The Relationship Between Alcohol Consumption and Hip Fracture Recovery Among Older Adults

Abstract

Background: We examined the relationship between alcohol consumption and hip fracture recovery. Methods: Repeated measures analysis was used to analyze Baltimore Hip Studies (BHS) seventh cohort 12-month prospective data of hip fracture patients. The analytical sample was limited to individuals with baseline and follow-up alcohol data, representing n = 278 sample size, 49% male, and mean age 81 years. Results: In the year prior to fracture, sample reporting indicated 45% nondrinking, 48% one to seven drinks per week, and 7% eight or more drinks per week alcohol levels. There were some changes in alcohol status during the study period (p < .001); 42% remained nondrinkers and 47% remained alcohol consumers, but 8% stopped alcohol use, and 3% reported alcohol consumption after nondrinking at baseline. Alcohol was a predictor (p < .05) of disability and physical function, not showing worse recovery for drinkers. Conclusion: Almost half of the sample consumed alcohol throughout the study period, with no clear indication of negative effects on hip fracture recovery.

Keywords

drinkers hospitalization disability hip fractures

Introduction

It is imperative to better understand the factors for successful hip fracture recovery and those that can undermine the recovery process. Annually, 250,000 adults aged 65 and older are hospitalized for hip fracture (Centers for Disease Control and Prevention, 2015) and hip fracture results in an average of 1.8-year reduction in life expectancy and US$20 billion national lifetime health care costs (Braithwaite, Col, & Wong, 2003). The majority of hip fractures are due to falls and physical risk factors such as low bone density and prior fracture (Nguyen, Pongchaiyakul, Center, Eisman, & Nguyen, 2005), along with modifiable lifestyle risk factors, such as alcohol consumption. Research examining alcohol consumption and hip fractures has been inconsistent; some studies indicate that moderate alcohol consumption is associated with lower risk for hip fracture (Berg et al., 2008; Peel, McClure, & Hendrikz, 2006; Wilson, Chase, Chrischilles, & Wallace, 2006) or no increased risk of hip fracture (Kanis et al., 2005). A nonlinear relationship has also been identified, indicating the lowest risk of hip fracture with moderate alcohol consumption, even when compared with abstainers (Berg et al., 2008; Cawthon et al., 2006; Mukamal, Robbins, Cauley, Kern, & Siscovick, 2007; Zhang, Yu, Yu, & Qu, 2015). Several studies also indicate heavy alcohol consumption is associated with increased hip fracture risk, compared with nondrinkers, partly due to increased likelihood of falling (Berg et al., 2008; Cawthon et al., 2006; Høidrup, Grønbæk, Gottschau, Lauritzen, & Schroll, 1999; Jonsson, Sernbo, Kristenssen, & Johnell, 1993; Kanis et al., 2005; Mukamal et al., 2007; Trimpou, Landin-Wilhelmsen, Odén, Rosengren, & Wilhelmsen, 2010; Zhang et al., 2015).

Individual differences in alcohol consumption have also been considered in the post hip fracture recovery period (Hershkovitz, Kalandariov, Hermush, Weiss, & Brill, 2007). Findings have been inconsistent, with some studies concluding that alcohol consumption is not a predictor of hip fracture outcomes such as recovery status and functional independence (Cummings et al., 1988; Semel, Gray, Ahn, Nasr, & Chen, 2010). Other studies have indicated reduced survival for alcohol consumers after hip fracture (Carpintero et al., 2005; Yuan et al., 2001). There is also evidence for shorter hospital stays and lower mortality rates in alcohol consumers after hip fractures (Johnston & Parker, 2014). Given that alcohol intake is a potentially modifiable factor with regard to both risk of fracture and optimization of recovery, further research is needed to better understand previous assertions. Therefore, the purpose of this analysis was to examine alcohol consumption among older adults who were hospitalized for a hip fracture, to better understand how alcohol behavior can affect the hip fracture recovery process.

