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AFTER THE FALL | PART 1

Hip fractures a mortal test for elders and for medicine

As Angeline Scardino struggled to stand with help from nurse Jane Ashley, her repaired left leg buckled under her. But she tried again and managed to walk a few steps.
As Angeline Scardino struggled to stand with help from nurse Jane Ashley, her repaired left leg buckled under her. But she tried again and managed to walk a few steps. (Globe Staff Photo / Bill Greene)

A nurse beckoned and Angeline Scardino, leaning lightly on the cane that was an unwanted 81st birthday present, calmly made her way toward the examining room.

It was time for her regular physical, and, although she had her share of worries, she expected no bad news.

Then, partway down the familiar corridor, the toe of her sneaker stuck in the carpet. Angie flailed for a grip, but her cane tipped and she crashed sideways to the floor.

Wedged against the wall, she tried to sit up, but fell back as pain surged through her left side. Her doctor, Luis Carreiro , came quickly from his private office. Angie heard a nurse blurt out, "Don't touch her. I think she broke her hip."

Angie had been focused on her heart -- she'd had major surgery seven months earlier. Now she stared at her left foot, which was pointing out at an unnatural angle.

"This is it," she whispered to herself. "I'm going to die here."

The fear that enveloped Angie that day has not, more than a year later, let her go.

She had broken a bone her surgeon could fix -- that would be the easy part. But, with the break, so much more seemed to give way. Other health issues intensified. And her self-confidence, so critical to recovery, was abruptly undermined.

It wouldn't claim Angie, but this is how hip fracture typically leads to death -- through devastating complications, of body and mind, through the power of fear itself.

Remarkably, 29 percent of older people who break a hip die within a year, according to research by the University of Maryland School of Medicine commissioned by the Globe. That's higher than the one-year death rate from stroke. And unlike stroke deaths, the rate of hip fracture is rising -- up from 24 percent found by other researchers in the late 1980s.

Each year, approximately 300,000 Americans over 64 break their hips -- three-quarters of them women. They are two to five times more likely to die within a year than seniors of the same age without a break. And with baby boomers by the millions heading for these fragile years, the number of fractures could double by 2040.

"We're looking a train wreck in the face," said Dr. L. Joseph Melton III , an epidemiologist at the Mayo Clinic in Rochester, Minn.

Medicine has made some headway -- improving surgical techniques and preventing many serious complications. And osteoporosis treatment appears to be reducing the risk of fractures.

But there is still a long way to go. Even among the healthiest elders, almost a quarter of those who suffer hip fractures die within a year. And the combination of a fracture with chronic disease leads to death in up to 75 percent of cases, the Globe study found.

Not nearly enough is known about why hip fracture is so destructive. Medicine has focused more on prevention than treatment. Indeed, compared to other deadly health threats -- heart disease, cancer, stroke -- hip fracture has drawn scant attention.

Some research shows that up to half of all hip fracture patients who die within a month of a break could be saved with better care, if only medicine could figure out what better care is.

"We can fix the hip," said Dr. Kenneth Minaker , chief of geriatric medicine at Massachusetts General Hospital , "but can we fix the patient?"

So for now, survival remains, to a large extent, in the hands and minds of the patients themselves. How badly do they want to make it back? How quickly can they conquer the fear of falling again? How much support do they have from family and friends?

To understand the toll of hip fractures, the Globe spoke to specialists and commissioned research into the prevalence of hip fracture deaths. More important, however, was a yearlong immersion in the lives of two women -- Angie, who is the focus today, and Rita Erichsen of Holliston, who longed for death after suffering the break.

She almost got her wish.

Challenge for a strong will
Angie's journey began on Aug. 1, 2005, as doctors evaluated her at Milford Regional Medical Center , an excruciating 12-mile ambulance ride from Franklin.

X-rays showed a simple break in the femur, which is the largest bone in the body and is topped by the ball of the hip joint. Doctors said they planned to operate, but not until they could be sure her heart would withstand the surgery.

Angie's daughter, Joanne Hogan , rushed to the emergency room from her job in Boston. She struggled to figure out what was best for her mother. Was the surgeon suggesting she wouldn't survive the operation? Was there an alternative?

Decades ago, traction -- using tension to hold the broken bone in place -- was the preferred treatment in older people. But too many older patients died from complications caused by weeks or months of immobilization. The Milford surgeon put it bluntly: That's how people leave this earth.

