An observational study of patients with Parkinson’s presenting with fractured hip in 2020: characteristics, outcomes and rates of prior bone health assessment

Introduction

Parkinson’s disease affects 145 000 people in the UK¹, with approximately 750 affected within Swindon and North Wiltshire. Several studies have demonstrated that Parkinson’s disease is associated with an increased risk of osteoporosis and fracture². The fracture risk in people with Parkinson’s disease, is particularly elevated at the hip³, likely at least in part to the mechanism of falls in people with Parkinson’s and the failure of protective arm abduction during falling. Hip fracture in the general population is associated with high levels of mortality and morbidity. Studies have demonstrated that people with Parkinson’s disease who suffer a hip fracture are at even higher risk of post-operative complications and death⁴.

Despite this, recognition of fracture risk associated with Parkinson’s disease is low; post-menopausal women with Parkinson’s disease perceive themselves as likely or less likely to fracture than their peers⁵. Rates of bone health assessments within Parkinson’s services in the UK are also low; the 2015 Parkinson’s UK audit identified evidence of osteoporosis or fracture risk assessment in only 36.4% of patients with documented concerns about falls or balance⁶. Anecdotally, rates of bone health assessments within our own service have also been low. Henderson et al. published the “BONE-PARK” algorithm in 2017, recognising the higher fracture risk for patients with Parkinson’s disease, incorporating the revised NOGG risk thresholds and addressing Parkinson’s specific factors in the assessment and management on fracture risk in this population⁷.

The arrival of the Covid-19 Pandemic in the UK in 2020 presented unique challenges to the way in which we care for all patients. Throughout the year, the Parkinson’s service in the Great Western Hospital underwent dramatic and rapid changes. This presented a great many challenges, but also demonstrated an ability within the team and our patients to rapidly adapt to new ways of working. This, alongside changes in staffing within the service provided an unprecedented opportunity to re-evaluate the service and identify areas which may require greater focus, and how best to address these.

Objectives

To identify those patients living within Swindon and North Wiltshire with Parkinson’s disease who presented with hip fracture to the Great Western Hospital between 1 January to 31 December 2020, and describe their characteristics and outcomes

Review rates of bone health assessment within those patients with Parkinson’s disease who sustained a fractured neck of femur, and retrospectively estimate how many may have been eligible for osteoporosis investigation or treatment.

Consider changes to service to improve rates of bone health assessments and care for those who sustain a hip fracture.

Methods

National Hip Fracture Database records were collected for all patients resident in Swindon and North Wiltshire who presented with a hip fracture between 1 January and 31 December 2020. Those with a diagnosis of Parkinson’s disease or Parkinsonism were identified by cross-referencing NHS numbers with a list of the Parkinson’s Disease Specialist Nurses’ current caseload and deceased patients list since 1 January 2020. Demographics, and data related to the hip fracture episode were extracted from the National Hip Fracture Database; where patients presented with a second hip fracture during the time period studied, data from only the first episode was examined.

Hospital electronic records and GP electronic records were then examined in the preceding year to ascertain whether bone protection had been considered prior to the fracture, and the nature and timeframe of contact with the Parkinson’s service in preceding 12 months. A retrospective estimate of osteoporosis risk was derived using the BONE-PARK algorithm, based on previously recorded height and weight in GP records and recording all patients as having a secondary cause for osteoporosis on the basis of their Parkinson’s disease diagnosis.

Results

9 patients with Parkinson’s disease presented within the time period studied with a fractured neck of femur. 7 (77%) were male. Mean age was 82 (range 71 to 90). None were independently mobile without walking aids at presentation; 2 (22%) were able to mobilise outdoors with one aid, 2 (22%) were able to mobilise outdoors with two aids and 5 (55%) reported some degree of indoor mobility only. Figure 1.

1 patient (11%) was taking anti-resorptive treatment at presentation; 1 patient had been prescribed anti- resorptive treatment by the GP, but wasn’t taking this at the time of presentation, with no reason documented in the notes. The remainder (7, 77%) were not taking anti-resorptive treatment. All patients had had contact with the PD service within the 12 months prior to presenting with hip fracture; bone health discussions were recorded for 1 (11%) patient, with a recommendation that the GP review this, but on review of the GP records,

this did not occur. Bone health assessment was not recorded by the PD service for the remainder (8, 88%) of patients in the 12 months before fracture. Retrospectively estimating the patients’ fracture risk using the BONE-PARK algorithm (with height and weight as recorded on the GP records and using Parkinson’s disease as a secondary risk factor) suggested that all 7 patients who weren’t prescribed anti-resorptive treatment would have been eligible for further investigation or treatment of possible osteoporosis. 2 patients (22%) had records of serum vitamin D measurement prior to their hip fracture. 4 of the remainder had a serum vitamin D measured after their fracture and 2 of these were found to be deficient. Delirium with a 4AT score above 3 was present in 5 (55%) of patients. Mean length of stay in the acute trust was 15.9 days (range 9 to 25).

