Craig Whitehead

Early discharge and home rehabilitation after hip fracture achieves functional improvements: a randomized controlled trial:

Objective: To compare hospital and home settings for the rehabilitation of patients following hip fracture. Design: Randomized controlled trial comparing accelerated discharge and home-based rehabilitation (n = 34) with conventional hospital care (n = 32) for patients admitted to hospital with hip fracture. Setting: Three metropolitan hospitals in Adelaide, Australia. Subjects: Sixty-six patients with fractured hip. Interventions: Patients assigned to the home-based rehabilitation group were discharged within 48 hours of randomization. The project team therapists made visits to the patient’s home and negotiated a set of realistic, short-term and measurable treatment goals with both the patient and carer. Those randomized to usual care remained in hospital for conventional rehabilitation. Main outcome measures: Physical and social dependence, balance con”dence, quality of life, carer strain, patient and carer satisfaction, use of community services and incidence of adverse events such as re-admission and falls. Results: While there was no difference between the groups for all measures of quality of life, patients in the accelerated discharge and home-based rehabilitation group recorded a greater improvement in MBI from randomization (p < 0.05) and scored higher on the Falls Ef”cacy Scale (p < 0.05) at four months. There was no difference in falls rates. Patients in the home-based rehabilitation group had a shorter stay in hospital (p < 0.05) but a longer stay in rehabilitation overall (p < 0.001). The groups were comparable on the rate and length of admissions after discharge, use of community services, need for carer input and contact with general practitioner (GP) after discharge.

Corrected Arm Muscle Area: An Independent Predictor of Long-Term Mortality in Community-Dwelling Older Adults?

OBJECTIVES: Older people are at risk of undernutrition because of a number of physiological conditions and lifestyle factors. The purpose of this study was to explore the predictive relationship of corrected arm muscle area (CAMA) with 8‐year mortality in a representative sample of older Australians.

Patient and caregiver outcomes 12 months after home-based therapy for hip fracture: a randomized controlled trial.

OBJECTIVE To compare the effect of early discharge and home-based therapy with conventional hospital rehabilitation on patient and caregiver outcomes at 12 months after hip fracture. DESIGN Randomized controlled trial. SETTING Acute and subacute care with follow-up in a community setting in Australia. PARTICIPANTS Sixty-six older adults admitted to acute care after hip fracture who were assessed as needing rehabilitation. INTERVENTIONS Eligible patients were randomized to either home-based (n=34) or hospital (n=32) rehabilitation. Patients assigned to the home-based group were discharged home within 48 hours of randomization. Patients assigned to hospital rehabilitation received usual care. MAIN OUTCOME MEASURES Modified Barthel Index (MBI), timed up and go (TUG) test, Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and Caregiver Strain Index. RESULTS At 12 months, 56 of 66 (85%) participants were available for follow-up assessment. Both groups achieved significant improvements in MBI and TUG test scores. Patients in both groups had a significant decline in the physical score of the SF-36 and there were no differences between groups. Caregivers of patients allocated to receive home-based therapy reported a reduction in burden after 12 months. Over that period, there was a significant reduction in the burden for caregivers of those patients who received home rehabilitation (P=.020). CONCLUSION For patients who were previously functionally independent and living in the community, early return home with increased involvement of caregivers after hip fracture resulted in similar patient outcomes (home vs hospital) and less caregiver burden at 12 months.

Nutritional supplementation and resistance training in nutritionally at risk older adults following lower limb fracture: a randomized controlled trial

Objective: To describe the independent and combined effects of oral nutrition supplementation and resistance training on health outcomes in nutritionally at risk older adults following lower limb fracture. Design: Randomized controlled trial with 12-week masked outcome assessment. Setting: Teaching hospital. Participants: One hundred nutritionally at risk older adults hospitalized following a fall-related lower limb fracture. Intervention: Commenced seven days after injury. Consisted of daily multinutrient energy-dense oral supplement (6.3 kJ/mL) individually prescribed for six weeks (n =25), tri-weekly resistance training for 12 weeks (n =25), combined treatment (n =24) or attention control plus usual care and general nutrition and exercise advice (n =26). Measurements: Weight change, quadriceps strength, gait speed, quality of life and health care utilization at completion of the 12-week intervention. Results: At 12 weeks, all groups lost weight: nutrition -6.2% (-8.4, -4.0); resistance training -6.3% (-8.3, -4.3); nutrition and resistance training -4.7% (-7.4, -2.0); attention control -5.2% (-9.0, -1.5). Those receiving resistance training alone lost more weight than those receiving the combined treatment (P = 0.029). Significant weight loss was prevented if supplement was consumed for at least 35 days. Groups were no different at 12 weeks for any other outcome. Conclusion: Frail, undernourished older adults with a fall-related lower limb fracture experience clinically significant weight loss that is unable to be reversed with oral nutritional supplements. Those receiving a programme of resistance training without concurrent nutrition support are at increased risk of weight loss compared with those who receive a combined nutrition and resistance training intervention. In this high-risk patient group it is possible to prevent further decline in nutritional status using oral nutritional supplements if strategies are implemented to ensure prescription is adequate to meet energy requirements and levels of adherence are high.

