Functional outcome of cognitively impaired hip fracture patients on a geriatric rehabilitation unit

The impact of dementia on rehabilitation outcomes following hip fracture

Objective

To compare clinical outcomes between patients for whom their participation in inpatient rehabilitation was and was not impacted by dementia through matching patients reporting dementia (dementia group) with those not reporting dementia (non-dementia group).

Methods

Prospectively collected data held by the Australasian Rehabilitation Outcome Centre (AROC) were analyzed for patients aged 65 years or older receiving inpatient rehabilitation in public hospitals in Australia following a hip fracture and discharged between July 1, 2014, and June 30, 2019. Patients reported as having dementia impacting their rehabilitation program were matched to patients not reporting dementia based on age, admission motor Functional Independence Measure (FIM) score, and accommodation prior to rehabilitation. The matched cohorts were compared in relation to clinical outcomes (motor and cognitive FIM improvement, FIM efficiency, length of stay, and discharge destination) following participation in hospital-based rehabilitation using univariate analysis.

Results

Patients with dementia had significantly lower cognitive FIM scores on commencing rehabilitation (17.6 and 26.9, respectively, P < 0.001) and their median length of stay was 2 days shorter than those without dementia (21 and 23 days, respectively, P < 0.001). Relative change in FIM score and FIM efficiency (per week) were lower in the dementia group [relative FIM score change of dementia vs non-dementia, respectively, 26.2% vs. 44.0% (P < 0.001) and FIM efficiency, 6.5 vs. 8.9 (P < 0.001)]. Discharge destination between the two groups was statistically different, with 35.7% of patients with dementia being discharged to residential aged care facilities (RACFs) compared to 21.7% of those without dementia (P < 0.001). More patients with dementia had carers in their private residence in the post-rehabilitation phase, 82.2% vs. 57.6% (P < 0.001).

Conclusion

Patients with dementia who sustain a fractured hip benefit from inpatient rehabilitation, although their clinical outcomes are not as good as those without dementia. FIM change and FIM efficiency were lower in the dementia group. Length of stay in the hospital for patients with dementia was shorter due to earlier recognition for the need for placement in either an RACF or at home with carer support. The need for placement in an RACF or carer support in a private residence was significantly greater in the dementia group.

An intervention to improve outcomes of falls in dementia: the DIFRID mixed-methods feasibility study

BACKGROUND

Fall-related injuries are a significant cause of morbidity and mortality in people with dementia. There is presently little evidence to guide the management of such injuries, and yet there are potentially substantial benefits to be gained if the outcomes of these injuries could be improved. This study aimed to design an appropriate new health-care intervention for people with dementia following a fall and to assess the feasibility of its delivery in the UK NHS.

OBJECTIVES

To determine whether or not it is possible to design an intervention to improve outcomes of falls in dementia, to investigate the feasibility and acceptability of the DIFRID (Developing an Intervention for Fall related Injuries in Dementia) intervention and to investigate the feasibility of a future randomised controlled trial and the data collection tools needed to evaluate both the effectiveness and the cost-effectiveness of the DIFRID intervention.

DESIGN

This was a mixed-methods feasibility study. A systematic review (using Cochrane methodology) and realist review [using Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) methodology] explored the existing evidence base and developed programme theories. Searches were carried out in November 2015 (updated in January 2018) for effectiveness studies and in August 2016 for economic studies. A prospective observational study identified service use via participant diary completion. Qualitative methods (semistructured interviews, focus groups and observation) were used to explore current practice, stakeholder perspectives of the health and social care needs of people with dementia following a fall, ideas for intervention and barriers to and facilitators of change. Each of the resulting data sets informed intervention development via Delphi consensus methods. Finally, a single-arm feasibility study with embedded process evaluation was conducted.

SETTING

This study was set in the community.

PARTICIPANTS

The participants were (1) people with dementia presenting with falls necessitating health-care attention in each setting (primary care, the community and secondary care) at three sites and their carers, (2) professionals delivering the intervention, who were responsible for training and supervision and who were members of the intervention team, (3) professionals responsible for approaching and recruiting participants and (4) carers of participants with dementia.

INTERVENTIONS

This was a complex multidisciplinary therapy intervention. Physiotherapists, occupational therapists and support workers delivered up to 22 sessions of tailored activities in the home or local area of the person with dementia over a period of 12 weeks.

MAIN OUTCOME MEASURES

(1) Assessment of feasibility of study procedures; (2) assessment of the acceptability, feasibility and fidelity of intervention components; and (3) assessment of the suitability and acceptability of outcome measures for people with dementia and their carers (number of falls, quality of life, fear of falling, activities of daily living, goal-setting, health-care utilisation and carer burden).

RESULTS

A multidisciplinary intervention delivered in the homes of people with dementia was designed based on qualitative work, realist review and recommendations of the consensus panel. The intervention was delivered to 11 people with dementia. The study suggested that the intervention is both feasible and acceptable to stakeholders. A number of modifications were recommended to address some of the issues arising during feasibility testing. The measurement of outcome measures was successful.

CONCLUSIONS

The study has highlighted the feasibility of delivering a creative, tailored, individual approach to intervention for people with dementia following a fall. Although the intervention required greater investment of time than usual practice, many staff valued the opportunity to work more closely with people with dementia and their carers. We conclude that further research is now needed to refine this intervention in the context of a pilot randomised controlled trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41760734 and PROSPERO CRD42016029565.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 59. See the NIHR Journals Library website for further project information.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Access to rehabilitation services for older adults living with dementia or in a residential aged care facility following a hip fracture: healthcare professionals' views

PURPOSE

To enhance understanding of access to rehabilitation services in Australian and New Zealand acute care facilities for older adults living with dementia and/or living in residential aged care facilities (RACFs) following a hip fracture.

METHODS

Information on hip fracture rehabilitation was obtained from an online survey of 40 health professionals who were members of the Australian and New Zealand Hip Fracture Registry Network. This information was supplemented with key informant interviews with five geriatricians and five rehabilitation physicians.

