A multi-component cognitive behavioural intervention for the treatment of fear of falling after hip fracture (FIT-HIP): protocol of a randomised controlled trial

Walking self-confidence and lower levels of anxiety are associated with meeting recommended levels of physical activity after hip fracture: a cross-sectional study

PURPOSE

To explore whether psychological factors are associated with ability to meet recommended physical activity thresholds after hip fracture.

MATERIALS AND METHODS

Cross-sectional observational study of 216 community-dwelling adults aged ≥65 years after hip fracture (mean age 79 SD 7 years, 70% female). Multiple ordinal regression analysis determined factors associated with meeting physical activity thresholds related to positive health outcomes: 4,400 and 7,100 daily steps. Explanatory variables were: walking self-confidence; falls self-efficacy; depression; anxiety; co-morbidities; previous gait aid use; nutritional status; age; and gender.

RESULTS

Forty-three participants (20%) met the lower threshold of ≥4,400 to <7,100 steps and thirty participants (14%) met the upper threshold of ≥7,100 steps. Walking self-confidence was positively associated with meeting higher physical activity thresholds (adjusted odds ratio [AOR] 1.32: 95% CI 1.11 to 1.57, p = 0.002). Age (AOR 0.93: 95% CI 0.89 to 0.98, p = 0.003), DASS-21 anxiety score (AOR 0.81: 95% CI 0.69 to 0.94, p = 0.008) and comorbidity index score (AOR 0.52: 95% CI 0.36 to 0.72, p < 0.001) were negatively associated with meeting higher physical activity thresholds.

CONCLUSION

Walking self-confidence and anxiety are potentially modifiable factors associated with meeting physical activity thresholds related to positive health outcomes after hip fracture.

Physiotherapists' perspectives of barriers and facilitators to effective community provision after hip fracture: a qualitative study in England

PURPOSE

to investigate physiotherapists' perspectives of effective community provision following hip fracture.

METHODS

qualitative semi-structured interviews were conducted with 17 community physiotherapists across England. Thematic analysis drawing on the Theoretical Domains Framework identified barriers and facilitators to implementation of effective provision. Interviews were complemented by process mapping community provision in one London borough, to identify points of care where suggested interventions are in place and/or could be implemented.

RESULTS

four themes were identified: ineffective coordination of care systems, ineffective patient stratification, insufficient staff recruitment and retention approaches and inhibitory fear avoidance behaviours. To enhance care coordination, participants suggested improving access to social services and occupational therapists, maximising multidisciplinary communication through online notation, extended physiotherapy roles, orthopaedic-specific roles and seven-day working. Participants advised the importance of stratifying patients on receipt of referrals, at assessment and into appropriately matched interventions. To mitigate insufficient staff recruitment and retention, participants proposed return-to-practice streams, apprenticeship schemes, university engagement, combined acute-community rotations and improving job description advertisements. To reduce effects of fear avoidance behaviour on rehabilitation, participants proposed the use of patient-specific goals, patient and carer education, staff education in psychological strategies or community psychologist access. Process mapping of one London borough identified points of care where suggested interventions to overcome barriers were in place and/or could be implemented.

CONCLUSION

physiotherapists propose that effective provision of community physiotherapy following hip fracture could be improved by refining care coordination, utilising stratification techniques, employing enhanced recruitment and retainment strategies and addressing fear avoidance behaviours.

Prospective Associations Between Fear of Falling, Anxiety, Depression, and Pain and Functional Outcomes Following Surgery for Intertrochanteric Hip Fracture

Objective

Fear of falling, anxiety, depression, and pain levels are important risk factors for poor functional outcomes that may potentially be modifiable. We aimed to examine prospective associations between those factors following surgery for intertrochanteric hip fracture.

Methods

This study is a prospective observational cohort study of patients aged over 65 diagnosed with isolated intertrochanteric hip fracture. Three hundred and seventy patients who underwent intramedullary fixation surgery were screened; 188 cases were included in our final evaluation. Patients with any concomitant fracture, major psychiatric/neurocognitive and neurological disorders and those with any other major disease were excluded from the study. Age, Charlson Comorbidity Index (CCI), Geriatric Depression Scale (GDS), State-Trait Anxiety Inventory (STAI), Falls Efficacy Scale International (FES-I), and Visual Analog Scale (VAS) scores on the day of surgery (baseline) were evaluated as predictors of poor/good outcome at 90 days after surgery, by Harris Hip Score (HHS) with a cut-off score of 70.

Results

HHS score was significantly predicted at baseline by the full model [χ2 (7) = 18.18, P = .01]. However, only STAI-state scores were significantly added to the model [Exp (B) 95% CI: .92 (.86-.99)].

Conclusions

In this prospective cohort study, we found that higher levels of anxiety state on the day of surgery predicts a poor outcome at 90 days following surgery. We did not find significant associations between other variables, including age, GDS, STAI-trait, FES-I, VAS, and CCI. This potentially modifiable psychological factor may inform surgeons and could be a potential mediator. Future prospective studies are needed to replicate these findings.

Level of evidence

Prognostic level I.

