Aging Clinical and Experimental Research

, Volume 30, Issue 6, pp 643–650 | Cite as

Determinants of functional outcome in hip fracture: the role of comorbidity

  • Bernardo Gialanella
  • Paola Prometti
  • Vittoria Monguzzi
  • Cristina Ferlucci
  • Paola Baiardi
  • Laura Comini
Original Article


Background and aims

Executed studies did not clearly identify which index of comorbidity was an independent outcome determinant. The aim of this prospective observational cohort study was to address this issue.


We analyzed 200 consecutive patients with hip fracture. All patients underwent rehabilitation. At admission comorbidity was assessed through the cumulative severity, severity index, and comorbidity index of the Cumulative Illness Rating Scale. Discharge scores and effectiveness in the Functional Independence Measure motor subscale, and discharge destination were the outcome measures. Multivariate regression analyses were performed to identify determinants of outcome.


Mini Mental State Examination and comorbidity index of the Cumulative Illness Rating Scale were important independent determinants of final (respectively, β = 0.46 and −0.25) and effectiveness (respectively, β = 0.47 and −0.25) in motor Functional Independence Measure scores, while hip strength and Rankin score were determinants of final motor Functional Independence Measure score (respectively, β = 0.21 and −0.20). Comorbidity index of the Cumulative Illness Rating Scale (odds ratio 8.18 for ≥3 versus < 3 comorbidity score; 95% confidence interval, 1.03–64.7) and Geriatric Depression Scale (odds ratio 4.02 for ≥6 versus ≤5 depression scale score; 95% confidence interval, 1.52–10.63) were risk indicators for nursing home.


Among the indices of the Cumulative Illness Rating Scale, comorbidity index is the sole independent determinant of both motor Functional Independence Measure scores and discharge destination in hip fracture patients. This suggests to specifically evaluate this index to identify the patients who may be admitted to a rehabilitation program.


Comorbidity Activities of daily living Outcome Rehabilitation 



The authors thank Rosemary Allpress for English revision of the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


The research was not supported by Pharmaceutical Companies, but by institutional funding.

Ethical approval

The Technical Scientific Committee of our Institute approved the study protocol. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Informed consent

All patients gave their written informed consent to participate.

Supplementary material

40520_2017_812_MOESM1_ESM.xlsx (48 kb)
Supplementary material 1 (XLSX 47 KB)


