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Rehabilitation After a Hip Fracture
Objective
To analyze the impact of rehabilitation treatment on social functioning in elderly patients after hip fracture during a rehabilitation program.
Methods
This study included 203 patients with hip fracture. Four groups were analyzed on rehabilitation: Group 1, at admission, Group 2, at discharge, Group 3, three months after discharge and Group 4, six months after discharge. The analyzed parameters included: musculoskeletal, neurological and cognitive impairments. Impairment severity was graded by cumulative index rating scale for geriatrics (CIRS-G). Evaluation of social functioning was completed by social functioning component (SFC) from quality of life (SF-36) questionnaire.
Results
There was a significant improvement in SF-36 SFC values for observed impairments from admission to six months after discharge for each severity degree (p<0.01), except for CIRS-G severity degree 4 for cognitive impairment, where significance was p<0.05. For the group of patients with musculoskeletal impairment, there was a significant difference between the values of SF-36 SFC concerning different severity degrees of CIRS-G only at six months after discharge (p<0.05). Patients with neurological or cognitive impairments have shown significant differences between the values of SF-36 SFC in regard to severity degrees of CIRS-G in all observational groups.
Conclusion
Different degrees of observed impairments influence the degree of social functioning recovery in the elderly after hip fracture.Level of Evidence II, Prognostic Studies .
To discuss proximal femoral (hip) fractures as the leading cause of hospitalization for injuries among older persons, using a case example that illustrates not only the orthopedic injury but also how an older person's chronic problems complicate the acute event.
Extensive review of scientific literature on the conditions discussed, supplemented by the case study.
Hip fractures in older adults can present multiple challenges to care when complicated by preexisting or coexisting conditions. This case of an older man with a hip fracture emphasizes the resuscitation priorities for the patient found after a "long lie" and the impact of chronic alcoholism and malnutrition, which lead to serious complications.
Careful physical and psychosocial assessment is important for determining the presenting problem and comorbid conditions. Priorities for postoperative management of hip fracture and its complications guide the nurse practitioner through the successful return of the patient to the community.
To determine whether a home-based systematic multicomponent rehabilitation strategy leads to improved outcomes relative to usual care.
A randomized controlled trial with 12 months of follow-up.
General community; 27 home care agencies.
Three hundred four nondemented persons at least 65 years of age who underwent surgical repair of a hip fracture at two hospitals in New Haven, CT, and returned home within 100 days.
Systematic multicomponent rehabilitation strategy addressing both modifiable physical impairments (physical therapy) and activities of daily living (ADL) disabilities (functional therapy) versus usual care.
A battery of self-report and performance-based measures of physical and social function.
There was no significant difference in the proportion of participants in the two groups who recovered to prefracture levels in self-care ADL at 6 months (71% vs 75%) or 12 months (74% in both groups) or in home management ADL at 6 months (35% vs 44%) or 12 months (44% vs 48%). There also was no difference between the two groups in social activity levels, two timed mobility tasks, balance, or lower extremity strength at either 6 or 12 months. Compared with participants who received usual care, those in the multicomponent rehabilitation program showed slightly greater upper extremity strength at 6 months (p = .04) and a marginally better gait performance (p = .08).
The systematic multicomponent rehabilitation program was no more effective in promoting recovery than usual home-based rehabilitation. Compared with previous cohorts, however, participants randomized to usual care in our study received more rehabilitative and home care services and experienced a higher rate of recovery. This finding is important given the current pressures to reduce home services. The challenge is to determine the composition and duration of rehabilitation and home services that will ensure optimal functional recovery most efficiently in older persons after hip fracture.
A 2-month follow-up of nutritional status was performed in forty elderly patients with recent hip fracture. Patients were nutritionally assessed on admission to our rehabilitation unit (day 0), then monthly (day 30, day 60) by measurement of resting energy expenditure (REE), anthropometric, impedance and biological variables. Patients were defined as undernourished (n 13) or normally nourished (n 27) on the basis of mid-arm circumference (MAC) and triceps skinfold thickness (TST) measurements. Seven patients recovered a walking autonomy and were discharged from the hospital before day 30 (group I) whereas thirteen patients were discharged after day 30 (group II); twenty patients remained in the study at day 60 (group III). MAC and TST decreased in normally nourished patients from group III throughout the study whereas they did not change in group II or in undernourished patients from group III. REE values in relation to fat-free mass were increased compared with normal values and were similar in the three groups on day 0; they did not change during the study. Daily energy intake in relation to body weight was higher in group I and increased in group II and in undernourished patients from group III throughout the study. In contrast, it was below the recommended value at day 0 and it did not significantly improve in normally nourished patients from group III. Serum albumin, transthyretin and transferrin levels on day 0 were below reference intervals in the three groups. Albumin levels increased in group III throughout the study. Inflammatory proteins decreased in groups II and III, with C-reactive protein levels returning to normal values in group II by day 30 and in group III at day 60, while orosomucoid levels did not become completely normal over this period. Our findings indicate no improvement in nutritional status in undernourished patients after surgery for recent hip fracture, despite an adequate energy intake. An insufficient spontaneous energy intake for normally nourished patients was associated with a delayed favourable outcome resulting in a prolonged duration of hospitalization. A hypermetabolic state persisted during the 3 months after surgery.
