958–964www.elsevier.com/locate/bone

Bone 41 (2007)

Survival and functional outcome according to hip fracture type:A one-year prospective cohort study in elderly women with

an intertrochanteric or femoral neck fracture

P. Haentjens a,⁎, P. Autier b, M. Barette b, K. Venken c, D. Vanderschueren c, S. Boonen c

on behalf of the Hip Fracture Study Group 1

a Department of Orthopaedics and Traumatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, B-1090 Brussels, Belgiumb Unit of Epidemiology and Prevention of Cancer, Jules Bordet Institute, Brussels, Belgium

c Bone Research Unit, Leuven University Department of Experimental Medicine, Katholieke Universiteit Leuven, Belgium

Received 21 February 2007; revised 10 July 2007; accepted 21 August 2007Available online 30 August 2007

Abstract

We conducted a prospective study among elderly women with a first hip fracture to document survival and functional outcome and todetermine whether outcomes differ by fracture type.

The design was a one-year prospective cohort study in the context of standard day-to-day clinical practice. The main outcome measures weresurvival and functional outcome, both at hospital discharge and 1 year later. Functional outcome was assessed using the Rapid Disability RatingScale version-2.

Of the 170 women originally enrolled, 86 (51%) had an intertrochanteric and 84 (49%) a femoral neck fracture. There were no significantdifferences between the two groups with respect to median age (80 and 78 years, respectively), type and number of comorbidities and prefractureresidence at the time of injury. At hospital discharge, intertrochanteric hip fracture patients had a higher mortality ( p=0.006) and were functionallymore impaired ( p=0.005). One year later, mortality was still significantly higher after intertrochanteric fracture (relative risk 2.5; 95% confidenceinterval: 1.3 to 5.1; p=0.008), but functional outcome among surviving patients was similar in both groups.

We conclude that intertrochanteric fractures are associated with increased mortality compared to femoral neck fractures. Functional outcomediffers according to fracture type at hospital discharge, but these differences do not persist over time. These differences cannot be explained bydifferences in age or comorbidity. To address the mechanism(s) by which intertrochanteric fractures carry excess mortality compared to femoral neckfractures, future studies in hip fracture patients should include a comprehensive assessment of the degree of frailty, vitamin D status, and falldynamics.© 2007 Elsevier Inc. All rights reserved.

Keywords: Hip fracture type; Survival; Functional outcome

Introduction

Hip fractures are classified according to the anatomic lo-cation of fracture into fractures of the femoral neck (cervical,intracapsular) or intertrochanteric (extracapsular) regions[38,46]. However, most survival studies in hip fracture patients

⁎ Corresponding author. Fax: +32 2 477 86 89.E-mail address: patrick.haentjens@uzbrussel.be (P. Haentjens).

1 All members of the study group are listed in the Acknowledgments section.

8756-3282/$ - see front matter © 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.bone.2007.08.026

have not analyzed these different fracture types separately[7,9,13,21–23,33,35,39,47,48]. In those survival studies that didfocus on fracture type, women with an intertrochanteric fracturewere found to be almost twice as likely to die than those with afemoral neck fracture [1,3,6,8,12,15,24,25,29,34,43,45,49], butit remains unclear if and to what extent these differences inmortality might be due to differences in comorbidity.

Data on potential differences in long-term functional out-come between both hip fracture types are even more sparse andconflicting, with some studies reporting less functional recovery

Table 1Selected baseline characteristics of all the patients initially enrolled, stratified byfracture type a

Prefracture characteristics Femoralneckfracture a

(n=84)

Intertrochantericfracture a

(n=86)

pvalue b

Age at time of injuryMean (years) 78.1 80.2 0.133Median (years) 78 80 –Range (years) 52–95 50–99 –Body weight (kg) 59.9 57.5 0.186Length (cm) 161.2 160.1 0.285BMI (body mass index: kg/m2) 22.9 22.4 0.339

