Multicomponent Home-based Physical Therapy Versus Usual Care for Recovery After Hip Fracture.

OBJECTIVE: To quantify the effect of 2 home-based 16-week multi-component physical therapy interventions on functional recovery compared to usual care after hip fracture. DESIGN: Cross-study comparison using participants from the Community Ambulation Project (CAP; a randomized controlled trial) were compared to the Baltimore Hip Studies-seventh cohort (BHS-7; an observational cohort study) at 3 different time points (CAP: 15, 31, 55 weeks; BHS-7: 8, 26, and 52 weeks). SETTING: General community PARTICIPANTS: Combined convenience sample of hip-fracture patients 8-26 weeks post admission from a prospective cohort study and randomized controlled trial. (N=549) INTERVENTIONS: CAP participants were randomized to one of 2 interventions (PUSH: specific multi-component intervention; PULSE: non-specific multi-component intervention) after standard rehabilitation; BHS-7 participants received usual care. MAIN OUTCOME MEASURES: Mean function (as measured by Short Physical Performance Battery (SPPB) and gait speed) was estimated in each cohort as quadratic functions of time using data from 3 post-fracture assessments in both studies (CAP: 15, 31, 55 weeks; BHS-7: 8, 26, and 52 weeks). RESULTS: The harmonized samples included 101 PUSH, 100 PULSE, and 128 BHS-7 participants that had different demographic and clinical characteristics. Mean baseline SPPB scores (meters per second) were PUSH: 5.5 (SD=2.2), PULSE: 5.5 (SD=2.4), and BHS-7: 4.6 (SD=2.5); and mean gait speeds were 0.60 m/s (SD=0.20) for PUSH, 0.59 m/s (SD=0.17) for PULSE, and 0.46 m/s SD=(0.21) for BHS-7, respectively. Estimated between-group differences for SPPB improvement from 75 days to 1-year post admission were 0.7 (P=.04) in PUSH vs BHS-7; and 0.9 (P=.01) in PULSE vs BHS-7. Mean differences in change in gait speed were 0.08 (P=.002) for PUSH vs BHS-7; and 0.06 (P=.02) PULSE vs BHS-7 (P=.02). CONCLUSIONS: Findings from this cross-study comparison that combined participants from 2 separate studies, with different designs and samples, suggest that home-based multi-component physical therapy programs were associated with greater functional improvement after hip fracture compared to usual care.

Effect of Multicomponent Home-Based Training on Gait and Muscle Strength in Older Adults After Hip Fracture Surgery: A Single Site Randomized Trial.

OBJECTIVE: To investigate the effect of 16-week home-based physical therapy interventions on gait and muscle strength. DESIGN: A single-blinded randomized controlled trial. SETTING: General community. PARTICIPANTS: Thirty-four older adults (N=34) post hip fracture were randomly assigned to either experimental group (a specific multi-component intervention group [PUSH], n=17, 10 women, age=78.6±7.3 years, 112.1±39.8 days post-fracture) or active control (a non-specific multi-component intervention group [PULSE], n=17, 11 women, age=77.8±7.8 years, 118.2±37.5 days post-fracture). INTERVENTION: PUSH and PULSE groups received 32-40 sessions of specific or non-specific multi-component home-based physical therapy, respectively. Training in the PUSH group focused on lower extremity strength, endurance, balance, and function for community ambulation, while the PULSE group received active movement and transcutaneous electrical nerve stimulation on extremities. MAIN OUTCOME MEASURES: Gait characteristics, and ankle and knee muscle strength were measured at baseline and 16 weeks. Cognitive testing of Trail Making Test (Part A: TMT-A; Part-B: TMT-B) was measured at baseline. RESULTS: At 16 weeks, both groups demonstrated significant increases in usual (P<.05) and fast (P<.05) walking speed, while there was no significant difference in increases between the groups. There was only 1 significant change in lower limb muscle strength over time (non-fractured side) between the groups, such that PUSH did better (mean: 4.33%, 95% confidence interval:1.43%-7.23%). The increase in usual and fast walking speed correlated with the baseline Trail-making Test-B score (r=-0.371, P=.037) and improved muscle strength in the fractured limb (r=0.446, P=.001), respectively. CONCLUSION: Gait speed improved in both home-based multicomponent physical therapy programs in older adults after hip fracture surgery. Muscle strength of the non-fractured limb improved in the group receiving specific physical therapy training. Specific interventions targeting modifiable factors such as muscle strength and cognitive performance may assist gait recovery after hip fracture surgery.

