,002), higher ASA-Score (p = 0,001) and Charlson-Comorbidity-Index (p = 0,018), cognitive impaired patients (p < 0,001), possible depression (p = 0,029) or delirium (p = 0,002) and in occurrence of a Type II complication (p < 0,001). Better functional outcome was seen in patients treated with total hip arthroplasty (p = 0,012). Multivariate analysis showed age (p = 0,020), Barthel-Index prior to hip fracture (p < 0,001), Mini Mental State Examination (p < 0,001) and occurrence of Type II complication (p = 0,001) as independent risk factors affecting the functional outcome. While age and functional status before hip fracture cannot be influenced, special attention should be payed regarding cognitive impairment and prevention of Type II complications. Since prevalence of cognitive impairment increases with higher age it is to be assumed, that this fragile group of patients will gain more clinical relevance. Methods for early detection and special treatment of any kind of dementia should be established in clinical routine. Occurrence of Type II complications may signalize a more fragile patient and early diagnosis and treatment are essential to preserve long-term functionality.