Jorunn L. Helbostad

Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial

BACKGROUNDnMost patients with hip fractures are characterised by older age (>70 years), frailty, and functional deterioration, and their long-term outcomes are poor with increased costs. We compared the effectiveness and cost-effectiveness of giving these patients comprehensive geriatric care in a dedicated geriatric ward versus the usual orthopaedic care.nnnMETHODSnWe did a prospective, single-centre, randomised, parallel-group, controlled trial. Between April 18, 2008, and Dec 30, 2010, we randomly assigned home-dwelling patients with hip-fractures aged 70 years or older who were able to walk 10 m before their fracture, to either comprehensive geriatric care or orthopaedic care in the emergency department, to achieve the required sample of 400 patients. Randomisation was achieved via a web-based, computer-generated, block method with unknown block sizes. The primary outcome, analysed by intention to treat, was mobility measured with the Short Physical Performance Battery (SPPB) 4 months after surgery for the fracture. The type of treatment was not concealed from the patients or staff delivering the care, and assessors were only partly masked to the treatment during follow-up. This trial is registered with ClinicalTrials.gov, number NCT00667914.nnnFINDINGSnWe assessed 1077 patients for eligibility, and excluded 680, mainly for not meeting the inclusion criteria such as living in a nursing home or being aged less than 70 years. Of the remaining patients, we randomly assigned 198 to comprehensive geriatric care and 199 to orthopaedic care. At 4 months, 174 patients remained in the comprehensive geriatric care group and 170 in the orthopaedic care group; the main reason for dropout was death. Mean SPPB scores at 4 months were 5·12 (SE 0·20) for comprehensive geriatric care and 4·38 (SE 0·20) for orthopaedic care (between-group difference 0·74, 95% CI 0·18-1·30, p=0·010).nnnINTERPRETATIONnImmediate admission of patients aged 70 years or more with a hip fracture to comprehensive geriatric care in a dedicated ward improved mobility at 4 months, compared with the usual orthopaedic care. The results suggest that the treatment of older patients with hip fractures should be organised as orthogeriatric care.nnnFUNDINGnNorwegian Research Council, Central Norway Regional Health Authority, St Olav Hospital Trust and Fund for Research and Innovation, Liaison Committee between Central Norway Regional Health Authority and the Norwegian University of Science and Technology, the Department of Neuroscience at the Norwegian University of Science and Technology, Foundation for Scientific and Industrial Research at the Norwegian Institute of Technology (SINTEF), and the Municipality of Trondheim.

Physical Behavior and Function Early After Hip Fracture Surgery in Patients Receiving Comprehensive Geriatric Care or Orthopedic Care—A Randomized Controlled Trial

BACKGROUNDnThis study is a part of the randomized controlled trial, the Trondheim Hip Fracture Trial, and it compared physical behavior and function during the first postoperative days for hip fracture patients managed with comprehensive geriatric care (CGC) with those managed with orthopedic care (OC).nnnMETHODSnTreatment comprised CGC with particular focus on mobilization, or OC. A total of 397 hip fracture patients, age 70 years or older, home dwelling, and able to walk 10 m before the fracture, were included. Primary outcome was measurement of upright time (standing and walking) recorded for 24 hours the fourth day postsurgery by a body-worn accelerometer-based activity monitor. Secondary outcomes were number of upright events on Day 4, need for assistance in ambulation measured by the Cumulated Ambulation score on Days 1-3, and lower limb function measured by the Short Physical Performance Battery on Day 5 postsurgery.nnnRESULTSnA total of 317 (CGC n = 175, OC n = 142) participants wore the activity monitor for a 24-hour period. CGC participants had significantly more upright time (mean 57.6 vs 45.1 min, p = .016), higher number of upright events (p = .005) and better Short Physical Performance Battery scores (p = .002), than the OC participants. Cumulated Ambulation score did not differ between groups (p = .234).nnnCONCLUSIONSnWhen treated with CGC, compared with OC, older persons suffering a hip fracture spent more time in upright, had more upright events, and had better lower limb function early after surgery despite no difference in their need for assistance during ambulation.

