Authors: Bernardo Gialanella, MD Paola Prometti, MD Vittoria Monguzzi, MD Cristina Ferlucci, MD
Outcomes
Affiliations: From the Unit of Recovery and Functional Rehabilitation, Scientific Institute of Lumezzane, Fondazione Salvatore Maugeri, IRCCS, Lumezzane, Brescia, Italy.
Correspondence: All correspondence and requests for reprints should be addressed to Bernardo Gialanella, MD, Unit`a Operativa di Recupero e Rieducazione Funzionale, Fondazione Salvatore Maugeri, IRCCS, Via G Mazzini, 129-25065, Lumezzane (BS), Italy.
Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/14/9307-0562 American Journal of Physical Medicine & Rehabilitation Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0000000000000062
ORIGINAL RESEARCH ARTICLE
Neuropsychiatric Symptoms and Rehabilitation Outcomes in Patients with Hip Fracture ABSTRACT Gialanella B, Prometti P, Monguzzi V, Ferlucci C: Neuropsychiatric symptoms and rehabilitation outcomes in patients with hip fracture. Am J Phys Med Rehabil 2014;93:562Y569.
Objective: The aim of this study was to determine the association between functional recovery and neuropsychiatric symptoms in hip fracture patients undergoing in-hospital rehabilitation. Very few studies have extensively evaluated neuropsychiatric symptoms in hip fracture patients, and the relationship between these symptoms and rehabilitation outcome is not yet clearly defined.
Design: This study was conducted on 200 patients with hip fracture who underwent a rehabilitation program. The Neuropsychiatric Inventory was used to identify neuropsychiatric symptoms. Efficiency and effectiveness in terms of the motorYFunctional Independence Measure and length of stay were considered as outcome measures.
Results: At admission, 74% of the patients had neuropsychiatric symptoms. At the end of rehabilitation, the patients with neuropsychiatric symptoms had a lower motor YFunctional Independence Measure effectiveness (P = 0.015) and efficiency (P = 0.002) and a longer length of stay (P = 0.008) than those without neuropsychiatric symptoms. However, after adjustment for the Mini-Mental State Examination, the patients with neuropsychiatric symptoms differed from those without symptoms only in terms of longer length of stay (P = 0.006) and lower motor YFunctional Independence Measure efficiency (P = 0.008).
Conclusions: Neuropsychiatric symptoms make the rehabilitation process slower and less efficient in hip fracture patients. Understanding the relationship between neuropsychiatric symptoms and outcome may be useful to physicians for the management of hip fracture patients. Key Words: Neuropsychiatric Inventory, Cognitive Impairment, Activities of Daily Living, Length of Stay
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METHODS
ehavioral and psychologic symptoms of dementia, also known as neuropsychiatric symptoms, represent Ba heterogeneous range of psychological reactions, psychiatric symptoms, and behaviors frequently occurring in people with dementia of any etiology.[1 The pathogenesis of neuropsychiatric symptoms has not been clearly delineated, but it is probably the result of a complex interplay of psychologic, social, and biologic factors. Recent studies have emphasized the role of neurochemical, neuropathologic, and genetic factors underlying the clinical manifestations of neuropsychiatric symptoms.2 Several validated instruments have been developed to quantify neuropsychiatric symptoms, with some scales assessing a wide range of neuropsychiatric symptoms3 and others focusing on specific symptoms (e.g., aggression and agitation). Although neuropsychiatric symptoms can be present singly, it is more common that various psychopathologic features co-occur simultaneously in a patient. Neuropsychiatric symptoms include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. Neuropsychiatric symptoms have been detected in dementia, stroke, multiple sclerosis, Parkinson disease, and also in hip fracture.4,5 In hip fracture patients, several studies have assessed delirium and depression, and these showed that these two neuropsychiatric symptoms are associated with poor outcome after hip fracture.6Y9 However, very few studies have analyzed a wider range of neuropsychiatric symptoms in these patients,10,11 and the relationship between these symptoms and motorYFunctional Independence Measure (FIM) outcome has not been clearly defined. Understanding of the relationship between neuropsychiatric symptoms and outcome may be useful to physicians for the management of hip fracture patients because it could improve the rehabilitation measures and allow pharmacologic and nonpharmacologic interventions that are able to optimize outcomes in this patient population. Therefore, the current study was carried out to determine the association between neuropsychiatric symptoms and functional recovery in patients undergoing rehabilitation after hip fracture. Specifically, the authors aimed to verify whether neuropsychiatric symptoms affected negatively the rehabilitation outcomes, as efficiency and effectiveness, in hip fracture patients.
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Patients This prospective study was carried out at the Rehabilitation Centre of Lumezzane of the Salvatore Maugeri Foundation (Italy) in hip fracture patients. After surgery, the patients were referred to the Rehabilitation Centre from orthopedic departments within the local territory of Brescia (Italy). Between January 2009 and December 2012, all consecutive patients with primary diagnosis of hip fracture admitted to the rehabilitation unit were included in the study. Patients referred from other departments outside the province of Brescia for concomitant acute events during rehabilitation or patients who died during rehabilitation were not included. The Technical Scientific Committee of the authors’ institution approved the study protocol. All patients gave their written informed consent to participate. This study was conducted in accordance with the principles of the Declaration of Helsinki.
Mode of Assessment Clinical evaluation of all patients was performed at admission and at the end of rehabilitation by a qualified team of physiatrists and geriatrician. Evaluation was based on a standard clinical examination by means of scales of demonstrated reliability, validity, and sensitivity that have been used in previous studies concerning hip fracture recovery.3,11 Patient characteristics (age, sex, educational level, and family status) and clinical comprehensive data including orthopedic treatment (arthroplasty, osteosynthesis, or other), time from fracture to surgery or immobilization (in days), time from fracture to admission for rehabilitation (days), and length of stay (LOS; days) were also recorded.
