Comorbid cognitive impairment and depression is a significant predictor of poor outcomes in hip fracture rehabilitation

Comparing survival rates and mortality in operative versus nonoperative treatment for femoral neck fractures among Alzheimer's disease patients: A retrospective cohort study

Introduction

Addressing femoral neck fractures resulting from ground-level falls in older adults with Alzheimer's disease (AD) involves a personalized treatment plan. There is considerable ongoing debate concerning the relative advantages and disadvantages of surgical treatment (internal fixation or arthroplasty) vs nonoperative treatment for femoral neck fractures in older persons with AD.

Methods

This retrospective cohort study compared the mortality, hazard ratio, and survival rate between operative and nonoperative treatments, controlling for patients' demographic information and baseline health status. The study population consisted of Optum beneficiaries diagnosed with AD who experienced an initial femoral neck fracture claim between January 1, 2012, and December 31, 2017. Kaplan-Meier survival curves were applied to compare the treatment groups' post-fracture survival rates and mortality. Cox regression was used to examine the survival period by controlling the covariates.

Results

Out of the 4157 patients with AD with femoral neck fractures, 59.8% were women (n = 2487). The median age was 81 years. The 1-year survival rate for nonoperative treatment (70.19%) was lower than that for internal fixation (75.27%) and arthroplasty treatment (82.32%). Compared with the nonoperative group, arthroplasty surgical treatment had significant lower hazard risk of death (arthroplasty hazard ratio: 0.850, 95% CI: 0.728-0.991, P < 0.05).

Discussion

The findings suggest that the operative treatment group experiences higher survival rates and lower mortality rates than the nonoperative group. This paper provides insights into treatment outcomes of older adults with AD receiving medical care for femoral neck fractures.

Hip Fractures in Patients with Dementia: An Emerging Orthopedic Concern

Hip fractures are a very common injury in the elderly population associated with an increased mortality rate. Currently, more and more elderly patients are diagnosed with dementia. Demented patients are more prone to falls and hip fractures compared to the general population because of conditions related to their disease such as instability, osteoporosis, poor muscle control and weakness. The coexistence of dementia and hip fractures is a difficult situation for both the patients and the treating physicians because of postoperative complications in this frail subgroup of patients and their inability to stand up and walk. To enhance the literature, we reviewed published studies of hip fracture patients suffering from dementia to discuss why they have more frequent hip fractures, to review their associated in-hospital complications, and to emphasize on their postoperative management to be able to reach the pre-injury activity level and optimal quality of life.

Effects of depressive symptoms on osteoporotic bone metabolism and prognosis of joint replacement surgery in elderly male patients with femoral neck fracture

OBJECTIVE

To investigate the effect of depressive symptoms on osteoporotic bone metabolism and prognosis of joint replacement surgery in elderly male patients with femoral neck fractures.

METHOD

102 elderly male patients with femoral neck fractures hospitalized in the Beijing Hospital from January 2017 to January 2019 were included. The patients with femoral neck fractures were divided into the depression group and the control group. The observation indicators included: bone mineral density, serum alkaline phosphatase, serum calcium, serum phosphorus, 25-hydroxy-vitamin D, osteocalcin, Type I procollagen amino-terminal propeptide, serum β-isomer of C-terminal telopeptide of type I collagen, hip function scores, and pain visual analogue scale at pre- and post-operative examinations.

RESULTS

The BMD was significantly lower in the depressed group than in the control group [either for lumbar spine or hip, P < 0.05]. Serum 25-(OH)-D levels and serum OC levels were lower (both P < 0.05) in the depression group, while serum -CTX levels were higher in the depression group than in the control group (P < 0.05). Depression severity (GDS score) was negatively correlated with BMD (r = -0.456, P < 0.05), 25(OH)D (r = -0.546, P < 0.05), and OC (r = -0.215, P < 0.05), while positively correlated with β-CTX (r = 0.372, P < 0.05). The Harris scores of the depression group were lower than the control group (P < 0.001). In the control group, VAS scores decrease at 12 months postoperatively while in the depressed group, VAS scores increased (P < 0.001).

CONCLUSION

Depression is a risk factor for low bone mineral density and fracture, and adversely affects functional recovery and pain relief after artificial femoral head replacement. Special care should be taken for those patients with depressive symptoms in orthopedic practice.

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.

Factors predictive of functional outcomes and quality of life in patients with fragility hip fracture: A retrospective cohort study

To determine the predictors of functional outcomes and quality of life (QoL) of patients who were surgically treated for fragility hip fracture. This was a retrospective cohort study performed in the 3 tertiary rehabilitation facilities. A total of 165 patients who had undergone surgery for fragility hip fracture were followed up to 6 months postoperatively. The factors expected to be related to the functional outcomes and QoL at 6 months post-surgery were as follows: baseline demographics, fracture site, operation type, fall characteristics including fall location and fall direction, comorbidities, and initial functional status. The following were comorbidities: hypertension, diabetes mellitus, dementia, cerebrovascular accident, and osteoporosis. Functional outcome and QoL measures were represented using the Koval grade, functional ambulatory category (FAC), Berg balance scale, 4-m walking speed test, the Korean version of Mini-Mental State Examination, EuroQol 5-dimension (EQ-5D) questionnaire, the Korean version of Modified Barthel Index, and the Korean version of instrumental activities of daily living (K-IADL). For all tests, each patient was assessed immediately after transfer and at 6 months post-surgery. Multivariable regression analyses adjusting for factors mentioned above were as follows. Old age led to a significantly less favorable outcome on FAC and K-IADL at 6 months. Intertrochanteric fracture had a significantly positive impact on Koval at 6 months compared to femur neck and intertrochanteric fractures. Total hip replacement arthroplasty and bipolar hemiarthroplasty had a significantly positive impact on EQ-5D and FAC at 6 months respectively compared to other operation types. Fall characteristics didn't reveal any significant impact on functional outcomes and QoL. Patients with hypertension and diabetes mellitus had a significantly negative outcome on EQ-5D and K-IADL respectively. Among initial assessments of function and QoL, initial 4-m walking speed test, Korean version of Mini-Mental State Examination, K-IADL, and Korean version of Modified Barthel Index were independent predictors of function and QoL at 6 months. This study confirmed that age, fracture site, operation type, comorbidities, and initial physical and cognitive function significantly influenced recovery of function and QoL at 6 months in patients with fragility hip fractures.

Antidepressant medications in dementia: evidence and potential mechanisms of treatment-resistance

Depression in dementia is common, disabling and causes significant distress to patients and carers. Despite widespread use of antidepressants for depression in dementia, there is no evidence of therapeutic efficacy, and their use is potentially harmful in this patient group. Depression in dementia has poor outcomes and effective treatments are urgently needed. Understanding why antidepressants are ineffective in depression in dementia could provide insight into their mechanism of action and aid identification of new therapeutic targets. In this review we discuss why depression in dementia may be a distinct entity, current theories of how antidepressants work and how these mechanisms of action may be affected by disease processes in dementia. We also consider why clinicians continue to prescribe antidepressants in dementia, and novel approaches to understand and identify effective treatments for patients living with depression and dementia.

The role of perceived patient injustice on pain related and functional outcomes in orthopaedic patients; a systematic review

Introduction

Higher levels of perceived patient injustice has been associated with higher levels of pain and poor functional outcomes in patients with chronic musculoskeletal pain. We wanted to investigate if there was any evidence of this association in patients who underwent orthopaedic surgery.

Materials and methods

A systematic search of the literature was performed independently by two researchers on the electronic databases of MEDLINE, EMBASE, Google Scholar, Web of Science, and the Cochrane Database of Systematic Reviews and data extracted in accordance with PRISMA guidelines for systematic reviews. Outcomes of interest were pain, pain intensity, pain interference, opiate use, disability, physical function, return to work, quality of life, depression, anxiety, post-traumatic stress, social functioning and quality of life.

Results

Five studies were identified for qualitative analysis involving elective and trauma orthopaedic patients. All studies identified a positive correlation between higher levels of perceived injustice and depression, pain intensity and interference as well as reduced function and higher levels of disability.

Conclusions

Higher levels of perceived patient injustice is associated with worse pain and functional outcomes in patients who undergo orthopaedic surgery in the traumatic and elective setting. Further research is warranted to further elucidate this association and identify potential therapeutic interventions.

Prevalence and prognostic significance of depressive symptoms in a geriatric post-hip fracture assessment

OBJECTIVES

To investigate the prevalence and prognostic significance of post-hip fracture depressive symptoms.