Associating Outcomes After Hip Arthroscopy With Patient Resilience

Background

Higher patient resilience has been shown to be associated with improved patient-reported outcome measures (PROMs) at 6 months after hip arthroscopy.

Purpose

To examine the relationship between patient resilience and PROMs at minimum 2 years after hip arthroscopy.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Included were 89 patients (mean age, 36.9 years; mean follow-up, 4.6 years). Patient demographics, surgical details, and preoperative International Hip Outcome Tool-12 (iHOT-12) and visual analog scale (VAS) pain scores were collected retrospectively. Postoperative variables were collected via a survey and included the Brief Resilience Scale (BRS), Patient Activation Measure-13 (PAM-13), Pain Self-efficacy Questionnaire-2 (PSEQ-2), VAS satisfaction, and postoperative iHOT-12, and VAS pain scores. Based on the number of standard deviations from the mean BRS score, patients were stratified as having low resilience (LR; n = 18), normal resilience (NR; n = 48), and high resilience (HR; n = 23). Differences in PROMs were compared between the groups, and a multivariate regression analysis was performed to assess the relationship between pre- to postoperative change (Δ) in PROMs and patient resilience.

Results

There were significantly more smokers in the LR group compared with the NR and HR groups (P = .033). Compared with the NR and HR groups, patients in the LR group had significantly more labral repairs (P = .006), significantly worse postoperative iHOT-12, VAS pain, VAS satisfaction, PAM-13, and PSEQ-2 scores (P < .001 for all), and significantly lower ΔVAS pain and ΔiHOT-12 scores (P = .01 and .032, respectively). Regression analysis showed significant associations between ΔVAS pain and NR (β = -22.50 [95% CI, -38.81 to -6.19]; P = .008) as well as HR (β = -28.31 [95% CI, -46.96 to -9.67; P = .004) and between ΔiHOT-12 and NR (β = 18.94 [95% CI, 6.33 to 31.55]; P = .004) as well as HR (β = 20.63 [95% CI, 6.21 to 35.05]; P = .006). Male sex was a significant predictor of ΔiHOT-12 (β = -15.05 [95% CI, -25.42 to -4.69]; P = .006).

Conclusion

The study results indicate that lower postoperative resilience scores were associated with significantly worse PROM scores, including pain and satisfaction, at 2 years after hip arthroscopy.

Longitudinal associations of concurrent falls and fear of falling with functional limitations differ by living alone or not

Background

Falls and fear of falling (FOF) are independent risk factors for functional limitations in older adults. However, the combined effect of falls and FOF on functional limitations and the moderating role of living alone or not is unclear. We aimed to examine (1) the independent and combined effect of falls and FOF on functional limitations in older adults and (2) whether living alone moderates these associations.

Methods

We used data from the National Health and Aging Trends Study (NHATS) and included 5,950 U.S. community-dwelling older adults aged 65 and older from Round 1 (Year 2011) and Round 2 (Year 2012). Falls and FOF were ascertained by asking participants whether they had any falls in the last year and whether they had worried about falling in the previous month at R1. Assessed functional limitations included any difficulties with mobility, self-care, or household activities at R2. Poisson regression models were used to examine the longitudinal associations of falls and FOF with functional limitations and the moderation effects of baseline living alone.

Results

Of the 5,950 participants, 16.3% had falls only; 14.3% had FOF only; 14.3% had both, and 55.1% had neither at baseline. In the adjusted model, those who experienced concurrent falls and FOF in R1 had a higher risk of functional limitations at R2 than those with neither (Mobility: Incidence risk ratio [IRR] = 1.34, 95% CI: 1.24-1.45; Self-care: IRR = 1.18, 95% CI: 1.11-1.26; Household: IRR = 1.20, 95% CI: 1.11-1.30). Moreover, living alone significantly moderated the longitudinal associations of concurrent falls and FOF with mobility activity limitations.

Conclusion

The findings suggest that strategies to improve falls and FOF together could potentially help prevent functional limitations. Older adults who live with others and have falls or FOF should receive interventions to promote their mobility activities.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

The role of digital health for post-surgery care of older patients with hip fracture: A scoping review

BACKGROUND

Digital health interventions can potentially improve the integration of the health care systems. Hip fracture is a serious injury for older people and integrated post-surgery care is vital for good recovery.

OBJECTIVE

We aimed to characterise digital health interventions used for hip fracture post-surgery care, and further to examine the extent to which of these interventions address the World Health Organisation (WHO) integrated care for older people (ICOPE) framework.

METHODS

A scoping review was conducted, by searching the literature from English and Chinese databases and trial registries. Keywords included hip fracture, post-surgery care and digital health interventions. Interventional, observational, qualitative studies and case reports were included. We used a combined framework, WHO ICOPE and WHO digital health intervention classifications, to support data synthesis.

RESULTS

A total of 4,542 articles were identified, of which 39 studies were included in the analysis. We identified only six randomised controlled trials. Digital health interventions were mainly used to help doctors provide clinical care and facilitate service delivery between the patients and healthcare providers. No studies focused on health workforce, financial policy or the development of infrastructure. The primary users were healthcare providers and patients, without healthcare managers or the use of data services. Most digital health interventions focused on physical therapy, bone protection and falls prevention. Limited interventions were implemented in low-and middle-income countries.

