Effects of Geriatric Interdisciplinary Home Rehabilitation on Independence in Activities of Daily Living in Older People With Hip Fracture: A Randomized Controlled Trial

Home health care is associated with an increased risk of readmission and cost of care without reducing risk of complication following shoulder arthroplasty: a propensity-score analysis

BACKGROUND

Home health services provide patients with additional professional care and supervision following discharge from the hospital to theoretically reduce the risk of complication and reduce health care utilization. The aim of this investigation was to determine if patients assigned home health services following total shoulder arthroplasty (anatomic [TSA] and reverse [RSA]) exhibited lower rates of medical complications, lower health care utilization, and lower cost of care compared with patients not receiving these services.

METHODS

A national insurance database was retrospectively reviewed to identify all patients undergoing primary TSA and RSA from 2010 to 2019. Patients who received home health services were matched using a propensity score algorithm to a set of similar patients who were discharged home without services. We compared medical complication rates, emergency department (ED) visits, readmissions, and 90-day cost of care between the groups. Multivariate regression analysis was performed to determine the independent effect of home health services on all outcomes.

RESULTS

A total of 1119 patients received home health services and were matched to 11,190 patients who were discharged home without services. There was no significant difference in patients who received home health services compared with those who did not receive home health services with respect to rates of ED visits within 30 days (OR 1.293; P = .0328) and 90 days (OR 1.215; P = .0378), whereas the home health group demonstrated increased readmissions within 90 days (OR 1.663; P < .001). For all medical complications, there was no difference between cohorts. Episode-of-care costs for home health patients were higher than those discharged without these services ($12,521.04 vs. $9303.48; P < .001).

CONCLUSION

Patients assigned home health care services exhibited higher cost of care and readmission rates without a reduction in the rate of complication or early return to the ED. These findings suggest that home health care services should be strongly analyzed on a case-by-case basis to determine if a patient may benefit from its implementation.

Early supported discharge for older adults admitted to hospital after orthopaedic surgery: a systematic review and meta-analysis

BACKGROUND

Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home, continuing to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. Existing literature demonstrates the concept having a reduced length of stay in stroke inpatients and medical older adults. This systematic review aims to explore the totality of evidence for the use of ESD in older adults hospitalised with orthopaedic complaints.

METHODS

A literature search of Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL), EMBASE, CINAHL and MEDLINE in EBSCO was carried out on January 10th, 2024. Randomised controlled trials or quasi-randomised controlled trials were the study designs included. For quality assessment, The Cochrane Risk of Bias Tool 2.0 was used and GRADE was applied to evaluate the certainty of evidence. Acute hospital length of stay was the primary outcome. Secondary outcomes included the numbers of fallers and function. A pooled meta-analysis was conducted using RevMan software 5.4.1.

RESULTS

Seven studies with a population of older adults post orthopaedic surgery met inclusion criteria, with five studies included in the meta-analysis. Study quality was predominantly of a high risk of bias. Statistically significant effects favouring ESD interventions were only seen in terms of length of stay (FEM, MD = -5.57, 95% CI -7.07 to -4.08, I2 = 0%). No statistically significant effects favouring ESD interventions were established in secondary outcomes.

CONCLUSION

In the older adult population with orthopaedic complaints, ESD can have a statistically significant impact in reducing hospital length of stay. This review identifies an insufficient existing evidence base to establish the key benefits of ESD for this population group. There is a need for further higher quality research in the area, with standardised interventions and outcome measures used.

Cost modelling rehabilitation in the home for reconditioning in the Australian context

BACKGROUND

Inpatient rehabilitation services are challenged by increasing demand. Where appropriate, a shift in service models towards more community-oriented approaches may improve efficiency. We aimed to estimate the hypothetical cost of delivering a consensus-based rehabilitation in the home (RITH) model as hospital substitution for patients requiring reconditioning following medical illness, surgery or treatment for cancer, compared to the cost of inpatient rehabilitation.

METHODS

Data were drawn from the following sources: the results of a Delphi survey with health professionals working in the field of rehabilitation in Australia; publicly available data and reports; and the expert opinion of the project team. Delphi survey data were analysed descriptively. The costing model was developed using assumptions based on the sources described above and was restricted to the Australian National Subacute and Non-Acute Patient Classification (AN-SNAP) classes 4AR1 to 4AR4, which comprise around 73% of all reconditioning episodes in Australia. RITH cost modelling estimates were compared to the known cost of inpatient rehabilitation. Where weighted averages are provided, these were determined based on the modelled number of inpatient reconditioning episodes per annum that might be substitutable by RITH.

RESULTS

The cost modelling estimated the weighted average cost of a RITH reconditioning episode (which mirrors an inpatient reconditioning episode in intensity and duration) for AN-SNAP classes 4AR1 to 4AR4, to be A$11,371, which is 28.1% less than the equivalent weighted average public inpatient cost (of A$15,820). This represents hypothetical savings of A$4,449 per RITH reconditioning substituted episode of care.

CONCLUSIONS

The hypothetical cost of a model of RITH which would provide patients with as comprehensive a rehabilitation service as received in inpatient rehabilitation, has been determined. Findings suggest potential cost savings to the public hospital sector. Future research should focus on trials which compare actual clinical and cost outcomes of RITH for patients in the reconditioning impairment category, to inpatient rehabilitation.

The Effects of COVID-19 Pandemic on the Recovery of Hip Fracture Patients

Purpose

To figure out how complete control of family visits to prevent infection of coronavirus disease 2019 (COVID-19) affected the activity recovery of hip fracture patients admitted to nursing hospitals.

Materials and Methods

Eighty-one patients with hip surgery in the two years prior to COVID-19 pandemic were classified as Group A, and 103 patients in the next two years were designated as Group B. The subjects' walking ability was evaluated by using the modified Koval index (MKI). In order to analyze the impact of the family visit control to the subjects, each group was classified into two different groups: (1) inpatients group who admitted to nursing hospitals and (2) home-treated patients. Additionally, statistical elements were processed in consideration of other factors that may affect the results of the experiment.

Results

The MKI evaluated at 6 months postoperative was 3.31±1.79 in Group A and 2.77±1.91 in Group B, and it was meaningfully low after the pandemic (P=0.04). There was significantly low among both of Group A 2.74±1.76 and Group B 1.93±1.81 after the pandemic (P=0.03) among those treated at the nursing hospital. The rate of deterioration of the MKI was 35 (43.2%) in Group A and 57 (55.3%) in Group B, which increased by 12.1% after the pandemic.

