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Hip fractures among old people: their prevalence, consequences and complications, and the evaluation of a multi-factorial intervention program designed to prevent falls and injuries and enhance performance of activities of daily living
Umeå University, Faculty of Medicine, Community Medicine and Rehabilitation.
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The number of old people is growing and will increase future demands on healthcare services for old people. Hip fracture is one of the diagnoses that increases with age and it has become a major problem, both for those suffering a fracture and for society due to the large numbers involved, the morbidity with complications such as falls, functional decline, and the high mortality rate among those affected. The main purposes of this thesis were, to study the impact of previous hip fractures on their life among the very old, to study in-patient falls, fall-related injuries and fall-risk factors, and to evaluate a multidisciplinary, multi-factorial intervention program designed to reduce in-patient falls and to enhance functional performance among old people who have sustained a femoral neck fracture.

The impact of a hip fracture was examined in a cross-sectional population-based study, among the very old (Umeå 85+). After adjustment for potential covariates, participants with a history of hip fracture were found to be more dependent in the performance of Personal/Primary Activities of Daily Living (P-ADL) (p=0.024), walked less independently (p=0.040) and used a wheelchair more frequently (p=0.017). Most of the participants with earlier hip fractures who had moved to institutional care or begun using mobility aids, as compared to before the fracture, had started to do so permanently in connection with the fracture incident.

In-patient falls, fall-related injuries and fall-risk factors were studied in 97 participants, aged 70 or more, treated for a femoral neck fracture. There were 60 postoperative falls occurring among 26/97 participants (27%). Thirty-two percent of the falls resulted in injuries, 25 % were minor, and 7 % were serious. Delirium after day seven, (Hazard Rate Ratio (HRR) with a 95% Confidence Interval (CI)), 4.62 (1.30-16.37), male sex 3.92 (1.58-9.73), and sleeping disturbances 3.49 (1.24-9.86), were associated with in-patient falls. Forty-five percent of the participants were delirious on the day they fell.

The effects of a multidisciplinary, multi-factorial intervention program on in-hospital falls and injuries as well as the short- and long-term effects on living conditions, walking ability and performance of activities of daily living were evaluated in a randomised controlled trial among 199 participants with femoral neck fracture, aged ≥70 years. Participants were randomised to care in a geriatric ward (intervention, n=102) or to conventional postoperative routines (control, n=97). The intervention consisted of staff education, individualized care planning and rehabilitation, systematic assessment and treatment of fall-risk factors, active prevention, and detection and treatment of postoperative complications and an intervention follow up at four-months. The staff worked in teams to apply comprehensive geriatric assessment, management and rehabilitation.

Twelve participants fell a total 18 times in the intervention group compared to 26 participants suffering a total 60 falls in the control group. Only one participant with dementia fell in the intervention group compared to 11 participants with dementia in the control group. The fall incidence rate was 6.29/1000 days vs. 16.28/1000 for the intervention and control groups respectively. The Incidence Rate Ratio (IRR) was 0.38 (95% CI: 0.20-0.76, p=0.006) for the total sample and 0.07 (95% CI: 0.01-0.57, p=0.013) among participants with dementia. No new fractures were incurred in the intervention group but there were four in the control group. In addition, despite shorter hospitalization, significantly more people from the intervention group had regained independence in P-ADL performance at the four- and twelve-month follow ups, Odds Ratios (OR), with 95% CI, were 2.51 (1.00-6.30) and 3.49 (1.31-9.23) respectively. More participants in the intervention group had also regained the ability to walk independently without walking aids indoors, at the end of the study period, 3.01 (1.18-7.61).

In conclusion, hip fracture among the very old seems to be associated with poorer P-ADL performance and poorer mobility. Falls and injuries are common during in-patient rehabilitation after a femoral neck fracture, delirium and sleep disturbances and male gender are factors associated with in-patient falls. Having a team apply comprehensive geriatric assessments and rehabilitation, including the prevention, detection and treatment of fall-risk factors, can successfully prevent in-patient falls and fall-related injuries, even among participants with dementia, and can also enhance the performance of Activities of Daily Living (ADL) and mobility after a hip fracture, in both short- and long-term perspectives.