METHODS

A naturalistic clinical cohort study. Data were collected on admission to hospital, geriatric assessment 4-6 months post-fracture and by telephone interview one-year post fracture. Depressive symptoms were assessed at the geriatric assessment using the 15-item Geriatric Depression Scale (GDS-15). Logistic regression analyses with multivariable models were conducted to examine the association of depressive symptoms with changes in mobility and living arrangements and Cox proportional hazards models for mortality between the geriatric assessment and one-year follow-up.

RESULTS

Of the 1070 patients, 22% (n = 238) had mild and 6% (n = 67) moderate to severe depressive symptoms. Patients with depressive symptoms had poorer nutritional status at baseline, lower scores on the cognitive and physical performance tests and poorer functional abilities in the geriatric assessment than those without. No association was observed between depressive symptoms and any of the outcomes at one-year follow-up. Poor nutritional status and physical functioning remained significant prognostic indicators.

CONCLUSION

Post-hip fracture depressive symptoms are common and deserve attention during post-hip fracture recovery and rehabilitation. Nonetheless, depressive symptoms have no impact on the change in mobility or living arrangements or mortality. These latter outcomes are mainly explained by poor nutritional status and functioning.

Coping strategies of older adults with a recent hip fracture within inpatient geriatric rehabilitation

OBJECTIVES

Coping strategies may play an important role as facilitator or barrier for functional recovery after hip fracture. This study explored 1] active and passive coping strategies in hip fracture patients within inpatient geriatric rehabilitation (GR) 2] the association of these coping strategies with depression, anxiety, pain and health-related quality of life (HRQoL).

METHOD

Secondary data analysis (FIT-HIP trial). Participants were patients with hip fracture, aged 65+ years, admitted to post-acute GR units. Coping was assessed using the 'Active Tackling' and 'Passive Reacting' subscale of Utrecht Coping List (UCL). Depression, anxiety, pain and HRQoL was assessed using GDS-8, HADS-A, NPRS and EQ5D-VAS. Based on UCL norm tables - for both subscales - we dichotomized the group into (extremely) high use of this coping strategy i.e. 'predominantly active coping' (PAC), and 'predominantly passive coping' (PPC); versus their corresponding 'residual groups', i.e. the remaining participants.

RESULTS

72 participants were included. Participants mostly used active coping (PAC: 33.3%), however those engaging in passive coping (23.6%) had significantly more depression and anxiety symptoms (GDS-8 ≥ 3: 31.1% respectively 9.1%, p = 0.040; HADS-A ≥ 7: 58.8% vs 10.9%; p = 0.00).

CONCLUSION

Active tackling and passive reacting coping strategies are used by up to one-third of patients with recent hip fracture. Passive coping was associated with more symptoms of depression and anxiety, which in turn may influence rehabilitation negatively. Screening of (passive) coping strategies could contribute to prompt identification of hip fracture patients at risk for negative health outcomes.

Cognitive impairment is associated with greater preoperative symptoms, worse health-related quality of life, and reduced likelihood of recovery after cervical and lumbar spine surgery

Background

Cognitive impairment (CI) is associated with prolonged hospital stays and increased complications; however, its role in symptom severity and health-related quality of life (HRQoL) among spine patients is unknown. We determined 1) prevalence of preoperative CI; 2) associations between CI and preoperative pain, disability, and HRQoL; and 3) association between CI and postoperative improvements in HRQoL.

Methods

This is a prospective cohort study of 453 consecutive adult spine surgery patients between October 2019 and March 2021. We compared pain (Numeric Rating Scale, NRS), pain-related disability (Oswestry/Neck Disability Index, O/NDI), and HRQoL (PROMIS-29 profile, version 2.0) among participants having severe (PROMIS-29 Cognitive Abilities score ≤30), moderate (31-35), or mild CI (36-40) or who were unimpaired (score >40), using analysis of variance. Likelihood of clinical improvement given the presence of any CI was estimated using logistic regression. All comparisons were adjusted for age, gender, comorbidity, and use of opioid medication during the last 30 days. Alpha=.05.

Results

Eighty-five respondents endorsed CI (38 mild; 27 moderate; 20 severe). Preoperatively, those with CI had more severe back pain (p=.005) and neck pain (p=.025) but no differences in leg or arm pain. Those with CI had greater disability on ODI (p<.001) and NDI (p<.001) and worse HRQoL in all domains (all, p<.001). At 6 and 12 months postoperatively, those with CI were less likely to experience clinical improvement in disability and HRQoL (anxiety, pain interference, physical function, and satisfaction with ability to participant in social roles) (all, p<.05).

Conclusions

CI was present in nearly 20% of spine patients before surgery and was independently associated with worse preoperative back and neck pain, disability, and HRQoL. Those with CI had approximately one-half the likelihood of achieving meaningful clinical improvement postoperatively. These results indicate a need to evaluate spine patients' cognitive impairment prior to surgery.

Level of Evidence

III.

Major depressive disorder, when under treatment, may not affect functional outcomes in patients with tibial plateau fractures

BACKGROUND

The purpose of this study is to determine if treated psychological depression is associated with poorer functional outcomes in patients who sustain tibial plateau fractures.

METHODS

Patients with a tibia plateau fracture were prospectively followed. Functional status was assessed using the Short Musculoskeletal Function Assessment (SMFA) at baseline (pre-injury), 3 months, 6 months, and 1 year post injury. Clinical outcomes were recorded at each follow up visit and radiographic outcomes were obtained from follow up radiographs. Records were reviewed to identify patients who were being treated for major depressive disorder (MDD). SMFA scores and clinical outcomes were compared between the depression and no depression cohorts.

RESULTS

420 patients were treated for a tibial plateau fracture and the mean age was 50.83 ± 15.60 years. Forty-two (10%) patients with 42 fractures were being treated for MDD at the time of their fracture. Patients with MDD were older (p = 0.05) and were more likely female (p < 0.01). At baseline, the clinical depression cohort had worse Total SMFA scores compared to the non-depressed cohort (5.90 ± 14.41 vs. 2.69 ± 8.35, p < 0.01). There were no differences in total SMFA score or any SMFA subscores at 3, 6, and 12 months. The incidence of wound complications, reoperations, and radiographic outcomes also did not differ between the cohorts.

CONCLUSION

Despite patients with MDD reporting higher SMFA (poorer) scores at baseline, MDD was not associated with worse injuries, diminished clinical or poorer functional outcomes following tibial plateau fractures.

Assessing the Outcome of Rehabilitation after Hip Fracture with a Wearable Device-A Study Protocol for a Randomized Control Trial in Community Healthcare

BACKGROUND

The increase of the aging population is a challenge to society, as age is related to dependence. Injuries such as hip fractures cause morbidity, loss of independent life, and mortality. The purpose of this protocol is to describe a randomized control trial, with three intervention arms, aiming at investigating if there are any differences in outcomes after hip fracture between different rehabilitation interventions including (1) High-Intensity Functional Exercise (HIFE), (2) HIFE with the addition of continuous measures of movement and body positions with a wearable device, or (3) standard rehabilitation. A secondary aim is to evaluate physiotherapists' satisfaction with using the wearable device in rehabilitation.

METHOD

Patients with hip fracture that require rehabilitation at home will be invited to participate and randomly assigned to one intervention arm. The primary outcome is balance, measured by postural sway using an Inertial Measurement Unit and by Functional Balance test for Geriatric patients. Secondary outcomes are functional independence in everyday activities, measured with the Barthel Index, and health-related quality of life measured with EuroQol 5 Dimension questionnaire and EuroQol Visual Analogue Scale for health and user satisfaction measured by the User Satisfaction Evaluation Questionnaire.

DISCUSSION

This study protocol is the first step in securing the research process before performing a full randomized controlled trial. The next step will be a pilot- and feasibility study.

Evaluation of a new screening instrument for psychological distress in postacute rehabilitation in older person

PURPOSE

Although psychological distress has a negative impact on functional recovery, institutionalisation and mortality rates, there is typically no established procedure to screen for psychological distress in geriatric rehabilitation. The aim of the study was to evaluate a brief single-item Verbal Numerical Rating Scale (VNRS-PD) as a screening tool for psychological distress in multimorbid geriatric rehabilitation patients.

