key: cord-0905341-5m2w0rm1
authors: Ronel, Dror; Keren, Yaniv; Muallem, Aiman; M, Elboim-Gabyzon
title: The effect of physical and social isolation due to the COVID-19 pandemic on the incidence of hip fractures among senior citizens
date: 2021-10-22
journal: Geriatr Nurs
DOI: 10.1016/j.gerinurse.2021.10.018
sha: b45e95c6f8465887e1d9a266a29c9e4bfa2d107b
doc_id: 905341
cord_uid: 5m2w0rm1

This study aimed to explore the effects of the lockdown due to the coronavirus disease 2019 pandemic on the incidence and characteristics of hip fracture in older adults. Data from the three-month lockdown period and the corresponding period in the previous year were obtained from the computerized medical records of a large acute-care hospital. No significant differences were observed in the absolute and relative numbers of hip fractures. There were no significant differences in terms of socio-demographic and clinical characteristics, which are considered risk factors for falls. Similarly, there was no difference in the length of time between admission and surgery and the mean length of hospital stay. Compared to the previous year, there was a significantly higher incidence of hip fractures in older adults living alone during the lockdown. Health policy should provide social support and monitoring of healthcare, particularly to older adults living alone.

The coronavirus disease 2019 (COVID- 19) pandemic has placed older adults at the forefront of public interest worldwide because of their higher vulnerability to the virus. 1 Accordingly, health policy gradually advanced from instructing older adults to maintain social distancing by reducing outdoor activities to participation in full lockdowns for extended periods of time during which the entire population was obliged to stay home. This resulted in prolonged periods of physical and social isolation. 2, 3 Being restricted to the home environment and minimizing outdoor activities may have promoted a more sedentary lifestyle. Sedentary behavior is associated with muscle weakness, decreased balance, and reduced aerobic capacity in older adults, 4 which increase the risk of falls and consequently of hip fractures. 5 As a result of restricted mobility in public spaces, increased loneliness was reported by older adults, 6-8 with a higher incidence reported among those living alone. 7, 8 A review of previous studies indicated that the level of loneliness and its negative consequences on mental state following the COVID-19 lockdown depend on the duration and frequency of isolation periods. 7 Anxiety is the most frequently reported psychological distress among older adults during the COVID-19 pandemic. 9 Risk factors for increased anxiety among older adults include advanced age, living alone, being unmarried, and having a lower level of education. 8 A survey of changes in medication among older adults during the COVID-19 pandemic revealed increased consumption of antidepressants and antianxiety drugs. 10 Anxiolytic drugs (antidepressants and antianxiety medications) are reported to increase the risk of fall, 11, 12 and this may have affected the incidence of falls during the COVID-19 pandemic. Indeed, consumption of such drugs has been shown to increase the risk of hip fractures. 13 Fall-related hip fractures in older adults are devastating events with significant consequences on the morbidity and disability of the individual and the healthcare system at large. 14, 2 Accordingly, it is important to explore whether the imposed physical and social isolation during the COVID-19 lockdown increased the incidence of fall-related hip fractures among older adults.

Several reviews have demonstrated that the COVID-19 pandemic resulted in a decrease in the total referral load to orthopedic wards, regardless of patient age. Additionally, the lockdown imposed during this period resulted in a shift in the types of injuries presented, with notably fewer injuries related to motor vehicle accidents and sporting activities banned during this period. 5, 15, 16 However, systematic reviews by Blum 15 and Lim 5 did not specifically examine the impact of COVID-19 on the incidence of hip fractures among older adults. In contrast, in a systematic review by Jain et al., 16 several studies considered hip fractures. 2, [17] [18] [19] The results of studies evaluating the effect of the pandemic on the incidence of hip fractures in older adults are not consistent, with some studies reporting no change between the preceding period and the time of lockdown due to the pandemic, 17, 20 some reporting an increase in the incidence of hip fractures, 19, 21, 22 and other studies reporting a decrease in the incidence of hip fractures. [23] [24] [25] These contrasting results may be related to the study country and/or methodology. Additionally, the proportionately higher mortality rate in older adults with COVID-19 in certain countries (e.g., Italy) may have masked the incidence of hip fractures in this age group during the pandemic. 24 Finally, the method of calculation of the effects of the pandemic on the incidence of hip fractures varied between studies. Some studies compared the absolute number of hip fractures before and during the pandemic, 20, 23, 24 while others analyzed the proportion of hip fractures in relation to other injuries requiring admission to orthopedic wards, which may not directly reflect the incidence of hip fractures, but rather illustrates a change in the number of other types of injuries. 17, 21, 22 To address these conflicting results, the purpose of this study was to compare (1) the incidence of hip fractures among older adults admitted to a large general hospital in Northern Israel during the first lockdown period of the COVID-19 pandemic with the corresponding period in 2019; (2) the characteristics of patients with hip fractures between these two periods (e.g., age, sex, place of residence, medicine consumption); and (3) the characteristics of fracture management in terms of time to operation, surgeon seniority, and hospital stay.