RESULTS

Availability of hip fracture rehabilitation services differed by region and country. Around one in 10 respondents indicated that their facility had specific rehabilitation protocols for people living in RACFs or who were living with dementia. Barriers to providing hip fracture rehabilitation were commonly related to availability of resources. Rehabilitation pathways were determined according to individual patient characteristics and perceived potential benefit. Decision making was mainly informed by the patient's pre-fracture morbidity and residence. Three key themes and nine sub-themes emerged from the interviews.

CONCLUSIONS

The development of consistent decision criteria and pathways for access to hip fracture rehabilitation could provide a standard approach to access to rehabilitation, particularly for patients with cognitive impairment and/or who reside in RACFs.IMPLICATIONS FOR REHABILITATIONNeed to establish evidence-based criteria for patients who will benefit from hip fracture rehabilitation.Consistent decision criteria for access to hip fracture rehabilitation will assist in guiding a standard approach to providing rehabilitation, particularly for patients with cognitive impairment and/or who reside in RACFs.There is a need to ensure the availability of physiotherapy services in RACFs to assist with rehabilitation provision.Rehabilitation provided to patients with cognitive impairment and/or who are living in RACFs should be tailored to their physical and mental ability.

Developing an Intervention for Fall-Related Injuries in Dementia (DIFRID): an integrated, mixed-methods approach

BACKGROUND

Falls in people with dementia can result in a number of physical and psychosocial consequences. However, there is limited evidence to inform how best to deliver services to people with dementia following a fall. The aim of the DIFRID study was to determine the feasibility of developing and implementing a new intervention to improve outcomes for people with dementia with fall-related injuries; this encompasses both short-term recovery and reducing the likelihood of future falls. This paper details the development of the DIFRID intervention.

METHODS

The intervention was designed using an integrated, mixed-methods approach. This involved a realist synthesis of the literature and qualitative data gathered through interviews and focus groups with health and social care professionals (n = 81). An effectiveness review and further interviews and observation were also conducted and are reported elsewhere. A modified Delphi panel approach with 24 experts was then used to establish a consensus on how the findings should translate into a new intervention. After feedback from key stakeholders (n = 15) on the proposed model, the intervention was manualised and training developed.

RESULTS

We identified key components of a new intervention covering three broad areas: • Ensuring that the circumstances of rehabilitation are optimised for people with dementia • Compensating for the reduced ability of people with dementia to self-manage • Equipping the workforce with the necessary skills and information to care for this patient group Consensus was achieved on 54 of 69 statements over two rounds of the Delphi surveys. The statements were used to model the intervention and finalise the accompanying manual and protocol for a feasibility study. Stakeholder feedback was generally positive and the majority of suggested intervention components were approved. The proposed outcome was a 12-week complex multidisciplinary intervention primarily based at the patient's home.

CONCLUSIONS

A new intervention has been developed to improve outcomes for people with dementia following a fall requiring healthcare attention. The feasibility of this intervention is currently being tested.

TRIAL REGISTRATION

ISRCTN41760734 (16/11/2015).

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

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

Dementia

Dementia is a syndrome seen most commonly in older people and characterized by a decline in cognitive performance which impacts on the person's ability to function. There are approximately 47 million people worldwide with dementia and there are 10 million new cases every year. It is a major cause of disability and dependence and impacts on the physical, psychologic, and social well-being of families and carers. Alzheimer's disease is the most common form of dementia. Gait and balance impairments are common in people with dementia and contribute to the significantly elevated risk of falls. Older people with dementia are at increased risk of injury, institutionalization, hospitalization, morbidity, and death after a fall. There is preliminary evidence, predominantly from relatively small studies, that falls and disability can be prevented in this population. However, more good-quality research is needed, both to provide some certainty around the existing evidence base as well as to explore alternate approaches to prevention, including combined cognitive-motor training and cognitive pharmacotherapy.

Fear of Falling and Cognitive Impairments in Elderly People with Hip Fractures

Background/Aim

The purpose of this study was to investigate the estimated prevalence of dementia and the relationship between cognitive impairment and fear of falling in patients with hip fractures.

Methods

Analysis 1 included 100 patients with hip fractures. Analysis 2 included a subgroup of subjects with ≥75 years of functional independence: 46 patients with hip fractures and 46 control subjects without hip fractures, and presence or absence of dementia. We used an informant-rated questionnaire including the AD8 for screening for dementia, the Barthel Index for assessing activities of daily living, and the Short Falls Efficacy Scale-International (FES-I) for assessing fear of falling.

Results

The estimated prevalence of dementia was 66% in patients with hip fractures. There were significant fracture and dementia effects, with significant covariate effects of age and gender on the Short FES-I scores.

Conclusion

Our results suggested that more than two-thirds of patients with hip fractures had dementia. Fear of falling may reflect not only physical functions but also cognitive impairments.

Physiotherapy interventions for people with dementia and a hip fracture-a scoping review of the literature

BACKGROUND

People with dementia are 2.7 times more likely to suffer a hip fracture than those without and their management is estimated to cost £0.92 billion per year. Yet there has been little focus on the effectiveness of interventions for this population.

OBJECTIVE

The aim of this scoping review was to summarise the current available evidence for physiotherapy interventions for people with dementia who fracture their hip as well as to identify gaps in the literature that may require further research.

DATA SOURCES

A systematic search of the following databases was undertaken-TRIP, CINAHL, Amed, Embase, PEDro, PsycINFO, Cochrane Library, Open Grey, Ethos, ISRCTN, Proquest, PROSPERO and UK Clinical Trials Gateway.

STUDY SELECTION

Articles were included if they described an intervention which is considered within the scope of a physiotherapist and targeted those with both a hip fracture and dementia.

SYNTHESIS METHODS

A narrative summary was then undertaken to describe the current state of the literature.

RESULTS

Twenty six studies were included, of which thirteen were observational, six RCTs, two qualitative, two surveys and three systematic reviews. Only nine studies focused explicitly on physiotherapy interventions.