METHODS

In this cross-sectional study, N = 132 geriatric rehabilitation in-patients (M = 82 years old; 70.5% female) completed a verbal numerical rating scale (VNRS-PD) on satisfaction with their mood as well as the Hospital Anxiety and Depression Scale (HADS) and the short-form of the Geriatric Depression Scale (GDS). Based on the questionnaire data, the rehabilitation patients were classified as high or low in psychopathology. Using receiver-operating characteristic (ROC) curve analysis, optimal cutoff scores of the VNRS-PD were calculated for each questionnaire to detect significant psychological distress.

RESULTS

Between 28.8% (HADS ≥ 18) and 43.9% (GDS ≥ 6) of the sample had above-cutoff questionnaire scores. The area under the curve (AUC) of the VNRS-PD varied from 0.785 (95%-CI 0.709-0.861) (GDS ≥ 6) and 0.790 (95%-CI 0.716-0.864) (HADS ≥ 18) to 0.807 (95%-CI 0.734-0.880) (GDS ≥ 7). A score of ≤ 5 in the VNRS-PD proved to be the cutoff with an optimal trade-off between sensitivity (0.776-0.867) and specificity (0.638-0.703).

CONCLUSION

The VNRS-PD may be a suitable screening instrument to detect patients with psychological distress in inpatient geriatric rehabilitation for and to initiate further diagnostics within a graduated psychodiagnostic scheme. This first step may help to identify older patients with psychological distress and mental disorders, to initiate targeted interventions. Further research is needed to replicate these findings in a larger sample.

Influence of comorbidities on functional outcomes in patients with surgically treated fragility hip fractures: a retrospective cohort study

Background

The incidence and number of fragility hip fractures are gradually increasing, resulting in a wide consumption of medical resources. Various factors affecting functional recovery in patients with fragility hip fractures are known, and comorbid diseases are one of them. The purpose of this study is to determine the effect of comorbidities on functional outcomes in patients surgically treated for fragility hip fractures, thereby contributing to the efficient distribution of medical resources.

Methods

This was a retrospective cohort study performed in the three tertiary rehabilitation facilities. A total of 211 patients (50 men and 161 women; average age 81.6 ± 6.7 years) who had undergone surgery for fragility hip fractures were followed up from immediately after transfer to the Department of Rehabilitation Medicine to 6 months postoperatively. Comorbidities referred to a summary of the following conditions: hypertension, diabetes mellitus, chronic liver disease, dementia, cerebrovascular accident, and osteoporosis. Functional outcomes included Koval’s grade, Functional Ambulatory Category (FAC), Functional Independence Measure (FIM)-locomotion, Modified Rivermead Mobility Index, Berg Balance Scale (BBS), 4-Meter Walking speed Test (4MWT), the Korean version of the Mini-Mental State Examination(K-MMSE), Geriatric Depression Scale (GDS), EuroQol Five-Dimension (EQ-5D) questionnaire, the Korean version of the Modified Barthel Index (K-MBI), the Korean version of the Instrumental Activities of Daily Living (K-IADL), and Korean version of Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight scale (K-FRAIL). For all tests, each patient was assessed immediately after transfer and 6 months post-surgery.

Results

Multivariate linear regression analyses adjusted for age, sex, the initial variable of the functional outcomes, and comorbidities revealed that dementia had a significant negative impact on Koval’s grade and K-FRAIL 6 months postoperatively. Diabetes mellitus had a significant negative impact on the FAC, GDS, EQ-5D, K-IADL, and K-FRAIL 6 months postoperatively. Patients with osteoporosis showed a significant negative outcome of FIM-locomotion 6 months postoperatively. A cerebrovascular accident revealed a significant negative impact on the BBS 6 months postoperatively. In addition, hypertension led to significantly less favorable outcomes of the K-FRAIL 6 months postoperatively.

Conclusions

This study confirmed that comorbidities, particularly dementia and diabetes mellitus, significantly influence functional outcomes 6 months after fragility hip fracture surgeries.

Prevalence of depression in older people with hip fracture: A systematic review and meta-analysis

INTRODUCTION

Hip fracture disrupts general health and is one of the most common physical injuries in the elderly. Depression is the most common mood disorder in older people and one of the main complications of hip fractures.

AIM AND METHODS

We conducted a meta-analysis to estimate the prevalence of depression in older people with hip fractures. Relevant literature published until July 2019 was obtained and screened according to established inclusion criteria. Two researchers independently carried out quality assessment and data extraction before the meta-analysis. We calculated proportions with 95% confidence intervals (CI). To investigate the sources of heterogeneity, we performed subgroup analyses based on study design, follow-up duration, type of fracture, and gender.

RESULTS

Twenty-seven studies with a combined sample size of 11958 were included. The overall prevalence of depression in older people with hip fracture was 23% (95% CI: 0.18 to 0.29). The lowest and highest prevalence of depression was in Asia (0.19) and America (0.27) respectively.

CONCLUSION

In this systematic review and meta-analysis the estimated prevalence of depression among older hip fracture patients was 23%. Further research is needed to identify strategies for preventing and treating mood disorders in this population.

What Predicts Health-Related Quality of Life for Patients With Displaced Femoral Neck Fractures Managed With Arthroplasty? A Secondary Analysis of the HEALTH Trial

BACKGROUND

Total hip arthroplasty (THA) has been argued to improve health-related quality of life (HRQoL) and function in femoral neck fracture patients compared with hemiarthroplasty (HA). The HEALTH trial showed no clinically important functional advantages of THA over HA. The current analysis explores factors associated with HRQoL and function in this population.

METHODS

Using repeated measures regression, we estimated the association between HRQoL and function [Short Form-12 (SF-12) physical component score (PCS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score] and 23 variables.

RESULTS

THA as compared to monopolar HA, but not bipolar HA, was more likely to improve PCS scores (adjusted mean difference [AMD] 1.88 points, P = 0.02), whereas higher American Society of Anesthesiologists score (AMD -2.64, P < 0.01), preoperative use of an aid (AMD -2.66, P < 0.01), and partial weight-bearing status postoperatively (AMD -1.38, P = 0.04) demonstrated less improvement of PCS scores over time. THA improved WOMAC function scores over time compared with monopolar HA (but not bipolar HA) (AMD -2.40, P < 0.01), whereas higher American Society of Anesthesiologists classification (AMD 1.99, P = 0.01) and preoperative use of an aid (AMD 5.39, P < 0.01) were associated with lower WOMAC function scores. Preoperative treatment for depression was associated with lower functional scores (AMD 7.73, P < 0.01).

CONCLUSION

Patients receiving THA are likely to receive small and clinically unimportant improvements in health utility and function compared with those receiving monopolar HA and little improvement compared with those receiving bipolar HA. Patient-specific characteristics seem to play a larger role in predicting functional improvement among femoral neck fracture patients.

LEVEL OF EVIDENCE

Prognostic Level II.

Living settings and cognitive impairment are stronger predictors of nursing home admission after hip fracture surgery than physical comorbidities A nationwide Danish cohort study

INTRODUCTION

Sustaining a hip fracture is a life changing event for many elderlies. While doctors and researchers tend to be preoccupied with mortality and complication rates, patients are more concerned by other aspects e.g. loss of independence and ability to remain in their own home. This study aimed to i) determine age-stratified one-year event rates of admission to nursing home after discharge, and ii) identify risk factors associated with nursing home admission.

METHODS

Community dwelling patients aged 60-100 years undergoing their first hip fracture surgery in 2005 - 2015 were identified in nationwide administrative registries. Outcome was admission to nursing home within one year of discharge. To assess risk factors, we performed age-stratified cumulative incidence curves and multivariate cause specific cox regression models adjusted for age, sex, social factors, and comorbidities.

RESULTS

A total of 53,157 patients were included. One-year risk increased with advancing age from 3.2% of patients aged 60 to 69, up to 22.4% in the eldest group aged 90-100 years. Living alone and dementia were strong risk factors HR 9.22 [95% CI 5.60-15.18, p = <0.0001] and HR 6.73 [95% CI 4.80- 9.44, p = 0.0001] respectively for patients aged 60 to 69 years, the effect decreased with higher age down to HR 2.75 [95% CI 2.12- 3.57, p = <0.0001] and HR 2.15 [95% CI 1.88- 2.46, p = <0.0001] for patients ≥ 90 years. Other important risk factors were pre-injury home care, Parkinson's disease and depression. Surprisingly, physical comorbidities i.e. kidney disease, chronic obstructive pulmonary disease, diabetes and cancer did not increase the risk of nursing home admission.