CONCLUSION

A stronger evidence base is needed to expand the use of digital health for post-surgery care of hip fracture patients, including high-quality larger-scale studies, more focus in resource-constrained settings, expanding to more users and capabilities of interventions, and exploring the role of digital health for the integrated care model to mitigate health system challenges.

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.

An analysis of implementation of evidence-based nursing model in health education for early fracture patients and its therapeutic influences

OBJECTIVE

To investigate the implementation of evidence-based nursing model (EBNM) in health education and its influences on the therapeutic effects, degrees of pain, adverse emotions, postoperative complications and degrees of cognition of health knowledge of elderly fracture patients.

METHODS

A total of 75 elderly patients with hip fractures receiving surgery in the First People's Hospital of Chuzhou from January 2019 to June 2020 were selected as the study subjects, and were divided into control group (n = 37) and experimental group (n = 38) in accordance with random number table method. The control group received conventional health education, while the experimental group received health education intervention based on EBNM. The changes in therapeutic effects, degrees of pain, complications, adverse emotional reactions and degrees of cognition of health knowledge were compared between the two groups.

RESULTS

After intervention, the hospital stay and fracture healing time in the experimental group were shorter than those in the control group (P < 0.05). Compared with those before intervention, the scores of Berg balance scale (BBS) and Fugl-Meyer assessment (FMA) were elevated, while numerical rating scale (NRS) score was decreased remarkably after intervention. After intervention, the experimental group showed remarkably higher scores of BBS and FMA and degrees of cognition of health knowledge and significantly lower scores of NRS and the overall risk of postoperative complications than the control group (P < 0.05). The scores of self-rating depression scale (SDS) and self-rating anxiety scale (SAS) in the two groups decreased after intervention (P < 0.05).

CONCLUSION

Health education intervention based on EBNM can effectively improve patients' understanding of the fracture, quality of prognosis, fracture healing time, the occurrence of adverse emotions and the incidence rate of complications of elderly fracture patients.

Feasibility of a multicomponent cognitive behavioral intervention for fear of falling after hip fracture: process evaluation of the FIT-HIP intervention

BACKGROUND

This study describes the process evaluation of an intervention developed to reduce fear of falling (FoF) after hip fracture, within an inpatient geriatric rehabilitation setting. This 'FIT-HIP intervention' is a multicomponent cognitive behavioral intervention, conducted by physiotherapists and embedded in usual care in geriatric rehabilitation in the Netherlands. A previous study (cluster randomized controlled trial) showed no beneficial effects of this intervention when compared to usual care. The aim of this study was to gain insight into factors related to the intervention process that may have influenced the effectiveness of the intervention.

METHODS

This process evaluation was conducted using an observational prospective study design. Based on quantitative and qualitative data derived from session logs, evaluation questionnaires and interviews, we addressed: 1] recruitment and reach; 2] performance according to protocol; 3] patients' adherence; and 4] opinions of patients and facilitators on the intervention. Participants in this study were: a) patients from 6 geriatric rehabilitation units, who were invited to participate in the intervention (39 adults aged ≥65 years with hip fracture and FoF) and; b) intervention facilitators (14 physiotherapists and 8 psychologists who provide coaching to the physiotherapists).

RESULTS

Thirty-six patients completed the intervention during inpatient geriatric rehabilitation. Apart from cognitive restructuring and telephonic booster (which was not provided to all patients), the intervention was performed to a fair degree in accordance with protocol. Patients' adherence to the intervention was very good, and patients rated the intervention positively (average 8.1 on a scale 0-10). Although most facilitators considered the intervention feasible, a limited level of FoF (possibly related to timing of intervention), and physiotherapists' limited experience with cognitive restructuring were identified as important barriers to performing the intervention according to protocol.

CONCLUSIONS

The FIT-HIP intervention was only partly feasible, which may explain the lack of effectiveness in reducing FoF. To improve the intervention's feasibility, we recommend selecting patients with maladaptive FoF (i.e. leading to activity restriction), being more flexible in the timing of the intervention, and providing more support to the physiotherapists in conducting cognitive restructuring.

TRIAL REGISTRATION

Netherlands Trial Register: NTR5695 (7 March 2016).

Resilience in the Orthopaedic Patient

➤

Resilience is a dynamic psychological construct that refers to the ability to adapt and improve when facing adversity or other stressors.

➤

Recent investigations in various orthopaedic subspecialties have demonstrated that resilience may contribute to favorable mental health and physical function after a surgical procedure.

➤

More research, using well-designed prospective studies, is necessary to better define the role that resilience and other factors play in the health and outcomes of patients with orthopaedic conditions.

➤

Orthopaedic surgeons can consider incorporating resilience assessments into their practices to aid in identifying patients who will do well with a surgical procedure and those who may benefit from specialized therapy to optimize their health and function.

Longitudinal changes in physical activity levels and fear of falling after hip fracture

BACKGROUND AND PURPOSE

Due to global ageing, more people will suffer from hip fracture in the future, and many will be left with permanent physical impairments. The care burden for people post hip fracture is high. The aim of this study is to measure longitudinal changes in physical activity levels and fear of falling in people after hip fracture who return home after inpatient rehabilitation.