Method

This was a secondary data analysis of the Baltimore Hip Studies seventh cohort (BHS-7). The BHS-7 was a 12-month prospective study of hospitalized older hip fracture patients (n = 339), designed to include equal numbers of male and female patients, unlike previous studies with majority women. Eligible patients were individuals 65 years of age or older admitted with a diagnosis of hip fracture (ICD-9 codes 820.00-820.9), community-dwelling, and admitted for surgical repair of a nontraumatic hip fracture at any of eight study hospitals. Patients were excluded if they had a pathologic fracture (e.g., Paget’s disease or bone metastases), were non-English-speaking, were bedbound for 6 months prior, resided >70 miles from the hospital, weighed >300 pounds (weight restrictions on dual energy X-ray absorptiometers), or had hardware in the contralateral hip. The protocol was approved by the host Institutional Review Board (IRB) and each study hospital. Study subjects provided consent (or proxy provided consent) within 15 days of admission. Baseline assessments occurred within 22 days of hospital admission, and again at 2, 6, and 12-months post admission between May 2006 and June 2011. Data were collected by trained research staff and included medical record abstractions, questionnaires, and measures of functional performance. Self-report study assessments were completed by the participants and when requested, staff assistance was provided.

A total of 1,709 hip fracture patients were screened and 917 (54%) were study eligible; from which 180 men and 182 women consented to participate in the study. Twenty-three participants were withdrawn from the study. Specifically, five of these individuals failed to provide data at the baseline and 2-month follow-up visit and another 18 participants were removed as a result of an IRB-requested post procedure audit. The audit identified six participants to be ineligible due to screening errors and 12 participants were ineligible due to failures in the informed consent process, resulting in a final sample of 339 participants (168 men and 171 women). The analytical study sample (N = 278) was limited to individuals with baseline and at least one follow-up for alcohol use in the original study, with n = 146 having complete data, after loss at follow-up at 2 months (n = 21), 6 months (n = 85), and 12 months (n = 93). Individuals lost to follow-up had no drinking or demographics mean level baseline differences. All study measures were obtained at baseline, 2, 6, and 12 months and had previously established reliability and validity evidence, described in more detail in earlier publications (Gruber-Baldini, et al. 2003; Magaziner, Chiles, & Orwig, 2015; Resnick, et al., 2016).

Measures

Alcohol consumption was based on participant self-report responses to how many alcoholic drinks are consumed in a typical week (none, occasional, 1-3, 4-7, 8-14, 15-21, 22-27, and 28 or more drinks per/week). At baseline, participants were asked to report on alcohol for the year before the fracture and at follow-up about alcohol consumption during the intervals after hospital discharge. Collectively, these data were used to create alcohol status: drinkers versus nondrinkers across study status, and for each time point: baseline, 2-month, 6-month, and 12-month drinking status.

Health Indicators

Data were obtained from study participants to assess cognitive status (Modified Mini-Mental State [3MS] Examination; Teng & Chui, 1987), comorbidity (Charlson Comorbidity Index; Charlson, Pompei, Ales, & MacKenzie, 1987), social activity levels (House, Robbins, & Metzner, 1982), depression (Center for Epidemiologic Studies Depression Scale [CES-D]; Radloff, 1977), resilience (Physical Resilience Scale; Resnick, Galik, Dorsey, Scheve, & Gutkin, 2011), and health status (Jenkinson, Wright, & Coulter, 1994).

Physical function/disability was evaluated by self-report and performance measures. The physical activities of daily living (ADLs) assessment captured self-reported function of both upper and lower extremity activities. Lower extremity function was assessed using a modified form of the Functional Status Index (Jette, 1980), to address functioning relevant to hip fractures. Instrumental activities of daily living (IADLs) were assessed using a modified version of the Older Americans Resources and Services Instrument (Plotnikoff, Brez, & Hotz, 2000). For both ADLs and IADLs, the baseline corresponds with prefracture functioning. In addition, physical performance was measured using the Short Physical Performance (SPPB) at follow-up time points (Guralnik et al., 2000).