CONCLUSION

Future initiatives aimed to reduce loss of independence and nursing home admission, among patients with first time hip fracture, should devote attention to living settings and cognitive impairment rather than physical comorbidity.

Effects of fragility fracture integrated rehabilitation management on mobility, activity of daily living and cognitive functioning in elderly with hip fracture

OBJECTIVE

To determine the effectiveness of Fragility Fracture Integrated Rehabilitation Management (FIRM) on mobility, activity of daily living and cognitive functioning in elderly with hip fracture.

METHODS

A randomized control trial was conducted at Seoul National University Bundang Hospital, South Korea from August 2017 to January 2018. Patients of both genders with the age 65-95 years, diagnosed cases of hip fracture specifically fractures neck of femur, intertrochanteric, subtrochantric, patients who got bipolar hemiarthroplasty, total hip replacement arthroplasty, reduction and internal fixation were included in this study. A total of n=39 sample was collected through non probability convenience sampling technique and randomly divided into Fragility Integrated Rehabilitation Management (FIRM) group (n=20) and Conventional Physical therapy (CPT) group (n=19). The data was collected through KOVAL for walking ability, modified barthal index (MBI) for behaviors related to activities of daily living (ADLS) and mini mental status examination (MMSE) for cognitive functions at baseline on 2nd postoperative day and after 10th FIRM session on 15th postoperative day.

RESULTS

The mean age of study participants was 82.07±6.00 years. The post intervention comparison did not show any significant difference (p>0.05) in walking ability, overall ADLs and cognitive functioning. But FIRM group showed significant improvement in stair climbing {0(5) ver. 2(7.5), p=0.049} and ambulation or walker use {8(5) ver. 2(4), p=0.037}, as compared to CPT group.

CONCLUSION

Both groups improved in indoor mobility with walker and crutches as well as activities of daily living. But FIRM showed more improving ambulation with walker and stair climbing. While cognitive functioning was observed only in FIRM group.

Quality of life in elderly people after a hip fracture: a prospective study

BACKGROUND

Hip fracture is an important social and medical problem due to its increasing prevalence, the consequences for health and the economic impact on the health care system, but there is no doubt that it also has repercussions on health-related quality of life (HRQoL). Hence the importance of understanding and determining the impact of the condition on everyday life from the perspective of the patient's physical, emotional and social well-being.

PURPOSE

To determine the impact of hip fracture on HRQoL of people over the age of 65 1 month after surgery, related factors and the effects on functional ability and mood.

METHODS

Prospective observational study conducted in the traumatology units of two university hospitals in the province of Cáceres with consecutive sampling of all patients over the age of 65 admitted for hip fracture surgery during the study period. Sociodemographic and clinical data were recorded at the time of admission and prospectively at the follow-up visit 1 month later. Clinical, social, quality of life (EQ-5D-), basic functional and instrumental capacity (Barthel Index (BI) and Lawton & Brody Scale), and geriatric depression (Yesavage) variables were collected.

RESULTS

The study included 224 patients with a median age of 84.6 years (SD ± 6.1), 76.3% were female. Charlson's comorbidity was 5.3 (SD ± 1.2). The EQ-5D index decreased from 0.62 (SD ± 0.35) to 0.16 at 1 month follow up (SD ± 0.20) p <  0.001. The mean Visual Analog Scale (VAS) score of EQ-5D decreased from 72.8 (SD ±15.8) to 48.3 (SD ± 17.2) p <  0.001. All dimensions of EQ-5D showed a significant reduction from the time of pre-fracture status to 1 month after surgery. Independent factors associated with HRQoL 1 month after surgery were pre-fracture status Barthel Index score, Lawton and Brody scale, presence of depression, and type of surgery.

CONCLUSIONS

After a hip fracture, patients experience considerable deterioration in their HRQoL, especially in self-care, daily activities, and mobility. There is also a significant decline in functional capacity for both the basic and instrumental activities of daily living. One month after surgery, HRQoL is a long way from pre-fracture levels.

The influence of depression on patient-reported outcomes for hip-fracture patients 1 year after surgery: a prospective cohort study

BACKGROUND

Depression is common in elderly hip-fracture patients and together with cognitive impairment is associated with increased risk of mortality.

AIM

We aimed to examine the influence depression has on patient-reported outcome up to 1 year after acute hip fracture.

METHODS

162 hip-fracture patients participated in the prospective observational cohort study and were followed up at baseline, and 3 and 12 months using patient-reported outcome scores. Patients with cognitive impairment were excluded. Depression was defined as a score ≥ 8 on the depression subscale of the Hospital Anxiety Depression Scale (HADS D), having a diagnosis of depression or being treated with anti-depressant medication. Hip function was assessed using Harris Hip Score (HHS), EQ-5D was used to assess health status and Quality of life, and the Pain Numerical Rating Scale (PRNS) was used to assess pain levels. A linear regression model adjusted for group, age, sex, and ASA class was used to identify risk factors for functional outcome 12 months after fracture.

RESULTS

35 patients were included in the depression group versus 127 in the control group. No statistical differences were found in the demographic data (age, sex, ASA class, fracture type, operation method, living situation, activities of daily living ADL and clinical pathway) between the groups. In the regression model, we found no correlation between depression and the patient-reported outcome.

CONCLUSION

In young elderly hip fracture patients without cognitive dysfunction, depression may not be of major importance for the rehabilitation of hip function in the short term.

Risk factors of mortality in older patients with dementia in psychiatric care

OBJECTIVE

To examine the mortality risk, and its risk factors, of older patients with dementia in psychiatric care.

METHODS

We constructed a cohort of dementia patients through data linkage of four Dutch registers: the Psychiatric Case Register Middle Netherlands (PCR-MN), the hospital discharge register, the population register, and the national cause of death register. All dementia patients in PCR-MN aged between 60 and 100 years between 1 January 2000 and 31 December 2010 were included. Risk factors of mortality were investigated using Cox proportional hazard regression models with adjustment for age, sex, setting of care, nationality, marital status, dementia type, and psychiatric and somatic comorbidities.

RESULTS

In total, 4297 patients were included with a median age of 80 years. The 1-year, 3-year, and 5-year mortality were 16.4%, 44.4%, and 63.5%, respectively. Determinants that increased the 1-year mortality were: male sex (adjusted hazard ratio [HR]: 1.49; 95% confidence interval [95% CI], 1.26-1.76), higher age (HR 1.08; 95% CI, 1.07-1.09), inpatient psychiatric care (HR 1.52; 95% CI, 1.19-1.93), more somatic comorbidities (HR 1.67; 95% CI, 1.49-1.87), and cardiovascular disease separately (HR 1.54; 95% CI, 1.30-1.82). Results for 3-year and 5-year mortality were comparable. Living together/married increased the 3- and 5-year mortality, and Dutch nationality increased the 5-year mortality. There were no differences in mortality with different types of psychiatric comorbidity.

CONCLUSION

Mortality of dementia patients in psychiatric care was high, much higher than mortality in the general older population. The results of this study should raise awareness about their unfavourable prognosis, particularly older patients, men, inpatients, and patients with more somatic comorbidity.

Predictors of poor functional outcomes and mortality in patients with hip fracture: a systematic review

Background

Hip fracture is an important and prevalent medical condition associated with adverse outcomes. The aim of this article is to systematically review and summarise the predictors of poor functional outcomes and mortality for patients with hip fractures.

Methods

We conducted a systemic literature search using PubMed, EMBASE and Cochrane Library. We included English peer-reviewed cohort studies that examined predictors of poor functional outcomes (such as independence in Activities of Daily Living) and mortality for patients with hip fracture published in the past 15 years (from 1 Jan 2004 up to 30 May 2019). Two independent researchers evaluated the articles for eligibility. Consensus on the eligibility was sought and a third researcher was involved if there was disagreement. A standardised form was used to extract relevant data. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies.

Results

We retrieved 4339 and included 81 articles. We identified two emerging predictors of poor functional outcomes and mortality for patients with hip fractures: low hand grip strength and frailty in line with an emerging concept of “physical performance”. The predictors identified in this systematic review can be grouped into 1) medical factors, such as presence of co-morbidities, high American Society of Anesthesiologists (ASA) grade, sarcopenia, 2) surgical factors including delay in operation (e.g. > 48 h), type of fracture s, 3) socio-economic factors which include age, gender, ethnicity, and 4) system factors including lower case-volume centers.

