Terence P. Finnegan

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

BACKGROUNDnHip fracture is a major cause of morbidity and mortality in older people and its impact, both on the individual and to society, is substantial.nnnOBJECTIVESnTo examine the effects of co-ordinated multidisciplinary inpatient rehabilitation, compared with usual (orthopaedic) care, for older patients with hip fracture.nnnSEARCH STRATEGYnWe searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2002), MEDLINE (1966 to December 2002), conference proceedings and reference lists of articles and books. We also contacted colleagues and trialists.nnnSELECTION CRITERIAnRandomised and quasi-randomised trials of post-surgical care using specialised rehabilitation of mainly older patients (aged 65 years or over) with hip fracture.nnnDATA COLLECTION AND ANALYSISnTrial 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.nnnMAIN RESULTSnIn this minor update, new data for two already included trials have been incorporated, resulting in only slight changes to the pooled results.The nine included trials involved 1887 patients. The combined outcomes of death or requiring institutional care showed no significant difference between intervention and control groups (relative risk 0.93; 95% confidence interval 0.83 to 1.05). There was considerable heterogeneity in length of stay and cost data. Using death and deterioration in function as a further combined outcome variable yielded a relative risk of 0.91 (95% confidence interval 0.83 to 1.01). This should be interpreted with caution due to heterogeneity. No quality of life measures were reported and the two trials investigating carer burden showed no evidence of detrimental effect from the intervention. The review update did not result in any new data for these outcomes.nnnAUTHORS CONCLUSIONSnThe available trials reviewed had different aims, interventions and outcomes. Combined outcome measures (e.g. death or institutional care) tended to be better for patients receiving co-ordinated inpatient rehabilitation, but the results were heterogeneous and not statistically significant.Future trials of post-surgical care involving inpatient rehabilitation, or other models such as early supported discharge and hospital at home schemes, should aim to establish both effectiveness and cost effectiveness of multidisciplinary rehabilitation overall, rather than attempt to evaluate its components.

Multidisciplinary rehabilitation for older people with hip fractures.

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

Recurrent and Injurious Falls in the Year Following Hip Fracture: A Prospective Study of Incidence and Risk Factors From the Sarcopenia and Hip Fracture Study

BACKGROUNDnThe incidence and etiology of falls in patients following hip fracture remains poorly understood.nnnMETHODSnWe prospectively investigated the incidence of, and risk factors for, recurrent and injurious falls in community-dwelling persons admitted for surgical repair of minimal-trauma hip fracture. Fall surveillance methods included phone calls, medical records, and fall calendars. Potential predictors of falls included health status, quality of life, nutritional status, body composition, muscle strength, range of motion, gait velocity, balance, walking endurance, disability, cognition, depression, fear of falling, self-efficacy, social support, physical activity level, and vision.nnnRESULTSn193 participants enrolled in the study (81 +/- 8 years, 72% women, gait velocity 0.3 +/- 0.2 m/s). We identified 227 falls in the year after hip fracture for the 178 participants with fall surveillance data. Fifty-six percent of participants fell at least once, 28% had recurrent falls, 30% were injured, 12% sustained a new fracture, and 5% sustained a new hip fracture. Age-adjusted risk factors for recurrent and injurious falls included lower strength, balance, range of motion, physical activity level, quality of life, depth perception, vitamin D, and nutritional status, and greater polypharmacy, comorbidity, and disability. Multivariate analyses identified older age, congestive heart failure, poorer quality of life, and nutritional status as independent risk factors for recurrent and injurious falls.nnnCONCLUSIONSnRecurrent and injurious falls are common after hip fracture and are associated with multiple risk factors, many of which are treatable. Interventions should therefore be tailored to alleviating or reversing any nutritional, physiological, and psychosocial risk factors of individual patients.

MULTI-DISCIPLINARY REHABILITATION AFTER HIP FRACTURE IS ASSOCIATED WITH IMPROVED OUTCOME: A SYSTEMATIC REVIEW

BACKGROUNDnWhile hip fractures are an important cause of disability, dependency and death in older adults, the benefit of multi-disciplinary rehabilitation for people who have sustained hip fracture has not been demonstrated.nnnMETHODSnSystematic review of randomized controlled trials which compare co-ordinated multi-disciplinary rehabilitation with usual orthopaedic care in older people who had sustained a hip fracture. Outcome measures included: mortality, return home, poor outcome, total length of hospital stay, readmissions and level of function.nnnRESULTSnWe identified 11 trials including 2177 patients. Patients who received multi-disciplinary rehabilitation were at a lower risk (Risk Ratio 0.84, 95% CI 0.73-0.96) of a poor outcome - that is dying or admission to a nursing home at discharge from the programme, and showed a trend towards higher levels of return home (Risk Ratio 1.07, 95% CI 1.00-1.15). Pooled data for mortality did not demonstrate any difference between multi-disciplinary rehabilitation and usual orthopaedic care.nnnCONCLUSIONnThis is the first review of randomized trials to demonstrate a benefit from multi-disciplinary rehabilitation; a 16% reduction in the pooled outcome combining death or admission to a nursing home. This result supports the routine provision of organized care for patients following hip fracture, as is current practice for patients after stroke.