This paper examines the current care and management of the elderly patient with a hip fracture. It identifies issues regarding the role of the orthopaedic nurse in relation to the rehabilitation of this vulnerable group of older patients, and questions the appropriateness of the orthopaedic trauma ward as an environment in which to provide effective care. The paper offers ideas for alternative strategies to those currently commonly used in practice.
The levels of activity of two populations of fall victims (at home and in an institution) were studied before and then 6 months after an apparently minor fall, in comparison with a control group. The fall victims had a lower level of activity than the controls. They walked less indoors, and found it more difficult to get out. These differences may be considered predictive factors for falls. It was also found that the falls resulted in a restriction of activity and appear to be a factor that aggravates and accelerates the effects of ageing. Language: en
The objective of this prospective study was to analyze the role of mental impairment on nutritional status and functional capacity after hip fracture. Fifty-seven women aged 75 years or older, acutely admitted to a university hospital with a hip fracture, were consecutively included. Nutritional status with anthropometry and body composition, functional condition and activities of daily living (ADL) were collected 4-6 days and 3 months after surgery. Both lucid and mentally impaired women deteriorated in nutritional status in the postoperative period owing to loss of fat and muscle mass. In the mentally impaired group there was a 50% greater loss of body weight (not significant), causing underweight, mean body mass index 19.5 +/- 3.0 kg m-2, whereas body mass index remained normal in the lucid group, 21.3 +/- 3.0 kg m-2. Ability for activity, mobility and continence deteriorated significantly, whereas food and fluid intake remained unchanged in the mentally impaired group. Mental impairment is a major risk indicator for loss of functional capacities after an acute hip fracture. The development of malnutrition and underweight is explained by the lower pre-fracture body weight, giving little margin for the further post-fracture weight loss in this group. Actions to preserve preoperative ability regarding activity, mobility and continence among mentally impaired women seem warranted. A special caring programme directed towards the special needs of this high-risk group might increase their well-being and ability to continue living in their own homes.
This prospective study focused on elderly patients with hip fractures progressing from an acute rehabilitation unit to home care, with and without case management. The intervention included case managers in both settings and care planning tools. The case managed group evidenced shorter lengths of stay on the rehabilitation unit and reduced resource utilization in home care while maintaining functional outcomes as measured by the Functional Independence Measure (FIM). The use of case management allowed two unaffiliated institutions to improve communications and maintain patient care outcomes across a portion of the post-acute continuum of care.
To review and summarize the literature from nursing, medical, and ancillary fields on falls among the elderly. Major injuries from falls are associated with mortality, especially among the elderly. Researchers indicate that, in many cases, falls can be prevented. A summary of the available literature provides information which can be used to plan interventions.
Over 100 publications, 1979-1996 related to falls by elderly were reviewed. Descriptive terms used for searching MEDLINE were falls, elderly, and accidents. Literature from several disciplines was reviewed.
Fall risk can be predetermined and nursing actions can be taken to reduce the occurrence and severity of falls.
To reduce the deleterious effects of falls in the elderly, knowledge-based practice is essential.
To evaluate the contribution of specific nutritional deficiencies (as indicated by zinc; vitamin A, C, and E; albumin; and haemoglobin concentrations) to the risk of pressure sores.
Observational cohort study.
St James's University Hospital, Leeds.
21 elderly patients presenting consecutively to the orthopaedic unit with femoral neck fracture.
Full thickness epidermal break over a pressure bearing surface.
10 patients (48%) developed a pressure sore during their hospital stay. Indices of zinc status and concentrations of albumin, haemoglobin, and vitamins A and E were similar in patients who developed a pressure sore and those who did not. Mean leucocyte vitamin C concentration, however, was 6.3 (SD 2.2) micrograms/10(8) cells in patients who developed a pressure sore as compared with 12.8 (4.6) micrograms/10(8) cells in patients who did not.