Depressive symptom heterogeneity among older adults after hip fracture.

OBJECTIVE: to evaluate patterns of depressive symptoms after hip fracture and examine their impact on functional recovery. METHODS: participants (n = 304) included older adults from the Baltimore Hip Studies 7th cohort who experienced a hip fracture. Depressive symptoms were measured at baseline or 2-, 6- or 12-month post-hip fracture using the 20-item Center for Epidemiologic Studies Depression scale. Gait speed was measured after hip fracture at 2-, 6- or 12-month follow-up. Latent class analysis was used to identify individuals with similar patterns of depressive symptoms after hip fracture. Item response probabilities characterised symptom profiles, and posterior probability estimates were used to assign participants to a baseline depressive symptom subtype. Weighted estimated equations compared post-fracture gait speed between baseline symptomatic and asymptomatic groups. RESULTS: four patterns of depressive symptoms were identified: asymptomatic (50.8%), somatic (28.6%), melancholic (11.4%) and anhedonic (9.2%). The somatic subtype was characterised by difficultly concentrating and reduced energy and movement, whereas anhedonic symptoms were associated with the inability to experience pleasure. Melancholic symptoms corresponded to anhedonia, decreased physical activity and other psychological and somatic complaints. Compared with the asymptomatic group, somatic symptoms were consistently associated with slower gait speed, -0.03 metres per second (m/s) and between-group differences for melancholic symptomology were as large as -0.05 m/s, but the associations were not statistically significant. CONCLUSION: findings demonstrate unique depressive symptom subtypes in older adults after hip fracture and provide confirmatory evidence of unique clinical phenotypes; however, their impact on functional recovery after hip fracture remains unclear.

Residual Disability, Mortality, and Nursing Home Placement After Hip Fracture Over 2 Decades.

OBJECTIVE: To examine trends in 12-month postfracture residual disability, nursing home placement, and mortality among patients with a hip fracture between 1990 and 2011. DESIGN: Secondary analysis of 12-month outcomes from 3 cohort studies and control arms of 2 randomized controlled trials. SETTING: Original studies were conducted as part of the Baltimore Hip Studies (BHS). PARTICIPANTS: Community-dwelling patients ≥65 years of age hospitalized for surgical repair of a nonpathologic hip fracture (N=988). MAIN OUTCOME MEASURES: Twelve-month residual disability, mortality, and nursing home residency were examined in case-mix adjusted models by sex and study. Residual disability was calculated by subtracting prefracture scores of Lower Extremity Physical Activities of Daily Living from scores at 12 months postfracture. We also examined the proportion of individuals with a 12-month score higher than their prefracture score (residual disability>0). RESULTS: Only small improvements were seen in residual disability between 1990 and 2011. No significant differences were seen for men between BHS2 (enrollment 1990-1991; mean residual disability=3.1 activities; 95% confidence interval [CI], 2.16-4.10) and BHS7 (enrollment 2006-2011; mean=3.1 activities; 95% CI, 2.41-3.82). In women, residual disability significantly improved from BHS2 (mean=3.5 activities; 95% CI, 2.95-3.99) to BHS3 (enrollment 1992-1995; mean=2.7 activities; 95% CI, 2.01-3.30) with no significant improvements in later studies. After adjustment, a substantial proportion (91% of men and 79% of women) had a negative outcome (residual disability, died, or nursing home residence at 12 months) in the most recently completed study (BHS7). CONCLUSIONS: Over 2 decades, patients undergoing usual care post-hip fracture still had substantial residual disability. Additional clinical and research efforts are needed to determine how to improve hip fracture treatment, rehabilitation, and subsequent outcomes.

Trunk Muscle Composition 2 Months After Hip Fracture: Findings From the Baltimore Hip Studies.

