Effects of dementia on postoperative outcomes of older adults with hip fractures: a population-based study

Strategies to improve end-of-life decision-making and palliative care following hip fracture in frail older adults: a scoping review

BACKGROUND

Although surgery is the gold standard following a hip fracture, the potential for rehabilitation and survival rates are low in frail older patients. Some patients may derive more benefit from palliative care. The objectives of this review were to identify the available strategies to improve end-of-life decision-making and palliative care for frail patients with hip fractures and to synthetise their level of support.

METHODS

We conducted a scoping review of the scientific and grey literature, searching seven databases and websites of associations. We included all study designs, expert opinion articles and clinical practice guidelines (CPGs). Data were synthetised according to the Approach to Patient with Limited Life Expectancy and Hip Fracture framework. The number of research items and their level of evidence were tabulated for each of the recommended strategies.

RESULTS

Of the 10 591 items identified, 34 were eligible. The majority of included articles were original research studies (n = 15). Half of the articles and CPGs focused on intervention categories (55%) such as goals of care discussion and comfort care, followed by factors to consider in the end-of-life decision-making process (25%) and prognosis assessments (20%), mainly through the estimation of life expectancy. The level of evidence for these strategies remains low, given the limited number of prospective studies supporting them.

CONCLUSIONS

This scoping review highlighted that end-of-life care in frail older patients with a hip fracture remains understudied. The strategies identified could be prioritised for future research to improve the well-being of the target population while promoting sustainable resource management.

Association between postoperative hyperactive delirium and major complications in elderly patients undergoing emergency hip fracture surgery: A large-scale cohort study

AIM

This cohort study aimed to explore the connection between postoperative hyperactive delirium and major complications in elderly patients undergoing emergency hip fracture surgery.

METHODS

Elderly patients aged 65 years and older undergoing emergency hip fracture surgery were included in the study. The presence of postoperative hyperactive delirium was assessed, and logistic regression analysis, following propensity score matching, was conducted to investigate the association between postoperative hyperactive delirium and major complications occurring 30 and 90 days post-surgery. The analysis controlled for potential confounding factors.

RESULTS

After propensity score matching, the analysis included 13 590 patients, equally distributed with 6795 in each group. The group experiencing postoperative hyperactive delirium exhibited a significantly elevated risk of 30-day postoperative complications, including acute renal failure, pneumonia, septicemia, and stroke, with adjusted odds ratios ranging from 1.64 to 2.39. Furthermore, this group displayed notably higher rates of 90-day postoperative complications, encompassing mortality, acute renal failure, pneumonia, septicemia, and stroke, with a significantly increased incidence of mortality within 90 days.

CONCLUSION

Postoperative hyperactive delirium in elderly patients undergoing emergency hip fracture surgery is significantly linked to an increased risk of major complications at both 30 and 90 days post-surgery. These findings underscore the critical importance of delirium prevention and management in this patient population, offering the potential to reduce the occurrence of postoperative complications. Geriatr Gerontol Int 2024; 24: 730-736.

Factors Associated with Costly Hospital Care among Patients with Dementia and Acute Respiratory Failure

Rationale: Understanding contributors to costly and potentially burdensome care for patients with dementia is of interest to healthcare systems and may facilitate efforts to promote goal-concordant care. Objective: To identify risk factors, in particular whether an early goals-of-care discussion (GOCD) took place, for high-cost hospitalization among patients with dementia and acute respiratory failure. Methods: We conducted an electronic health record-based retrospective cohort study of 298 adults with dementia hospitalized with respiratory failure (receiving ⩾48 h of mechanical ventilation) within an academic healthcare system. We collected demographic and clinical characteristics, including clinical markers of advanced dementia (weight loss, pressure ulcers, hypernatremia, mobility limitations) and intensive care unit (ICU) service (medical, surgical, neurologic). We ascertained whether a GOCD was documented within 48 hours of ICU admission. We used logistic regression to identify patient characteristics associated with high-cost hospitalization measured using the hospital system accounting database and defined as total cost in the top third of the sample (⩾$145,000). We examined a path model that included hospital length of stay as a final mediator between exposure variables and high-cost hospitalization. Results: Patients in the sample had a median age of 71 (IQR, 62-79) years. Approximately half (49%) were admitted to a medical ICU, 29% to a surgical ICU, and 22% to a neurologic ICU. More than half (59%) had a clinical indicator of advanced dementia. A minority (31%) had a GOCD documented within 48 hours of ICU admission; those who did had a 50% lower risk of a high-cost hospitalization (risk ratio, 0.50; 95% confidence interval, 0.2-0.8). Older age, limited English proficiency, and nursing home residence were associated with a lower likelihood of high-cost hospitalization, whereas greater comorbidity burden and admission to a surgical or neurologic ICU compared with a medical ICU were associated with a higher likelihood of high-cost hospitalization. Conclusions: Early GOCDs for patients with dementia and respiratory failure may promote high-value care by ensuring aggressive and costly life support interventions are aligned with patients' goals. Future work should focus on increasing early palliative care delivery for patients with dementia and respiratory failure, in particular in surgical and neurologic ICU settings.

Association between surgery and rate of incident dementia in older adults: A population-based retrospective cohort study

BACKGROUND

The risk of incident dementia after surgery in older adults is unclear. The study objective was to examine the rate of incident dementia among older adults after elective surgery compared with a matched nonsurgical control group.

METHODS

We conducted a population-based, propensity-matched retrospective cohort study using data from linked administrative databases in Ontario, Canada. All community-dwelling individuals aged 66 years and older who underwent one of five major elective surgeries between April 1, 2007 and March 31, 2011 were included. Each surgical patient was matched 1:1 on surgical specialty of the surgeon at consultation, age, sex, fiscal year of entry, and propensity score with a patient who attended an outpatient visit with a surgeon of the same surgical specialty but did not undergo surgery. Patients were followed for up to 5 years after cohort entry for the occurrence of a new dementia diagnosis, defined from administrative data. Cause-specific hazard models were used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for the association between surgery and the hazard of incident dementia. Subgroup and sensitivity analyses were performed.

RESULTS

A total of 27,878 individuals (13,939 matched pairs) were included in the analysis. A total of 640 (4.6%) individuals in the surgical group and 965 (6.9%) individuals in the control group developed dementia over the 5-year follow-up period. Individuals who underwent surgery had a reduced rate of incident dementia compared with their matched nonsurgical controls (HR 0.88; 95% CI 0.80-0.97; p = 0.01). This association was persistent in most subgroups and after sensitivity analyses.

CONCLUSIONS

Elective surgery did not increase the rate of incident dementia when compared with matched nonsurgical controls. This could be an important consideration for patients and surgeons when elective surgery is considered.

Observation of the short-term curative effect of using SuperPATH approach to treat elderly femoral neck fractures with schizophrenia

As China enters an aging society, the incidence of femoral neck fractures is increasing year by year. For some patients, total hip arthroplasty (THA) is the treatment of choice for displaced femoral neck fractures. Schizophrenia is a common combination of elderly patients with femoral neck fractures, and there are few reports on the treatment. This study describes the short-term efficacy of the supercapsular percutaneously assisted (SuperPATH) approach in the treatment of patients suffered with displaced femoral neck fractures combined with schizophrenia. A retrospective analysis of 20 elderly patients with displaced femoral neck fractures combined with schizophrenia who underwent THA using the SuperPATH approach. Record demographic data, postoperative reexamination of X-ray film to observe the position and the loosening condition of the prosthesis, the length of hospitalization, complications in the hospital and after discharge. The Harris score of hip joint function was used to evaluate postoperative hip joint function. The average age of the 20 patients was 73.1 years. All patients were followed up by outpatient clinic or telephone. The follow-up time was 3-12 months, with an average of 9.2 months. There was no incision infection, no tissue structure damage such as important nerves and blood vessels, and no complications such as early dislocation, loosening of the joint prosthesis, and deep vein thrombosis of lower extremities. The efficacy of the last follow-up was evaluated according to the Harris score of hip joint function: an average of 91 points (78-98 points); 13 cases were excellent, 5 cases were good, and 2 cases were fair. The SuperPATH approach has the advantages of less surgical damage, shorter recovery time, good surgical safety, preserving the normal tension of the muscles around the hip joint, and reducing the incidence rate of early postoperative dislocation of the joint prosthesis. The THA of the SuperPATH approach can treat patients with displaced femoral neck fractures combined with schizophrenia safely and effectively.