2 patients (22%) presented within the time frame studied with a fracture of the contralateral hip, one of whom later died. At follow up after fracture, 2 patients (22%) were deceased, 1 patient (11%) was resident in a new nursing home placement and 6 (66%) were living in their own home or sheltered accommodation.

The distribution of presentations throughout the year is demonstrated in figure xxx. 6 (66%) of the patients presenting with fractured hip did so prior to the widespread arrival of Covid-19 in the UK and the first national lockdown on 23 March 2020. No patients with Parkinson’s disease presented with fractured neck of femur during either of the two national lockdowns in the UK. No patients with Parkinson’s disease and hip fracture had positive Covid PCR

Discussion

The numbers of patients with Parkinson’s disease who presented with a hip fracture in 2020 were small, meaning that it was not possible to ascertain statistical significance when comparing with the patients without a diagnosis of Parkinson’s disease in the same time frame. However, it is worth noting that many of the patients with Parkinson’s disease had functional limitations in terms of their mobility pre-fracture, as has been reported elsewhere in the literature⁸. Post-operative delirium and subsequent fracture of the contralateral hip were also common in this patients group, in keeping with previous studies^4,9.

Missed opportunities to evaluate bone health in these patients were identified in both primary and secondary care, in keeping with published data on low rates of bone health assessment in patients with Parkinson’s disease⁶. This was evident even when estimating the FRAX score using just height, weight, age and Parkinson’s disease diagnosis; it was not possible to ascertain all risk factors included in FRAX, so this is likely to have been an under-estimate for some patients.

Given the additional complexities that some patients with Parkinson’s disease may face when accessing osteoporosis assessment and treatment, in terms of fitting in additional medications alongside complex medication regimes and limited mobility that may preclude DEXA scanning, we propose changes to our service that will facilitate the application of the BONE-PARK algorithm during clinic appointments, rather than recommending that this be done in primary care.

It was notable that the majority of patient with Parkinson’s disease presenting with hip fracture in 2020 did so prior to the introduction of the first national lockdown. The anecdotal experience of our MDT suggested that persons with Parkinson’s disease were often very fearful during this time and spent most of their time at home with additional support from family members who were more present and better able to assist the person with activities of daily living and ensure medications were received on time. This may well have reduced the opportunities for patients to mobilise and be at risk of falls. It would be interesting to compare the 2020 data with preceding and subsequent years for any change in numbers of patients presenting with hip fracture. An unintended consequence of the lockdowns is the risk of physical deconditioning, and the effects of this are yet to be understood. In our service, face-to-face physiotherapy has resumed but there has been a backlog. To ensure equitable access for those who are unable to respond to invitations to phone to arrange physiotherapy review, the list of non-responders will be reviewed jointly by physiotherapy and Parkinson’s Disease Nurse Specialists to identify those that may need extra support in accessing physiotherapy.

Conclusions

There were missed opportunities for bone health assessment in those patients with Parkinson’s disease who presented with hip fracture in 2020.

There were high rates of delirium and subsequent contralateral hip fracture in patients with Parkinson’s disease who sustained a hip fracture in 2020

More research into the longer term effects on people with Parkinson’s disease of the Covid-19 pandemic and lockdown restrictions should be considered.

Proposed changes to service

Blood panel for all patients newly diagnosed with Parkinson’s disease to include serum vitamin D and eGFR measurement

Education for all doctors and nurses within the Parkinson’s service at GWH on bone health assessment and implementation of BONE-PARK algorithm to be considered on an annual basis

Height and weight to be recorded at all face-to-face contacts to enable FRAX assessment

Resumption of Parkinson’s nurse inpatient reviews for all inpatients with Parkinson’s disease, with increased frequency as staffing permits.

Parkinson’s nurse review of all patients who do not take up written invitation to make appointment for annual physiotherapy review to identify those who may benefit but who may have apathy or other barriers to booking appointment.

Creation of Parkinson’s disease-specific patient information leaflets on bone health to be distributed during clinics.

Acknowledgements

My thanks go to Parkinson’s disease Nurse Specialists Sue Thompson and Rachel Gardner, Dr Nic Watson and Dr Tania Elias for their assistance and support with the project.

References

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