Conclusions

This systematic review identified multiple significant predictors of poor functional outcomes and mortality, with the hand grip strength and frailty being important emerging predictors in the most recent literature. These predictors would further inform healthcare providers of their patients’ health status and allow for early intervention for modifiable predictors.

Multifactorial intervention for hip and pelvic fracture patients with mild to moderate cognitive impairment: study protocol of a dual-centre randomised controlled trial (OF-CARE)

Background

A hip or pelvic fracture is a major fall-related injury which often causes a decline in mobility performance and physical activity. Over 40% of patients with hip fracture have cognitive impairment or dementia and poorer rehabilitation outcomes than those without cognitive impairment. In this subgroup, there is a lack of evidence on the best practices supporting recovery. The main aim of this study is to investigate the effects of a transitional care intervention after inpatient rehabilitation on physical activity and functional performance in this group of cognitively impaired patients.

Methods/design

This dual-centre, randomised controlled trial compares a multifactorial intervention with usual care as control condition. Two hundred and forty community-dwellers (≥ 65 years) with a hip or pelvic fracture and mild to moderate cognitive impairment (MMSE 17–26) are recruited at the end of inpatient rehabilitation.

The four-month intervention consists of (a) an individually tailored, progressive home exercise program and physical activity promotion delivered by professional instructors and lay instructors (two home visits per week) and (b) a long-term care counselling approach addressing unmet care needs, pleasurable activities, and caregiver issues if needed. Primary outcome parameters are physical activity, measured as daily walking duration with an accelerometer-based activity monitor (activPAL™) over 72 h, and functional performance, assessed with Short Physical Performance Battery sum scores. Secondary outcome parameters are fear of falling, fall related self-efficacy, falls, quality of life, depression and activity of daily living. Data are collected at the end of rehabilitation, before the intervention at the patient’s home (baseline), after four months (post-intervention), and seven months (follow-up). In addition to completer and intent-to-treat analyses of outcomes, economic data and incremental cost-effectiveness are analysed.

Discussion

Existing service models of volunteer services and legal counselling provided by care counsellors were considered when developing the intervention protocol. Therefore, it should be feasible to translate and deliver the intervention into real-world practice if it has been demonstrated to be effective.

Trial registration

German Clinical Trials Register, DRKS00008863 (Accessed 17 Apr 2019), ISRCTN registry, ISRCTN69957256 (Accessed 17 Apr 2019).

Late-Life Depressive and Anxiety Symptoms Following Rehabilitation Services in Medicare Beneficiaries

OBJECTIVE

The aim of this study was to determine whether patients who received rehabilitation services had an increased risk of having late-life depressive or anxiety symptoms within the year following termination of services.

METHODS

The National Health and Aging Trends Study (NHATS) is a population-based, longitudinal cohort survey of a nationally representative sample of Medicare beneficiaries aged 65years and older. This study involved 5,979 participants from the 2016 NHATS survey. The Patient Health Questionnaire-2 and Generalized Anxiety Disorder 2-item assessed for clinically significant depressive and anxiety symptoms.

RESULTS

The prevalence of depressive and anxiety symptoms was higher in older adults who had received rehabilitation services in the year prior and varied by site: no rehabilitation (depressive and anxiety symptoms): 10.4% and 8.8%; nursing home or inpatient rehabilitation: 38.8% and 23.8%; outpatient rehabilitation: 8.6% and 5.5%; in-home rehabilitation: 35.3% and 20.5%; multiple rehabilitation sites: 20.3% and 14.4%; and any rehabilitation site: 18.4% and 11.8%. In multiple logistic regression analyses, nursing home and inpatient and in-home rehabilitation services, respectively, were associated with an increased risk of having subsequent depressive symptoms (odds ratio: 3.51; 95% confidence interval [CI]: 1.85-6.63; OR: 2.15; 95% CI: 1.08-4.30) but not anxiety symptoms.

CONCLUSION

Older adults who receive rehabilitation services are at risk of having depressive and anxiety symptoms after these services have terminated. As mental illness is associated with considerable morbidity and may affect rehabilitation outcomes, additional efforts to identify and treat depression and anxiety in these older adults may be warranted.

Prevalence and Potential Associated Factors of Depression among Chinese Older Inpatients

INTRODUCTION

Little is known about the current representative depression situation among Chinese older inpatients. The aim of this study is to examine prevalence of depression and associated risk factors among Chinese older inpatients by a large-scale cross-sectional national survey.

METHODS

This study is based on baseline survey data from a large-scale cohort study in a representative sample of Chinese older inpatients. The procedure of this study involves physical examination and face-to-face questionnaire interviews. Depression was assessed based on the Geriatric Depression Scale 15. Mixed-effect Poisson regression model was used to examine the relationship between depression and covariates by controlling the cluster effect of hospital wards.

RESULTS

Of all 9727 respondents, the mean age of all respondents was 72.4±5.7 years, from 65 to 97. The average GDS score was 2 (1, 4). The prevalence rate of depression was 16.7% (95%CI: 15.8-17.4%) among older inpatients. The prevalence rates were 14.6% for males and 19.5% for females respectively. After controlling the cluster effect of hospital wards, age, gender, ADL score, educational level, BMI, frail, marriage, falls, alcohol drinking, cognitive function, living conditions, vision, hearing, sleep and defecation function were associated with depression. Emaciation (OR=1.176, 95%CI: 1.107-1.249), frail (OR=1.562, 95%CI: 1.489-1.639), divorced or widowed (OR=1.083 95%CI: 1.017-1.153), living in the bungalow (OR=1.075, 95%CI: 1.023-1.130), falls (OR=1.078, 95%CI: 1.030-1.128), cognitive function (OR=1.142, 95%CI: 1.091-1.195), vision dysfunction (OR=1.125, 95%CI: 1.076-1.177), hearing dysfunction (OR=1.061, 95%CI: 1.011-1.113), sleep dysfunction (OR=1.237, 95%CI: 1.194-1.282), defecation dysfunction (OR=1.160, 95%CI: 1.103-1.221) could increase prevalence risk of depression.

CONCLUSIONS

There was a high prevalence of depression among Chinese older inpatients. Demographic characteristics, physical and mental conditions indicators have strong effect on prevalence and strength of depression. Therefore, it is essential to assess depression and perform comprehensive measures to improve physical and mental conditions in order to manage depressive symptoms in older inpatients.

Association of joint replacement surgery with incident dementia diagnosis in German claims data

ABSTRACTBackground:Cognitive decline is an important complication of joint replacement surgeries in senior people.

METHODS

We determined incidence rates of dementia diagnosis following endoprosthetic joint replacement surgery (upper and lower extremities). The observation period covered up to 28 quarters using German claims data comprising 154,604 cases 65 years and older. Effects were controlled for cerebrovascular and vascular risk factors, age, sex, the presence of a diagnosis of delirium, and regular prescription of sedative or analgesic drugs (SAD).

RESULTS

The rate of incident dementia diagnoses in people without joint replacement surgery was 21.34 per 1,000 person years, compared with 80.76 incident cases when joint replacement surgery was conducted during the quarter of the incident dementia diagnosis; rates declined to 21.77 incident cases 7 and more quarters after joint replacement surgery had taken place. This pattern was maintained when controlling for delirium diagnosis and regular prescription of SAD. Among 10,563 patients with at least one joint replacement surgery, patients with a diagnosis of delirium in the quarter of the surgery were at increased risk of a dementia diagnosis compared to patients without such a diagnosis (HR=2.00, p < 0.001).

CONCLUSION

In people surviving the high-risk phase for dementia immediately after surgery, long-term risk of dementia may reach the level of those without surgery. These findings encourage consequent perioperative management to reduce the risk of dementia as well as prospective studies of potentially beneficial effects of joint replacement surgery on mid- to long-term recovery of mobility and cognition in geriatric patients.

The value of a standardized and reproducible surgical technique in treatment of Vancouver B2 periprosthetic fractures: our experience

PURPOSE

To retrospectively review results and complications of our standardized surgical technique addressed exclusively to Vancouver B2 fractures.

METHODS

From January 2006 to July 2016, we treated 235 consecutive patients, 47 males and 188 females, mean age at surgery of 71 ± 10 years, with periprosthetic B2 fractures. Exclusion criteria were other kind of periprosthetic fractures and other femoral fractures. The patients were assessed clinically and radiographically following our standard protocol at the last available follow-up. The mean follow-up time was 6.4 years. Radiographic evaluation was performed according to Beals and Tower's criteria and clinical evaluation was performed using the Harris Hip Score and clinical exam.