Neuropsychiatric Inventory The Neuropsychiatric Inventory (NPI) was used to evaluate neuropsychiatric symptoms.3 The NPI is a validated informant-based interview that is widely used in clinical research to evaluate neuropsychiatric symptoms. The NPI consists of 12 domains/ subscales that are designed to rate specific behavioral characteristics (delusions, hallucinations, agitation/aggression, depression/dysphoria, anxiety, elation/euphoria, apathy/indifference, disinhibition, irritability/lability, aberrant motor behavior, nighttime behavior, and change in appetite/eating). Data are obtained through an interview with the patient’s caregiver. For each domain, the frequency and the severity of each behavior type are rated, and Outcomes in Patients with Hip Fracture
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the domain score is calculated by multiplying severity by frequency. Severity is scored from 1 (mild) to 3 (severe); and frequency, from 1 (occasionally) to 4 (very frequently). If the symptom is absent, the domain score is 0. The NPI total score is the sum of the individual domain scores and ranges from 0 to 144, with higher scores indicating more severe psychopathology. The patients were assessed at admission only.
Cumulative Illness Rating Scale The Cumulative Illness Rating Scale was used to evaluate comorbidities.12 This is an instrument that measures disease burden in individuals with various chronic diseases. The Cumulative Illness Rating Scale provides a comprehensive review of medical problems concerning 14 organ systems. It is based on a 0Y4 rating of each organ system. The instrument gives information about severity and comorbidity of chronic diseases. The current study considered the total score only.
Functional Independence Measure The FIM was used to assess the patients’ degree of independence and need of assistance in performing basic activities of daily living.13 It is an 18-item ordinal scale with seven levels ranging from 1 (total dependence) to 7 (total independence). The FIM can be subdivided into a 13-item motor subscale and a 5-item cognitive subscale. The motor and cognitive subscale scores range from 13 to 91 (motor-FIM) and from 5 to 35 (cognitive-FIM). The maximum total score is 126. The patients were tested by a qualified physiatrist.
Mini-Mental State Examination The Mini-Mental State Examination (MMSE) was used to evaluate cognitive impairment.14 The MMSE is scored from 0 to 30, with higher scores indicating better cognitive performance.
Geriatric Depression Scale The 15-item Geriatric Depression Scale (GDS) was used to evaluate baseline depressive symptoms.15 A GDS score of 6 or higher (range, 0Y15) was the cutoff used to define significant depressive symptoms.
Muscle Strength Grading Scale The Muscle Strength Grading Scale (Oxford Scale; score, 0Y5, where 5 represents the best performance)16 was used to assess muscle strength, and a standard goniometer was used to measure the range of motion of the hip joint. In this study, strength of the flexor and abductor muscles and
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range of motion of flexion and abduction were measured.
Rehabilitation Program Rehabilitation was performed in a setting of Bspecialistic in-hospital rehabilitation,[ which, in Italy, is expected to provide 378 mins per week of physical therapy and a daily medical visit for each patient, for a minimum of 3 wks of in-hospital stay. The rehabilitation program started the day after admission. Needs, specific goals set, and rehabilitation achievements were discussed at admission and bimonthly by the rehabilitation team (composed of physicians, physiotherapists, and occupational therapist) on a patient-by-patient basis. All patients underwent 330 mins per week of motor rehabilitation (6 days per week), 150 mins per week of electrostimulation of the quadriceps femoris and mechanotherapy (5 days per week), and 150 mins per week of occupational therapy (5 days per week). The motor rehabilitation program was based on range of motion, strengthening and conditioning exercises, and bed-to-chair mobility, wheelchair skills, pregait (sit-to-stand and standing balance) and gait (parallel bars, walker, and crutches) activities, bathroom skills, and activities of daily living training. The patients were discharged only when it was considered by the rehabilitation team that no further in-hospital improvement with rehabilitation was likely to occur.
Statistical Analysis Statistical analysis was based on descriptive statistics (mathematical mean, standard deviation, and percentage), W2 tests (Fisher’s exact or Pearson test, as appropriate), and Student’s t test for comparisons between groups. Pearson correlation coefficients were used to assess the relationship between variables. Efficiency and effectiveness as testified by motorFIM scores and LOS were considered outcome measures. Efficiency was defined as the improvement in the rating score of each scale divided by the duration of rehabilitation; it represents the mean increase per day obtained by therapy.17 Effectiveness was defined as the proportion of potential improvement achieved during rehabilitation, calculated by the following formula17: ([final score j initial score]/[maximum score j initial score]) 100. All statistical analyses were performed with the software application Statistica version 6 (StatSoft, Tulsa, OK, 2001). P values of less than 0.05 were considered as statistically significant.
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RESULTS During the study period, 212 patients with primary diagnosis of hip fractures were admitted to the rehabilitation unit. During in-hospital rehabilitation, 12 patients died or were transferred back to acute care hospitals. As a result, 200 patients were included in the outcome analysis. At the time of hip fracture, all patients admitted to the study lived at home. Table 1 presents the patients’ demographic and clinical characteristics.
Neuropsychiatric Symptoms The participants in this study were divided into two groups on the basis of the NPI score: the patients with an NPI score of 0 were considered without neuropsychiatric symptoms, whereas those with an NPI score of 1 or greater were patients with neuropsychiatric symptoms. At admission, the mean (SD) NPI score was 9.97 (13), and neuropsychiatric symptoms were present in 148 patients (74%). NPI score was related to MMSE score (0.35), GDS (0.35), psychiatric comorbidity (0.33), admission cognitive-FIM score TABLE 1 Demographic and clinical characteristics of patients (n = 200) Age, yrs Male/female Education, yrs Orthopedic treatment (arthroplasty, osteosynthesis, other) MMSE GDS Cumulative Illness Rating Scale Onset to admission interval, days NPI Length of hospital stay, days At admission ROM Muscle strength Motor-FIM Cognitive-FIM Total-FIM At discharge ROM Muscle strength Motor-FIM Cognitive-FIM Total-FIM Efficiency in motor-FIM Effectiveness in motor-FIM Destination at discharge (home/nursing home)
81.3 (9.6) 30/170 4.9 (1.9) 101/91/8 21.7 (6.1) 22.0 (6.1) 22.5 (5.8) 26.0 (31.0) 9.97 (13.0) 36.4 (10.0) 85.9 (22.0) 5.2 (1.0) 33.6 (11.0) 26.6 (6.2) 48.5 (11.0) 117.8 (19.0) 6.9 (0.9) 59.4 (15.0) 27.5 (6.1) 87.0 (19.0) 0.76 (0.3) 46.6 (22.0) 132/68
Data are shown as mean (standard deviation) or number. Comparison between groups was performed with the W2 test for sex, orthopedic treatment, and destination and the t test for all other variables. ROM, range of motion.