Conclusion

The pandemic had a negative effect on the recovery of postoperative activities of elderly hip fracture patients who admitted to nursing hospitals when family access was completely restricted to prevent infection.

Post-surgery interventions for hip fracture: a systematic review of randomized controlled trials

BACKGROUND

Interventions provided after hip fracture surgery have been shown to reduce mortality and improve functional outcomes. While some systematic studies have evaluated the efficacy of post-surgery interventions, there lacks a systematically rigorous examination of all the post-surgery interventions which allows healthcare providers to easily identify post-operative interventions most pertinent to patient's recovery.

OBJECTIVES

We aim to provide an overview of the available evidence on post-surgery interventions provided in the acute, subacute and community settings to improve outcomes for patients with hip fractures.

METHODS

We performed a systematic literature review guided by the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA). We included articles that were (1) randomized controlled trials (RCTs), (2) involved post-surgery interventions that were conducted in the acute, subacute or community settings and (3) conducted among older patients above 65 years old with any type of non-pathological hip fracture that was surgically treated, and who were able to walk without assistance prior to the fracture. We excluded (1) non-English language articles, (2) abstract-only publications, (3) articles with only surgical interventions, (4) articles with interventions that commenced pre-surgery or immediately upon completion of surgery or blood transfusion, (5) animal studies. Due to the large number of RCTs identified, we only included "good quality" RCTs with Jadad score ≥ 3 for data extraction and synthesis.

RESULTS

Our literature search has identified 109 good quality RCTs on post-surgery interventions for patients with fragility hip fractures. Among the 109 RCTs, 63% of the identified RCTs (n = 69) were related to rehabilitation or medication/nutrition supplementation, with the remaining RCTs focusing on osteoporosis management, optimization of clinical management, prevention of venous thromboembolism, fall prevention, multidisciplinary approaches, discharge support, management of post-operative anemia as well as group learning and motivational interviewing. For the interventions conducted in inpatient and outpatient settings investigating medication/nutrition supplementation, all reported improvement in outcomes (ranging from reduced postoperative complications, reduced length of hospital stay, improved functional recovery, reduced mortality rate, improved bone mineral density and reduced falls), except for a study investigating anabolic steroids. RCTs involving post-discharge osteoporosis care management generally reported improved osteoporosis management except for a RCT investigating multidisciplinary post-fracture clinic led by geriatrician with physiotherapist and occupational therapist. The trials investigating group learning and motivational interviewing also reported positive outcome respectively. The other interventions yielded mixed results. The interventions in this review had minor or no side effects reported.

CONCLUSIONS

The identified RCTs regarding post-surgery interventions were heterogeneous in terms of type of interventions, settings and outcome measures. Combining interventions across inpatient and outpatient settings may be able to achieve better outcomes such as improved physical function recovery and improved nutritional status recovery. For example, nutritional supplementation could be made available for patients who have undergone hip fracture surgery in the inpatient settings, followed by post-discharge outpatient osteoporosis care management. The findings from this review can aid in clinical practice by allowing formulation of thematic program with combination of interventions as part of bundled care to improve outcome for patients who have undergone hip fracture surgery.

Development and validation of a novel nomogram of 1-year mortality in the elderly with hip fracture: a study of the MIMIC-III database

OBJECTIVE

Hip fracture is a prevalent condition with a significant death rate among the elderly. We sought to develop a nomogram-based survival prediction model for older patients with hip fracture.

DESIGN

A retrospective case-control study.

SETTING

The data from Medical Information Mart for Intensive Care III (MIMIC-III V.1.4).

PARTICIPANTS

The clinical features of elderly patients with hip fracture, including basic information, comorbidities, severity score, laboratory tests and therapy, were filtered out based on the MIMIC-III V.1.4.

METHODS AND MAIN OUTCOME MEASURES

All patients included in the study were from critical care and randomly divided into training and validation sets (7:3). On the basis of retrieved data, the least absolute shrinkage and selection operator (LASSO) regression and multiple logistic regression analysis were used to identify independent predictive variables of 1-year mortality, and then constructed a risk prediction nomogram. The predictive values of the nomogram model were evaluated by the concordance indexes (C-indexes), receiver operating characteristic curve, decision curve analysis (DCA) and calibration curve.

RESULTS

A total of 341 elderly patients with hip fracture were included in this study; 121 cases died within 1 year. After LASSO regression and multiple logistic regression analysis, a novel nomogram contained the predictive variables of age, weight, the proportion of lymphocyte count, liver disease, malignant tumour and congestive heart failure. The constructed model proved satisfactory discrimination with C-indexes of 0.738 (95% CI 0.674 to 0.802) in the training set and 0.713 (95% CI 0.608 to 0.819) in the validation set. The calibration curve shows a good degree of fitting between the predicted and observed probabilities and the DCA confirms the model's clinical practicability.

CONCLUSIONS

The novel prediction model provides personalised predictions for 1-year mortality in elderly patients with hip fractures. Compared with other hip fracture models, our nomogram is particularly suitable for predicting long-term mortality in critical patients.

Post hip fracture orthogeriatric care-a Canadian position paper addressing challenges in care and strategies to meet quality indicators

INTRODUCTION

Osteoporosis is a major disease state associated with significant morbidity, mortality, and health care costs. Less than half of the individuals sustaining a low energy hip fracture are diagnosed and treated for the underlying osteoporosis.

OBJECTIVE

A multidisciplinary Canadian hip fracture working group has developed practical recommendations to meet Canadian quality indicators in post hip fracture care.

METHODS

A comprehensive narrative review was conducted to identify and synthesize key articles on post hip fracture orthogeriatric care for each of the individual sections and develop recommendations. These recommendations are based on the best evidence available today.

CONCLUSION

Recommendations are anticipated to reduce recurrent fractures, improve mobility and healthcare outcomes post hip fracture, and reduce healthcare costs. Key messages to enhance postoperative care are also provided.

Association of depressive disorders and dementia with mortality among older people with hip fracture

BACKGROUND

Hip fracture (HF) is a significant cause of mortality among older people. Almost half of the patients with HF have dementia, which increases the mortality risk further. Cognitive impairment is associated with depressive disorders (DDs) and both dementia and DDs are independent risk factors for poor outcome after HF. However, most studies that evaluate mortality risk after HF separate these conditions.

AIMS

To investigate whether dementia with depressive disorders (DDwD) affects the mortality risk at 12, 24, and 36 months after HF among older people.