OBJECTIVE: To determine if hip fracture patients would have smaller cross-sectional area (CSA) and lower radiological attenuation (suggesting greater fat infiltration) in all trunk muscles as compared to older adults without hip fractures. DESIGN: Cross-sectional analysis of computed tomography (CT) scans. SETTING: Clinical imaging facility. PARTICIPANTS: Forty-one white participants (19 men, 22 women) from the Baltimore Hip Studies seventh cohort at 2 months postfracture were compared to 693 white participants (424 men, 269 women) from the Health, Aging and Body Composition (Health ABC) study at the year 6 visit (N=734). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Trunk muscle CSA and attenuation values were obtained from a single 10-mm, axial CT scan completed at the L4-L5 disc space in each participant. RESULTS: The hip fracture cohort had significantly smaller CSA for all trunk muscles (range: 12.1%-38% smaller) compared to the Health ABC cohort (P<.01), with the exception of the rectus abdominus muscle in men (P=.12). But, hip fracture patients, particularly female patients, had higher attenuation levels (lower intramuscular fat) in all trunk muscles (P<.0001). CONCLUSIONS: Findings are consistent with atrophy of the trunk muscles in the hip fracture population without a high level of intramuscular fat. Future work should evaluate the role of trunk muscle composition in the functional recovery of older adults after hip fracture.

Effect of a Multicomponent Home-Based Physical Therapy Intervention on Ambulation After Hip Fracture in Older Adults: The CAP Randomized Clinical Trial.

Importance: Disability persists after hip fracture in older persons. Current rehabilitation may not be sufficient to restore ability to walk in the community. Objective: To compare a multicomponent home-based physical therapy intervention (training) with an active control on ability to walk in the community. Design, Setting, and Participants: Parallel, 2-group randomized clinical trial conducted at 3 US clinical centers (Arcadia University, University of Connecticut Health Center, and University of Maryland, Baltimore). Randomization began on September 16, 2013, and ended on June 20, 2017; follow-up ended on October 17, 2017. Patients aged 60 years and older were enrolled after nonpathologic, minimal trauma hip fracture, if they were living in the community and walking without human assistance before the fracture, were assessed within 26 weeks of hospitalization, and were not able to walk during daily activities at the time of enrollment. A total of 210 participants were randomized and reassessed 16 and 40 weeks later. Interventions: The training intervention (active treatment) (n = 105) included aerobic, strength, balance, and functional training. The active control group (n = 105) received transcutaneous electrical nerve stimulation and active range-of-motion exercises. Both groups received 2 to 3 home visits from a physical therapist weekly for 16 weeks; nutritional counseling; and daily vitamin D (2000 IU), calcium (600 mg), and multivitamins. Main Outcomes and Measures: The primary outcome (community ambulation) was defined as walking 300 m or more in 6 minutes at 16 weeks after randomization. The study was designed to test a 1-sided hypothesis of superiority of training compared with active control. Results: Among 210 randomized participants (mean age, 80.8 years; 161 women [76.7%]), 197 (93.8%) completed the trial (187 [89.0%] by completing the 6-minute walk test at 16 weeks and 10 [4.8%] by adjudication of the primary outcome). Among these, 22 of 96 training participants (22.9%) and 18 of 101 active control participants (17.8%) (difference, 5.1% [1-sided 97.5% CI, -∞ to 16.3%]; 1-sided P = .19) became community ambulators. Seventeen training participants (16.2%) and 15 control participants (14.3%) had 1 or more reportable adverse events during the intervention period. The most common reportable adverse events reported were falls (training: 6 [5.7%], control: 4 [3.8%]), femur/hip fracture (2 in each group), pneumonia (training: 2, control: 0), urinary tract infection (training: 2, control: 0), dehydration (training: 0, control: 2), and dyspnea (training: 0, control: 2). Conclusions and Relevance: Among older adults with a hip fracture, a multicomponent home-based physical therapy intervention compared with an active control that included transcutaneous electrical nerve stimulation and active range-of-motion exercises did not result in a statistically significant improvement in the ability to walk 300 m or more in 6 minutes after 16 weeks. Trial Registration: ClinicalTrials.gov Identifier: NCT01783704.

Persistence of depressive symptoms and gait speed recovery in older adults after hip fracture.