Effect of in-hospital comprehensive geriatric assessment (CGA) in older people with hip fracture. The protocol of the Trondheim Hip Fracture Trial

BackgroundHip fractures in older people are associated with high morbidity, mortality, disability and reduction in quality of life. Traditionally people with hip fracture are cared for in orthopaedic departments without additional geriatric assessment. However, studies of postoperative rehabilitation indicate improved efficiency of multidisciplinary geriatric rehabilitation as compared to traditional care. This randomized controlled trial (RCT) aims to investigate whether an additional comprehensive geriatric assessment of hip fracture patients in a special orthogeriatric unit during the acute in-hospital phase may improve outcomes as compared to treatment as usual in an orthopaedic unit.Methods/designThe intervention of interest, a comprehensive geriatric assessment is compared with traditional care in an orthopaedic ward. The study includes 401 home-dwelling older persons >70 years of age, previously able to walk 10 meters and now treated for hip fracture at St. Olav Hospital, Trondheim, Norway. The participants are enrolled and randomised during the stay in the Emergency Department. Primary outcome measure is mobility measured by the Short Physical Performance Battery (SPPB) at 4 months after surgery. Secondary outcomes measured at 1, 4 and 12 months postoperatively are place of residence, activities of daily living, balance and gait, falls and fear of falling, quality of life and depressive symptoms, as well as use of health care resources and survival.DiscussionWe believe that the design of the study, the randomisation procedure and outcome measurements will be of sufficient strength and quality to evaluate the impact of comprehensive geriatric assessment on mobility and other relevant outcomes in hip fracture patients.Trials registrationClinicalTrials.gov, NCT00667914

Comparison of programs for determining temporal-spatial gait variables from instrumented walkway data: PKmas versus GAITRite.

BackgroundMeasurement of temporal-spatial gait variables is common in aging research with several methods available. This study investigated the differences in temporal-spatial gait outcomes derived from two different programs for processing instrumented walkway data.MethodData were collected with GAITRite® hardware from 86 healthy older people and 44 older people four months following surgical repair of hip fracture. Temporal-spatial variables were derived using both GAITRite® and PKmas® processing programs from the same raw footfall data.ResultsThe mean differences between the two programs for most variables were negligible, including for Speed (mean difference 0.3u2009±u20090.6xa0cm/sec, or 0.3% of the mean GAITRite® Speed). The mean absolute percentage difference for all 18 gait variables examined ranged from 0.04% for Stride Duration to 66% for Foot Angle. The ICCs were almost perfect (≥0.99) for all variables apart from Base Width, Foot Angle, Stride Length Variability, Step Length Variability, Step Duration Variability and Step Width Variability, which were all never-the-less above 0.84. There were systematic differences for Base Width (PKmas® values 1.6xa0cm lower than GAITRite®) and Foot Angle (PKMAS® values 0.7° higher than GAITRite®). The differences can be explained by the differences in definitions and calculations between the programs.ConclusionsThe study demonstrated that for most variables the outcomes from both programs can be used interchangeably for evaluation of gait among older people collected with GAITRite® hardware. However, validity and reliability for Base Width and Foot Angle derived by PKMAS® would benefit from further investigation.

Prognostic factors for self-rated function and perceived health in patient living at home three months after a hip fracture

Purpose: To explore the relationship between prefracture sociodemographic and health characteristics, basic activities of daily living, instrumental activities of daily living and perceived health 3 months after a hip fracture aged 65 or older.Methods: Age, sex, living alone or not, use of walking aids and whether they had experienced another fall during the previous 6 months, were recorded in hospital and at a three-month follow-up. A total of 277 patients were included. The Barthel Index, the Nottingham Extended ADL Index, the Short Form-12 questionnaire, and the Mini Mental State Examination were used.Results: Prefracture use of a walking aid outdoors was a predictor of postfracture dependency in basic activities of daily living: odds ratio (OR) 2.0, 95% confidence intervals (CI 1.1–3.6), reduced score in instrumental activities of daily living (OR 1.8; 95% CI 1.0–3.2) and reduced perceived physical health (pu2009=u20090.04). Prefracture instrumental activity of daily living was a predictor for dependency in basic activities of daily living (OR 3.3; 95% CI 1.7–6.3). Cognitive dysfunction was a risk factor for dependency in basic activities of daily living (OR 0.1; 95% CI 0.01–0.7).Conclusions: Prefracture use of outdoor walking aids, perceived physical health, cognitive function, instrumental activity of daily living and female gender were all predictors explaining the three-month outcomes for basic activities of daily living and instrumental activity of daily living. Implications for Rehabilitation The use of a walking aid before hip fracture may be a poor prognostic factor affecting 3-months rehabilitation outcome of hip-fractured patients. It is of importance to having knowledge of the patient’s prefracture status when planning rehabilitation.

