Theodora M. Stavrinos

Effects of High-Intensity Progressive Resistance Training and Targeted Multidisciplinary Treatment of Frailty on Mortality and Nursing Home Admissions after Hip Fracture: A Randomized Controlled Trial

RATIONALEnExcess mortality and residual disability are common after hip fracture.nnnHYPOTHESISnTwelve months of high-intensity weight-lifting exercise and targeted multidisciplinary interventions will result in lower mortality, nursing home admissions, and disability compared with usual care after hip fracture.nnnDESIGNnRandomized, controlled, parallel-group superiority study.nnnSETTINGnOutpatient clinicnnnPARTICIPANTSnPatients (n = 124) admitted to public hospital for surgical repair of hip fracture between 2003 and 2007.nnnINTERVENTIONnTwelve months of geriatrician-supervised high-intensity weight-lifting exercise and targeted treatment of balance, osteoporosis, nutrition, vitamin D/calcium, depression, cognition, vision, home safety, polypharmacy, hip protectors, self-efficacy, and social support.nnnOUTCOMESnFunctional independence: mortality, nursing home admissions, basic and instrumental activities of daily living (ADLs/IADLs), and assistive device utilization.nnnRESULTSnRisk of death was reduced by 81% (age-adjusted OR [95% CI] = 0.19 [0.04-0.91]; P < .04) in the HIPFIT group (n = 4) compared with usual care controls (n = 8). Nursing home admissions were reduced by 84% (age-adjusted OR [95% CI] = 0.16 [0.04-0.64]; P < .01) in the experimental group (n = 5) compared with controls (n = 12). Basic ADLs declined less (P < .0001) and assistive device use was significantly lower at 12 months (P = .02) in the intervention group compared with controls. The targeted improvements in upper body strength, nutrition, depressive symptoms, vision, balance, cognition, self-efficacy, and habitual activity level were all related to ADL improvements (P < .0001-.02), and improvements in basic ADLs, vision, and walking endurance were associated with reduced nursing home use (P < .0001-.05).nnnCONCLUSIONnThe HIPFIT intervention reduced mortality, nursing home admissions, and ADL dependency compared with usual care.

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.

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.

Continuous Hemodynamic Response to Maximal Dynamic Strength Testing in Older Adults

OBJECTIVEnTo quantify acute changes in blood pressure and heart rate during a maximal dynamic strength-single-repetition maximum lift (1-RM)-testing session in older adults with a low burden of chronic disease.nnnDESIGNnDescriptive, cross-sectional study.nnnSETTINGnUniversity rehabilitation center.nnnPARTICIPANTSnVolunteer sample of 43 community-dwelling, nonresistance-trained older adults aged 60 years and older (mean, 68+/-6y).nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnSystolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate was obtained by plethysmography at rest and during 1-RM strength testing on leg press, knee extension, and knee flexion resistance machines.nnnRESULTSnAverage resting SBP (132+/-28mmHg), DBP (54+/-15mmHg), and heart rate (65+/-11 beats/min) were independent of hypertensive diagnosis and overweight status. Maximal SBP, DBP, and heart rate increased significantly during the 1-RM in all exercises compared with rest (P<.001). Highest values of SBP (236+/-51mmHg) and DBP (140+/-46mmHg) were measured during the leg press at 99.5%+/-6.7% of 1-RM. Lowest values of SBP (79+/-25mmHg) and DBP (38+/-15mmHg), and the highest (123+/-44 beats/min) and lowest heart rate (41+/-23 beats/min) were measured during the knee extension at 97.4%+/-8.1% of 1-RM. Absolute falls in SBP were greatest in treated hypertensive participants. No cardiovascular symptoms or events occurred in 129 1-RM tests.nnnCONCLUSIONSnLarge, very transient, asymptomatic excursions in blood pressure and heart rate were measured during 1-RM testing. The most robust hemodynamic response occurred during the leg press. Thus the leg press may be the most important exercise to focus hemodynamic monitoring efforts upon during strength testing in clinical cohorts.