ComorbiditiesNeuropsychiatric disorders 5 (06%) 6 (07%) 0.786Hypertension 14 (17%) 23 (27%) 0.112Ischemic and/or valvularheart disease

25 (30%) 16 (19%) 0.090

Diabetes mellitus 8 (10%) 9 (10%) 0.838Thyroid disease 4 (05%) 3 (04%) 0.676Osteoarthritis 32 (38%) 22 (26%) 0.056Epilepsy 1 (01%) 2 (02%) 0.574Parkinson's disease 3 (04%) 3 (04%) 0.931Cerebrovascular disease 9 (11%) 11 (13%) 0.675Visual impairment 5 (06%) 5 (06%) 0.612Hematologic disorders 1 (01%) 5 (06%) 0.111Gastrointestinal disorders 13 (16%) 12 (14%) 0.474Chronic obstructive pulmonary disease 6 (07%) 11 (13%) 0.705Urinary incontinence 5 (06%) 4 (05%) 0.758Renal failure 3 (04%) – 0.078

Number of comorbidities per womanNone or one 27 (32%) 32 (37%) 0.297Two or more 57 (68%) 54 (63%)

Prefracture residenceLiving in own house 37 (44%) 26 (30%)Living with relatives 25 (30%) 29 (34%) 0.243Living in nursing home 22 (26%) 31 (63%)a Data on comorbidities are presented as the number of women with the

percentages in parentheses.b The unpaired Student's t test was used for analyzing differences between

means. The unadjusted χ2 test was used for analyzing differences betweenproportions.

959P. Haentjens et al. / Bone 41 (2007) 958–964

1 year after injury among patients with an intertrochantericfracture [24] and other studies reporting similar functional out-comes [3,15,26,28,36,37,45]. Moreover, differences in baselinecharacteristics between intertrochanteric and femoral neckfracture patients in these studies make it difficult to interpretthese results. More specifically, differences in age and comor-bidity – known determinants of mortality and functional out-come after hip fracture [5] – may have confounded the results.

In a one-year prospective cohort study conducted amongunselected, consecutively recruited elderly women with a firsthip fracture [4,5,17], we observed no differences in age and pre-fracture comorbidities between our patients with an intertro-chanteric or a femoral neck fracture. In this regard, this cohortprovides an opportunity to address the question as to whethermortality and functional outcome are affected directly by hipfracture type.

Participants and methods

Study design and source of study population

The current paper is based on a large observational study undertaken betweenNovember 1995 and July 1996 with the aim to collect data on risk factors for hipfracture, current surgical practice, mortality, clinical outcome, and costs of careafter hip fractures in women aged 50 years and older. A detailed description of thestudy design, recruitment strategy, participant characteristics, outcome assess-ment, and statistical analysis has been previously published [4,5,17].

Briefly, at four Belgian hospitals, unselected women 50 years old and morewho sustained a first hip fracture (femoral neck or intertrochanteric) wereconsecutively recruited for inclusion. Exclusion criteria were a history ofprevious hip fracture and a pathologic fracture resulting from metastatic disease.All patients were identified at the time of admission, had operative treatment, andwere prospectively followed for 1 year. Baseline questionnaires inquired aboutthe pre-fracture mental status, the pre-fracture comorbidities, and the habitualplace of residence before the fracture. Where required, these questions wereasked to relatives.

The focus of the current report is on survival and functional outcomeaccording to hip fracture type. To this end, two mutually exclusive groups weredefined according to whether the patients had a femoral neck (cervical orintracapsular) or an intertrochanteric (extracapsular) fracture.

Outcome assessment

Mortality rates among hip fracture patients were documented at hospitaldischarge and 1 year later.

Functional outcome of hip fracture women was assessed using the RapidDisability Rating Scale version-2 (RDRS-2) [31] (Appendix A). This scalecomprises 18 items grouped into three domains: activities of daily living (8 items,including eating, walking, mobility, bathing, dressing, toileting, grooming, andadaptive tasks), degree of dependence (7 items, including communication,hearing, sight, diet, stay in bed during the day, incontinence, andmedication), andcognitive impairment (3 items, including mental confusion, uncooperativeness,and depression). The 18 items are ranked on a four-point scale, with 1 pointindicating the best function and 4 points the worst. Therefore, total scores canrange from 18 (no functional impairment) to 72 (severe global functionalimpairment). Scores can be reported as the score for each item, the sum of thescores for each domain (daily living, dependence, and cognitive impairment) oras an aggregate score, with higher scores always indicating poorer function(Appendix A).

The RDRS-2 score was assessed by trained interviewers, both at hospitaldischarge and at 12 months after discharge. In all participants, the same inter-viewers performed the baseline and follow-up assessments. Only patients whocompleted the RDRS-2 questionnaires at discharge and 12 months later wereincluded in the analyses.

Statistical analyses

The unadjusted χ2 test was used for analyzing differences betweenproportions.

Differences in functional status among the two fracture groups and changes infunctional status during the one-year evaluation period were analyzed by usingunpaired and paired Student’s t tests, respectively. As RDRS-2 data werepositively skewed, a log transformation was applied before performing statisticaltests.

All statistical tests were two sided.

Results

Participants’ characteristics

All eligibility criteria were met by a total of 184 hip fracturepatients, of which 170 (92.4%) accepted to participate. Patients

960 P. Haentjens et al. / Bone 41 (2007) 958–964

or their relatives who declined to participate typically did sobecause they did not want to participate in a long-term study. Ofthe 170 women originally enrolled, 84 (49%) and 86 (51%)women had a femoral neck fracture or an intertrochantericfracture, respectively, with a corresponding ratio of femoral neckto intertrochanteric fracture patients of 0.98.

Table 1 summarizes the clinical baseline characteristics ofboth groups, with no significant differences between inter-trochanteric and femoral neck fracture patients. In particular, theproportion of women with a specific comorbid condition did notdiffer between the fracture groups. There were no significantdifferences between the two groups with respect to prefractureresidence.

Mortality

None of the women originally enrolled was lost to follow-up.Mortality rates were significantly higher among intertrochan-teric fracture patients, both at hospital discharge and 12 monthsafter fracture (Table 2).

During the initial hospitalization period, 10 (12%) womenwith an intertrochanteric fracture died, as compared with onlyone woman with a femoral neck fracture ( p=0.006). One-yearafter injury, 23 (28%) of the 86 elderly women with an inter-trochanteric fracture had died, compared to 9 (11%) of the 84patients with a femoral neck fracture (relative risk 2.5; 95%confidence interval: 1.3 to 5.1; p=0.008).

Functional outcome

Although none of the women was lost to follow-up, 4women were withdrawn from the study because their RDRS-2questionnaires were not properly completed (one woman with afemoral neck fracture and three women with an intertrochantericfracture, Table 2).

Table 2Relationships between the type of fracture, the number of women initiallyenrolled, short-term (initial hospitalization) and long-term (one-year) mortality,and the number of women for whom functional outcome was available bothupon hospital discharge and 1 year after injury

Characteristic Femoralneckfracture

Intertrochantericfracture

pvalue a

Number of women initially enrolled 84 86Mortality during acute hospital stay 1/84 (1%) 10/86 (12%) 0.006Mortality after hospital discharge(post-discharge period)

8/84 (10%) 13/86 (16%) 0.268

Mortality at 1 year after injury 9/84 (11%) 23/86 (27%) 0.008Number of women still alive at 1year after injury

75 63

Number of women who did notproperly complete the RDRS-2questionnaires

1/75 (1%) 3/63 (5%) 0.232

Number of women with RDRS-2data available at discharge andat 1 year

74/75 (99%) 60/63 (95%)

a The unadjusted χ2 test was used for analyzing differences betweenproportions.

For the remaining 74 women with a femoral neck fractureand the 60 women with an intertrochanteric fracture, completeRDRS-2 data were available both upon hospital discharge andat 1 year after injury. Sixty-eight percent of the women wereable to answer the questionnaires directly: 50 women in thefemoral neck and 40 women in the intertrochanteric fracturegroup. For those women who were unable to answer questionsaccurately because of illness or mental disability (32%), thecompletion of the questionnaires was performed with the helpof a “proxy-responder”—that is, a person in close contact withthe patient (generally, a family member). There were no sig-nificant differences between the two groups in this regard.

Table 3 shows the functional measurements at hospitaldischarge (initial RDRS-2 score) and 1 year after hospital dis-charge (one-year RDRS-2 score).

At hospital discharge, patients with an intertrochanteric hipfracture were less able to walk independently than patients with afemoral neck fracture (0.4 units difference; p=0.005; Table 3,lower panel, line 3, column 2 versus column 5). For all the other17 items there were no differences between patients with a fem-oral neck or an intertrochanteric fracture at hospital discharge(Table 3, column 2 versus column 5).

One year after hospital discharge, functional results amongsurviving patients were similar in both hip fracture groups forall 18 items grouped into three domains (Table 3, column 3versus column 6).

During the one-year period after hospital discharge, the totalRDRS-2 scores improved in both hip fracture groups. In femoralneck fracture patients, total RDRS-2 scores improved by2.6 units during the one-year period after hospital discharge( p=0.015, Table 3, column 2 versus column 3). During thesame period, ADL scores improved by 2.5 units ( p=0.004).Likewise, functional status improved significantly in inter-trochanteric patients, with a change in total RDRS-2 scores andADL scores of 3.9 units ( p=0.003) and 3.6 units ( pb0.001,Table 3, column 5 versus column 6), respectively. In bothgroups, this improvement was due to a significant improvementin walking ability ( p=0.006 and pb0.001 in femoral neck andintertrochanteric fracture groups, respectively) and mobility( pb0.001 and p=0.001, respectively). None of the patientgroups showed any change in the degree of disability or cog-nitive impairment.

Discussion

Our findings provide evidence that mortality and functionaloutcome following a hip fracture vary according to fracture type.At hospital discharge, womenwho sustained an intertrochanterichip fracture had a higher mortality and were less able to walkindependently than women with a femoral neck fracture. Oneyear later, mortality was still higher after intertrochantericfracture, but functional outcome among surviving patients wasnot different between both groups.

An increase in mortality in intertrochanteric fracture patientshas been observed in previous studies. Lawton et al. [29] wereamong the first to assess absolute risks of death according to hipfracture type, with a reported mortality at 1 month of 50% in

Table 3RDRS-2 results obtained at hospital discharge and 1 year after hospital discharge in hip fracture patients stratified by type a

Outcome measure b Femoral neck fractures (n=74) Intertrochanteric fractures (n=60)

Score at hospitaldischarge (95% CI)

One-year score(95% CI)

p value c Score at hospitaldischarge (95% CI)

One-year score(95% CI)

p value c

Total RDRS-2 score 32.5 (30.4–35.2) 29.9 (27.6–32.4) 0.015 35.9 (33.5–38.5) 32.0 (29.1–35.2) 0.003Assistance with activitiesof daily living (ADL)

18.6 (16.9–20.4) 16.1 (14.6–17.7) 0.004 20.8 (19.2–22.6) 17.2 (15.3–19.2) b0.001

Walking 2.4 d (2.1–2.6) 2.0 (1.7–2.2) 0.006 2.8 d (2.6–3.2) 2.2 (1.9–2.5) b0.001Mobility 2.9 (2.6–3.3) 2.4 (2.2–2.7) b0.001 3.0 (2.6–3.4) 2.5 (2.2–2.8) 0.004

Degree of disability 9.9 (9.3–10.6) 9.7 (9.3–10.6) 0.566 10.7 (9.9–11.6) 10.5 (9.9–11.6) 0.629Degree of cognitive impairment 3.8 (3.5–4.0) 3.8 (3.5–4.1) 0.863 4.0 (3.7–4.4) 4.0 (3.7–4.4) 0.834a This table includes data on the 134 patients who were still alive 1 year after hospital discharge and who completed the entire one-year testing protocol.b Outcome measure: Rapid Disability Rating Scale version-2 (RDRS-2) score [31]. Higher scores always indicate poorer function. The best possible score is 18

points; the worst score possible is 72 points (95% CI: ninety-five percent confidence interval).c p value for paired Student's t test, testing the difference between score at hospital discharge and 1 year later in one fracture group.d p value=0.005 for Student's t test, testing the difference in scores between the femoral neck and the intertrochanteric fracture groups.

961P. Haentjens et al. / Bone 41 (2007) 958–964

patients with intertrochanteric fractures compared to 29% inthose with femoral neck fractures. Subsequent studies confirmedhigher mortality rates among intertrochanteric fracture patientsat different time points: during hospitalization (3% versus 2%[15]), at 2 months (6% versus 4% [15]), at 6 months (33% versus24% [25], 14% versus 11% [15], 16% versus 6% [8]), at 1 yearafter fracture (38% versus 28% [15], 18% versus 17% [15], 15%versus 9% [45], and 29% versus 26% [45]), and at 5 years (22%versus 16% [6], 25% versus 19% [3], and 49% versus 35%[24]). In these studies the ratio of femoral neck to intertrochan-teric fracture patients varied from 0.50 [24] to 1.21 [29], com-pared to 0.98 in the current study.

However, the extent to which this excess mortality in thesestudies reflects differences in age or comorbidity remains to beclarified. In most studies, patients with intertrochanteric frac-tures were older and had more existing comorbidities than thosewith a femoral neck fracture, and it has been hypothesized thatthe increase in mortality among women with an intertrochantericfracture reflects poor underlying health status in addition to thefracture itself. However, even when accounting for age andcomorbid conditions by using multivariable analyses, severalreports found significantly higher mortality rates among patientswith an intertrochanteric fracture [1,24,34,45,49]. Compared tothis type of mathematical modeling, empirical data obtained inthe context of prospective studies would be expected to provideeven more robust information. The findings of our currentanalysis provide further evidence that differences in mortalitybetween hip fracture types cannot be entirely explained bydifferences in age or comorbidities. Even in the absence of suchdifferences, we observed excessmortality among elderly womenwho sustained an intertrochanteric fracture, suggesting thatfracture type is an independent predictor of mortality in hipfracture patients, both at 1 month and at 1 year after injury. Themechanism(s) by which intertrochanteric fractures carry excessmortality compared to femoral neck fractures remain, as yet,unidentified and will require further research. It is tempting tospeculate that, even in the absence of a significant difference inthe number of comorbidities, the excess mortality in inter-trochanteric patients might be driven by differences in frailty.While the definition of frailty has evolved over the years, frailty

cannot be simply measured by counting the number of comor-bidities [18]. Many of the components of the frailty syndrome areknown risk factors for mortality after hip fracture—includingmobility, balance, muscle strength, cognition, nutritional status,physical activity, and risk of falls [14]. We hypothesize that dif-ferences in some of these componentsmay have accounted for theobserved difference in mortality and suggest that future studies inhip fracture patients should include a formal and comprehensiveassessment of frailty.

With regard to functional outcome, no long-term differenceswere seen between intertrochanteric fracture patients and fe-moral neck fracture patients. Our findings are in line with mostprevious studies, reporting similar functional outcomes in bothfracture types at 6 months [37] and at 1 year [3,15,26,28,36,45].At hospital discharge, we did observe a difference in short-termfunctional recovery, but this difference should be interpretedwith caution as it is likely to reflect differences in surgicalprocedures and/or rehabilitative strategies [20,27,42]. The typeof surgical intervention is largely driven by the type of hipfracture and is known to be one of the main determinants ofshort-term functional recovery during hospitalization. In a studyby Koval et al. [27], intertrochanteric patients who had hadinternal fixation bore substantially less weight on the injuredlimb than those with femoral neck fractures who had had pros-thetic replacement surgery at 3 weeks; by 6 weeks, there were nosignificant differences among the groups with regard to weight-bearing or gait parameters. Additionally, a number of studieshave provided evidence that post-fracture rehabilitation isanother critical determinant of short-term functional recoveryin hip fracture patients [20,42]. Because our study was per-formed in the context of standard care, it is most likely thatdifferences in surgical technique or rehabilitative strategies havecontributed to the observed differences in functional recoveryduring hospitalization.

Methodological strengths of our study include its prospec-tive design, the long-term (one-year) follow-up period, therelatively large sample size, the consecutive recruitment ofunselected patients with a first hip fracture (not excludinginstitutionalized or demented elderly women), a high proportionof eligible patients being enrolled, the virtually complete patient

962 P. Haentjens et al. / Bone 41 (2007) 958–964

follow-up, and the use of a well-validated instrument to measurefunctional outcome [31].

The current study, on the other hand, also has a number oflimitations. It is possible that unmeasured differences inpatients’ characteristics or medical therapies may have contri-buted to our results. In particular, our study did not include acomprehensive assessment of the different components of thefrailty syndrome, which may have accounted for the observeddifference in outcome, even in the absence of differences in ageor number of comorbidities. Likewise, we did not assess anypotential differences in the degree of vitamin D insufficiencyaccording to hip fracture type. This relationship might be ofspecial relevance because vitamin D insufficiency has beenassociated with the occurrence of intertrochanteric fracture [44]and may be an independent risk factor for poorer postoperativerecovery in elderly patients with a hip fracture [11]. Althoughage is one of the main determinants of circulating levels ofvitamin D [32], we acknowledge that, even in the absence of anage difference between intertrochanteric fracture patients andfemoral neck fracture patients, a difference in vitamin D statusbetween both fracture types cannot be excluded. Also, we hadno data available on the causes of death and were unable toexplore any potential relationship with baseline comorbidity. Inaddition, we did not collect data on pre-fracture fall dynamics,another potential determinant of fracture type [19,40]. The factthat we did not assess fall dynamics is another limitation of ourstudy, although it should be noted that a number of studies[2,16,41] did not report an association between fall character-istics and the type of hip fracture and that any retrospective dataassessment of pre-fracture characteristics is subject to signifi-cant recall bias [10,19,30]. Finally, our study did not assess thepotential impact of specific operative or rehabilitative proce-dures on differences in short-term functional outcome betweenfracture types.

In conclusion, our findings indicate that, in the long term (at 1year), functional outcome is similar in intertrochanteric andfemoral neck fracture patients; short-term differences in functionalrecovery (during the initial hospitalization) do not persist overtime. However, even in patients of similar age, intertrochantericfractures carry a higher risk of mortality than femoral neckfractures, both in the short term and in the long term. To address themechanism(s) by which intertrochanteric fractures carry excessmortality compared to femoral neck fractures, future studies in hipfracture patients should include a comprehensive assessment of thedegree of frailty, vitamin D status, and fall dynamics.

Acknowledgments

We are indebted to the participating women and theirfamilies. We would also like to thank Health ManagementCreative (Brussels) for the professional way they ensured theinterviews and the follow-up of patients.

S. Boonen and D. Vanderschueren are both Senior ClinicalInvestigator of the Fund for Scientific Research-Flanders,Belgium (F.W.O.-Vlaanderen) and holders of the LeuvenUniversity Chair in Metabolic Bone Diseases, supported byRoche & GSK.

This paper was selected for oral presentation at the ECCEO-4meeting.

