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Team-based home rehabilitation after hip fracture in older adults: effects, experiences and impact of dementia
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University.
2021 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Teambaserad hemrehabilitering efter höftfraktur bland äldre människor : effekter, upplevelser och påverkan av demens på utfallen (Swedish)
Abstract [en]

BACKGROUND: For an older adult a hip fracture may be a traumatic and life-changing event and has shown to be associated with reduced health-related quality of life, disability and increased mortality. Previous rehabilitation studies have often excluded older adults with cognitive impairment and those living in residential care facilities, groups with an additional risk of poor outcome. Moreover, there are few randomized controlled trials that have evaluated interdisciplinary home rehabilitation after hip fracture. These studies did not include older adults with severe cognitive impairment or dementia, those with serious medical conditions, or those living in residential care.

OBJECTIVE: The aim of the thesis was to investigate the effects of early discharge followed by geriatric interdisciplinary home rehabilitation (GIHR) for older adults with hip fracture, and specifically among those with dementia, compared to in-hospital geriatric care according to a multifactorial rehabilitation program. An additional aim was to explore how older adults experienced their rehabilitation and recovery during the year following the fracture.

METHODS: The thesis evaluated a randomized controlled trial that included 205 participants with hip fracture, 70 years or older, living in ordinary housing or residential care facilities. In hospital, both the GIHR and control groups received care and rehabilitation according to a multifactorial rehabilitation program, but with the aim of early discharge for the GIHR group. The individually designed GIHR intervention focused on walking ability indoors and outdoors, independence in activities of daily living (ADL), and multifactorial fall prevention during a maximum period of 10 weeks. Participants were assessed in-hospital and at 3- and 12-month follow-up visits. Independence in walking and use of walking aids was assessed via an interview along with gait speed tests. Independence in ADL was measured using the Barthel ADL Index, and the ADL Staircase including the Katz ADL Index, and hospital length of stay (LOS) was recorded from medical charts. The effects of GIHR intervention among participants with dementia were investigated in a post hoc subgroup analysis where additional outcomes were falls, mortality and readmissions between discharge and 12 months. Individual interviews were conducted with 20 selected participants just after the 12-month follow-up. Data were analysed using qualitative content analysis.

RESULTS: The postoperative hospital LOS was significantly reduced by a median of six days in the GIHR group compared to the control group, although not significantly reduced in the GIHR group for participants with dementia. Binary logistic regression analyses revealed no significant differences between the GIHR and control groups regarding independent walking ability, the ability to walk without a walking device, or independence in ADL at 3 and 12 months. Gait speed was comparable between the two groups at 3 and 12 months. At 12 months, 56% in the GIHR group and 58% in the control group had recovered their prefracture walking ability, and 41% vs. 42% in GIHR and control groups, respectively, had regained their prefracture Barthel ADL Index score. Interaction analyses showed that the GIHR group vs. the control group had comparable effects on walking ability and ADL at 3 and 12 months, and on falls and mortality between discharge and 12 months, regardless of whether the participants had dementia or not (P≥0.05 for all). The number of readmissions and hospital days after discharge was comparable between GIHR and control groups for participants with dementia. Overall, dementia was associated with significantly impaired walking ability and greater dependence in ADL at 3 and 12 months and with increased risk of falling and increased mortality between discharge and 12 months compared to participants without dementia. The interviews revealed that access to rehabilitation, provided by skilled staff, and support from others were important for participants’ well-being and recovery. Participants experienced a fundamental change in their self-image after the fracture, and faced a number of difficulties, but strove for independence and used adaptive strategies to find contentment in their lives.

