Enhanced interdisciplinary care improves self-care ability and decreases emergency department visits for older Taiwanese patients over 2 years after hip-fracture surgery: A randomised controlled trial.
Shyu Yea-Ing L,Liang Jersey,Tseng Ming-Yueh,Li Hsiao-Juan,Wu Chi-Chuan,Cheng Huey-Shinn,Chou Shih-Wei,Chen Ching-Yen,Yang Ching-Tzu
International journal of nursing studies
BACKGROUND:Little evidence is available on the longer-term effects (beyond 12 months) of intervention models consisting of hip fracture-specific care in conjunction with management of malnutrition, depression, and falls. OBJECTIVE:To compare the relative effects of an interdisciplinary care, and a comprehensive care programme with those of usual care for elderly patients with a hip fracture on self-care ability, health care use, and mortality. DESIGN:Randomised experimental trial. SETTING:A 3000-bed medical centre in northern Taiwan. PARTICIPANTS:Patients with hip fracture aged 60 years or older (N=299). METHOD:Patients were randomly assigned to three groups: comprehensive care (n=99), interdisciplinary care (n=101), and usual care (control) (n=99). Usual care entailed only one or two in-hospital rehabilitation sessions. Interdisciplinary care included not only hospital rehabilitation, but also geriatric consultation, discharge planning, and 4-month in-home rehabilitation. Building upon interdisciplinary care, comprehensive care extended in-home rehabilitation to 12 months and added management of malnutrition and depressive symptoms, and fall prevention. Patients' self-care ability was measured by activities of daily living and instrumental activities of daily living using the Chinese Barthel Index and Chinese version Instrumental Activities of Daily Living scale, respectively. Outcomes were assessed before discharge, and 1, 3, 6, 12, 18, 24 months following hip fracture. Hierarchical linear models were used to analyse health outcomes and health care utilisation, including emergency department visit and hospital re-admission. RESULTS:The comprehensive care group had better performance trajectories for both measures of activities of daily living and fewer emergency department visits than the usual care group, but no difference in hospital readmissions. The interdisciplinary care and usual care groups did not differ in trajectories of self-care ability and service utilisation. The three groups did not differ in mortality during the 2-year follow-up. CONCLUSION:Comprehensive care, with enhanced rehabilitation, management of malnutrition and depressive symptoms, and fall prevention, improved self-care ability and decreased emergency department visits for elders up to 2 years after hip-fracture surgery, above and beyond the effects of usual care and interdisciplinary care.
10.1016/j.ijnurstu.2015.12.005
[Hip fracture in elderly patients; additional value of a multidisciplinary approach and concentration of care].
van der Vet P,Kussen J,van Dijk M,Houwert R M,Verleisdonk E J M M,van der Velde D
Nederlands tijdschrift voor geneeskunde
Management of elderly patients with a proximal femoral fracture is an increasing challenge for the Dutch healthcare system. Proximal femoral fractures in the elderly have high morbidity and mortality rates. Furthermore, healthcare costs for this group of patients are rising. Referral, operation and postoperative care demand efficient collaboration between healthcare professionals. Every step in this chain of events is crucial for optimal treatment results. Multidisciplinary orthogeriatric trauma care shows promising results. In addition, high volume care results in better outcome of geriatric trauma patients.
Waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: A cohort study.
Kelly-Pettersson Paula,Samuelsson Bodil,Muren Olle,Unbeck Maria,Gordon Max,Stark André,Sköldenberg Olof
International journal of nursing studies
BACKGROUND:Hip fractures are common in the elderly and are associated with a high adverse event and mortality rate. Time to surgery is one of the major modifiable risk factors influencing adverse outcomes in hip-fracture patients. National guidelines and recommendations have been introduced which advocate specific time frames in which surgery should be performed i.e. within 24-48h. These time constraints have been arbitrarily set without being modelled on the linear assumption i.e. that risk increases continually over time and not within specific cut-off times. OBJECTIVES:To investigate how waiting time to surgery influenced the risk of serious adverse events in hip-fracture patients during the hospital stay and to examine how the risk increased over time. DESIGN:An observational single cohort study Participants 576 patients (72.4% females, mean [SD] age 82 [10]) years, with a hip fracture were included in the cohort study. METHODS:The outcomes of the study were the occurrence of serious adverse events during hospital stay, length of stay and one-year mortality. A structured medical record review was carried out to identify outcomes and mortality data was obtained from the Swedish National Death Registry. Waiting time to surgery was used as the exposure variable and age, sex, type of fracture, comorbidities using the American Society of Anaesthesiologists classification score and the presence of cognitive dysfunction were identified as confounders. A logistic regression analysis was performed to identify risk factors influencing outcomes. RESULTS:A total of 119 patients (20.6%) suffered 397 (range 1-5) serious adverse events during hospital stay. Every 10h of waiting time to surgery increased the risk of serious adverse events by 12% (odds ratio 1.12 [95% confidence interval 1.02-1.23]). We found no optimal cut-off times for waiting time to surgery. For every 24h of waiting time, the length of stay from surgery was increased by 0.6days (95% CI 0.1-1.1). We found no correlation between waiting time to surgery and one-year mortality. CONCLUSIONS:A large proportion of patients suffered from at least one serious adverse event after hip-fracture surgery and there are no safe limits for waiting time to surgery for hip-fracture patients. As the risk increases with every hour of waiting time, patients with higher American Society of Anesthesiologists classification scores, males and those with subtrochanteric fractures should be prioritized for surgery.
10.1016/j.ijnurstu.2017.02.003
Comparative effectiveness of fragility fracture integrated rehabilitation management for elderly individuals after hip fracture surgery: A study protocol for a multicenter randomized controlled trial.
Lee Sang Yoon,Beom Jaewon,Kim Bo Ryun,Lim Seung-Kyu,Lim Jae-Young,
Medicine
INTRODUCTION:Although it is essential to provide comprehensive rehabilitation after hip fracture to restore the patient to preoperative physical functioning, feasibility issues remain. Here, we describe a protocol for a randomized controlled trial (RCT) to evaluate the effectiveness of fragility fracture integrated rehabilitation management (FIRM) for elderly individuals after hip fracture surgery. We also examine the feasibility of applying FIRM in a chronic-care hospital or community-based setting. METHODS AND ANALYSIS:Elderly patients will be randomly assigned to either the FIRM, conventional, or control group for a 2-week intervention period following hip fracture surgery. The primary outcome of this study is Koval walking ability. All functional outcomes will be measured 1 and 3 weeks, 3, 6, and 12 months after the surgical intervention. Researchers will be blind to group allocation, and participants will be blind to outcome. A sample size of 282 participants will be necessary to demonstrate the effect of the FIRM program. After the RCT has been conducted in 3 core hospitals, FIRM will be applied in 6 community-based local hospitals to investigate the feasibility of the program. The data will be analyzed using the intention-to-treat principle. TRIAL REGISTRATION NUMBER:NCT03430193.
10.1097/MD.0000000000010763
Mixed methods process evaluation of an enhanced community-based rehabilitation intervention for elderly patients with hip fracture.
Roberts Jessica Louise,Pritchard Aaron W,Williams Michelle,Totton Nikki,Morrison Val,Din Nafees Ud,Williams Nefyn H
BMJ open
OBJECTIVES:To describe the implementation of an enhanced rehabilitation programme for elderly hip fracture patients with mental capacity, in a randomised feasibility study compared with usual rehabilitation. To compare processes between the two and to collect the views of patients, carers and therapy staff about trial participation. DESIGN:Mixed methods process evaluation in a randomised feasibility study. SETTING:Patient participants were recruited on orthopaedic and rehabilitation wards; the intervention was delivered in the community following hospital discharge. PARTICIPANTS:Sixty-one older adults (aged ≥65 years) recovering from surgical treatment (replacement arthroplasty or internal fixation) following hip fracture, who were living independently prior to fracture and had mental capacity and 31 of their carers. INTERVENTIONS:Usual care (control) or usual care plus an enhanced rehabilitation package (intervention). The enhanced rehabilitation consisted of a patient-held information workbook, goal-setting diary and up to six additional therapy sessions. PROCESS EVALUATION COMPONENTS:Recruitment of sites and rehabilitation teams, response of rehabilitation teams, recruitment and reach in patient and carer participants, intervention delivery, delivery to individuals, response of individual patients to the enhanced intervention or usual rehabilitation, response of carer participants, unintended consequences and testing intervention theory and context. RESULTS:Usual rehabilitation care was very variable. The enhanced rehabilitation group received a mean of five additional therapy sessions. All of the returned goal-setting diaries had inputs from the therapy team, and half had written comments by the patients and carers. Focus group themes: variation of usual care and its impact on delivering the intervention; the importance of goal setting; the role of the therapist in providing reassurance about safe physical activities; and acceptability of the extra therapy sessions. CONCLUSIONS:Lessons learnt for a future definitive RCT include how to enhance recruitment and improve training materials, the workbook, delivery of the extra therapy sessions and recording of usual rehabilitation care. TRIAL REGISTRATION NUMBER:ISRCTN22464643; Post- results.
10.1136/bmjopen-2018-021486
[Implementation of an integrated clinical process for the care of hip fracture in patients older than 65 years].
De Borja-Sobrón F,Alonso-Polo B
Acta ortopedica mexicana
Hip fracture in the elderly is considered to be a serious sanitary problem. In our country, these fractures have experimented an exponential growth, becoming an important challenge for healthcare management. This study is aimed to evaluate the 1-year-follow-up results after the pilot implementation of a multidisciplinary clinical pathway for hip fractures in over-65-year-old patients. MATERIAL AND METHODS:We performed an observational retrospective cohort study. All over-65-year-old patients diagnosed with hip fracture were included. The analysed periods were the year 2013 (previous to the implementation of the clinical pathway, 84 patients) and the year 2015 (after the pilot implantation of the clinical pathway, 85 patients). We studied the following variables: rate of patients that underwent surgery during the first 48 hours, preoperative length of stay, total length of stay and one year mortality rate. RESULTS:The rate of surgery during the first 48 hours was 24.3% in 2013 and 64.6% in 2015. The median of the preoperative and total length of stay decreased three days. One year mortality rates of both groups were not found to be statistically different. CONCLUSION:Our study suggests that improvements of the care efficiency may be achieved after the implementation of a clinical pathway for the hip fracture in the elderly. It was not possible to demonstrate a lower one year mortality rate.
