Having specific combinations of underlying health problems is a significant risk for poorer health outcomes in older adults who have had a fracture, according to a new study from the Garvan Institute for Medical Research.
The study was conducted on more than 300,000 Danes aged 50 or older who had suffered a fracture. In patients with fractures closer to the center of the body (for example, in the hip, spine, upper arm, or leg), the researchers found a higher mortality rate than expected for the general population of the same age. If those people with fractures also had multiple or complex health problems, the risk of mortality was again higher.
The researchers found that certain groups of conditions were associated with increased mortality rates, suggesting that this information could be used by clinicians to highlight patients who may need more intensive medical care.
This is an important study that could really change the way we provide medical treatment to older people. This could potentially be a new way of thinking about how we look at people with fractures, considering the location of the fracture in light of their specific underlying health conditions.”
Professor Jacqueline Center, head of the Clinical Research and Epidemiology Laboratory and lead author of the study
The new study is published in the journal JAMA Network Open.
Typically, the management of health conditions such as osteoporosis, heart disease, or diabetes is viewed from the perspective of the individual disease. However, these new findings suggest that looking at clusters of underlying diseases may indicate that someone is at high risk for worse outcomes, over and above the risk of the condition being treated.
The researchers found that chronic health conditions at the time of the fracture were naturally clustered into five specific groups for men and four for women: a relatively healthier group with usually only one or no health conditions, a cardiovascular group, a diabetes group, and a group with cancer with additional liver/inflammatory group for men.
Visiting Scientist Robert Blank adds: “It is not enough to count other diseases. Their weight and their combinations should also be taken into account. Many patients with a history of previous cancers, for example, were not in what we call a cancer cluster, but the cancer cluster included almost all those who had evidence of advanced cancer. The same kind of sorting by severity was observed in the other clusters.”
Interestingly, a fracture located closer to the center of the body, such as the femur, vertebrae, or bones of the upper arm, has a higher risk of mortality. In contrast, those in the healthy group who had fractures further up the body, such as the arms and forearms, had virtually no increase in mortality.
Having specific groups of health conditions in people increases the likelihood of death after these fractures far more than the fractures or health problems alone. For example, the death rate after hip fracture among men in the cancer cluster was 41% higher than that of men of the same age in the general community. And diabetes in otherwise healthy people is not associated with an increased risk of mortality, but diabetes combined with heart, vascular, or kidney disease is.
“This study highlights that there is an interaction between the fracture and a patient’s set of health conditions – their underlying health – and that this can be a good way to identify people at risk,” said Dr Thach Tran of Garvan, first author of the study . “We can identify people who are likely to do poorly. Importantly, the findings of this study may be applicable to many disease conditions in which sentimental events occur with preexisting health disorders.”
It is not understood why there is a link between multiple underlying conditions, the type of fracture and poor outcomes, but Professor Center believes it may be the interaction with bone and the immune system. “Bone is not inert. “When you break a bone, you get increased bone turnover and the associated inflammatory factors, and I suspect that in underlying diseases this process is not well controlled and the fracture can fuel the underlying health problems,” she says.
The next steps are to determine whether these clusters are evident in other diseases—whether they are universal—and whether they can be used as a predictive tool for clinicians.
Raven Institute of Medical Research
Tran, T., et al. (2022) Association of multimorbidity and excess mortality after fractures among elderly Danes. JAMA Network Open. doi.org/10.1001/jamanetworkopen.2022.35856.