METHODS

Longitudinal observational study. Participants were recruited from three rehabilitation centres in Victoria, Australia. Self-reported fear of falling (Short Falls Efficacy Scale - International) and physical activity levels (Human Activity Profile - Adjusted Activity Score and Frenchay Activity Index) were assessed at 2 weeks, 3 and 6 months after discharge. Mobility (walking speed) and balance (Timed Up-and-Go test and Step Test) were measured at discharge from rehabilitation.

RESULTS

Thirty-four participants (mean age: 82 years [SD 8]; 62% female) with unilateral hip fracture were recruited. Participants had moderately impaired balance and mobility at discharge compared to age-matched normative data; they were all discharged with a walking aid and were 40% slower in their walking speed. Participants had increased fear of falling and reduced physical activity 2 weeks after discharge, which improved significantly (p < 0.01) over the following 6 months, but scores were still lower than the normative values. At 6 months, participants also had moderate to high levels of fear of falling and were less active than the general population of similar age.

DISCUSSION

Although fear of falling and physical activity improved in the 6 months following discharge, both remained negatively affected compared to normative data. Rehabilitation post hip fracture should include routine assessment of fear of falling as a potential barrier for return of physical activities.

Neuroticism predicts fear of falling after hip fracture

OBJECTIVES

Fear of falling (FoF) is common and associated with poorer functional outcomes after hip fracture. We sought to differentiate patterns of FoF at 4 and 12 weeks after surgical repair for hip fracture and examine predictors of FoF.

METHODS/DESIGN

Secondary analysis of existing data from a 52-week prospective study examining recovery after hip fracture. Participants (N = 263) were aged 60 and older with recent hip fracture recruited from eight hospitals. FoF was measured 4 and 12 weeks postfracture with the Short Falls Efficacy Scale-International. Latent class mixed models were constructed to identify distinct patterns of FoF from 4 to 12 weeks postfracture and predictors of FoF. Predictors examined included age, gender, neuroticism, depression, negative affect, perceived social support, medical comorbidity, functional ability, cognition, and pain.

RESULTS

Three latent classes of FoF were identified: a group with minimal FoF at weeks 4 and 12 (72%), a group with high FoF that decreased (17%), and a group with high FoF that increased from week 4 to 12 (11%). In a multivariate model, higher neuroticism was associated with greater risk for high FoF (increasing or decreasing), whereas higher premorbid medical comorbidity was associated with increasing FoF, poorer premorbid functional ability was associated with decreasing FoF, and social support was not significantly associated.

CONCLUSIONS

Older adults with higher neuroticism are more likely to have FoF in the first 12 weeks after a hip fracture. Screening for neuroticism in health care settings might identify individuals who would benefit from interventions to improve outcomes during recovery.

Do subjectively and objectively impaired oral health parameters influence geriatric assessment results in hospitalized geriatric patients?

BACKGROUND

Impaired oral health affects oral health-related quality of life (OHrQoL) in orthogeriatric hospitalized patients, and both might be associated with potential risk factors for functional impairment, based on the comprehensive geriatric assessment (CGA) and related blood laboratory values. As data on this field are scarce, we investigated possible associations between oral health, items of the geriatric oral health assessment instrument (GOHAI), CGA assessment tools, and relevant laboratory values.

METHODS

Explorative cross-sectional pilot study investigating oral and general health, OHrQoL, and functionality based on objective oral health, GOHAI, CGA, and routinely assessed laboratory parameters of orthogeriatric patients. Correlations (Spearman's rho and Pearson's) and regression analysis were performed for the dependent variables functionality, cognition, Mini-Nutritional Assessment, Falls Efficacy Scale (FES), and the 15-item geriatric depression scale (GDS).

RESULTS

Among all participants (N = 40), several GOHAI single items (GOHAI 1,4,5,7,10,11) correlated with certain CGA assessment results (fear of falling, Barthel index, handgrip power). Reduced subjective oral health (GOHAI, xerostomia) and objective oral health (oral hygiene index, root caries index, unstimulated salivation rate) correlated with reduced general health and CGA results (polypharmacy, handgrip power, FES, GDS). Anemia was seen in all participants, but no associations between reduced oral health and laboratory blood values were detected.

CONCLUSION

Our results demonstrate the association between impaired subjective and objective oral health, OHrQoL, and physical functional impairment among orthogeriatric patients. Impaired GOHAI item results at the dentist, and the association between GOHAI values and CGA results that implies an association between physical and oral health, should encourage a geriatric check based on CGA, and vice versa. Results encourage interdisciplinary cooperation between geriatricians and dentists, but also indicate the need for further research in this field.

TRIAL REGISTRATION

DRKS00013230.

Is Occupational Therapy After Hip Fracture Surgery Effective in Improving Function?: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

OBJECTIVE

The aim of the study was to evaluate whether occupational therapy (OT) improves activities of daily living and overall physical functioning of patients after hip fracture surgery.

DATA SOURCES

The data sources are PubMed-Medline, Embase, and Cochrane Library databases.