[Geriatric fracture centers. Improved patient care and economic benefits].
Kates S L
Der Unfallchirurg
The world's population is aging resulting in changes in the way we manage geriatric care. Furthermore, this population has a considerable risk of fragility fractures, most notably hip fractures. Hip fractures are associated with significant morbidity and mortality and have large economic consequences. It is due to these factors that the concept of an elderly trauma center was developed. These trauma centers utilize the expertise in orthopedic and geriatric disciplines to provide coordinated care to the elderly hip fracture patient. As a result, studies have demonstrated improvements in clinical outcomes within the hospital stay, a reduction in iatrogenic complications, and improvements in 1-year mortality rates compared to the usual care given at a similar facility. Furthermore, economic models have demonstrated that there is a role for regionalized hip fracture centers that can be both profitable and provide more efficient care to these patients.
10.1007/s00113-015-0121-9
Integrated nutritional intervention in the elderly after hip fracture. A process evaluation.
Breedveld-Peters José J L,Reijven Petronella L M,Wyers Caroline E,van Helden Svenhjalmar,Arts J J Chris,Meesters Berry,Prins Martin H,van der Weijden Trudy,Dagnelie Pieter C
Clinical nutrition (Edinburgh, Scotland)
BACKGROUND & AIMS:Within a multicentre randomized controlled trial aimed at improving the nutritional status and increase the speed of recovery of elderly hip fracture patients, we performed a process evaluation to investigate the feasibility of the intervention within the present Dutch health care system. METHODS:Patients in the intervention group received nutritional counseling during 10 contacts. Oral nutritional supplements were advised as needed until three months after hip fracture surgery. The intervention was evaluated with respect to dieticians' adherence to the study protocol, content of nutritional counseling, and patients' adherence to recommendations given. RESULTS:We included 66 patients (mean age of 76, range 55-92 years); 74% women. Eighty-three percent of patients received all 10 contacts as planned, but in 62% of the patients one or more telephone calls had to be replaced by face to face contacts. Nutritional counseling was complete in 91% of contacts. Oral nutritional supplementation was needed for a median period of 76 days; 75% of the patients took the oral nutritional supplements as recommended. CONCLUSIONS:Nutritional counseling in elderly hip fracture patients through face to face contacts and telephone calls is feasible. However, individual tailoring of the intervention is recommended. The majority of hip fracture patients needed >2 months oral nutritional supplements to meet their nutritional requirements. The trial was registered at clincialtrails.gov as NCT00523575.
10.1016/j.clnu.2011.10.004
Cost-effectiveness of nutritional intervention in elderly subjects after hip fracture. A randomized controlled trial.
Wyers C E,Reijven P L M,Evers S M A A,Willems P C,Heyligers I C,Verburg A D,van Helden S,Dagnelie P C
Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA
UNLABELLED:Hip fracture patients can benefit from nutritional supplementation during their recovery. Up to now, cost-effectiveness evaluation of nutritional intervention in these patients has not been performed. Costs of nutritional intervention are relatively low as compared with medical costs. Cost-effectiveness evaluation shows that nutritional intervention is likely to be cost-effective. INTRODUCTION:Previous research on the effect of nutritional intervention on clinical outcome in hip fracture patients yielded contradictory results. Cost-effectiveness of nutritional intervention in these patients remains unknown. The aim of this study was to evaluate cost-effectiveness of nutritional intervention in elderly subjects after hip fracture from a societal perspective. METHODS:Open-label, multi-centre randomized controlled trial investigating cost-effectiveness of intensive nutritional intervention comprising regular dietetic counseling and oral nutritional supplementation for 3 months postoperatively. Patients allocated to the control group received care as usual. Costs, weight and quality of life were measured at baseline and at 3 and 6 months postoperatively. Incremental cost-effectiveness ratios (ICERs) were calculated for weight at 3 months and quality adjusted life years (QALYs) at 6 months postoperatively. RESULTS:Of 152 patients enrolled, 73 were randomized to the intervention group and 79 to the control group. Mean costs of the nutritional intervention was 613 Euro. Total costs and subcategories of costs were not significantly different between both groups. Based on bootstrapping of ICERs, the nutritional intervention was likely to be cost-effective for weight as outcome over the 3-month intervention period, regardless of nutritional status at baseline. With QALYs as outcome, the probability for the nutritional intervention being cost-effective was relatively low, except in subjects aged below 75 years. CONCLUSION:Intensive nutritional intervention in elderly hip fracture patients is likely to be cost-effective for weight but not for QALYs. Future cost-effectiveness studies should incorporate outcome measures appropriate for elderly patients, such as functional limitations and other relevant outcome parameters for elderly.
10.1007/s00198-012-2009-7
Clinical benefits of oral nutritional supplementation for elderly hip fracture patients: a single blind randomised controlled trial.
Myint Ma Wai Wai,Wu Jenny,Wong Euann,Chan Suk Ping,To Tze Shing Jess,Chau Mei Wa Rosanna,Ting Kwai Hing,Fung Pui Man,Au Kit Sing Derrick
Age and ageing
BACKGROUND:malnutrition is an important risk factor for poor outcome in patients recovering after hip fracture surgery. This study aimed to investigate the clinical, nutritional and rehabilitation effects of an oral nutritional supplementation (ONS) in an inpatient rehabilitation setting. METHODS:this was an observer-blinded randomised controlled trial of elderly post-surgical proximal femoral fracture patients. A ready-to-use oral liquid nutritional supplementation (18-24 g protein and 500 kcal per day) in addition to hospital diet was compared with hospital diet only. Both groups received usual rehabilitation therapy and oral calcium and vitamin D supplements. Outcomes were compared at discharge from rehabilitation and after 4 weeks of discharge. The primary outcome parameters were the serum albumin level, the body mass index (BMI), the functional independence measure (FIM) and the elderly mobility scale (EMS). Secondary outcome parameters were frequency of complications, inpatient length of stay, mortality and acute hospital use within 6 months after discharge. RESULTS:a total of 126 patients were recruited, 65 in the supplementation arm and 61 in the control arm. There was a significant difference in change in BMI with a decrease of 0.25 and 0.03 kg/m(2) in the ONS group and 0.72 and 0.49 kg/m(2) in the control group at hospital discharge and follow-up, respectively (P = 0.012). The length of stay in rehabilitation ward was shortened by 3.80 (SE = 1.81, P = 0.04) days favouring the ONS group. The total number of infection episodes was also reduced significantly. No difference was observed in the rate of change of the serum albumin level, the FIM and the EMS. CONCLUSION:clinical and nutritional benefits were seen in this trial but rehabilitation benefits could not be demonstrated.
10.1093/ageing/afs078
The effect of care pathways for hip fractures: a systematic overview of secondary studies.
Leigheb Fabrizio,Vanhaecht Kris,Sermeus Walter,Lodewijckx Cathy,Deneckere Svin,Boonen Steven,Boto Paulo A,Mendes Rita Veloso,Panella Massimiliano
European journal of orthopaedic surgery & traumatology : orthopedie traumatologie
The aim of this paper was to perform a systematic overview of secondary literature studies on care pathways (CPs) for hip fracture (HF). The online databases MEDLINE-PubMed, Ovid-EMBASE, CINAHL-EBSCO-host, and The Cochrane Library were searched. A total of six papers, corresponding to six secondary studies, were included but only four secondary studies were HF-specific and thus assessed. Secondary studies were evaluated for patients' clinical outcomes. There were wide differences among the studies that assessed the effects of CPs on HF patients, with some contrasting clinical outcomes reported. Secondary studies that were non-specific for CPs and included other multidisciplinary care approaches as well showed, in some cases, a shorter hospital length of stay (LOS) compared to usual care; studies that focused on promoting early mobilization showed better outcomes of mortality, morbidity, function, or service utilization; CPs mainly based on intensive occupational therapy and/or physical therapy exercises improved functional recovery and reduced LOS, with patients also discharged to a more favorable discharge destination; CPs principally focused on early mobilization improved functional recovery. A secondary study specifically designed for CPs showed lower odds of experiencing common complications of hospitalization after HF. In conclusion, although our overview suggests that CPs can reduce significantly LOS and can have a positive impact on different outcomes, data are insufficient for formal recommendations. To properly understand the effects of CPs for HF, a systematic review is needed of primary studies that specifically examined CPs for HF.
10.1007/s00590-012-1085-x
Comprehensive and subacute care interventions improve health-related quality of life for older patients after surgery for hip fracture: a randomised controlled trial.
Shyu Yea-Ing L,Liang Jersey,Tseng Ming-Yueh,Li Hsiao-Juan,Wu Chi-Chuan,Cheng Huey-Shinn,Chou Shih-Wei,Chen Ching-Yen,Yang Ching-Tzu
International journal of nursing studies
BACKGROUND:Elderly patients with hip fracture have been found to benefit from subacute care interventions that usually comprise usual care with added geriatric intervention, early rehabilitation, and supported discharge. However, no studies were found on the effects of combining subacute care and health-maintenance interventions on health outcomes for elders with hip fracture. OBJECTIVES:To compare the effects of an interdisciplinary comprehensive care programme with those of subacute care and usual care programmes on health-related quality of life (HRQoL) for elderly patients with hip fracture. DESIGN:Randomised controlled trial. SETTINGS:A 3000-bed medical centre in northern Taiwan. PARTICIPANTS:Patients with hip fracture (N=299) were randomised into three groups: subacute care (n=101), comprehensive care (n=99), and usual care (n=99). METHODS:Subacute care included geriatric consultation, continuous rehabilitation, and discharge planning. Comprehensive care consisted of subacute care plus health-maintenance interventions to manage depressive symptoms, manage malnutrition, and prevent falls. Usual care included only 1-2 in-hospital rehabilitation sessions, discharge planning without environmental assessment, no geriatric consultation, and no in-home rehabilitation. HRQoL was measured using the Medical Outcomes Study Short-Form 36 Taiwan version at 1, 3, 6, and 12 months after discharge. RESULTS:Participants in the comprehensive care group improved more in physical function, role physical, general health and mental health than those in the usual care group. The subacute care group had greater improvement in physical function, role physical, vitality, and social function than the usual care group. The intervention effects for both comprehensive and subacute care increased over time, specifically from 6 months after hip fracture onward, and reached a maximum at 12 months following discharge. CONCLUSIONS:Both comprehensive care and subacute care programmes may improve health outcomes of elders with hip fracture. Our results may provide a reference for health care providers in countries using similar programmes with Chinese/Taiwanese immigrant populations.