OBJECTIVE: Depression after hip fracture in older adults is associated with worse physical performance; however, depressive symptoms are dynamic, fluctuating during the recovery period. The study aim was to determine how the persistence of depressive symptoms over time cumulatively affects the recovery of physical performance. METHODS: Marginal structural models estimated the cumulative effect of persistence of depressive symptoms on gait speed during hip fracture recovery among older adults (n = 284) enrolled in the Baltimore Hip Studies 7th cohort. Depressive symptoms at baseline and at 2-month and 6-month postadmission for hip fracture were evaluated by using the Center for Epidemiological Studies Depression Scale, and persistence of symptoms was assessed as a time-averaged severity lagged to standardized 3 m gait speed at 2, 6, and 12 months. RESULTS: A 1-unit increase in time-averaged Center for Epidemiological Studies Depression score was associated with a mean difference in gait speed of -0.0076 standard deviations (95% confidence interval [CI]: -0.0184, 0.0032; P = .166). The association was largest in magnitude from baseline to 6 months: -0.0144 standard deviations (95% CI: -0.0303, 0.0015; P = 0.076). Associations for the other time intervals were smaller: -0.0028 standard deviations (95% CI: -0.0138, 0.0083; P = .621) at 2 months and -0.0121 standard deviations (95% CI: -0.0324, 0.0082; P = .238) at 12 months. CONCLUSION: Although not statistically significant, the magnitude of the numerical estimates suggests that expressing more depressive symptoms during the first 6 months after hip fracture has a meaningful impact on functional recovery.

Pain, Genes, and Function in the Post-Hip Fracture Period.

Post-hip fracture generalized pain can lead to a progressive decline in function and greater disability. The purpose of this study was to explore the factors that influence pain among older adults post-hip fracture, including genetic variability, and evaluate whether pain directly or indirectly influenced upper and lower extremity function. This was a secondary data analysis using data from the first 200 participants in a Baltimore Hip Study (BHS), BHS-7. Assessments were done at 2 months post-hip fracture and included age, sex, marital status, education, cognitive status, comorbidities, body mass index (BMI), upper and lower extremity function, single nucleotide polymorphisms (SNPs) from 10 candidate genes, and total areas of pain and pain intensity. Model testing was done using the AMOS statistical program. The full sample included 172 participants with an average age of 81. Fifty percent were female and the majority was Caucasian (93%). Model testing was done on 144 individuals who completed 2 month surveys. Across all models, age, cognition, and BMI were significantly associated with total areas of pain. Thirty SNPs from five genes (BDNF, FKBP5, NTRK2, NTRK3, and OXTR) were associated with areas of pain and/or pain intensity. Together, age, cognition, BMI, and the SNP from one of the five genes explained 25% of total areas of pain and 15% of pain intensity. Only age and cognition were significantly associated with lower extremity function, and only cognition was significantly associated with upper extremity function. The full model was partially supported in this study. Our genetic findings related to pain expand prior reports related to BDNF and NTRK2.

Association between pre-hip fracture depression and days at home after fracture and assessing sex differences.

BACKGROUND: Hip fracture and depression are important public health issues among older adults, but how pre-fracture depression impacts recovery after hip fracture is unknown, especially among males who often experience greater depression severity. Days at home (DAH), or the days spent outside a hospital or healthcare facility, is a novel, patient-centered outcome that can capture meaningful aspects of fracture recovery. How pre-fracture depression impacts DAH after fracture, and related sex differences, remains unclear. METHODS: Participants included 63,618 Medicare fee-for-service beneficiaries aged 65+ years, with a hospitalization claim for hip fracture surgery between 2010 and 2017. The primary exposure was a diagnosis of depression at hospital admission, and the primary outcome was total DAH over 12 months post-discharge. Longitudinal associations between pre-fracture depression and the count of DAH among beneficiaries were estimated using Poisson regression models after adjustment for covariates; sex-by-depression interactions were also assessed. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) reflecting relative differences were estimated from these models. RESULTS: Overall, beneficiaries with depression were younger, White females, and spent 11 fewer average DAH compared to counterparts without depression when demographic factors (age and sex) (IRR = 0.91; 95% CI = 0.90, 0.92; p < 0.0001) and social determinants of health (race, Medicaid dual eligibility, and poverty) were adjusted for (IRR = 0.92; 95% CI = 0.91, 0.93; p < 0.0001), but this association attenuated after adjusting for medical complexities (IRR = 0.99; 95% CI = 0.98, 1.01; p = 0.41) and facility and geographical factors (IRR = 1.0037; 95% CI = 0.99, 1.02; p = 0.66). There was no evidence of effect modification by sex. CONCLUSIONS: The comorbidity burden of preexisting depression may impact DAH among both male and female Medicare beneficiaries with hip fracture. Results suggest a holistic health approach and secondary prevention of depressive symptoms after hip fracture.

Longitudinal characteristics of physical frailty and its components in men and women post hip fracture.

