Treatment of dementia patients with fracture of the proximal femur in a specialized geriatric care unit compared to conventional geriatric care

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

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

A family care model for older persons with hip-fracture and cognitive impairment: A randomized controlled trial

BACKGROUND

Dementia and hip fracture are both associated with substantial disability and mortality. However, few studies have explored the effects of intervention programs on post-operative recovery of older persons with hip fracture and cognitive impairment.

OBJECTIVE

To examine the effects of a family-centered care model for older persons with hip fracture and cognitive impairment and their family caregivers.

DESIGN

Single-blinded clinical trial.

SETTING

A 3000-bed medical center in Taiwan.

PARTICIPANTS

Older persons hip fracture and cognitive impairment (N = 152); 76 in the intervention group, and 76 in the usual-care control group.

METHODS

A family-centered care model consisting of geriatric assessment, discharge planning, in-home rehabilitation, and family caregiver-training for dementia care. Outcomes were assessed 1-, 3-, 6- and 12-months following hospital discharge for older persons with hip fracture and cognitive impairment. Assessed outcomes were self-care ability (performance of activities of daily living and instrumental activities of daily living), nutritional status, self-rated health, health-related quality of life and self-efficacy, and competence of the family caregivers.

RESULTS

Relative to patients who received usual care, those who received the family-centered care intervention had a greater rate of improvement in self-rated health (β = 1.68, p < .05) and nutritional status (β = 0.23, p < .05), especially during the first 6 months following hospital discharge. Relative to family caregivers who received usual care, those who received family-centered care had a higher level of competence (β = 7.97, p < .01), a greater rate of improvement in competence (β = 0.57, p < .01), and a greater rate of improvement in self-efficacy (β = 0.74, p < .05) 3 months following hospital discharge.

CONCLUSIONS

A family-centered care model enhanced family caregivers' self-efficacy and competence but did not improve the physical recovery of the participants with hip fracture and dementia. We suggest adding an educational component to include geriatric assessment, discharge planning, in-home rehabilitation, and family caregiver-training for dementia care and assessing family caregiver outcomes in interventions for older persons with hip fracture and cognitive impairment.

TRIAL REGISTRATION

Registered with www.clinicaltrials.gov (NCT03894709) Tweetable abstract: A family-centered care model consisting of geriatric assessment, discharge planning, in-home rehabilitation, and family caregiver-training for dementia care of older persons with hip fracture and cognitive impairment enhanced family caregivers' self-efficacy and competence.

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.

Postoperative Rehabilitation after Hip Fracture: A Literature Review

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

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).

[Special care units for patients with cognitive impairment : Results of a nationwide survey in geriatric hospitals in Germany]

BACKGROUND

A large number of older acutely ill patients with cognitive impairment are treated in geriatric care units. Since 1990 some geriatric departments in Germany have established special care units (SCU) for this patient population. In 2010 the first inventory of SCUs in Germany was carried out, which was not based on a nationwide systematic survey.

OBJECTIVE

Nationwide systematic survey of SCUs for patients with cognitive impairment in geriatric institutions in Germany.

METHODS

An online questionnaire (SurveyMonkey®, San Mateo, CA, USA) was sent to all heads of geriatric departments that provide advanced education in geriatric medicine of at least 12 months as registered by the German Society for Geriatric Medicine (DGG).

RESULTS

The questionnaire was sent to 495 geriatric institutions of which 161 answered (response rate 32.5%). Additionally, 13 institutions answered through a weblink sent in a newsletter by the DGG. In 2017 a total of 42 SCUs existed with a mean size of 13.5 ± 4.7 beds. A further 15 hospitals plan to install an SCU in the near future, 5 probably in 2018. In four geriatric departments an existing SCU was closed down. All SCUs implemented special architectural, structural and personnel measures as recommended by the position paper of the DGG. The few conducted evaluations indicated beneficial results for mobility and disruptive behavior.

CONCLUSION

In recent years the number of SCUs has increased considerably. A methodologically sound evaluation with respect to patient-related outcomes including follow-up and cost-effectiveness is lacking and should be carried out in the near future.

Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomised feasibility study: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR)

BACKGROUND

Proximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking.

OBJECTIVES

To develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation.

DESIGN

Phase I - realist review, survey and focus groups to develop the rehabilitation package. Phase II - parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study.

SETTING

Recruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge.

PARTICIPANTS

Older adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area.

INTERVENTIONS

Participants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients' self-efficacy and increasing the amount and quality of patients' practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions.

MAIN OUTCOME MEASURES

The primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale - International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers.

RESULTS

Sixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control, n = 32; intervention, n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen's d = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen's d = 0.31) and 1.3 (Cohen's d = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported.

CONCLUSIONS

Trial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22464643.

