Surgical, nonsurgical management of hip fracture compared in nursing home residents with advanced dementia

Patients who had been managed surgically had less documented pain and fewer pressure ulcers, but use of antipsychotic drugs and physical restraints did not appear to differ, and few patients in either group remained ambulatory at six months.


Surgical hip fracture repair was associated with lower mortality rates than nonsurgical management in nursing home residents with advanced dementia, but adverse outcomes remained common regardless of treatment, a recent study reported.

In a retrospective cohort study, researchers used nationwide Medicare claims data to compare survival rates among nursing home patients with advanced dementia and hip fracture who received surgical versus nonsurgical management. Documented pain, use of antipsychotics, use of physical restraints, pressure ulcers, and ambulatory status were also compared in nonsurgical and surgical patients who survived for six months. The study results were published online May 7 by JAMA Internal Medicine.

A total of 3,083 patients were included in the study. Mean age was 84.2 years, and 79.2% were women. Surgical repair was performed in 2,615 patients (84.8%), while 468 (14.2%) were managed nonsurgically. Before the fracture, 879 patients (28.5%) had been ambulatory. At six-month follow-up, 31.5% of surgical patients and 53.8% of nonsurgical patients had died. The adjusted hazard ratio for death among surgery patients compared with nonsurgery patients was 0.88 (95% CI, 0.79 to 0.98).

Among the 2,007 patients who were alive at six-month follow-up, those who had been managed surgically had less documented pain and fewer pressure ulcers than those who had not (adjusted hazard ratios, 0.78 [95% CI, 0.61 to 0.99] and 0.64 [95% CI, 0.47 to 0.86], respectively). However, use of antipsychotic drugs and physical restraints did not appear to differ between groups, and few patients in either group remained ambulatory at six months (10.7% vs. 4.8%, respectively). Fewer than a quarter of patients (21.5%) received hospice care within six months of the fracture, and 1.1% of patients in both the surgical and nonsurgical groups got a “do not hospitalize” directive.

The authors noted that unmeasured differences between the groups may have affected their findings and that secondary outcomes were measured at one point in time, among other limitations. However, they concluded that their findings highlight the need for improved quality of care in nursing home residents with advanced dementia and hip fracture. “Proxies for these residents should consider the survival benefit of surgery together with the overall goals of care when making the difficult decision of whether to pursue surgery,” they wrote. They also recommended greater use of hospice and palliative care in this population, regardless of surgical repair.

An accompanying invited commentary said the study adds important new information about nursing home patients with advanced dementia who have a hip fracture but did not address factors that could help inform physicians' and families' choice of treatment, including risk for very early death and potential for postoperative complications. The commentary authors agreed with the study authors that there should be a larger role for hospice care and orders limiting hospitalization, calling the low rate of both the study's “most distressing finding,” since previous research has shown that hip fracture in advanced dementia is often a marker of the end of life.

“This situation calls for a discussion of goals of care and should prompt serious consideration of initiation of hospice care,” the commentary authors wrote. “Moreover, families and proxies need to understand the likely ultimate causes of death in patients with advanced dementia.”