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(j0.25), motor-FIM score (j0.25), and total-FIM score (j0.25). Depression (44.7%), nighttime behavioral disturbances (41.5%), anxiety (35.5%), and irritability (23.6%) were the most common disorders (Table 2) observed in the patients.
Functional Outcomes At admission, the patients with neuropsychiatric symptoms had lower MMSE (P = 0.002), motorFIM (P = 0.003), and total-FIM scores (P = 0.003) than the patients without neuropsychiatric symptoms. At the end of rehabilitation, the patients with neuropsychiatric symptoms showed a lower effectiveness (P = 0.015) and efficiency (P = 0.002) of rehabilitation in terms of motor-FIM score and had a longer LOS (P = 0.00) with respect to the patients without neuropsychiatric symptoms (Table 3). At the end of the rehabilitation program, 67.5% of the patients with neuropsychiatric symptoms returned home compared with 61.5% of the patients without neuropsychiatric symptoms (P = 0.429; Table 3). Because the groups differed regarding MMSE score, the two study groups were adjusted by selecting only those patients with an MMSE score of 10 or greater (Table 4). When the adjusted groups were compared, the patients with neuropsychiatric symptoms resulted as having only a lower efficiency of rehabilitation in terms of motor-FIM score (P = 0.010) and a longer LOS (P = 0.007) at the end of rehabilitation. The efficiency was related to depression (j0.17), elation/euphoria (0.24), apathy (j0.16), and irritability (j0.19). At the end of rehabilitation, 69.2% of the patients with neuropsychiatric symptoms returned home vs. 62.7% of the patients without neuropsychiatric symptoms (P = 0.399).
DISCUSSION This study shows that neuropsychiatric symptoms are present in 74% of the hip fracture patients. Depression, nighttime behavioral disturbances, anxiety, and irritability are the most common disorders in hip fracture patients with neuropsychiatric symptoms. In the literature, there are very few studies published that have evaluated extensively neuropsychiatric symptoms in hip fracture patients,10 and several of these have focused on single neuropsychiatric symptoms such as delirium and depression. Delirium is reported in 16%Y62% of patients after surgery for hip fracture,4,18 whereas depression is reported in 9%Y47%.4,19 In this study, depression was present in 45.5% of the patients; and delirium, in 10%. These data are in line with those of the literature. Outcomes in Patients with Hip Fracture
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TABLE 2 Patients’ scores on the NPI subscales (n = 200)
Delusions Hallucinations Agitation/aggression Depression/dysphoria Anxiety Elation/euphoria Apathy/indifference Disinhibition Irritability/lability Aberrant motor behavior Nighttime behavior disturbances Appetite and eating abnormalities
No. Patients Scoring NPI Q 1
% of Overall Patients
Mean (SD) Severity
20 17 48 89 71 4 39 8 47 20 83 53
10.0 8.5 24.0 44.5 35.5 2.0 19.5 4.0 23.5 10.0 41.5 26.5
0.39 (1.4) 0.36 (1.5) 0.87 (2.0) 1.83 (3.1) 1.23 (2.4) 0.04 (0.3) 0.92 (2.4) 0.08 (0.5) 091 (2.2) 0.33 (1.3) 2.17 (3.8) 1.06 (2.4)
In this study, NPI score was correlated with MMSE and initial functional status. This is consistent with data from other studies8,9 showing that cognitive impairment is an independent risk factor of delirium and that initial functional status and delirium are correlated. In the present study, the patients with neuropsychiatric symptoms had a lower efficiency and
effectiveness of rehabilitation as shown by motorFIM and a longer length of in-hospital stay with respect to the patients without neuropsychiatric symptoms at the end of rehabilitation. However, when the patient groups were adjusted for MMSE, they did not differ in terms of motor-FIM gain, that is, the effectiveness of rehabilitation, but only in terms of the length of hospital stay
TABLE 3 Demographic and clinical characteristics of the two patient groups not adjusted for the MMSE (n = 200)
Age, yrs Male/female Education MMSE GDS Cumulative Illness Rating Scale Onset to admission interval LOS At admission ROM Muscle strength Motor-FIM Cognitive-FIM Total FIM At discharge ROM Muscle strength Motor-FIM Cognitive-FIM Total FIM Gain in motor-FIM Efficiency in motor-FIM Effectiveness in motor-FIM, % Destination (home/nursing home)
No Neuropsychiatric Symptoms (NPI Score = 0) (n = 52)
Neuropsychiatric Symptoms (NPI Score Q 1) (n = 148)
P
82.6 (8.9) 44/8 5.1 (2.6) 23.9 (5.6) 14.1 (2.4) 21.5 (6.1) 28.0 (37.0) 33.0 (12.0)
80.3 (9.8) 126/22 4.8 (1.6) 20.9 (6.1) 24.8 (5.8) 22.8 (5.7) 25.2 (28.0) 37.5 (10.0)
0.239 0.928 0.361 0.002b 0.080 0.156 0.588 0.008b
89.3 (20.0) 5.2 (1.0) 37.6 (13.0) 27.9 (5.3) 52.6 (13.0)
84.7 (22.0) 6.1 (8.0) 32.2 (10.0) 26.1 (6.4) 47.1 (10.0)
0.202 0.464 0.003b 0.087 0.003b
117.8 (19.0) 6.9 (0.9) 65.1 (13.0) 28.8 (4.7) 94.0 (17.0) 27.4 (8.8) 0.91 (0.30) 53.0 (15.0) 32/20
114.8 (19.0) 8.7 (11.0) 57.4 (16.0) 27.1 (6.5) 84.5 (19.0) 25.5 (12.0) 0.72 (0.30) 44.4 (23.0) 100/48
0.300 0.274 0.002b 0.072 0.002b 0.304 0.002b 0.015a 0.429
Data are shown as mean (standard deviation) or number. Comparison between groups was performed with the W2 test for sex, orthopedic treatment, and destination upon discharge and the t test for all other variables. a P G 0.05. b P G 0.01. ROM, range of motion.
