Kristin Taraldsen

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

BACKGROUND Most 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. METHODS We 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. FINDINGS We 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). INTERPRETATION Immediate 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. FUNDING Norwegian 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.

Evaluation of a Body-Worn Sensor System to Measure Physical Activity in Older People With Impaired Function

Background There is limited information on reliable and valid measures of physical activity in older people with impaired function. Objective This study was conducted to compare the accuracy of single-axis accelerometers in recognizing postures and transitions and step counting with the accuracy of video recordings in people with stroke (n=14), older inpatients (n=14), people with hip fracture (n=8), and a reference group of 10 adults who were healthy. Design This was a cross-sectional study, evaluating the concurrent validity of small body-worn accelerometers against video observations as the criterion measure. Methods Activity data were collected from 3 sensors (activPAL) attached to the thighs and the sternum and from registration of the same activities from video recordings. Participants performed a test protocol of in-bed, transfer, and walking activities. Results The sensor system was highly accurate in classifying lying, sitting, and standing positions (100%) and in recognizing transitions from lying to sitting positions and from sitting to standing positions (100%). Placement of a sensor on the nonaffected leg resulted in less underestimation of step counts than placement on the affected leg. Still, the sensor system underestimated step counts during walking, especially at slow walking speeds (≤0.47 m/s) (limits of agreement=−2.01 to 16.54, absolute percent error=40.31). Limitations The study was performed in a controlled setting and not during the natural performance of activities. Conclusions The activPAL sensor system provides valid measures of postures and transitions in older people with impaired walking ability. Step counting needs to be improved for the sensor system to be acceptable for this population, especially at slow walking speeds.

Physical activity monitoring by use of accelerometer-based body-worn sensors in older adults: A systematic literature review of current knowledge and applications

OBJECTIVES To systematically review the literature on physical activity variables derived from body-worn sensors during long term monitoring in healthy and in-care older adults. METHODS Using pre-designed inclusion and exclusion criteria, a PubMed search strategy was designed to trace relevant reports of studies. Last search date was March 8, 2011. STUDY SELECTION Studies that included persons with mean or median age of >65 years, used accelerometer-based body-worn sensors with a monitoring length of >24h, and reported values on physical activity in the samples assessed. RESULTS 1403 abstracts were revealed and 134 full-text papers included in the final review. A variety of variables derived from activity counts or recognition of performed activities were reported in healthy older adults as well as in in-care older adults. Three variables were possible to compare across studies, level of Energy Expenditure in kcal per day and activity recognition in terms of total time in walking and total activity. However, physical activity measured by these variables demonstrated large variation between studies and did not distinguish activity between healthy and in-care samples. CONCLUSION There is a rich variety in methods used for data collection and analysis as well as in reported variables. Different aspects of physical activity can be described, but the variety makes it challenging to compare across studies. There is an urgent need for developing consensus on activity monitoring protocols and which variables to report.

Validation of the Falls Efficacy Scale-International in fall-prone older persons

SIR—Fear of falling in community-dwelling older persons [1, 2] may lead to activity restriction [3]. It can predict future falls [4] and is an important fall-related psychological outcome [5–9]. The widely used 10-item Falls Efficacy Scale (FES) [5] does not evaluate the social dimension of fear of falling and refers almost exclusively to very basic activities of daily living, making it insensitive when used in active older persons. To remedy this, a new 16-item Falls Efficacy Scale-International (FES-I) [10] has been developed by the Prevention of Falls Network Europe (ProFaNE, www.profane.eu.org), showing excellent psychometric properties in a cross-cultural context [11]. Furthermore, a seven-item FES-I has been developed and recommended for use as part of a test battery and for screening purposes [12]. The evaluation of the FES-I has so far been performed in community-dwelling non-clinical samples. To examine the relevance of the two FES-I versions for health care settings, further evaluation of the instrument should include fall-prone older persons. The aim of this study was to test the psychometric properties of the Norwegian version of the 16-item FES-I in samples of fall-prone older home-dwelling persons recruited from the health care system and to assess if the seven-item FES-I has the same properties as the 16-item FES-I in these samples.