We hypothesized that the increase in the risk factors of fall during the lockdown period would result in an increase in the absolute and relative incidence of fall-related hip fractures in older adults compared to the pre-pandemic period. We did not expect age or gender to be related to the increased incidence of hip fractures, but expected that living conditions will affect this incidence.

Further, we did not expect changes in fracture management during the COVID-19 pandemic.

This was a retrospective study based on the review of computerized medical records using a specialized software. This study was approved by the hospital's Helsinki Board.

Data were collected from a major 1,000-bed general hospital in Northern Israel, which includes two orthopedic wards with a total of 70 beds.

Inclusion criteria: Patients aged ≥ 65 years admitted to one of the two orthopedic wards following intertrochanteric, subtrochanteric, or subcapital hip fractures due to a fall during the first three months of the lockdown period due to COVID-19 (March 19, 2020, to June 18, 2020) or during the corresponding period in 2019.

The following data were extracted: 1. Demographic data: age, sex, marital status, number of children, body mass index (BMI), and dwelling information; 2. Clinical characteristics: number of medications consumed, consumption of anti-anxiety and antidepressant medications (benzodiazepines and selective serotonin reuptake inhibitors), consumption of medications for hypertension, alcohol consumption, and smoking; 3. Characteristics of fracture management: time to operation, duration of hospital stay, and surgeon's seniority.

Descriptive statistics of continuous variables are reported as the mean and standard deviation (SD), and those of categorical variables are reported as numbers and percentages. The normality of the distribution of the quantitative parameters was tested using the Shapiro-Wilk test. Twosample t-tests and Mann-Whitney tests were used to compare data between the two-time frames for parametric and non-parametric data, respectively. Categorical parameters were compared using Fisher's exact test or Pearson chi-square tests. Statistical significance was set at P<0.05. 

During the lockdown period, the hospital operated in an emergency mode, with specialized intensive care units and internal medicine wards admitting large numbers of patients with COVID-19, which reduced the elective activity throughout the hospital.

The number of hip fractures and patient characteristics during the two time periods are presented in Table 1 Information regarding fracture management is presented in Table 2 . No significant differences between the two groups were noted in the time between arrival at the hospital's emergency room and the day of surgery, or in the mean length of hospital stay. A significant difference was found in the experience of the operating surgeons, as during the COVID-19 period, more patients were operated by senior surgeons (69%) than in the preceding year (48%).

[Insert Table 1 about here]

The COVID-19 pandemic has brought many changes to our daily lives. It has raised many health and ethical concerns and has influenced everyday social interactions. It also influenced hospital routines, which had to adapt to the situation caused by the outbreak. 26 The aim of the current study was to explore the effect of the COVID-19 pandemic on the incidence of hip fractures, patient characteristics, and fracture management among older adults in Israel.

The findings indicate no significant increase in the relative and absolute incidence of hip fractures during the lockdown period compared to the previous year. The analyses of both the absolute and relative numbers of hip fractures are consistent with some of the reports of previous studies, 17, 20, 27 which showed that the COVID-19 pandemic did not significantly affect the incidence of hip fractures. However, it is difficult to compare our findings with those of previous studies that demonstrated opposite results due to different study methodologies (such as patient age, period of data collection, and methods of calculation of the incidence of hip fracture). It has been suggested that the incidence of hip fractures may be related to the geographic and ethnic background of older adults due to factors such as exposure to the sun (vitamin D), genetic factors, dietary habits, or bone mineral density. 28, 29 Therefore, we compared the current results with those of other studies conducted in Israel. However, the comparison yielded no results, as the other studies in Israel were conducted during different periods of the COVID-19 pandemic when the levels of social isolation and movement restrictions were different. [30] [31] [32] [33] These studies presented a pattern similar to that observed in global studies; most studies showed a decrease in the absolute number of hip fractures, 30, 31, 33 and one study showed an increase. 32 . As noted in studies from all over the world, this inconsistent pattern is probably the result of the high variability between studies in terms of data collection duration and period.