Place, publisher, year, edition, pages
Umeå: Samhällsmedicin och rehabilitering , 2006. , 77 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1040
Keyword [en]
accidental falls, activities of daily living, aged, geriatric medicine, hip fracture, in-hospital, intervention, physiotherapy, randomised controlled trial, rehabilitation
National Category
Geriatrics
Identifiers
URN: urn:nbn:se:umu:diva-870ISBN: 91-7264-133-9 (print)OAI: oai:DiVA.org:umu-870DiVA: diva2:144819
Public defence
2006-10-14, Aula, Vårdvetarhuset, Umeå universitet 901 87, Umeå, 10:00 (English)
Opponent
Supervisors
Available from: 2006-09-21 Created: 2006-09-21 Last updated: 2009-10-29Bibliographically approved
List of papers
1. Having had a hip fracture: association with dependency among the oldest old
Open this publication in new window or tab >>Having had a hip fracture: association with dependency among the oldest old
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2005 (English)In: Age and Ageing, ISSN 0002-0729, E-ISSN 1468-2834, Vol. 34, no 3, 294-297 p.Article in journal (Refereed) Published
Keyword
Activities of Daily Living, Aged, Aged; 80 and over/*psychology, Cross-Sectional Studies, Dependency (Psychology), Female, Hip Fractures/epidemiology/*physiopathology/rehabilitation, Humans, Male, Residential Facilities, Self-Help Devices, Sweden/epidemiology
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-8294 (URN)10.1093/ageing/afi042 (DOI)15863415 (PubMedID)
Available from: 2008-01-16 Created: 2008-01-16 Last updated: 2017-12-14Bibliographically approved
2. Inpatient falls and injuries in older patients treated for femoral neck fracture.
Open this publication in new window or tab >>Inpatient falls and injuries in older patients treated for femoral neck fracture.
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2006 (English)In: Archives of gerontology and geriatrics (Print), ISSN 0167-4943, E-ISSN 1872-6976, Vol. 43, no 3, 389-399 p.Article in journal (Refereed) Published
Abstract [en]

A prospective inpatient study was performed at the Orthopedic and Geriatric Departments at the Umeå University Hospital, Sweden, to study inpatient falls, fall-related injuries, and risk factors for falls following femoral neck fracture surgery. Ninety-seven patients with femoral neck fracture aged 70 years or older were included, background characteristics, falls, injuries, and other postoperative complications were assessed and registered during the hospitalization. There were 60 postoperative falls among 26/97 patients (27%). The postoperative fall event rate was 16.3/1000 Days (95% CI 12.2-20.4). Thirty two percent of the falls resulted in injuries, 25% minor, and 7% serious ones. In multiple regression analyses, delirium after Day 7, HRR 4.62 (95% CI 1.24-16.37), male sex 3.92 (1.58-9.73), and sleeping disturbances 3.49 (1.24-9.86), were associated with inpatient falls. Forty-five percent of the patients were delirious the day they fell. Intervention programs, including prevention and treatment of delirium and sleeping disturbances, as well as better supervision of male patients, could be possible fall prevention strategies. Improvement of the quality of care and rehabilitation, with the focus on fall prevention based on these results, should be implemented in postoperative care of older people.

Keyword
Accidental Falls/*statistics & numerical data, Aged, Aged; 80 and over, Female, Femoral Neck Fractures/*epidemiology/etiology/surgery, Fracture Fixation/*methods, Humans, Incidence, Inpatients/*statistics & numerical data, Male, Prospective Studies, Risk Factors, Sweden/epidemiology, Trauma Severity Indices
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-14313 (URN)10.1016/j.archger.2006.01.004 (DOI)16540190 (PubMedID)
Available from: 2008-01-16 Created: 2008-01-16 Last updated: 2017-12-14Bibliographically approved
3. A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture.
Open this publication in new window or tab >>A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture.
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2007 (English)In: Osteoporosis International, ISSN 0937-941X, E-ISSN 1433-2965, Vol. 18, no 2, 167-175 p.Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: This study evaluates whether a postoperative multidisciplinary, intervention program, including systematic assessment and treatment of fall risk factors, active prevention, detection, and treatment of postoperative complications, could reduce inpatient falls and fall-related injuries after a femoral neck fracture.