A randomised trial of hip protector use by frail older women living in their own homes

Objectives: To investigate the efficacy and effectiveness of hip protectors in frail community living older women. Design: Randomised controlled trial. Setting: Aged care health services in New South Wales, Australia. Patients: 600 women 74 years of age or more (mean age 83 years), who had two or more falls or one fall requiring hospital admission in the previous year, and who lived in their own homes. Intervention: Use of hip protectors. Main outcome measures: Adherence with use of hip protectors, falls, incidence of hip fracture, and adverse effects of use of hip protectors. Results: Adherence was approximately 53% over the duration of the study and hip protectors were worn at the time of 51% of falls in the intervention group. The risk of hip fracture when falling while wearing hip protectors, compared with a fall with no hip protectors in place, was significantly reduced (relative risk (RR) 0.23, 95% confidence interval (CI) 0.08 to 0.67). On an intention to treat analysis, 21 and 22 hip fractures occurred in the intervention and control groups respectively (adjusted RR 0.92, 95% CI 0.51 to 1.68). Three users of hip protectors sustained a hip fracture while wearing properly applied protectors, while 16 hip protector users (5%) developed minor local complications. Conclusions: Hip protectors prevent hip fractures in community dwelling older women if worn at the time of a fall. The overall effectiveness of hip protectors was not established in this study, because of incomplete adherence with use of the protectors, and limited statistical power.

Methodology and Baseline Characteristics for the Sarcopenia and Hip Fracture Study: A 5-Year Prospective Study

BACKGROUNDnAge-related hip fractures are associated with poor functional outcomes, resulting in substantial personal and societal burden. There is a need to better identify reversible etiologic predictors of suboptimal functional recovery in this group.nnnMETHODSnThe Sarcopenia and Hip Fracture (SHIP) study was a 5-year prospective cohort study following community-dwelling older persons admitted to three Sydney hospitals for hip fracture. Information was collected at baseline, and 4 and 12 months, including health status, quality of life, nutritional status, body composition, muscle strength, range of motion, gait velocity, balance, walking endurance, disability, cognition, depression, fear of falling, self-efficacy, social support, physical activity level, vision, and fall-related data, with residential status, disability, and mortality reassessed at 5 years.nnnRESULTSn193 participants enrolled (81 +/- 8 years, 72% women). High levels of activities of daily living, disability and sedentariness were present prior to fracture. At admission, the cohort had high levels of chronic disease; 38% were depressed, 38% were cognitively impaired, and 26% had heart disease. Seventy-one percent of participants were sarcopenic, 58% undernourished, and 55% vitamin D deficient. Mobility, strength, and vision were severely impaired. There was little evidence that these comorbidities were either recognized or treated during hospitalization. Disability, sedentariness, malnutrition, and walking endurance predicted acute hospitalization length of stay.nnnCONCLUSIONSnThe complex comorbidity, pre-existing functional impairment, and sedentary behavior in patients with hip fracture suggest the need for thorough screening and targeting of potentially reversible impairments. Rehabilitation outcomes are likely to be highly dependent on amelioration of these highly prevalent accompaniments to hip fracture.

A 12‐Month Fever Surveillance Study in a Veterans' Long‐Stay Institution

This report describes a 12‐month fever surveillance survey in a 258‐bed veterans long‐term care institution. There were 128 episodes of fever (one episode per 24 patient‐months); 114 were studied. Lower respiratory tract infections were most frequent, 36 (32%), with 26 (23%) urinary tract infections. Streptococcus pneumoniae was the most common pathogen in the chest infections and Proteus mirabilis the most common of the urinary tract infections. In 40 (35%) there was no evidence of a lower respiratory tract, urinary tract, or other bacterial infection. Most recovered rapidly, many with no specific treatment. There was a 16% mortality associated with the febrile episodes.

How important are quality and safety for clinician managers? Evidence from triangulated studies

Aims to discover the work hospital clinician managers think they do and observe them in practice. A total of 14 managerial interests and concerns were identified in focus group discussions. Clinician managers’ jobs are pressurised, and are more about negotiation and persuasion than command and control. Their work is of considerable complexity, pace and responsibility and it is predicated more on managing inputs (e.g. money and people) than care processes, systems, outputs and outcomes. Thus the capacity of clinicians in these roles to respond to reforms such as those envisaged in the Bristol Inquiry may be problematic. Qualitative studies are re‐affirmed as important in providing grounded insights into not only clinical activities, but also organisational behaviour and processes.

Can occupational therapy intervention play a part in maintaining independence and quality of life in older people? A randomised controlled trial

Abstract: The main objective of this study was to see if older people could maintain their quality of life and independence after their homes had been modified and they were using community services as recommended by an occupational therapist. There were 167 study participants aged 69 to 94 years from the Northern Sydney Area. After being assessed at home by an occupational therapist, 105 were randomly allocated to one of two groups, to either have or not have the occupational therapists recommendations carried out. They were assessed again after six months. A third group did not require any intervention. This group was followed up by telephone and postal questionnaire at six months. The main outcome measures used were the Sickness Impact Profile, the Philadelphia Geriatric Center Morale Scale, the Life Satisfaction Index, assessment of Activities of Daily Living, the Health Assessment Questionnaire and change in residence. After six months there were no difference in outcomes among the three groups. Most study participants remained at a satisfactory level on each measure. Three people had died. One had moved to hostel care and one had moved to a nursing home. A further 14 from the group having no intervention had withdrawn from the study. A secondary objective of this study was to indicate the responsiveness of these outcome measures to change in the short term (over six months) in an elderly population. Twelve‐month assessments are in progress and may indicate what to expect from these outcome measures in the medium term.

Estimation of lean body weight in older women with hip fracture

AbstractObjectiveLean body weight (LBW) decreases with age while total body fat increases, resulting in altered drug pharmacokinetics. A semi-mechanistic equation estimating LBW using height, weight and sex has been developed for potential use across a wide range of body compositions. The aim of this study was to determine the ability of the LBW equation to estimate dual energy x-ray absorptiometry-derived fat free mass (FFMDXA) in a population of older women with recent hip fracture.MethodsBaseline, four and 12 month data obtained from 23 women enrolled in the Sarcopenia and Hip Fracture study were pooled to give 58 measurements. LBW was estimated using the equation: