Multidisciplinary rehabilitation for older people with hip fractures.

BACKGROUND: Hip fracture is a major cause of morbidity and mortality in older people, and its impact on society is substantial. After surgery, people require rehabilitation to help them recover. Multidisciplinary rehabilitation is where rehabilitation is delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician. This is an update of a Cochrane Review first published in 2009. OBJECTIVES: To assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE and Embase (October 2020), and two trials registers (November 2019). SELECTION CRITERIA: We included randomised and quasi-randomised trials of post-surgical care using multidisciplinary rehabilitation of older people (aged 65 years or over) with hip fracture. The primary outcome - 'poor outcome' - was a composite of mortality and decline in residential status at long-term (generally one year) follow-up. The other 'critical' outcomes were health-related quality of life, mortality, dependency in activities of daily living, mobility, and related pain. DATA COLLECTION AND ANALYSIS: Pairs of review authors independently performed study selection, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. MAIN RESULTS: The 28 included trials involved 5351 older (mean ages ranged from 76.5 to 87 years), usually female, participants who had undergone hip fracture surgery. There was substantial clinical heterogeneity in the trial interventions and populations. Most trials had unclear or high risk of bias for one or more items, such as blinding-related performance and detection biases. We summarise the findings for three comparisons below. Inpatient rehabilitation: multidisciplinary rehabilitation versus 'usual care' Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 20 trials. Multidisciplinary rehabilitation probably results in fewer cases of 'poor outcome' (death or deterioration in residential status, generally requiring institutional care) at 6 to 12 months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.80 to 0.98; 13 studies, 3036 participants; moderate-certainty evidence). Based on an illustrative risk of 347 people with hip fracture with poor outcome in 1000 people followed up between 6 and 12 months, this equates to 41 (95% CI 7 to 69) fewer people with poor outcome after multidisciplinary rehabilitation. Expressed in terms of numbers needed to treat for an additional harmful outcome (NNTH), 25 patients (95% CI 15 to 100) would need to be treated to avoid one 'poor outcome'. Subgroup analysis by type of multidisciplinary rehabilitation intervention showed no evidence of subgroup differences. Multidisciplinary rehabilitation may result in fewer deaths in hospital but the confidence interval does not exclude a small increase in the number of deaths (RR 0.77, 95% CI 0.58 to 1.04; 11 studies, 2455 participants; low-certainty evidence). A similar finding applies at 4 to 12 months' follow-up (RR 0.91, 95% CI 0.80 to 1.05; 18 studies, 3973 participants; low-certainty evidence). Multidisciplinary rehabilitation may result in fewer people with poorer mobility at 6 to 12 months' follow-up (RR 0.83, 95% CI 0.71 to 0.98; 5 studies, 1085 participants; low-certainty evidence). Due to very low-certainty evidence, we have little confidence in the findings for marginally better quality of life after multidisciplinary rehabilitation (1 study). The same applies to the mixed findings of some or no difference from multidisciplinary rehabilitation on dependence in activities of daily living at 1 to 4 months' follow-up (measured in various ways by 11 studies), or at 6 to 12 months' follow-up (13 studies). Long-term hip-related pain was not reported. Ambulatory setting: supported discharge and multidisciplinary home rehabilitation versus 'usual care' Three trials tested this comparison in 377 people mainly living at home. Due to very low-certainty evidence, we have very little confidence in the findings of little to no between-group difference in poor outcome (death or move to a higher level of care or inability to walk) at one year (3 studies); quality of life at one year (1 study); in mortality at 4 or 12 months (2 studies); in independence in personal activities of daily living (1 study); in moving permanently to a higher level of care (2 studies) or being unable to walk (2 studies). Long-term hip-related pain was not reported. One trial tested this comparison in 240 nursing home residents. There is low-certainty evidence that there may be no or minimal between-group differences at 12 months in 'poor outcome' defined as dead or unable to walk; or in mortality at 4 months or 12 months. Due to very low-certainty evidence, we have very little confidence in the findings of no between-group differences in dependency at 4 weeks or at 12 months, or in quality of life, inability to walk or pain at 12 months. AUTHORS' CONCLUSIONS: In a hospital inpatient setting, there is moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of 'poor outcome' (death or deterioration in residential status). There is low-certainty evidence that multidisciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low-certainty evidence that multidisciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. No conclusions can be drawn on other outcomes, for which the evidence is of very low certainty. The generally very low-certainty evidence available for supported discharge and multidisciplinary home rehabilitation means that we are very uncertain whether the findings of little or no difference for all outcomes between the intervention and usual care is true. Given the prevalent clinical emphasis on early discharge, we suggest that research is best orientated towards early supported discharge and identifying the components of multidisciplinary inpatient rehabilitation to optimise patient recovery within hospital and the components of multidisciplinary rehabilitation, including social care, subsequent to hospital discharge.

Which Aged Care inpatients are potentially suitable for community-based acute care?