METHODS

Patients with acute HF (n = 404) were included in this retrospective analysis of two randomized controlled trials performed in orthopedic and geriatric departments. Depressive symptoms were assessed using the Geriatric Depression Scale and cognitive function was assessed using the Mini-Mental State Examination. A consultant geriatrician made final depressive disorder and dementia diagnoses using the Diagnostic and Statistical Manual of Mental Disorders criteria, with support from assessments and medical records. The 12-, 24- and 36-month mortality after HF was analyzed using logistic regression models adjusted for covariates.

RESULTS

In analyses adjusted for age, sex, comorbidity, pre-fracture walking ability, and fracture type, patients with DDwD had increased mortality risks at 12 [odds ratio (OR) 4.67, 95% confidence interval (CI) 1.75-12.51], 24 (OR 3.61, 95% CI 1.71-7.60), and 36 (OR 4.53, 95% CI 2.24-9.14) months. Similar results were obtained for patients with dementia, but not depressive disorders, alone.

CONCLUSION

DDwD is an important risk factor for increased mortality at 12, 24, and 36 months after HF among older people. Routinely assessments after HF for cognitive- and depressive disorders could identify patients at risk for increased mortality, and enable early interventions.

TRIAL REGISTRATION

RCT2: International Standard Randomized Controlled Trial Number Register, trial registration number: ISRCTN15738119.

Developing a model for rehabilitation in the home as hospital substitution for patients requiring reconditioning: a Delphi survey in Australia

BACKGROUND

Reconditioning for patients who have experienced functional decline following medical illness, surgery or treatment for cancer accounts for approximately 26% of all reported inpatient rehabilitation episodes in Australia. Rehabilitation in the home (RITH) has the potential to offer a cost-effective, high-quality alternative for appropriate patients, helping to reduce pressure on the acute care sector. This study sought to gain consensus on a model for RITH as hospital substitution for patients requiring reconditioning.

METHODS

A multidisciplinary group of health professionals working in the rehabilitation field was identified from across Australia and invited to participate in a three-round online Delphi survey. Survey items followed the patient journey, and also included items on practitioner roles, clinical governance, and budgetary considerations. Survey items mostly comprised statements seeking agreement on 5-point Likert scales (strongly agree to strongly disagree). Free text boxes allowed participants to qualify item answers or make comments. Analysis of quantitative data used descriptive statistics; qualitative data informed question content in subsequent survey rounds or were used in understanding item responses.

RESULTS

One-hundred and ninety-eight health professionals received an invitation to participate. Of these, 131/198 (66%) completed round 1, 101/131 (77%) completed round 2, and 78/101 (77%) completed round 3. Consensus (defined as ≥ 70% agreement or disagreement) was achieved on over 130 statements. These related to the RITH patient journey (including patient assessment and development of the care plan, case management and program provision, and patient and program outcomes); clinical governance and budgetary considerations; and included items for initial patient screening, patient eligibility and case manager roles. A consensus-based model for RITH was developed, comprising five key steps and the actions within each.

CONCLUSIONS

Strong support amongst survey participants was found for RITH as hospital substitution to be widely available for appropriate patients needing reconditioning. Supportive legislative and payment systems, mechanisms that allow for the integration of primary care, and appropriate clinical governance frameworks for RITH are required, if broad implementation is to be achieved. Studies comparing clinical outcomes and cost-benefit of RITH to inpatient rehabilitation for patients requiring reconditioning are also needed.

Effectiveness of outpatient geriatric rehabilitation after inpatient geriatric rehabilitation or hospitalisation: a systematic review and meta-analysis

BACKGROUND

Due to the increasing number of older people with multi-morbidity, the demand for outpatient geriatric rehabilitation (OGR) will also increase.

OBJECTIVE

To assess the effects of OGR on the primary outcome functional performance (FP) and secondary outcomes: length of in-patient stay, re-admission rate, patients' and caregivers' quality of life, mortality and cost-effectiveness. We also aim to describe the organisation and content of OGR.

METHODS

Systematic review and meta-analysis. Five databases were queried from inception to July 2022. We selected randomised controlled trials written in English, focusing on multidisciplinary interventions related to OGR, included participants aged ≥65 and reported one of the main outcomes. A meta-analysis was performed on FP, patients' quality of life, length of stay and re-admissions. The structural, procedural and environmental aspects of OGR were systematically mapped.

RESULTS

We selected 24 studies involving 3,405 participants. The meta-analysis showed no significant effect on the primary outcome FP (activity). It demonstrated a significant effect of OGR on shortening length of in-patient stay (P = 0.03, MD = -2.41 days, 95%CI: [-4.61-0.22]). Frequently used elements of OGR are: inpatient start of OGR with an interdisciplinary rehabilitation team, close cooperation with primary care, an OGR coordinator, individual goal setting and education for both patient and caregiver.

CONCLUSION

This review showed that OGR is as effective as usual care on FP activity. It shows low certainty of evidence for OGR being effective in reducing the length of inpatient stay. Further research is needed on the various frequently used elements of OGR.

The Femoral Nerve Block Setting the Agenda for Nursing Care of Older Patients With hip Fractures-A Qualitative Study

Introduction

Hip fractures among older people are common worldwide, and it is often associated with preoperative pain. Due to increased comorbidity and high age, traditional pain relief can be a challenge. An alternative to traditional pain relief is a femoral nerve block, which is safe and suitable for anesthesia and analgesia for hip fractures among patients with or without dementia. It is essential to provide adequate pain management, and nurses report negative attitudes toward opioids and seem to prefer alternative pain management. To our knowledge, no study has focused on staff's experiences of nursing care for patients treated with femoral nerve block.

Aim

To describe staff's experiences providing nursing care in preoperative pain and pain management to older patients with a hip fracture who received a femoral nerve block.

Design

A qualitative exploratory design.

Method

Semistructured interviews with 19 nurses or assistant nurses in an orthopedic ward or emergency department. They were experienced in caring for patients with hip fractures who received treatment with a femoral nerve block. The interviews were subjected to qualitative content analysis.

Results

Staff described the femoral nerve block as setting the agenda when caring for older patients with hip fractures in the preoperative phase. The outcome of the femoral nerve block affected nursing care, depending on if the femoral nerve block was successful or not. Nursing care requires timing, with a need for staff orienting to time and customizing their communication. Further, staff faced ethical challenges regarding doing good and not harm, relieving pain, and avoiding side effects.

Conclusions

The femoral nerve block was an important issue for nursing staff in patients with hip fractures in the preoperative phase. Our results point toward the benefits of giving femoral nerve blocks as soon as possible to facilitate nursing care, however, this should be studied in future research.