10.1016/j.ijnurstu.2012.11.020
Sense of coherence: effect on adherence and response to resistance training in older people with hip fracture history.
Portegijs Erja,Read Sanna,Pakkala Inka,Kallinen Mauri,Heinonen Ari,Rantanen Taina,Alen Markku,Kiviranta Ilkka,Sihvonen Sanna,Sipilä Sarianna
Journal of aging and physical activity
Our aim was to study the effects of sense of coherence (SOC) on training adherence and interindividual changes in muscle strength, mobility, and balance after resistance training in older people with hip fracture history. These are secondary analyses of a 12-week randomized controlled trial of progressive resistance training in 60- to 85-year-old community-dwelling people 0.5-7 years after hip fracture (n = 45; ISRCTN34271567). Pre- and posttrial assessments included SOC, knee extension strength, walking speed, timed up-and-go (TUG), and Berg Balance Scale (BBS). Group-by-SOC interaction effects (repeated-measures ANOVA) were statistically significant for TUG (p = .005) and BBS (p = .040), but not for knee extension strength or walking speed. Weaker SOC was associated with poorer training adherence (mixed model; p = .009). Thus, more complicated physical tasks did not improve in those with weaker SOC, independently of training adherence. Older people with weaker SOC may need additional psychosocial support in physical rehabilitation programs to optimize training response.
10.1123/japa.2012-0229
Accelerated care versus standard care among patients with hip fracture: the HIP ATTACK pilot trial.
CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne
BACKGROUND:A hip fracture causes bleeding, pain and immobility, and initiates inflammatory, hypercoagulable, catabolic and stress states. Accelerated surgery may improve outcomes by reducing the duration of these states and immobility. We undertook a pilot trial to determine the feasibility of a trial comparing accelerated care (i.e., rapid medical clearance and surgery) and standard care among patients with a hip fracture. METHODS:Patients aged 45 years or older who, during weekday, daytime working hours, received a diagnosis of a hip fracture requiring surgery were randomly assigned to receive accelerated or standard care. Our feasibility outcomes included the proportion of eligible patients randomly assigned, completeness of follow-up and timelines of accelerated surgery. The main clinical outcome, assessed by data collectors and adjudicators who were unaware of study group allocations, was a major perioperative complication (i.e., a composite of death, preoperative myocardial infarction, myocardial injury after noncardiac surgery, pulmonary embolism, pneumonia, stroke, and life-threatening or major bleeding) within 30 days of randomization. RESULTS:Of patients eligible for inclusion, 80% consented and were randomly assigned to groups (30 to accelerated care and 30 to standard care) at 2 centres in Canada and 1 centre in India. All patients completed 30-day follow-up. The median time from diagnosis to surgery was 6.0 hours in the accelerated care group and 24.2 hours in the standard care group (p < 0.001). A major perioperative complication occurred in 9 (30%) of the patients in the accelerated care group and 14 (47%) of the patients in the standard care group (hazard ratio 0.60, 95% confidence interval 0.26-1.39). INTERPRETATION:These results show the feasibility of a trial comparing accelerated and standard care among patients with hip fracture and support a definitive trial. TRIAL REGISTRATION:ClinicalTrials.gov, no. NCT01344343.
10.1503/cmaj.130901
What determines health-related quality of life in hip fracture patients at the end of acute care?--a prospective observational study.
Buecking B,Struewer J,Waldermann A,Horstmann K,Schubert N,Balzer-Geldsetzer M,Dodel R,Bohl K,Ruchholtz S,Bliemel C
Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA
UNLABELLED:Hip fractures are associated with reduced health-related quality of life (HrQoL). We found pre-existing need of care or limited function, cognitive impairment, and depression to be independent factors associated with lower HrQoL during the postsurgical period. In contrast, joint replacement was associated with better HrQoL compared to internal fixation. Patients' treatment should be focused on functional recovery and treatment of depression. INTRODUCTION:The aim of the study was to identify independent factors that were correlated with health-related quality of life (HrQoL) after hip fracture. METHODS:A total of 402 patients with a mean age of 81 years suffering from a hip fracture were included in this prospective, observational cohort study. HrQoL (determined by the EuroQol instrument) was measured at admission and at discharge from an acute care hospital. Independent factors correlated with HrQoL at discharge and changes from pre-fracture to discharge were determined using multivariate analyses. The influence of antidepressants was evaluated by an ANOVA with repeated measurements. RESULTS:Need of care prior to fracture was the most important determinant of EQ-5D index at discharge (ß = -0.359, p = 0.003). Additionally, low Mini Mental Status Examination (MMSE) was associated with a lower EQ-5D index at discharge (MMSE 0-9: ß = -0.238, p <0.001; MMSE 10-19: ß = -0.294, p <0.001) and a greater decrease in EQ-5D during hospitalisation (MMSE 10-19: ß = 0.281, p <0.001), while joint replacement (compared to internal fixation) was associated with a higher EQ-5D index (ß = 0.188, p = 0.002) and a lower decrease in the index (ß = -0.216, p = 0.003). EQ VAS values at discharge were correlated with pre-fracture Barthel Index (ß = 0.253, p <0.001) and Geriatric Depression Scale scores (ß = -0.135, p = 0.026). Depressive patients on antidepressants demonstrated less of a decrease in the EQ-5D index compared to patients not receiving medication (F = 2.907, p = 0.090). CONCLUSIONS:Acute care of hip fracture patients should be focused on functional recovery and treatment of depression. When the preferred surgical strategy is unclear, joint replacement should be considered.
10.1007/s00198-013-2415-5
Tight calorie control in geriatric patients following hip fracture decreases complications: a randomized, controlled study.
Anbar R,Beloosesky Y,Cohen J,Madar Z,Weiss A,Theilla M,Koren Hakim T,Frishman S,Singer P
Clinical nutrition (Edinburgh, Scotland)
BACKGROUND & AIMS:Optimizing nutritional intake has been recommended for geriatric patients undergoing hip-fracture surgery. Whether nutritional support guided by repeated measurements of resting energy requirements (REE) improves outcomes in these patients is not known. METHODS:A randomized, controlled, unblinded, prospective, cohort study comparing provision of energy with a goal determined by repeated REE measurements using indirect calorimetry, with no intervention. Oral nutritional supplements were started 24 h after surgery and the amount adjusted to make up the difference between energy received from hospital food and measured energy expenditure. RESULTS:50 Geriatric patients were included in the study. Patients in the intervention group (n = 22) received significantly higher daily energy intake than the control group (n = 28) (1121.3 ± 299.0 vs. 777.1 ± 301.2 kcal, p = 0.001). This was associated with a significantly less negative cumulative energy balance (-1229.9 ± 1763 vs. -4975.5 ± 4368 kcal, p = 0.001). A significant negative correlation was found between the cumulative energy balance and total complication rate (r = -0.417, p = 0.003) as well as for length of hospital stay (r = -0.282, p = 0.049). CONCLUSION:We have demonstrated that nutritional support actively supervised by a dietician and guided by repeated measurements of REE was achievable and improved outcomes in geriatric patients following surgery for hip fractures. Clinicaltrials.gov Identifier: NCT017354435.
10.1016/j.clnu.2013.03.005
Physical behavior and function early after hip fracture surgery in patients receiving comprehensive geriatric care or orthopedic care--a randomized controlled trial.
Taraldsen Kristin,Sletvold Olav,Thingstad Pernille,Saltvedt Ingvild,Granat Malcolm H,Lydersen Stian,Helbostad Jorunn L
The journals of gerontology. Series A, Biological sciences and medical sciences
BACKGROUND:This study is a part of the randomized controlled trial, the Trondheim Hip Fracture Trial, and it compared physical behavior and function during the first postoperative days for hip fracture patients managed with comprehensive geriatric care (CGC) with those managed with orthopedic care (OC). METHODS:Treatment comprised CGC with particular focus on mobilization, or OC. A total of 397 hip fracture patients, age 70 years or older, home dwelling, and able to walk 10 m before the fracture, were included. Primary outcome was measurement of upright time (standing and walking) recorded for 24 hours the fourth day postsurgery by a body-worn accelerometer-based activity monitor. Secondary outcomes were number of upright events on Day 4, need for assistance in ambulation measured by the Cumulated Ambulation score on Days 1-3, and lower limb function measured by the Short Physical Performance Battery on Day 5 postsurgery. RESULTS:A total of 317 (CGC n = 175, OC n = 142) participants wore the activity monitor for a 24-hour period. CGC participants had significantly more upright time (mean 57.6 vs 45.1 min, p = .016), higher number of upright events (p = .005) and better Short Physical Performance Battery scores (p = .002), than the OC participants. Cumulated Ambulation score did not differ between groups (p = .234). CONCLUSIONS:When treated with CGC, compared with OC, older persons suffering a hip fracture spent more time in upright, had more upright events, and had better lower limb function early after surgery despite no difference in their need for assistance during ambulation.
10.1093/gerona/glt097
Management of fractures in a geriatric surgical patient.
Tinubu Jide,Scalea Thomas M
The Surgical clinics of North America
Trauma is an increasingly common problem in geriatric patients; fractures are frequent among the elderly. Life expectancy continues to rise. Advances in medical care allow people to live longer and better lives. Medications, surgical advances (treatment for coronary artery disease, coronary bypass grafting), and joint replacement surgery can be safely performed in elderly patients. Thus, geriatric patients are no longer confined to a life of inactivity. They are out of their homes and interacting in the community, exercising and leading active lives. Thus, they are more likely to become injured and present to trauma centers for care.
10.1016/j.suc.2014.09.017
Identifying outcomes associated with co-managed care models for patients who have sustained a hip fracture: an integrative literature review.