REVIEW METHODS

We searched for randomized controlled trials comparing occupational therapy with comprehensive postoperative care (without occupational therapy) after hip fracture surgery. A pairwise meta-analysis using fixed- and random-effects models was performed. The primary outcome of interest was performance of activities of daily living assessed in any manner. The secondary outcomes were other functional parameters: (1) physical function; (2) health perception and emotion; and (3) fall occurrence. Effect sizes were computed as standardized mean differences with 95% confidence intervals.

RESULTS

Five randomized controlled trials including a total of 524 participants were retrieved. There was a trend toward improvement in activities of daily living, physical function, and fall occurrence, and these changes were not significant. However, health perception and patient emotions improved significantly in the occupational therapy group (standardized mean difference = 0.391, 95% confidence interval = 0.104 to 0.678, P = 0.008).

CONCLUSIONS

Occupational therapy after hip fracture surgery seems to improve overall function. Indeed, the positive effects of occupational therapy on health perception and emotions were evident. Therefore, occupational therapy can be suggested in comprehensive rehabilitation programs after hip fracture surgery.

Understanding the role of social factors in recovery after hip fractures: A structured scoping review

Poor recovery among older adults with hip fractures can occur despite successful surgical repair and rehabilitation, suggesting other factors might play a role in recovery, such as social factors. The aim of this scoping review was to provide an overview of the literature on the role of social factors in older adult's recovery after hip fracture. This review followed the York Framework and its modifications and recent reporting guidelines. Two independent researchers searched main medical databases (CINAHL, EMBASE, Medline, PsycINFO and the Cochrane libraries) from inception to June 2017, for studies investigating social factors and recovery post hip fracture. Studies were excluded if they were qualitative, perspective papers or if participants were < 65 years or they were not living in the community. We screened 2,503 unique abstracts in total and 19 studies fulfilled the inclusion criteria. Social factors investigated in the included studies were social support, socioeconomic factors and living arrangement. We classified outcomes in the studies into three subgroups: physical functional recovery, mortality and other outcomes (pain, hospital length of stay and quality of life). We found evidence that social support and socioeconomic factors (e.g. socioeconomic status) were significantly associated with an increase in functional recovery, a decrease in mortality and other outcomes, but conflicting evidence was found for the effect of one's living arrangement. Only two included studies were randomised controlled trials. To conclude, social factors, such as social support and socioeconomic status, affect physical functional recovery and mortality in older adults with hip fractures. However, this is an under researched area that lacks rigorously designed studies and would benefit from more studies with rigorous designs.

Older Adults With Hip Arthroplasty: An Individualized Transitional Care Program

BACKGROUND

Most older adults with hip fracture surgery experience functional decline (FD), causing devastating outcomes. However, few studies have examined the effects of nursing interventions to reduce FD for them.

PURPOSE

The aim of the study was to evaluate an individualized transitional care program (ITCP) to reduce FD for older adults with hip arthroplasty.

METHODS

The study was quasiexperimental, with a nonequivalent control group design. A total of 37 participants scheduled for hip arthroplasty were recruited-21 in the experimental and 16 in the control group.

FINDINGS

Two weeks following surgery (i.e., just prior to discharge), the ITCP group displayed less fear of falling than the usual care group. Moreover, the experimental group displayed objectively less FD with increased activities of daily living and Timed Up and Go scores, 6 weeks after hip arthroplasty.

CONCLUSIONS

This study provides evidence of the effectiveness of nurse-led rehabilitative practices to reduce FD in older adults with hip arthroplasty.

CLINICAL RELEVANCE

The ITCP promoted individual physical functioning for older adults with hip arthroplasty. This study results can aid healthy transitions of elderly patients with other various diseases.

Effects of the FIT-HIP Intervention for Fear of Falling After Hip Fracture: A Cluster-Randomized Controlled Trial in Geriatric Rehabilitation

OBJECTIVES

Fear of falling (FoF) is common after hip fracture and can impede functional recovery because of activity restriction. The Fear of falling InTervention in HIP fracture geriatric rehabilitation (FIT-HIP intervention) was designed to target FoF and consequently to improve mobility. The aim of this study was to evaluate the effect of the FIT-HIP intervention in patients with FoF in geriatric rehabilitation (GR) after hip fracture.

DESIGN, SETTING, AND PARTICIPANTS

This cluster-randomized controlled trial was performed in 11 post-acute GR units in the Netherlands (2016-2017). Six clusters were assigned to the intervention group, 5 to the usual care group. We included 78 patients with hip fracture and FoF (aged ≥65 years; 39 per group).

INTERVENTION(S)

The FIT-HIP intervention is a multicomponent cognitive behavioral intervention conducted by physiotherapists, embedded in usual care in GR. The FIT-HIP intervention was compared to usual care in GR.

MEASUREMENTS

FoF was assessed with the Falls Efficacy Scale-International (FES-I) and mobility, with the Performance Oriented Mobility Assessment (POMA). Data were collected at baseline, discharge, and 3 and 6 months postdischarge from GR. Primary endpoints were change scores at discharge. Linear mixed models were used to evaluate the treatment effect.