Effectiveness of multicomponent home-based rehabilitation in older patients after hip fracture surgery: A systematic review and meta-analysis

BACKGROUND

Hip fracture is a major burden on health care systems worldwide and requires hospitalisation for a long period.

OBJECTIVE

The aim was to evaluate the effectiveness of multicomponent home-based rehabilitation compared with different control interventions (in-hospital rehabilitation, active control or usual care) in older patients after hip fracture surgery.

DESIGN

Systematic review and meta-analysis of randomised controlled studies.

DATA SOURCES

We searched three electronic databases, including Ovid-MEDLINE, Ovid-Embase, CINAHL and the Cochrane Library for relevant articles up to March 2020.

REVIEW METHODS

Two investigators independently extracted data and assessed study quality using the risk of bias. Data were analysed using Review Manager 5.3. The current review employs the PRISMA procedure.

RESULTS

Out of 2996 studies, 22 articles were relevant for this review and meta-analysis. Among them, five compared the multicomponent home-based rehabilitation with in-hospital rehabilitation, one compared it with active control, six with usual care and ten compared the home exercise only with usual care. There was no significant difference in activities of daily living (ADL) between multicomponent home-based rehabilitation and in-hospital rehabilitation, while multicomponent home-based rehabilitation significantly increased in ADL when compared to usual care. Home exercises also had significant effects on ADL, quality of life(QoL), balance, gait and muscle strength of the knee extensor compared with usual care (p < .05).

CONCLUSIONS

Multicomponent home-based rehabilitation is comparable to in-hospital rehabilitation regarding improvements in muscle strength, gait speed, balance, ADL and QoL.

RELEVANT TO CLINICAL PRACTICE

Multicomponent home-based rehabilitation is comparable to in-hospital rehabilitation regarding improvements in muscle strength, gait speed, balance, ADL and QoL. Also, high adherence to home exercise may be associated with better clinical outcomes. Therefore, more compliance-oriented multicomponent home-based rehabilitation programmes for older patients after hip fracture must be developed by health care professionals, including physical therapist, to ensure optimum home-based rehabilitation.

Delphi-Based Consensus to Determine Core Aspects of Post-Hip-Fracture Surgery Rehabilitation Based on the International Classification of Functioning, Disability, and Health

A hip fracture is a major adverse event for older individuals that has extremely high rates of mortality and morbidity, specifically functional decline. Thus, effective post-hip fracture rehabilitation is crucial to enable patients to regain function and improve their quality of life. Most post-hip fracture rehabilitation programs focus only on physical functioning, but rehabilitation goals related to the quality of life, social participation, and environmental issues are also crucial considerations. This study aimed to develop a core set of considerations based on the International Classification of Functioning, Disability, and Health (ICF) for use as a reference in designing comprehensive rehabilitation programs for patients with hip fractures. For this purpose, we recruited 20 experts from related fields working at a university hospital to complete a three-round Delphi-based questionnaire. Before beginning this process, a literature review related to ICF category selection was conducted. Next, a 5-point Likert scale was employed to rate the importance of each proposed category, and Spearman's rank correlation coefficient and semi-interquartile range indices were analyzed to rate the consensus status. Categories for the ICF core set of considerations for post-hip-fracture rehabilitation were chosen on the basis of a high level of consensus and a mean score of ≥4.5 in the third Delphi-based questionnaire round. After selection, the ICF core set comprised 34 categories, namely 15 for bodily functions, 5 for bodily structures, 13 for activities and participation, and 1 for environmental factors. The proposed post-hip-fracture rehabilitation ICF core set can serve as a reference for developing effective rehabilitation strategies and goal setting by interdisciplinary teams. However, further feasibility evaluation is recommended for individualized rehabilitation program design.

Interventions for improving mobility after hip fracture surgery in adults

BACKGROUND

Improving mobility outcomes after hip fracture is key to recovery. Possible strategies include gait training, exercise and muscle stimulation. This is an update of a Cochrane Review last published in 2011.

OBJECTIVES

To evaluate the effects (benefits and harms) of interventions aimed at improving mobility and physical functioning after hip fracture surgery in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, trial registers and reference lists, to March 2021.

SELECTION CRITERIA

All randomised or quasi-randomised trials assessing mobility strategies after hip fracture surgery. Eligible strategies aimed to improve mobility and included care programmes, exercise (gait, balance and functional training, resistance/strength training, endurance, flexibility, three-dimensional (3D) exercise and general physical activity) or muscle stimulation. Intervention was compared with usual care (in-hospital) or with usual care, no intervention, sham exercise or social visit (post-hospital).

DATA COLLECTION AND ANALYSIS

Members of the review author team independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We used the assessment time point closest to four months for in-hospital studies, and the time point closest to the end of the intervention for post-hospital studies. Critical outcomes were mobility, walking speed, functioning, health-related quality of life, mortality, adverse effects and return to living at pre-fracture residence.