Lynch Genni,Tower Marion,Venturato Lorraine
International journal of orthopaedic and trauma nursing
AIMS AND OBJECTIVES:The aim of this integrative literature review is to identify themes associated with improved patient outcomes related to orthogeriatric co-managed inpatient unit models of care for patients who had sustained a hip fracture. APPROACH:An integrative literature review was undertaken from 2002-July 2013 using electronic databases with specific search terms. METHODS:The theoretical framework of Whittemore and Knafl was used to guide the review. This framework was chosen as it allows for the inclusion of varied methodologies and has the capability to increase informed evidence-based nursing practice. RESULTS:Five distinct themes relating to outcomes emerged from the analysis, which were: time from admission to surgery; complications; length of stay; mortality and initiation of osteoporosis treatment. CONCLUSION:The analysis of this integrative literature review clearly indicates the need for national and international sets of agreed outcome measures to be adopted to facilitate the comparison of models of care. This would significantly improve the way in which outcomes and costs are reported, further enhancing international partnerships as the health care team strive to achieve overall improvements in the management of older people presenting to hospital with hip fracture.
10.1016/j.ijotn.2014.07.002
Multidisciplinary, multi-modal nutritional care in acute hip fracture inpatients - results of a pragmatic intervention.
Bell Jack J,Bauer Judith D,Capra Sandra,Pulle Ranjeev Chrys
Clinical nutrition (Edinburgh, Scotland)
BACKGROUND & AIMS:Malnutrition is highly prevalent and resistant to intervention following hip fracture. This study investigated the impact of individualised versus multidisciplinary nutritional care on nutrition intake and outcomes in patients admitted to a metropolitan hospital acute hip fracture unit. METHODS:A prospective, controlled before and after comparative interventional study aligning to the CONSORT guidelines for pragmatic clinical trials. Randomly selected patients receiving individualised nutritional care (baseline) were compared with post-interventional patients receiving a new model of nutritional care promoting nutrition as a medicine, multidisciplinary nutritional care, foodservice enhancements, and improved nutrition knowledge and awareness. Malnutrition was diagnosed using the Academy of Nutrition and Dietetics criteria. RESULTS:Fifty-eight weighed food records were available for each group across a total of 82 patients (n = 44, n = 38). Group demographics were not significantly different with predominantly community dwelling (72%), elderly (82.2 years), female (70%), malnourished (51.0%) patients prone to co-morbidities (median 5) receiving early surgical intervention (median D1). Multidisciplinary nutritional care reduced intake barriers and increased total 24-h energy (6224 vs. 2957 kJ; p < 0.001) and protein (69.0 vs. 33.8 g; p < 0.001) intakes, reduced nutritional deterioration over admission (5.4 vs. 20.5%; p = 0.049), and increased discharge directly back to the community setting (48.0 vs. 17.6%; p = 0.012). Trends suggested a reduction in median length of stay (D13 vs. D14). Inpatient mortality remained low across groups (5.2%, 2.3%). CONCLUSIONS:Multidisciplinary nutritional care improves nutrition intake and outcomes in acute hip fracture inpatients. Similar pragmatic study designs should be considered in other elderly inpatient populations perceived resistant to nutritional intervention.
10.1016/j.clnu.2013.12.003
Determinants of outcome in hip fracture: role of daily living activities.
Gialanella B,Ferlucci C,Monguzzi V,Prometti P
European journal of physical and rehabilitation medicine
BACKGROUND:Very few studies have investigated activities of daily living (ADLs) post hip-surgery as a possible determinant of functional outcome after hip fracture. AIM:This prospective, observational study aimed to correlate hip-fracture patients' ADLs on admission to in-hospital rehabilitation with their functional outcome post-rehabilitation. METHODS:Of 216 consecutive hip-fracture patients admitted to our Rehabilitation Unit, 204 patients were eligible for the final analyses. All patients underwent the usual rehabilitation. At admission, basic ADLs were assessed by the Functional Independence Measure (FIM) scale. Discharge scores, efficiency and effectiveness in motor-FIM, and discharge destination were outcome measures. Backward stepwise regressions were performed to identify determinants of outcome measures. Age, sex, education, number of relatives, orthopedic treatment, onset to admission interval, Mini Mental State Examination (MMSE), Cumulative Illness Rating Scale, Neuropsychiatric Inventory, ROM, Muscle Strength, and FIM scores at admission were independent variables. RESULTS:There was functional gain in all ADLs post-rehabilitation, walking being the FIM-item with the highest efficiency and effectiveness (respectively, 0.14±0.0 and 64.2±21). Multivariate analyses showed that MMSE was a determinant of final score, efficiency, and effectiveness in motor-FIM. Bladder control was a determinant of final score and effectiveness in motor-FIM, while eating and bathing were determinants of final motor-FIM score. Bowel management was the only determinant of discharge destination. CONCLUSION:Basic ADLs, in particular eating, bathing, bladder and bowel management, are important determinants of outcome in hip fracture. CLINICAL REHABILITATION IMPACT:The results of this study suggest that, in designing studies on outcome prediction in hip fracture, researchers should include tests assessing performance of basic ADLs as independent variables, as this could allow to identify new prognostic indicators that may be helpful for physicians in managing hip fracture patients post-rehabilitation.
Rehabilitation Interventions for Older Individuals With Cognitive Impairment Post-Hip Fracture: A Systematic Review.
Journal of the American Medical Directors Association
PURPOSE:Currently, most rehabilitation services for individuals who sustain a hip fracture are not designed to meet the complex needs of those who also have cognitive impairment. The goal of this review was to identify current best practices for rehabilitation in long-term care settings and approaches to optimize outcomes among individuals with dementia and other cognitive impairments post-hip fracture. PROCEDURES:The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was used to guide the review. Five electronic databases, including PubMed, EMBASE, CINAHL (EBSCO), Medline (EBSCO), and PsycINFO (EBSCO), were searched for intervention studies published in English language journals. Studies were eligible if they focused on rehabilitation interventions post-hip fracture among older individuals (≥ 65 years) with cognitive impairment who were living in or transferred to long-term care or postacute/rehabilitation settings post-hip fracture. Studies were excluded if they did not enroll individuals with cognitive impairment, the study was descriptive without any intervention content, or the intervention components were only medication, surgical approach or medical treatment. MAIN FINDINGS:A total of 4478 records were identified, 1915 of which were duplicative, 2563 were relevant based on title, and after careful review 7 studies were included. Two included studies were randomized controlled trials, one was a single group pre- and post-test, one a descriptive comparison between those with and without cognitive impairment, one a case controlled matched trial, one a nonequivalent groups trial, and one a case report. The interventions varied between manipulating the type and amount of exercise or testing multifactorial issues including environmental interventions and the use of an interdisciplinary team to address psychosocial factors, medication management, use of assistive devices, and specific preferences or concerns of the individuals. CONCLUSIONS:The evidence summarized in this review suggests that it is feasible to implement rehabilitation programs focused on individuals with cognitive impairment in postacute care settings. Moreover, there was evidence to suggest that intensive rehabilitation and exercise activities are beneficial, although innovative approaches may be needed to engage individuals with cognitive impairment.
10.1016/j.jamda.2015.10.004
Physical Activity Levels During Acute Inpatient Admission After Hip Fracture are Very Low.
Davenport Sarah J,Arnold Meaghan,Hua Carol,Schenck Amie,Batten Sarah,Taylor Nicholas F
Physiotherapy research international : the journal for researchers and clinicians in physical therapy
BACKGROUND AND PURPOSE:Hip fractures are very common in older adults and result in serious health consequences. Early mobilization post-surgical intervention for hip fractures is very important. The purpose of this study was to determine physical activity levels during an acute inpatient admission of patients after surgery for hip fracture. METHODS:The observational study was completed on an orthopaedic ward in an acute general hospital. Twenty patients (18 women, mean age ± standard deviation, 79.1 ± 9.3 years) post-surgical intervention for a hip fracture were included. Physical activity levels were measured using an accelerometer to record the percentage of time spent in lying/sitting, standing and walking, number of steps taken and average energy expenditure. RESULTS:Physical activity levels were extremely low, with participants spending an average of 99% of the day either lying or sitting and a little more than 1% of the day either standing or walking (16 min). Participants took an average of 35.7 ± 80.4 steps per day. Patients received more physiotherapy intervention on weekdays compared with weekends. There was no significant difference in activity levels between weekdays to weekends. No measures of physical activity were associated with length of stay. A mild to moderate association (r = 0.26-0.41) was observed between the measures of physical activity and the amount of physiotherapy received during the weekdays. DISCUSSION:Physical activity levels during an acute inpatient admission surgery for hip fracture are very low. Patients may have difficulty completing basic activities of daily living post-discharge into the community. Physical activity should be optimized as early in the rehabilitation process as able.
10.1002/pri.1616
Prevalence of pre-sarcopenia and sarcopenia in Hong Kong Chinese geriatric patients with hip fracture and its correlation with different factors.
Ho A Wh,Lee M Ml,Chan E Wc,Ng H My,Lee C W,Ng W S,Wong S H
Hong Kong medical journal = Xianggang yi xue za zhi
INTRODUCTION:Sarcopenia and osteoporosis are age-related declines in the quantity of muscle and bone, respectively. Both contribute in disability, fall, and hip fracture in the elderly. This study reported the prevalence of sarcopenia in Chinese geriatric patients with hip fracture, and the correlation between relative appendicular skeletal muscle mass index and other factors. METHODS:This case series was conducted in Kowloon West Cluster Orthopaedic Rehabilitation Centre in Hong Kong. Data of all geriatric patients with primary hip fracture admitted to the above Centre from June to December 2014 were studied. Isometric grip strength, the maximal handgrip strength, was measured using a JAMAR hand dynamometer. Body composition including appendicular and whole-body lean body mass was measured using dual-energy X-ray absorptiometry. Pearson's correlation was used to examine the correlation between relative appendicular skeletal muscle mass index and other factors. RESULTS:A total of 239 patients with a mean age of 82 years were included in the study. Stratifying patients as male or female, the mean (± standard deviation) hand grip strength was 20.6 ± 7.3 kg and 13.6 ± 4.5 kg, the mean relative appendicular skeletal muscle mass index was 5.72 ± 0.83 kg/m(2) and 4.87 ± 0.83 kg/m(2), and the mean hip bone mineral density was 0.696 ± 0.13 g/cm(2) and 0.622 ± 0.12 g/cm(2), respectively. The prevalence of sarcopenia based on relative appendicular skeletal muscle mass index and hand grip strength according to the Asian Working Group for Sarcopenia definition was 73.6% in males and 67.7% in females. According to the European Working Group on Sarcopenia definition, the prevalence of pre-sarcopenia was 20.8% in males and 12.4% in females. Relative appendicular skeletal muscle mass index was positively correlated with hand grip strength, body weight, hip bone mineral density, body mass index, and total fat mass in males; and hand grip strength, body weight, body height, body mass index, and total fat mass in females. Except for body height in females, all correlations were statistically significant. CONCLUSION:The prevalence of sarcopenia was very high in geriatric hip fracture patients, and much higher than that in community-dwelling elderly population. Apart from the need to prescribe osteoporosis medicine, sarcopenia screening and treatment should be offered and is essential to reduce subsequent fall, subsequent fracture, fracture-related complications and economic burden to Hong Kong.