Analyses

Analysis of variance was used to analyze baseline associations by alcohol status: drinkers versus nondrinkers (Table 1). Longitudinal outcomes were analyzed using repeated measures analysis of covariance, accounting for time and all other study variables (Time 2). All analysis of covariance accounted for demographics: age, gender, income, and education, and included baseline study health indicators: cognition, depression, health status, disability, functioning, resilience, social interaction, comorbidity, and inflammation.

Table 1.

Comparison of Baseline Variables by Alcohol Consumption Status.

Variables	Total sample, N = 278	Nondrinkers, N = 116 (42%)	Drinkers, N = 162 (58%)	p values
Age years, mean (range)	80.9 (65-100)	81.3	80.6	.500
Gender, % male	49%	45%	52%	.250
Education, mean (range)	13.2 (4-20)	12.9	13.4	.2913
Income, mean (median; mode)	US$25,789 (US$30,000-US$39,999; more than US$50,000)	US$21,500 (US $25,000-US$29,999; more than US$50,000)	US$28,499 (US$30,000-US$39,999; more than US$50,000)	.002
Alcohol, % 1-7 drinks/week	48%	0%	82% (12%; 8 or more drinks/week)	—
	M (SD)	M	M
Cognition (3MS)	84.6 (7.8)	80.9	87.3	.002
Depression (CES-D)	16.8 (10.4)	17.3	16.4	.515
Health status	2.6 (1.1)	2.7	2.6	.485
ADL disability: total	4.7 (3.9)	5.4	4.3	.016
ADL disability: lower	2.6 (2.6)	2.9	2.4	.109
ADL disability: upper	0.2 (0.6)	0.3	0.1	.002
IADL disability	1.98 (1.5)	2.2	1.8	.021
Resilience	5.6 (0.9)	5.6	5.7	.194
Social interaction	10.5 (9.1)	8.8	11.8	.007
Comorbidity	2.0 (1.8)	2.0	2.0	.960

Note. 3MS = Modified Mini-Mental State; CES-D = Center for Epidemiologic Studies Depression Scale; ADLs = activities of daily living; IADLs = instrumental activities of daily living.

Results

Sample

The sample was 49% male, mean age 81 years, median education 12 years, and median annual income US$25,000 to US$39,000 at baseline. In the year prior to fracture, 45% (n = 125) reported nondrinking (0 drinks/week), 48% (n = 133) reported 1 to 7 drinks/week, and 7% (n = 20) 8 or more drinks/week alcohol consumption (Table 1). Nondrinkers reported significantly lower income, cognition, and social interaction, and higher disability levels at baseline (p < .05).

Alcohol

As indicated in Table 2, there was a decrease in alcohol consumption during the study period (p < .001), with 8% (n = 23) stopping alcohol use. In the remaining sample, 3% (n = 9) reported alcohol use after reporting nondrinking prior to fracture; 42% (n = 116) remained consistent nondrinkers, and 47% (n = 130) were consistent alcohol consumers. Baseline cognition was identified as the only predictor of alcohol status change (F = 2.76, p = .0433), indicating lower baseline cognitive levels at baseline for individuals who stopped alcohol use.

Table 2.

Change Overtime for Health Outcomes.

	Baseline level	2-Month level	6-Month level	12-Month level	Time effect (p values)
	Mean level change				Time effect (p values)
Alcohol	0.56	0.25	0.33	0.36	<.001
Cognition	87.09	85.37	86.08	84.08	<.001
Depression	17.19	9.94	9.65	9.85	<.001
Health status	2.51	2.67	2.73	2.70	.132
ADL disability
Lower^a	2.64	7.23*	5.50*	5.33*	<.001
Upper^b	0.11	0.31*	0.33	0.38	<.001
Total^a	4.65	10.66*	8.47*	8.43*	<.001
IADL disability^a	1.88*	3.37*	2.61*	2.61*	<.001
Physical performance^c,d	—	3.32*	4.29	4.29	<.001

Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living.

Denotes significant 2-month drinking status effect.

Denotes significant 12-month drinking status effect.

Denotes significant overall drinking status effect.

Denotes significant baseline drinking status effect.

Significant drinking status level differences.