MAIN RESULTS

We included 40 randomised controlled trials (RCTs) with 4059 participants from 17 countries. On average, participants were 80 years old and 80% were women. The median number of study participants was 81 and all trials had unclear or high risk of bias for one or more domains. Most trials excluded people with cognitive impairment (70%), immobility and/or medical conditions affecting mobility (72%). In-hospital setting, mobility strategy versus control Eighteen trials (1433 participants) compared mobility strategies with control (usual care) in hospitals. Overall, such strategies may lead to a moderate, clinically-meaningful increase in mobility (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.10 to 0.96; 7 studies, 507 participants; low-certainty evidence) and a small, clinically meaningful improvement in walking speed (CI crosses zero so does not rule out a lack of effect (SMD 0.16, 95% CI -0.05 to 0.37; 6 studies, 360 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to short-term (risk ratio (RR) 1.06, 95% CI 0.48 to 2.30; 6 studies, 489 participants; low-certainty evidence) or long-term mortality (RR 1.22, 95% CI 0.48 to 3.12; 2 studies, 133 participants; low-certainty evidence), adverse events measured by hospital re-admission (RR 0.70, 95% CI 0.44 to 1.11; 4 studies, 322 participants; low-certainty evidence), or return to pre-fracture residence (RR 1.07, 95% CI 0.73 to 1.56; 2 studies, 240 participants; low-certainty evidence). We are uncertain whether mobility strategies improve functioning or health-related quality of life as the certainty of evidence was very low. Gait, balance and functional training probably causes a moderate improvement in mobility (SMD 0.57, 95% CI 0.07 to 1.06; 6 studies, 463 participants; moderate-certainty evidence). There was little or no difference in effects on mobility for resistance training. No studies of other types of exercise or electrical stimulation reported mobility outcomes. Post-hospital setting, mobility strategy versus control Twenty-two trials (2626 participants) compared mobility strategies with control (usual care, no intervention, sham exercise or social visit) in the post-hospital setting. Mobility strategies lead to a small, clinically meaningful increase in mobility (SMD 0.32, 95% CI 0.11 to 0.54; 7 studies, 761 participants; high-certainty evidence) and a small, clinically meaningful improvement in walking speed compared to control (SMD 0.16, 95% CI 0.04 to 0.29; 14 studies, 1067 participants; high-certainty evidence). Mobility strategies lead to a small, non-clinically meaningful increase in functioning (SMD 0.23, 95% CI 0.10 to 0.36; 9 studies, 936 participants; high-certainty evidence), and probably lead to a slight increase in quality of life that may not be clinically meaningful (SMD 0.14, 95% CI -0.00 to 0.29; 10 studies, 785 participants; moderate-certainty evidence). Mobility strategies probably make little or no difference to short-term mortality (RR 1.01, 95% CI 0.49 to 2.06; 8 studies, 737 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to long-term mortality (RR 0.73, 95% CI 0.39 to 1.37; 4 studies, 588 participants; low-certainty evidence) or adverse events measured by hospital re-admission (95% CI includes a large reduction and large increase, RR 0.86, 95% CI 0.52 to 1.42; 2 studies, 206 participants; low-certainty evidence). Training involving gait, balance and functional exercise leads to a small, clinically meaningful increase in mobility (SMD 0.20, 95% CI 0.05 to 0.36; 5 studies, 621 participants; high-certainty evidence), while training classified as being primarily resistance or strength exercise may lead to a clinically meaningful increase in mobility measured using distance walked in six minutes (mean difference (MD) 55.65, 95% CI 28.58 to 82.72; 3 studies, 198 participants; low-certainty evidence). Training involving multiple intervention components probably leads to a substantial, clinically meaningful increase in mobility (SMD 0.94, 95% CI 0.53 to 1.34; 2 studies, 104 participants; moderate-certainty evidence). We are uncertain of the effect of aerobic training on mobility (very low-certainty evidence). No studies of other types of exercise or electrical stimulation reported mobility outcomes.

AUTHORS' CONCLUSIONS

Interventions targeting improvement in mobility after hip fracture may cause clinically meaningful improvement in mobility and walking speed in hospital and post-hospital settings, compared with conventional care. Interventions that include training of gait, balance and functional tasks are particularly effective. There was little or no between-group difference in the number of adverse events reported. Future trials should include long-term follow-up and economic outcomes, determine the relative impact of different types of exercise and establish effectiveness in emerging economies.

Effects of transitional care based on the social support theory for older patients with osteoporotic vertebral compression fractures: A quasi-experimental trial

OBJECTIVES

This study aimed to investigate the effects of transitional care (TC) programs on the health outcomes of discharged older patients with osteoporotic vertebral compression fractures (OVCFs).

METHODS

A total of 160 older patients were recruited from two campuses of a public teaching hospital in China. Patients were grouped according to the campus to which they were admitted. The TC programs commenced one day before discharge and lasted 6 months after discharge. Repeated-measures analysis of variance was used to analyse the effects of the TC programs.

RESULTS

The TC programs improved the discharge of older patients with OVCF in their activities of daily living (ADLs), pain levels and social support, and decreased fracture recurrence rates.

CONCLUSIONS

This study provides evidence of concurrent clinical improvements and health outcomes in discharged older patients with OVCFs from the effects of TC programs based on social support theory.

Rehabilitation interventions for persons with hip fracture and cognitive impairment: A scoping review

Background

Hip fractures are common fall-related injuries, with rehabilitation and recovery often complicated by cognitive impairment. Understanding what interventions exist, and in what settings, for people with hip fracture and co-occurring cognitive impairment is important in order to provide more evidence on rehabilitation and related outcomes for this population.

Objective

To examine the extent, nature, and range of literature on rehabilitation interventions for adults with hip fracture and cognitive impairment.

Methods

Articles were required to: include an adult population with hip fracture and cognitive impairment, include a rehabilitation intervention, and be published between January 1, 2000 and November 19, 2021. Articles were excluded if they were opinion pieces, study protocols, conference abstracts, or if they did not describe the rehabilitation intervention. Relevant articles were searched on the following electronic databases: MEDLINE, EMBASE, CINAHL Plus, APA PsycINFO, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database. All articles were double-screened by two reviewers and disagreements were resolved through consensus. Data were extracted and synthesized using descriptive approaches.

Results

Seventeen articles were included in this scoping review. We identified a variety of interventions targeting this population; about half were specific to physical rehabilitation, with the other half incorporating components that addressed multiple aspects of the care journey. Interventions had varying outcomes and no studies qualitatively explored patient or family experiences. All intervations were initiated in hospital, with less than half including cross-sectoral components. About half of the articles described modifying or tailoring the intervention to the participants’ needs, but there was limited information on how to adapt rehabilitation interventions for individuals with cognitive impairment.

Conclusions

More work is need to better understand patient, family, and provider experiences with rehabilitation interventions, how to tailor interventions for those with cognitive impairment, and how to successfully implement sustainable interventions across sectors.

A National Analysis of Discharge Disposition in Older Adults with Burns—Estimating the Likelihood of Independence at Discharge

Whereas older age predicts higher burn mortality, the impact of age on discharge disposition is less well defined in older adults with burns. This investigation assesses the relationship between older age and discharge disposition after burns in a nationally representative sample. We queried the 2007-2015 National Trauma Data Bank for non-fatal burn hospitalizations in older adults. Pre-defined age categories were 55-64 years (working-age comparison group), 65-74 years (young-old), 75-84 years (middle-old), and 85+ years (old-old). Covariables included inhalation injury, comorbidities, burn total body surface area, injury mechanism, and race/ethnicity. Discharge to non-independent living (nursing home, rehabilitation, and other facilities) was the primary outcome. Logistic regression assessed the association between older age and discharge to non-independent living. There were 25,840 non-fatal burn hospitalizations in older adults during the study period. Working-age encounters comprised 53% of admissions, young-old accounted for 28%, middle-old comprised 15% and old-old comprised 4%. Discharge to non-independent living increased with burn TBSA and older age in survivors. Starting in young-old, the majority (65 %) of patients with burns ≥20% TBSA were discharged to non-independent living. Adjusted odd ratios for discharge to non-independent living were 2.0 for young-old, 3.3 for middle-old and 5.6 for old-old patients, when compared to working-age patients (all p&lt;0.001). Older age strongly predicts non-independent discharge after acute burn hospitalization. Matrix analysis of discharge disposition indicates a stepwise rise in discharge to non-independent living with higher age and TBSA, providing a realistic discharge framework for treatment decisions and expectations about achieving independent living after burn hospitalization.