Low concentrations of leucocyte vitamin C appear to be associated with subsequent development of pressure sores in elderly patients with femoral neck fractures.
A prospective study was performed to determine the effect of protein depletion and postoperative nutritional status on the outcome in sixty-three elderly patients who had been admitted to the hospital because of a fracture of the hip. The parameters that were used to determine the degree of protein depletion included levels of albumin, of prealbumin, and of transferrin; total lymphocyte count; and nitrogen-balance studies. The outcomes that were examined were the development of complications, the length of the stay in the hospital, the ability to return to the pre-fracture level of function, and over-all survivorship. The hypothesis was that the acute fracture and the subsequent operation are severe stresses in these elderly, often compromised patients. The results supported the hypothesis. Thirty-seven patients (58 per cent) in the study group were in a protein-depleted state during the period of hospitalization. The patients who were protein-depleted had a higher prevalence of complications, were less likely to return to their pre-fracture environment, and tended to stay in the hospital longer, as compared with the nonprotein-depleted patients. Survivorship analysis showed that protein-depleted patients had a significantly lower probability of survival one year after the fracture of the hip (p = 0.02). Elderly patients who sustain the trauma of a fracture of the hip should be managed appropriately with regard to intake of nutrients in the postoperative period.
A group of 40 consecutive patients with hip fractures were studied and confirmed to have a high incidence of protein-calorie malnutrition. The prospective nutritional assessment performed for this study included: serum albumin, serum transferrin, anthropometric measurements, skin testing for delayed hypersensitivity, total lymphocyte count, and a 24-h urine collection for metabolic and nitrogen balance determinations. At 3 months after their hip fracture, 37.5% returned to their premorbid ambulatory status; 42.5% sustained a decrement in their ambulatory status or independence; 12.5% died; 7.5% were lost to follow-up. Of the nutritional parameters studied, albumin was significantly associated with mortality (p = 0.004). Considering those patients with an albumin less than 3.0, a mortality rate of 70% was observed in follow-up (maximum of 11 months), compared with a mortality rate of 18% in patients with an albumin greater than or equal to 3.0. It is concluded that the serum albumin has value as a nutritional index without specialized nutritional parameters, and that a more aggressive approach to nutritional support is needed for the hypoalbuminemic patient with a hip fracture, particularly for those with a serum albumin below 3.0.
An incidence study of fractures of the proximal femur has been conducted over a 10-year period. The results show a doubling of the fracture rate in each decade of life after age 50 years. A comparison of age-adjusted fracture rates with populations in different countries shows that in both men and women, the hip fracture is highest in the United States population examined in this study. The fracture rate is much greater in women than in men, and by age 90 years, about 32% of women and 17% of men had suffered a fracture. An estimate of the number of proximal hip fractures occurring in the United States suggests that approximately 113,000 women and 34,000 men older than 50 years of age will suffer a hip fracture each year. This represents a considerable cost, approaching one billion dollars annually, to health care in the United States.
Women who had lived at home before hip fracture repair (N = 120, M age = 79.9) were interviewed before hospital discharge and at 2, 8, and 14 weeks postdischarge to determine (a) early recovery patterns in function and mood, (b) factors predictive of assistance needed in mobility and perceived mobility compared to prefracture status, (c) problems faced, and (d) advice to others. The mobility pattern was that of a relatively rapid gain until 8 weeks, with a smaller gain from 8 to 14 weeks. Affective mood distress was low except in those going to nursing homes. Somatic mood distress was high, decreasing only gradually. Factors predictive of needed assistance in mobility and of perceived mobility included both those without potential for nursing intervention (age, prefracture mobility, how fell, and type of surgical procedure), and those with the potential for intervention (affective distress, fatigue, and urinary problems). Persistent problems related to limitations in mobility, especially in dressing. Overwhelmingly, subjects advised the need for maintaining a good mental attitude.
The risk of hip fracture among the 7,527 respondents to the Longitudinal Study on Aging (LSOA) is prospectively modeled using
logistic regression techniques. Based on existing studies, a seven-stage hierarchical model serially introduces ecological,
demographic, and social factors as well as general health status before considering symptoms and diseases conducive to hip
fracture, falling history and body mass, and previous hip fracture. Interaction terms involving age and white women are then
introduced to explore novel hypotheses. Of the LSOA respondents, 368 (4.9%) experienced hip fracture between 1984 and 1991.