Now, surgeons try to operate within 24 to 48 hours of the break. Quick surgery allows patients to get back on their feet sooner and helps reduce the likelihood of blood clots, pneumonia, and bedsores, and may reduce the risk of death.

Worried about her mother's heart, Joanne decided she wanted the surgery done at Beth Israel Deaconess Medical Center , where Angie's cardiologist could monitor her recovery. By the time the hospitals could arrange the transfer, Angie had been confined to bed for 2 1/2 days.

Finally in a room at Beth Israel, Angie looked every bit her age. Sunlight from a scorcher of a day beat in, bleaching her white hair and highlighting the weariness in her plump face. She was tethered to the bed by tubes that carried oxygen and fluids and by compression booties that kept blood moving in her legs to avoid clots. When the boots inflated, she said, it felt like her beloved dachshunds, Symantha and Sydney , pawing at her legs. The thought brought an ear-to-ear grin and a momentary sparkle to her eyes.

Then she shifted, and the pain exploded -- more than a match for the Tylenol with codeine she had accepted from the nurses, with great hesitation. "In all my years, I never took an aspirin," she said. "Now, I'm making up for it."

Angie allowed herself a spoonful of self-pity, but no more. A few of her friends from the Franklin Senior Center had recently broken their hips and were not doing well. She raged at her bad luck.

Then, she turned to the nurse and lightened the mood. "I heard it was too quiet here. I had to come and stir the pot."

It was typical Angie. For eight decades, she had surmounted one obstacle after another on the strength of good humor, zeal for work, and a strong will. When her husband dropped dead of a heart attack 40 years ago, she had three children under 12 and no income. Her oldest son, Joseph, named for his father, performed mouth-to-mouth resuscitation in vain, Angie recalled, as tears clouded her large hazel eyes.

It felt like a family curse. Her own father had died when she was 11, leaving her mother with seven to raise.

After her husband's death, Angie had to find work that would feed the children and keep them in their small house in a suburb of Schenectady , N.Y. With only a general equivalency diploma and no recent experience, she settled on a part-time sales job at a local department store. Later she found a better job with the state. She scraped and scrimped.

But she never remarried. "I had a stepfather," she said, by way of explanation.

Life was work and her children, whom she brought up to stand on their own feet, especially Joanne, her youngest and only girl. Joanne came to Boston University, then stayed to work in the city as a corporate headhunter. While Angie's tough core is wrapped in softness, Joanne is direct and business-like. She is also fiercely protective of her mother.

As Angie entered her 70s, decades of good health gave way to heart trouble -- first a few clogged blood vessels, then a twisted carotid artery that required surgery in 2000. Joanne insisted she come to Boston for cardiac care and encouraged her to stay for long stretches at the large colonial Joanne and her husband, Jack , had bought in Franklin so there'd be room for all three. But Angie treasured her independence and returned home as often as she could.

By 2001, however, Angie was losing the battle of wills and spending more time in Franklin. At Joanne's, she went out every day, driving to the supermarket or senior center or taking a stroll around the block. She kept busy doing much of the housework and cooking despite Joanne's attempts to spare her. Being useful is essential to Angie.

"I used to throw the mops out. I used to hide them underneath my car," Joanne said. "But she'd just buy another one."

A new treatment approach
Soon after Angie's arrival at Beth Israel, orthopedic surgeon Douglas Ayres swept into her room for a pre-surgery check-in. Angie greeted him with a question, "When am I going to get off my back?"

"This evening," boomed Ayres, an affable hip and knee specialist, exaggerating a bit.

But first, he and his colleague, geriatrician Anne Fabiny , wanted to talk about the fall.

Beth Israel was trying a new approach with older hip fracture patients, teaming a bone surgeon with a doctor who specializes in treating the elderly. The hope was to address, from the start, some of the physical and mental problems that make recovery tougher and account for many of the deaths in hip fracture cases.

Another change was to treat patients after surgery in a special unit for the elderly, where nurses are more attuned to common complications such as delirium and depression.

At several other hospitals nationwide and abroad, a similar approach has allowed more patients to go directly home after surgery and, in some cases, reduced the death rate.