Dementia and Hip Fractures: A Comprehensive Review of Management Approaches

» The elderly population is the fastest growing demographic, and the number of dementia cases in the United States is expected to double to 10 million by 2050.» Patients with dementia are at 3× higher risk of hip fractures and have higher morbidity and mortality after hip fractures.» Hip fracture patients with dementia benefit from early analgesia and timely surgical fixation of fracture.» Early and intensive inpatient rehabilitation is associated with improved postoperative outcomes in patients with dementia.» Coordination of care within a "orthogeriatric" team decreases mortality, and fracture liaison services show potential for improving long-term outcomes in hip fracture patients with dementia.

Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures

PURPOSE OF REVIEW

The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities.

RECENT FINDINGS

There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.

Association of neurocognitive disorders with morbidity and mortality in older adults undergoing major surgery in the USA: a retrospective, population-based, cohort study

BACKGROUND

Neurocognitive disorders become increasingly common as patients age, and increasing numbers of surgical interventions are done on older patients. The aim of this study was to understand the clinical characteristics and outcomes of surgical patients with neurocognitive disorders in the USA in order to guide future targeted interventions for better care.

METHODS

This retrospective cohort study used claims data for US Medicare beneficiaries aged 65 years and older with a record of inpatient admission for a major diagnostic or therapeutic surgical procedure between Jan 1, 2017, and Dec 31, 2018. Data were retrieved through a data use agreement between Dartmouth Hitchcock Medical Center and US Centers for Medicare and Medicaid Services via the Research Data Assistance Center. The exposure of interest was the presence of a pre-existing neurocognitive disorder as defined by diagnostic code within 3 years of index hospital admission. The primary outcome was mortality at 30 days, 90 days, and 365 days from date of surgery among all patients with available data.

FINDINGS

Among 5 263 264 Medicare patients who underwent a major surgical procedure, 767 830 (14·59%) had a pre-existing neurocognitive disorder and 4 495 434 (85·41%) had no pre-existing neurocognitive disorder. Adjusting for demographic factors and comorbidities, patients with a neurocognitive disorder had higher 30-day (hazard ratio 1·24 [95% CI 1·23-1·25]; p<0·0001), 90-day (1·25 [1·24-1·26]; p<0·0001), and 365-day mortality (1·25 [1·25-1·26]; p<0·0001) compared with patients without a neurocognitive disorder.

INTERPRETATION

Our findings suggest that the presence of a neurocognitive disorder is independently associated with an increased risk of mortality. Identification of a neurocognitive disorder before surgery can help clinicians to better disclose risks and plan for patient care after hospital discharge.

FUNDING

Department of Anesthesiology and Perioperative Medicine at Dartmouth Hitchcock Medical Center.

Association Between Cognitive Impairment and Repeat Fractures in Medicare Beneficiaries Recently Hospitalized for Hip Fracture

BACKGROUND

Repeat fractures contribute substantially to fracture incidents in older adults. We examined the association between cognitive impairment and re-fractures during the first 90 days after older adults with hip fractures were discharged home from a skilled nursing facility rehabilitation short stay.

METHODS

Multilevel binary logistic regression was used to analyze 100% of U.S. national postacute-care fee-for-service Medicare beneficiaries who had a hospital admission for hip fracture from January 1, 2018, to July 31, 2018; were admitted for a skilled nursing facility stay within 30 days of hospital discharge; and were discharged to the community after a short stay. Our primary outcome was rehospitalization for any re-fractures within 90 days of skilled nursing facility discharge. Cognitive status assessed at skilled nursing facility admission or before discharge was classified as either intact or having mild or moderate/severe impairment.

RESULTS

In 29 558 beneficiaries with hip fracture, odds of any re-fracture were higher in those with minor (odds ratio: 1.48; 95% confidence interval: 1.19-1.85; p < .01) and moderate/major cognitive impairment (odds ratio: 1.42; 95% confidence interval: 1.07-1.89; p = .0149) than in those classified as intact.

CONCLUSIONS

Beneficiaries with cognitive impairment were more likely than their counterparts with no cognitive impairment to experience re-fractures. Community-dwelling older adults with minor cognitive impairment may experience a higher likelihood of experiencing a repeat fracture leading to rehospitalization.

Outcomes for patients with dementia undergoing emergency and elective colorectal surgery: A large multi-institutional comparative cohort study

BACKGROUND

Alzheimer's Disease and Related Dementias (ADRD) may result in poor surgical outcomes. The current study aims to characterize the risk of ADRD on outcomes for patients undergoing colorectal surgery.

METHODS

Colorectal surgery patients with and without ADRD from 2007 to 2017 were identified using electronic health record-linked Medicare claims data from two large health systems. Unadjusted and adjusted analyses were performed to evaluate postoperative outcomes.

RESULTS

5926 patients (median age 74) underwent colorectal surgery of whom 4.8% (n = 285) had ADRD. ADRD patients were more likely to undergo emergent operations (27.7% vs. 13.6%, p < 0.001) and be discharged to a facility (49.8% vs 28.9%, p < 0.001). After multi-variable adjustment, ADRD patients were more likely to have complications (61.1% vs 48.3%, p < 0.001) and required longer hospitalization (7.1 vs 6.1 days, p = 0.001).

CONCLUSIONS

The diagnosis of ADRD is an independent risk factor for prolonged hospitalization and postoperative complications after colorectal surgery.

Effect of dementia on all-cause mortality in hip fracture surgery: a retrospective study on a nationwide Korean cohort

OBJECTIVES

We aimed to evaluate the effect of dementia on the 1-year all-cause mortality in elderly patients who underwent hip fracture surgery, using a nationwide cohort in Korea.

DESIGN, SETTING, AND PARTICIPANTS

This was a nationwide, retrospective study. Elderly patients (≥60 years) with and without dementia who underwent hip fracture surgery between January 2005 and December 2012 were distinguished using the data from the Korean National Health Insurance Service-Senior cohort.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

The mortality rates with 95% CIs and the impact of dementia on all-cause mortality were calculated using a generalised linear model with Poisson distribution and a multivariable-adjusted Cox proportional hazards model, respectively.

RESULTS

Among the 10 833 patients who underwent hip fracture surgery, 13.4% were diagnosed with dementia. During the 1-year follow-up period, 1586 patients with hip fracture without dementia died in 8356.5 person-years (incidence rate (IR)=189.2 per 1000 person-years, 95% CI 179.91 to 198.99), while 340 deaths were confirmed in patients with hip fracture with dementia in 1240.8 person-years (IR, 273.1 per 1000 person-years, 95% CI 244.94 to 304.58). Patients with hip fracture and dementia were 1.23 times more likely to die than those in the control group in the same period (HR=1.23, 95% CI 1.09 to 1.39).

CONCLUSION

Dementia is a risk factor for 1-year all-cause mortality after hip fracture surgery. To improve the postoperative outcomes of patients with dementia who have undergone hip fracture surgery, effective treatment models such as multidisciplinary diagnosis and strategic rehabilitation should be established.

The Effect of Postoperative Physical Therapy Following Hip Fracture: A Literature Review

Hip fractures in the elderly have become a major public health concern as the population ages. Post-operative rehabilitation is associated with improved outcomes and a greater likelihood of returning to pre-operative functional capacity. Several studies have been conducted to investigate various post-operative recovery pathways. However, little is known about which post-operative rehabilitation pathways for hip fractures are most effective in improving patient outcomes. No clear evidence-based guidelines for a standard mobilization protocol for patients are currently available. This review aims to investigate post-operative recovery pathways to help patients suffering from hip fracture return to pre-fracture condition and to quantify pre-operative and post-operative scores for objective rehabilitation evaluation. Measuring pre-operative activity and comparing it to post-operative follow-up values can help predict post-operative rehabilitation functional outcomes.

Implementing an intervention to enhance care delivery and consistency for people with hip fracture and cognitive impairment in acute hospital wards: a mixed methods process evaluation of a randomised controlled feasibility trial (PERFECTED)

OBJECTIVES

To determine how, and under what circumstances, the PERFECT-ER intervention was implemented in five acute hospital wards and impacted on staff practices and perceptions.

DESIGN

Mixed methods process evaluation (undertaken between 2016 and 2018).

SETTING

Five acute hospital wards across three different UK regions.

PARTICIPANTS

Patients (n=3) admitted to acute wards with hip fracture and cognitive impairment, their relatives (n=29) and hospital staff (n=63).

