Acknowledgements

1. Recovering From Hip FractureJay Magaziner, PhD, MSHyg and Nancy Chiles, BSUniversity of Maryland School of Medicine Baltimore, Maryland2016 Symposium for State and Local Commissions on Aging September 22, 2016

2. Acknowledgements • The many investigators and staff in the Baltimore Hip Studies Program • The patients and hospitals that participated in studies over the past 30 years • The National Institute on Aging, which has funded this work on hip fracture recovery for the past 30 years

3. Disclosures • During the past year, Dr. Magaziner has consulted or served on advisory boards for: American Orthopaedic Association; Ammonett; Novartis; Pluristem; Scholar Rock; Viking Therapeutics

4. Overview of Presentation • Magnitude of the Problem • 30 Years of Evidence from the Baltimore Hip Studies Program: From Observation to Intervention • Consequences • Recovery Patterns • How This Information Informs Intervention Targets

5. Magnitude of Problem • Estimated 3.9 million hip fractures worldwide annually • Three-quarters of hip fractures are in women • Despite advances in surgical procedures, post-operative care, and long term rehabilitation, hip fractures rank in the top ten worldwide in terms of disability and functional decline.

6. 3.5 Projected Data 3.0 Men 2.5 Women Hip Fractures Worldwide, n (million) 2.0 1.5 1.0 0.5 0 1990 2000 2010 2020 2030 2040 2050 Year Hip Fractures Are Common:Number Projected to Increase Gullberg B, et al. Osteoporos Int. 1997;7:407–413.

7. Assessing the Risk for Hip Fracture1,2 Strength of Bone Fall-Related Trauma Risk of Fall Neuromuscular Function Environmental Hazards Time Spent at Risk Bone Turnover Bone Mass Force of Impact Type of Fall Protective Responses Energy Absorption Bone Quality 1. Kanis JA. Osteoporosis. Blackwell Healthcare Communications Ltd; 1997. 2. Cumming RG, et al. Epidemiol Rev. 1997;19:244–257.

8. FALLSPREVALENCE IN OLDER PERSONS Falls (percentage of men and women falling each year) Community 33 percent Institution 50 percent

9. THE BALTIMORE HIP STUDIES

10. Goals of Baltimore Hip Fracture Studies To identify, develop, and evaluate strategies to optimize recovery from hip fracture.

11. The Baltimore Hip Studies (BHS) • Over the past 30 years, the BHS have enrolled and followed more than 4,000 hip fracture patients admitted to 25 Baltimore area hospitals. • Outcomes studied include mortality, functional recovery, and changes in bone mineral density, muscle mass and composition, bone and muscle strength. • Studies have progressed from observational to interventional. • BHS Investigators have collaborated on many single and multi-center studies of hip fracture outcomes outside Baltimore

12. Consequences of Hip FractureSelected Finding FromBaltimore Hip Studies

13. Some Consequences of Hip Fracture Death 18-33% die within 1 year Hospitalization 3-8 days, regional variation Disability and Dependency 15-25% to institution for 1+ years 25-75% do not regain pre-fracture functioning Burden Patients Family Health care systems

14. Consequences of Hip Fracture: Increased Hip Bone Loss (BMD) Over 1 Year Hip fracture patients Expected in non-hip fracture population Total Hip Femoral Neck 1 1 0 0 –1 –1 –2 –2 Mean Percent Loss From Baseline –3 –3 –4 –4 –5 –5 –6 –6 –7 –7 0 2 4 6 8 10 12 0 2 4 6 8 10 12 Months Post-Fracture Error bars represent standard error of the mean. Expected values based on interpolated data obtained over a 42.3-month period, Study of Osteoporotic Fractures. Magaziner J, et al. Osteoporos Int. 2006;17:971-977.

15. Lean Body Mass 40000 39500 39000 38500 Average Mass (grams) 38000 37500 37000 36500 36000 0 3-10 60 120 180 240 300 360 Days Post-fracture Fox KM, et al. Osteoporos Int. 2000;11:31-35.

16. Fat Mass 18000 17500 17000 Average Mass (grams) 16500 16000 15500 0 3-10 60 120 180 240 300 360 Days Post-fracture Fox KM, et al. Osteoporos Int. 2000;11:31-35.

17. 100 90 80 70 60 Percentage New Impairment at 12 Months 50 40 30 20 10 0 Rise From Chair Put on Pants In/Out Bed Walk 10 Feet Walk 1 Block On/Off toilet In/Out Bath Climb 5 Stairs Lower Extremity Activities of Daily Living Percentage of Those Unimpaired Pre-Fracture With Impairment at 12 Months Post-Fracture Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507.

18. Other Functional Consequences of Hip Fracture • Loss of Neuromuscular Function (gait/balance) • More Difficulties with Instrumental Tasks (Shopping/housework) • Increase in Cognitive Deficits (50% in hospital; 25% at 2 months) • Increase in Depressive Symptoms (50% in hospital; 25% at 2 months) • Changes in Social Function (visiting with others/participating in activities) Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507. Magaziner J, et al. J Gerontol. 1990;45:M101-M107.

19. Patterns Of Recovery

20. 80 70 60 Get In/Out of Bed 50 Walk 10 Feet 40 Rise From Chair 30 Walk 1 Block 20 10 0 2 6 12 18 24 Months Recovery In Lower Extremity ADLs

21. LowerExtremity ADL Instrumental ADL Social Gait Balance Cognition UpperExtremity ADL Depression 0 2 4 6 8 10 12 14 16 Time (Months) Time to Recuperation Following Hip Fracture Summary Measures of Functioning Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507.

22. Hip Fracture Recovery Process RECOVERYFROM IMPAIRMENTS • Hip Fracture RECOVERY IN FUNCTIONAL LIMITATIONS • Neuromusculargait/balance • Cognitive • Affective • Strength RECOVERY IN DISABILITY • Lower Extremity ADLs • Instrumental ADLs • Social Activities PATHOLOGY • Osteoporsis • Sarcopenia • Chronic Conditions Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507.

23. Interventions and Their Timing

24. Hip Fracture Recovery Process RECOVERYFROM IMPAIRMENTS • Hip Fracture RECOVERY IN FUNCTIONAL LIMITATIONS • Neuromusculargait/balance • Cognitive • Affective • Strength RECOVERY IN DISABILITY • Lower Extremity ADLs • Instrumental ADLs • Social Activities PATHOLOGY • Osteoporsis • Sarcopenia • Chronic Conditions Magaziner J, et al. J Gerontol A Biol Sci Med Sci. 2000;55A:M498-M507.

25. Hip Fracture Treatments Suggested By Deficits and Recovery Sequence Recovery Process Possible Treatments Treat Pathology Osteoporosis Bone strengthening medications Sarcopenia Pharmacalogic agents Chronic conditions Stabilize exacerbations, control complications Vitamin D, Calcium, Protein, other nutrition Treat Impairment Hip fracture Surgical management , anesthesia, transfusion Reduce Functional Limitations Neuromuscular Gait training, balance training, strength training Cognitive Medical stabilization, orientation therapy Affective Medication, psychological therapy Minimize Disability ADLs Physical therapy IADLs Occupational therapy Social activity Social engagement strategies

26. Conclusion

27. The Future • Multidisciplinary/multi-component interventions have the potential to improve long term outcomes • Need to design programs using effective components that target individual patient need, and evaluate their combined effect • Packages of interventions need to be tested and translated for use in practice • Need strategies for delivering these interventions in a coordinated manner

28. Hip fracture is a multi-faceted problem which requires multiple treatments/interventions