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TABLE 4 Demographic and clinical characteristics of patient groups adjusted for MMSE (n = 178)
Age, yrs Male/female Education Orthopedic treatment (arthroplasty, osteosynthesis, other) MMSE GDS Cumulative Illness Rating Scale Onset to admission interval, days LOS, days At admission ROM Muscle strength Total FIM Motor-FIM Cognitive-FIM At discharge ROM Muscle strength Total FIM Motor-FIM Cognitive-FIM Gain in motor-FIM Efficiency in motor-FIM Effectiveness in motor-FIM, % Destination upon discharge (home/nursing home)
No Neuropsychiatric Symptoms (NPI score = 0) (n = 51)
Neuropsychiatric Symptoms (NPI Score Q 1) (n = 127)
P
82.4 (8.8) 43/8 5.1 (2.6) 23/26/1
81.0 (7.5) 110/17 5.0 (1.7) 68/53/6
0.309 0.689 0.743 0.451
24.1 (5.5) 12.3 (2.4) 21.6 (6.1) 28.4 (37.0) 33.1 (12.0)
22.7 (4.1) 14.1 (2.8) 22.6 (5.8) 26.1 (29.0) 37.9 (10.0)
0.073 0.660 0.317 0.666 0.007b
89.9 (20.0) 5.2 (1.0) 52.8 (13.0) 37.8 (13.0) 28.0 (5.3)
84.8 (22.0) 6.07 (8.0) 48.6 (10.0) 33.6 (10.0) 27.0 (5.2)
0.170 0.495 0.026a 0.026a 0.259
116.6 (17.0) 6.98 (0.9) 94.4 (17.0) 65.4 (14.0) 29.0 (4.7) 27.5 (8.8) 0.91 (0.3) 53.4 (15.0) 32/19
115.2 (17.0) 8.65 (11.0) 88.2 (17.0) 60.0 (14.0) 28.2 (5.8) 26.6 (12.0) 0.75 (0.3) 47.0 (23.0) 88/39
0.630 0.296 0.035a 0.026a 0.406 0.619 0.010b 0.075 0.399
Data are shown as mean (standard deviation) or number. Comparison between groups was performed with the W2 test for sex, orthopedic treatment, and destination upon discharge and the t test for all other variables. a P G 0.05. b P G 0.01. ROM, range of motion.
and efficiency of rehabilitation (based on motorFIM score). These findings indicate that, after a rehabilitation program, patients with neuropsychiatric symptoms can have a similar functional outcome as that of patients without neuropsychiatric symptoms. However, neuropsychiatric symptoms have a negative impact on hip fracture rehabilitation and slow down the rehabilitation program. Thus, patients with neuropsychiatric symptoms require a longer period of rehabilitation with a consequent longer LOS. These findings are consistent with those of Lenze et al.,11 who found that hip fracture patients with depression, amotivation, or mild-to-moderate cognitive impairment have similar outcomes as those of nondepressed, motivated, and cognitively intact elderly when they were treated in inpatient rehabilitation facilities,11 and with Holmes and House4 and Hershkovitz et al.,20 who showed that delirium and depressive symptoms are independently www.ajpmr.com
associated with a longer length of hospital stay in hip fracture patients. Conversely, the findings of this study are in disagreement with those of Mossey et al.,6 Edlund et al.,7 Marcantonio et al.,8 and JuliebL et al.9 Edlund et al.,7 Marcantonio et al.,8 and JuliebL et al.9 reported that hip fracture patients who developed delirium preoperatively or postoperatively were more functionally impaired than those remaining lucid.7Y9 Mossey et al.6 reported that older people with hip fracture with few depressive symptoms were three times more likely to achieve independence in walking and nine times more likely to return to their prefracture level of function than those with more depressive symptoms.6 However, there are differences between this study and those of the abovementioned authors. All the abovementioned studies analyzed patients with delirium or depression only,6Y9 whereas this study analyzed patients with a wider range of neuropsychiatric symptoms, using the NPI to evaluate Outcomes in Patients with Hip Fracture
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neuropsychiatric symptoms, which considers 12 neuropsychiatric symptoms (among which depression and delirium are also included). Moreover, in the studies of Edlund et al.,7 Mossey et al.,6 and JuliebL et al.,9 patients with delirium and depression were more cognitively impaired than those without neuropsychiatric symptoms.6,7,9 This may have influenced their findings because cognitive impairment is an independent risk factor of poor outcome in hip fracture patients.20Y23 In this study, efficiency in terms of motor-FIM was lower in the patients with than in those without neuropsychiatric symptoms. An explanation for this finding might be that neuropsychiatric symptoms reduce patients’ participation in the rehabilitation treatment, thus prolonging their LOS in rehabilitation.22 Indeed, efficiency represents the mean increase per day obtained by therapy and is inversely related to LOS. In this study, efficiency in motorFIM was related to depression, euphoria/elation, apathy, and irritability, that is, conditions that may reduce the patient’s participation in rehabilitation treatment.22 Indeed, Lenze et al.22 found that depressed patients, as well as those who were not depressed, had a poor functional outcome of rehabilitation because they were unable to participate in their therapy sessions. Moreover, the low efficiency of motor-FIM of patients with neuropsychiatric symptoms might cause the beginning of other neuropsychiatric symptoms. Some studies in the literature7,9,24 reported that patients who develop delirium and neuropsychiatric symptoms have higher impairment of activities of daily living. In this study, LOS was more than 30 days in both groups, being significantly longer in the patients with neuropsychiatric symptoms. Moreover, in the current study, LOS lasted more than that reported by Hershkovitz et al.20 and Munin et al.25 This result might be explained by the higher intensity of the rehabilitation program reported in the abovementioned studies,20,25 with respect to the lower rehabilitation program intensity of this study. Rehabilitation intensity is a variable that significantly influences functional outcomes in hip fracture patients.11 Lenze et al.11 showed that hip fracture patients with depression, amotivation, or mild-to-moderate cognitive impairment treated in inpatient rehabilitation facilities had significantly better functional outcomes than those of patients treated in lesser-intensity skilled nursing home facilities. In the present study, the patients with neuropsychiatric symptoms had, at admission, lower