INTERVENTIONS

PERFECT-ER, a multicomponent intervention designed to enhance the recovery of patients with hip fracture and cognitive impairment was implemented for 18 months. PERFECT-ER was implemented at ward level ensuring that multiple new and existing practices were undertaken consistently, on the assumption that collectively, small individual advances would improve care delivery for patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

Implementation of the PERFECT-ER intervention examined through regular intervention scores, service improvement staff reports and action plans, and semi-structured interviews and focus groups.

RESULTS

The process evaluation identified points of implementation vulnerability and strength. All wards implemented some elements of PERFECT-ER. Implementation was fragile when ward pressures were high and when ward staff perceived the relative priority of intervention practices to be low. Adaptations to the implementation process may have reduced whole-ward staff engagement with implementation. However, strategical enlistment of senior ward influencers (such as ward managers, orthogeriatricians) combined with service improvement lead in-ward peer pressure tactics facilitated implementation processes.

CONCLUSIONS

Our study suggests that implementation was expediated when senior staff were on board as opinion leaders and formally appointed internal implementation leaders exerted their power. Within hierarchical settings such as acute wards, key individuals appeared to influence implementation through endorsement and sometimes enforcement. This indicates that whole-ward interventions may not always require cognitive engagement from all ward staff to implement changes. Future ward-level implementation studies could consider how best to engage staff and most importantly, which staff to best target.

TRIAL REGISTRATION NUMBER

ISRCTN99336264.

Impact of Dementia on Long-Term Hip Fracture Surgery Outcomes: An Electronic Health Record Analysis

OBJECTIVE

Older adults with dementia are at higher risk for sustaining hip fracture and their long-term health outcomes after surgery are usually worse than those without dementia. Widespread adoption of electronic health records (EHRs) may allow hospitals to better monitor long-term health outcomes in patients with dementia after hospitalization. This study aimed to (1) estimate how dementia influences discharge location, mortality, and readmission 180 days and 1 year after hip fracture surgery in older adults, and (2) demonstrate the feasibility of using selection-bias reduced EHR data for research and long-term health outcomes monitoring.

DESIGN

Retrospective observational cohort study using EHRs.

SETTING AND PARTICIPANTS

A cohort of 1171 patients over age 65 years who had an initial hip fracture surgery between October 2015 and December 2018 was extracted from EHRs of one health system; 376 of these patients had dementia.

METHODS

Logistic regression was applied to estimate influences of dementia on discharge disposition and Cox proportional hazards model for mortality. The Fine and Gray regression model was used to analyze readmission, accounting for the competing risk of death. To reduce selection bias in EHRs, inverse probability of treatment weighting using propensity scores was implemented before modeling.

RESULTS

Dementia had significant impacts on all outcomes: being discharged to facilities [odds ratio (OR) = 2.11, 95% confidence interval (CI) 1.19-3.74], 180-day mortality [hazard ratio (HR) = 1.69, 95% CI 1.20-2.38], 1-year mortality (HR = 1.78, 95% CI 1.33-2.38), 180-day readmission (HR = 1.62, 95% CI 1.39-1.89), and 1 year readmission (HR = 1.39, 95% CI 1.21-1.58).

CONCLUSIONS AND IMPLICATIONS

Dementia was a significant risk factor for worse long-term outcomes. The inverse probability of treatment weighting approach can be used to reduce selection bias in EHR data for research and monitoring long-term health outcomes in the target population. Such monitoring could foster collaborations with post-acute and long-term health care services to improve recovery outcomes in patients with dementia after hip fracture surgery.

Preoperative Comorbidities Associated With Early Mortality in Hip Fracture Patients: A Multicenter Study

OBJECTIVE

Multiple comorbidities in hip fracture patients are associated with increased mortality and complications. The goal of this study was to characterize the relationship between specific patient factors including comorbidities and outcomes in geriatric hip fractures, including length of stay, unplanned ICU admission, discharge disposition, complications, and mortality.

METHODS

This is a retrospective review of a trauma database from five Level 1 and Level 2 trauma centers of patients with hip fractures of the femoral neck and intertrochanteric region who underwent treatment using hip pinning, hemiarthroplasty, total hip arthroplasty, cephalomedullary nailing, or dynamic hip screw fixation. Mortality was the primary outcome variable (including in-hospital mortality, 30-day mortality, 60-day mortality, and 90-day mortality). Secondary outcome variables included in-hospital adverse events, unplanned transfer to the ICU, postoperative length of stay, and discharge disposition. Regression analyses were used for evaluation of relationships between comorbidities as independent variables and primary and secondary outcomes as dependent variables.

RESULTS

Two thousand three hundred patients were included. The mortality was 1.8%, 7.0%, 10.9%, and 14.1% for in-hospital, 30-day, 60-day, and 90-day mortality, respectively. Diabetes and cognitive impairment present on admission were associated with mortality at all-time intervals. COPD was the only comorbidity that signaled in-hospital adverse event with an odds ratio of 1.67 (P = 0.012). No patient factors, time to surgery, or comorbidities signaled unplanned ICU transfer. Patients with renal failure and COPD had longer hospital stays after surgery.

CONCLUSION

Geriatric hip fractures continue to have high short-term morbidity and mortality. Identifying patients with increased odds of early mortality and adverse events can help teams optimize care and outcomes. Patients with diabetes, cognitive impairment, renal failure, and COPD may benefit from continued and improved medical optimization during the perioperative period as well as being more closely managed by a medicine team without delaying time to the operating room.

Recent advances in geriatric anaesthesia

The World Health Organization defines healthy ageing as 'the process of developing and maintaining the functional ability that enables well-being in older age'. This functional ability is the characteristic of the individual's own physical and mental status influenced by the environmental and socio-economic factors. Preoperative preparation of the elderly patients includes functional assessment to identify preexisting cognitive impairment or cardio-pulmonary reserve, frailty, nutrition, polypharmacy and anti-coagulation issues. Intraoperative management includes anaesthetic mode and pharmacology, monitoring, intravenous fluid and transfusion management, lung protective ventilation and hypothermia. Postoperative checklist includes perioperative analgesia, postoperative delirium and cognitive dysfunction.

Trajectories and prognostic factors for recovery after hip fracture: a longitudinal cohort study

PURPOSE

The aim of this study was to determine recovery trajectories and prognostic factors for poor recovery in frail and non-frail patients after hip fracture.

METHODS

Patients with a hip fracture aged 65 years and older admitted to a hospital in the Netherlands from August 2015 to November 2016 were asked to complete questionnaires at one week and one, three, six, 12, and 24 months after injury. The questionnaires included the ICEpop CAPability measure for older people, Health Utility Index, and the Hospital Anxiety Depression Scale. Latent class trajectory analysis was used to determine trajectories of recovery. Patient and injury characteristics for favourable and unfavourable outcome were compared with logistic regression.

RESULTS

In total, 696 patients were included of which 367 (53%) patients were frail. Overall, recovery trajectories in frail patients were worse compared to trajectories in non-frail patients. In frail patients, poor recovery was significantly associated with dementia. Lower age was a prognostic factor for good recovery. Immobility, loneliness and weight loss were prognostic for respectively poor capability and symptoms of anxiety and depression. In non-frail patients, recovery after hip fracture was associated with loneliness and the type of hip fracture.

CONCLUSION

Although frailty is associated with poor recovery in older patients with hip fracture, a large proportion of frail patients show good recovery. Loneliness determines poor recovery with anxiety and depressive symptoms.

TRAIL REGISTRATION

ClinicalTrials.gov identifier: NCT02508675 (July 27, 2015).

The Impact of Hip Fracture on Geriatric Care and Mortality Among Older Swedes: Mapping Care Trajectories and Their Determinants

In this study, we examined the impact of hip fractures on trajectories of home care, nursing home residence, and mortality among individuals aged 65 years or more and explored the impacts of living arrangements, cohabitation, frailty, and socioeconomic position on these trajectories. Based on a linkage of nationwide Swedish population registers, our study included 20,573 individuals with first hip fracture in 2014-2015. Care trajectories during the 2 years following the fracture were visualized and compared with those of 2 hip-fracture-free control groups drawn from the general population: age- and sex-matched controls and health-matched controls identified through propensity score matching. Multistate modeling was employed to identify sociodemographic and health-related factors associated with care trajectories among hip fracture patients. We found that hip fracture patients already had worse health than the general population before their fracture. However, when controlling for prefracture health, hip fractures still had a considerable impact on use of elder-care services and mortality. Comparisons with the health-matched controls suggest that hip fractures have an immediate, yet short-term, impact on care trajectories. Long-term care needs are largely attributable to poorer health profiles independent of the fracture itself. This emphasizes the importance of adequate comparison groups when examining the consequences of diseases which are often accompanied by other underlying health problems.

Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

STUDY OBJECTIVE

To determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.

DESIGN

A systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.

SETTING

Preoperative assessment.

PATIENTS

Older patients (≥ 60 years) undergoing non-cardiac surgery.

MEASUREMENTS

Outcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.

RESULTS

Fifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).

CONCLUSIONS

Preoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.

Predictors of Moderate or Severe Cognitive Impairment at Six Months of the Hip Fracture in the Surgical Patient over 65 Years of Age

Background: cognitive impairment is known to be very common in patients with hip fractures, but studies are needed to help understand the relationship between both events. Our goal was to determine the relationship between moderate or severe cognitive impairment and hip fractures during the six months following that episode. Methods: a retrospective longitudinal study was conducted on a sample of 665 people over 65 years of age. The main variable of the study was cognitive impairment at six months of fracture, assessed using the Pfeiffer scale (PS). Other data related to clinical features were also collected for further analysis. Results: binary logistic regression analyses showed that the main factors related to moderate or severe cognitive impairment at the sixth month of the fracture were age (OR = 1.078), initial cognitive impairment (OR = 535.762), and discharge (OR = 547.91), cognitive worsening at the sixth month with respect to the time of admission (OR = 7.024), moderate dependence on admission (OR = 15.474) and at six months (OR = 8.088), poor ambulation at discharge (OR = 5.071) and institutionalization prior to admission (OR = 5.349) or during the first semester after fracture (OR = 6.317). Conclusions: this research provides evidence about the clinical factors that predict moderate or severe cognitive decline at the sixth month in patients undergoing surgery for a hip fracture.

Accuracy, feasibility and predictive ability of different frailty instruments in an acute geriatric setting

Aim

To investigate the feasibility and accuracy of four frailty instruments: FRAIL, Clinical Frailty Scale (CFS), hand grip strength (HGS) and the Spanish Frailty-VIG; and to evaluate their ability to predict adverse outcomes in an acute care setting (ACS).

Findings

The four instruments had high feasibility but provided variable prevalence of frailty. FRAIL and CFS predicted well for three-month mortality, and FRAIL also for length of stay. However, none of the instruments predicted for the other outcomes.

Message

The FRAIL and CFS may be of value in diagnostic and therapeutic decision-making in an acute geriatric setting, given their prognostic ability and feasibility. Further studies are needed to identify the best frailty instrument in an ACS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00645-1.

Purpose

To analyze the feasibility, accuracy and the ability of different frailty instruments to predict adverse outcomes.

Methods

A prospective cohort study was conducted in patients ≥ 70 years admitted to the acute care setting (ACS). Feasibility and prevalence of frailty were assessed by FRAIL, Clinical Frailty Scale (CFS), hand grip strength (HGS) and the Spanish Frailty-VIG. Receiver operator characteristic (ROC) curves and area under the curve (AUC) were performed to identify frailty according to each instrument, setting VIG as the reference. For each instrument, multiple logistic regressions were used to examine the effect of frailty on primary outcome (i.e., three-month mortality) and secondary outcomes (i.e., in-hospital mortality, length of stay, institutionalization, functional decline and 30-day readmission).

Results

A total of 185 patients were included, with a median age of 89 years. The feasibility of the instruments was 100%, except for HGS (67%). The prevalence of frailty varied from 65.2% (FRAIL) to 86.7% (VIG). AUCs against VIG ranged from 0.69 (95% confidence interval [CI] 0.57–0.81: FRAIL) to 0.77 (95% CI 63.5–90.2: CFS). Frail patients defined by FRAIL were 2.7times more likely to have a prolonged length of stay than non-frail patients (95% CI 1.385–5.416). Three-month mortality occurred more among frail patients, either defined by FRAIL (OR 2.5; 95% CI 1.072–5.881) or CFS (OR 3.7; 95% CI 1.255–10.812), than in non-frail patients.

Conclusion

The four instruments had high feasibility providing variable prevalence of frailty. FRAIL and CFS predicted well for three-month mortality, and FRAIL also for length of stay. However, none of the instruments predicted for the other secondary outcomes of the study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00645-1.

Optimization of transdisciplinary management of elderly with femur proximal extremity fracture: A patient-tailored plan from orthopaedics to rehabilitation

Fractures of femur proximal extremity (FFPE) are the most common fragility fractures requiring hospitalization, with a high risk of mortality, low independence in the activities of daily living and severe consequences on health-related quality of life. Timing for surgery has a key role in the management of elderly patients with FFPE as recommended by the Australian and New Zealand guidelines and the National Institute for Health and Care Excellence guidelines. Early surgery (within 48 h from hospital admission) allows significant benefits in terms of lower rates of postoperative complications and risk of death and can provide better functional outcomes. Therefore, time for surgery could be considered as a comorbidity marker. The choice between conservative or surgical approach surprisingly seems to be still not strongly supported by available literature, but it seems that both 30 d and 1 year risk of mortality is higher with the conservative treatment rather than with surgery. In light of these considerations, the optimization of FFPE management care is mandatory to improve functional outcomes and to reduce sanitary costs. Albeit it is widely accepted that transdisciplinary approach to patients suffering from FFPE is mandatory to optimize both short-term and long-term outcomes, the feasibility of a comprehensive approach in clinical practice is still a challenge. In particular, the large variability of figures involved could be considered both a resource and an additional disadvantage taking into account the difficulty to coordinate multidisciplinary approach covering care in all settings. Therefore, the aim of the present article was to summarize current evidence supporting transdisciplinary management of patients with FFPE, highlighting the benefits, feasibility and limitations of this approach.

Impact of Dementia on Patterns of Home Care After Inpatient Rehabilitation Discharge for Older Adults After Hip Fractures

OBJECTIVE

To describe differences in home care use in the 30 days after discharge from inpatient rehabilitation after a hip fracture among older adults with dementia compared with those without dementia.

DESIGN

Retrospective cohort study of individually linked health administrative data.

SETTING

Community-dwelling older adults after discharge from inpatient rehabilitation facilities in Ontario, Canada.

PARTICIPANTS

A total of 17,263 older adults (N=17,263), of whom 2489 had dementia (14.4%), who were treated for hip fracture in acute care and then admitted to inpatient rehabilitation facilities between January 1, 2011 and March 31, 2017.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The proportion receiving home care services and number of visits (physiotherapy, occupational therapy, nursing, personal/homemaking) in the 30 days after discharge were compared by dementia status with multivariate models, stratified by sex.

RESULTS

Compared with those without dementia, adults with dementia were older, had lower functional scores, and were more likely to receive home care services in the 30 days after discharge from inpatient rehabilitation (87.0% vs 79.0%, P<.001), including personal/homemaking services (66.1% vs 46.4%, P<.001) and occupational therapy (45.3% vs 37.4, P<.001) but not physiotherapy (55.8% vs 56.2%, P=.677) or nursing (19.6% vs 18.7%, P=.268). After adjustment, older adults with dementia were more likely to receive home care in both men (odds ratio [OR] =2.01; 95% confidence interval [CI], 1.57-2.57) and women (OR=1.50; 95% CI, 1.30-1.74) as well as more services (rate ratio men=1.60; 95% CI, 1.44-1.79; rate ratio women=1.50; 95% CI, 1.41-1.60).

CONCLUSIONS

Among older adults discharged from inpatient rehabilitation, older adults with dementia received home care services more often than older adults without dementia. However, irrespective of sex and dementia status, almost half of this population (44%) did not receive physiotherapy. We recommend that, resources permitting, all older adults receive physiotherapy to facilitate recovery.

Trends of Dementia among Community-Dwelling Adults in Ontario, Canada, 2010-2015

BACKGROUND

There are increasing numbers of people living with dementia (PLWD) and most reside in community settings. Characterizing the number of individuals affected with dementia and their transitions are important to understand in order to plan for their healthcare needs. Using administrative health data in Ontario, Canada, we examined recent trends in the prevalence and incidence of dementia among the community-dwelling population, described their characteristics, and investigated admissions to long-term care (LTC) and overall survival.

METHODS

Using a validated case ascertainment algorithm, we performed a population-based retrospective cohort study of community-dwelling PLWD aged 40-105 years old between 2010 and 2015. We assessed crude and age- and sex-adjusted prevalence and incidence, cohort characteristics, and time to LTC admission and survival.

