Cognitive screening of nursing home residents: factor structures of the Mini-Mental State Examination

Compliance with CBT referral in nursing home residents diagnosed with depression: Results from a feasibility study

Objectives

Patient-level factors that influence compliance with a recommendation for CBT in nursing home residents diagnosed with depression were identified.

Methods

Within a cluster-randomized trial on stepped care for depression in nursing homes (DAVOS-study, Trial registration: DRKS00015686), participants received an intake interview administered by a licensed psychotherapist. If psychotherapy was required, patients were offered a referral for CBT. Sociodemographic characteristics, severity of depression, loneliness, physical health, antidepressant medication, prior experience with psychotherapy, and attitudes towards own aging were assessed. A binary regression determined predictors of compliance with referral.

Results

Of 123 residents receiving an intake interview, 80 were recommended a CBT. Forty-seven patients (58.8 %) followed the recommendation. The binary logistic regression model on compliance with recommended CBT was significant, χ2(9) = 21.64, p = .010. Significant predictors were age (Odds Ratio (OR) = 0.9; 95 % Confidence Interval (CI) = 0.82, 0.99; p = .024) and depression (OR = 1.33; 95 % CI = 1.08, 1.65; p = .008).

Conclusion

Within the implemented setting compliance rate was comparable to other age groups. Future interventions should include detailed psychoeducation on the benefits of psychotherapy on mild depressive symptoms in older age and evidence-based interventions to address the stigma of depression. Interventions such as reminiscence-based methods or problem-solving could be useful to increase compliance with referral, especially in very old patients (80+). Language barriers and a culturally sensitive approach should be considered when screening residents.

Factor structure of the Modified Mini Mental State (3MS) exam among participants in inpatient neurorehabilitation

OBJECTIVE

To evaluate the factor structure of the Modified Mini Mental State (3MS) Exam and its suitability as a cognitive screening tool among individuals admitted to an inpatient rehabilitation unit for new-onset neurological injury/illness.

METHOD

A retrospective chart review was conducted. Of the 187 individuals meeting the inclusion criteria, 116 had a diffuse pattern of neurological injury/illness; 71 had a focal injury/illness. Confirmatory and exploratory factor analyses (CFA; EFA) were conducted for the whole sample and separately by group.

RESULTS

The CFA suggested poor fit indices. The EFA of the total sample suggested a three-factor solution (Orientation/Awareness; Learning/Recall and Executive Functioning; Psychomotor Ability). The EFA of the diffuse subsample suggested a three-factor solution (Attention and Learning/Recall; Psychomotor Ability; Expressive Language). The Orientation/Awareness, Learning/Recall, Executive Functioning, Psychomotor Ability, and Expressive Language four-factor solution observed among the focal subsample was considered invalid.

CONCLUSION

The 3MS provides information about the pattern of cognitive performance among individuals in neurorehabilitation; clinicians are advised to interpret total scores with caution. Among individuals with focal injuries/illnesses, clinicians might use the 3MS to compare the pattern of cognitive ability to expectations for performance and to support strengths-based approaches to participation in rehabilitation therapies.

Evaluation of a Japanese version of the Mini-Mental State Examination in elderly persons

AIM

This study aimed to examine the validity and item-response characteristics of the Mini-Mental State Examination (MMSE), which is used for assessing cognitive function, in Japanese older adults.

METHODS

Factor analysis and item response analysis were carried out for MMSE responses (n = 1971) from older adults living in the community (n = 1339) or in a nursing home (n = 632), including Alzheimer-type dementia (n = 330), vascular dementia (n = 36), frontotemporal dementia (n = 7), mixed Alzheimer-type and frontotemporal type dementia (n = 27), and age-related cognitive decline (n = 29). When choosing the cut-off score of 23 points for the MMSE, sensitivity and specificity for each item were calculated.

RESULTS

A three-factor solution was found to be most appropriate by factor analysis: complex processing, simple processing and working memory. The item characteristics curves showed unidimensionality with high reproducibility. We identified a simplified scale comprising 10 items in all participants: "naming", "three-step command", "registration", "repeat a sentence", "write a complete sentence", "copies drawing of two polygons", "orientation to place", "delayed recall", "orientation to time" and "serial sevens" tasks. Sensitivity and specificity for both "year" task and "day" task were more than 90% ("year": sensitivity 92.5%, specificity 96.3%; "day": sensitivity 92.4%, specificity 91.7%). For the Alzheimer-type dementia patients, the five-factor solution was suggested by factor analysis and the MMSE also had unidimensionality in terms of level of difficulty.

CONCLUSIONS

We found that the MMSE had multiple cognitive areas. We showed that the MMSE could be used as an essentially unidimensional measure of cognitive ability and the question about orientation to time might be useful in the simplest assessment to identify cognitive dysfunction.

Consequences from use of reminiscence--a randomised intervention study in ten Danish nursing homes

Background

Reminiscence is the systematic use of memories and recollections to strengthen self-identity and self-worth. The study aim was to investigate the consequences for nursing home residents and staff of integrating reminiscence into daily nursing care.

Methods

In this randomised study, ten nursing homes were matched into two groups on the basis of location, type and size. In the period August 2006 - August 2007, staff in the Intervention Group were trained and supported in the use of reminiscence, involving individual and group sessions with residents as well as reminiscence boxes, posters and exhibitions. At baseline and again 6 and 12 months after the intervention start, data were collected on residents' cognitive level, agitated behaviour, general functioning and proxy-assessed quality of life, as well as on staff well-being and job satisfaction. Mixed linear modelling was used to analyse differences in outcome between the intervention and control groups.

Results

Project drop-out rates were 32% for residents and 38% for nursing staff. Most staff in the Intervention Group considered reminiscence a useful tool that improved their communication with residents, and that they would recommend to other nursing homes. There were no significant differences between residents in the Intervention and the Control Group in cognitive level, agitated behaviour or general functioning. Residents in the Intervention Group showed significant higher score at 6 months in quality of life subscale 'Response to surroundings', but there was no significant difference at 12 months.

Positive effects of reminiscence were observed for all staff outcome measures, the only exception being SF-12 self-rated physical health. At 6 months after start of reminiscence, staff in the Intervention Group had significantly better scores than those in the Control Group for Personal accomplishment, Emotional exhaustion, Depersonalisation, 'Attitude towards individual contact with residents' and SF-12 self-rated mental health. At 12 months after start of reminiscence, staff in the Intervention Group had significantly better scores than those in the Control Group for Emotional exhaustion and 'Professional role and development'.

Conclusions

The use of reminiscence appeared to have little long-term effect on the nursing home residents. Nursing staff in the Intervention Group experienced greater satisfaction with professional roles and developed a more positive view of the residents.

International Standard Randomised Controlled Trial Number Register: ISRCTN90253170.

Dimensions underlying the mini-mental state examination in a sample with low-education levels: the Bambuí health and aging study

OBJECTIVES

To investigate the validity of previously suggested dimensions underlying the Mini-Mental State Examination (MMSE) and differences in associations of these dimensions with sociodemographic and health characteristics in an older Latin-American community sample with low levels of education.

DESIGN

Secondary analysis of baseline data from a population-based cohort study.

SETTING

Bambuí, Brazil.

PARTICIPANTS

Of 1,742 total residents aged 60 years or older, 1,558 (89.4%) participated at this study.

MEASUREMENTS

A standard Brazilian version of the MMSE.

RESULTS

A five-factor solution (Concentration, Language/Praxis, Orientation, Attention, and Memory) for the MMSE was generated from Principal Components Analysis, and the five-factor solutions proposed in previous studies of developed nation samples were tested in this sample by Confirmatory Factor Analysis. In the adjusted linear regression models, MMSE factors varied in their correlates: for example, female gender was associated with higher concentration, orientation, and attention but lower Language/Praxis; increased age was inversely associated only with language and attention; and activity of daily living impairment was principally associated with lower Language/Praxis.

CONCLUSION

This study provides support for the cross-sectional equivalence of the MMSE, suggesting that most of the items and underlying constructs remain meaningful after alteration and translation in a low-education sample with lower overall distribution of scores.

Consistency of information from persons with dementia

This analysis examines the ability of persons with mild to moderate dementia (MMSE scores 13—30 and/or a dementia diagnosis) to provide consistent and accurate information. Data come from interviews with 213 persons with dementia (PWDs) and their family caregivers (CG). Consistency was assessed by determining agreement between responses provided by PWDs during two in-person interviews. Accuracy was assessed by determining agreement between PWD responses and CG responses. Overall, PWDs provided consistent and accurate responses to fact-based questions and were consistent in their responses to state-dependent items. Less impaired respondents were more consistent in their responses to fact-based items. Among respondents with more severe impairment, there were no significant differences in consistency by question type. This work responds to the need to gain a better understanding of the opinions and experiences of dementia and offers further evidence that many PWDs can provide consistent and accurate information. Findings support increased involvement of individuals with dementia in research and care planning.

Identifying the most efficient items from the Mini-Mental State Examination for cognitive function assessment in older Taiwanese patients

AIMS

The purpose of the study was to identify the most efficient items from the Mini-Mental State Examination for assessment of cognitive function.

BACKGROUND

The Mini-Mental State Examination is the most frequently used cognitive screening instrument. However, the Mini-Mental State Examination has been criticized for insensitivity to mild cognitive dysfunction, limited memory assessment and variability in level of difficulty of the individual items.

METHOD

This study used secondary data analysis. Item response theory two-parameter model was used to analyse the data from the admission assessment of mental status by the Mini-Mental State Examination for 801 patients.

RESULTS

By using item response analysis, 16 items were selected from the original 30-item Mini-Mental State Examination. The 16 items included mainly the measures of orientation, recall and attention and calculation. The internal consistency of the 16-item Mini-Mental State Examination was 0.84. The proposed new cut-off point for the 16-item Mini-Mental State Examination was 11. The correct classification rate was 0.94, the sensitivity was 100% and the specificity was 97.4%, when compared with the original 30-item Mini-Mental State Examination from the cut-off point of 24. This new cut-off point was determined for the purpose of over-identifying patients at risk so as to ensure early detection of and prevention from the onset of cognitive disturbance.

CONCLUSION

Only a few items are needed to describe the subject's cognitive status. Using item response theory analysis, the study found that the Mini-Mental State Examination could be simplified.

RELEVANCE TO CLINICAL PRACTICE

Deleting the items with less variation makes this assessment tool not only shorter, easier to administer and less strenuous for respondents, but also enables one to maintain validity as a cognitive function test for clinical setting.

Mini-Mental Status Examination: A short form of MMSE was as accurate as the original MMSE in predicting dementia

OBJECTIVES

This study assesses the properties of the Mini-Mental State Examination (MMSE) with the purpose of improving the efficiencies of the methods of screening for cognitive impairment and dementia. A specific purpose was to determine whether an abbreviated version would be as accurate as the original MMSE in predicting dementia.

STUDY DESIGN AND SETTING

A population-based post hoc examination of the performance characteristics of the MMSE for detecting dementia in an existing data set of 243 elderly persons.

RESULTS

Sensitivity, specificity, and predictive values were computed for the original MMSE as well as new MMSE scale models derived from a Rasch model item analysis. The optimal threshold for the original MMSE screen yielded sensitivity and specificity estimates of 72.5% and 91.3%, respectively. The use of a subscale resulted in a slightly lower sensitivity (71.0%), specificity (88.4%), and positive predictive value (71.0%) but equal area under the receiver operating characteristic curve. Cross-validation on follow-up data confirmed the results.

CONCLUSION

A short, valid MMSE, which is as sensitive and specific as the original MMSE for the screening of cognitive impairments and dementia is attractive for research and clinical practice, particularly if predictive power can be enhanced by combining the short MMSE with neuropsychological tests or informant reports.

Mini-Mental Status Examination: Mixed Rasch model item analysis derived two different cognitive dimensions of the MMSE

OBJECTIVES

This study published in two companion papers assesses properties of the Mini-Mental State Examination (MMSE) with the purpose of improving the efficiencies of the methods of screening for cognitive impairment and dementia.

STUDY DESIGN AND SETTING

An item analysis by conventional and mixed Rasch models was used to explore empirically derived cognitive dimensions of the MMSE, to assess item bias, and to construct diagnostic cut-points. The scores of 1,189 elderly residents were analyzed.

RESULTS

Two dimensions of cognitive function, which are statistically and conceptually different from those obtained in previous studies, were derived. The corresponding sum scales were (1) age-correlated MMSE scale (A-MMSE scale: orientation to time, attention/calculation, naming, repetition, and three-stage command) and (2) non-age-correlated MMSE scale (B-MMSE scale: orientation to place, registration, recall, reading, and copying). The "writing" item was not included due to differential effects of age and sex. The analysis also showed that the study sample consisted of two cognitively different groups of elderly.

CONCLUSIONS

The findings indicate that a two-scale solution is a stable and statistically supported framework for interpreting data obtained by means of the MMSE. Supplementary analyses are presented in the companion paper to explore the performance of this item response theory calibration as a screening test for dementia.

Symptoms of depression in older home-care patients: patient and informant reports

The purpose of this study was to examine the level of agreement and patterns of disagreement between home-care patient and informant reports of depressive symptoms. The authors interviewed a sample of 355 older home-care patients and their informants using the Structured Diagnostic Interview for DSM-IV (R. L. Spitzer, M. Gibbon, & J. B. Williams, 1995). Informants reported more psychological symptoms than patients, and this type of discrepancy was higher for patients with cognitive impairment and patients who had younger informants. Younger informants also reported more cognitive symptoms, whereas patients were more likely to report suicidal thoughts or ideation if they were not cognitively impaired. The patterns of these discrepancies may reflect age- and cohort-related response bias in the reports of depressive symptoms obtained from older adults.

Bioelectrical impedance analysis and other hydration parameters as risk factors for delirium in rural nursing home residents

BACKGROUND

The study investigators conducted a vigorous screening protocol for delirium in rural long-term care (LTC) facilities for a period of 28 days focusing on Bioelectrical Impedance Analysis (BIA) and other hydration parameters as risk factors.

METHODS

A two-stage cluster sampling procedure was used to randomly select participants (n = 313) from 13 LTC facilities located in southeastern Iowa, stratified on facility bed size. BIA was used to estimate intracellular water (ICW), extracellular water (ECW), and total body water (TBW) on four occasions--baseline and follow-up days 7, 14, and 28. Volume estimates were calculated as a percent of body weight (%WT). Serum electrolytes and hematology were also measured. Delirium was measured with four strict criteria: a NEECHAM Confusion Scale score < 25, Vigilance "A" score > 2, a Mini-Mental Status Examination < baseline, and a positive Confusion Assessment Method score.

RESULTS

There were n = 69 delirium cases (22.0%). Blood urea nitrogen/creatinine ratios greater than 21:1 (odds ratio = 1.76, 95% confidence interval 1.02-3.06). No significant risk for delirium was associated with ICW, ECW, or TBW as a percent of body weight.

CONCLUSIONS

Some changes were observed with a slight decrease in ICW between day 7 and day 14 of follow-up that tended to follow an increase in delirium events, but in general the BIA measures did not predict delirium events.

Postoperative cognitive changes among older Taiwanese patients

The purpose of the study was to describe variations in cognitive/behavioural changes during the course of delirium among older Taiwanese patients after elective surgery. A total of 106 patients assessed four times (admission, onset of delirium, delirium day 3 and delirium day 5) by the Mini Mental State Examination (MMSE) were included in the analysis to understand the neurocognitive/behaviour change during the course of delirium. Repeated measures anova was used to analyse within-subject differences across these four time points for those who became delirious and those who did not. The findings showed that patients who experienced delirium had significantly (P < 0.01) lower MMSE scores than non-delirious patients. Scores for the delirious group were also significantly different across the four assessments (P < 0.01) within the group. The subscales of orientation to time, orientation to place, registration and recall were the major changes from time 1 (admission assessment) to time 2 (onset of delirium) for delirious patients. When scores for time 4 (delirium day 5) and time 1 (admission assessment) were compared, the subscales of orientation to time, orientation to place and visual construction showed the least improvement among the subscales at time 4. The findings of the study suggest that mental status assessments are important during the patient's admission and hospital stay. The repeated assessments can be incorporated into routine nursing care so that problems can be detected and appropriate nursing care implemented.

Construct validity of the 15-item geriatric depression scale in older medical inpatients

The construct validity of the 15-item Geriatric Depression Scale (sfGDS) has been assessed in selected populations. The aim of this study was to assess the appropriateness of applying the sfGDS to unselected older inpatients. The main component analysis of sfGDS was performed in 2032 medical inpatients (mean age = 76.3 +/- 8.4). sfGDS did not qualify as a unidimensional test. Three factors explained 47.7% of variance and explored the following dimensions: positive attitude toward life, distressing thoughts/negative judgment about the own condition, and inactivity/reduced self-esteem. The internal homogeneity was poor (Cronbach's alpha = .46). A higher fraction of variance was explained in patients independent in all or dependent in > or = 1 activity of daily living (ADL). In older medical inpatients, sfGDS is not a single construct, which prevents the univocal interpretation of the final score. The higher fraction of explained variance in patients with comparable ADL performance probably reflects the dependency of affective from physical status.

Factor structure of the Mini-Mental State Examination in adult psychiatric inpatients

The factor structure of the Mini-Mental State Examination (MMSE) has been examined primarily in geriatric populations using differing methodology and yielding inconsistent results. This study examined the MMSE in 339 adult inpatients at a nonforensic state psychiatric hospital. Data were analyzed in the form of 30 dichotomous variables (1 for each scored response). A 5-factor oblique solution was retained, comprising factors of Orientation, Attention-Working Memory, Verbal Recall, Comprehension-Praxis, and Naming. Higher order factors of Executive Functioning and Language-Praxis were also found. The results fit the traditional neurocognitive domains of a mental status examination and generally replicated findings from the 2 largest studies published to date despite differences in population, suggesting that the obtained factors are fairly robust.

A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients

OBJECTIVES

To develop and test the effect of a nurse-led interdisciplinary intervention program for delirium on the incidence and course (severity and duration) of delirium, cognitive functioning, functional rehabilitation, mortality, and length of stay in older hip-fracture patients.

DESIGN

Longitudinal prospective before/after design (sequential design).

SETTING

The emergency room and two traumatological units of an academic medical center located in an urban area in Belgium.

PARTICIPANTS

60 patients in an intervention cohort (81.7% females, median age = 82, interquartile range (IQR) = 13) and another 60 patients in a usual care/nonintervention cohort (80% females, median age = 80, IQR = 12).

INTERVENTION

(1) Education of nursing staff, (2) systematic cognitive screening, (3) consultative services by a delirium resource nurse, a geriatric nurse specialist, or a psychogeriatrician, and (4) use of a scheduled pain protocol.

MEASUREMENTS

All patients were monitored for signs of delirium, as measured by the Confusion Assessment Method (CAM). Severity of delirium was assessed using a variant of the CAM. Cognitive and functional status were measured by the Mini-Mental State Examination (MMSE) (including subscales of memory, linguistic ability, concentration, and psychomotor executive skills) and the Katz Index of activities of daily living (ADLs), respectively.

RESULTS

Although there was no significant effect on the incidence of delirium (23.3% in the control vs 20.0% in the intervention cohort; P =.82), duration of delirium was shorter (P =.03) and severity of delirium was less (P =.0049) in the intervention cohort. Further, clinically higher cognitive functioning was observed for the delirious patients in the intervention cohort compared with the nonintervention cohort. Additionally, a trend toward decreased length of stay postoperatively was noted for the delirious patients in the intervention cohort. Despite these positive intervention effects, no effect on ADL rehabilitation was found. Results for risk of mortality were inconclusive.

CONCLUSIONS

This study demonstrated the beneficial effects of an intervention program focusing on early recognition and treatment of delirium in older hip-fracture patients and confirms the reversibility of the syndrome in view of the delirium's duration and severity.

Mini mental state examination in geriatric stroke patients. Validity, differences between subgroups of patients, and relationships to somatic and mental variables

To study the validity of the Mini Mental State Examination (MMSE) in geriatric stroke patients, 116 patients were tested 2-8 weeks and 6 months post-stroke. A neuropsychological test battery consisting of five tests measuring memory, calculation and spatial ability was used for validation. Motor activity, depression, aphasia and activities of daily living were assessed. Confusion in the acute stage, Barthel Index, depression scores, level of motor activity, and most of the neuropsychological tests correlated to the MMSE. Logistic regression showed 4 independent variables which could predict the MMSE scores. A factor analysis showed 3 factors which could explain 53% of the variance. The sensitivity for detecting dementia was 56%, and increased to 68% if patients with isolated spatial dysfunction were excluded. The MMSE had acceptable validity in detecting cognitive dysfunction early poststroke in this old patient population.