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motor- and total-FIM scores than those of the patients without neuropsychiatric symptoms, but gain and effectiveness in motor-FIM were not different at the end of rehabilitation. In addition, although the patients with and without neuropsychiatric symptoms had low MMSE scores at admission, both groups had a good functional improvement. These findings indicate that functional benefits of rehabilitation after hip fracture are not influenced by neuropsychiatric symptoms and support the assertion that functional benefit of rehabilitation is not diminished by impairments in cognition.11,26 The association between neuropsychiatric symptoms and poorer rehabilitation outcome suggests that treatment of all neuropsychiatric symptoms is important in the management of hip fracture patients. The current prophylactic treatment of neuropsychiatric symptoms consists of both pharmacologic treatment and nonpharmacologic interventions, the latter seeming to be more effective.27,28 The definitive treatment of neuropsychiatric symptoms depends on the identification and correction of the underlying etiology.29 Reports in the literature suggest that in patients with significant prefracture impairment, the stress related to hip fracture and its surgical repair may be sufficient in itself to precipitate delirium, despite otherwise optimal management,24 and delirium is preventable in general medical practice using a unit-based multifactorial intervention30,31 including obligatory supplemental oxygen already in the ambulance, intravenous fluids and blood transfusion to maintain normal circulatory and oxygen delivery, adequate pain treatment, reduction of antiemetics and anticholinergics, extra nutrition, and improved transfer logistics.30 All these interventions may be useful also for other neuropsychiatric symptoms. Despite these considerations, the present study has some limitations. First of all, it was not a population-based study (the patients were referred to the authors by general hospitals), and, therefore, not all hip fracture patients were represented. Second, the authors analyzed only some risk factors of psychiatric symptoms. Moreover, the authors considered psychiatric symptoms as a comorbidity and did not estimate by specific scales, administered to family members, the prefracture psychiatric impairment of the patients. This could be useful to better investigate the role of psychiatric symptoms in hip fracture patients. In conclusion, this study highlights that neuropsychiatric symptoms are present in 74% of the hip fracture patients. Such symptoms slow down the rehabilitation program and lower the rehabilitation efficiency in hip fracture patients. The NPI may be
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useful to detect and assess the wide variety of neuropsychiatric symptoms present in hip fracture patients. Knowledge of neuropsychiatric symptoms and diagnostic skills to identify and implement optimal treatment of these symptoms are hence of major importance in the management of patients with hip fracture. ACKNOWLEDGMENTS
The authors thank Rosemary Allpress for editing the manuscript. REFERENCES
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25. Munin MC, Seligman K, Dew MA, et al: Effect of rehabilitation site on functional recovery after hip fracture. Arch Phys Med Rehabil 2005;86:367Y72
9. JuliebL V, BjLro K, Krogseth M, et al: Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture. J Am Geriatr Soc 2009;57: 1354Y61 10. Dorra HH, Lenze EJ, Kim Y, et al: Clinically relevant behaviors in elderly hip fracture inpatients. Int J Psychiatry Med 2002;32:249Y59 11. Lenze EJ, Skidmore ER, Dew MA, et al: Does depression, apathy or cognitive impairment reduce the benefit of inpatient rehabilitation facilities for elderly hip fracture patients? Gen Hosp Psychiatry 2007;29:141Y6 12. Parmelee PA, Thuras PD, Katz IR, et al: Validation of the Cumulative Illness Rating Scale in a geriatric residential population. J Am Geriatr Soc 1995;43:130Y7
26. Muir SW, Yohannes AM: The impact of cognitive impairment on rehabilitation outcomes in elderly patients admitted with a femoral neck fracture: A systematic review. J Geriatr Phys Ther 2009;32:24Y32 27. Siddiqi N, Stockdale R, Britton AM, et al: Interventions for preventing delirium in hospitalised patients. Cochrane Database Syst Rev 2007;18:CD005563 28. de Jonghe A, van Munster BC, van Oosten HE, et al: The effects of melatonin versus placebo on delirium in hip fracture patients: Study protocol of a randomised, placebo-controlled, double blind trial. BMC Geriatr 2011;11:34 29. Gleason OC: Donepezil for postoperative delirium. Psychosomatics 2003;44:437Y8
13. Granger CV, Cotter AC, Hamilton BB, et al: Functional assessment: A study of persons after stroke. Arch Phys Med Rehabil 1993;74:133Y8
30. Bjo¨rkelund KB, Hommel A, Thorngren KG, et al: Reducing delirium in elderly patients with hip fracture: A multi-factorial intervention study. Acta Anaesthesiol Scand 2010;54:678Y88
14. Folstein MF, Folstein SE, Mc Hugh PR: BMini-mental state[. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189Y98
31. Chong CP, Savige JA, Lim WK: Medical problems in hip fracture patients. Arch Orthop Trauma Surg 2010;130:1355Y61
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Outcomes in Patients with Hip Fracture Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Affiliations: From the Unit of Recovery and Functional Rehabilitation, Scientific Institute of Lumezzane, Fondazione Salvatore Maugeri, IRCCS, Lumezzane, Brescia, Italy.
Correspondence: All correspondence and requests for reprints should be addressed to Bernardo Gialanella, MD, Unit`a Operativa di Recupero e Rieducazione Funzionale, Fondazione Salvatore Maugeri, IRCCS, Via G Mazzini, 129-25065, Lumezzane (BS), Italy.
Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/14/9307-0562 American Journal of Physical Medicine & Rehabilitation Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0000000000000062
ORIGINAL RESEARCH ARTICLE
Neuropsychiatric Symptoms and Rehabilitation Outcomes in Patients with Hip Fracture ABSTRACT Gialanella B, Prometti P, Monguzzi V, Ferlucci C: Neuropsychiatric symptoms and rehabilitation outcomes in patients with hip fracture. Am J Phys Med Rehabil 2014;93:562Y569.
Objective: The aim of this study was to determine the association between functional recovery and neuropsychiatric symptoms in hip fracture patients undergoing in-hospital rehabilitation. Very few studies have extensively evaluated neuropsychiatric symptoms in hip fracture patients, and the relationship between these symptoms and rehabilitation outcome is not yet clearly defined.
Design: This study was conducted on 200 patients with hip fracture who underwent a rehabilitation program. The Neuropsychiatric Inventory was used to identify neuropsychiatric symptoms. Efficiency and effectiveness in terms of the motorYFunctional Independence Measure and length of stay were considered as outcome measures.