Falls in community-dwelling older persons following hip fracture: impact on self-efficacy, balance and handicap

Objective: To compare the four-month outcomes of fallers and nonfallers as well as those with slow gait speed in patients with hip fracture successfully discharged back to the community. Design: Prospective study with four-month follow-up data. Setting: Community sample of survivors of hip fracture who have completed their rehabilitation programme. Subjects: A consecutive sample of 73 community-dwelling, cognitively intact older adults admitted to hospital following a fall-related hip fracture and available to complete a follow-up assessment at four months. Main outcome measures: At baseline, data collection consisted of the Modified Barthel Index (MBI), Mini Mental State Examination (MMSE), sociodemographics and medical history. At four months follow-up, data collection consisted of the MBI, London Handicap Scale (LHS), Berg Balance Scale (BBS), a 10-metre timed walk test, Falls Efficacy Scale (FES) and the Activities Balance Confidence (ABC) scale. Participants were also asked to recall if they had fallen in the four months since their fracture. Results: Seventy-three participants had complete data for evaluation. There was minimal disability with a mean MBI of 91.2 but there was some residual handicap with a mean LHS of 0.67. Those who had fallen had lower selfefficacy (FES) and greater handicap (LHS). Those with slower gait speed were more handicapped (LHS), had lower self-efficacy (FES and ABC) and lower balance scores (BBS). Conclusions: Measuring ADL disability alone loses valuable information in community-dwelling survivors of hip fracture. Falls after hip fracture should be a target for treatment and our data give some weight to the idea of a fall fracture cycle. Gait speed, which may re‘ect lower limb strength, is also a target for therapeutic interventions. These measures should be included in clinical practice.

Use of an interactive video gaming program compared with conventional physiotherapy for hospitalised older adults: a feasibility trial

Purpose: To assess the feasibility of a physiotherapy intervention using an interactive gaming program compared with conventional physiotherapy for hospitalised older people. Methods: Randomised controlled pilot study in a geriatric rehabilitation unit within an acute public hospital. Participants were randomly allocated to physiotherapy using an interactive gaming program (n = 22) or conventional physiotherapy in a ward-based gym (n = 22). Feasibility was assessed by comparing the effects of the intervention on clinical outcome measures (primary outcome: mobility as assessed by the Timed Up and Go test, secondary outcomes: safety, adherence levels, eligibility and consent rates). Results: Participants (n = 44) had a mean age of 85 years (SD 4.5) and the majority (80%) were women. Univariable analyses showed no significant difference between groups following intervention. However, multivariable analyses suggested that participants using the interactive gaming program improved more on the Timed Up and Go test (p = 0.048) than participants receiving conventional physiotherapy. There were no serious adverse events and high levels of adherence to therapy were evident in both groups. Only a small proportion of patients screened were recruited to the study. Conclusions: In this feasibility study, the use of a commercially available interactive gaming program by physiotherapists with older people in a hospital setting was safe and adherence levels were comparable with conventional therapy. Preliminary results suggest that further exploration of approaches using games as therapy for older people could include commonly used measures of balance and function. Implications for Rehabilitation The use of an interactive gaming program by physiotherapists with hospitalised older people appeared to be safe and resulted in improvements in balance and mobility. Use of these programs may be limited to a relatively small proportion of older people, only those able to use and interested in this technological approach to therapy.

Transitional care facility for elderly people in hospital awaiting a long term care bed: randomised controlled trial

Abstract Objective To assess the effectiveness of moving patients who are waiting in hospital for a long term care bed to an off-site transitional care facility. Design Randomised controlled trial. Setting Three public hospitals in Southern Adelaide. Participants 320 elderly patients (mean age 83 years) in acute hospital beds (212 randomised to intervention, 108 to control). Interventions A transitional care facility where all patients received a single assessment from a specialist elder care team and appropriate ongoing therapy. Main outcome measures Length of stay in hospital, rates of readmission, deaths, and patients functional level (modified Barthel index), quality of life (assessment of quality of life), and care needs (residential care scale) at four months. Results From admission, those in the intervention group stayed a median of 32.5 days (95% confidence interval 29 to 36 days) in hospital. In the control group the median length of stay was 43.5 days (41 to 51 days) (95% confidence interval for difference 6 to 16 days). Patients in the intervention group took a median of 21 days (6 to 27 days) longer to be admitted to permanent care than those in the control group. In both groups few patients went home (14 (7%) in the intervention group v 9 (9%) in the control group). There were no significant differences in death rates (28% v 27%) or rates of transfer back to hospital (28% v 25%). Conclusions For frail elderly patients who are awaiting a residential care bed transfer out of hospital to an off-site transitional care unit with focus on aged care “unblocks beds” without adverse effects.