CONCLUSIONS: In older adults with hip fracture, early discharge followed by interdisciplinary home rehabilitation significantly reduced postoperative hospital LOS. Functional recovery during the year following the fracture was nevertheless comparable to in-hospital geriatric care according to a multifactorial rehabilitation program. The GIHR intervention seems to be appropriate also for older adults with dementia since the effects were not different in this subgroup, except for postoperative hospital LOS, which was not significantly reduced in the GIHR group for participants with dementia. Further studies with larger samples are needed to validate these results. Overall, dementia was associated with a substantial negative impact on the outcomes. According to participants’ experiences, receiving rehabilitation and support after the hip fracture seems crucial for successful recovery. Negative psychological reactions were common, suggesting that future interventions should consider both physical and psychological aspects. Different rehabilitation alternatives were appreciated by the participants. Rehabilitation should thus be customised to suit wishes and needs of older adults and may accordingly be carried out in different settings, where rehabilitation in the home can be one suitable alternative. The findings of this thesis indicate that geriatric interdisciplinary home rehabilitation after hip fracture can be an alternative and a complement to in-hospital care and rehabilitation for older adults with and without dementia.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2021. , p. 80
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2112
Keywords [en]
hip fracture, geriatrics, dementia, home rehabilitation, interdisciplinary rehabilitation, walking ability, activities of daily living, recovery, length of stay, accidential falls, qualitative
National Category
Physiotherapy Geriatrics
Research subject
Geriatrics; Orthopaedics
Identifiers
URN: urn:nbn:se:umu:diva-178151ISBN: 978-91-7855-424-9 (print)ISBN: 978-91-7855-425-6 (electronic)OAI: oai:DiVA.org:umu-178151DiVA, id: diva2:1514097
Public defence
2021-01-29, Triple Helix, Universitetsledningshuset, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2021-01-08 Created: 2021-01-04 Last updated: 2022-07-25Bibliographically approved
List of papers
1. Effects of Geriatric Interdisciplinary Home Rehabilitation on Walking Ability and Length of Hospital Stay After Hip Fracture: A Randomized Controlled Trial
Open this publication in new window or tab >>Effects of Geriatric Interdisciplinary Home Rehabilitation on Walking Ability and Length of Hospital Stay After Hip Fracture: A Randomized Controlled Trial
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2016 (English)In: Journal of the American Medical Directors Association, ISSN 1525-8610, E-ISSN 1538-9375, Vol. 17, no 5, p. 464.e9-464.e15Article in journal (Refereed) Published
Abstract [en]

Objective: To evaluate if Geriatric Interdisciplinary Home Rehabilitation could improve walking ability for older people with hip fracture compared with conventional geriatric care and rehabilitation. A secondary aim was to investigate the postoperative length of hospital stay (LOS).

Design: Randomized controlled trial.

Setting: Geriatric ward, ordinary housing, and residential care facilities.

Participants: People operated on for a hip fracture (n = 205), aged 70 or older, including those with cognitive impairment, and living in the north of Sweden.

Intervention: Home rehabilitation with the aim of early hospital discharge that was individually designed and carried out by an interdisciplinary team for a maximum of 10 weeks. Special priority was given to prevention of falls, independence in daily activities, and walking ability both indoors and outdoors.

Measurements: Walking ability and the use of walking device was assessed in an interview during the hospital stay. These assessments were repeated along with gait speed measurements at 3- and 12-month follow-up. The length of the hospital stay after the hip fracture was recorded.

Results: No significant differences were observed in walking ability, use of walking device, and gait speed at the 3- and 12-month follow-up between the groups. At 12 months, 56.3% of the intervention group and 57.7% of the control group had regained or improved their prefracture walking ability. The median postoperative LOS in the geriatric ward was 6 days shorter for the intervention group (P = .003).

Conclusion: Participants receiving Geriatric Interdisciplinary Home Rehabilitation regained walking ability in the short-and long-term similar to those receiving conventional geriatric care and rehabilitation according to a multifactorial rehabilitation program. The intervention group had a significantly shorter postoperative LOS in the hospital.

Keywords
Hip fracture, home rehabilitation, interdisciplinary rehabilitation, walking ability, geriatrics, length of stay
National Category
Geriatrics Physiotherapy Nursing
Identifiers
urn:nbn:se:umu:diva-121563 (URN)10.1016/j.jamda.2016.02.001 (DOI)000375217300026 ()26975205 (PubMedID)2-s2.0-84960154398 (Scopus ID)
Available from: 2016-06-30 Created: 2016-06-03 Last updated: 2023-03-24Bibliographically approved
2. Effects of Geriatric Interdisciplinary Home Rehabilitation on Independence in Activities of Daily Living in Older People With Hip Fracture: A Randomized Controlled Trial
Open this publication in new window or tab >>Effects of Geriatric Interdisciplinary Home Rehabilitation on Independence in Activities of Daily Living in Older People With Hip Fracture: A Randomized Controlled Trial
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2020 (English)In: Archives of Physical Medicine and Rehabilitation, ISSN 0003-9993, E-ISSN 1532-821X, Vol. 101, no 4, p. 571-578Article in journal (Refereed) Published
Abstract [en]

Objective: To evaluate the effects of early discharge followed by geriatric interdisciplinary home rehabilitation for older people with hip fracture on independence in activities of daily living (ADL) compared with inhospital geriatric care according to a multifactorial rehabilitation program.

Design: Planned analysis of a randomized controlled trial with 3- and 12-month follow-ups.

Setting: Geriatric ward, ordinary housing, and residential care facilities.

Participants: Of 466 people screened for eligibility, participants (N=205) with acute hip fracture, aged 70 years or older, including those with cognitive impairment and those living in residential care facilities, were randomized to intervention or control groups.