CONCLUSION

The findings of this scoping review suggest there is limited evidence to guide physiotherapists in the management of people with dementia who fracture their hip. No evidence was found about perceptions or experiences of patients in this group or of the physiotherapists involved in their care. Further research is needed to develop and evaluate physiotherapy interventions for people with dementia who fracture their hip.

Use of Goal Attainment Scaling in a Dementia Special Care Unit

Evaluation of Dementia Special Care Units presents particular challenges, including measuring the attainment ofgoals for residents with limited potential for treatment and rehabilitation. Goal Attainment Scaling (GAS) has been found to be a sensitive measure of individualized tangible outcomes in geriatric rehabilitation and mental health settings. In this study, GAS was used to set individualized functional and recreation goals for 10 residents of a Dementia Special Care Unit in a chronic care and rehabilitation hospital. Goal attainment was measured over a two month follow-up period GAS was found to be a feasible and responsive method of measuring individualized client goals. GAS is a promising clinical and research tool for measurement of client-centered outcomes in individuals with dementia

Reliability of the Berg Balance Scale as a Clinical Measure of Balance in Community-Dwelling Older Adults with Mild to Moderate Alzheimer Disease: A Pilot Study

PURPOSE

To measure test-retest and interrater reliability of the Berg Balance Scale (BBS) in community-dwelling adults with mild to moderate Alzheimer disease (AD). Method : A sample of 15 adults (mean age 80.20 [SD 5.03] years) with AD performed three balance tests: the BBS, timed up-and-go test (TUG), and Functional Reach Test (FRT). Both relative reliability, using the intra-class correlation coefficient (ICC), and absolute reliability, using standard error of measurement (SEM) and minimal detectable change (MDC95) values, were calculated; Bland-Altman plots were constructed to evaluate inter-tester agreement. The test-retest interval was 1 week. Results : For the BBS, relative reliability values were 0.95 (95% CI, 0.85-0.98) for test-retest reliability and 0.72 (95% CI, 0.31-0.91) for interrater reliability; SEM was 6.01 points and MDC95 was 16.66 points; and interrater agreement was 16.62 points. The BBS performed better in test-retest reliability than the TUG and FRT, tests with established reliability in AD. Between 33% and 50% of participants required cueing beyond standardized instructions because they were unable to remember test instructions. Conclusions : The BBS achieved relative reliability values that support its clinical utility, but MDC95 and agreement values indicate the scale has performance limitations in AD. Further research to optimize balance assessment for people with AD is required.

Hip fracture and the influence of dementia on health outcomes and access to hospital-based rehabilitation for older individuals

BACKGROUND

For older individuals who sustain a hip fracture, the presence of dementia can influence their access to hospital-based rehabilitation.

PURPOSE

This study compares the characteristics and health outcomes of individuals with and without dementia following a hip fracture; and access to, and outcomes following, hospital-based rehabilitation in a population-based cohort.

METHOD

An examination of hip fractures involving individuals aged 65 years and older with and without dementia using linked hospitalisation, rehabilitation and mortality records during 2009-2013.

RESULTS

There were 8785 individuals with and 23 520 individuals without dementia who sustained a hip fracture. Individuals with dementia had a higher age-adjusted 30-d mortality rate compared to individuals without dementia (11.7% versus 5.7%), a lower proportion of age-adjusted 28-d re-admission (17.3% versus 24.4%) and a longer age-adjusted mean length of stay (22.2 versus 21.9 d). Compared to individuals without dementia, individuals with dementia had 4.3 times (95% CI: 3.90-4.78) lower odds of receiving hospital-based rehabilitation. However, when they did receive rehabilitation they achieved significant motor functional gain at discharge compared to admission using the Functional Independence Measure, but to a lesser extent than individuals without dementia.

CONCLUSION

Within a population-based cohort, older individuals with dementia can benefit from access to, and participation in, rehabilitation activities following a hip fracture. This will ensure that they have the best chance of returning to their pre-fracture physical function and mobility. Implications for Rehabilitation Older individuals with dementia can benefit from rehabilitation activities following a hip fracture. Early mobilisation of individuals post-hip fracture surgery, where possible, is advised. Further work is needed on how best to work with individuals with dementia after a hip fracture in residential aged care to maximise any potential functional gains.

Factors associated with changes in mobility and living arrangements in a comprehensive geriatric outpatient assessment after hip fracture

PURPOSE

To examine factors associated with changes in mobility and living arrangements in a comprehensive geriatric outpatient assessment after hip fracture.

METHOD

Population-based prospective data on 887 consecutive hip fracture patients aged 65 years and older. The domains of the geriatric assessment were the independent and changes in mobility level and living arrangements 4 months postoperatively the outcome variables.

RESULTS

Of the survivors, 499 (73%) attended the assessment. The mobility level had declined in 39% of the attendees and 38% of them had moved to more supported living arrangements 4 months after the hip fracture. In the age-adjusted univariate logistic regression analyses, almost all the domains of the comprehensive geriatric assessment were significantly associated with both outcomes. In the forward stepwise multivariate analysis, disability in activities of daily living, poor performance in Timed Up and Go and comorbidity as measured by the American Society of Anesthesiologists scores remained significantly associated with the outcomes.

CONCLUSIONS

While comorbidity and disability in activities of daily living and mobility are the major indicators of poor outcomes of mobility and living arrangements after hip fracture, all the domains in the comprehensive geriatric assessment deserve attention during hip fracture care and rehabilitation.

IMPLICATIONS FOR REHABILITATION

In almost half of the patients the mobility level and living arrangements had deteriorated 4 months after the hip fracture, suggesting an urgent need for more effective postoperative rehabilitation. Almost all the domains of the comprehensive geriatric assessment were associated with poor outcomes and require equal attention during the acute and postacute phases of hip fracture care and in the course of rehabilitation. A geriatric outpatient assessment a few months after the hip fracture provides a check-point for the outcomes and an opportunity to target interventions at different domains of the comprehensive assessment.

[Influence of cognition on treatment outcome in geriatric patients: association between MMSE and gain in activities of daily living]

BACKGROUND

Cognitive impairment or dementia influence the results of geriatric treatment. The aim of the study was to quantify this influence.