RESULTS

From the starter cohort of 235, 207 patients (88.1%) were fully evaluated, while 28 were lost to follow-up. According to Beal and Tower's criteria, we found excellent results in 72 patients (34.8%), good results in 133 patients (64.3%), and poor results in 2 patients (0.9%). Mean HHS was 75 ± 9 points, with a statistically significant correlation between good functional results and better radiographic assessment (p = 0.001). The use of support plate (p = 0.008) and the acetabular revision (p = 0.002) showed a statistically significant distribution with worse radiographic results. Late complications detected were ten dislocations.

CONCLUSION

Our experience suggests that using a standardized and reproducible surgical technique, as our technique proposed, can surely reduce surgical time, the complication rate, and the mortality rate. During acetabular evaluation, the choice of performing a cup revision must be weighed on overall patient's assessment.

Determinants of functional outcome in hip fracture: the role of comorbidity

BACKGROUND AND AIMS

Executed studies did not clearly identify which index of comorbidity was an independent outcome determinant. The aim of this prospective observational cohort study was to address this issue.

METHODS

We analyzed 200 consecutive patients with hip fracture. All patients underwent rehabilitation. At admission comorbidity was assessed through the cumulative severity, severity index, and comorbidity index of the Cumulative Illness Rating Scale. Discharge scores and effectiveness in the Functional Independence Measure motor subscale, and discharge destination were the outcome measures. Multivariate regression analyses were performed to identify determinants of outcome.

RESULTS

Mini Mental State Examination and comorbidity index of the Cumulative Illness Rating Scale were important independent determinants of final (respectively, β = 0.46 and -0.25) and effectiveness (respectively, β = 0.47 and -0.25) in motor Functional Independence Measure scores, while hip strength and Rankin score were determinants of final motor Functional Independence Measure score (respectively, β = 0.21 and -0.20). Comorbidity index of the Cumulative Illness Rating Scale (odds ratio 8.18 for ≥3 versus < 3 comorbidity score; 95% confidence interval, 1.03-64.7) and Geriatric Depression Scale (odds ratio 4.02 for ≥6 versus ≤5 depression scale score; 95% confidence interval, 1.52-10.63) were risk indicators for nursing home.

CONCLUSIONS

Among the indices of the Cumulative Illness Rating Scale, comorbidity index is the sole independent determinant of both motor Functional Independence Measure scores and discharge destination in hip fracture patients. This suggests to specifically evaluate this index to identify the patients who may be admitted to a rehabilitation program.

Potentially Inappropriate Medications and the Time to Full Functional Recovery After Hip Fracture

BACKGROUND

Older adults after hip fracture are at increased risk of being prescribed potentially inappropriate medications, and may be particularly vulnerable to their adverse effects.

OBJECTIVE

The objective of this study was to examine the association of potentially inappropriate medication use with the time to full functional recovery within 1 year of hip fracture repair.

METHODS

We conducted a secondary analysis of a prospective longitudinal study of eight hospitals in St. Louis, MO, USA. The participants were older adults (n = 477) aged 60 years or older who had undergone surgical repair of a hip fracture free of delirium, dementia or depression at baseline. Drugs at baseline were categorised using the American Geriatrics Society 2012 Beers criteria. The outcome was the Functional Recovery Scale total score measured at four time points during a 12-month period of observation. Cox proportional hazards models examined the time to 95% recovery of function ('full recovery'), adjusting for demographics, cognition, depression, medical co-morbidity, pre-fracture functioning and pain as covariates.

RESULTS

Potentially inappropriate medication use was common following hip fracture, with 51% of participants prescribed at least one potentially inappropriate medication and 17.4% prescribed two or more potentially inappropriate medications. Potentially inappropriate medication use was significantly associated with a longer time to achieve full recovery with a hazard ratio of 0.69 (95% confidence interval 0.52-0.92; p = 0.012) and this association was stronger for two or more potentially inappropriate medications compared with one potentially inappropriate medication (hazard ratio = 0.60; 95% confidence interval 0.40-0.90; p = 0.014).

CONCLUSION

Potentially inappropriate medication use was associated with a longer time to full functional recovery in older adults who underwent surgery for a hip fracture, particularly in those using two or more potentially inappropriate medications at baseline.

How much do combined affective and cognitive impairments worsen rehabilitation outcomes after hip fracture ?

Background

To investigate the association between isolated and combined affective and cognitive impairments with functional outcomes and discharge destination in older patients admitted to rehabilitation after a hip fracture.

Methods

Prospective study in 612 community-dwelling patients aged 65 years and over, admitted to rehabilitation after surgery for hip fracture. Information on socio-demographics, medical, functional, affective, and cognitive status was systematically collected at admission. Functional status, length of stay and destination were assessed at discharge. Functional improvement was defined as any gain on the Barthel Index score between admission and discharge from rehabilitation.

Results

At admission, 8.2% of the patients had isolated affective impairment, 27.5% had cognitive impairment only, and 7.5% had combined impairments. Rate of functional improvement steadily decreased from 91.2% in patients with no cognitive nor affective impairment to 73.8% in those with combined impairments. Compared to patients without any impairment, those with combined impairments had lower odds of functional improvement, even after adjustment for age, gender, health and functional status at admission (adjOR: 0.40; 95%CI: 0.16–1.0; p = .049). The proportion of patients discharged back home gradually decreased from 82.8% among patients without any impairment to only 45.6% in patients with combined impairments. In multivariate analysis, the odds of returning home remained significantly reduced in these latter patients (adjOR: 0.31; 95%CI:0.15–0.66; p = .002).

Conclusions

Affective and cognitive impairments had both independent, and synergistic negative association with functional outcome and discharge destination in patients admitted to rehabilitation after a hip fracture. Nevertheless, patients with combined affective and cognitive impairments still achieved significant functional improvement, even though its magnitude was reduced. Further studies should investigate whether these patients would benefit from better targeted, longer, or more intensive rehabilitation interventions to optimize their functional recovery.

Medical Complications Predict Cognitive Decline in Nondemented Hip Fracture Patients-Results of a Prospective Observational Study

OBJECTIVE

The aim of this study was to identify factors that are associated with cognitive decline in the long-term follow-up after hip fractures in previously nondemented patients.

METHODS

A consecutive series of 402 patients with hip fractures admitted to our university hospital were analyzed. After exclusion of all patients with preexisting dementia, 266 patients were included, of which 188 could be examined 6 months after surgery. Additional to several demographic data, cognitive ability was assessed using the Mini-Mental State Examination (MMSE). Patients with 19 or less points on the MMSE were considered demented. Furthermore, geriatric scores were recorded, as well as perioperative medical complications. Mini-Mental State Examination was performed again 6 months after surgery.

RESULTS

Of 188 previously nondemented patients, 12 (6.4%) patients showed a cognitive decline during the 6 months of follow-up. Multivariate regression analysis showed that age ( P = .040) and medical complications ( P = .048) were the only significant independent influencing factors for cognitive decline.

CONCLUSIONS

In our patient population, the incidence of dementia exceeded the average age-appropriate cognitive decline. Significant independent influencing factors for cognitive decline were age and medical complications.

Dementia and co-occurring chronic conditions: a systematic literature review to identify what is known and where are the gaps in the evidence?

OBJECTIVE

The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co-occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality.

METHODS

This systematic literature review searched PubMed databases through 2011 (updated in 2016) using key constructs of older adults, moderate-to-severe cognitive impairment (both diagnosed and undiagnosed dementia), and chronic conditions. Reviewers assessed papers for eligibility and extracted key data from each included manuscript. An independent expert panel rated the strength and quality of evidence and prioritized gaps for future study.

RESULTS

Four thousand thirty-three articles were identified, of which 147 met criteria for review. We found that moderate-to-severe cognitive impairment increased risks of mortality, was associated with prolonged institutional stays, and decreased function in persons with multiple chronic conditions. There was no relationship between significant cognitive impairment and use of cardiovascular or hypertensive medications for persons with these comorbidities. Prioritized areas for future research include hospitalizations, disease-specific outcomes, diabetes, chronic pain, cardiovascular disease, depression, falls, stroke, and multiple chronic conditions.

CONCLUSIONS

This review summarizes that living with significant cognitive impairment or dementia negatively impacts mortality, institutionalization, and functional outcomes for people living with multiple chronic conditions. Our findings suggest that chronic-disease management interventions will need to address co-occurring cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.