AIM: To identify Aged Care inpatients potentially suitable for Acute/Post-Acute Care (APAC)-Aged Care, a new service offering community-based acute care as an alternative to hospital admission for frail older people. METHODS: Criteria were developed to identify suitable patients for APAC-Aged Care and applied to consecutive Aged Care inpatient admissions at Royal North Shore Hospital, Sydney, Australia, through retrospective chart review. RESULTS: Only 5/90 reviewed patients were potentially suitable for APAC-Aged Care. All five were from Residential Aged Care Facilities. The median age of the 90 patients was 86 years; 30% lived in Residential Aged Care Facilities; 53% of patients were medically stable on presentation; 70% required investigations beyond a standard baseline set; 27% had either no new functional decline on presentation or adequate community support to manage this; 91% had allied health input and 41% had medical/surgical consultation. CONCLUSION: APAC-Aged Care is a potentially suitable alternative to acute inpatient hospitalisation in a select minority of Aged Care patients.

WITHDRAWN: Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures.

BACKGROUND: Hip fracture is a major cause of morbidity and mortality in older people and its impact, both on the individual and to society, is substantial. OBJECTIVES: To examine the effects of co-ordinated multidisciplinary inpatient rehabilitation, compared with usual (orthopaedic) care, for older patients with hip fracture. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2002), MEDLINE (1966 to December 2002), conference proceedings and reference lists of articles and books. We also contacted colleagues and trialists. SELECTION CRITERIA: Randomised and quasi-randomised trials of post-surgical care using specialised rehabilitation of mainly older patients (aged 65 years or over) with hip fracture. DATA COLLECTION AND ANALYSIS: Trial assignment to included, excluded and awaiting assessment categories, was by consensus. Two reviewers independently assessed trial quality and extracted data. Limited additional information was sought from most trialists. As well as pooling data from primary outcomes, supplementary analyses were performed to combine clinically relevant outcomes and investigate possible explanatory factors. MAIN RESULTS: In this minor update, new data for two already included trials have been incorporated, resulting in only slight changes to the pooled results.The nine included trials involved 1887 patients. The combined outcomes of death or requiring institutional care showed no significant difference between intervention and control groups (relative risk 0.93; 95% confidence interval 0.83 to 1.05). There was considerable heterogeneity in length of stay and cost data. Using death and deterioration in function as a further combined outcome variable yielded a relative risk of 0.91 (95% confidence interval 0.83 to 1.01). This should be interpreted with caution due to heterogeneity. No quality of life measures were reported and the two trials investigating carer burden showed no evidence of detrimental effect from the intervention. The review update did not result in any new data for these outcomes. AUTHORS' CONCLUSIONS: The available trials reviewed had different aims, interventions and outcomes. Combined outcome measures (e.g. death or institutional care) tended to be better for patients receiving co-ordinated inpatient rehabilitation, but the results were heterogeneous and not statistically significant.Future trials of post-surgical care involving inpatient rehabilitation, or other models such as 'early supported discharge' and 'hospital at home' schemes, should aim to establish both effectiveness and cost effectiveness of multidisciplinary rehabilitation overall, rather than attempt to evaluate its components.

Multidisciplinary rehabilitation for older people with hip fractures.

BACKGROUND: Hip fracture is a major cause of morbidity and mortality in older people and its impact on society is substantial. OBJECTIVES: To examine the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older patients with hip fracture. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2009), The Cochrane Library (2009, Issue 2), MEDLINE and EMBASE (both to April 2009). SELECTION CRITERIA: Randomised and quasi-randomised trials of post-surgical care using multidisciplinary rehabilitation of older patients (aged 65 years or over) with hip fracture. The primary outcome, 'poor outcome' was a composite of mortality and decline in residential status at long-term (generally one year) follow-up. DATA COLLECTION AND ANALYSIS: Trial selection was by consensus. Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate. MAIN RESULTS: The 13 included trials involved 2498 older, usually female, patients who had undergone hip fracture surgery. Though generally well conducted, some trials were at risk of bias such as from imbalances in key baseline characteristics.There was substantial clinical heterogeneity in the trial interventions and populations. Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 11 trials. Pooled results showed no statistically significant difference between intervention and control groups for poor outcome (risk ratio 0.89; 95% confidence interval 0.78 to 1.01), mortality (risk ratio 0.90, 95% confidence interval 0.76 to 1.07) or hospital readmission. Individual trials found better results, often short-term only, in the intervention group for activities of daily living and mobility. There was considerable heterogeneity in length of stay and cost data. Three trials reporting carer burden showed no evidence of detrimental effect from the intervention. Overall, the evidence indicates that multidisciplinary rehabilitation is not harmful.The trial comparing primarily home-based multidisciplinary rehabilitation with usual inpatient care found marginally improved function and a clinically significantly lower burden for carers in the intervention group. Participants of this group had shorter hospital stays, but longer periods of rehabilitation. One trial found no significant effect from doubling the number of weekly contacts at the patient's home from a multidisciplinary rehabilitation team. AUTHORS' CONCLUSIONS: While there was a tendency to a better overall result in patients receiving multidisciplinary inpatient rehabilitation, these results were not statistically significant.Future trials of multidisciplinary rehabilitation should aim to establish both effectiveness and cost effectiveness of multidisciplinary rehabilitation overall, rather than evaluate its components.