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. 21, No. 44. See the NIHR Journals Library for further project information.

Dementia-friendly interventions to improve the care of people living with dementia admitted to hospitals: a realist review

OBJECTIVES

To identify features of programmes and approaches to make healthcare delivery in secondary healthcare settings more dementia-friendly, providing a context-relevant understanding of how interventions achieve outcomes for people living with dementia.

DESIGN

A realist review conducted in three phases: (1) stakeholder interviews and scoping of the literature to develop an initial programme theory for providing effective dementia care; (2) structured retrieval and extraction of evidence; and (3) analysis and synthesis to build and refine the programme theory.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, NHS Evidence, Scopus and grey literature.

ELIGIBILITY CRITERIA

Studies reporting interventions and approaches to make hospital environments more dementia-friendly. Studies not reporting patient outcomes or contributing to the programme theory were excluded.

RESULTS

Phase 1 combined findings from 15 stakeholder interviews and 22 publications to develop candidate programme theories. Phases 2 and 3 identified and synthesised evidence from 28 publications. Prominent context-mechanism-outcome configurations were identified to explain what supported dementia-friendly healthcare in acute settings. Staff capacity to understand the behaviours of people living with dementia as communication of an unmet need, combined with a recognition and valuing of their role in their care, prompted changes to care practices. Endorsement from senior management gave staff confidence and permission to adapt working practices to provide good dementia care. Key contextual factors were the availability of staff and an alignment of ward priorities to value person-centred care approaches. A preoccupation with risk generated responses that werelikely to restrict patient choice and increase their distress.

CONCLUSIONS

This review suggests that strategies such as dementia awareness training alone will not improve dementia care or outcomes for patients with dementia. Instead, how staff are supported to implement learning and resources by senior team members with dementia expertise is a key component for improving care practices and patient outcomes.

TRIAL REGISTRATION NUMBER

CRD42015017562.

[Non-pharmacological treatment of dementia in geriatric psychiatry care units : Scoping review]

BACKGROUND

The number of persons suffering from dementia will continuously increase in the coming years; therefore, evidence-based interventions are needed in geriatric psychiatric care. When evidence is poor scoping reviews may help to identify knowledge gaps and needs for research.

AIM OF THE ARTICLE

To present an overview of clinical trials on non-pharmacological treatment for elderly with dementia in hospitals, wards and nursing homes, specializing in gerontopsychiatric care.

MATERIAL AND METHODS

A systematic search was carried out by one of the authors for clinical trials (randomized controlled, controlled and single group pre-post design, English and German, 1998-2014) in PsycINFO, PubMED, PSYNDEX and the Cochrane Library as well as a manual search in two relevant German peer-reviewed journals. Two authors included studies according to a priori defined inclusion criteria. One author extracted data after consulting the second author in cases of ambiguity. The risk of bias of the studies was not assessed.

RESULTS AND DISCUSSION

A total of 77 studies were identified, 29 studies on restructured treatment pathways or settings, 14 trials on environmental changes and 34 studies on therapeutic single or group interventions. Both the methodological quality of the studies and the evidence for the efficacy of non-pharmacological treatment were limited. There are clear indications for an advantage of specialized environments and treatment settings for the elderly with dementia in hospitals, wards and nursing homes. There are consistent indications for positive effects of psychosocial activation alone or in combination with cognitive or physical activation, partly with high-quality study designs. This is consistent with the German S3 guidelines for dementia. For single interventions, such as electroconvulsive therapy or horticultural activities, the level of evidence remains limited.

Rehabilitation Interventions for Older Individuals With Cognitive Impairment Post-Hip Fracture: A Systematic Review

PURPOSE

Currently, most rehabilitation services for individuals who sustain a hip fracture are not designed to meet the complex needs of those who also have cognitive impairment. The goal of this review was to identify current best practices for rehabilitation in long-term care settings and approaches to optimize outcomes among individuals with dementia and other cognitive impairments post-hip fracture.

PROCEDURES

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was used to guide the review. Five electronic databases, including PubMed, EMBASE, CINAHL (EBSCO), Medline (EBSCO), and PsycINFO (EBSCO), were searched for intervention studies published in English language journals. Studies were eligible if they focused on rehabilitation interventions post-hip fracture among older individuals (≥ 65 years) with cognitive impairment who were living in or transferred to long-term care or postacute/rehabilitation settings post-hip fracture. Studies were excluded if they did not enroll individuals with cognitive impairment, the study was descriptive without any intervention content, or the intervention components were only medication, surgical approach or medical treatment.