METHODS: A randomized, controlled trial at the orthopedic and geriatric departments at Umeå University Hospital, Sweden, included 199 patients with femoral neck fracture, aged >or=70 years.

RESULTS: Twelve patients fell 18 times in the intervention group compared with 26 patients suffering 60 falls in the control group. Only one patient with dementia fell in the intervention group compared with 11 in the control group. The crude postoperative fall incidence rate was 6.29/1,000 days in the intervention group vs 16.28/1,000 days in the control group. The incidence rate ratio was 0.38 [95% confidence interval (CI): 0.20 - 0.76, p=0.006] for the total sample and 0.07 (95% CI: 0.01-0.57, p=0.013) among patients with dementia. There were no new fractures in the intervention group but four in the control group.

CONCLUSION: A team applying comprehensive geriatric assessment and rehabilitation, including prevention, detection, and treatment of fall risk factors, can successfully prevent inpatient falls and injuries, even in patients with dementia.

Keyword
Accidental Falls/*prevention & control, Aged, Aged; 80 and over, Delirium/complications, Dementia/complications, Female, Femoral Neck Fractures/complications/*surgery, Humans, Kaplan-Meiers Estimate, Male, Patient Care Team, Postoperative Care/*methods, Postoperative Complications/*prevention & control, Program Evaluation/methods, Risk Factors
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-8291 (URN)10.1007/s00198-006-0226-7 (DOI)17061151 (PubMedID)
Available from: 2008-01-16 Created: 2008-01-16 Last updated: 2017-12-14Bibliographically approved
4. Improved performance in activities of daily living and mobility after a multidisciplinary postoperative rehabilitation in older people with femoral neck fracture: a randomized controlled trial with 1-year follow-up.
Open this publication in new window or tab >>Improved performance in activities of daily living and mobility after a multidisciplinary postoperative rehabilitation in older people with femoral neck fracture: a randomized controlled trial with 1-year follow-up.
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2007 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 39, no 3, 232-238 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To investigate the short- and long-term effects of a multidisciplinary postoperative rehabilitation programme in patients with femoral neck fracture.

DESIGN AND SUBJECTS: A randomized controlled trial in patients (n = 199) with femoral neck fracture, aged >or= 70 years.

METHODS: The primary outcomes were: living conditions, walking ability and activities of daily living performance on discharge, 4 and 12 months postoperatively. The intervention consisted of staff education, individualized care planning and rehabilitation, active prevention, detection and treatment of postoperative complications. The staff worked in teams to apply comprehensive geriatric assessment, management and rehabilitation. A geriatric team assessed those in the intervention group 4 months postoperatively, in order to detect and treat any complications. The control group followed conventional postoperative routines.

RESULTS: Despite shorter hospitalization, significantly more people from the intervention group had regained independence in personal activities of daily living performance at the 4- and 12-month follow-ups; odds ratios (95% confidence interval (CI) ) 2.51 (1.00-6.30) and 3.49 (1.31-9.23), respectively. More patients in the intervention group had also regained the ability to walk independently indoors without walking aids by the end of the study period, odds ratio (95% confidence interval) 3.01 (1.18-7.61).

CONCLUSION: A multidisciplinary postoperative intervention programme enhances activities of daily living performance and mobility after hip fracture, from both a short-term and long-term perspective.

Keyword
Activities of Daily Living, Aged, Aged; 80 and over, Female, Femoral Neck Fractures/physiopathology/*rehabilitation/surgery, Follow-Up Studies, Geriatric Assessment, Humans, Male, Motor Activity, Patient Care Team, Postoperative Complications/physiopathology/rehabilitation, Recovery of Function, Time Factors, Walking/physiology
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-8288 (URN)10.2340/16501977-0045 (DOI)17468792 (PubMedID)
Available from: 2008-01-16 Created: 2008-01-16 Last updated: 2017-12-14Bibliographically approved

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