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

BACKGROUND This 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). METHODS Treatment 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. RESULTS A 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). CONCLUSIONS When 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

Mobile health applications to promote active and healthy ageing.

The European population is ageing, and there is a need for health solutions that keep older adults independent longer. With increasing access to mobile technology, such as smartphones and smartwatches, the development and use of mobile health applications is rapidly growing. To meet the societal challenge of changing demography, mobile health solutions are warranted that support older adults to stay healthy and active and that can prevent or delay functional decline. This paper reviews the literature on mobile technology, in particular wearable technology, such as smartphones, smartwatches, and wristbands, presenting new ideas on how this technology can be used to encourage an active lifestyle, and discusses the way forward in order further to advance development and practice in the field of mobile technology for active, healthy ageing.

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.

Daily Physical Activity in Total Hip Arthroplasty Patients Undergoing Different Surgical Approaches: A Cohort Study.

Objective Muscle weakness due to trauma from the surgical approach is anticipated to affect the ability of the patient to undertake daily physical activity early after total hip arthroplasty (THA). The objective of this study was to compare daily physical activity on days 1 to 4 after discharge, in patients following THA performed by 1 of 3 surgical approaches. Design A cohort study included 60 hip osteoarthritis patients, scheduled for THA, allocated to direct lateral approach, posterior approach, or anterior approach. Daily physical activity was measured by an accelerometer, with upright time per 24 hours as primary outcome and walking time, number of steps, and number of upright events per 24 hours as secondary outcomes. Results There were no statistically significant group differences in any of the measures of daily physical activity (P > 0.290) or between days of follow-up (P > 0.155). Overall, the median participant had 3.50 hours (interquartile range, 2.85–4.81 hours) of upright time, and participants showed wide variation in all outcomes of daily physical activity. Conclusions There were no differences in daily physical activity between THA patients undergoing different surgical approaches. The surgical approach may not be a limiting factor for daily physical activity early after surgery in a fast-track treatment course.

Effectiveness of task specific gait and balance exercise 4 months after hip fracture: protocol of a randomized controlled trial--the Eva-hip study.

BACKGROUND AND PURPOSE Regular rehabilitation is not sufficient for regaining function after a hip fracture, and more targeted interventions for home-dwelling elderly hip-fracture patients are needed. This paper describes the protocol of a study assessing the effectiveness and cost effectiveness of a task specific progressive gait and balance exercise programme for hip-fracture patients, performed 4 months after the fracture. METHODS/DESIGN A single blind two-arm pragmatic randomised controlled trial was conducted with 142 hip-fracture patients randomized to a 10-week home-based exercise programme or to practice as usual 4 months following the surgery. Inclusion criteria were age >70 years and being home dwelling prior to the fracture. Exclusion criteria are life expectancy <3 months and inability to walk 10 m prior to the fracture. The content and organization of the programme was developed in collaboration between physiotherapy researchers and primary health-care physiotherapists. Participants were followed for 1 year post-surgery, evaluating short-term and long-term effects of the programme. The primary outcome is gait speed, and the secondary outcomes are spatial and temporal gait parameters, free living physical behaviour by activity monitoring, mobility performance, activities of daily living, fear of falling, cognitive function, depression and health-related quality of life. Cost-effectiveness analysis is planned. DISCUSSION This paper describes a task specific exercise programme aimed to improve gait and balance after a hip fracture. Inclusion started in February 2011, and the last 1-year follow-up is performed in March 2014. Broad inclusion criteria and physiotherapy-guided home-based exercises may facilitate the participation from frail patients and thereby increase the generalizability of the findings. Development and completion of the intervention within routine clinical practice will enlighten the implementation of results into clinical practice. Results may add new insight into how physiotherapy can improve gait and thereby activity and functioning in everyday life and have implications on future content and organization of physiotherapy after a hip fracture.