BACKGROUND: Frailty is an important geriatric syndrome predicting adverse health outcomes in older adults. However, the longitudinal characteristics of frailty components in post-hip fracture patients are less understood. Adopting the Fried frailty definition, we examined the longitudinal trends and sex trajectory differences in frailty and its components over 1 year post-fracture. METHODS: Three hundred and twenty-seven hip fracture patients (162 men and 165 women with mean age 80.1 and 81.5) from Baltimore Hip Studies 7th cohort with measurements at 22 days after admission, and months 2, 6, and 12 post-fracture were analyzed. Frailty components included: grip strength, gait speed, weight, total energy expenditure, and exhaustion. Longitudinal analysis used mixed effect models. RESULTS: At baseline, men were sicker with worse cognitive status, and had higher weight and grip strength, but lower total energy expenditure than women (p < 0.001). The prevalence of frailty was 31.5%, 30.2%, and 28.2% at months 2, 6, and 12 respectively, showing no longitudinal trends or sex differences. However, its components showed substantial recovery trends over the post-fracture year after confounding adjustments, including increasing gait speed, reducing risk of exhaustion, and stabilized weight loss and energy expenditure over time. Particularly, while men's grip strength tended to remain stable over first year post surgery within patients, women's grip strength reduced significantly over time within patients. On average over time within patients, women were more active with higher energy expenditures but lower grip strength and weight than men. CONCLUSION: Significant recovery trends and sex differences were observed in frailty components during first year post-fracture. Overall frailty status did not show those trends over months 2-12 since a summary measure might obscure changes in components. Therefore, frailty components provided important multi-dimensional information on the complex recovery process of patients, indicating targets for intervention beyond the global binary measure of frailty.

Sustained IL-6 and sTNF-αR1 levels after hip fracture predict 5-year mortality: A prospective cohort study from the Baltimore Hip Studies.

BACKGROUND: Persistent inflammation is associated with adverse health outcomes, but its impact on mortality has not been investigated previously among hip fracture patients. This article aims to investigate the influence of changes in levels of cytokines in the 2 months after a hip fracture repair on 5-year mortality. METHODS: This is a prospective cohort study from the Baltimore Hip Studies (BHS) with 191 community-dwelling older men and women (≥65 years) who had recently undergone surgical repair of an acute hip fracture, with recruitment from May 2006 to June 2011. Plasma interleukin-6 (IL-6), soluble tumor necrosis factor alpha receptor1 (sTNFα-R1), and interleukin-1 receptor agonist (IL-1RA) were obtained within 22 days of admission and at 2 months. All-cause mortality over 5 years was determined. Logistic regression analysis tested the associations between the cytokines' trajectories and mortality over 5 years, adjusted for covariates (age, sex, education, body mass index, lower extremity physical activities of daily living, and Charlson comorbidity index). RESULTS: High levels of IL-6 and sTNFα-R1 at baseline with small or no decline at 2 months were associated with higher odds of 5-year mortality compared with those with lower levels at baseline and greater decline at 2 months after adjustment for age, and other potential confounders (OR = 4.71, p = 0.01 for IL-6; OR = 15.03, p = 0.002 for sTNFα-R1). Similar results that failed to reach significance were found for IL-1RA (OR = 2.40, p = 0.18). Those with higher levels of cytokines at baseline with greater decline did not have significantly greater mortality than the reference group, those with lower levels at baseline and greater decline. CONCLUSION: Persistent elevation of plasma IL-6 and sTNFα-R1 levels within the first 2 months after hospital admission in patients with hip fracture is associated with higher 5-year mortality. These patients may benefit from enhanced care and earlier intensive interventions to reduce the risk of death.

Effects of Multicomponent Home-Based Intervention on Muscle Composition, Fitness, and Bone Density After Hip Fracture.

BACKGROUND: Mechanistic factors on the pathway to improving independent ambulatory ability among hip fracture patients by a multicomponent home-based physical therapy intervention that emphasized aerobic, strength, balance, and functional training are unknown. The aim of this study was to determine the effects of 2 different home-based physical therapy programs on muscle area and attenuation (reflects muscle density) of the lower extremities, bone mineral density (BMD), and aerobic capacity. METHODS: Randomized controlled trial of home-based 16 weeks of strength, endurance, balance, and function exercises (PUSH, n = 19) compared to seated active range-of-motion exercises and transcutaneous electrical neurostimulation (PULSE, n = 18) in community-dwelling adults >60 years of age within 26 weeks of hip fracture. RESULTS: In PUSH and PULSE groups combined, the fractured leg had lower muscle area and muscle attenuation and higher subcutaneous fat than the nonfractured leg (p < .001) at baseline. At 16 weeks, mean muscle area of the fractured leg was higher in the PUSH than PULSE group (p = .04). Changes in muscle area were not significantly different when compared to the comparative PULSE group. There was a clinically relevant difference in change in femoral neck BMD between groups (p = .05) that showed an increase after PULSE and decrease after PUSH. There were generally no between-group differences in mean VO2peak tests at 16-week follow-up, except the PUSH group reached a higher max incline (p = .04). CONCLUSIONS: The treatment effects of a multicomponent home-based physical therapy intervention on muscle composition, BMD, and aerobic capacity were not significantly different than an active control intervention in older adults recovering from hip fracture. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01783704.