Effects of a Multifactorial Falls Prevention Program for People With Stroke Returning Home After Rehabilitation: A Randomized Controlled Trial

OBJECTIVES To determine whether a multifactorial falls prevention program reduces falls in people with stroke at risk of recurrent falls and whether this program leads to improvements in gait, balance, strength, and fall-related efficacy. DESIGN A single blind, multicenter, randomized controlled trial with 12-month follow-up. SETTING Participants were recruited after discharge from rehabilitation and followed up in the community. PARTICIPANTS Participants (N=156) were people with stroke at risk of recurrent falls being discharged home from rehabilitation. INTERVENTIONS Tailored multifactorial falls prevention program and usual care (n=71) or control (usual care, n=85). MAIN OUTCOME MEASURES Primary outcomes were rate of falls and proportion of fallers. Secondary outcomes included injurious falls, falls risk, participation, activity, leg strength, gait speed, balance, and falls efficacy. RESULTS There was no significant difference in fall rate (intervention: 1.89 falls/person-year, control: 1.76 falls/person-year, incidence rate ratio=1.10, P=.74) or the proportion of fallers between the groups (risk ratio=.83, 95% confidence interval=.60-1.14). There was no significant difference in injurious fall rate (intervention: .74 injurious falls/person-year, control: .49 injurious falls/person-year, incidence rate ratio=1.57, P=.25), and there were no significant differences between groups on any other secondary outcome. CONCLUSIONS This multifactorial falls prevention program was not effective in reducing falls in people with stroke who are at risk of falls nor was it more effective than usual care in improving gait, balance, and strength in people with stroke. Further research is required to identify effective interventions for this high-risk group.

Interventions to delay functional decline in people with dementia: a systematic review of systematic reviews

Objective To summarise existing systematic reviews that assess the effects of non-pharmacological, pharmacological and alternative therapies on activities of daily living (ADL) function in people with dementia. Design Overview of systematic reviews. Methods A systematic search in the Cochrane Database of Systematic Reviews, DARE, Medline, EMBASE and PsycInfo in April 2015. Systematic reviews of randomised controlled trials conducted in people with Alzheimers disease or dementia measuring the impact on ADL function were included. Methodological quality of the systematic reviews was independently assessed by two authors using the AMSTAR tool. The quality of evidence of the primary studies for each intervention was assessed using GRADE. Results A total of 23 systematic reviews were included in the overview. The quality of the reviews varied; however most (65%) scored 8/11 or more on the AMSTAR tool, indicating high quality. Interventions that were reported to be effective in minimising decline in ADL function were: exercise (6 studies, 289 participants, standardised mean difference (SMD) 0.68, 95% CI 0.08 to 1.27; GRADE: low), dyadic interventions (8 studies, 988 participants, SMD 0.37, 95% CI 0.05 to 0.69; GRADE: low) acetylcholinesterase inhibitors and memantine (12 studies, 4661 participants, donepezil 10 mg SMD 0.18, 95% CI 0.03 to 0.32; GRADE: moderate), selegiline (7 studies, 810 participants, SMD 0.27, 95% CI 0.13 to 0.41; GRADE: low), huperzine A (2 studies, 70 participants, SMD 1.48, 95% CI 0.95 to 2.02; GRADE: very low) and Ginkgo biloba (7 studies, 2530 participants, SMD 0.36, 95% CI 0.28 to 0.44; GRADE: very low). Conclusions Healthcare professionals should ensure that people with dementia are encouraged to exercise and that primary carers are trained and supported to provide safe and effective care for the person with dementia. Acetylcholinesterase inhibitors or memantine should be trialled unless contraindicated. Trial registration number CRD42015020179.

Use of In-Patient Hospital Beds by People Living in Residential Care

Background: There is concern that people living in residential care in Australia make significant and often inappropriate use of acute in-patient hospital services. To date, no factual information has been collected in Australia and its absence may allow myths and negative stereotypes to proliferate. Objective: To determine how and why people living in residential care in Australia use in-patient hospital beds. To determine the outcome of hospitalisation and functional status at 3 months following discharge. Methods: Prospective study of 184 consecutive admissions to hospital following Emergency Department (ED) attendance involving people aged over 65 years and living in residential care in southern Adelaide, South Australia. Information was obtained from the facilities’ transfer letters, and where these were inadequate or absent, telephone interviews were held with residential care staff. Results: 153 people accounted for the 184 admissions. They had a mean age of 84 years and 69% were female. 61% came from hostels and 35% from nursing homes. They had a wide range of clinical problems and twice as many were admitted to medical than to surgical units. Their mean length of hospital stay was 7.9 days, 2.3 days higher than for non-same-day patients and was higher for hostel than for nursing home residents. All but two admissions were considered unavoidable though the provision of specialised care within residential care could have prevented a further 19 (10%) admissions. 96% of admissions resulted in survival to leave hospital and in 74%, people returned directly to their place of origin. At 3 months follow-up, a further 20% of the group had died while 5% were in hospital. In all, 14% of the original group were in a different long-term care facility while 56% were living at their former residence. Conclusions: People living in residential care are often hospitalised because of acute illness. In the vast majority of cases hospitalisation is both appropriate and unavoidable. Most did not require prolonged hospitalisation and were discharged alive, usually to their original residence. However, within 3 months many had died or had functionally declined. Strategies that prevent health breakdown in the residential care setting need to be developed and trialed.