RESULTS

Between 2010 and 2015, the adjusted community prevalence increased by 9.5% (p < 0.001), while the incidence decreased by 15.8% (p < 0.001). Demographic and socioeconomic characteristics remained similar over time, while the prevalence of comorbidities increased significantly from 2010 to 2015. There was no difference in the time to LTC admission for individuals diagnosed in 2014 when compared to 2010 (p = 0.06). A lower risk of 2-year mortality was observed for individuals diagnosed in 2015 compared to 2010 (HR 0.93, 95% CI 0.90-0.97, p < 0.001).

CONCLUSION

There was an increase in the prevalence of dementia despite decreasing incidence among community-dwelling PLWD. Lower rates of mortality indicate that PLWD are surviving longer following diagnosis. Adequate resources and planning are required to support this growing population, considering the changing population size and characteristics.

Experiences of community-dwelling older people with dementia participating in a person-centred multidimensional interdisciplinary rehabilitation program

BACKGROUND

There is great need for development of feasible rehabilitation for older people with dementia. Increased understanding of this population's experiences of rehabilitation participation is therefore important. The aim of this study was to explore the experiences of community-dwelling older people with dementia participating in a person-centred multidimensional interdisciplinary rehabilitation program.

METHODS

Sixteen older people with dementia were interviewed about their experiences of participation in a person-centred multidimensional interdisciplinary rehabilitation program. The program comprised assessments by a comprehensive team of rehabilitation professionals followed by a rehabilitation period of 16 weeks, including interventions based on individualized rehabilitation goals conducted with the support of the rehabilitation team. The rehabilitation was performed in the participants' homes, in the community and at an outpatient clinic, including exercise with social interaction in small groups offered twice a week to all participants. The interviews were conducted at the end of the rehabilitation period and analysed with qualitative content analysis.

RESULTS

The analysis resulted in one overarching theme: Empowered through participation and togetherness and four sub-themes: Being strengthened through challenges; Gaining insights, motives, and raising concerns about the future; Being seen makes participation worthwhile; and Feelings of togetherness in prosperity and adversity. The participants increased their self-esteem by daring and coping in the rehabilitation. The insights about themselves and their condition motivated them to continue with their prioritized activities, but also raised concerns about how the future would play out. Collaboration in the group and being seen and acknowledged by staff strengthened their own motivation and self-efficacy.

CONCLUSION

According to community-dwelling older people with dementia, a person-centred multidimensional interdisciplinary rehabilitation program was experienced as viable and beneficial. The participants seemed empowered through the rehabilitation and expressed mostly positive experiences and perceived improvements. Providers of interdisciplinary rehabilitation programs for this group should consider aspects raised by the participants e.g. the positive experience of being challenged in both exercise and daily activities; the importance of being seen and feeling secure; the benefits and challenges of collaboration with others in the same situation; and the generation of new perspectives of current and future situation.

Dementia and patient outcomes after hip surgery in older patients: A retrospective observational study using nationwide administrative data in Japan

Objective

To investigate whether dementia is associated with incidence of adverse events and longer hospital stays in older adults who underwent hip surgery, after adjusting for individual social and nursing care environment.

Design and setting

Retrospective observational study using the linked data between the Japanese Diagnosis Procedure Combination database and the reports of the medical functions of hospital beds database in Japan (April 2016—March 2017).

Participants

A total of 48,797 individuals aged 65 and older who underwent hip surgery and were discharged during the study period.

Methods

Outcomes included in-hospital death, in-hospital pneumonia, in-hospital fracture, and longer hospital stay. We performed two-level, multilevel models adjusting for individual and hospital characteristics.

Results

Among all participants, 20,638 individuals (42.3%) had dementia. The incidence of adverse events for those with and without dementia included in-hospital death: 2.11% and 1.11%, in-hospital pneumonia: 0.15% and 0.07%, and in-hospital fracture: 3.76% and 3.05%, respectively. The median (inter quartile range) length of hospital stay for those with and without dementia were 26 (19–39) and 25 (19–37) days, respectively. Overall, the odds ratios (95% confidence interval (CI)) of dementia for in-hospital death, in-hospital pneumonia, and in-hospital fracture were 1.12 (0.95–1.33), 0.95 (0.51–1.80), and 1.08 (0.92–1.25), respectively. Dementia was not associated with the length of hospital stay (% change) (-0.7%, 95% CI -1.6–0.3%). Admission from home, discharge to home, and lower nurse staffing were associated with prolonged hospital stays.

Conclusions

Although adverse events are more likely to occur in older adults with dementia than in those without dementia after hip surgery, we found no evidence of an association between dementia and adverse events or the length of hospital stay after adjusting for individual social and nursing care environment.

Healthcare professionals' perspectives on rehabilitating persons with cognitive impairment

Background and Objectives

Despite emerging evidence that persons with cognitive impairment (CI) (including dementia and/or delirium) can be rehabilitated post-hip fracture surgery, there still remains a paucity of research on best practice rehabilitation strategies that help healthcare providers effectively rehabilitate persons with CI. Therefore, this qualitative study explores healthcare professionals’ (HCPs) perspectives who have been successfully providing rehabilitation for people with CI.

Research Design and Methods

Sixteen HCPs with a specialty in rehabilitating persons with CI from one inpatient rehabilitation facility with various professional backgrounds were purposively sampled using a maximum diversity sampling strategy. Three focus group discussions were conducted to explore their experiences of providing rehabilitation to persons with CI. A hybrid inductive–deductive approach was used to analyze the data.

Findings

HCPs acknowledged that older adults with CI deserved the opportunity for inpatient rehabilitation and that good outcomes were achievable; however, their knowledge, skills, and attitudes required reframing. The analysis identified three essential components to rehabilitation: (1) staff education and support, (2) tailored rehabilitation approaches, and (3) care partner involvement and support.

Discussion and Implications

Rehabilitation of persons with CI post-hip fracture surgery is achievable, and HCPs can learn to modify their practices to achieve positive patient outcomes. The attitudes of the healthcare team members had to be shifted to embrace the belief that persons with CI can be rehabilitated. However, it takes a steep learning curve, creativity, ingenuity, and tailored approaches to rehabilitate persons with CI successfully. This involves knowing the individual, maintaining routines, and learning the best ways to engage and motivate the person. As well, care partners’ knowledge and understanding of the individual improved the chances of a successful rehabilitation stay and discharge. Essential to the success of rehabilitation of persons with CI includes a supportive management team to help create the processes to enable their staff to succeed.

Preexisting Dementia Is Associated with Increased Risks of Mortality and Morbidity Following Major Surgery: A Nationwide Propensity Score Matching Study

Patients with dementia are predisposed to multiple physiological abnormalities. It is uncertain if dementia associates with higher rates of perioperative mortality and morbidity. We used reimbursement claims data of Taiwan’s National Health Insurance and conducted propensity score matching analyses to evaluate the risk of mortality and major complications in patients with or without dementia undergoing major surgery between 2004 and 2013. We applied multivariable logistic regressions to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for the outcome of interest. After matching to demographic and clinical covariates, 7863 matched pairs were selected for analysis. Dementia was significantly associated with greater risks of 30-day in-hospital mortality (aOR: 1.71, 95% CI: 1.09–2.70), pneumonia (aOR: 1.48, 95% CI: 1.16–1.88), urinary tract infection (aOR: 1.59, 95% CI: 1.30–1.96), and sepsis (OR: 1.77, 95% CI: 1.34–2.34) compared to non-dementia controls. The mortality risk in dementia patients was attenuated but persisted over time, 180 days (aOR: 1.49, 95% CI: 1.23–1.81) and 365 days (aOR: 1.52, 95% CI: 1.30–1.78) after surgery. Additionally, patients with dementia were more likely to receive blood transfusion (aOR: 1.32, 95% CI: 1.11–1.58) and to need intensive care (aOR: 1.40, 95% CI: 1.12–1.76) compared to non-dementia controls. Senile dementia and Alzheimer’s disease were independently associated with higher rates of perioperative mortality and complications, but vascular dementia was not affected. We found that preexisting dementia was associated with mortality and morbidity after major surgery.

Association Between Exposure to General Versus Regional Anesthesia and Risk of Dementia in Older Adults

BACKGROUND/OBJECTIVES

Cognitive changes are commonly observed in older adults following surgical procedures. There are concerns that exposure to general anesthesia (GA) may contribute to an increased risk of Alzheimer's disease. Our study examined the associations between exposure to GA compared with regional anesthesia (RA) administered for elective surgical procedures and the development of dementia.

DESIGN

Population-based propensity matched retrospective cohort study.