PATIENTS AND METHODS

Data of 2527 patients from the years 2006 to 2009 were analysed in order to quantify the influence of cognition measured with the Mini Mental Status Examination (MMSE) on the improvement of activities of daily living as reflected by the Functional Independence Measure (FIM).

RESULTS

Impaired cognition is accompanied by a lower FIM score on admission and on discharge. But the improvement of the FIM of slightly cognitively impaired patients (MMSE 20-26) is the same as in patients without cognitive impairment (MMSE 27-30). Patients with a MMSE below 20 points have smaller improvements in their FIM score but nevertheless 40 % of the patients with a MMSE of 10-19 and still 30 % of the patients with a MMSE of 0-9 points show better improvements than the average of all patients.

CONCLUSION

Patients with a MMSE below 20 should not generally be excluded from geriatric treatment, but individual factors should be considered.

Cognitive impairment and 1-year outcome in elderly patients with hip fracture

Background

Hip fracture is common in elderly patients. However, few effective studies had linked cognitive impairment to patient clinical outcome.

Material/Methods

A total of 244 elderly hip fracture patients were prospectively followed up for 12 months. At 30 days, 6 months, and 1 year after hip repair surgery, patients and/or primary caregivers were interviewed by phone by trained, blinded interviewers. Functional evaluation, from pre-injury through 1 year after the operation, was assessed using the Barthel Index.

Results

Among 244 patients, 43 were diagnosed as having cognitive impairment (Mini-Mental State Examination score <24). Compared to those without cognitive impairment, the 30-day, 6-month, and 1-year mortalities in the impaired patients were significantly higher than that of the cognitively intact patients. Six months after hip repair surgery, the cognitively intact patients presented significantly higher activities of daily living (ADL) scores than the cognitively impaired patients, and only 38.5% of impaired patients returned to their pre-operation baseline levels afterwards. The ADL scores in the impaired patients were similar to the intact ones at 1 year after the operation.

Conclusions

Although they had a higher risk of mortality in hip fracture, functional gain in the cognitively impaired patients was similar to that in the cognitively intact patients at 1-year follow-up.

Evaluation of patient-centered rehabilitation model targeting older persons with a hip fracture, including those with cognitive impairment

Background

The purpose of this study was to evaluate outcomes for older persons post-hip fracture repair, including those with cognitive impairment (CI), following implementation of a novel model of care – the Patient-Centered Rehabilitation Model including persons with CI (PCRM-CI). The PCRM-CI is an interdisciplinary rehabilitation program that incorporates education for healthcare professionals (HCPs), including nurses, which is focused on geriatric care including management of dementia and delirium, support for HCPs from an Advanced Practice Nurse, and family support and education. Primary outcome measures were mobility gain from admission to discharge and whether or not patients returned home post-discharge.

Methods

The PCRM-CI intervention was evaluated using a quasi-experimental design, following implementation in two community hospital inpatient rehabilitation units. One hundred forty-nine patients aged 65 and older participated as patients in the usual care (76) or PCRM-CI intervention (73) groups. Patient mobility was assessed at admission and discharge by the Functional Independence Measure Motor Subscale (FIMM); the difference in mobility scores was defined as mobility gain. Patient discharge location was also captured to determine whether or not patients returned home from inpatient rehabilitation.

Results

No difference in mobility gain was found between the usual care and PCRM-CI groups as measured by the FIMM. Patients in the intervention group were more likely to return home post-discharge than those in the usual care group (p = 0.02).

Conclusions

Results of the PCRM-CI evaluation suggest that older adults with CI can successfully be rehabilitated post-hip fracture repair using this novel, interdisciplinary rehabilitation program.

Trial registration

This trial has been registered with the US National Institutes of Health (ID: NCT01566136)

Effect of cognitive impairment on basic activities of daily living in hip fracture patients: a 1-year follow-up

BACKGROUND AND AIMS

To compare changes in basic self-care activities in various cognitive groups of hip fracture patients by the Katz Index of Independence in activities of daily living (ADL).

METHODS

117 community-dwelling elderly subjects with acute hip fracture (age 67-92 years), referred to the geriatric unit of Jyväskylä Central Hospital for rehabilitation, participated in the study. Basic self-care activities were evaluated by the Katz ADL Index and cognition by the Mini-Mental State Examination (MMSE).

RESULTS

Prior to hip fracture, the patients in the lowest MMSE group had a significantly lower Katz Index than the other three groups (p<0.001). Disability increased in a statistically significantly way post-surgery in all four MMSE groups (p<0.001). In the two lower MMSE groups, the Katz Index remained at the lower level, and in the two higher groups it improved in a statistically significant way from 2 weeks to 3 months post-operatively, after which it deteriorated slightly. A significantly larger proportion of patients in the higher MMSE groups were independent in all basic ADLs, both before and after fracture (from p=0.023 to p<0.001), except in continence prior to fracture.

CONCLUSIONS

Prior to hip fracture, patients with low MMSE scores had a significantly greater degree of basic ADL dependence than the other three groups. Despite similar post-operative multidisciplinary treatment, functional ability remained at the lower level in the two lower MMSE groups, whereas recovery was much better in the higher MMSE groups.

Prevention and clinical management of hip fractures in patients with dementia

Hip fractures and dementia increase exponentially with age, and patients who are afflicted by both conditions suffer significant morbidity and mortality. The aging of our population heightens the need to recognize the interaction of these conditions in order to improve our efforts to prevent hip fractures, provide acute care that improves outcomes, and provide secondary prevention and rehabilitation that returns patients to their previous level of functioning. Identification and treatment of vitamin D deficiency and osteoporosis and assessment and interventions to reduce falls in patients with dementia can significantly impact the incidence of first and subsequent hip fractures. Acute management of hip fractures that focuses on comanagement by orthopedic surgeons and geriatricians and uses protocol-driven geriatric-focused care has been shown to decrease mortality, length of hospitalization, readmission rates, and complications including delirium. Patients with mild-to-moderate dementia benefit from intensive geriatric rehabilitation to avoid nursing home placement. Recognizing the need to optimize primary and secondary prevention of hip fractures in patients with dementia and educating providers and families will lead to improved quality of life for patients affected by dementia and hip fractures.