The long-term effect of comprehensive geriatric care on gait after hip fracture: the Trondheim Hip Fracture Trial—a randomised controlled trial

SummaryAt present, most hip fracture patients are treated in orthopaedic wards. This study showed that a relatively short hospital intervention based on principles of comprehensive geriatric assessment resulted in safer and more efficient gait as long as 1xa0year following the fracture as compared to conventional orthopaedic treatment.IntroductionHip fracture patients are frail, and the fracture is usually followed by substantial decline in gait function. Few studies have assessed gait characteristics other than gait speed and knowledge about the effect of early intervention on long-term gait outcome is sparse. The purpose of this study was to evaluate the long-term effect of pre- and post-surgery Comprehensive Geriatric Care (CGC) on ability to walk, self-reported mobility and gait characteristics in hip fracture patients.MethodsTwo armed, parallel group randomised controlled trial comparing CGC to conventional Orthopaedic Care (OC) in pre- and early post-surgery phase. Hip fracture patients (nu2009=u2009397), community-dwelling, age >70xa0years and able to walk at time of the fracture were included. Spatial and temporal gait characteristics were collected using an instrumented walkway (GAITRite® system) 4 and 12xa0months post-surgery.ResultsParticipants who received CGC had significantly higher gait speed, less asymmetry, better gait control and more efficient gait patterns, more participants were able to walk and participants reported better mobility 4 and 12xa0months following the fracture as compared to participants receiving OC.ConclusionsPre- and post-surgery CGC showed an effect on gait as long as 1xa0year after hip fracture. These findings underscore the importance of targeting the vulnerability of these patients at an early stage to prevent gait decline in the long run. As presently, most hip fracture patients are treated in orthopaedic wards with larger focus on the fracture than on frailty, these results are important to inform new models for hip fracture care.

Who benefits from orthogeriatric treatment? Results from the Trondheim hip-fracture trial

BackgroundHip fracture patients are heterogenous. Certain patient characteristics are associated with poorer prognosis, but less is known about differences in response to treatment among subgroups. The Trondheim Hip Fracture trial found beneficial effects on mobility and function from comprehensive geriatric care (CGC) compared to traditional orthopaedic care (OC). The aim of this study was to explore differences in response to CGC among subgroups in this trial.MethodsSecondary analysis of the complete dataset from Trondheim Hip Fracture Trial, a randomised controlled trial including 397 home-dwelling older adults (≥70xa0years) with a hip fracture. Subgroups were age (over/under 80xa0years), gender, fracture type (intra-/extracapsular), and pre-fracture instrumental ADL (i-ADL) (defined as over/under 45 on the Nottingham Extended ADL scale). Dependent variables were mobility (Short Physical Performance Battery), personal ADL (p-ADL) (Barthel Index), i-ADL (Nottingham Extended ADL scale), cognition (Mini-Mental Status Examination), four and 12xa0months after hip fracture. Data were analysed by linear mixed models with interactions (treatment, time, and subgroup), reporting treatment effects being clinically and statistically significant within and between subgroups.ResultsAnalyses within subgroups showed beneficial effects of CGC on mobility and i-ADL either at four or twelve months in all subgroups except for males, extra-capsular fractures and patients with impaired pre-fracture i-ADL. Beneficial effect on p- ADL was found in patientsu2009<u200980xa0years, intra-capsular fractures and patients with impaired pre-fracture i-ADL. Effects on cognition were found in patientsu2009<u200980xa0years and men.The interaction analyses showed that CGC had statistically significant better treatment effect on i-ADL for younger participants at four months (pu2009=u20090.004), on p-ADL both at four (pu2009=u20090.037) and twelve months (pu2009=u20090.045) and mobility at twelve months (pu2009=u20090.021), for participants with intracapsular as compared to extracapsular fractures, and on i-ADL at twelve months for participants with higher pre-fracture function (pu2009=u20090.012).ConclusionContrary to our hypothesis that the most vulnerable patients would benefit the most from CGC, we found the intervention effect was most pronounced in younger, female participants with higher pre-fracture i-ADL function.Trial rigistrationClinicalTrials.gov registration number: NCT00667914.