SETTING

Linked administrative databases were accessed from ICES (formerly called the Institute for Clinical Evaluative Services) in Ontario, Canada.

PARTICIPANTS

We included all community-dwelling individuals aged 66 and older who underwent one of five elective surgical procedures in Ontario, Canada, between April 1, 2007, and March 31, 2011. Individuals with evidence of dementia preceding cohort entry were excluded. Individuals who received GA were matched within surgical procedures to those who received RA on age, sex, cohort entry year, and a propensity score to control for potential confounders.

MEASUREMENTS

The baseline characteristics of the study sample were compared before and after matching. Individuals were followed for up to 5 years following cohort entry for the occurrence of dementia using a validated algorithm. Cox proportional hazards analysis was used to determine the hazard ratio (HR) and 95% confidence interval (CI) for the association between anesthetic type and dementia. Subgroup and sensitivity analyses were undertaken.

RESULTS

A total of 7,499 matched pairs were included in the final analysis. Overall, no difference was observed in the risk of being diagnosed with dementia for individuals who received GA when compared with RA (HR = 1.0; 95% CI = .8-1.2). There was also no association between anesthesia and dementia in most subgroup and sensitivity analyses.

CONCLUSION

Elective surgery using GA was not associated with an overall elevated risk of dementia when compared with RA. Future studies are required to determine whether surgery is a risk factor for dementia irrespective of anesthetic technique.

Geriatric Interdisciplinary Home Rehabilitation After Hip Fracture in People with Dementia - A Subgroup Analysis of a Randomized Controlled Trial

PURPOSE

To investigate if the effects of geriatric interdisciplinary home rehabilitation after hip fracture were different among people with dementia compared to those without dementia and to describe the overall outcome after hip fracture in people with dementia.

PATIENTS AND METHODS

A post hoc subgroup analysis of a randomized controlled trial was conducted including 205 people with hip fracture, aged ≥70, living in ordinary housing or residential care facilities. Early discharge followed by individually designed interdisciplinary home rehabilitation for a maximum of 10 weeks was compared to in-hospital geriatric care according to a multifactorial rehabilitation program. Outcomes were hospital length of stay (LOS), readmissions, falls, mortality, performance in activities of daily living (ADL), and walking ability.

RESULTS

Interdisciplinary home rehabilitation vs in-hospital care had comparable effects on falls and mortality between discharge and 12 months and on ADL and walking ability at 3 and 12 months regardless of whether the participants had dementia or not (P≥0.05 for all). Among participants with dementia, postoperative LOS was a median of 18 days (interquartile range [IQR] 14-30) in the home rehabilitation group vs 23 days (IQR 15-30) in the control group (P=0.254) with comparable numbers of readmissions after discharge. Dementia was associated with increased risk of falling (odds ratio [OR] 3.86; 95% confidence interval [CI]: 2.05-7.27; P<0.001) and increased mortality (OR 4.20; 95% CI 1.79-9.92, P=0.001) between discharge and 12 months and with greater dependence in ADL and walking at 3 and 12 months compared to participants without dementia (P<0.001 for all).

CONCLUSION

The effects of geriatric interdisciplinary home rehabilitation vs in-hospital geriatric care did not differ in participants with and without dementia. However, the statistical power of this subgroup analysis was likely insufficient to detect differences between the groups. Dementia was associated with a substantial negative impact on the outcomes following the hip fracture. Our findings support offering interdisciplinary home rehabilitation after hip fracture to people with dementia.

Postoperative Rehabilitation after Hip Fracture: A Literature Review

As the proportion of elderly individuals within the population grows, the incidence of hip fractures increases. Traditionally, orthopedic surgeons used to focus on surgical treatment of hip fractures; however, the field's appreciation for the importance of postoperative rehabilitation has been increasing recently. Many studies have shown that proper rehabilitation after hip fracture surgery can shorten hospital stays and improve clinical outcomes. However, such studies use different methods and published rehabilitation protocols address varying aspects that do not always overlap. Here, we review and summarize the latest guidelines and studies on postoperative rehabilitation of elderly patients with hip fractures.

Geriatric patients with dementia show increased mortality and lack of functional recovery after hip fracture treated with hemiprosthesis

PURPOSE

Operative timing, perioperative management and postoperative rehabilitation are rising challenges in orthopedic geriatric trauma. The aim of this study was to determine the outcome of patients with dementia or with a high number of comorbidities treated with hemiprosthesis after hip fracture. Literature regarding patients with high comorbidities is scarce, leaving nothing but endoprosthetic treatment for even the sickest, immobile patients.

METHODS

A retrospective chart review of 326 patients (mean age 81 ± 9 years; 230 women and 96 men) with hip fractures treated between 2012 and 2017 with a hemiprosthesis was performed. Primary outcome measures were surgical and nonsurgical complication rates, best achievable mobilisation during the hospital stay and mortality.

RESULTS

Patients with dementia had 20-fold increased risk to be bedridden after surgery and ninefold increased risk of dying (p < 0.005). Furthermore, they needed significantly more revision surgeries because of surgical complications. Patients classified ASA IV and V had significantly lower postoperative mobilization levels with only 10% able to walk with crutches and 53% bedridden. They also had significantly more non-surgical complications while dementia had no effect on non-surgical complication rate.

CONCLUSION

Patients classified ASA IV and V or suffering dementia show poor outcome after hip fracture treated with hemiprosthesis. Multidisciplinary approaches including surgeons, geriatricians, physiotherapists and psychiatrists are needed to improve the outcome of these patients. Especially in a subgroup of patients, where no mobilization is expected, alternative treatment options may be considered.

Hospitalization and discharge routes of elderly hip fracture patients with and without dementia: a nationwide cross-sectional exploratory study using the Japanese Diagnostic Procedure Combination database

PURPOSE

The characteristics of elderly hip fracture patients in acute care hospitals were analyzed based on hospitalization and discharge route and the presence or absence of a dementia diagnosis.

METHODS

The study was conducted as a cross-sectional exploratory study using data from the Diagnosis Procedure Combination database in Japan from April 2014 to March 2016. Patients aged 65 years or older who had surgery for a hip fracture were identified. We subsequently extracted patients whose home, medical institution (including convalescent rehabilitation wards), or elderly care facility was both the admission and discharge route. A total of 105 122 patients were included.

RESULTS

19% of patients were diagnosed with dementia. Patients with dementia had a shorter length of acute care hospital stay than those without dementia. The hospitalization route for dementia patients was 51% at home and 40% at a care facility. Dementia patients were discharged to hospital and care facilities at 41% each. Nearly all patients received hospital-based postoperative rehabilitation regardless of dementia but patients with dementia had lower gains in activities of daily living.

CONCLUSION

Hip fracture patients with dementia have less opportunity for continuous hospital-based rehabilitation and need an environment that allows for continuous elderly care facility-based and community-based rehabilitation.IMPLICATIONS FOR REHABILITATIONIn Japan, an aging society, one in five elderly patients undergoing hip fracture surgery was diagnosed with dementia.Many hip fracture patients with dementia have a shorter length of hospital stay and may have fewer opportunities to change hospitals to receive rehabilitation.It is necessary to establish an ongoing and proactive community- and elderly care facility-based rehabilitation system for patients with hip fracture with dementia after acute care hospital discharge.

Insufficient Postoperative Rehabilitation in Patients with Both Proximal Femoral Fracture and Antecedent Mental Illness

Introduction:

Though a combination of proximal femoral fracture and mental illness is likely, the management of this combination is not well established. The aim of this study was to clarify the current disposition of acute care and rehabilitation for patients with this combination of conditions at our institution.

Methods:

We retrospectively analyzed the records of 192 patients hospitalized in the psychiatric ward who present with a proximal femoral fracture and an antecedent mental illness. We investigated walking ability prior to injury and after surgery, at discharge from our institution, using the Functional Independence Measure (FIM) score.

Results:

Although patients in the psychiatric ward demonstrated postoperative hospital stays approximately 10 days longer than those in the orthopedic ward, more than half of the patients in the psychiatric ward were discharged from our institution with a functional level of complete dependence for walking ability. In addition, nearly 90% of the patients studied were transferred to a psychiatric hospital where no physical therapy or rehabilitation was provided to the inpatients.

Conclusions:

At our institution, patients with proximal femoral fracture and antecedent mental illness tended to be discharged with complete dependence in walking ability, often to a psychiatric hospital without physical therapy or rehabilitation. We hope this paper will draw attention to the need for rehabilitation in these patients.