Associations of sex, Alzheimer's disease and related dementias, and days alive and at home among older Medicare beneficiaries recovering from hip fracture.

BACKGROUND: Males constitute 25% of older adults who experience hip fractures in the United States; a concerning upward trend given poorer health and outcomes among male survivors. Male sex is associated with worse cognitive performance after hip fracture, impacting participation in rehabilitation and long-term outcomes especially for those with Alzheimer's disease or related dementias (ADRD). However, little research has evaluated whether sex differences in post-fracture recovery are greater among those living with ADRD. METHODS: Data were drawn from 2010 to 2017 Medicare fee-for-service beneficiaries aged 65 years and older who survived hospitalization for hip fracture (n = 69,581). The primary outcome was days alive and at home (DAAH), a validated patient-centered claims-based outcome calculated as 365 days from fracture minus days in hospital, nursing home, rehabilitation facility, emergency department, or time after death. Multivariable Poisson regressions with an interaction term between sex and ADRD status were to model the association between DAAH and ADRD in the 12 months post hip fracture, adjusting for demographics, injury severity, chronic disease burden, and hospital-level fixed effects. RESULTS: Compared to females, males were younger and had more comorbidities at the time of fracture. Among survivors, males with ADRD spent a mean of 160.7 DAAH compared to 228.4 for males without ADRD, 177.8 for females with ADRD, and 248.0 for females without ADRD. In adjusted analyses, males without ADRD spent 8.2% fewer DAAH compared to females (rate ratio [RR] = 0.92, 95% CI 0.92-0.92). This relative sex difference increased significantly when comparing those living with ADRD, with males spending an additional 3.3% fewer DAAH (interaction RR = 0.96, 95% CI 0.96-0.97). CONCLUSIONS: Males spend fewer DAAH after hip fracture than females, and this difference increases modestly for males living with ADRD compared to females. This suggests that cognitive impairment may be a small but significant contributor to sex-based differences observed during hip fracture recovery.

Associations between living alone, social interactions, and physical performance differ by sex: Results from the Baltimore Hip Studies.

BACKGROUND: There is mixed evidence on whether living arrangements and social interactions are associated with poorer health outcomes after hip fracture repair. Distinct social profiles among male and female older adults may explain some of the differences. However, prior studies did not evaluate these differences by sex. This article aims to assess if the associations between living alone, social interaction, and physical performance differ by sex among hip fracture survivors. METHODS: This prospective cohort study is part of the Baltimore Hip Studies seventh cohort, with 168 male and 171 female hip fracture patients assessed at baseline (≤22 days after hospitalization) and at 2, 6, and 12 months post admission. Living arrangements and interaction with children or siblings and others in the past 2 weeks were collected at all visits. Physical performance was measured in the follow-up visits with the Short Physical Performance Battery (SPPB). Linear mixed models tested associations of living alone and social interaction with SPPB over time adjusted for age, education, comorbidities, physical functioning pre-fracture, cognitive function, self-rated health, and time. RESULTS: For men only, living alone was associated with worse performance (0.7 points lower SPPB scores, p = 0.05). Higher social interaction was associated with 0.8 and 1.2 point higher SPPB scores for men and women, respectively (p < 0.05). Visiting with friends was significantly associated with better function among males, while visiting with children or siblings was associated with worse SPPB among females. CONCLUSIONS: Living arrangements and types of social interaction are differentially associated with physical function for older men and women. Screening for social isolation/integration and including interventions that promote social interaction and participation should be considered in healthcare programs for hip fracture survivors.

Predictors of mobility status one year post hip fracture among community-dwelling older adults prior to fracture: A prospective cohort study.