RESULTS

No significant between-group differences were observed for primary outcome measures. With the usual care group as reference, the FES-I estimated difference between mean change scores was 3.3 [95% confidence interval (CI) -1.0, 7.5, P = .13] at discharge from GR; -4.1 (95% CI -11.8, 3.6, P = .29) after 3 months; and -2.8 (95% CI -10.0, 4.4, P = .44) after 6 months. POMA estimated difference was -0.3 (95% CI -6.5, 5.8, P = .90).

CONCLUSION/IMPLICATIONS

The FIT-HIP intervention was not effective in reducing FoF. Possibly FoF (shortly) after hip fracture can to some extent be appropriate. This may imply the study was not able to accurately identify and accordingly treat FoF that is maladaptive (reflective of disproportionate anxiety).

Fear of Outdoor Falling Among Community-Dwelling Middle-Aged and Older Adults: The Role of Neighborhood Environments

Background and Objectives

Fear of falling is a substantial barrier to walking and has been associated with increased fall risks. This study examines neighborhood environmental risk factors related to fear of outdoor falling in middle-aged and older adults.

Research Design and Methods

A total of 394 participants aged 50 years or older living independently in the community were recruited between 2013 and 2014 from an integrated health care network serving Central Texas. Fear of outdoor falling and perceived neighborhood environmental variables were assessed using self-reported questionnaires. Logistic regression identified perceived neighborhood environmental variables associated with fear of outdoor falling.

Results

Sixty-nine (17.9%) of 385 participants reported having a fear of outdoor falling. Compared to those who did not report a fear of outdoor falling, those who reported having a fear of outdoor falling were more likely to be adults aged 65 years or older (odds ratio [OR] = 2.974, 95% confidence interval [CI] = 1.247-7.094), be female (OR = 4.423, 95% CI = 1.830-10.689), have difficulty with walking for a quarter of a mile (OR = 2.761, 95% CI = 1.124-6.782), and have had a fall in the past year (OR = 4.720, 95% CI = 1.472-15.137). Among the neighborhood environmental characteristics examined, low traffic speed on streets (OR = 0.420, 95% CI = 0.188-0.935), drainage ditches (OR = 2.383, 95% CI = 1.136-5.000), and broken sidewalks (OR = 3.800, 95% CI = 1.742-8.288) were associated with the odds of having a fear of outdoor falling.

Discussion and Implications

In addition to the individual factors, findings from this study suggest the importance of addressing the environmental risk factors in identifying and reducing fear of outdoor falling among middle-aged and older adults.

[Effect on fear of falling and functionality of three intervention programs. A randomised clinical trial]

INTRODUCTION

The fear of falling has a high prevalence in the community, and intervention programs for this condition are scarce, making it is necessary to strengthen this type of therapy in order to prevent adverse consequences in the elderly population.

OBJECTIVE

To establish the effectiveness of three intervention programs in reducing the fear of falling and increasing functionality in elderly people in the city of Manizales.

PARTICIPANTS AND METHODS

A randomised trial was conducted on ambulatory elderly patients with fear of falling and functional limitation of the city of Manizales. A total of 125 individuals were randomised to one of three interventions: Tai Chi (TCh), cognitive behavioural therapy (CBT), and postural control (CP) exercises. The primary outcomes were: fear of falling (evaluated by the Falls Efficacy Scale [FES-I]), and functionality using the Short Physical Performance Battery (SPPB). The data was collected before initiating the interventions and after the 8 weeks intervention.

RESULTS

An intention-to-treat analysis was conducted on 119 elderly patients. The three interventions reduced the fear of falling and increased physical performance, with no significant differences observed between them (P=.13). As regards gait speed, differences were only found between the pre- and post-intervention with CP (P<.001).

CONCLUSIONS

The results suggest that the TCh, CBT and CP interventions helped the elderly to reduce their fear of falling. Only CP demonstrated an improvement in the speed of walking at the end of the eight weeks of intervention (identifier NCT03211429).

Living with painful diabetic neuropathy: insights from focus groups into fears and coping strategies

OBJECTIVE

Painful diabetic neuropathy (PDN) is known to negatively affect quality of life. Being physically active is a crucial part of successful diabetes self-management, but regimen adherence is often low. Coping strategies and fears have shown to be related to less physical activity (PA). The aim of the present study was to obtain more in-depth information on psychological risk factors leading to less PA in persons with PDN.

DESIGN

Three semi-structured focus group interviews were conducted with a representative sample of persons with PDN (N = 12). Data were transcribed verbatim and analysed using a hybrid method of thematic analyses and a grounded theory approach.

MAIN OUTCOME MEASURES

Fears and coping strategies related to PA in persons with PDN.

RESULTS

Several specific fears were identified; fear of hypoglycaemia, fear of pain increase, fear of total exhaustion, fear of physical injury, fear of falling, fear of loss of identity, and fear of negative evaluation by others. To cope with these fears, avoidance, remaining active, cognitive distraction, and acceptance strategies were described.

CONCLUSION

In persons with PDN, diabetes-related fears and pain-related fears play a role in less engagement in PA, indicating the need for new methods for improving self-management in persons with PDN.

Interventions for preventing falls in older people in care facilities and hospitals

BACKGROUND

Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010 and updated in 2012.