Outcomes of Common Major Surgical Procedures in Older Adults With and Without Dementia

This cross-sectional study uses data from the Premier Healthcare Database to compare in-hospital mortality, home discharge, and hospital length of stay among older adults with and without dementia who have undergone major surgical procedures.

Prognostic Factors for All-Cause Mortality in Thai Patients with Fragility Fracture of Hip: Comorbidities and Laboratory Evaluations

Background and Objectives: Although the types of comorbidities and laboratory evaluations are major factors associated with mortality after hip fractures, there have been no studies of the association of these factors and mortality in Thai hip-fracture patients. This study aimed to identify prognostic factors associated with mortality after a hip fracture in the Thai population, including types of comorbidities, treatment-related factors, and laboratory evaluations. Materials and Methods: This five-year retrospective study was conducted in a tertiary care hospital in Thailand. A total of 775 Thai patients who had been admitted with a hip fracture resulting from a simple fall were identified using the International Classification of Disease 10 codes, and a review of their medical charts was conducted. Associations between general factors, comorbidities, laboratory evaluations, treatment factors including type of treatment, and time to death were analyzed using the Cox proportional hazard regression and the hazard ratio (HR). Results: The overall mortality rate of hip fracture patients was 13.94%. Independent prognostic factors found to be significantly associated with mortality were nonoperative treatment (HR = 3.29, p < 0.001), admission glomerular filtration rate (GFR) < 30 mL/min/1.73 m² (HR = 3.40, p < 0.001), admission hemoglobin concentration <10 g/dL. (HR = 2.31, p < 0.001), chronic obstructive pulmonary disorder (HR = 2.63, p < 0.001), dementia or Alzheimer’s disease (HR = 4.06, p < 0.001), and active malignancy (HR = 6.80, p < 0.001). Conclusion: The types of comorbidities and laboratory evaluation findings associated with mortality in Thai patients with hip fractures include chronic obstructive pulmonary disorder, dementia or Alzheimer’s disease, active malignancy, admission GFR < 30 mL/min/1.73 m², and admission hemoglobin concentration <10 g/dL. The risks of mortality for Thai hip-fracture patients with these comorbidities or laboratory evaluation findings were 2.5, 4, 7, 3.5, and 2.5 times higher, respectively, than patients without those factors.

Cognitive impairment assessment and interventions to optimize surgical patient outcomes

For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.

The identification of adverse events in hip fracture patients using the Global Trigger Tool: A prospective observational cohort study

INTRODUCTION

Hip fracture is common in the elderly and is associated with high comorbidity, mortality and complication rates. There has been an increase in the investigation of healthcare-related adverse events (AEs) in some patient groups but there is limited knowledge about hip fracture patients. The aim was to explore the incidence, preventability and nature of AEs in hip fracture patients.

METHODS

One hundred and sixty three hip fracture patients participated. A record review was conducted of prospectively collected data using Global Trigger Tool methodology to identify AEs up to 90 days after surgery.

RESULTS

Sixty two (38.0%) of 163 patients had at least one AE (range 1-7). One hundred and two AEs were identified and 62 (60.8%) were deemed preventable. Healthcare-associated infections e.g. pneumonia, urinary tract infections and pressure ulcers were common. AEs were more common in older patients and those with pre-existing health conditions. Fifty eight (56.9%) AEs caused temporary harm and 4 (3.9%) contributed to patient death.

CONCLUSION

AEs are common in hip fracture patients and most are preventable. If the focus is on improving healthcare for these patients, we should be concentrating our efforts on reducing the number of these preventable AEs, with a particular emphasis on improving the care of older patients with pre-existing health conditions.

Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery

BACKGROUND

Hip fracture is a major injury that causes significant problems for affected individuals and their family and carers. Over 40% of people with hip fracture have dementia or cognitive impairment. The outcomes of these individuals after surgery are poorer than for those without dementia. It is unclear which care and rehabilitation interventions achieve the best outcomes for these people. This is an update of a Cochrane Review first published in 2013.

OBJECTIVES

(a) To assess the effectiveness of models of care including enhanced rehabilitation strategies designed specifically for people with dementia following hip fracture surgery compared to usual care. (b) To assess for people with dementia the effectiveness of models of care including enhanced rehabilitation strategies that are designed for all older people, regardless of cognitive status, following hip fracture surgery, compared to usual care.

SEARCH METHODS

We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group Specialised Register, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 16 October 2019.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials evaluating the effectiveness of any model of enhanced care and rehabilitation for people with dementia after hip fracture surgery compared to usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion and extracted data. We assessed risk of bias of the included trials. We synthesised data only if we considered the trials to be sufficiently homogeneous in terms of participants, interventions, and outcomes. We used the GRADE approach to rate the overall certainty of evidence for each outcome.

MAIN RESULTS

We included seven trials with a total of 555 participants. Three trials compared models of enhanced care in the inpatient setting with conventional care. Two trials compared an enhanced care model provided in inpatient settings and at home after discharge with conventional care. Two trials compared geriatrician-led care in-hospital to conventional care led by the orthopaedic team. None of the interventions were designed specifically for people with dementia, therefore the data included in the review were from subgroups of people with dementia or cognitive impairment participating in randomised controlled trials investigating models of care for all older people following hip fracture. The end of follow-up in the trials ranged from the point of acute hospital discharge to 24 months after discharge. We considered all trials to be at high risk of bias in more than one domain. As subgroups of larger trials, the analyses lacked power to detect differences between the intervention groups. Furthermore, there were some important differences in baseline characteristics of participants between the experimental and control groups. Using the GRADE approach, we downgraded the certainty of the evidence for all outcomes to low or very low. The effect estimates for almost all comparisons were very imprecise, and the overall certainty for most results was very low. There were no data from any study for our primary outcome of health-related quality of life. There was only very low certainty for our other primary outcome, activities of daily living and functional performance, therefore we were unable to draw any conclusions with confidence. There was low-certainty that enhanced care and rehabilitation in-hospital may reduce rates of postoperative delirium (odds ratio 0.04, 95% confidence interval (CI) 0.01 to 0.22, 2 trials, n = 141) and very low-certainty associating it with lower rates of some other complications. There was also low-certainty that, compared to orthopaedic-led management, geriatrician-led management may lead to shorter hospital stays (mean difference 4.00 days, 95% CI 3.61 to 4.39, 1 trial, n = 162).

AUTHORS' CONCLUSIONS

We found limited evidence that some of the models of enhanced rehabilitation and care used in the included trials may show benefits over usual care for preventing delirium and reducing length of stay for people with dementia who have been treated for hip fracture. However, the certainty of these results is low. Data were available from only a small number of trials, and the certainty for all other results is very low. Determining the optimal strategies to improve outcomes for this growing population of patients should be a research priority.

Age comorbidity scores as risk factors for 90-day mortality in patients with a pancreatic head adenocarcinoma receiving a pancreaticoduodenectomy: A National Population-Based Study

Background

To estimate easily assessed preoperative factors for predicting 90‐day mortality in patients with a pancreatic head adenocarcinoma (PHA) receiving a pancreaticoduodenectomy.

Methods

We analyzed data from the Taiwan Cancer Registry Database of patients with a PHA who received a pancreaticoduodenectomy. Basic demographic characteristics, including gender and age, were categorized. The selection of preoperative comorbidities was based on the preoperative American Society of Anesthesiologists score and Charlson comorbidity index.

Results

We enrolled 8490 patients with a PHA who received a pancreaticoduodenectomy without distant metastasis. Currently, a pancreaticoduodenectomy for a PHA achieves an overall 90‐day mortality rate of 8.39%. Univariate and multivariate Cox regression analyses indicated that an older age (65‐74 and ≥75 years) and specific comorbidities (chronic obstructive pulmonary disease, chronic kidney disease, dementia, and sepsis) were significant independent prognostic factors for predicting 90‐day mortality after a pancreaticoduodenectomy. After adjustment, the adjusted hazard ratios (aHRs) (95% confidence intervals [CIs]) of subjects with middle and high comorbidity scores for 90‐day mortality in 65 to 74‐year‐old patients were 1.36 (1.05‐1.75) and 2.25 (1.03‐4.90), respectively, compared to subjects with low comorbidity scores. The aHRs (95% CIs) of subjects with middle and high comorbidity scores for 90‐day mortality in ≥75‐year‐old patients were 1.35 (1.07‐1.78) and 2.07 (1.19‐3.62), respectively, compared to those with low comorbidity scores.