10.12809/hkmj154570
The long-term effect of comprehensive geriatric care on gait after hip fracture: the Trondheim Hip Fracture Trial--a randomised controlled trial.
Thingstad P,Taraldsen K,Saltvedt I,Sletvold O,Vereijken B,Lamb S E,Helbostad J L
Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA
SUMMARY:At present, most hip fracture patients are treated in orthopaedic wards. This study showed that a relatively short hospital intervention based on principles of comprehensive geriatric assessment resulted in safer and more efficient gait as long as 1 year following the fracture as compared to conventional orthopaedic treatment. INTRODUCTION:Hip fracture patients are frail, and the fracture is usually followed by substantial decline in gait function. Few studies have assessed gait characteristics other than gait speed and knowledge about the effect of early intervention on long-term gait outcome is sparse. The purpose of this study was to evaluate the long-term effect of pre- and post-surgery Comprehensive Geriatric Care (CGC) on ability to walk, self-reported mobility and gait characteristics in hip fracture patients. METHODS:Two armed, parallel group randomised controlled trial comparing CGC to conventional Orthopaedic Care (OC) in pre- and early post-surgery phase. Hip fracture patients (n = 397), community-dwelling, age >70 years and able to walk at time of the fracture were included. Spatial and temporal gait characteristics were collected using an instrumented walkway (GAITRite® system) 4 and 12 months post-surgery. RESULTS:Participants who received CGC had significantly higher gait speed, less asymmetry, better gait control and more efficient gait patterns, more participants were able to walk and participants reported better mobility 4 and 12 months following the fracture as compared to participants receiving OC. CONCLUSIONS:Pre- and post-surgery CGC showed an effect on gait as long as 1 year after hip fracture. These findings underscore the importance of targeting the vulnerability of these patients at an early stage to prevent gait decline in the long run. As presently, most hip fracture patients are treated in orthopaedic wards with larger focus on the fracture than on frailty, these results are important to inform new models for hip fracture care.
10.1007/s00198-015-3313-9
Is preoperative state anxiety a risk factor for postoperative delirium among elderly hip fracture patients?
Van Grootven Bastiaan,Detroyer Elke,Devriendt Els,Sermon An,Deschodt Mieke,Flamaing Johan,Dubois Christophe,Milisen Koen
Geriatrics & gerontology international
AIM:To determine if preoperative state anxiety is a risk factor for postoperative delirium in older hip fracture patients. METHODS:A secondary data analysis comprising data from a prospective non-randomized trial including 86 patients with a hip fracture aged 65 years and older was carried out. State anxiety was measured preoperatively using the State-Trait Anxiety Inventory. Delirium and its severity was measured pre- and postoperatively (day 1, 3, 5, 8) by trained research nurses using the Confusion Assessment Method and Delirium Index. RESULTS:A total of 24 patients (27.9%) developed delirium postoperatively. Preoperative state anxiety (State-Trait Anxiety Inventory) was not associated with postoperative delirium (rb = 0.135, P = 0.353), duration of postoperative delirium (rho = 0.038, P = 0.861) or severity of postoperative delirium (rho = 0.153, P = 0.160). Independent predictors of postoperative delirium were lower MMSE scores (OR 0.75, 95% CI 0.60-0.95, P = 0.015), osteosynthesis surgery (OR 3.66, 95% CI 1.02-13.15, P = 0,047) and lowest intraoperative diastolic blood pressure (OR 0.92, 95% CI 0.85-0.99, P = 0.031). CONCLUSION:No relationship between state anxiety and postoperative delirium was found, but significant methodological hurdles were observed and discussed providing important groundwork for further research in this area. Further research should focus on reliable measurement of state anxiety in cognitively impaired older populations. Geriatr Gerontol Int 2016; 16: 948-955.
10.1111/ggi.12581
Initial Preoperative Management of Geriatric Hip Fractures.
Ikpeze Tochukwu C,Mohney Stephen,Elfar John C
Geriatric orthopaedic surgery & rehabilitation
Hip fractures are a common emergency among the geriatric population and often requires immediate hospitalization for proper assessment. More than 90% of the time, hip fractures are suffered by individuals older than 65 and are usually precipitated predominantly by falls. Current studies show that the average individual over 65 years falls at least once a year, and roughly 1 out of every 4 of these individuals succumb to their injuries just 12 months following surgical treatment. Moreover, timely treatment and management of these hip fractures have shown to decrease mortality by reducing cardiopulmonary and venous thromboembolic complications that often accompany hip surgeries. As a result, an emphasis on initial preoperative assessment is important to help identify the presence of ancillary factors such as preexisting comorbidities, which can impact the course of treatment. Delaying surgical management of hip fractures has been linked to decreased functional outcomes and increased mortality rates. Time, rather than technique, appears to be a recurring factor that can impact the long-term survival of these patients. The initial preoperative assessment, therefore, presents a window of opportunity where possible interventions can be made in an effort to reduce the delay of surgery, minimize postsurgical complications, and ultimately improve mortality rate among patients with hip fracture.
10.1177/2151458516681145
Association Between Orthostatic Hypotension and Handgrip Strength With Successful Rehabilitation in Elderly Hip Fracture Patients.
Hartog L C,Winters A M,Roijen H,Kamper A M,Inia H,Kleefstra N,Bilo H J G,van Hateren K J J
Archives of physical medicine and rehabilitation
OBJECTIVE:To investigate the relationship between orthostatic hypotension (OH) and muscle strength versus time to successful rehabilitation within elderly patients with hip fracture. DESIGN:A prospective, observational cohort study. Handgrip strength was measured at the day of admission and OH as soon as possible after surgery. Cox proportional hazard modeling was used to investigate the relationship between OH or handgrip strength (kg) and time to successful rehabilitation, expressed as hazard ratios (HRs). OH was defined as a decrease in systolic blood pressure of ≥20mmHg or diastolic blood pressure of ≥10mmHg after postural change (dichotomous). Handgrip strength was measured with a hand dynamometer (continuous). SETTING:General hospital. PARTICIPANTS:Patients (N=116) aged ≥70 years with a hip fracture were recruited on the day of hospital admission. INTERVENTIONS:Not applicable. MAIN OUTCOME MEASURES:Primary outcome was time to successful rehabilitation, which was defined as discharge to patients' own homes. RESULTS:During a median follow-up period of 36 days (interquartile range, 9-57d), 103 patients (89%) were successfully rehabilitated. No statistically significant relationships were found between OH and time to successful rehabilitation (HR=1.05; 95% confidence interval [CI], .67-1.66). Also, handgrip strength and successful rehabilitation were not statistically significantly related (HR=1.03; 95% CI, .99-1.06). CONCLUSIONS:OH measured during the first days of hospitalization is not related to time to successful rehabilitation in patients with hip fracture who have undergone surgery. Although no significant relationship was seen in the present study, the width of the CIs does not exclude a relevant relationship between handgrip strength and time to successful rehabilitation.
10.1016/j.apmr.2016.11.009
How balance task-specific training contributes to improving physical function in older subjects undergoing rehabilitation following hip fracture: a randomized controlled trial.
Monticone Marco,Ambrosini Emilia,Brunati Roberto,Capone Antonio,Pagliari Giulia,Secci Claudio,Zatti Giovanni,Ferrante Simona
Clinical rehabilitation
OBJECTIVE:To evaluate the efficacy of a rehabilitation programme including balance task-specific training in improving physical function, pain, activities of daily living (ADL), balance and quality of life in subjects after a hip fracture. DESIGN:Randomized controlled trial. SUBJECTS:A total of 52 older subjects selected for internal fixation due to extra-capsular hip fracture were randomized to be included in an experimental ( n = 26) and control group ( n = 26). INTERVENTIONS:The experimental group underwent a rehabilitation programme based on balance task-specific training. The control group underwent general physiotherapy, including open kinetic chain exercises and walking training. Both groups individually followed programmes of 90-minute sessions five times/week for three weeks. OUTCOME MEASURES:The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a Pain Numerical Rating Scale, the Berg Balance Scale, the Functional Independence Measure and the 36-item Short-Form Health Survey. The participants were evaluated before and after training, and after 12 months. RESULTS:Significant effects of time, group and time × group were found for all outcome measures in favour of the experimental group. A clinically important between-group difference of 25 points was achieved after training and at follow-up in terms of the primary outcome (WOMAC function before treatment, after treatment and at follow-up was 84.8 (3.7), 39.8 (4.9) and 35.7 (6.2) for the experimental group and 80.9 (5.7), 65.2 (7.1) and 61.0 (11.1) for the control group). CONCLUSION:An inpatient rehabilitation programme based on balance task-specific training is useful in improving physical function, pain, ADL and quality of life in older patients after hip fracture.
10.1177/0269215517724851
Structured exercise improves mobility after hip fracture: a meta-analysis with meta-regression.