Health Outcomes

There was significant change in all selected health indicators with the exception of health status (Table 2). Alcohol was a significant independent predictor for ADL disability: lower (F = 3.20, p = .0239), upper (F = 3.19, p = .0242), total (F = 4.43, p = .0046); IADL disability (F = 3.22, p = .0235); and physical performance (F = 6.12, p = .0030; F = 6.82, p = .0016) change overtime, indicating differences in trajectories based on drinking status (seen in Figure 1). Trajectories were most differentiated at 2 months post hip fracture, showing lower levels of disability for drinkers. There was no alcohol effect across time, for cognition, depression, and health status change.

Figure 1.

Drinking effects on performance trajectories.

Discussion

Study results showed that almost half of the sample consumed alcohol throughout the study period, with most alcohol consumption levels within guidelines (National Institute on Aging, 2015), of not more than 1 to 7 drinks/week. Trends over time indicated a decrease in alcohol consumption, followed by a gradual restoration of baseline alcohol consumption levels. The alcohol trajectories seen in this study are indicative of contextual factors for recovery. Specifically, most study participants early during the recovery process may have resided in inpatient rehabilitation prior to returning to home, where alcohol use is limited by treatment facility regulations (Cox et al., 2016).

Associations were identified between alcohol, disability, and physical functioning, showing alcohol status differentiated health outcomes, even after accounting for individual health characteristics. In the current study, drinkers appear to represent a more vigorous health group with greater psychosocial and physiological vitality. Worse health indicators for nondrinkers may reflect psychosocial and physical limits for alcohol (Loprinzi & VanWagner, 2015). This was seen in the current study, with the observation that alcohol consumers had greater income, cognition, social interaction, and greater self-reported physical function at baseline. The greater economic and psychosocial status of drinkers has been similarly seen in earlier studies (Zanjani, et al. 2013), reflecting a late life vitality phenomenon.

Study findings should be considered with the understanding that alcohol consumption is a leading predictor of falls and fall-related fatality, a leading risk factor for hip fracture (Berg et al., 2008; Cawthon et al., 2006; Mukamal et al., 2007; Trimpou et al., 2010). While no clear harms were made evident in the current findings for consuming alcohol during hip fracture recovery, this study needs to be replicated before recommendations can be made. Almost no participants consumed more than 14 drinks per week. It is imperative to understand that most study participants consumed low amounts of alcohol that are within national recommendations of seven or fewer alcoholic drinks/week, similar to earlier studies (Carpintero et al., 2005; Trimpou et al., 2010).

Also, study findings need to be interpreted within the limitations of having a willing sample of participants from a concentrated urban region. This sample was balanced for gender, designed to include equal numbers of male and female patients, unlike previous studies with majority women. Because this study intentionally oversampled male hip recovery ratios, consequently, it has limitations on generalizability beyond old-age hip fracture survivors. Finally, despite having control variables and self-report being a reliable method for data collection (Zanjani & Oslin, 2006 ), future studies should consider using biomarkers for alcohol consumption and create balanced characteristics across drinking status.

In summary, in the current study, approximately half of the older hip fracture recovery patients were consuming alcohol throughout the process, specifically consuming 7 or fewer alcoholic drinks/week, with alcohol consumption declining after hip fracture. There were no clear negative health consequences identified for continued alcohol consumption at national level recommendation, during hip fracture recovery, and no indication of any positive evidence for alcohol initiation post hip fracture. In conclusion, continuing to consume national level recommendation of 7 or fewer drinks/week during hip fracture recovery presents no clear harm to the hip fracture recovery process.

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Jay Magaziner has consulting agreements with Ammonett, Novartis, Viking, and Pluristem. Dr. Denise Orwig has consulting agreements with Kinexum and Viking. The remainder authors have no conflicts of interest to declare. Study approved at Institutional Review Board (IRB) at the University of Maryland, Baltimore, MD (HP-00040312).

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by grants from the National Institute on Drug Abuse (1K01DA031764) and National Institute on Aging (R37 AG09901 MERIT Award, R01 AG029315, T32 AG00262, P30 AG028747).

ORCID iD

Faika Zanjani

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