The Hip Fracture Study Group consists of the followinginvestigators: P. Autier, MD (Division of Epidemiology andBiostatistics, European Institute of Oncology, Milan, Italy, andCenter for Research in Epidemiology and Health InformationSystems Luxemburg, Grand Duchy of Luxemburg), J.M.Baillon, MD (Department of Orthopedics, Ixelles-EtterbeekHospital, Brussels, Belgium), M. Barette, MD (Unit ofEpidemiology and Prevention of Cancer, Jules Bordet Institute,Brussels, Belgium), J. Bentin, MD (Service of Rheumatology,Louis Cathy Hospital, Baudourt, Belgium), S. Boonen, MD,PhD (Leuven University Center for Metabolic Bone Diseasesand Division of Geriatric Medicine, Katholieke UniversiteitLeuven, Leuven, Belgium), R. Bouillon, MD, PhD (LeuvenUniversity Center for Metabolic Bone Diseases and Division ofEndocrinology, Katholieke Universiteit Leuven, Leuven, Bel-gium), P. Broos, MD, PhD (Leuven University Center forMetabolic Bone Diseases and Division of Traumatology andEmergency Surgery, Katholieke Universiteit Leuven, Leuven,Belgium), M.C. Closon, PhD (Interdisciplinary Center in HealthEconomics, Université Catholique de Louvain, Brussels,Belgium), AR. Grivegnée, PhD (Unit of Epidemiology andPrevention of Cancer, Jules Bordet Institute, Brussels, Belgium),P. Haentjens, MD, PhD (Department of Orthopaedics andTraumatology, Vrije Universiteit Brussel, Brussels, Belgium),and P. Opdecam, MD, PhD (Department of Orthopaedics andTraumatology, Vrije Universiteit Brussel, Brussels, Belgium).

Appendix A

Rapid Disability Rating Scale version-2 (RDRS-2), adaptedfrom Linn and Linn [31]

Assistance with activities of daily living

Eating None A little A lot Spoon-feed;

intravenous tube

Walking (with cane

or walker if used)

None A little A lot Does not walk

Mobility (going outsideand getting about withwheelchair, etc., ifused)

None

A little A lot Is housebound

Bathing (include gettingsupplies, supervising)

None

A little A lot Must be bathed

Dressing (include help inselecting clothes)

None

A little A lot Must be dressed

Toileting (include helpwith clothing,cleaning, or help withostomy, catheter)

None

A little A lot Used bedpan orunable to care forostomy/catheter

Grooming (shaving formen, hairdressing forwomen, nails, teeth)

None

A little A lot Must be groomed

Adaptive tasks(managingmoney/possessions;telephoning; buyingnewspaper, toiletarticles, snacks)

None

A little A lot Cannot manage

963P. Haentjens et al. / Bone 41 (2007) 958–964

Degree of disability

Appendix A (continued )

Communication(expressing self)

None

A little A lot Does notcommunicate

Hearing (with aidif used)

None

A little A lot Does not seemto hear

Sight (with glasses,if used)

None

A little A lot Does not see

Diet (deviation fromnormal)

None

A little A lot Fed byintravenous tube

In bed during day(ordered orself-initiated)

None

A little(b3 hours)

A lot

Most/all the time

Incontinence(urine/feces,with catheter orprosthesis, if used)

None

Sometimes Frequently(weekly+)

Does not control

Medication

None Sometimes Daily,takenorally

Daily; injection;(+oral if used)

Degree of cognitive impairment

Mental confusion None A little A lot Extreme Uncooperativeness

(combat efforts tohelp with care)

None

A little A lot Extreme

Depression

None A little A lot Extreme

Directions: rate what the person does to reflect current behavior. Circle one ofthe four choices for each item. Consider rating with any aids or prosthesesnormally used. None=completely independent or normal behavior. Total= thatperson cannot, will not, or may not (because of medical restriction) perform abehavior or has the most severe form of disability or problem.

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