Improving hip fracture care: striving for excellence

Hip fracture is a common and potentially devastating injury that occurs mainly in older people. The incidence is predicted to rise by 30% in the next 10 years alone. Many of those who recover suffer a loss of mobility and independence. There is growing emphasis to improve the care of patients sustaining hip fracture, especially in those with concurrent cognitive impairment. This review focuses on current best practice as well as several key areas of management, including analgesia, anaemia and nutrition. In doing so, we hope to identify interventions that may form the basis of a future Enhanced Recovery Pathway dedicated to hip fracture care.

An inpatient rehabilitation model of care targeting patients with cognitive impairment

BACKGROUND

The course and outcomes of hip fracture patients are often complicated by the presence of dementia and delirium, referred to as cognitive impairment (CI), which limits access to in-patient rehabilitation. In response to this concern, members of our team developed and piloted an in-patient rehabilitation model of care (Patient-Centred Rehabilitation Model; PCRM) targeting patients with hip fracture and CI (PCRM-CI). We are now conducting a 3-year study comparing an inpatient rehabilitation model of care for community dwelling individuals with hip fracture and CI (PCRM-CI) to usual care to determine whether it results in improved mobility at the time of discharge from inpatient rehabilitation.

METHODS/DESIGN

A non-equivalent pre-post design is being used to evaluate the PCRM-CI compared to usual care. All community dwelling (private home or retirement home) patients following a hip fracture are eligible to participate. Recruitment of both cohorts is taking place at two facilities. Target accrual is 70 hip fracture patients in the PCRM-CI cohort and 70 patients in the usual care cohort. We are also recruiting 70 health care providers (HCPs), who are being trained to implement the PCRM-CI, and their unit managers. Patient data are collected at baseline, discharge, and 6 months post-discharge from an inpatient rehabilitation program. Evaluations include mobility, physical function, and living arrangement. Additional outcome variables are being collected from medical records and from the patients via their proxies. Data on the prevalence and severity of dementia and delirium are being collected. Staff data are collected at baseline and one year after implementation of the model to determine change in staff knowledge and attitudes toward patients with hip fracture and CI. Bi-monthly semi-structured interviews with unit managers have been conducted to examine factors and barriers influencing the model implementation. Data collection began in 2009 and is expected to be completed in 2012. The control cohort of 70 patients has been recruited, and 45 patients have been accrued to the intervention group to date.

DISCUSSION

Evaluation of this model of care is timely given the increasing proportion of persons with cognitive impairment and hip fractures.

TRIAL REGISTRATION

The study is registered at http://clinicaltrials.gov, Identifier NCT01566136.

Two-year effects of an interdisciplinary intervention on recovery following hip fracture in older Taiwanese with cognitive impairment

OBJECTIVE

This article aims to evaluate the long-term effects of an interdisciplinary intervention program on cognitively impaired older persons after hip fracture in Taiwan.

METHODS

Of 160 subjects randomly assigned to control (n = 81) and intervention (n  =  79) groups, 24 (29.6%) and 27 (34.2%) were cognitively impaired in the control and intervention groups, respectively, and outcomes were followed for 2 years after discharge.

RESULTS

Among cognitively impaired subjects, more in the intervention group recovered their previous walking ability (odds ratio [OR] =3.49; confidence interval [CI] = 1.64 to 7.42), activities of daily life performance (β  =  18.59; p = 0.0002), and more were readmitted to the hospital (OR  =  4.44, CI  =  1.53 to 12.89) than those in the control group during the first 2 years following discharge. Among subjects without cognitive impairment, more in the intervention group recovered their previous walking ability (OR  =  2.6; CI  =  1.33 to 5.07), had fewer falls (OR  =  0.47; CI  =  0.25 to 0.86), and made fewer emergency room visits (OR  =  0.33; CI = 0.11 to 0.97) during the first 2 years following discharge than those in the control group.

CONCLUSIONS

Cognitively impaired individuals benefited from our interdisciplinary intervention by improving their walking ability and physical function during the first 2 years following discharge. Specific strategies on fall prevention following hip fracture need to be further developed for cognitively impaired individuals.

Is pre-fracture functional status better than cognitive level in predicting short-term outcome of elderly hip fracture patients?

INTRODUCTION

The aim of the study was to determine to what extent severe cognitive impairment impacts short-term rehabilitation outcomes of elderly patients with proximal hip fracture.

MATERIAL AND METHODS

A total of 337 community-dwelling elderly patients with acute hip fracture were observed during a 12-month period at a major teaching hospital in Serbia. Cognitive status was assessed at admission with the Short Portable Mental Status Questionnaire (SPMSQ). Outcome after 4 months was analysed with respect to presence of severe cognitive impairment, defined as an SPMSQ score of < 3. Outcome assessment included presence of postoperative complications, absolute motor Functional Independence Measure (FIM) gain, Activities of Daily Living index (ADL), Instrumental Activities of Daily Living score (IADL), and walking ability.

RESULTS

An SPMSQ score of < 3 was observed in 36 patients (10.7%) with acute hip fracture. Patients with an SPMSQ score of < 3 achieved worse short-term outcomes regarding all observed variables. However, cognitive status was found to be an independent predictor only with respect to mortality at 4 months (odds ratio (OR) = 0.969, 95% confidence interval (CI) = 0.947-0.992, p = 0.009). In contrast, pre-fracture motor FIM independently predicted mortality (OR = 2.982, 95% CI = 1.271-7.000, p = 0.012), and preserved walking ability at 4 months follow-up (OR = 0.945, 95% CI = 0.912-0.980, p = 0.002). Correspondingly, pre-fracture ADL was an independent predictor of absolute motor FIM gain at 4 months follow-up (OR = 0.175, 95% CI = 0.405-11.426, p = 0.035).