MAIN FINDINGS

A total of 4478 records were identified, 1915 of which were duplicative, 2563 were relevant based on title, and after careful review 7 studies were included. Two included studies were randomized controlled trials, one was a single group pre- and post-test, one a descriptive comparison between those with and without cognitive impairment, one a case controlled matched trial, one a nonequivalent groups trial, and one a case report. The interventions varied between manipulating the type and amount of exercise or testing multifactorial issues including environmental interventions and the use of an interdisciplinary team to address psychosocial factors, medication management, use of assistive devices, and specific preferences or concerns of the individuals.

CONCLUSIONS

The evidence summarized in this review suggests that it is feasible to implement rehabilitation programs focused on individuals with cognitive impairment in postacute care settings. Moreover, there was evidence to suggest that intensive rehabilitation and exercise activities are beneficial, although innovative approaches may be needed to engage individuals with cognitive impairment.

Geriatric patients with cognitive impairment

BACKGROUND

Hospitals are now faced with increasing numbers of cognitively impaired patients aged 80 and older who are at increased risk of treatment complications. This study concerns the outcomes when such patients are treated in a specialized ward for cognitive geriatric medicine.

METHODS

Observation of a cohort of 2084 patients from 2009 to 2014, supplemented by a sample of 380 patients from the hospital cohort of the Longitudinal Urban Cohort Ageing Study (LUCAS) for the years 2010 and 2011.

RESULTS

Geriatric inpatients with cognitive impairment tend to be multimorbid. Half of the patients studied (1031 of 2084 patients) were admitted to the hospital on an emergency basis. Complications arising on the ward that necessitated transfer elsewhere arose in 2.6% (51 of 2084 patients). Moreover, analysis of the sample of 380 patients from the LUCAS cohort revealed that the treatments they underwent during hospitalization were associated with an improvement of their functional state: their mean overall score on the Barthel index rose from 39.8 ± 24.3 (median, 35) on admission to 52.7 ± 27.0 (median, 55) on discharge. The percentage of patients being treated with 5 or more drugs fell from 98.2% (373/380) on admission to 79.3% (314/362) on discharge. The percentage receiving potentially inappropriate medications (PIM), as defined by the PRISCUS list, fell from 45% to 13.3%, while the percentage of drug orders and prescriptions involving PIM fell from 7.8 % (327/4181) to 2.0% (53/2600). 70% of the patients were discharged to the same living situation where they had been before admission.

CONCLUSION

In this study, structured geriatric treatment in a cohort of older acutely ill patients with cognitive impairment was associated with improvement of functions that are relevant to everyday life, as well as with a reduction of polypharmacy. Controlled studies are needed to confirm the observed benefit.

[Special care units for acutely ill patients with cognitive impairment in Germany. Position paper]

BACKGROUND

Dementia is an increasing challenge for care providers in nursing homes and hospitals. Since the 1980s, special acute care units in nursing homes have developed rapidly. In Germany, the first unit in a hospital opened in 1990. In 2013, there were 22 units.

MATERIALS AND METHODS

In the following paper, the German Geriatric Society ("Deutsche Gesellschaft für Geriatrie e. V.") recommends basic standards for these wards.

RESULTS

The basic standards for these wards include the following: a maximum of 20 beds, an area physically separated from the geriatric hospital department, their own dayroom and therapy room, a structured daily routine suitable for patients with dementia, the selection of permanent staff on a voluntary basis, specialized training, extended geriatric assessment, and special consideration of the background and social situation of the patients.

[Hospitalization and dementia: what was new in 2012?: literature review]

The present work provides a review of literature published in 2012 that were found in a PubMed search with the terms "hospitalization and dementia. Further information was obtained from personal contacts. The rate of publications was ten times higher in 2012 as in previous years. Frequency of dementia, hospital admission, acute coronary syndrome, femoral neck fracture, stroke, complications during hospital stay, outcomes after hospitalization, prediction, rehabilitation, and training are the common topics.

Caring for people with dementia in general hospitals: an education curriculum from the Alzheimer's Society of Lower Saxony, Germany

Since 2006, the Alzheimer's Society of Lower Saxony, Germany, has been working to improve care and medical treatment for people with cognitive impairment or dementia in general hospitals. An interdisciplinary team systematically worked on the topic for several years and presented results at various symposia. In 2011, a two-stage curriculum was completed and sent in combination with additional training documents to all hospitals and nursing training colleges in Lower Saxony, Germany. The manual comprised a two-step approach with a 14-h training for hospital staff and a 160-h training for qualification of trainers and dementia appointees/chaperones. In addition, the manual included a list of 13 essential points for "dealing with demented people in a general hospital," the information sheet of the German Alzheimer's Society on aspects requiring special attention when a demented person is admitted to a hospital, short descriptions of best practice models, a list of established speakers in the field, and a 30-min film. In 2012, the project won the "Preis für Engagement und Selbsthilfe" of the Hertie Foundation and the "Niedersächsischen Gesundheitspreis" awarded by the Lower Saxon Ministry for Social, Women, Family, and Health Affairs.