Medication in older hip fracture patients. Falls, fractures, and mortality

Abstract: Background and aim: Due to an increasingly ageing population, the number of hip fracture patients, often with multiple chronic diseases and multiple pharmacotherapy, is set to rise. The high risk of adverse outcomes that hip fractures lead to in older individuals is well described, including high first-year mortality. This thesis aim to improve our knowledge of older hip fracture patients’ treatment with drugs that potentially increases the risk of falls, fractures, bleeding, and death, in order to identify potentially effective interventions for preventing adverse outcome from the medication. Methods and results: Three general population-based cohort studies and one observational cohort study, on medication in hip fracture patients, are included. National registry data for 2,043 patients (I, II, III) and medical journals for 255 patients (IV) were analysed. Paper I aimed to describe the use of fall-risk-increasing drugs (FRID) and to analyse whether there were any changes in the prescribing six months after a hip fracture, compared to six months before. A majority was exposed to FRID prior to the fracture and an increase of thirty percentage-points in post-fracture prescribing was found. Anti-osteoporosis treatment increased only marginally, but in hospitals offering geriatric support the prescribing of anti-osteoporosis drugs increased significantly compared to hospitals without this support. In Paper II, first-year mortality was shown to be significantly higher in patients exposed to ≥4 FRID, polypharmacy, psychotropic and cardiovascular drugs. Regression analyses of treatment with FRID, adjusted for age, sex and any ≥ 4 drugs, showed higher mortality in patients exposed to ≥4 FRID compared to ≤3 FRID. In Paper III, exposure to potentially inappropriate medication (PIM) was found in 81% of the patients. Logistic regression, data adjusted for age, sex, and use of ≥5 drugs, indicated that exposure to any PIM and analgesic-PIM (tramadole, dextropropoxyphene) increased six months’ mortality significantly. Exposure to other categories of opioids did not indicate higher mortality, Patients with a length of in-hospital stay (LOS) ≥10 days had a higher six months’ mortality than patients with a LOS of ≤ 9 days. In Paper IV, regression analysis of hip fracture patients’ exposure to low-dose acetylsalicylic acid (LdAA), adjusted for multiple confounders, showed higher first-year mortality and that more blood transfusions were given to patients treated with LdAA compared to non-users. Levels of coagulation factors were also significantly higher in the blood of patients treated with LdAA compared to unexposed patients. Conclusions: The thesis proposes that older hip fracture patients are frequently exposed to FRID and PIM, that exposure to ≥ 4 FRID, any PIM, analgesic-PIM, LdAA, polypharmacy, and a LOS of ≥ 10 days are factors associated with higher mortality. Additionally was found that exposure to FRID increases significantly after the fracture and that anti-osteoporosis treatment is more frequently prescribed to orthopaedic patients when geriatric support is available. The overall conclusion lies in the identification of plausible ways to reduce adverse outcome and improve the care of hip fracture patients. Further studies on ways of improving the care of hip fracture patients should be explored by evaluating methods of preventing drug-related adverse outcome, as well as of strengthening the collaboration between orthopaedic and geriatric professionals.