The reason for no increase in the incidence of hip fracture during the COVID-19 period , as we had hypothesized, may be that being home bound led older adults to adopt a more careful behavior avoiding indoor activities that could cause falls. The lack of difference in the incidence of hip fracture may also be attributed to the fact that there was no difference between the periods in terms of the generally cited risk factors for fall. [34] [35] [36] [37] Considering the recurrent waves of the COVID-19 pandemic, it is possible that we may observe an increased risk of falls in the future, which was not evident during the first three months of social and mobility restriction.

The present study demonstrated no significant differences between the two time periods in terms of patient age and sex distribution, marital status, and number of children, which is similar to the findings of previous studies. 17, 20, 32, 33, 38 Previous studies have indicated that a larger percentage of fractures in general, 5, 19 particularly hip fractures, occurred at home during the COVID-19 period. 33 This is because the lockdown limited outdoor activities. In the current study, information regarding fall locations was not available in most medical records. In light of the literature 5, 19, 33 and the lockdown conditions, we assume that most of the fractures in our sample occurred in or near the place of residence of the older adults. However, data collected in the present study included the place of residence (home/assisted living facility) and living conditions (alone/not alone). The results indicate no significant differences in residence location between the two periods (before and during the pandemic). However, a significantly higher percentage of older adults who fell during the COVID-19 pandemic lived alone (28%), compared to only 10% in the preceding year (p=0.02).

Thus, the results indicate that the lockdown period may have increased the vulnerability of older adults, which is supported by studies indicating that social isolation and loneliness experienced by older people, particularly among those who live alone, increase the risk of falls. 39, 40 Solitary living, even under normal circumstances, has been proven to increase the risk of fall and have a negative effect on the recovery of functional independence, rate of institutionalization, and mortality. 41, 42, 43, 44 However, the lockdown intensified the excessive risk of living alone, probably due to extreme behavioral, psychological, and/or physical changes in daily routines.

For example, during the lockdown period, older adults were forced to perform demanding daily activities for which they usually receive external assistance.

As most low-energy injuries and hip fractures during the lockdown period occurred in the home environment, Zhu et al. 19 stressed the need to adopt injury prevention strategies in the home environment. These include avoiding hazardous situations (e.g., lack of sufficient light or wet floor) and adopting cautious behavior by wearing antiskid shoes, showering in a sitting position, transferring slowly with assistance of external support (handrail or armchair) after prolonged sitting or lying.

The present results highlight the need to establish structured healthcare services for older adults living at home, particularly when alone, designed to address prolonged periods of crisis (such as pandemics or rainstorms) and creating networks of digital online communication with medical staff and supportive social communities, as well as instituting technological means for healthcare monitoring. This may include systems detecting and alerting regarding movements that might lead to a fall and home-based fall-prevention exercise programs [45] [46] [47] to minimize the negative effects of isolation on older adults living alone. 48, 49 A decrease in elective activity in the hospital (as experienced during the pandemic) may result in more available operating rooms and shorten the mean time to operation. However, this was not the case in the present study. In this study, we observed an interesting difference in the seniority of the surgeon performing hip fracture fixation. In 2019, during "normal" hospital routine, approximately half of the hip fractures were operated on by senior surgeons and half by residents, while during the COVID-19 lockdown in 2020, 69% of hip fractures were operated on by senior surgeons. This was due to the decrease in elective activity and increased availability of senior surgeons in the evenings. Further studies are required to determine whether this shift influences long-term surgical outcomes, as previous studies have suggested better outcomes with more experienced surgeons. 50, 51 Although rehabilitation facilities had to cope with the COVID-19 outbreaks, and referral to such facilities was limited during the pandemic period, the length of hospital stay seemed to remain the same. However, we have no data regarding where patients were sent after their acute hospital stay or how this affected their rehabilitation. Thus, the primary limitation of this study was that the hospital data did not include patient follow-up. Furthermore, although data were collected from one of the largest acute-care hospitals in Israel, the total number of cases reviewed was limited.

We showed that a short period of social isolation due to the COVID-19 pandemic did not have a direct effect on the absolute number of fall-related hip fractures in older adults compared to an identical period during the previous year (2019). A higher incidence of hip fractures occurred during the social isolation period among older adults who lived alone. Based on the current results, we suggest that health policy should include social support and health monitoring, particularly for older adults who live alone. Future studies should include larger populations, longer follow-up periods, and evaluate the effects of longer periods of lockdowns, particularly in more vulnerable older adults. 

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