Intervention: Individually designed interdisciplinary home rehabilitation for a maximum of 10 weeks. The intervention aimed at early hospital discharge and focused on prevention of falls, independence in daily activities, and walking ability indoors and outdoors.

Main Outcome Measures: Independence in ADL was measured using the Barthel ADL Index, and the ADL Staircase including the Katz ADL Index during hospital stay (prefracture performance) and at the follow-up visits in the participants’ homes.

Results: There were no significant differences in ADL performance between the groups, and they recovered their prefracture level of independence in personal and instrumental ADL comparably. At 12 months, 33 (41.3%) in the intervention group vs 33 (41.8%) in the control group (P=.99) had regained or improved their prefracture ADL performance according to the Barthel ADL Index, and 27 (37.0%) vs 36 (48.6%) according to the ADL Staircase (P=.207).

Conclusions: In older people with hip fracture, early discharge followed by geriatric interdisciplinary home rehabilitation resulted in a comparable recovery of independence in ADL at 3 and 12 months as inhospital geriatric care and rehabilitation.

Place, publisher, year, edition, pages
Elsevier, 2020
Keywords
Activities of daily living, Geriatrics, Hip fractures, Patient care team, Rehabilitation
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-173439 (URN)10.1016/j.apmr.2019.12.007 (DOI)000543000800001 ()31935353 (PubMedID)2-s2.0-85079068977 (Scopus ID)
Conference
World Confederation for Physical Therapy Congress, Geneva, Switzerland, May 10–13, 2019
Funder
Region VästerbottenThe Dementia Association - The National Association for the Rights of the DementedThe Kempe Foundations
Available from: 2020-07-10 Created: 2020-07-10 Last updated: 2023-03-24Bibliographically approved
3. Geriatric Interdisciplinary Home Rehabilitation After Hip Fracture in People with Dementia-A Subgroup Analysis of a Randomized Controlled Trial
Open this publication in new window or tab >>Geriatric Interdisciplinary Home Rehabilitation After Hip Fracture in People with Dementia-A Subgroup Analysis of a Randomized Controlled Trial
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2020 (English)In: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 15, p. 1575-1586Article in journal (Refereed) Published
Abstract [en]

Purpose: To investigate if the effects of geriatric interdisciplinary home rehabilitation after hip fracture were different among people with dementia compared to those without dementia and to describe the overall outcome after hip fracture in people with dementia. Patients and Methods: A post hoc subgroup analysis of a randomized controlled trial was conducted including 205 people with hip fracture, aged >70, living in ordinary housing or residential care facilities. Early discharge followed by individually designed interdisciplinary home rehabilitation for a maximum of 10 weeks was compared to in-hospital geriatric care according to a multifactorial rehabilitation program. Outcomes were hospital length of stay (LOS), readmissions, falls, mortality, performance in activities of daily living (ADL), and walking ability. Results: Interdisciplinary home rehabilitation vs in-hospital care had comparable effects on falls and mortality between discharge and 12 months and on ADL and walking ability at 3 and 12 months regardless of whether the participants had dementia or not (P 0.05 for all). Among participants with dementia, postoperative LOS was a median of 18 days (interquartile range [IQR] 14-30) in the home rehabilitation group vs 23 days (IQR 15-30) in the control group (P=0.254) with comparable numbers of readmissions after discharge. Dementia was associated with increased risk of falling (odds ratio [OR] 3.86; 95% confidence interval [CI]: 2.05-7.27; P<0.001) and increased mortality (OR 4.20; 95% CI 1.79-9.92, P=0.001) between discharge and 12 months and with greater dependence in ADL and walking at 3 and 12 months compared to participants without dementia (P<0.001 for all). Conclusion: The effects of geriatric interdisciplinary home rehabilitation vs in-hospital geriatric care did not differ in participants with and without dementia. However, the statistical power of this subgroup analysis was likely insufficient to detect differences between the groups. Dementia was associated with a substantial negative impact on the outcomes following the hip fracture. Our findings support offering interdisciplinary home rehabilitation after hip fracture to people with dementia.

Place, publisher, year, edition, pages
DOVE MEDICAL PRESS LTD,, 2020
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-175642 (URN)10.2147/CIA.S250809 (DOI)000569480000002 ()32943858 (PubMedID)2-s2.0-85091192468 (Scopus ID)
Available from: 2020-10-08 Created: 2020-10-08 Last updated: 2023-03-24Bibliographically approved
4. "It´s only thanks to rehab that I´m back on my feet": older adults´ experiences of rehabilitation and recovery after hip fracture
Open this publication in new window or tab >>"It´s only thanks to rehab that I´m back on my feet": older adults´ experiences of rehabilitation and recovery after hip fracture
(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-178148 (URN)
Available from: 2021-01-04 Created: 2021-01-04 Last updated: 2021-01-04

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