CONCLUSIONS

Failure to consider functional status prior to fracture might overestimate the impact of cognitive status on functional outcome of hip fracture patients.

Physical training improves motor performance in people with dementia: a randomized controlled trial

OBJECTIVES

To determine whether a specific, standardized training regimen can improve muscle strength and physical functioning in people with dementia.

DESIGN

Double-blinded, randomized, controlled trial with 3-month intervention and 3-month follow-up period in 2006 to 2009.

SETTING

Outpatient geriatric rehabilitation.

PARTICIPANTS

Individuals with confirmed mild to moderate dementia, no severe somatic or psychological disease, and ability to walk 10 m. Most participants were still living independently with or without supportive care.

INTERVENTION

Supervised, progressive resistance and functional group training for 3 months specifically developed for people with dementia (intervention, n = 62) compared with a low-intensity motor placebo activity (control, n = 60).

MEASUREMENTS

Primary outcome measures were one-repetition maximum in a leg press device for maximal strength and duration of the five-chair-stand test for functional performance. Secondary outcome measures were assessed for a number of established parameters for maximal strength, physical function, and physical activity.

RESULTS

Training significantly improved both primary outcomes (percentage change from baseline: maximal strength, intervention group (IG): +51.5 ± 41.5 kg vs control group (CG): -1.0 ± 28.9 kg, P < .001; functional performance, IG: -25.9 ± 15.1 seconds vs CG: +11.3 ± 60.4 seconds, P < .001). Secondary analysis confirmed effects for all strength and functional parameters. Training gains were partly sustained during follow-up. Low baseline performance on motor tasks but not cognitive impairment predicted positive training response. Physical activity increased significantly during the intervention (P < .001).

CONCLUSION

The intensive, dementia-adjusted training was feasible and substantially improved motor performance in frail, older people with dementia and may represent a model for structured rehabilitation or outpatient training.

The Montreal Cognitive Assessment (MoCA) in geriatric rehabilitation: psychometric properties and association with rehabilitation outcomes

BACKGROUND

Cognitive status has been reported to be an important predictor of rehabilitation outcome. The Montreal Cognitive Assessment (MoCA) was designed to overcome some of the limitations of established cognitive screening tools such as the Mini-Mental State Examination (MMSE). The purpose of this study is to evaluate the psychometric characteristics of the MoCA as a screening tool in a geriatric rehabilitation program and its ability to predict rehabilitation outcome.

METHODS

Forty-seven geriatric rehabilitation program patients participated in the study. Assessments of each patient's functional (Functional Independence Measure) and cognitive status (MMSE and MoCA) were performed. Information on discharge destinations were obtained and rehabilitation efficacy and efficiency scores were calculated.

RESULTS

Significant correlations were found between the MoCA and other cognitive status measures. Cognitive status at admission and successful rehabilitation were also associated. Defining rehabilitation success on the basis of relative functional efficacy (an indicator that includes the patient's potential for improvement), the sensitivity and specificity of the MoCA were 80% and 30% respectively. The attention subscale of the MoCA was also uniquely predictive of rehabilitation success. The attention subscale (cutoff 5/6) of the MoCA had a sensitivity of 40% and specificity of 90%, as did the MMSE.

CONCLUSIONS

As a cognitive screening tool, the MoCA appears to have acceptable psychometric properties. Results suggest that the MoCA can have a considerable advantage over the MMSE in sensitivity and equivalence in specificity using both total and attention scale scores. The MoCA may be a more useful measure for detecting cognitive impairment and predicting rehabilitation outcome in this population.

Proximal femoral fractures in the elderly: how are we measuring outcome?

INTRODUCTION

Patients with proximal femoral fractures present a difficult problem to health care systems in view of their complex presentations and co-morbidities. Traditionally, the focus of outcome measurement for this patient group has been on mortality and surgical implant success. Increasing recognition of the need to diversify outcome measurements has led to the creation and use of a number of outcome scales. We sought to examine how these scales are being used in the current literature.

METHODS

Abstracts to over 4000 papers related to proximal femoral fracture research were screened to identify commonly used scales in the five main categories of general quality of life measures (QoL), Activities of Daily Living scales (ADL), mobility and physical performance scales, disease-specific scales and hip-specific scales. The 14 identified scales were then searched for directly, and papers analysed for scale usage, timing and interpretation.

RESULTS

ADL scales were the most commonly used group, followed by QoL measures, which are validated for elderly patients. Scale timing and use varied widely between studies. A large number of scales were found in addition to the 14 identified scales. None of the 14 identified scales were validated for the proximal femoral fracture population.

DISCUSSION

A good scale must be appropriate in content, method and clinical utility. Its method of application must be reliable, responsive, and validated for the population in question. Outcome scale usage was difficult to assess in proximal femoral fracture research due to difficulties in isolating the relevant research, and in differences in scale timing and interpretation. Scale prevalence was skewed by use by specific research groups.

CONCLUSION

There is no single unifying scale in widespread use for proximal femoral fracture patients. We would recommend the validation of commonly used scales for this population, and would advise the use of scales from more than one category to assess outcome.

Prevalence of dementia and cognitive impairment among older adults with hip fractures

BACKGROUND

Dementia and cognitive impairment are known to be risk factors for hip fractures and are associated with increased postoperative morbidity and mortality. Little is known of the prevalence of dementia and cognitive impairment among older adults with hip fractures.

METHODS

We completed searches of the electronic databases for observational studies and report the prevalence of either dementia or cognitive impairment among individuals with hip fractures. We included studies that reported the prevalence of dementia using standard diagnostic criteria or cognitive impairment as measured on cognitive screening tests. We used random-effects meta-analysis to arrive at pooled estimates of the prevalence of dementia and cognitive impairment.

RESULTS

Five studies reported the prevalence of dementia and 34 studies reported the prevalence of cognitive impairment in older adults with hip fractures. The estimated prevalence of dementia among older adults with hip fractures was 19.2% (95% confidence interval [CI]: 11.4% to 30.6%), whereas the prevalence of cognitive impairment was 41.8% (95% CI: 37.0% to 46.8%). In subgroup analyses, individuals admitted from long-term care were more likely to have dementia when compared with individuals admitted from the community, whereas there were no significant differences in the prevalence of cognitive impairment according to gender or study setting.