BACKGROUND: Orthopedists and other clinicians assess recovery potential of hip fracture patients at 2 months post-fracture for care planning. It is unclear if examining physical performance (e.g., balance, gait speed, chair stand) during this follow-up visit can identify individuals at a risk of poor functional recovery, especially mobility, beyond available information from medical records and self-report. METHODS: Data came from 162 patients with hip fracture enrolled in the Baltimore Hip Studies-7th cohort. Predictors of mobility status (ability to walk 1 block at 12 months post-fracture) were the Short Physical Performance Battery (SPPB) comprising balance, walking and chair rise tasks at 2 months; baseline medical chart information (sex, age, American Society of Anesthesiologist physical status rating, type of fracture and surgery, and comorbidities); and self-reported information about the physical function (ability to walk 10 feet and 1 block at pre-fracture and at 2 months post-fracture). Prediction models of 12-month mobility status were built using two methods: (1) logistic regression with least absolute shrinkage and selection operator (LASSO) regularization, and (2) classification and regression trees (CART). Area under ROC curves (AUROC) assessed discrimination. RESULTS: The participants had a median age of 82 years, and 49.3% (n = 80) were men. Two-month SPPB and gait speed were selected as predictors of 12-month mobility by both methods. Compared with an analytic model with medical chart and self-reported information, the model that additionally included physical performance measures had significantly better discrimination for 12-month mobility (AUROC 0.82 vs. 0.88, p = 0.004). CONCLUSION: Assessing SPPB and gait speed at 2 months after a hip fracture in addition to information from medical records and self-report significantly improves prediction of 12-month mobility. This finding has important implications in providing tailored clinical care to patients at a greater risk of being functionally dependent who would not otherwise be identified using regularly measured clinical markers.

A theory-based online hip fracture resource center for caregivers: effects on dyads.

BACKGROUND: Hip fracture is a serious injury for older adults, usually requiring surgical repair and extensive therapy. Informal caregivers can help older adults make a successful recovery by encouraging them to adhere to the therapy plans and improve their health behaviors. Few resources, however, are available for these caregivers to learn about how to assist their care receivers and cope with their unique caregiving situations. OBJECTIVE: The study aims were to develop a comprehensive theory-based online hip fracture resource center (OHRC) for caregivers, Caring for Caregivers, and conducted a feasibility trial. METHODS: The OHRC included self-learning modules, discussion boards, Ask the Experts, and a virtual library. The feasibility of the intervention was assessed by usage and usability. The feasibility of the future trial was tested using a one-group pre-post design on 36 caregiver-care receiver dyads recruited from six hospitals. The caregivers used the OHRC for 8 weeks. The impact of the intervention was assessed on both caregivers (primary) and care receivers (secondary). The data were analyzed by descriptive statistics, paired t tests, and content analyses. RESULTS: On average, caregivers reviewed five modules and used the discussion board 3.1 times. The mean perceived usability score for the OHRC was 74.04 ± 7.26 (range, 12-84). Exposure to the OHRC significantly improved caregivers' knowledge about the care of hip fracture patients (t = 3.17, p = .004) and eHealth literacy (t = 2.43, p = .002). Changes in other caregiver outcomes (e.g., strain, coping, and social support) and care receiver outcomes (e.g., self-efficacy for exercise and osteoporosis medication adherence) were favorable but not significant. DISCUSSION: The findings suggest that the OHRC was user-friendly and could be beneficial for caregivers. Additional larger-scale trials are needed to assess the effectiveness of the intervention on outcomes.

Thigh Muscle Composition and Its Relationship to Functional Recovery Post Hip Fracture Over Time and Between Sexes.

BACKGROUND: Computed tomography (CT)-scan measures of muscle composition may be associated with recovery post hip fracture. METHODS: In an ancillary study to Baltimore Hip Studies Seventh cohort, older adults were evaluated at 2 and 6 months post hip fracture. CT-scan measures of muscle were acquired at 2 months. Short Physical Performance Battery (SPPB) was measured at 2 and 6 months. Generalized estimating equations were used to model the association of muscle measures and physical function, adjusting for age, sex, body mass index, and time postfracture. RESULTS: Seventy-one older adults (52% males, age 79.6 ± 7.3 years) were included. At 2-months, males had greater thigh cross-sectional area (CSA, p < .0001) and less low-density muscle (p = .047), and intermuscular adipose tissue (p = .007) than females on the side of the fracture, while females performed better on the SPPB (p = .05). Muscle measures on the fractured side were associated with function at 2 months in both sexes. Participants with the lowest tertile of muscle CSA difference at 2-months, indicating greater symmetry in CSA between limbs, performed better than the other 2 tertiles at 6-months. Males performed worse in functional measures at baseline and did not recover as well as females (p = .02). CONCLUSION: CT-scan measures of muscle CSA and fatty infiltration were associated with function at 2-months post hip fracture and with improvement in function by 6 months. Observed sex differences in these associations suggest that rehabilitation strategies may need to be adapted by sex after hip fracture.