Diong Joanna,Allen Natalie,Sherrington Catherine
British journal of sports medicine
OBJECTIVES:To determine the effect of structured exercise on overall mobility in people after hip fracture. To explore associations between trial-level characteristics and overall mobility. DESIGN:Systematic review, meta-analysis and meta-regression. DATA SOURCES:MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register and the Physiotherapy Evidence Database to May 2014. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS:Randomised controlled trials of structured exercise, which aimed to improve mobility compared with a control intervention in adult participants after surgery for hip fracture were included. DATA EXTRACTION AND SYNTHESIS:Data were extracted by one investigator and checked by an independent investigator. Standardised mean differences (SMD) of overall mobility were meta-analysed using random effects models. Random effects meta-regression was used to explore associations between trial-level characteristics and overall mobility. RESULTS:13 trials included in the meta-analysis involved 1903 participants. The pooled Hedges' g SMD for overall mobility was 0.35 (95% CI 0.12 to 0.58, p=0.002) in favour of the intervention. Meta-regression showed greater treatment effects in trials that included progressive resistance exercise (change in SMD=0.58, 95% CI 0.17 to 0.98, p=0.008, adjusted R2=60%) and delivered interventions in settings other than hospital alone (change in SMD=0.50, 95% CI 0.08 to 0.93, p=0.024, adjusted R2=49%). CONCLUSIONS AND IMPLICATIONS:Structured exercise produced small improvements on overall mobility after hip fracture. Interventions that included progressive resistance training and were delivered in other settings were more effective, although the latter may have been confounded by duration of interventions.
10.1136/bjsports-2014-094465
Less than one-third of hip fracture patients return to their prefracture level of instrumental activities of daily living in a prospective cohort study of 480 patients.
Moerman Sophie,Mathijssen Nina Mc,Tuinebreijer Wim E,Nelissen Rob Ghh,Vochteloo Anne Jh
Geriatrics & gerontology international
AIM:A significant loss of instrumental activities of daily living (IADL) after a hip fracture has been reported. The aim of the present study was to identify specific predictors for low IADL after a hip fracture, in order to target better postoperative care for these patients. METHODS:A prospective observational cohort study of 480 hip fracture patients was carried out. IADL was measured at baseline, and after 3 and 12 months using the Groningen Activity Restriction Scale. Multivariable logistic regression analysis was carried out using age, sex, American Society of Anesthesiologists classification, prefracture living with a partner, prefracture living situation, prefracture use of walking aids, type of fracture, type of anesthesia, length of hospital stay, postoperative complications and prefracture IADL as potential predictors for low IADL after a hip fracture. The correlation between IADL, mobility and living situation, both at admission, and 3 and 12 months postoperatively, were measured. RESULTS:Three months after hip fracture treatment, 24% of patients returned to their baseline IADL level, at 12 months postoperative this was 29%. Factors associated with a larger loss in IADL after a hip fracture were older age, prefracture living with a partner, prefracture living at home, prefracture use of walking aids and longer length of hospital stay. The correlation between IADL and living situation was 0.69, and between IADL and use of walking aids was 0.80. CONCLUSIONS:A return to prefracture IADL level was low. Healthier patients have a steeper decline in postoperative IADL. Geriatr Gerontol Int 2018; 18: 1244-1248.
10.1111/ggi.13471
Excess risk of venous thromboembolism in hip fracture patients and the prognostic impact of comorbidity.
Pedersen A B,Ehrenstein V,Szépligeti S K,Sørensen H T
Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA
Hip fracture patients were at increased excess risk of venous thromboembolism (VTE) up to 1 year following hip fracture. During the first year, interaction between hip fracture and comorbidity was observed among patients with severe and very severe comorbidity. INTRODUCTION:We compared the risk of VTE in hip fracture patients with that in the general population. We also examined whether and to what extent the association between hip fracture and VTE varied by comorbidity level. METHODS:Nationwide cohort study based on Danish health registries, 1995-2015. We identified hip fracture patients (n = 110,563) and sampled a comparison cohort without hip fracture from the general population (n = 552,774). Comorbidity was assessed using the Charlson comorbidity index. We calculated attributable fraction, as the proportion of the VTE rate, among persons exposed to both hip fracture and comorbidity, attributed to exposure interaction. RESULTS:The cumulative incidences of VTE were 0.73% within 30 days and 0.83% within 31-365 days among hip fracture patients, and 0.05 and 0.43% in the general population. Adjusted hazard ratios (HRs) of VTE among hip fracture patients were 17.29 [95% confidence interval (CI) 14.74-20.28] during the first 30 days and 2.13 (95% CI 1.95-2.32) during 31-365 days following hip fracture. The relative risks of VTE were 1.03 (95% CI 0.96-1.11) and 1.11 (95% CI 1.00-1.23) after 1-5 years and 6-10 years. During the first 30 days and 31-365 days, 14%/28% of VTE rates and 5%/4% of VTE rates were attributable to the interaction between hip fracture and severe/very severe comorbidity, respectively. Mortality risks within 30 days of VTE were 29.4% in hip fracture and 11.0% in general population cohorts. CONCLUSIONS:Hip fracture patients were at increased excess risk of VTE up to 1 year following their fracture. During the first year, interaction between hip fracture and comorbidity was observed among patients with severe and very severe comorbidity.
10.1007/s00198-017-4213-y
Effectiveness of preoperative physical therapy for older patients with hip fracture.
Sawaguchi Akira,Momosaki Ryo,Hasebe Kiyotaka,Chono Masayuki,Kasuga Seiji,Abo Masahiro
Geriatrics & gerontology international
AIM:To clarify the effectiveness of preoperative physical therapy for older patients after hip fracture in an acute care hospital. METHODS:In the present retrospective observational study, data from the Japan Rehabilitation Database were analyzed for patients admitted to an acute care hospital with hip fracture between 2005 and 2015. In this study, all eligible patients received surgery within 10 days of admission. Propensity score analysis was used to compare outcomes between patients who underwent preoperative rehabilitation and those who did not. The primary outcome was motor Functional Independence Measure (FIM) gain. RESULTS:Of the 681 patients eligible after applying exclusion criteria, 50% underwent preoperative rehabilitation after hip fracture. Both before and after adjustment by inverse probability weighting, motor FIM gain was significantly higher in patients who underwent preoperative rehabilitation (motor FIM gain 31.1 ± 18.2 before weighting, 31.1 ± 18.2 after weighting) than in those who did not (motor FIM gain 24.6 ± 18.1 before weighting, P < 0.01; 26.2 ± 17.6 after weighting, P < 0.02). In addition, motor FIM effectiveness and motor FIM at discharge were significantly higher among patients who underwent preoperative rehabilitation. CONCLUSIONS:Our data suggest that preoperative rehabilitation after hip fracture is associated with better rehabilitation outcomes than no preoperative rehabilitation. Geriatr Gerontol Int 2018; 18: 1003-1008.
10.1111/ggi.13290
Quality of life after hip fracture in the elderly: A systematic literature review.
Peeters Charles M M,Visser Eva,Van de Ree Cornelis L P,Gosens Taco,Den Oudsten Brenda L,De Vries Jolanda
Injury
BACKGROUND:With an increasing ageing population, hip fractures have become a major public health issue in the elderly. It is important to examine the health status (HS) and health-related quality of life (HRQOL) of the elderly faced with the epidemic of hip fractures. OBJECTIVE:To provide an overview of reported HS and HRQOL in elderly patients with a hip fracture. DESIGN:A systematic literature search was performed in Embase, Medline, Web of Science, Scopus, CINAHL, Cochrane, PsycINFO, Pubmed, and Google Scholar in July 2014. Studies which reported the HS or HRQOL based on standardised questionnaires in patients older than 65 years with a hip fracture were considered eligible for inclusion. RESULTS:After inspecting the 2725 potentially eligible studies, 49 fulfilled the inclusion criteria. All included studies were randomised controlled trials or prospective cohort studies. The methodological quality of the studies was moderate. Patients' functioning on the physical, social, and emotional domains were affected after a hip fracture. The HS and HRQOL of the majority of patients recovered in the first 6 months after fracture. However, their HS did not return to prefracture level. Mental state, prefracture functioning on physical and psychosocial domains, comorbidity, female gender, nutritional status, postoperative pain, length of hospital stay, and complications were factors associated with HS or HRQOL. Treatment with total hip arthroplasty or hemi-arthroplasty provided better HS than treatment with internal fixation with displaced femoral neck fractures. Supportive psychotherapy in "low-functioning" patients, (home) rehabilitation programmes and nutritional supplementation appeared to have beneficial effects on HS. CONCLUSIONS:Optimizing nutrition intake, (home) rehabilitation programmes, and the possibility for psychological counselling in patients with difficulties in the psychosocial dimensions would be recommended after hip fracture surgery. Besides HS questionnaires like EQ-5D and SF-36, adequate measurements like the WHOQOL-Bref or ICECAP-O are warranted in future studies regarding hip fracture surgery and postoperative treatment options.
10.1016/j.injury.2016.04.018
Contra-lateral hip fracture in the elderly: are decreased body mass index and skin thickness predictive factors?
Aurégan Jean-Charles,Frison Aurélien,Bégué Thierry,Hannouche Didier,Bosser Catherine,Bensidhoum Morad,Hoc Thierry
International orthopaedics
PURPOSE:A correlation between soft tissue thickness and osteoporosis has been suggested. We aimed to estimate if a low body mass index (BMI) and/or a decrease of skin thickness could estimate the risk of contra-lateral hip fracture. METHODS:First, we performed a retrospective analysis of 1268 patients treated for a hip fracture. The 146 patients who had a contra-lateral hip fractures-study group-were compared with the 1078 patients who did not-control group. Four BMI categories were considered: obese, overweight, normal weight and low weight. Second, we enrolled prospectively 1000 consecutive patients in the emergency department. History of fractures, BMI, and skin aspect on the dorsum of both hands-classified as severe decrease thickness, moderate decrease thickness or normal-were recorded. RESULTS:pt?>In the first part, we found that patients with contra-lateral fractures had a significantly lower BMI than those in the control group (22.2 Vs 26.5 kg/m, p = 0.01). In the second part, 48 on 1000 patients had a hip fracture. Among them, six had a contra-lateral fracture. BMI was 23.4 kg/m in bilateral hip fractures, 33.68 kg/m in the unilateral fracture group, and 28.04 kg/m in the non-fracture group (p = 0.04). Finally, patients with contra-lateral hip fractures had a severe decrease thickness of the skin. CONCLUSION:A low BMI and a decreased skin thickness increase independently the risk of fractures by three times. When associated, they increase the risk of fracture risk by five times. This combination had a sensitivity at 71 % and a specificity at 90 % for predicting hip fracture.
10.1007/s00264-016-3264-6
Improved outcomes following implementation of a multidisciplinary care pathway for elderly hip fractures.