CONCLUSIONS

We conclude that dementia and cognitive impairment are common among older adults with hip fractures. Clinicians providing care for individuals with hip fractures should be aware of the high prevalence of cognitive impairment in this population. Effective strategies to prevent hip fractures and improve postoperative outcomes for older adults with dementia are needed.

[Special care units for the treatment of acutely ill, cognitively impaired geriatric patients in Germany]

During recent years, specialized wards have been established in geriatric hospital departments as a consequence of the growing need of special care for acutely ill older patients, who are also cognitively impaired. However, there are neither established standards nor any commonly agreed concept of care. A written survey among 12 specialized wards in Germany revealed some characteristics of these wards: extended geriatric assessment, special education of staff including validation and gerontopsychiatric issues, and particular equipment/architecture, such as hidden doors and group rooms, and in some cases loop tracks for walking, therapeutic facilities, and 'living rooms' on the wards. There is a wide variability with respect to the designation of these wards, the number of beds, length of stay, and admission criteria. It appears from this survey that there should be an exchange of empirical experience made on these wards, and there is a need of collaborative research on its usefulness.

Validation on Efficiency Pattern Analysis for Geriatric Hip Fractures Rehabilitation

Seven hundred and sixty-three elderly patients with hip fractures were recruited in the study. The Functional Independence Measure (FIM) was used to measure their functional status on admission and upon discharge, and their difference was defined as functional change. An Efficiency Pattern Analysis Matrix was formed with Efficiency Pattern Analysis (EPA) and was used for in-depth matrix characteristics analysis. A validation study was also conducted with another group of patients (n = 455) so that the stability of EPA across time was affirmed. We found that 23.3% of patients are in “higher efficiency” group [higher motor-FIM gains with shorter length of stay (LOS)], 8.5% in “higher gain and longer stay” group (higher motor-FIM gains with longer LOS), 32.5% in “average efficiency” group, 12% in “lower gain and shorter stay” (lower motor-FIM gain and shorter LOS), and 23.7% of patients in “lower efficiency” group (intermediate motor-FIM gains with longer LOS). The demographic and functional characteristics among these groups would be also analysed.

Follow-up for Alzheimer patients: European Alzheimer Disease Consortium position paper

BACKGROUND AND PURPOSE

Alzheimer disease (AD) is one of the leading causes of dependence in the elderly. Providing care for patients with AD is complex and the type of care required depends on the stage of the disease and varies over time. The aim of this article is to discuss available care strategies once the AD diagnosis has been made and to propose a follow-up plan as standard of care at a European level.

METHODS

The proposals developed in this article stem from the collaborative work of a panel of multidisciplinary experts involved in the care of AD patients (European Alzheimer Disease Consortium) based on the results of published scientific studies and on their experience from clinical practice.

CONCLUSION

Suggestions for follow-up frequency and easily administered and scored assessment tools are provided, thereby increasing efficiency and quality of care for patients with Alzheimer disease.

Concurrent validity of administering the functional independence measure (FIM) instrument by interview

In this study, we measure the concurrent validity of administering the Functional Independence Measure instrument by interview. Data from 28 community-dwelling, cognitively intact, elderly patients with hip fracture were collected in 5 postacute rehabilitation facilities. Within 72 hrs of admission to (and at discharge from) the postacute facilities, both a Functional Independence Measure-certified interviewer and a multidisciplinary team administered the Functional Independence Measure instrument to each participant concurrently. At admission, the mean Functional Independence Measure ratings assigned by the interviewer and by the team were 84.3 and 80.5, respectively (P < 0.001). At discharge, the mean Functional Independence Measure ratings were 104.4 and 103.4 (P > 0.50), reflecting the participants' functional recovery during postacute rehabilitation. The intraclass correlation between the Functional Independence Measure ratings assigned by the interviewer and by the team was 0.74 (95% confidence interval = 0.58-0.91) at admission and 0.76 (95% confidence interval = 0.60-0.92) at discharge. Functional Independence Measure ratings assigned by Functional Independence Measure-certified interviewers are valid indicators of the functional status of groups of older people recovering from hip fracture and feasible for longitudinal study.

The association between patients' cognitive status and rehabilitation outcome in a geriatric day hospital

PURPOSE

To assess whether and to what extent cognitive status affects functional gain in mobility and extended activities of daily living (ADL) in patients admitted to a geriatric day hospital.

METHODS

During 2003, 135 older patients admitted to a rehabilitation day hospital were evaluated by the Mini Mental State Examination (MMSE) and the Cognitive Functional Independence Measure (FIM). On admission and at discharge, they were assessed by the Nottingham Extended ADL Index (NEAI) and the Timed Get Up and Go test (TUG).

RESULTS

Orthopedic and stroke patients achieved significant functional gain in mobility regardless of their cognitive status. Nevertheless, cognitively intact stroke patients achieved higher admission and discharge NEAI scores, manifesting greater absolute functional gain than cognitively impaired patients. The patients' ability to extract their rehabilitation potential was significantly better.

CONCLUSIONS

Cognitively impaired patients can improve in mobility and performance of extended ADL during day hospital rehabilitation. Evaluation of the patients' cognitive status may enable the multidisciplinary team to develop suitable individual programs and better allocate resources. Cognitively intact stroke patients may benefit from extended rehabilitation treatment compared to impaired stroke patients as they are more capable of utilizing their potential to achieve independence in daily tasks.

Patient participation and physical activity during rehabilitation and future functional outcomes in patients after hip fracture

OBJECTIVE

To examine the association between physical activity recorded by actigraphy during therapy sessions (therapy) with therapist-rated patient participation and self-reported future functional outcomes. We hypothesized those participants who were more active during rehabilitation would have higher participation scores and better functional outcomes after hip fracture compared with those who were less active.