Four Square Step Test Performance in Hip Fracture Patients.

BACKGROUND AND PURPOSE: Preventing subsequent falls in persons recovering from hip fracture is paramount. The Four Square Step Test (FSST) is a fast, easy measure of dynamic balance, with times more than 15 seconds previously associated with multiple fall risk in older adults. This study investigates among hip fracture patients (1) FSST performance, and how (2) unique population characteristics (such as fracture side) and (3) cognition impact FSST performance. METHODS: Patients with hip fracture (n = 40) 60 years and older came from an ancillary study to a larger randomized controlled trial testing two 16-week in-home physical therapy interventions after completion of usual care rehabilitation. Baseline measurers included: FSST, demographics, fracture characteristics, Modified Mini-Mental State Examination (3MS), Hooper Visual Organization Test (HVOT), and Trails Making Tests (TMT) A and B. RESULTS: Of 40 patients with hip fracture, 13 did not complete the FSST at baseline and were significantly older (P = .040) and performed worse on cognitive tests (3MS, HVOT, TMT-B; P < .05). Mean FSST time was 24.3 ± 13.1 seconds for the other 27, of whom 7 finished in less than 15 seconds. A significant 3-way interaction was observed, such that those with left-side pertrochanteric fractures who performed poorly on the HVOT did significantly worse on the FSST (P < .01, R2 = 0.93). DISCUSSION: Almost one-third of patients with hip fracture could not perform the FSST after completing usual care rehabilitation. Inability to perform the FSST was not random, as those without the FSST were physically and cognitively worse than those who did perform the FSST. Among those who could attempt the FSST, few performed well. Cognitive ability related to spatial orientation and fracture characteristics such as fracture side and fracture type has a synergistic effect on FSST performance. CONCLUSIONS: This is one of the first studies to assess the FSST in a population with hip fracture. At 4 months after hip fracture, most patients cannot perform the FSST in less than 15 seconds. Fracture side and fracture type appear important to FSST performance, as does cognition. More work needs to be done longitudinally to study the FSST in patients with hip fracture.

Impact of psychological resilience on walking capacity in older adults following hip fracture.

BACKGROUND: Community-dwelling older adults experiencing hip fracture often fail to achieve adequate walking capacity following surgery and rehabilitation. Effects of psychological factors on post-fracture walking capacity are poorly understood. Accordingly, this paper investigates effects of psychological resilience on observed walking capacity measures in older adults following hip fracture, controlling for important covariates. METHODS: Data were drawn from the Community Ambulation Project, a clinical trial of 210 community-dwelling adults aged ≥60 years who experienced a minimal trauma hip fracture and were randomized to one of two 16-week home-based physical therapist-guided interventions. Psychological resilience was measured at study baseline using the 6-item Brief Resilience Scale (BRS); scores were classified into groups in order to distinguish levels of self-reported resilience. Walking capacity was assessed at study baseline and 16 weeks later using 4-Meter Gait Speed (4MGS), 50-Foot Walk Test (50FWT), and 6-Minute Walk Distance (SMWD). In multivariate analyses of covariance in which 16-week follow-up values of each walking measure were outcomes, covariates included clinical trial arm, gender, age, and baseline values of: walking measure corresponding to the outcome; body mass index; depressive symptom severity; degree of psychological optimism; cognitive status; informal caregiver need; and days from hospital admission to randomization. RESULTS: Increases between baseline and 16 weeks later in mean gait speed in meters/sec (m/s) and walking distance in meters (m) in 4MGS, 50FWT and SMWD were 0.06 m/s (p = 0.061), 0.11 m/s (p < 0.01), and 25.5 m (p = 0.056) greater, respectively, in the most resilient BRS group compared to the least resilient BRS group. CONCLUSION: Higher levels of psychological resilience were associated with greater walking speed and distance. Psychological resilience represents a potentially clinically important pathway and intervention target, toward the goal of improving walking capacity among older adults known to have substantial residual disability following hip fracture.