Wallace Raina,Angus L D George,Munnangi Swapna,Shukry Sally,DiGiacomo Jody C,Ruotolo Charles
Aging clinical and experimental research
BACKGROUND:Hip fractures in patients 65 years and older are associated with significant morbidity and mortality. With the steady increase in the elderly population, we implemented an evidence-based clinical practice guideline for the management of hip fractures to optimize patient care and surgical outcomes. AIMS:To evaluate the effects of a multidisciplinary hip fracture care pathway on patient outcomes in the care of elderly patients. METHODS:A retrospective analysis of the differences in outcomes prior to (January-October 2014) and after (November 2014-April 2016) implementation of a hip fracture care pathway at a regional Level I trauma center was performed. RESULTS:There were 80 patients in the pre-pathway group and 191 patients in the post-pathway group with an average age of 83.18 ± 8.24 years. The analysis demonstrated that the post-pathway group had a lower incidence of in-hospital complications (9.95 vs 30.00%; p ≤ 0.001), shorter emergency room length of stay (3.76 ± 2.43 vs 6.78 ± 2.88 h; p ≤ 0.0001), and shorter overall hospital length of stay (5.03 ± 3.46 vs 7.44 ± 6.66 days; p = 0.0028). The in-hospital mortality rate was similar between groups (4.71 vs 6.25%; p = 0.6018). DISCUSSION:The development of a multidisciplinary approach to the care of elderly patients with hip fractures improved morbidity and showed a downward trend in mortality. CONCLUSIONS:Elderly patients with hip fractures treated at our trauma center had improved clinical outcomes after the implementation of a multidisciplinary care pathway.
10.1007/s40520-018-0952-7
Nutritional markers may identify patients with greater risk of re-admission after geriatric hip fractures.
International orthopaedics
PURPOSE:Osteoporotic hip fractures are increasing in prevalence with the growing elderly population. Morbidity and mortality remain high following osteoporotic hip fractures despite advances in medical and surgical treatments. The associated costs and medical burdens are increased with a re-admission following hip fracture treatment. This study sought to identify demographic and clinical values that may be a predictive model for 30-day re-admission risk following operative management of an isolated hip fracture. METHODS:Between January 1, 2013 and April 30, 2015 all patients admitted to a single academic medical centre for treatment of a hip fracture were reviewed. Candidate variables included standard demographics, common laboratory values, and markers of comorbid conditions and nutrition status. A 30-day, all-cause re-admission model was created utilizing multivariate logistic regression. RESULTS:A total of 607 patients with hip fractures were identified and met the inclusion criteria; of those patients, 67 were re-admitted within 30 days. Univariate analysis indicates that the re-admission group had more comorbidities (p < 0.001) and lower albumin (p = 0.038) and prealbumin (p < 0.001). The final, reduced model contained 12 variables and incorporated four out of five nutritional makers with an internally, cross-validated C-statistic of 0.811 (95% CI: 0.754, 0.867). CONCLUSION:Our results indicate that specific nutritional laboratory markers at the index admission may identify patients that have a greater risk of re-admission after hip fracture. This model identifies potentially modifiable risk factors and may allow orthogeriatricians to better educate patients and better treat post-operative nutritional status and care.
10.1007/s00264-017-3663-3
Effect of Lower-Limb Progressive Resistance Exercise After Hip Fracture Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Studies.
Lee Sang Yoon,Yoon Byung-Ho,Beom Jaewon,Ha Yong-Chan,Lim Jae-Young
Journal of the American Medical Directors Association
OBJECTIVE:Although several studies have reported the effect of progressive resistance exercise (PRE) after hip fracture surgery, little is known about the functional efficacy of PRE. Thus, we conducted a meta-analysis to evaluate whether PRE can improve (1) mobility and (2) other physical functions in elderly patients after hip fracture surgery. METHODS:Eight randomized controlled trials investigating the effects of PRE after hip fracture surgery were retrieved from a PubMed, Embase, and Cochrane Library search. Our pair-wise meta-analysis used a fixed or random effects model. RESULTS:PRE significantly improved participants' overall physical functions after hip fracture surgery compared with the control group (standardized mean difference = 0.408; 95% confidence interval, 0.238-0.578; P < .001). It was particularly effective in the areas of mobility (standardized mean difference = 0.501; 95% confidence interval, 0.297-0.705; P < .001), activities of daily living, balance, lower-limb strength or power, and performance task. CONCLUSIONS:Our meta-analysis revealed that PRE after hip fracture surgery improves mobility, activities of daily living, balance, lower-limb strength or power, and performance task outcomes. Because of the small sample size in this meta-analysis and considering the increasing incidence of hip fractures, there is a need for large-scale randomized controlled trials to confirm the functional improvement and adverse effects of PRE.
10.1016/j.jamda.2017.08.021
Risk factors and prognostic implications of aspiration pneumonia in older hip fracture patients: A multicenter retrospective analysis.
Byun Seong-Eun,Shon Hyun-Chul,Kim Ji Wan,Kim Hyung Kyung,Sim Youngsuk
Geriatrics & gerontology international
AIM:The present study aimed to investigate the risk factors and prognostic implications of aspiration pneumonia in older hip fracture patients. METHODS:A total of 394 female and 125 male hip fracture patients aged ≥60 years who underwent surgery between 2015 and 2018 were retrospectively analyzed. To identify risk factors of aspiration pneumonia, demographic factors, the American Society of Anesthesiologists classification, past medical history, known risk factors of aspiration and factors associated with surgery were compared between the aspiration pneumonia group and the control group. Regression analysis was also carried out. To assess the prognostic implications of aspiration pneumonia, hospital stay, frequency of the intensive care unit admission and in-hospital mortality rates were compared between groups. RESULTS:Aspiration pneumonia was diagnosed in 8.8% of the hip fracture patients. Increased age, low body mass index, malnutrition, longer duration of surgery and delayed surgery were identified as risk factors of aspiration pneumonia. Regarding prognostic implications, hospital stay, the frequency of intensive care unit care and in-hospital mortality rates were significantly higher in the aspiration pneumonia group (P < 0.001, <0.001 and 0.001, respectively). CONCLUSIONS:Older hip fracture patients with aspiration pneumonia showed worse prognostic outcome compared with patients without aspiration pneumonia. Longer duration of surgery and delayed surgery, as well as patient characteristics including increased age, low body mass index and malnutrition were identified as risk factors for aspiration pneumonia. Therefore, surgeons should try to reduce the operation time and the time interval between injury and surgery when treating older patients for hip fractures. Geriatr Gerontol Int 2019; 19: 119-123.
10.1111/ggi.13559
Effects of a simple home exercise program and vitamin D supplementation on health-related quality of life after a hip fracture: a randomized controlled trial.
Renerts K,Fischer K,Dawson-Hughes B,Orav E J,Freystaetter G,Simmen H-P,Pape H-C,Egli A,Theiler R,Bischoff-Ferrari H A
Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation
PURPOSE:To test the effects of vitamin D intervention and a simple home exercise program (HE) on health-related quality of life (HRQL) in the first 12 months after hip fracture. METHODS:HRQL was reported in 173 acute hip fracture patients (mean age 84 years, 79% females, 77% community dwelling) who were enrolled in the 12-month 2 × 2 factorial Zurich Hip Fracture Trial. Pre-fracture HRQL was assessed at baseline (4.2 ± 2.2 days post-surgery) and then again at 6 and 12 months after hip fracture surgery by the EuroQol EQ-5D-3L index value (EQ-5D-3L questionnaire). The effects of vitamin D intervention (2000 vs. 800 IU vitamin D) and exercise (HE vs. no HE) or of the combined interventions on HRQL were assessed using multivariable-adjusted repeated-measures linear mixed-effects regression models. RESULTS:The EQ-5D-3L index value significantly worsened from 0.71 pre-fracture to 0.57 over 12 months, but the degree of worsening did not differ between individual or combined interventions. However, regarding only the late recovery between 6 and 12 months, the group receiving neither intervention (800 IU/day and no HE) experienced a significant further decline in the EQ-5D-3L index value (adjusted mean change = 0.08 [95% CI 0.009, 0.15], p = 0.03) while all other groups remained stable. CONCLUSION:Hip fractures have a long-lasting negative effect on HRQL up to 12 months after hip fracture. However, HE and/or 2000 IU vitamin D per day may help prevent a further decline in HRQL after the first 6 months following the acute hip fracture event.
10.1007/s11136-019-02100-4
The association between decreased hand grip strength and hip fracture in older people: A systematic review.
Denk Katharina,Lennon Sheila,Gordon Susan,Jaarsma Ruurd Lucas
Experimental gerontology
Hip fractures are a global concern, resulting in poor outcomes and high health care costs. They mostly affect people >80 years. Hip fractures are influenced by various (modifiable) risk factors. Emerging evidence suggests hand grip strength (HGS) to be one of several useful tools to identify hip fracture risk. This is the first systematic review that aims to assess the evidence underlying the relationship between hip fracture incidence and HGS. Eleven studies were selected for this review (six case-control and five cohort studies), comprising 21,197 participants. Where reported, HGS was significantly decreased in individuals with a hip fracture near the time of injury as compared to controls (p < 0.001); HGS was associated with increased hip fracture risk in all included studies. Meta-analysis was not possible. All studies included in this systematic review confirmed a relationship between decreased HGS and hip fracture incidence. We were not able to quantify the strength of this relationship, due to the heterogeneity of the included studies. HGS merits further investigation as a useful tool for identifying individuals that might be at elevated risk for sustaining a hip fracture.
10.1016/j.exger.2018.06.022
Secular trends of hip fractures in France: impact of changing characteristics of the background population.