Place orientation and visual construction subdomains of the Mini Mental State Examination test as predictors of rehabilitation outcome of post-acute hip-fractured patients

PURPOSE

The study aimed at assessing the relationship between various Mini Mental State Examination (MMSE) subdomains and rehabilitation achievements in post-acute hip-fractured patients.

METHOD

Six hundred and five hip-fractured patients admitted during 2010-2013 to a post-acute geriatric rehabilitation center were included in the study. Main outcome measures were the Functional Independence Measure (FIM) instrument, the motor FIM (mFIM), the Montebello Rehabilitation Factor Score (MRFS) on the mFIM and length of stay (LOS). A logistic regression analysis tested the predictive value of MMSE subdomains for achieving a satisfactory functional gain (mFIM MRFS >30%) on operated patients admitted from community.

RESULTS

Of all the six MMSE subdomains, place orientation and visual construction demonstrated significant predictive values for rehabilitation outcome. Patients who did not err on place orientation and visual construction MMSE domains had better probabilities [(OR 1.28, 95%CI, 1.05-1.58; p = 0.017); (OR 2.15, 95%CI, 1.28-3.59; p = 0.004), respectively] of achieving better rehabilitation achievements. Similar results were obtained for cognitively impaired patient groups [(OR 1.40 95%CI, 1.11-1.77; p = 0.005); (OR 2.47, 95%CI, 1.15-5.30; p = 0.021), respectively]. For the cognitively intact patient group, the variables with significant predictive value were time orientation and visual construction MMSE subdomains [(OR 2.26, 95%CI, 1.18-4.33; p = 0.014); (OR 2.87, 95%CI, 1.16-7.09; p = 0.022), respectively].

CONCLUSIONS

Post-acute hip-fractured patients scoring normally on place orientation and visual construction MMSE subdomains have a better chance of achieving favorable rehabilitation outcome. Implications for Rehabilitation Post-acute hip-fractured patients have a better chance to achieve a favorable rehabilitation outcome when scoring normally on place orientation and visual construction MMSE subdomains. Patients having difficulties in orientation and visual construction may need more rehabilitation time as they lack planning and organizational capacity to follow instructions. Assessing MMSE subdomains may reveal subtle cognitive impairment in patients scored within the normal range on the MMSE test. Identifying subtle cognitive impairment may assist in coordinating the patients and their caregivers' expectations, efficiently allocating resources and help in advanced care planning.

Measuring Health-Related Quality of Life of Adults With Down Syndrome

This study examined self- and caregiver-reported health-related quality of life (HRQOL) of 60 adults with Down syndrome (DS) using the QualityMetric Short Form-12 version 2 (SF-12v2). All HRQOL scores exceeded means and fell within one standard deviation of the SF-12v2 normative sample. Similarities between eight self- and caregiver-reported HRQOL scales were found with the exception of role physical scores (impact of health problems on typical accomplishments), which were lower when obtained by caregiver-report. A positive association was found between self- and caregiver-reported physical functioning scores (impact of health problems on physical activity). The SF-12v2 had high construct validity in this study. These findings support the feasibility of measuring HRQOL of adults with DS using self-report rather than reliance on caregiver-report.

Rehabilitation of Older Adults with Dementia After Hip Fracture

OBJECTIVES

To evaluate the effects of postoperative rehabilitation on the outcomes of older adults with dementia who experienced hip fracture.

DESIGN

Retrospective cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Community-dwelling adults with dementia who underwent hip fracture surgery between 2003 and 2011. Participants were categorized as no rehabilitation, complex continuing care (CCC), home-care based rehabilitation (HCR), and inpatient rehabilitation (IPR).

MEASUREMENTS

Time to long-term care (LTC) placement, mortality, and risk of repeat hip fracture and falls.

RESULTS

Of 11,200 individuals with dementia who experienced a hip fracture during the study period, 4,494 (40.1%) received no rehabilitation, 2,474 (22.1%) were admitted to CCC, 1,157 (10.3%) received HCR, and 3,075 (27.4%) received IPR. HCR and IPR were associated with less risk of LTC admission after discharge from hospital than no rehabilitation. All three forms of rehabilitation were associated with lower risk of mortality than no rehabilitation, with the greatest effect observed with IPR. HCR was associated with a higher risk of falls than no rehabilitation (P=.03); there were no other significant between-group differences in risk of falls or repeat fractures (P>.05).

CONCLUSION

Postfracture rehabilitation for older adults with dementia is associated with lower risk of LTC placement and mortality. Improving access to rehabilitation services for this vulnerable population may improve postfracture outcomes.

Factors Influencing The Six-Month Mortality Rate In Patients With A Hip Fracture: DEJAVNIKI, KI VPLIVAJO NA ŠESTMESEČNO STOPNJO UMRLJIVOSTI PRI BOLNIKIH Z ZLOMOM KOLKA

Background

There are several potential risk factors in patients with a hip fracture for a higher rate of mortality that include: comorbid disorders, poor general health, age, male gender, poor mobility prior to injury, type of fracture, poor cognitive status, place of residence. The aim of this study was to assess the influence of potential risk factors for six-month mortality in hip fracture patients.

Methods

The study included all patients with a hip fracture older than 65 who had been admitted to the Clinic for orthopaedic surgery during one year. One hundred and ninety-two patients were included in the study.

Results

Six months after admission due to a hip fracture, 48 patients had died (6-month mortality rate was 25%). The deceased were statistically older than the patients who had survived. Univariate regression analysis indicated that six variables had a significant effect on hip fracture patients’ survival: age, mobility prior to the fracture, poor cognitive status, activity of daily living, comorbidities and the place where they had fallen. Multivariate regression modelling showed that the following factors were independently associated with mortality at 6 months post fracture: poor cognitive status, poor mobility prior to the fracture, comorbid disease.

Conclusion

Poor cognitive status appeared to be the strongest mortality predictor. The employment of brief tests for cognitive status evaluation would enable orthopaedists to have good criteria for the choice of treatment for each patient screened.

Initiation of Antidepressant Medication After Hip Fracture in Community-Dwelling Older Adults

OBJECTIVE

To evaluate the incidence, characteristics, and correlates of antidepressant drug therapy initiation among community-dwelling older adults following hip fracture.

DESIGN

Retrospective cohort study using linked, population-based administrative data.

SETTING

Province of Ontario, Canada.

PARTICIPANTS

Older adults, aged 65 years or older, with a hip fracture and hip fracture surgery between April 1, 2003, and February 28, 2011. The study sample was restricted to individuals who returned home following surgery and who had not been dispensed an antidepressant in the year prior to their fracture (N=25,436).

MEASUREMENTS

We determined the incidence of new antidepressant use defined by the dispensing of antidepressant drug therapy within 90 days of discharge home. We identified independent correlates of antidepressant initiation using multivariate regression.

RESULTS

Overall, antidepressants were newly initiated in 8.8% of older adults with hip fracture in the 90 days following hospital discharge. There was a statistically significant, 1.3-fold increase in incidence of antidepressant prescribing from 2003 to 2010. Trazodone, frequently prescribed at a low dose, accounted for 39.0% of newly dispensed antidepressants, followed by selective serotonin reuptake inhibitors (36.9%). Rehabilitation admission, psychiatric evaluation, a diagnosis of dementia, and baseline benzodiazepine use were the strongest independent correlates of antidepressant initiation.

CONCLUSION

The period after a hip fracture is associated with a high rate of initiation of antidepressant therapy. The data raise the possibility that antidepressants are frequently prescribed off-label in these patients. Further research is needed to investigate the safety and efficacy of antidepressant use in this vulnerable population.

Long-term quality of life after liver donation in the adult to adult living donor liver transplantation cohort study (A2ALL)

BACKGROUND & AIMS

There are few long-term studies of the health-related quality of life (HRQOL) in living liver donors. This study aimed to characterize donor HRQOL in the Adult to Adult Living Donor Liver Transplantation Study (A2ALL) up to 11 years post-donation.

METHODS

Between 2004 and 2013, HRQOL was assessed at evaluation, at 3 months, and yearly post-donation in prevalent liver donors using the short-form survey (SF-36), which provides a physical (PCS) and a mental component summary (MCS).