Significant risks of hip fracture were associated with age, female gender, white race, being hospitalized (for any cause)
in the year prior to baseline, having fallen at least once in the year prior to baseline, and leaner body mass. The risk associated
with increasing age diminishes over the life course. Similarly, the protective effect of body mass diminishes over the life
course. Finally, previous ecological findings are clarified by identifying an elevated risk for white women living in the
rural south.
The aim of the study was to examine the serum albumin levels of patients admitted with hip fractures to see whether there was any relationship between serum albumin and subsequent mortality.
A group of 39 consecutive patients with hip fractures was followed for a period of 12 months. The serum albumin was determined preoperatively. No patient was lost to follow up.
Ten patients died at 12 months. Those who died had a significantly lower serum albumin level than those alive at the end of the follow up period.
The results of this study show that preoperative serum albumin determination in patients with hip fractures is a useful guide to postfracture mortality.
There were an estimated 1.66 million hip fractures world-wide in 1990. According to the epidemiologic projections, this worldwide annual number will rise to 6.26 million by the year 2050. This rise will be in great part due to the huge increase in the elderly population of the world. However, the age-specific incidence rates of hip fractures have also increased during the recent decades and in many countries this rise has not leveled off. In the districts where this increase has either showed or leveled off, the change seems to especially concern women's cervical fractures. In men, the increase has continued unabated almost everywhere. Reasons for the age-specific increase are not known: increase in the age-adjusted incidence of falls of the elderly individuals with accompanying deterioration in the age-adjusted bone quality (strength, mineral density) may partially explain the phenomenon. The growth of the elderly population will be more marked in Asia, Latin America, the Middle East, and Africa than in Europe and North America, and it is in the former regions that the greatest increments in hip fracture are projected so that these regions will account for over 70% of the 6.26 million hip fractures in the year 2050. The incidence rates of hip fractures vary considerably from population to population and race to race but increase exponentially with age in every group. Highest incidences have been described in the whites of Northern Europe (Scandinavia) and North America. In Finland, for example, the 1991 incidence of hip fractures was 1.1% for women and 0.7% for men over 70 years of age. Among elderly nursing home residents, the figures can be as high as 6.2% and 4.9%. The lifetime risk of a hip fracture is 16%-18% in white women and 5%-6% in white men. At the age of 80 years, every fifth woman and at the age of 90 years almost every second woman has suffered a hip fracture. Since populations are aging worldwide, the mean age of the hip fracture patients are increasing rapidly, too. Between 1970 and 1991, the mean age of male Finnish patients increased dramatically from 52.9 years to 69.0 years. In women, the corresponding figures were 71.6 and 78.9 years. This change is likely to cause increasing problems in the treatment and rehabilitation of the patients. In 1990, 72% of the hip fractures worldwide occurred in women. All over the world, the hip fracture incidences are about two times higher in women than in men. Women's overrepresentation has been explained by women's lower bone mass and density and higher frequency of falling. Epidemiologic studies show that trochanteric fractures are an increasing problem since compared with cervical fractures their relative number increases progressively with age in women after the age of 60 years and since their incidence has been shown to increase in both sexes and all age groups during the recent decades. This may have direct public health implication since mortality, morbidity, and costs caused by trochanteric fractures are higher than those of the cervical fractures. Reduced bone density (strength) by age and over the recent decades has been the most frequently mentioned reason for the increase of trochanteric fractures. Also, the fall characteristics of the elderly may have changed during the recent decades resulting in increasing numbers of this type of hip fractures since the type of the hip fracture (cervical or trochanteric) also depends on the impact angle of the greater trochanter at the moment of the floor contact.
The purpose of the study was to determine the relationship of preoperative health status and time to surgery to mortality and late functional outcome in hip fracture patients. The records of 168 consecutive patients who had operations for 171 intertrochanteric or femoral neck fractures were reviewed retrospectively. Preoperative health status was assessed by the American Society of Anesthetists (ASA) classification. Postoperative outcome was determined by mortality and ambulatory status. The follow-up period for survivors averaged 33 months. The overall mortality was 14% at 1 year, which rose to 26% at 2 years, and 33% at 3 years. The 3-year mortality was significantly less for ASA I and II patients (23%) than for ASA III, IV, and V patients (39%). There was also a significant difference in mortality between patients having surgery within 24 hours of admission (20%) and those having surgery beyond 24 hours of admission (50%). Even when only the healthy subgroup of ASA I and II patients were considered, the relative risk of death was 4.5 times greater if surgery occurred after 24 hours from admission. These data support the concept that hip fracture patients are not a homogeneous group with respect to mortality and that the ASA classification is a good predictor of mortality. Patients who had surgery within 24 hours of admission had a significantly lower mortality rate than did patients having surgery beyond 24 hours of admission, regardless of their preoperative ASA classification.