Structure of the Mini-Mental State Examination: a comparison between normal and clinical subjects

The Mini-Mental State Examination was administered to a sample of 133 Italians ranging from 60 to 80 years of age. From a Principal Components Analysis three factors were retained, being results of both varimax and oblimin rotations. These were labeled (1) Memory, (2) Verbal Comprehension, and (3) Attention. These factors are similar to those obtained with normal elderly Americans, but they are different from the factors based on clinical samples. No age differences in the factor scores were found among the normal elderly subjects when education was considered. In contrast, significant differences were found between a group of 25 demented patients and a matched group randomly extracted from the normal sample.

Prevalence of senile dementia in a rural community in Japan: the Tajiri project

Knowledge of the prevalence of dementia in different age groups is needed for the planning of a health policy. This study shows the prevalence of dementia and magnetic resonance imaging (MRI) findings in elderly people aged 65 years and over, living in the town of Tajiri in the northern part of Japan. They were shown by two cognitive screening tests, the Mini-Mental State examination (MMS) and the Dementia Screening Test (DST) and medical diagnosis. Two subject groups were assessed, those who completed both tests (Subjects I, n=2066) and those from among the 200 'MRI-administered subjects' who were interviewed and diagnosed (Subjects II, n=170). For Subjects I, there were 6.3 and 10.2% 'dementia range' according to the severe and mild criteria, respectively. As for Subjects II, 9.4% were clinically diagnosed as having dementia. They met the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria of probable Alzheimer's disease (AD) or possible AD with cerebrovascular disease. The estimated prevalence rate of dementia was 8.0%. Visual ratings of brain atrophy using MRI disclosed two distribution patterns. The 'continuous' pattern of the frontal and temporal lobes atrophy suggest that both are affected by the aging process, while a 'discontinuous' pattern of the hippocampal atrophy could indicate a pathologic background such as early changes of AD.

A factor analysis of the Mini-Mental State Examination in schizophrenic disorders

The Mini-Mental State Examination (MMSE) is frequently used in schizophrenia studies. Therefore, it is surprising that no factor analysis of MMSE has been carried out in schizophrenic patients. The MMSE ratings of 80 long-term in-patients with DSM-III-R schizophrenia or schizoaffective disorder were introduced into a principal-component analysis with varimax rotation which generated three MMSE factors or subscales (frontal, memory and spatial). The limitations of this pilot study are the small sample size and the inclusion of only hospitalized patients.

Postoperative variation in neurocognitive and functional status in elderly hip fracture patients

Regaining independence in the performance of activities of daily living (ADL) is a nursing priority in the postoperative care of hip fracture patients, though often impeded by a temporary yet reversible decrease in cognitive status postoperatively. This study investigated the incidence and evolution of decreased cognitive status in geriatric hip fracture patients from admission through to the fifth postoperative day, and the relationship between cognitive abilities and functional (ADL) status. Twenty-six elderly hip fracture patients (f: 21, m: 5) with a mean age of 79.5 years (SD = 8.2) admitted to the emergency room of an academic medical centre were monitored longitudinally from admission until the fifth postoperative day regarding neurocognitive status and ADL status, as measured by the mini-mental state exam (MMSE; including subscales of memory, linguistic ability, concentration and psychomotor executive skills) and an adapted version of the Katz ADL-scale, respectively. Patients were categorized on the basis of cognitive status as follows: no cognitive impairment (MMSE > or = 24), moderate (MMSE < or = 23 but > or = 18) and severe impairment (MMSE < or = 17). Nineteen of the 26 patients (73.1%) showed cognitive impairment (MMSE < or = 23) at some point in time before and/or after surgery. Some improvement in cognitive status was observed yet only selectively across patient cohorts and neurocognitive dimensions. Cognitive status, especially memorial ability and psychomotor executive skills, seemed to be most vulnerable to becoming impaired after hip fracture surgery. A relationship was found between cognitive and functional status, specifically, strong associations between memory and psychomotor skills relative to ADL and modest associations between linguistic ability and concentration relative to ADL. Further, patients with decreased cognitive status postoperatively remained more ADL-dependent than non-impaired patients. This study underscores the importance of a systematic assessment of the cognitive status of elderly hip fracture patients and linking these observations to functional ability in order to enhance the postoperative rehabilitation of this patient group.