  1. 1.
    Zuckerman JD, Fabian DR, Aharanoff G, Koval KJ, Frankel VH (1993) Enhancing independence in the older hip fracture patient. Geriatrics 48:76–78, 81PubMedGoogle Scholar
  2. 2.
    Koren-Hakim T, Weiss A, Hershkovitz A et al (2012) The relationship between nutritional status of hip fracture operated elderly patients and their functioning, comorbidity and outcome. Clin Nutr 31:917–921CrossRefPubMedGoogle Scholar
  3. 3.
    Feng L, Scherer SC, Tan BY, Chan G, Fong NP, Ng TP (2010) Comorbid cognitive impairment and depression is a significant predictor of poor outcomes in hip fracture rehabilitation. Int Psychogeriatr 22:246–253CrossRefPubMedGoogle Scholar
  4. 4.
    Mathew RO, Hsu WH, Young Y (2013) Effect of comorbidity on functional recovery after hip fracture in the elderly. Am J Phys Med Rehabil 92:686–696CrossRefPubMedGoogle Scholar
  5. 5.
    Parmelee PA, Thuras PD, Katz IR, Lawton MP (1995) Validation of the Cumulative Illness Rating Scale in a geriatric residential population. J Am Geriatr Soc 43:130–137CrossRefPubMedGoogle Scholar
  6. 6.
    Cummings JL (1997) The neuropsychiatric inventory: assessing psychopathology in dementia patients. Neurology 48(5 Suppl 6):S10–S16CrossRefPubMedGoogle Scholar
  7. 7.
    Granger CV, Cotter AC, Hamilton BB, Fiedler RC (1993) Functional assessment: a study of persons after stroke. Arch Phys Med Rehabil 74:133–138PubMedGoogle Scholar
  8. 8.
    van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J (1988) Interobserver agreement for the assessment of handicap in stroke patients. Stroke 19:604–607CrossRefPubMedGoogle Scholar
  9. 9.
    Folstein MF, Folstein SE, McHugh PR (1975) “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198CrossRefPubMedGoogle Scholar
  10. 10.
    Sheikh JI, Yesavage JA, Brooks JO 3rd, Friedman L, Gratzinger P, Hill RD, Zadeik A, Crook T (1991) Proposed factor structure of the Geriatric Depression Scale. Int Psychogeriatr 3:23–28CrossRefPubMedGoogle Scholar
  11. 11.
    Miller DW, Hahn JF (1996) General methods of clinical examination. In: Youmans JR (ed). Neurological surgery, ed 4. W.B. Saunders Philapdelphia, pp 31–32Google Scholar
  12. 12.
    Shah S, Vanclay F, Cooper B (1990) Efficiency, effectiveness and duration of stroke rehabilitation. Stroke 21:241–246CrossRefPubMedGoogle Scholar
  13. 13.
    Kristensen MT (2011) Factors affecting functional prognosis of patients with hip fracture. Eur J Phys Rehabil Med 47:257–264PubMedGoogle Scholar
  14. 14.
    Di Giorgio L, Sodano L, Touloupakis G, Piciocco P, Attala D, Villani C (2012) Proximal femur fractures in elderly patients: the influence of comorbidity on prognosis in the short, medium and long term. Clin Ter 163:95–99Google Scholar
  15. 15.
    Bernardini B, Meinecke C, Pagani M et al (1995) Comorbidity and adverse clinical events in the rehabilitation of older adults after hip fracture. J Am Geriatr Soc 43:894–898CrossRefPubMedGoogle Scholar
  16. 16.
    Patrick L, Knoefel F, Gaskowski P, Rexroth D (2001) Medical comorbidity and rehabilitation efficiency in geriatric inpatients. J Am Geriatr Soc 49:1471–1477CrossRefPubMedGoogle Scholar
  17. 17.
    Press Y, Grinshpun Y, Berzak A, Friger M, Clarfield AM (2007) The effect of co-morbidity on the rehabilitation process in elderly patients after hip fracture. Arch Gerontol Geriatr 45:281–294CrossRefPubMedGoogle Scholar
  18. 18.
    Chiu KY, Pun WK, Luk KD, Chow SP (1992) A prospective study on hip fractures in patients with previous cerebrovascular accidents. Injury 23:297–299CrossRefPubMedGoogle Scholar
  19. 19.
    Langhorne P, Stott DJ, Robertson L et al (2000) Medical complications after stroke: a multicenter study. Stroke 31:1223–1229CrossRefPubMedGoogle Scholar
  20. 20.
    Guerini F, Frisoni GB, Morghen S, Speciale S, Bellelli G, Trabucchi M (2010) Clinical instability as a predictor of negative outcomes among elderly patients admitted to a rehabilitation ward. J Am Med Dir Assoc 11:443–448CrossRefPubMedGoogle Scholar
  21. 21.
    Jamal Sepah Y, Umer M, Khan A, Ullah Khan Niazi A (2010) Functional outcome, mortality and in-hospital complications of operative treatment in elderly patients with hip fractures in the developing world. Int Orthop 34:431–435CrossRefPubMedGoogle Scholar
  22. 22.
    Shebubakar L, Hutagalung E, Sapardan S, Sutrisna B (2009) Effects of older age and multiple comorbidities on functional outcome after partial hip replacement surgery for hip fractures. Acta Med Indones 41:195–199PubMedGoogle Scholar
  23. 23.
    Pautex S, Jacques MC, Sant A, Herrmann F, Chevalley T (2005) A short comprehensive assessment to predict outcome of elderly patients after hip fracture. Aging Clin Exp Res 17:116–120CrossRefPubMedGoogle Scholar
  24. 24.
    Titler M, Dochterman J, Xie XJ et al (2006) Nursing interventions and other factors associated with discharge disposition in older patients after hip fractures. Nurs Res 55:231–242CrossRefPubMedGoogle Scholar
  25. 25.
    Becker C, Gebhard F, Fleischer S et al (2003) Prediction of mortality, mobility and admission to long-term care after hip fractures. Unfallchirurg 106:32–38CrossRefPubMedGoogle Scholar
  26. 26.
    Thorngren KG, Ceder L, Svensson K (1993) Predicting results of rehabilitation after hip fracture. A ten-year follow-up study. Clin Orthop Relat Res (287):76–81Google Scholar
  27. 27.
    Ottenbacher KJ, Linn RT, Smith PM, Illig SB, Mancuso M, Granger CV (2004) Comparison of logistic regression and neural network analysis applied to predicting living setting after hip fracture. Ann Epidemiol 14:551–559CrossRefPubMedGoogle Scholar
  28. 28.
    Ishida Y (2004) Mortality and functional outcome of hip fractures in the elderly. Clin Calcium 14:408–417PubMedGoogle Scholar
  29. 29.
    Lenze EJ, Munin MC, Dew MA et al (2004) Adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture. Int J Geriatr Psychiatry 19:472–478CrossRefPubMedGoogle Scholar
  30. 30.
    Kos N, Burger H, Vidmar G (2011) Mobility and functional outcomes after femoral neck fracture surgery in elderly patients: a comparison between hemiarthroplasty and internal fixation. Disabil Rehabil 33:2264–2271CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Bernardo Gialanella
    • 1
  • Paola Prometti
    • 2
  • Vittoria Monguzzi
    • 3
  • Cristina Ferlucci
    • 1
  • Paola Baiardi
    • 4
  • Laura Comini
    • 1
  1. 1.Istituti Clinici Scientifici Maugeri, IRCCS, Institute of LumezzaneLumezzane (Brescia)Italy
  2. 2.Istituti Clinici Scientifici Maugeri, IRCCS, Institute of CastelgoffredoMantovaItaly
  3. 3.Istituti Clinici Scientifici Maugeri, Institute of LissoneLissone (Milano)Italy
  4. 4.Istituti Clinici Scientifici Maugeri, IRCCS, Institute of PaviaPaviaItaly

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