The Impact of COVID-19 on SARSCoV-2-Negative Elderly Patients with Hip Fractures: A Single-Center Retrospective Study from Shanghai, China

Purpose

Coronavirus disease 2019 (COVID-19) has brought an unprecedented change in wellbeing globally. The spread of the pandemic reportedly reduced the incidence of activity-related trauma, while that of fragility fractures remained stable. Here, we aimed to identify the risk factors associated with the prognosis of SARS-CoV-2 negative elderly patients with hip fractures.

Patients and Methods

This retrospective study included elderly patients with hip fractures between 1st January and 9th May during the COVID-19 pandemic (Experiment group) and the same period from 2017 to 2019 (Control group). Perioperative mortality, complications, and functional recovery were compared between two groups of different time frame in the total cohort and patients who received surgical treatment. Multiple linear regression was carried out to identify the risk factors influencing the prognosis of COVID-negative elderly patients with hip fractures.

Results

The proportion of patients with admission time less than 24 hours and the 6-month postoperative Parker score were significantly decreased during COVID-19 compared with the pre-COVID-19 period (p < 0.001). Multiple linear regression demonstrated that TTA (defined as time from injury to admission), rehabilitation after discharge and outpatient follow-up were associated with the 6-month Parker score in the total population (p < 0.001) and in patients who received surgical treatment (p < 0.001).

Conclusion

Elderly patients with hip fractures had a poorer prognosis in epidemic period despite being COVID-19 negative. Factors including timely admission, postoperative follow-up, and rehabilitation could optimize safety and significantly improve the prognosis of elderly COVID-19 negative patients with hip fractures, even during a pandemic.

Older adults' perspectives on rehabilitation and recovery one year after a hip fracture - a qualitative study

Background

In order to improve quality of care and recovery after hip fracture we need to include the perspectives of the individual older adults when evaluating different rehabilitation interventions. The aim of this study was therefore to explore older adults’ experiences of their rehabilitation after a hip fracture and of the recovery process during the 12 months following the fracture.

Methods

Qualitative interviews were conducted with 20 older adults (70–91 years of age) who had participated in a randomised controlled trial evaluating the effects of early discharge followed by geriatric interdisciplinary home rehabilitation compared to in-hospital care according to a multifactorial rehabilitation program. Ten participants from each group were interviewed shortly after the one-year follow-up when the study was completed. Data were analysed with qualitative content analysis.

Results

The analysis resulted in four themes: Moving towards recovery with the help of others; Getting to know a new me; Striving for independence despite obstacles; and Adapting to an altered but acceptable life. The participants emphasised the importance of having access to rehabilitation that was provided by skilled staff, and support from family members and friends for well-being and recovery. They experienced a change in their self-image but strove for independence despite struggling with complications and functional limitations and used adaptive strategies to find contentment in their lives.

Conclusions

Rehabilitation interventions provided by competent health care professionals, as well as support from family members and friends, were emphasised as crucial for satisfactory recovery. Participants’ experiences further highlight the importance of targeting both physical and psychological impacts after a hip fracture. To improve recovery, rehabilitation providers should customise future interventions to suit each individual´s wishes and needs and provide rehabilitation in various settings throughout the recovery process.

Trial registration

The trial is registered at Current Controlled Trials Ltd, ICRCTN 15738119. Date of registration 16/06/2008, retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03119-y.

Effectiveness of Multicomponent Home-Based Rehabilitation in Elderly Patients after Hip Fracture Surgery: A Randomized Controlled Trial

This randomized controlled study aimed to assess the clinical effectiveness of an 8-week personalized multicomponent home-based rehabilitation (MHR) program by comparing it with a home exercise program after discharge. Forty patients (≥60 years old) who underwent hip surgery were randomly assigned to multicomponent home-based rehabilitation (MHR) and home exercise groups. The MHR program included strength, endurance, balance, and breathing exercises; modifications to the home environment; education on assistive device use; pressure ulcer care; nutrition management; and motivational counseling. The MHR group received 24 visits from rehabilitation staff for 8 weeks (3 times a week), while the home exercise group received home exercises focusing on strengthening described in the leaflet. The rehabilitation staff prescribed the intensity of exercise at the first visit, and the home exercise group exercised without supervision after that for 8 weeks. Both groups received a 10-min phone call once a week for overall counseling to ensure high adherence to home exercises. Among the 40 participants, 29 (72.5%) completed the trial. The primary outcomes were balance and mobility. Balance was assessed using the functional reach test (FRT), and the timed up-and-go test (TUG) was used to assess balance and mobility. Data were analyzed using the intention-to-treat principle. The MHR group showed significant improvement compared to the home exercise group for FRT (mean difference (MD) 4.4 cm; 95% confidence interval (CI) 1.0 to 7.8) and TUG (MD: −4.2 s; 95% CI −8.0 to −0.3) after 8 weeks of intervention. Subjective pain and physical components of general health-related quality of life also improved significantly in the MHR group. No serious adverse events related to the interventions were observed. The eight-week of MHR program can effectively improve balance and mobility.

Morbidity and Mortality After Second Hip Fracture With and Without Nursing Care Program

Background

Hip fractures are an increasingly common injury among older people who usually experience significantly worse mobility, independence in function, health, quality of life, and high rates of institutionalization. Studies have shown that only 40-60% of participants recover their pre-fracture level of mobility and ability to perform instrumental activities of daily living, while for those who are independent in self-care prior to the fracture, 20-60% still require assistance for various tasks one or two years after the fracture. As the cumulative incidence of a second hip fracture has been estimated to reach 8.4%, prevention of the second hip fracture is a major concern of the health system and the society focused mainly on lifestyle modifications, osteoporotic treatment, and fall-prevention strategies. The aim of the present study was to compare morbidity/mortality, functional results, and type of recovery between the first and second hip fractures in elderly patients.

Methods

Patients with a contralateral hip fracture were prospectively recruited during a three-year period (2016-2019). Level of independence, gait aids, type of rehabilitation, American Society of Anesthesiologists (ASA) physical status, Harris Hip Score (HHS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scale were evaluated at admission for the second fracture and at the last reexamination.

