Hip fracture is an injury primarily of elderly people, usually caused by a fall. It can affect a person's ability to walk, perform activities of daily living and remain independent. Hip fracture is more common in people with dementia and they can find it more difficult to recover. This is because they are at greater risk of becoming more confused and developing additional complications such as pressure sores and chest infections after their operation. They may also find it more difficult to express their pain and discomfort.
We wanted to find out whether different ways of treating people with dementia following hip fracture might affect how well they recover and what the associated costs of their recovery might be.
We searched for randomised controlled trials which compared any model of enhanced care and rehabilitation for people with dementia after hip fracture with the usual care provided in the trial setting. The last search was performed on 9th June 2014.
We identified five trials which studied a total of 316 people with dementia following hip fracture. Four trials compared an enhanced interdisciplinary rehabilitation and care programme, where all the different healthcare professionals worked collaboratively across hospital and community settings or just in hospital, to usual hospital care. One trial compared care in hospital led by a geriatrician with care led by an orthopaedic surgeon.
There was low-quality evidence that enhanced care and rehabilitation in hospital led to lower rates of some complications and that enhanced care provided across hospital and home settings reduced the chance of being in care such as a hospital, rehabilitation centre or care home at three months post-discharge. This difference was more uncertain at 12 months. The effect of enhanced care and rehabilitation in hospital and at home on functional outcomes was very uncertain because the quality of evidence was very low. The effect of geriatrician-led compared to orthopaedic-led management on delirium was very uncertain, based on very low-quality evidence.
Quality of the Evidence
The studies were small and at high risk of bias and so the following findings should be interpreted with caution. There was limited research available with none of the care models designed specifically for people with dementia. None of the studies looked at the effect of the care on the participants' dementia or quality of life. All of the studies had significant quality limitations.
We concluded that the current research was insufficient to determine the best ways to care for people with dementia after a hip fracture operation. However for almost all of the outcomes, the results were inconclusive because the studies were too small and of very low quality. More research is needed to establish what the best strategies are to improve the care of people with dementia following a hip fracture.
This review will form part of a funded NIHR Programme Grant (Reference Number: DTC-RP-PG-0311-10004; Chief Investigator: Fox). No authors declare any conflicts of interest in relation to this work.
There is currently insufficient evidence to draw conclusions about how effective the models of enhanced rehabilitation and care after hip fracture used in these trials are for people with dementia above active usual care. The current evidence base derives from a small number of studies with quality limitations. This should be addressed as a research priority to determine the optimal strategies to improve outcomes for this growing population of patients.
Hip fracture is a major fall-related injury which causes significant problems for individuals, their family and carers. Over 40% of people with hip fracture have dementia or cognitive impairment, and their outcomes after surgery are poorer than those without dementia. It is not clear which care and rehabilitation interventions achieve the best outcomes for these people.
(a) To assess the effectiveness of models of care including enhanced rehabilitation strategies designed specifically for people with dementia following hip fracture surgery compared to usual care.
(b) To assess the effectiveness for people with dementia of models of care including enhanced rehabilitation strategies which are designed for all older people, regardless of cognitive status, following hip fracture surgery compared to usual care.
We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group Specialised Register, up to and including week 1 June 2014 using the terms hip OR fracture OR surgery OR operation OR femur OR femoral.
We include randomised and quasi-randomised controlled clinical trials (RCTs) evaluating the effectiveness for people with dementia of any model of enhanced care and rehabilitation following hip fracture surgery compared to usual care.
Two review authors working independently selected studies for inclusion and extracted data. We assessed the risk of bias of included studies. We synthesised data only if we considered studies sufficiently homogeneous in terms of participants, interventions and outcomes. We used the GRADE approach to rate the overall quality of evidence for each outcome.
We included five trials with a total of 316 participants. Four trials evaluated models of enhanced interdisciplinary rehabilitation and care, two of these for inpatients only and two for inpatients and at home after discharge. All were compared with usual rehabilitation and care in the trial settings. The fifth trial compared outcomes of geriatrician-led care in hospital to conventional care led by the orthopaedic team. All papers analysed subgroups of people with dementia/cognitive impairment from larger RCTs of older people following hip fracture. Trial follow-up periods ranged from acute hospital discharge to 24 months post-discharge.
We considered all of the studies to be at high risk of bias in more than one domain. As subgroups of larger studies, the analyses lacked power to detect differences between the intervention groups. Further, there were some important differences in the baseline characteristics of the participants in experimental and control groups. Using the GRADE approach, we downgraded the quality of the evidence for all outcomes to 'low' or 'very low'.
No study assessed our primary outcome (cognitive function) nor other important dementia-related outcomes including behaviour and quality of life. The effect estimates for most comparisons were very imprecise, so it was not possible to draw firm conclusions from the data. There was low-quality evidence that enhanced care and rehabilitation in hospital led to lower rates of some complications and that enhanced care provided across hospital and home settings reduced the chance of being in institutional care at three months post-discharge (Odds Ratio (OR) 0.46, 95% confidence interval (CI) 0.22 to 0.95, 2 trials, n = 184), but this effect was more uncertain at 12 months (OR 0.90, 95% CI 0.40 to 2.03, 2 trials, n = 177). The effect of enhanced care and rehabilitation in hospital and at home on functional outcomes was very uncertain because the quality of evidence was very low from one small trial. Results on functional outcomes from other trials were inconclusive. The effect of geriatrician-led compared to orthopaedic-led management on the cumulative incidence of delirium was very uncertain (OR 0.73, 95% CI 0.22 to 2.38, 1 trial, n = 126, very low-quality evidence).