It is a controversial tactic — the evidence of long-term health benefits is

inconclusive and there is a national shortage of geriatricians. Beth Israel

hasn’t broadly implemented the program, focusing instead on training more

doctors and nurses in the special needs of older patients.

For Fabiny, learning about Angie's fall was the first step. More than 90 percent of hip fractures in the elderly result from falls and those who fall once are likely to do so again.

"I did not have a dizzy spell," Angie said. "I did not feel light-headed. I just caught my toe and went over. I feel like such a klutz."

She used her hands to pantomime the fall. "When the cane went down, there was nothing to hang on to. It all happened so quickly."

Fabiny probed for other explanations and learned that Angie had been on a drug, amiodarone , that helps prevent life-threatening heart rhythm disturbances. The drug can also lower the heart rate and cause confusion, Fabiny said, both of which can contribute to a fall. A normal heart rate for someone Angie's age is between 60 and 100, but Angie's was 50.

"When she began to fall, she couldn't correct for it," said Fabiny, who has since moved to the Cambridge Health Alliance . Despite the adrenaline rush that is part of the body's attempt to energize muscles in an emergency, "the heart rate can't go up."

Angie had fallen once before while recovering from her heart surgery, suffering a few bruises, and she was weaker than she used to be. But she had few of the other risk factors for falls and fractures. She had ample padding on her 5-foot-2 frame, wasn't a drinker or smoker and showed no signs of dementia. She had not been diagnosed with osteoporosis.

Surgery and uncertainty
About 5 p.m., Angie was wheeled into the operating room, already sedated. Ayres prepared to patch the break with a metal plate and compression screw, a technique used in many hip fractures.

He and an orthopedic resident painstakingly positioned Angie on the operating table, suspending her broken left leg in a sling. They cranked the leg up to eye level and out to the side, as a technician moved in an X-ray machine about 10 feet tall to guide the surgery. Two huge screens displayed Angie's hip, showing a faint black fracture line.

Eyes on the screen, Ayres moved the leg to align the two parts of the broken femur. Then he made the first incision, and, with gloved hands, felt for the broken bone.

He grabbed a slender drill, with a bit about 8 inches long, and began inserting a guide wire, checking progress on the X-rays. The drill whirred like a dentist's tool; the heart and lung monitors added their staccato beat.

Next, the doctors inserted a long screw designed to allow the weight of Angie's body to close the gap in the bone as she walks. Finally, they placed a metal plate on the outside of the femur and inserted four smaller screws to keep it in place. Angie's femur, unlike those of some older patients, was still solid enough to hold the hardware securely.

At 7:15 p.m., the surgery was done. "She should do well," said Ayres.

Thirteen hours later, Angie brightened as physical therapist Brian McDonnell came to get her out of bed. She had been begging to get off her back since she fell -- four long days earlier. With the pain reduced to a dull ache, she felt ready to take the first step.

McDonnell disconnected her oxygen nose plugs, detached the compression booties and lowered the bed. Then, he drew her left leg slowly toward the edge.

Angie trembled, her excitement suddenly eclipsed by fear. "I'm so afraid of falling now," she said. "Would you please stand by in case I haven't got the strength to stand up?"

McDonnell nodded and reassured her. Then, with a bear hug and a swooping motion, he helped her to sit. She swayed a bit, woozy, then steadied herself with her hands pressed against the bed. Using a bright orange web belt around her waist, he held her as she strained to stand and to move her walker a smidgen.

Her knuckles were white as McDonnell helped her inch slowly toward a reclining chair next to the bed. He braced himself and eased her down.

Angie blew out a deep breath with a soft "oh" that deflated her face and her body. She was exhausted.

But she kept her feelings to herself until McDonnell left.

"I didn't do so good. I expected to go out the door." The few steps had summoned memories of her fall, along with a vision of how her life would change.

"After this, the boss at home says I'll have to use a walker all the time," Angie said dejectedly. "I better just listen to reason. I won't be going back home to New York."

Tomorrow: Rita Erichsen at the edge

Alice Dembner can be reached at Dembner@globe.com

 PART 1: Hip fractures a mortal test for elders and for medicine (By Alice Dembner , Globe Staff, 12/10/06)
 AFTER THE FALL: A staggering death toll, but limited attention (By Alice Dembner, Globe Staff, 12/10/06)
 READ THE SERIES: After the Fall
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