Results: At admission, 74% of the patients had neuropsychiatric symptoms. At the end of rehabilitation, the patients with neuropsychiatric symptoms had a lower motor YFunctional Independence Measure effectiveness (P = 0.015) and efficiency (P = 0.002) and a longer length of stay (P = 0.008) than those without neuropsychiatric symptoms. However, after adjustment for the Mini-Mental State Examination, the patients with neuropsychiatric symptoms differed from those without symptoms only in terms of longer length of stay (P = 0.006) and lower motor YFunctional Independence Measure efficiency (P = 0.008).
Conclusions: Neuropsychiatric symptoms make the rehabilitation process slower and less efficient in hip fracture patients. Understanding the relationship between neuropsychiatric symptoms and outcome may be useful to physicians for the management of hip fracture patients. Key Words: Neuropsychiatric Inventory, Cognitive Impairment, Activities of Daily Living, Length of Stay
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B
METHODS
ehavioral and psychologic symptoms of dementia, also known as neuropsychiatric symptoms, represent Ba heterogeneous range of psychological reactions, psychiatric symptoms, and behaviors frequently occurring in people with dementia of any etiology.[1 The pathogenesis of neuropsychiatric symptoms has not been clearly delineated, but it is probably the result of a complex interplay of psychologic, social, and biologic factors. Recent studies have emphasized the role of neurochemical, neuropathologic, and genetic factors underlying the clinical manifestations of neuropsychiatric symptoms.2 Several validated instruments have been developed to quantify neuropsychiatric symptoms, with some scales assessing a wide range of neuropsychiatric symptoms3 and others focusing on specific symptoms (e.g., aggression and agitation). Although neuropsychiatric symptoms can be present singly, it is more common that various psychopathologic features co-occur simultaneously in a patient. Neuropsychiatric symptoms include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. Neuropsychiatric symptoms have been detected in dementia, stroke, multiple sclerosis, Parkinson disease, and also in hip fracture.4,5 In hip fracture patients, several studies have assessed delirium and depression, and these showed that these two neuropsychiatric symptoms are associated with poor outcome after hip fracture.6Y9 However, very few studies have analyzed a wider range of neuropsychiatric symptoms in these patients,10,11 and the relationship between these symptoms and motorYFunctional Independence Measure (FIM) outcome has not been clearly defined. Understanding of the relationship between neuropsychiatric symptoms and outcome may be useful to physicians for the management of hip fracture patients because it could improve the rehabilitation measures and allow pharmacologic and nonpharmacologic interventions that are able to optimize outcomes in this patient population. Therefore, the current study was carried out to determine the association between neuropsychiatric symptoms and functional recovery in patients undergoing rehabilitation after hip fracture. Specifically, the authors aimed to verify whether neuropsychiatric symptoms affected negatively the rehabilitation outcomes, as efficiency and effectiveness, in hip fracture patients.
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Patients This prospective study was carried out at the Rehabilitation Centre of Lumezzane of the Salvatore Maugeri Foundation (Italy) in hip fracture patients. After surgery, the patients were referred to the Rehabilitation Centre from orthopedic departments within the local territory of Brescia (Italy). Between January 2009 and December 2012, all consecutive patients with primary diagnosis of hip fracture admitted to the rehabilitation unit were included in the study. Patients referred from other departments outside the province of Brescia for concomitant acute events during rehabilitation or patients who died during rehabilitation were not included. The Technical Scientific Committee of the authors’ institution approved the study protocol. All patients gave their written informed consent to participate. This study was conducted in accordance with the principles of the Declaration of Helsinki.
Mode of Assessment Clinical evaluation of all patients was performed at admission and at the end of rehabilitation by a qualified team of physiatrists and geriatrician. Evaluation was based on a standard clinical examination by means of scales of demonstrated reliability, validity, and sensitivity that have been used in previous studies concerning hip fracture recovery.3,11 Patient characteristics (age, sex, educational level, and family status) and clinical comprehensive data including orthopedic treatment (arthroplasty, osteosynthesis, or other), time from fracture to surgery or immobilization (in days), time from fracture to admission for rehabilitation (days), and length of stay (LOS; days) were also recorded.
Neuropsychiatric Inventory The Neuropsychiatric Inventory (NPI) was used to evaluate neuropsychiatric symptoms.3 The NPI is a validated informant-based interview that is widely used in clinical research to evaluate neuropsychiatric symptoms. The NPI consists of 12 domains/ subscales that are designed to rate specific behavioral characteristics (delusions, hallucinations, agitation/aggression, depression/dysphoria, anxiety, elation/euphoria, apathy/indifference, disinhibition, irritability/lability, aberrant motor behavior, nighttime behavior, and change in appetite/eating). Data are obtained through an interview with the patient’s caregiver. For each domain, the frequency and the severity of each behavior type are rated, and Outcomes in Patients with Hip Fracture
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the domain score is calculated by multiplying severity by frequency. Severity is scored from 1 (mild) to 3 (severe); and frequency, from 1 (occasionally) to 4 (very frequently). If the symptom is absent, the domain score is 0. The NPI total score is the sum of the individual domain scores and ranges from 0 to 144, with higher scores indicating more severe psychopathology. The patients were assessed at admission only.
Cumulative Illness Rating Scale The Cumulative Illness Rating Scale was used to evaluate comorbidities.12 This is an instrument that measures disease burden in individuals with various chronic diseases. The Cumulative Illness Rating Scale provides a comprehensive review of medical problems concerning 14 organ systems. It is based on a 0Y4 rating of each organ system. The instrument gives information about severity and comorbidity of chronic diseases. The current study considered the total score only.
Functional Independence Measure The FIM was used to assess the patients’ degree of independence and need of assistance in performing basic activities of daily living.13 It is an 18-item ordinal scale with seven levels ranging from 1 (total dependence) to 7 (total independence). The FIM can be subdivided into a 13-item motor subscale and a 5-item cognitive subscale. The motor and cognitive subscale scores range from 13 to 91 (motor-FIM) and from 5 to 35 (cognitive-FIM). The maximum total score is 126. The patients were tested by a qualified physiatrist.
Mini-Mental State Examination The Mini-Mental State Examination (MMSE) was used to evaluate cognitive impairment.14 The MMSE is scored from 0 to 30, with higher scores indicating better cognitive performance.