RESULTS

Of the 458 donors enrolled in A2ALL, 374 (82%) had SF-36 data. Mean age at evaluation was 38 (range 18-63), 47% were male, 93% white, and 43% had a bachelor's degree or higher. MCS and PCS means were above the US population at all time points. However, at every time point there were some donors who reported poor scores (>1/2 standard deviation below the age and sex adjusted mean) (PCS: 5.3-26.8%,

MCS

10.0-25.0%). Predictors of poor PCS and MCS scores included recipient's death within the two years prior to the survey and education less than a bachelor's degree; poor PCS scores were also predicted by time since donation, Hispanic ethnicity, and at the 3-month post-donation time point.

CONCLUSIONS

In summary, most living donors maintain above average HRQOL up to 11 years prospectively, supporting the notion that living donation does not negatively affect HRQOL. However, targeted support for donors at risk for poor HRQOL may improve overall HRQOL outcomes for living liver donors.

Hip fractures in a geriatric population - rehabilitation based on patients needs

With an increased life expectancy in humans and thus an increase in the number of the elderly population, the frequency of hip fractures will rise as well. Aside from a higher incidence, hip fractures in a geriatric population is a significant problem due to the possible onset of severe and in some cases dramatic complications and consequences. The primary purpose of treatment and rehabilitation in the elderly after a hip fracture is to improve an individual's quality of life. It is important to underline that principles and methods of functional restoration after hip fracture should consider careful planning of a rehabilitation program individually for every patient and its implementation with respect to decisions made by the rehabilitation team.

Influence of selective comorbidity predictors on functional recovery after hip fracture in an older population

AIM

The purpose of the study was to evaluate the influence of four comorbidities from the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) and their severity on functional status outcome after a rehabilitation program measured by the Berg Balance Scale (BBS) in patients with hip fracture.

METHODS

The study included 203 patients whose functional status was evaluated by the BBS at admission (Group 1), at discharge (Group 2) and 3 months after discharge (Group 3). Further comorbidity parameters from the CIRS-G were assessed: musculoskeletal impairment, neurological, vascular and cognitive impairment. For the evaluation of CIRS-G severity degree we used the range 0-4.

RESULTS

At admission there were non-significant differences in mean values of BBS between parameters for the same CIRS-G severity degree. Significant differences between BBS values were noticed in the period after discharge (Group 2((musculoskeletal)); P<0.05, Group 2((neurological and cognitive)); P<0.01) and after 3 months of follow-up (Group 3((musculoskeletal, neurological and cognitive)); P<0.01). Higher effects of CIRS-G severity degree on BBS values in Group 2 and Group 3 for neurological impairment (η(2)(Group2)=29.76 and η(2)(Group3)=28.35) and even higher for cognitive impairment (η(2)(Group2)=34.35 and η(2)(Group3)=40.63) were noticed.

CONCLUSION

Increase in CIRS-G severity degree of cognitive and neurological impairment in patients after hip fracture that were included in the rehabilitation program correlates closely with functional status after discharge and after 3 months of follow-up. Rehabilitation of patients after hip fracture should be mandatory for functional recovery regardless of the comorbidity and functional status.

Effect of depression on femoral head avascular necrosis from femoral neck fracture in patients younger than 60 years

The purpose of this study was to determine the effect of depression on femoral head avascular necrosis (AVN) from femoral neck fracture in patients younger than 60 years and the relationship between depression and postoperative quality of life. The Beck Depression Inventory-II (BDI-II) was completed by 641 patients (352 men and 289 women; average age, 41.7±10.2 years; range, 20-60 years) postoperatively. Patients were divided into groups according to BDI-II score: a depressed group (BDI-II score of 14 or higher) and a nondepressed group (BDI-II score lower than 14). They were followed for an average of 28 months (range, 24-37 months). The postoperative diagnosis was confirmed by typical radiographs and single photon-emission computed tomography. Quality of life among patients was assessed using the Short Form-36 (SF-36) questionnaire. The overall incidences of depression and AVN were 30.6% (196 of 641) and 20.9% (134 of 641), respectively. Ninety-four (48.0%) patients in the depressed group and 40 (9.0%) patients in the nondepressed group ultimately developed AVN. Symptoms of depression significantly affected AVN. In addition, depression predicted patients' quality of life, as did sex, partner status, employment status, living alone, frequency of exercise, severity of fractures, and length of hospital stay. In a multiple linear regression model analyzing all of these variables, depression was the best independent predictor of quality of life. Depression in patients younger than 60 years with femoral neck fractures may increase postoperative femoral head AVN risk and greatly affect patients' quality of life.

What determines health-related quality of life in hip fracture patients at the end of acute care?--a prospective observational study

Hip fractures are associated with reduced health-related quality of life (HrQoL). We found pre-existing need of care or limited function, cognitive impairment, and depression to be independent factors associated with lower HrQoL during the postsurgical period. In contrast, joint replacement was associated with better HrQoL compared to internal fixation. Patients' treatment should be focused on functional recovery and treatment of depression.

INTRODUCTION

The aim of the study was to identify independent factors that were correlated with health-related quality of life (HrQoL) after hip fracture.

METHODS

A total of 402 patients with a mean age of 81 years suffering from a hip fracture were included in this prospective, observational cohort study. HrQoL (determined by the EuroQol instrument) was measured at admission and at discharge from an acute care hospital. Independent factors correlated with HrQoL at discharge and changes from pre-fracture to discharge were determined using multivariate analyses. The influence of antidepressants was evaluated by an ANOVA with repeated measurements.

RESULTS

Need of care prior to fracture was the most important determinant of EQ-5D index at discharge (ß = -0.359, p = 0.003). Additionally, low Mini Mental Status Examination (MMSE) was associated with a lower EQ-5D index at discharge (MMSE 0-9: ß = -0.238, p <0.001; MMSE 10-19: ß = -0.294, p <0.001) and a greater decrease in EQ-5D during hospitalisation (MMSE 10-19: ß = 0.281, p <0.001), while joint replacement (compared to internal fixation) was associated with a higher EQ-5D index (ß = 0.188, p = 0.002) and a lower decrease in the index (ß = -0.216, p = 0.003). EQ VAS values at discharge were correlated with pre-fracture Barthel Index (ß = 0.253, p <0.001) and Geriatric Depression Scale scores (ß = -0.135, p = 0.026). Depressive patients on antidepressants demonstrated less of a decrease in the EQ-5D index compared to patients not receiving medication (F = 2.907, p = 0.090).

CONCLUSIONS

Acute care of hip fracture patients should be focused on functional recovery and treatment of depression. When the preferred surgical strategy is unclear, joint replacement should be considered.

Cephalomedullary nail versus sliding hip screw for unstable intertrochanteric fractures in elderly patients

PURPOSE

To compare the short-term ambulatory function of elderly patients after fixation of unstable intertrochanteric fractures with either the AO-ASIF proximal femoral nail anti-rotation (PFNA) device or the dynamic hip screw (DHS).

METHODS

63 patients aged 60 years or older underwent fixation for unstable intertrochanteric fractures (AO types A2 and A3) using the PFNA (n=25) or DHS (n=38). The decision for the type of implant used was based on the lead surgeon's preference, according to perceived fracture stability and clinical experience. In patients having PFNA fixation, weight bearing ambulation and rehabilitation was commenced on day 2. The extent of weight bearing was decided by the lead surgeon based on the stability of the fracture. In patients having DHS fixation, non-weight bearing and ambulation with a walking aid was commenced on day 2. Ambulatory function before injury and after surgery was measured using the Parker Mobility Score (PMS). The 2 groups were compared in terms of the PMS, ambulatory independence, and environmental mobility.

RESULTS

Respectively in PFNA and DHS patients, 32% and 13% (p=0.035) were ambulant with a walking frame at discharge; the remainder were wheelchair bound. Patients treated with PFNA had significantly higher median PMS at 6 months (4 vs. 2, p=0.002), median ambulatory independence score at 6 months (4 vs. 3, p=0.004) and at 12 months (5 vs. 4, p=0.001), and median environmental mobility score at 6 months (2 vs. 1, p=0.007). They also had significantly higher percentage of patients able to ambulate outdoor and in community at 6 months (64% vs. 29%, p=0.02) and able to walk independently or with a walking aid at 12 months (96% vs. 69%, p=0.01). There were 3 complications. Two patients treated with PFNA had blade cut-out, owing to poor fracture reduction. One patient treated with DHS had screw cut-out and subsequently developed avascular necrosis of the femoral head.

CONCLUSION

Unstable intertrochanteric fractures in elderly patients with good pre-fracture ambulatory function stabilised with the PFNA resulted in better short-term ambulatory function.