Recurrent and injurious falls in the year following hip fracture: a prospective study of incidence and risk factors from the Sarcopenia and Hip Fracture study.

BACKGROUND: The incidence and etiology of falls in patients following hip fracture remains poorly understood. METHODS: We prospectively investigated the incidence of, and risk factors for, recurrent and injurious falls in community-dwelling persons admitted for surgical repair of minimal-trauma hip fracture. Fall surveillance methods included phone calls, medical records, and fall calendars. Potential predictors of falls included health status, quality of life, nutritional status, body composition, muscle strength, range of motion, gait velocity, balance, walking endurance, disability, cognition, depression, fear of falling, self-efficacy, social support, physical activity level, and vision. RESULTS: 193 participants enrolled in the study (81 +/- 8 years, 72% women, gait velocity 0.3 +/- 0.2 m/s). We identified 227 falls in the year after hip fracture for the 178 participants with fall surveillance data. Fifty-six percent of participants fell at least once, 28% had recurrent falls, 30% were injured, 12% sustained a new fracture, and 5% sustained a new hip fracture. Age-adjusted risk factors for recurrent and injurious falls included lower strength, balance, range of motion, physical activity level, quality of life, depth perception, vitamin D, and nutritional status, and greater polypharmacy, comorbidity, and disability. Multivariate analyses identified older age, congestive heart failure, poorer quality of life, and nutritional status as independent risk factors for recurrent and injurious falls. CONCLUSIONS: Recurrent and injurious falls are common after hip fracture and are associated with multiple risk factors, many of which are treatable. Interventions should therefore be tailored to alleviating or reversing any nutritional, physiological, and psychosocial risk factors of individual patients.

Methodology and baseline characteristics for the Sarcopenia and Hip Fracture study: a 5-year prospective study.

BACKGROUND: Age-related hip fractures are associated with poor functional outcomes, resulting in substantial personal and societal burden. There is a need to better identify reversible etiologic predictors of suboptimal functional recovery in this group. METHODS: The Sarcopenia and Hip Fracture (SHIP) study was a 5-year prospective cohort study following community-dwelling older persons admitted to three Sydney hospitals for hip fracture. Information was collected at baseline, and 4 and 12 months, including health status, quality of life, nutritional status, body composition, muscle strength, range of motion, gait velocity, balance, walking endurance, disability, cognition, depression, fear of falling, self-efficacy, social support, physical activity level, vision, and fall-related data, with residential status, disability, and mortality reassessed at 5 years. RESULTS: 193 participants enrolled (81 +/- 8 years, 72% women). High levels of activities of daily living, disability and sedentariness were present prior to fracture. At admission, the cohort had high levels of chronic disease; 38% were depressed, 38% were cognitively impaired, and 26% had heart disease. Seventy-one percent of participants were sarcopenic, 58% undernourished, and 55% vitamin D deficient. Mobility, strength, and vision were severely impaired. There was little evidence that these comorbidities were either recognized or treated during hospitalization. Disability, sedentariness, malnutrition, and walking endurance predicted acute hospitalization length of stay. CONCLUSIONS: The complex comorbidity, pre-existing functional impairment, and sedentary behavior in patients with hip fracture suggest the need for thorough screening and targeting of potentially reversible impairments. Rehabilitation outcomes are likely to be highly dependent on amelioration of these highly prevalent accompaniments to hip fracture.

Estimation of thigh muscle cross-sectional area by dual-energy X-ray absorptiometry in frail elderly patients.

BACKGROUND: Thigh muscle mass and cross-sectional area (CSA) are useful indexes of sarcopenia and the response to treatment in older patients. Current criterion methods are computed tomography (CT) and magnetic resonance imaging. OBJECTIVE: The objective was to compare thigh muscle mass estimated by dual-energy X-ray absorptiometry (DXA), a less expensive and more accessible method, with thigh muscle CSA determined by CT in a group of elderly patients recovering from hip fracture. DESIGN: Midthigh muscle CSA (in cm(2)) was assessed from a 1-mm CT slice and midthigh muscle mass (g) from a 1.3-cm DXA slice in 30 patients (24 women) aged 81 +/- 8 y during 12 mo of follow-up. Fat-to-lean soft tissue ratios were calculated with each technique to permit direct comparison of a variable in the same units. RESULTS: Baseline midthigh muscle CSA was highly correlated with midthigh muscle mass (r = 0.86, P < 0.001) such that DXA predicted CT-determined CSA with an SEE of 10 cm(2) (an error of approximately 12% of the mean CSA value). CT- and DXA-determined ratios of midthigh fat to lean mass were similarly related (intraclass correlation coefficient = 0.87, P < 0.001). When data were expressed as the changes from baseline to follow-up, CT and DXA changes were weakly correlated (intraclass correlation coefficient = 0.51, P = 0.019). CONCLUSIONS: Assessment of sarcopenia by DXA midthigh slice is a potential low-radiation, accessible alternative to CT scanning of older patients. The errors inherent in this technique indicate, however, that it should be applied to groups of patients rather than to individuals or to evaluate the response to interventions.