Geriatric Depression Scale The 15-item Geriatric Depression Scale (GDS) was used to evaluate baseline depressive symptoms.15 A GDS score of 6 or higher (range, 0Y15) was the cutoff used to define significant depressive symptoms.
Muscle Strength Grading Scale The Muscle Strength Grading Scale (Oxford Scale; score, 0Y5, where 5 represents the best performance)16 was used to assess muscle strength, and a standard goniometer was used to measure the range of motion of the hip joint. In this study, strength of the flexor and abductor muscles and
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range of motion of flexion and abduction were measured.
Rehabilitation Program Rehabilitation was performed in a setting of Bspecialistic in-hospital rehabilitation,[ which, in Italy, is expected to provide 378 mins per week of physical therapy and a daily medical visit for each patient, for a minimum of 3 wks of in-hospital stay. The rehabilitation program started the day after admission. Needs, specific goals set, and rehabilitation achievements were discussed at admission and bimonthly by the rehabilitation team (composed of physicians, physiotherapists, and occupational therapist) on a patient-by-patient basis. All patients underwent 330 mins per week of motor rehabilitation (6 days per week), 150 mins per week of electrostimulation of the quadriceps femoris and mechanotherapy (5 days per week), and 150 mins per week of occupational therapy (5 days per week). The motor rehabilitation program was based on range of motion, strengthening and conditioning exercises, and bed-to-chair mobility, wheelchair skills, pregait (sit-to-stand and standing balance) and gait (parallel bars, walker, and crutches) activities, bathroom skills, and activities of daily living training. The patients were discharged only when it was considered by the rehabilitation team that no further in-hospital improvement with rehabilitation was likely to occur.
Statistical Analysis Statistical analysis was based on descriptive statistics (mathematical mean, standard deviation, and percentage), W2 tests (Fisher’s exact or Pearson test, as appropriate), and Student’s t test for comparisons between groups. Pearson correlation coefficients were used to assess the relationship between variables. Efficiency and effectiveness as testified by motorFIM scores and LOS were considered outcome measures. Efficiency was defined as the improvement in the rating score of each scale divided by the duration of rehabilitation; it represents the mean increase per day obtained by therapy.17 Effectiveness was defined as the proportion of potential improvement achieved during rehabilitation, calculated by the following formula17: ([final score j initial score]/[maximum score j initial score]) 100. All statistical analyses were performed with the software application Statistica version 6 (StatSoft, Tulsa, OK, 2001). P values of less than 0.05 were considered as statistically significant.
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RESULTS During the study period, 212 patients with primary diagnosis of hip fractures were admitted to the rehabilitation unit. During in-hospital rehabilitation, 12 patients died or were transferred back to acute care hospitals. As a result, 200 patients were included in the outcome analysis. At the time of hip fracture, all patients admitted to the study lived at home. Table 1 presents the patients’ demographic and clinical characteristics.
Neuropsychiatric Symptoms The participants in this study were divided into two groups on the basis of the NPI score: the patients with an NPI score of 0 were considered without neuropsychiatric symptoms, whereas those with an NPI score of 1 or greater were patients with neuropsychiatric symptoms. At admission, the mean (SD) NPI score was 9.97 (13), and neuropsychiatric symptoms were present in 148 patients (74%). NPI score was related to MMSE score (0.35), GDS (0.35), psychiatric comorbidity (0.33), admission cognitive-FIM score TABLE 1 Demographic and clinical characteristics of patients (n = 200) Age, yrs Male/female Education, yrs Orthopedic treatment (arthroplasty, osteosynthesis, other) MMSE GDS Cumulative Illness Rating Scale Onset to admission interval, days NPI Length of hospital stay, days At admission ROM Muscle strength Motor-FIM Cognitive-FIM Total-FIM At discharge ROM Muscle strength Motor-FIM Cognitive-FIM Total-FIM Efficiency in motor-FIM Effectiveness in motor-FIM Destination at discharge (home/nursing home)
81.3 (9.6) 30/170 4.9 (1.9) 101/91/8 21.7 (6.1) 22.0 (6.1) 22.5 (5.8) 26.0 (31.0) 9.97 (13.0) 36.4 (10.0) 85.9 (22.0) 5.2 (1.0) 33.6 (11.0) 26.6 (6.2) 48.5 (11.0) 117.8 (19.0) 6.9 (0.9) 59.4 (15.0) 27.5 (6.1) 87.0 (19.0) 0.76 (0.3) 46.6 (22.0) 132/68
Data are shown as mean (standard deviation) or number. Comparison between groups was performed with the W2 test for sex, orthopedic treatment, and destination and the t test for all other variables. ROM, range of motion.
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(j0.25), motor-FIM score (j0.25), and total-FIM score (j0.25). Depression (44.7%), nighttime behavioral disturbances (41.5%), anxiety (35.5%), and irritability (23.6%) were the most common disorders (Table 2) observed in the patients.
Functional Outcomes At admission, the patients with neuropsychiatric symptoms had lower MMSE (P = 0.002), motorFIM (P = 0.003), and total-FIM scores (P = 0.003) than the patients without neuropsychiatric symptoms. At the end of rehabilitation, the patients with neuropsychiatric symptoms showed a lower effectiveness (P = 0.015) and efficiency (P = 0.002) of rehabilitation in terms of motor-FIM score and had a longer LOS (P = 0.00) with respect to the patients without neuropsychiatric symptoms (Table 3). At the end of the rehabilitation program, 67.5% of the patients with neuropsychiatric symptoms returned home compared with 61.5% of the patients without neuropsychiatric symptoms (P = 0.429; Table 3). Because the groups differed regarding MMSE score, the two study groups were adjusted by selecting only those patients with an MMSE score of 10 or greater (Table 4). When the adjusted groups were compared, the patients with neuropsychiatric symptoms resulted as having only a lower efficiency of rehabilitation in terms of motor-FIM score (P = 0.010) and a longer LOS (P = 0.007) at the end of rehabilitation. The efficiency was related to depression (j0.17), elation/euphoria (0.24), apathy (j0.16), and irritability (j0.19). At the end of rehabilitation, 69.2% of the patients with neuropsychiatric symptoms returned home vs. 62.7% of the patients without neuropsychiatric symptoms (P = 0.399).