Elderly patients with hip fractures have many medical, physical, and psychosocial challenges. Their care can become complex and require the integration of various disciplines. In this article, the author describes and explains the hip fracture preoperative assessment tool that contains various "red flag" indicators and tools used for data collection. The case manager can use this tool to assess patients before surgery and appropriately plan for discharge. Outcome results are discussed, including functional status, length of stay, and costs.
Background:
Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge.
Methods:
Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988-1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment. The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA).
Results:
In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P<.01). Stroke patients discharged to home health had the lowest rehospitalization rates (P<.05). Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P<.05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement.
Conclusions:
The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.
To determine the effect of cognitive status at admission on functional gain during rehabilitation of elderly hip-fractured patients.
Cohort study.
A hospital geriatric rehabilitation department.
Two hundred twenty-four elderly patients admitted consecutively for rehabilitation after surgery for hip fracture.
Cognitive status was assessed by the Mini-Mental State Examination and the cognitive subscale of the Functional Independence Measure (cognFIM); functional status was assessed by the motor subscale of FIM; absolute functional gain was determined by the motor FIM gain (deltamotFIM); and relative functional gain (based on the potential for improvement) by the Montebello rehabilitation factor score (MRFS).
A significant increase in FIM scores (19.7) occurred during rehabilitation, mainly due to motor functioning (19.1). When the relative functional gain (as measured by both motor MRFS efficacy [r = .591] and efficiency [r = .376] was compared with the absolute gain (as measured by deltamotFIM [r = .304]), a stronger association between cognFIM and the relative measures was found. In addition, motor FIM efficacy and efficiency were significantly lower in the cognitively impaired patients (p<.01). A better rehabilitation outcome was seen in patients with higher admission cognitive status, adjusting for the effects of age, sex, length of stay, and type of fracture (odds ratio = 2.2, 95% confidence interval 1.5-3.7).
Impaired cognitive status at admission lowered the rehabilitation outcome of elderly hip fracture patients. Cognitive impairment was strongly and directly associated with functional gain in these patients. Absolute motor gain appeared to be independent of cognitive status, whereas the relative motor gain depended on it. These findings support the implementation of comprehensive rehabilitation for selected cognitively impaired elderly hip fracture patients.
To develop a Functional Recovery Score for ambulatory elderly hip fracture patients related to independent functioning to assess restoration of function to prefracture status.
The phases of this effort consisted of: (a) identification of five relevant components represented by sixteen specific functional capacities; (b) assessment of the importance independent community-dwelling elderly gave to the sixteen functional capacities; (c) pilot testing of a sixteen-item preliminary questionnaire in recovering elderly hip fracture patients; and (d) modification of the questionnaire to an eleven-item score.
The resulting eleven-item Functional Recovery Score is comprised of three main components: basic activities of daily living (BADL) assessed by four items, instrumental activities of daily living (IADL) assessed by six items, and mobility assessed by one item. Basic activities of daily living comprise 44 percent of the score; instrumental activities of daily living comprise 23 percent, and mobility comprises 33 percent. Complete independence in basic and instrumental activities of daily living and mobility results in a score of 100 percent.
To identify determinants of mortality and institutionalization after hip fracture and to identify those older hip fracture patients at high risk of death or institutionalization after hip fracture.
Population-based prospective inception cohort study of hip fracture patients; patients were assessed in the hospital and at 3 months following the hip fracture.
Edmonton area hip fracture patients admitted to one of two Edmonton, Alberta, Canada, acute care centers between July 10, 1996, and August 31, 1997.
Patients were residents of the Edmonton area and over the age of 64. Those who had previously fractured the same hip within the past 5 years or had some pathological condition underlying the hip fracture were excluded. Of 610 eligible patients, 558 contributed some baseline information and were included in the mortality analysis; the institutionalization analysis was restricted to the 338 patients who lived in the community before fracture, survived the 3-month period postfracture, and had completed a 3-month follow-up interview.
The baseline interview was done in the hospital to assess mental status, prefracture physical function, prefracture health perception, and prefracture social support. The 3-month follow-up interview was done by phone to assess physical function, health perception, and social support 3 months postfracture. Demographic and comorbidity information was collected from medical records.