DESIGN

Longitudinal study with a 3- and 6-month follow-up.

SETTING

Participants were recruited from skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs).

PARTICIPANTS

Participants included 18 community-dwelling older adults admitted to SNFs or IRFs facilities after hip fracture. Participants were included if they were 60 years of age or older and ambulatory with or without assistance from a device or another person.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Physical activity was quantified during participants' rehabiliation by using the actigraph accelerometer worn consecutively over 5 days. The Pittsburgh Participation Rating Scale was used to quantify patient participation during their inpatient therapy sessions. Self-reported functional outcomes were measured by the Hip Fracture Functional Recovery Scale at baseline and 3 and 6 months after fracture.

RESULTS

Participants with higher actigraphy counts during rehabilitation were ranked by their therapists as having excellent participation compared with those who were less active. Participants who were more active reported better functional abilities at both the 3- and 6-month time points and achieved 78% and 91% recovery of self-reported prefracture function compared with those who were less active achieving 64% and 73% recovery.

CONCLUSIONS

Actigraphy provides an objective measure of physical activity exhibiting predictive validity for future functional outcomes and concurrent validity against patient participation in patients after hip fracture.

Outcomes for older adults in an inpatient rehabilitation facility following hip fracture (HF) surgery

The purpose of the study was to evaluate patient and system outcomes regarding older community-residing adults who participated in a rehabilitation program following HF surgery. The health care professionals on the rehabilitation unit in this feasibility study had never cared for such patients who were so frail, with multiple co-morbidities including cognitive impairment (CI). After an innovative model of care was developed and the staff trained in the novel approach to care, the unit opened for all patients living within the community who had fractured their hip, regardless of their CI. Of the 31 elderly patients consecutively admitted post-HF in this retrospective study, 18 were found to have CI postoperatively as determined by a Mini-Mental State Examination (MMSE) score < or = 23. There were no differences in length of stay (LOS), rehabilitation efficiency, and motor FIM gain scores between the two groups of patients. This feasibility retrospective study suggests that staff can learn how to care for patients with CI in rehabilitation settings, and that such clients can achieve outcomes comparable to those without CI in a setting dedicated to caring for patients with a HF.

Dementia as a cofactor for geriatric rehabilitation-outcome in patients with osteosynthesis of the proximal femur: a retrospective, matched-pair analysis of 250 patients

A raising number of patients with osteosynthesis of the proximal femur and additional dementia will be seen in hospitals in the future due to demographic changes. There is an ongoing discussion, if and to what extent cognitive abilities do influence functional outcome in geriatric rehabilitation. We therefore compared 250 patients with osteosynthesis of the proximal femur of whom one half had additional dementia, by a matched-pair analysis for the improvement of mobility assessed by the mobility items of the Barthel Index and the Tinetti mobility index. Dementia was an important cofactor for the success of geriatric rehabilitation. Patients with additional dementia reached lower mobility scores at discharge. Also, patients with dementia had significantly more in-hospital falls. Furthermore, the study revealed that demented patients received less individual and group therapy per hospital day. The study underlines the need for specialized wards treating demented patients with additional illnesses.

A multicenter examination of the Center for Medicare Services eligibility criteria in total-joint arthroplasty

OBJECTIVE

The Centers for Medicare and Medicaid Services (CMS) use a diagnostic category (revised in 2004) as one of eight criteria to determine whether a hospital is eligible for payment as an inpatient rehabilitation facility (IRF). Among the 13 specific categories of patients, there are three particular ones involving total knee arthroplasty (TKA) and hip arthroplasty (THA) patients. The purpose of this investigation was to analyze inpatient rehabilitation outcomes in TKA and THA patients, using these CMS criteria.

DESIGN

A multicenter, retrospective study using a consecutive patient sample from 15 independent inpatient rehabilitation facilities, conducted from January 1, 2002 through March 31, 2006. All patients had either primary or revision TKA or THA and were directly admitted for inpatient rehabilitation postacute care. Patients were 23,274 men and women, separated into three comparison pairs on the basis of CMS eligibility criteria: (1) unilateral or bilateral arthroplasty, (2) age <85 yrs or >or=85 yrs, or (3) body mass index (BMI) <50 or >or=50 kg/m2. All patients underwent a comprehensive rehabilitation program that included physical and occupational therapies for 3 hrs/day. Main outcomes were inpatient rehabilitation length of stay (LOS), functionality as assessed by the FIM instrument, FIM efficiency, hospital charges, and discharge disposition.

RESULTS

FIM efficiency scores were 8-21% lower in bilateral arthroplasties and patients aged >or=85 yrs, respectively (P < 0.0001). LOS was an average of 33% longer in patients >or=85 yrs than among patients <85 yrs (3.4 days; P < 0.0001). Total charges were 12-30% higher for patients with BMI >or=50 kg/m and >85 yrs than their comparative groups (P < 0.001). Arthroplasty patients <85 yrs were discharged more often to home compared with those >or=85 yrs (P = 0.0001). Patients >or=85 yrs were more likely to be transferred to a skilled nursing facility (7.4%) or back to acute care (3.9%) than those <85 yrs.

CONCLUSIONS

All arthroplasty patients demonstrated improved physical function after inpatient rehabilitation. Those aged >or=85 yrs demonstrated the lowest efficiency, the greatest cost, and were the least likely to return home.

[Acute orthogeriatric care (II). Clinical aspects]

The present article reviews the clinical principles of acute orthogeriatric care. The application of geriatric medicine to patients with hip fracture is explained. The principal stages of geriatric intervention in this process are mentioned, as are the interventions to be carried out by the geriatric team. Subsequently, we discuss the management of several frequent problems in these patients, such as high surgical risk, pain management, anaemia, delirium, malnutrition, and discharge planning. Lastly, the characteristics of several kinds of patients with special characteristics are mentioned, such as those diagnosed with dementia, nursing home residents or the oldest-old. Areas of improvement in the acute phase are also reviewed, such as mortality reduction, functional outcome improvement and the need for more efficient resource use in patients in the acute phase of hip fracture.