Results

Twenty-seven out of 33 patients, aged 87.93±6.6, underwent surgery for contralateral hip fracture and followed up for 42.52±16.46 months; the mean interval between the two fractures was 39.63 months. The HHS averaged 86.19±12.18 and 59.01±32.83 and the WOMAC 86.37±12.09 and 68.22±26.18 before and after the second fracture, respectively. The mortality rate was 37.03%, 14.8±12.93 months after the second operation, with a significant relationship between the mortality time and the interval between fractures (p=0.028). Twelve and 14 of the patients received geriatric nursing care after the first and second fracture, respectively, without significant improvement in their functional results compared to home care. Mobility of nursing care patients after the second fracture was significantly improved (p=0.019).

Conclusions

Mortality is higher in the second year after the second hip fracture and strongly correlated with the time interval between fractures. A higher possibility to return in previous mobility status occurs after geriatric nursing care. 

Functional status in relation to depression among elderly individuals in Indonesia: a cross-sectional analysis of the Indonesian National Health Survey 2018 among elderly individuals

BACKGROUND

Depression among elderly individuals is related to physical illness, functional status, prolonged treatment and other factors. Depression is not effectively treated with medication but can be alleviated by treating the physical illness and improving functional status. Therefore, this study aims to determine the relationship between functional status and depression in elderly individuals in Indonesia.

METHODS

The data used were obtained from a national survey dataset, namely, the Basic Health Research and Socio-Economic Survey in 2018, which was carried out in 34 provinces and 514 districts or cities. The total number of respondents was 93,829, aged ≥60 years. Functional status and depression were assessed using the Barthel index and MINI (Mini International Neuropsychiatric Interview), respectively. Furthermore, data processing was carried out with the Statistical Package for Social Sciences (SPSS) version 26 program and analyzed using the chi-square test and multiple logistic regression with the complex sample method.

RESULTS

Elderly individuals with severe dependence were at the greatest risk of becoming depressed compared to those without functional impairment or with independence after considering sociodemographic factors and disease history have 5.730 (95% CI = 4.302-7.632) the adj odds. Furthermore, this figure was higher than that of individuals with total dependence have 4.147 (95% CI = 3.231-5.231) the adj odds. The physical illness experienced also played a role in the risk for depression, which was higher among elderly individuals with stroke and a history of injury. The sociodemographic factors involved include low education and economic levels. In contrast, the area of residence and marital status had no statistically significant effect on the relationship between functional disorders and depression.

CONCLUSIONS

Elderly individuals with decreased functional status are prone to depression. The highest probability for depression was observed among those with severe dependence compared to those with total dependence. Consequently, interventions that involve various sectors, including social and family support, are needed.

New-onset depression after hip fracture surgery among older patients: Effects on associated clinical outcomes and what can we do?

BACKGROUND

Hip fracture in the elderly is a worldwide medical problem. New-onset depression after hip fracture has also received attention because of its increasing incidence and negative impact on recovery.

AIM

To provide a synthesis of the literature addressing two very important questions arising from postoperative hip fracture depression (PHFD) research: the risk factors and associated clinical outcomes of PHFD, and the optimal options for intervention in PHFD.

METHODS

We searched the PubMed, Web of Science, EMBASE, and PsycINFO databases for English papers published from 2000 to 2021.

RESULTS

Our results showed that PHFD may result in poor clinical outcomes, such as poor physical function and more medical support. In addition, the risk factors for PHFD were summarized, which made it possible to assess patients preoperatively. Moreover, our work preliminarily suggested that comprehensive care may be the optimal treatment option for PHFDs, while interdisciplinary intervention can also be clinically useful.

CONCLUSION

We suggest that clinicians should assess risk factors for PHFDs preoperatively, and future research should further validate current treatment methods in more countries and regions and explore more advanced solutions.

Multidisciplinary rehabilitation for older people with hip fractures

BACKGROUND

Hip fracture is a major cause of morbidity and mortality in older people, and its impact on society is substantial. After surgery, people require rehabilitation to help them recover. Multidisciplinary rehabilitation is where rehabilitation is delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician. This is an update of a Cochrane Review first published in 2009.

OBJECTIVES

To assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE and Embase (October 2020), and two trials registers (November 2019).

SELECTION CRITERIA

We included randomised and quasi-randomised trials of post-surgical care using multidisciplinary rehabilitation of older people (aged 65 years or over) with hip fracture. The primary outcome - 'poor outcome' - was a composite of mortality and decline in residential status at long-term (generally one year) follow-up. The other 'critical' outcomes were health-related quality of life, mortality, dependency in activities of daily living, mobility, and related pain.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently performed study selection, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome.

MAIN RESULTS

The 28 included trials involved 5351 older (mean ages ranged from 76.5 to 87 years), usually female, participants who had undergone hip fracture surgery. There was substantial clinical heterogeneity in the trial interventions and populations. Most trials had unclear or high risk of bias for one or more items, such as blinding-related performance and detection biases. We summarise the findings for three comparisons below. Inpatient rehabilitation: multidisciplinary rehabilitation versus 'usual care' Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 20 trials. Multidisciplinary rehabilitation probably results in fewer cases of 'poor outcome' (death or deterioration in residential status, generally requiring institutional care) at 6 to 12 months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.80 to 0.98; 13 studies, 3036 participants; moderate-certainty evidence). Based on an illustrative risk of 347 people with hip fracture with poor outcome in 1000 people followed up between 6 and 12 months, this equates to 41 (95% CI 7 to 69) fewer people with poor outcome after multidisciplinary rehabilitation. Expressed in terms of numbers needed to treat for an additional harmful outcome (NNTH), 25 patients (95% CI 15 to 100) would need to be treated to avoid one 'poor outcome'. Subgroup analysis by type of multidisciplinary rehabilitation intervention showed no evidence of subgroup differences. Multidisciplinary rehabilitation may result in fewer deaths in hospital but the confidence interval does not exclude a small increase in the number of deaths (RR 0.77, 95% CI 0.58 to 1.04; 11 studies, 2455 participants; low-certainty evidence). A similar finding applies at 4 to 12 months' follow-up (RR 0.91, 95% CI 0.80 to 1.05; 18 studies, 3973 participants; low-certainty evidence). Multidisciplinary rehabilitation may result in fewer people with poorer mobility at 6 to 12 months' follow-up (RR 0.83, 95% CI 0.71 to 0.98; 5 studies, 1085 participants; low-certainty evidence). Due to very low-certainty evidence, we have little confidence in the findings for marginally better quality of life after multidisciplinary rehabilitation (1 study). The same applies to the mixed findings of some or no difference from multidisciplinary rehabilitation on dependence in activities of daily living at 1 to 4 months' follow-up (measured in various ways by 11 studies), or at 6 to 12 months' follow-up (13 studies). Long-term hip-related pain was not reported. Ambulatory setting: supported discharge and multidisciplinary home rehabilitation versus 'usual care' Three trials tested this comparison in 377 people mainly living at home. Due to very low-certainty evidence, we have very little confidence in the findings of little to no between-group difference in poor outcome (death or move to a higher level of care or inability to walk) at one year (3 studies); quality of life at one year (1 study); in mortality at 4 or 12 months (2 studies); in independence in personal activities of daily living (1 study); in moving permanently to a higher level of care (2 studies) or being unable to walk (2 studies). Long-term hip-related pain was not reported. One trial tested this comparison in 240 nursing home residents. There is low-certainty evidence that there may be no or minimal between-group differences at 12 months in 'poor outcome' defined as dead or unable to walk; or in mortality at 4 months or 12 months. Due to very low-certainty evidence, we have very little confidence in the findings of no between-group differences in dependency at 4 weeks or at 12 months, or in quality of life, inability to walk or pain at 12 months.