Low mental status in hospital was found to increase the chances of mortality and institutionalization, and male gender was found to increase mortality risk fourfold. Each additional 10 years of age increased the risk of institutionalization approximately 2.5 times. Patients with lower postfracture physical function had at least five times the risk of institutionalization compared to patients with high postfracture physical function.
Cognitive impairment, older age, and gender were associated with increased risk of poor outcome following hip fracture. The socioeconomic variables--social support and health perception--did not contribute significant additional information in explaining mortality or institutionalization risk. While demographic factors cannot be modified, physical function 3 months postfracture may be amenable to intervention and may reduce the risk of institutionalization. Intervening to increase postfracture physical function may be particularly beneficial to older patients, or to those who are cognitively impaired.
Fractures of the hip are an important cause of later ill health and mortality in elderly people. People with hip fractures are often malnourished at the time of fracture, and have poor food intake in hospital.
This review assesses the effects of nutritional interventions in elderly people recovering from hip fracture.
We searched the Cochrane Musculoskeletal Injuries Group trials register, the Cochrane Controlled Trials Register, Medline, Nutrition Abstracts and Reviews, Embase, Biosis, Cinahl, Healthstar and reference lists. We contacted investigators, and hand searched The American Journal of Clinical Nutrition, Proceedings of the Nutrition Society, Clinical Nutrition and The Journal of Parenteral and Enteral Nutrition. Date of the most recent search: January 2000.
Randomised and quasi-randomised trials of nutritional interventions of mainly older patients (aged over 65 years) with hip fracture.
Trial allocation to included, excluded and awaiting assessment categories, was by consensus. Both reviewers independently extracted data and assessed trial quality. Additional information was sought from all trialists. Pooling of data for primary outcomes and select exploratory analyses were undertaken.
Fifteen randomised trials involving 1054 participants were included. Overall the quality of trials was poor; specifically in terms of allocation concealment, assessor blinding and intention to treat analysis. This, and the limited availability of outcome data, mean that the following results must be interpreted with caution. Oral multinutrient feeds (providing non-protein energy, protein, some vitamins and minerals), evaluated by five trials, may reduce unfavourable outcome (death or complications) (14/66 versus 26/73; relative risk 0.52, 95% confidence interval 0.32 to 0.84), but did not demonstrate an effect on mortality (12/91 versus 14/97; relative risk 0.85, 95% confidence interval 0.42 to 1.70). Four trials, examining nasogastric multinutrient feeding, showed no evidence for an effect on mortality (relative risk 0.99, 95% confidence interval 0.50 to 1.97), but the studies were heterogeneous regarding case-mix. Insufficient information was provided to evaluate unfavourable outcome. The effect of protein in an oral feed, tested in three trials, showed no evidence for an effect on mortality (relative risk 1.38, 95% confidence interval 0.82 to 2.34). It may have reduced the number of long term complications and days spent in rehabilitation wards. Two trials, testing intravenous thiamin (vitamin B1) and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of benefit for either vitamin supplement.
The strongest evidence for the effectiveness of nutritional supplementation exists for oral protein and energy feeds, but the evidence is still very weak. Future trials are required which overcome the defects of the reviewed studies, particularly inadequate size, methodology and outcome assessment.
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.
To examine the effects of co-ordinated multidisciplinary inpatient rehabilitation, compared with usual (orthopaedic) care, for older patients with hip fracture.
We searched the Cochrane Musculoskeletal Injuries Group specialised register (March 2001), MEDLINE (1966 to February 2001), PREMEDLINE (March 28th 2001), and reference lists of articles and books. We also contacted colleagues and trialists.
Randomised and quasi-randomised trials of post-surgical care using specialised rehabilitation of mainly older patients (aged 65 years or over) with hip fracture.
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.
In this substantive update, one new trial has been included. The nine included trials involved 1869 patients. The combined outcomes of death or requiring institutional care showed no significant difference between intervention and control groups (relative risk 0.92; 95% confidence interval 0.82 to 1.04). 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 0.92 (95% confidence interval 0.82 to 1.02). 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 detrimental effect from the intervention. The review update did not result in any new data for these outcomes.
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.
Treatment of common problems of the hip joint
- Goldstein
Continuity, assessment and feedback in orthopaedic nursing care practice is cost-effective
- Stromberg
Post-hip fracture rehabilitation in subacute care
- Sung
dwelling people who fracture their hip
- Overend
Functional status and psychological distress during inpatient rehabilitation: Stroke, lower limb amputation, and hip fracture
- Lin