August 19, 2013
After a hip fracture or other serious fall-related injury, how much independence older adults regained depended to a large extent on how well they were doing beforehand, a study showed. Functional trajectories were tightly linked, with rapid recovery observed only in those with no or mild disability before the fall, Thomas M. Gill, M.D., of Yale University, and colleagues found.
Individuals with progressive disability in the year prior to their fall had only a 25% chance of a "little recovery," whereas none with preexisting severe disability recovered at all, the researchers reported online in JAMA Internal Medicine. The findings should be useful in counseling patients and families on expectations for recovery and possibly for management decisions, Gill's group suggested. "Based on our findings, for example, palliative care might be recommended, in addition to rehabilitation, for patients who had moderate, progressive or severe disability before a hip fracture," they wrote. "In contrast, among patients who had no disability or mild disability before their serious fall injury, more aggressive rehabilitation could be pursued to enhance the likelihood of a rapid recovery."
However, the outlook wasn't actually that bleak for disabled older adults and shouldn't exclude them from "reasonable access to restorative services," Stephanie Studenski, M.D., M.P.H., of the University of Pittsburgh and its VA Healthcare System, argued in an accompanying invited commentary. The analysis stacked the cards with a definition of recovery based on time to change in the number of functions of daily living and mobility with which older adults required assistance. Because people with fewer independent functions before a fall-related injury have fewer to regain afterward, they could only be designated as having little or no recovery, Studenski explained.
Yet recovery by the common-use meaning of "getting back to normal" was about equally likely across the trajectories, she pointed out. The proportion that returned to their pre-fall level of functional independence was 56% for both those with no preexisting disability and those with moderate disability, and 61% for those with severe disability. "Certainly, expectations for function after a serious fall injury must be based in part on a clear understanding of pre-injury function," she wrote. But for disabled older persons, "if recovery means return to pre-injury status, then its probability is the same for them as for others in their age group."
The analysis included 130 individuals who sustained a serious fall-related injury among 754 in a prospective cohort study of community-living seniors who were all members of a large health plan. Participants were 70 and older and living near Yale. All were initially independent in the basic activities of daily living. About half lived alone, and less than a quarter had cognitive impairment or depression symptoms, but nearly two-thirds were physically frail. Monthly interviews indicated the trajectory of disability that accrued in the year preceding the injury, which was fairly evenly spread from full functional independence (12.3%) to mild (26.2%), moderate (26.2%), progressive (17.7%) and severe disability (17.7%).
Severe disability was characterized as needing assistance with about 10 of the 13 activities assessed: bathing, dressing, walking inside the house and transferring from a chair; shopping, housework, meal preparation, taking medications and managing finances; and mobility in terms of walking a quarter of a mile, climbing a flight of stairs, lifting or carrying 10 lbs. and driving. Progressive disability was associated with an increase in the number of disabilities from about five to more than seven during the year before the fall-related injury.
In the year afterward, those with no disability before the fall had a 45% probability of a rapid recovery and a 38% probability of gradual recovery. The probabilities of a rapid recovery were only 17% for those with mild disability and were nonexistent for the other groups. Gradual recovery was most likely for the mildly disabled (44% probability) and moderately disabled (35% probability). The overwhelming probability was no recovery for those with progressive disability before the fall (70%) or severe disability (100%). The trajectories of recovery were "consistently worse" for the 62 older adults who sustained a hip fracture than for the other fall-related injuries leading to hospitalization.
"Adjustment for relevant covariates had relatively little effect on the post-fall probabilities, suggesting that the primary determinant of the post-fall functional trajectory was the pre-fall functional trajectory," the researchers noted. Limitations included use of self-reported data rather than objective measurement of mobility and other functional capabilities, lack of data on who received interventions that could have altered the course of recovery, and the high level of physical frailty in the sample that might not generalize to other populations of older adults.
By Crystal Phend, Senior Staff Writer, MedPage Today