Garofoli R,Maravic M,Ostertag A,Cohen-Solal M
Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA
INTRODUCTION:Hip fractures are a societal burden because of their high morbidity and mortality and the cost they generate. With the aging of the population, worries grow about an increase of the incidence and incidence rate of hip fracture in the future. Controversial data have been provided in relation to the referencepopulation used. The aim of this study was to assess the impact of the choice of the reference population in the incidence rate of hip fracture. METHODS:Data were extracted from the French National Hospital Database related to the hospitalizations for hip fracture in France between 2002 and 2013 in patients over 59 years and were classified by gender and age (59-74, 75-84, over 84 years, over 59 years). The crude incidence rates of hip fracture were calculated by dividing the number of hospitalizations for hip fracture by the corresponding populations. To assess the impact of the choice of the reference population, we then calculated the adjusted incidence rates using direct standardization on age for the 2013 reference population. RESULTS:From 2002 to 2013, the incidence of hip fracture rose by 4.8% in women (from 49,287 to 51,661) and 21.8% in men (from 12,716 to 15,482) aged over 59 years. Meanwhile, French population over 59 years increased more with a rise of 21.3% in women and 28.7% in men, resulting in a decrease in the crude incidence rates of 13.6% in women and 5.4% in men. However, this decrease was larger after direct standardization on the 2013 population of reference as 25.6% in women and 19.2% in men as a result of a difference in age-structure of the population. CONCLUSIONS:The incidence of hip fractures continues to grow despite a reduced incidence rate throughout a 12-year-period.
10.1007/s00198-018-4666-7
Effects of essential amino acid supplementation and rehabilitation on functioning in hip fracture patients: a pilot randomized controlled trial.
Aging clinical and experimental research
BACKGROUND:Physical exercise and nutrition seem to have a key role in the management of hip fracture patients. AIM:To evaluate the impact of a 2-month rehabilitative protocol combined with dietetic counseling, with or without essential amino acid supplementation, on functioning in hip fracture patients. METHODS:In this pilot randomized controlled study, we recruited patients aged more than 65 years, at 3 months after hip fracture. We randomly assigned the participants into two groups (A and B). Both groups performed a physical exercise rehabilitative programme (five sessions of 40 min/week for 2 weeks, followed by a home-based exercise protocol) and received a dietetic counseling; only group A was supplemented with two sachets of 4 g/day of essential amino acids (Aminotrofic). We evaluated at baseline and after 2 months of intervention (T): hand grip strength, Timed Up and Go, and Iowa Level of Assistance scale (ILOA). RESULTS:The 32 hip fracture patients (mean aged 79.03 ± 7.80 years) were allocated into two groups: group A (n = 16) and group B (n = 16). All the participants showed significant differences in all outcomes at T (p < 0.017). Sarcopenic patients in group A (n = 10) showed statistically significant differences in all the primary outcomes at T (p < 0.017), whereas sarcopenic patients in group B (n = 13) showed a significant reduction of ILOA only. In non-sarcopenic patients, we found no differences at T in all outcome measures. DISCUSSION:Hip fractures are a complex multifactorial condition of the elderly that determines devastating effects on functioning and independence. CONCLUSION:A multidisciplinary rehabilitative and nutritional intervention seems to be effective on functioning in hip fracture patients, in particular sarcopenic ones.
10.1007/s40520-018-1090-y
Hip fracture audit: Creating a 'critical mass of expertise and enthusiasm for hip fracture care'?
Currie Colin
Injury
The care of frail older people admitted with hip fracture has improved greatly over the last half-century, largely as a result of combined medical care and surgical care and the rise - over the last four decades - of large-scale hip fracture audit. A series of European initiatives evolved. The first national hip fracture audit was the Swedish Rikshöft in the late 1980s, and the largest so far is the UK National Hip Fracture Database (NHFD), launched in 2007. An external evaluation of the NHFD demonstrated statistically significant increases in survival at up to 1 year associated with improved early care: with rising geriatrician involvement and falling delays to surgery, and from which lessons have been learned. Comparable national audits have emerged since in northern Europe and in Australia and New Zealand, and most recently in Spain and Japan. Like the NHFD, these use the synergy of agreed clinical standards and regular - ideally continuous - audit feedback that can prompt and monitor clinical and service developments, often demonstrating both rising quality and improved cost effectiveness. In addition, important benchmarking studies of hip fracture care have been reported from India and China, both of which face huge challenges in providing care of fragility fractures in populations characterised by first-generation mass ageing. The 'halo effect' of the impact of growing expertise in hip fracture care on the care of other fragility fractures is noteworthy and now relevant globally. Although many national audits have now published encouraging reports of progress, the details of context and process determinants of the initiation and development of effective hip fracture audit have received relatively little attention. To address this, an extended discussion section - based on the author's experience of participation in several substantial audits, variously supporting and observing many others, and from his numerous discussions with audit colleagues over the years - may be of value in offering practical advice on some obvious and less obvious practical issues that arise in the setting up of large-scale hip fracture audits in a variety of healthcare contexts.
10.1016/j.injury.2018.06.025
Hip fracture trends in the United States, 2002 to 2015.
Lewiecki E Michael,Wright N C,Curtis J R,Siris E,Gagel R F,Saag K G,Singer A J,Steven P M,Adler R A
Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA
An analysis of United States (US) Medicare claims data from 2002 to 2015 for women aged ≥ 65 years found that age-adjusted hip fracture rates for 2013, 2014, and 2015 were higher than projected, resulting in an estimated increase of more than 11,000 hip fractures. INTRODUCTION:Hip fractures are a major public health concern due to high morbidity, mortality, and healthcare expenses. Previous studies have reported a decrease in the annual incidence of hip fractures in the US beginning in 1995, coincident with the introduction of modern diagnostic tools and therapeutic agents for osteoporosis. In recent years, there has been less bone density testing and fewer prescriptions for osteoporosis treatments. The large osteoporosis treatment gap raises concern of possible adverse effects on hip fracture rates. METHODS:We assessed hip fracture incidence in the US to determine if the previous decline in hip fracture incidence continued. Using 2002 to 2015 Medicare Part A and Part B claims for women ≥ 65 years old, we calculated age-adjusted hip fracture rates, weighting to the 2014 population. RESULTS:We found that hip fracture rates declined each year from 2002 to 2012 and then plateaued at levels higher than projected for years 2013, 2014, and 2015. CONCLUSIONS:The plateau in age-adjusted hip fracture incidence rate resulted in more than 11,000 additional estimated hip fractures over the time periods 2013, 2014, and 2015. We recommend further study to assess all factors contributing to this remarkable change in hip fracture rate and to develop strategies to reduce the osteoporosis treatment gap.
10.1007/s00198-017-4345-0
Mediterranean diet and hip fracture incidence among older adults: the CHANCES project.
Benetou V,Orfanos P,Feskanich D,Michaëlsson K,Pettersson-Kymmer U,Byberg L,Eriksson S,Grodstein F,Wolk A,Jankovic N,de Groot L C P G M,Boffetta P,Trichopoulou A
Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA
The association between adherence to Mediterranean diet (MD) and hip fracture incidence is not yet established. In a diverse population of elderly, increased adherence to MD was associated with lower hip fracture incidence. Except preventing major chronic diseases, adhering to MD might have additional benefits in lowering hip fracture risk. INTRODUCTION:Hip fractures constitute a major public health problem among older adults. Latest evidence links adherence to Mediterranean diet (MD) with reduced hip fracture risk, but still more research is needed to elucidate this relationship. The potential association of adherence to MD with hip fracture incidence was explored among older adults. METHODS:A total of 140,775 adults (116,176 women, 24,599 men) 60 years and older, from five cohorts from Europe and the USA, were followed-up for 1,896,219 person-years experiencing 5454 hip fractures. Diet was assessed at baseline by validated, cohort-specific, food-frequency questionnaires, and hip fractures were ascertained through patient registers or telephone interviews/questionnaires. Adherence to MD was evaluated by a scoring system on a 10-point scale modified to be applied also to non-Mediterranean populations. In order to evaluate the association between MD and hip fracture incidence, cohort-specific hazard ratios (HR), adjusted for potential confounders, were estimated using Cox proportional-hazards regression and pooled estimates were subsequently derived implementing random-effects meta-analysis. RESULTS:A two-point increase in the score was associated with a significant 4% decrease in hip fracture risk (pooled adjusted HR 0.96; 95% confidence interval (95% CI) 0.92-0.99, p = 0.446). In categorical analyses, hip fracture risk was lower among men and women with moderate (HR 0.93; 95% CI 0.87-0.99) and high (HR 0.94; 95% CI 0.87-1.01) adherence to the score compared with those with low adherence. CONCLUSIONS:In this large sample of older adults from Europe and the USA, increased adherence to MD was associated with lower hip fracture incidence.
10.1007/s00198-018-4517-6
Outcomes of Fast-Track Multidisciplinary Care of Hip Fractures in Veterans: A Geriatric Hip Fracture Program Report.
Clinics in orthopedic surgery
BACKGROUND:Hip fractures are a significant cause of morbidity and mortality in the elderly. Fast-track multidisciplinary co-management of these patients, rapid preoperative optimization, early surgery, and expeditious rehabilitation may minimize morbidity and mortality. In this study, we evaluated outcomes of fixation of hip fractures in the elderly patients managed by Geriatric Hip Fracture Program at a military hospital in India. METHODS:A total of 114 patients above 60 years of age with hip fractures were enrolled. They were comanaged by a team of specialists and fast-tracked to surgery. Independent ambulation with support of a walker was achieved before discharge to home. Patients were followed up for 1 year. RESULTS:The average age of the 114 patients was 77 years; 24 patients were octogenarian. Eighty-four percent of injuries were due to a domestic fall. Hypertension (41%) and diabetes (22%) were the most common comorbidities. All patients were optimized before surgery. The average delay from injury to admission was 1.7 days (range, 0 to 14 days) and that from admission to surgery was 1.8 days (range, 0 to 19 days). Hence, the average time from injury to surgery was 3.5 days. The length of stay in hospital was, as per rehabilitative milestones achieved, 2 to 5 days in 40% of the patients and 6 to 15 days in 60% of the patients. At 1 year after surgery, 95 patients were independently ambulant (56 patients with support and 39 patients without support). Twenty-three percent of the patients had postoperative complications and eight patients died (7.7%) at 1-year follow-up; 11 patients were lost to follow-up. CONCLUSIONS:Elderly hip fracture has a high risk of mortality (14%-58%). Thus, expeditious surgery within 24 hours of admission has been advocated in the Western literature to minimize mortality. Mortality rate at 1 year after surgery remains at 10% to 24%. In our study, even with aggressive co-management, the average delay to hip fracture fixation was more than 3 days; however, the 1-year mortality was relatively low (7.7%). This indicates the importance of preoperative optimization and postoperative rehabilitation for independent ambulation and mortality reduction in the elderly population.
10.4055/cios.2019.11.4.388