AUTHORS' CONCLUSIONS

In a hospital inpatient setting, there is moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of 'poor outcome' (death or deterioration in residential status). There is low-certainty evidence that multidisciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low-certainty evidence that multidisciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. No conclusions can be drawn on other outcomes, for which the evidence is of very low certainty. The generally very low-certainty evidence available for supported discharge and multidisciplinary home rehabilitation means that we are very uncertain whether the findings of little or no difference for all outcomes between the intervention and usual care is true. Given the prevalent clinical emphasis on early discharge, we suggest that research is best orientated towards early supported discharge and identifying the components of multidisciplinary inpatient rehabilitation to optimise patient recovery within hospital and the components of multidisciplinary rehabilitation, including social care, subsequent to hospital discharge.

Analysis of Home-Based Rehabilitation Awareness, Needs and Preferred Components of Elderly Patients with Hip Fracture Surgery in South Korea

The importance and necessity of home-based rehabilitation with professional and systematic interventions should be considered since home-based rehabilitation has been institutionalized as it is more feasible, cost effective, and even safer than in-hospital rehabilitation in most countries—though not in South Korea. In addition, the need for home-based rehabilitation is increasing due to the increasing number of hip fracture patients and limited capacity of acute hospital rehabilitation. Therefore, the purpose of this study was to investigate the awareness, needs, and preferred components of home-based rehabilitation services after discharge for elderly patients with hip fracture surgery in South Korea. A survey of 98 elderly patients who recently underwent hip fracture surgery was performed using a questionnaire. More than 75% of patients agreed on the need for home-based rehabilitation, even though most had never heard of it. The reason for the need for home-based rehabilitation was that it is possible to receive continuously ongoing treatment (53.0%), and it alleviates the inconvenience of visiting hospitals (27.7%). In addition to this, about 15.7% of patients responded that they could achieve mental comfort. In other words, patients can recover in an emotionally stable environment without the psychological anxiety they might experience in hospital. Thus, in order to maximize the effectiveness of home-based rehabilitation and provide comprehensive guidance including exercise, education, motivational support, and environmental modification, to patients undergoing hip fracture surgery, the component of the rehabilitation program must be developed based upon rehabilitation experts’ knowledge and patients’ value. Additionally, corresponding policies should be established.

Physical Therapy Management of Older Adults With Hip Fracture

Hip fracture is a leading cause of profound morbidity in individuals aged 65 years and older, ranking in the top 10 causes of loss of disability-adjusted life-years for older adults. Worldwide, the number of people with hip fracture is expected to rise significantly due to the aging population and other factors. Physical therapist management is recommended within medical, surgical, and multidisciplinary clinical practice guideline (CPGs) and is considered to be the standard of care in rehabilitation for people with hip fracture. The goal of this CPG was to review the evidence relevant to physical therapist management and to provide evidence-based recommendations for physical therapy diagnosis, prognosis, intervention, and assessment of outcome in adults with hip fracture. J Orthop Sports Phys Ther 2021;51(2):CPG1-CPG81. doi:10.2519/jospt.2021.0301.

Effectiveness of community-based rehabilitation interventions incorporating outdoor mobility on ambulatory ability and falls-related self-efficacy after hip fracture: a systematic review and meta-analysis

There is limited evidence from 11 randomised controlled trials on the effect of rehabilitation interventions which incorporate outdoor mobility on ambulatory ability and/or self-efficacy after hip fracture. Outdoor mobility should be central (not peripheral) to future intervention studies targeting improvements in ambulatory ability.

PURPOSE

Determine the extent to which outdoor mobility is incorporated into rehabilitation interventions after hip fracture. Synthesise the evidence for the effectiveness of these interventions on ambulatory ability and falls-related self-efficacy.

METHODS

Systematic search of MEDLINE, Embase, PsychInfo, CINAHL, PEDro and OpenGrey for published and unpublished randomised controlled trials (RCTs) of community-based rehabilitation interventions incorporating outdoor mobility after hip fracture from database inception to January 2021. Exclusion of protocols, pilot/feasibility studies, secondary analyses of RCTs, nonrandomised and non-English language studies. Duplicate screening for eligibility, risk of bias, and data extraction sample. Random effects meta-analysis. Statistical heterogeneity with inconsistency-value (I²).

RESULTS

RCTs (n = 11) provided limited detail on target or achieved outdoor mobility intervention components. There was conflicting evidence from 2 RCTs for the effect on outdoor walking ability at 1-3 months (risk difference 0.19; 95% confidence intervals (CI): 0.21, 0.58; I² = 92%), no effect on walking endurance at intervention end (standardised mean difference 0.05; 95% CI: - 0.26, 0.35; I² = 36%); and suggestive (CI crosses null) of a small effect on self-efficacy at 1-3 months (standardised mean difference 0.25; 95% CI: - 0.29, 0.78; I² = 87%) compared with routine care/sham intervention.

CONCLUSION

It was not possible to attribute any benefit observed to an outdoor mobility intervention component due to poor reporting of target or achieved outdoor mobility and/or quality of the underlying evidence. Given the low proportion of patients recovering outdoor mobility after hip fracture, future research on interventions with outdoor mobility as a central component is warranted.

TRIAL REGISTRATION

PROSPERO registration: CRD42021236541.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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