Conclusions

Elderly patients with a PHA and moderate or high comorbidity scores have an increased risk of 90‐day mortality after a pancreaticoduodenectomy.

Structure and process of dementia care and patient outcomes after hip surgery in elderly people with dementia: A retrospective observational study in Japan

BACKGROUND

Japan introduced the financial incentives for dementia special care at hospitals in the fee schedule in April 2016.

OBJECTIVE

To investigate whether the financial incentives for dementia special care contributed to better patient outcomes after hip surgery for older adults with dementia.

DESIGN

Retrospective observational study using the Diagnosis Procedure Combination database and the Reporting on medical functions of hospital beds data.

SETTING

Acute care hospitals adopting the Diagnosis Procedure Combination system in Japan.

PARTICIPANTS

A total of 20,393 eligible patients aged 65 years or older with dementia who underwent hip surgeries and discharged from 405 hospitals from April 2016 to March 2017.

METHODS

There are two levels of dementia care quality categories in the financial incentives for dementia special care as follows: Type 1 requires a multidisciplinary team with geriatric and dementia care expertise and Type 2 requires to assign trained nurses who underwent dementia training at every general ward. The outcomes were in-hospital mortality, readmission within 30 days, and length of hospital stay. We performed generalized estimating equation model or logistic generalized estimating equation models adjusting for individual and hospital characteristics.

RESULTS

Among the 405 hospitals, the numbers of hospitals without dementia care incentive, those with Type 1, and those with Type 2 were 207, 99, and, 99, respectively. Overall, the prevalence of in-hospital death and readmission within 30 days was 2.01% and 2.70%, respectively. Overall, the mean (standard deviation, SD) length of hospital stay was 32.0 (20.0) days. There were no significant associations between dementia special care and in-hospital mortality in Type 1 (adjusted OR [odds ratio] =0.87, 95% confidence interval [CI] = 0.66-1.16) and Type 2 (adjusted OR = 1.18, 95% CI = 0.92-1.52), and readmission within 30 days in Type 1 (adjusted OR = 1.11, 95% CI = 0.89-1.38) and Type 2 (adjusted OR = 1.03, 95% CI = 0.83-1.29). Length of hospital stay was not significantly different among hospitals with and without incentive, Type 1 (coefficient -0.23, 95% CI = -2.64-2.18.), and Type 2 (coefficient 0.87, 95% CI = -1.54-3.28). An increase in patient-to-nurse ratio was significantly associated with 2.25 days longer length of hospital stay (95% CI 1.00-3.51).

CONCLUSION

Dementia care incentive was not associated with better outcomes in elderly with dementia who underwent hip surgery in Japan, but the worse nurse workload was associated with longer length of hospital stay. Further long-term assessment is necessary.

Anesthetic management of geriatric patients

The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.

Postoperative daily living activities of geriatric patients administered general or spinal anesthesia for hip fracture surgery: A retrospective cohort study

PURPOSE

Maintaining independence after hip fracture repair is important for geriatric patients and general welfare. We investigated the effects of anesthetic methods on postoperative activities of daily living (ADLs) following hip fracture surgery in elderly patients.

METHODS

The medical records of 12,342 patients aged ≥65 years who underwent typical surgeries for hip fracture using either general anesthesia or spinal anesthesia were reviewed. To adjust for baseline differences and minimize selection bias for the chosen method of anesthesia, patients were matched by propensity scores. Factors affecting the deterioration in ADLs during hospital stay were also investigated in all subjects using a multivariate logistic regression analysis. Eating, grooming, toileting, bathing, and walking were selected as the ADL parameters, as they are considered important for an independent life.

RESULTS

Of the 12,342 patients, 6918 (56.1%) received general anesthesia and 5424 (43.9%) received spinal anesthesia. After the propensity score matching, the anesthesia types were not associated with ADL scores except toileting at discharge. Results from the multivariate logistic regression analysis showed that the types of anesthesia were not associated with deterioration in ADL scores. Advanced age, male sex, high Charlson Comorbidity Index scores, psychiatric disease, no administration of nonsteroidal anti-inflammatory drugs, and short length of hospital stay were associated with deterioration in ADL scores.

CONCLUSION

The anesthesia types were not associated with ADL dependency except toileting at discharge. Spinal anesthesia adversely affected toilet use at hospital discharge. However, anesthesia types were not factors that affected deterioration in ADL during hospital stay in elderly patients who underwent hip fracture surgery.

Validation of orthopaedic surgeons' assessment of cognitive function in patients with acute hip fracture

BACKGROUND

About one fourth of patients with hip fracture have cognitive impairment. These patients are at higher risk of surgical and medical complications and are often excluded from participating in clinical research. The aim of the present study was to investigate orthopaedic surgeons' ability to determine the cognitive status of patients with acute hip fracture and to compare the treatment given to patients with and without cognitive impairment.

METHODS

The cognitive function of 1474 hip fracture patients reported by the orthopaedic surgeons to the nationwide Norwegian Hip Fracture Register was compared with data registered in quality databases in two hospitals with orthogeriatric service on the same patients. Cognitive function registered in the quality databases was determined either by the short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or by pre-fracture diagnosis of dementia. The information registered in the quality databases was defined as the reference standard. Cognitive function in the Norwegian Hip Fracture Register was reported as: Chronic cognitive impairment? "Yes", "Uncertain" or "No" by the orthopaedic surgeons. Sensitivity, specificity, negative and positive predictive values for chronic cognitive impairment reported to the Norwegian Hip Fracture Register by the orthopaedic surgeons was calculated. Baseline data and treatment of hip fractures in patients with and without cognitive impairment in the Norwegian Hip Fracture Register were compared.

RESULTS

Orthopaedic surgeons reported chronic cognitive impairment in 31% of the patients. Using documented dementia or IQCODE > 4.0 as the reference, this assessment of cognitive impairment by the orthopaedic surgeons had a sensitivity of 69%, a specificity of 90%, a positive predictive value of 78%, and a negative predictive value of 84% compared to information registered in the two hospital quality databases. There were no differences in type of hip fracture or type of surgical treatment by cognitive function.

CONCLUSION

The treatment of hip fractures was similar in patients with chronic cognitive impairment and cognitively well-functioning patients. The surgeons had an acceptable ability to identify and report chronic cognitive impairment in the peri-operative period, indicating that the Norwegian Hip Fracture Register is a valuable resource for future registry-based research also on hip fracture patients with chronic cognitive impairment.

[Multidisciplinary geriatric rehabilitation in the patient with hip fracture and dementia]

Hip fracture and dementia rates increase with age, and both groups of patients suffer increased morbidity and mortality and functional impairment. The management of these patients is a challenge for the orthogeriatric and rehabilitation team process, as despite the evidence on the benefit, the results analysed are still worse than in patients without cognitive impairment. For this reason, and due to the limitation in health resources, many of them have problems in accessibility to them, or are limited to a less intense rehabilitation. There are insufficient studies on the best rehabilitation interventions in this group of patients, but it is suggested: 1) to use a multidisciplinary rehabilitation model adapted to the patient with dementia, and 2) to redefine results of the rehabilitation of these patients not only in terms of functional improvement, without highlighting other concepts, such as quality of life, decrease in complications or improved social support.

Association between the instrumented timed up and go test and cognitive function, fear of falling and quality of life in community dwelling people with dementia

OBJECTIVE

To explore relationships between the instrumented timed up and go test (iTUG) and the following risk factors for falls: cognitive functioning, fear of falling (FoF), and quality of life (QoL) in people with dementia.

METHODS

83 community-dwelling older adults with dementia (mean±sd age 78.00±7.96 years; 60.2% male) completed an interview to capture global cognition (Mini-Addenbrooke's Cognitive Evaluation), FoF (Iconographical Falls Efficacy Scale) and QoL (ICEpopCAPability measure for Older people). Participants completed an iTUG whilst wearing an inertial sensor on their trunk. Linear accelerations and rotational velocities demarcated sub-phases of the iTUG. Relationships were explored through correlations and regression modelling.

RESULTS

Cognition was related to duration of walking sub-phases and total time to complete iTUG (r=0.25-0.28) suggesting gait speed was related to cognition. FoF was most strongly related to turning velocity (r=0.39-0.44), but also to sit-to-stand, gait sub-phases and total time to complete iTUG. Sub-phases explained 27% of the variance in FoF. There were no correlations between iTUG and QoL.

CONCLUSIONS

Cognition and FoF were related to time to complete walking sub-phases but FoF was more closely related to turning velocity and standing acceleration. iTUG may offer unique insights into motor behaviour in people with dementia.