OBJECTIVES

To assess the effects of interventions designed to reduce the incidence of falls in older people in care facilities and hospitals.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (August 2017); Cochrane Central Register of Controlled Trials (2017, Issue 8); and MEDLINE, Embase, CINAHL and trial registers to August 2017.

SELECTION CRITERIA

Randomised controlled trials of interventions for preventing falls in older people in residential or nursing care facilities, or hospitals.

DATA COLLECTION AND ANALYSIS

One review author screened abstracts; two review authors screened full-text articles for inclusion. Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We calculated rate ratios (RaR) with 95% confidence intervals (CIs) for rate of falls and risk ratios (RRs) and 95% CIs for outcomes such as risk of falling (number of people falling). We pooled results where appropriate. We used GRADE to assess the quality of evidence.

MAIN RESULTS

Thirty-five new trials (77,869 participants) were included in this update. Overall, we included 95 trials (138,164 participants), 71 (40,374 participants; mean age 84 years; 75% women) in care facilities and 24 (97,790 participants; mean age 78 years; 52% women) in hospitals. The majority of trials were at high risk of bias in one or more domains, mostly relating to lack of blinding. With few exceptions, the quality of evidence for individual interventions in either setting was generally rated as low or very low. Risk of fracture and adverse events were generally poorly reported and, where reported, the evidence was very low-quality, which means that we are uncertain of the estimates. Only the falls outcomes for the main comparisons are reported here.Care facilitiesSeventeen trials compared exercise with control (typically usual care alone). We are uncertain of the effect of exercise on rate of falls (RaR 0.93, 95% CI 0.72 to 1.20; 2002 participants, 10 studies; I² = 76%; very low-quality evidence). Exercise may make little or no difference to the risk of falling (RR 1.02, 95% CI 0.88 to 1.18; 2090 participants, 10 studies; I² = 23%; low-quality evidence).There is low-quality evidence that general medication review (tested in 12 trials) may make little or no difference to the rate of falls (RaR 0.93, 95% CI 0.64 to 1.35; 2409 participants, 6 studies; I² = 93%) or the risk of falling (RR 0.93, 95% CI 0.80 to 1.09; 5139 participants, 6 studies; I² = 48%).There is moderate-quality evidence that vitamin D supplementation (4512 participants, 4 studies) probably reduces the rate of falls (RaR 0.72, 95% CI 0.55 to 0.95; I² = 62%), but probably makes little or no difference to the risk of falling (RR 0.92, 95% CI 0.76 to 1.12; I² = 42%). The population included in these studies had low vitamin D levels.Multifactorial interventions were tested in 13 trials. We are uncertain of the effect of multifactorial interventions on the rate of falls (RaR 0.88, 95% CI 0.66 to 1.18; 3439 participants, 10 studies; I² = 84%; very low-quality evidence). They may make little or no difference to the risk of falling (RR 0.92, 95% CI 0.81 to 1.05; 3153 participants, 9 studies; I² = 42%; low-quality evidence).HospitalsThree trials tested the effect of additional physiotherapy (supervised exercises) in rehabilitation wards (subacute setting). The very low-quality evidence means we are uncertain of the effect of additional physiotherapy on the rate of falls (RaR 0.59, 95% CI 0.26 to 1.34; 215 participants, 2 studies; I² = 0%), or whether it reduces the risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 83 participants, 2 studies; I² = 0%).We are uncertain of the effects of bed and chair sensor alarms in hospitals, tested in two trials (28,649 participants) on rate of falls (RaR 0.60, 95% CI 0.27 to 1.34; I² = 0%; very low-quality evidence) or risk of falling (RR 0.93, 95% CI 0.38 to 2.24; I² = 0%; very low-quality evidence).Multifactorial interventions in hospitals may reduce rate of falls in hospitals (RaR 0.80, 95% CI 0.64 to 1.01; 44,664 participants, 5 studies; I² = 52%). A subgroup analysis by setting suggests the reduction may be more likely in a subacute setting (RaR 0.67, 95% CI 0.54 to 0.83; 3747 participants, 2 studies; I² = 0%; low-quality evidence). We are uncertain of the effect of multifactorial interventions on the risk of falling (RR 0.82, 95% CI 0.62 to 1.09; 39,889 participants; 3 studies; I² = 0%; very low-quality evidence).

AUTHORS' CONCLUSIONS

In care facilities: we are uncertain of the effect of exercise on rate of falls and it may make little or no difference to the risk of falling. General medication review may make little or no difference to the rate of falls or risk of falling. Vitamin D supplementation probably reduces the rate of falls but not risk of falling. We are uncertain of the effect of multifactorial interventions on the rate of falls; they may make little or no difference to the risk of falling.In hospitals: we are uncertain of the effect of additional physiotherapy on the rate of falls or whether it reduces the risk of falling. We are uncertain of the effect of providing bed sensor alarms on the rate of falls or risk of falling. Multifactorial interventions may reduce rate of falls, although subgroup analysis suggests this may apply mostly to a subacute setting; we are uncertain of the effect of these interventions on risk of falling.