Identification of gait domains and key gait variables following hip fracture

BackgroundRestoration of gait is an important goal of rehabilitation after hip fracture. Numerous spatial and temporal gait variables have been reported in the literature, but beyond gait speed, there is little agreement on which gait variables should be reported and which are redundant in describing gait recovery following hip fracture. The aims of this study were to identify distinct domains of gait and key variables representing these domains, and to explore how known predictors of poor outcome after hip fracture were associated with these key variables.MethodsSpatial and temporal gait variables were collected four months following hip fracture in 249 participants using an electronic walkway (GAITRite®). From the initial set of 31 gait variables, 16 were selected following a systematic procedure. An explorative factor analysis with oblique (oblimin) rotation was performed, using principal component analysis for extraction of factors. Unique domains of gait and the variable best representing these domains were identified. Multiple regression analyses including six predictors; age, gender, fracture type, pain, global cognitive function and grip strength were performed for each of the identified key gait variables.ResultsMean age of participants was 82.6 (SDu2009=u20096.0) years, 75xa0% were women, and mean gait speed was 0.6 (SDu2009=u20090.2) m/sec. The factor analysis revealed four distinct gait domains, and the key variables that best represented these domains were double support time, walk ratio, variability of step velocity, and single support asymmetry. Cognitive decline, low grip strength, extra capsular fracture and male gender, but not pain or age, were significant predictors of impaired gait.ConclusionsThis work proposes four key variables to represent gait of older people after hip fracture. These core variables were associated with known predictors of poor outcome after hip fracture and should warrant further assessment to confirm their importance as outcome variables in addition to gait speed.

The long-term effect of being treated in a geriatric ward compared to an orthopaedic ward on six measures of free-living physical behavior 4 and 12 months after a hip fracture - a randomised controlled trial

BackgroundThis study is part of the Trondheim Hip Fracture Trial, where we compared free-living physical behavior in daily life 4 and 12xa0months following hip surgery for patients managed with comprehensive geriatric care (CGC) in a geriatric ward with those managed with orthopedic care (OC) in an orthopedic ward.MethodsThis is a single centre, prospective, randomized controlled trial. 397 hip fracture patients were randomized to CGC (nu2009=u2009199) or OC (nu2009=u2009198) in the Emergency Department with follow-up assessments performed four and 12xa0months post-surgery. Outcomes were mean upright time, number and length of upright events recorded continuously for four days at four and 12xa0months post-surgery by an accelerometer-based activity monitor. Missing data were handled by multiple imputation and group differences assessed by linear regression with adjustments for gender, age and fracture type.ResultsThere were no group differences in participants’ pre-fracture characteristics. Estimated group difference in favor of CGC in upright time at 4xa0months was 34.6xa0min (17.4xa0%, CI 9.6 to 59.6, pu2009=u2009.007) and at 12xa0months, 27.7xa0min (13.9xa0%, CI 3.5 to 51.8, pu2009=u2009.025). Average and maximum length of upright events was longer in the CGC (p’su2009<u2009.042). No group difference was found for number of upright events (p’su2009>u2009.452).ConclusionParticipants treated with CGC during the hospital stay improved free-living physical behavior more than those treated with OC both 4 and 12xa0months after surgery, with more time and longer periods spent in upright. Results support findings from the same study for functional outcomes, and demonstrate that CGC impacts daily life as long as one year after surgery.Trials registrationClinicalTrials.gov, NCT00667914, April 18, 2008

Multiple Days of Monitoring Are Needed to Obtain a Reliable Estimate of Physical Activity in Hip-Fracture Patients

The aim of the study was to investigate the precision of estimated upright time during one week in community dwelling older adults after hip fracture when monitoring activity for different numbers of consecutive days. Information about upright time was collected by thigh-worn accelerometers during 7 consecutive days in 31 older adults (mean age 81.8 years ± 5.3) 3 months after hip-fracture surgery. Mean time in upright position, including both standing and walking, was 260.9 (± 151.2) min/day. A cutoff value of half an hour was used to provide recommendations about number of recording days. Large variability between participants between days, as well as a nonconstant within-participant variability between days indicates that at least 4 consecutive days of recording should be used to obtain a reliable estimate of upright time for individual persons. However, at a group level, one day of recording is sufficient.