The Role of Prefracture Health Status in Physical and Mental Function After Hip Fracture Surgery

OBJECTIVES

To examine the associations of 3 measures of prefracture health status (physical function, mental function, and comorbidity count) with trajectories of physical and mental function at 1.5, 3, 6, and 12 months after hip fracture surgery.

DESIGN

Single-center observational study.

SETTING

Singapore General Hospital (an acute hospital).

PARTICIPANTS

Patients aged ≥60 years who underwent first hip fracture surgery between June 2011 and July 2016 (N = 928).

INTERVENTION

None.

MEASUREMENTS

We used data collected prospectively from the hospital's hip fracture registry. We used the Short Form-36 (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) as indicators of physical and mental function, respectively, collected at admission and at 1.5, 3, 6, and 12 months after hip fracture surgery. Comorbidity count at admission was the sum from a list of 10 common diseases associated with poorer physical function.

RESULTS

Prefracture physical function and prefracture mental function demonstrated time-varying associations (interaction P < .001 and P = .001, respectively) with postfracture physical function; the associations were small initially but increased in strength up to 6 months and stabilized thereafter. In contrast, the strength of the association between comorbidity count and postfracture physical function were time-invariant (-0.52, P = .027). The strength of the associations between all 3 measures of prefracture health status and postfracture mental function were also constant over time (0.09, P = .004, for physical function; 0.38, P < .001, for mental function; -0.70, P = .034, for comorbidity count).

CONCLUSIONS/IMPLICATIONS

The time-varying associations between prefracture health status and postfracture physical function suggest that even for patients with good prefracture health status, initial recovery may be slow. Our findings can be useful to clinicians and therapists in their prognostic evaluations and in management of patients' expectation for recovery.

The Rothman Index Is Associated With Postdischarge Adverse Events After Hip Fracture Surgery in Geriatric Patients

BACKGROUND

The Rothman Index is a comprehensive measure of overall patient status in the inpatient setting already in use at many medical centers. It ranges from 100 (best score) to -91 (worst score) and is calculated based on 26 variables encompassing vital signs, routine laboratory values, and organ system assessments from nursing rounds from the electronic medical record. Past research has shown an association of Rothman Index with complications, readmission, and death in certain populations, but it has not been evaluated in geriatric patients with hip fractures, a potentially vulnerable patient population.

QUESTIONS/PURPOSES

(1) Is there an association between Rothman Index scores and postdischarge adverse events in a population aged 65 years and older with hip fractures? (2) What is the discriminative ability of Rothman Index scores in determining which patients will or will not experience these adverse events? (3) Are there Rothman Index thresholds associated with increased incidence of postdischarge adverse outcomes?

METHODS

One thousand two hundred fourteen patients aged 65 years and older who underwent hip fracture surgery at an academic medical center between 2013 and 2016 were identified. Demographic and comorbidity characteristics were characterized, and 30-day postdischarge adverse events were calculated. The associations between a 10-unit change in Rothman Index scores and postdischarge adverse events, mortality, and readmission were determined. American Society of Anesthesiologists (ASA) class was used as a measure of comorbidity because prior research has shown its performance to be equivalent or superior to that of calculated comorbidity measures in this data set. We assessed the ability of Rothman Index scores to determine which patients experienced adverse events. Finally, Rothman Index thresholds were assessed for an association with increased incidence of postdischarge adverse outcomes.

RESULTS

We found a strong association between Rothman Index scores and postdischarge adverse events (lowest score: odds ratio [OR] = 1.29 [1.18-1.41], p < 0.001; latest score: OR = 1.37 [1.24-1.52], p < 0.001) after controlling for age, sex, body mass index, ASA class, and surgical procedure performed. The discriminative ability of lowest and latest Rothman Index scores was better than those of age, sex, and ASA class for any adverse event (lowest value: area under the curve [AUC] = 0.641; 95% confidence interval [CI], 0.601-0.681; latest value: AUC = 0.640; 95% CI, 0.600-0.680); age (0.534; 95% CI, 0.493-0.575, p < 0.001 for both), male sex (0.552; 95% CI, 0.518-0.585, p = 0.001 for both), and ASA class (0.578; 95% CI, 0.542-0.614; p = 0.004 for lowest Rothman Index, p = 0.006 for latest Rothman Index). There was never a difference when comparing lowest Rothman Index value and latest Rothman Index value for any of the outcomes (Table 5). Patients experienced increased rates of postdischarge adverse events and mortality with a lowest Rothman Index of ≤ 35 (p < 0.05) or latest Rothman Index of ≤ 55 (p < 0.05).

CONCLUSIONS

The Rothman Index provides an objective method of assessing perioperative risk in the setting of hip fracture surgery in patients older than age 65 years and is more accurate than demographic measures or ASA class. Furthermore, there are Rothman Index thresholds that can be used to identify patients at increased risk of complications. Physicians can use this tool to monitor the condition of patients with hip fracture, recognize patients at high risk of adverse events to consider changing their plan of care, and counsel patients and families. Further investigation is needed to determine whether interventions based on Rothman Index values contribute to improved outcomes or value of hip fracture care.

LEVEL OF EVIDENCE

Level II, diagnostic study.