DISCUSSION This study shows that neuropsychiatric symptoms are present in 74% of the hip fracture patients. Depression, nighttime behavioral disturbances, anxiety, and irritability are the most common disorders in hip fracture patients with neuropsychiatric symptoms. In the literature, there are very few studies published that have evaluated extensively neuropsychiatric symptoms in hip fracture patients,10 and several of these have focused on single neuropsychiatric symptoms such as delirium and depression. Delirium is reported in 16%Y62% of patients after surgery for hip fracture,4,18 whereas depression is reported in 9%Y47%.4,19 In this study, depression was present in 45.5% of the patients; and delirium, in 10%. These data are in line with those of the literature. Outcomes in Patients with Hip Fracture
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TABLE 2 Patients’ scores on the NPI subscales (n = 200)
Delusions Hallucinations Agitation/aggression Depression/dysphoria Anxiety Elation/euphoria Apathy/indifference Disinhibition Irritability/lability Aberrant motor behavior Nighttime behavior disturbances Appetite and eating abnormalities
No. Patients Scoring NPI Q 1
% of Overall Patients
Mean (SD) Severity
20 17 48 89 71 4 39 8 47 20 83 53
10.0 8.5 24.0 44.5 35.5 2.0 19.5 4.0 23.5 10.0 41.5 26.5
0.39 (1.4) 0.36 (1.5) 0.87 (2.0) 1.83 (3.1) 1.23 (2.4) 0.04 (0.3) 0.92 (2.4) 0.08 (0.5) 091 (2.2) 0.33 (1.3) 2.17 (3.8) 1.06 (2.4)
In this study, NPI score was correlated with MMSE and initial functional status. This is consistent with data from other studies8,9 showing that cognitive impairment is an independent risk factor of delirium and that initial functional status and delirium are correlated. In the present study, the patients with neuropsychiatric symptoms had a lower efficiency and
effectiveness of rehabilitation as shown by motorFIM and a longer length of in-hospital stay with respect to the patients without neuropsychiatric symptoms at the end of rehabilitation. However, when the patient groups were adjusted for MMSE, they did not differ in terms of motor-FIM gain, that is, the effectiveness of rehabilitation, but only in terms of the length of hospital stay
TABLE 3 Demographic and clinical characteristics of the two patient groups not adjusted for the MMSE (n = 200)
Age, yrs Male/female Education MMSE GDS Cumulative Illness Rating Scale Onset to admission interval LOS At admission ROM Muscle strength Motor-FIM Cognitive-FIM Total FIM At discharge ROM Muscle strength Motor-FIM Cognitive-FIM Total FIM Gain in motor-FIM Efficiency in motor-FIM Effectiveness in motor-FIM, % Destination (home/nursing home)
No Neuropsychiatric Symptoms (NPI Score = 0) (n = 52)
Neuropsychiatric Symptoms (NPI Score Q 1) (n = 148)
P
82.6 (8.9) 44/8 5.1 (2.6) 23.9 (5.6) 14.1 (2.4) 21.5 (6.1) 28.0 (37.0) 33.0 (12.0)
80.3 (9.8) 126/22 4.8 (1.6) 20.9 (6.1) 24.8 (5.8) 22.8 (5.7) 25.2 (28.0) 37.5 (10.0)
0.239 0.928 0.361 0.002b 0.080 0.156 0.588 0.008b
89.3 (20.0) 5.2 (1.0) 37.6 (13.0) 27.9 (5.3) 52.6 (13.0)
84.7 (22.0) 6.1 (8.0) 32.2 (10.0) 26.1 (6.4) 47.1 (10.0)
0.202 0.464 0.003b 0.087 0.003b
117.8 (19.0) 6.9 (0.9) 65.1 (13.0) 28.8 (4.7) 94.0 (17.0) 27.4 (8.8) 0.91 (0.30) 53.0 (15.0) 32/20
114.8 (19.0) 8.7 (11.0) 57.4 (16.0) 27.1 (6.5) 84.5 (19.0) 25.5 (12.0) 0.72 (0.30) 44.4 (23.0) 100/48
0.300 0.274 0.002b 0.072 0.002b 0.304 0.002b 0.015a 0.429
Data are shown as mean (standard deviation) or number. Comparison between groups was performed with the W2 test for sex, orthopedic treatment, and destination upon discharge and the t test for all other variables. a P G 0.05. b P G 0.01. ROM, range of motion.
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TABLE 4 Demographic and clinical characteristics of patient groups adjusted for MMSE (n = 178)
Age, yrs Male/female Education Orthopedic treatment (arthroplasty, osteosynthesis, other) MMSE GDS Cumulative Illness Rating Scale Onset to admission interval, days LOS, days At admission ROM Muscle strength Total FIM Motor-FIM Cognitive-FIM At discharge ROM Muscle strength Total FIM Motor-FIM Cognitive-FIM Gain in motor-FIM Efficiency in motor-FIM Effectiveness in motor-FIM, % Destination upon discharge (home/nursing home)
No Neuropsychiatric Symptoms (NPI score = 0) (n = 51)
Neuropsychiatric Symptoms (NPI Score Q 1) (n = 127)
P
82.4 (8.8) 43/8 5.1 (2.6) 23/26/1
81.0 (7.5) 110/17 5.0 (1.7) 68/53/6
0.309 0.689 0.743 0.451
24.1 (5.5) 12.3 (2.4) 21.6 (6.1) 28.4 (37.0) 33.1 (12.0)
22.7 (4.1) 14.1 (2.8) 22.6 (5.8) 26.1 (29.0) 37.9 (10.0)
0.073 0.660 0.317 0.666 0.007b
89.9 (20.0) 5.2 (1.0) 52.8 (13.0) 37.8 (13.0) 28.0 (5.3)
84.8 (22.0) 6.07 (8.0) 48.6 (10.0) 33.6 (10.0) 27.0 (5.2)
0.170 0.495 0.026a 0.026a 0.259
116.6 (17.0) 6.98 (0.9) 94.4 (17.0) 65.4 (14.0) 29.0 (4.7) 27.5 (8.8) 0.91 (0.3) 53.4 (15.0) 32/19
115.2 (17.0) 8.65 (11.0) 88.2 (17.0) 60.0 (14.0) 28.2 (5.8) 26.6 (12.0) 0.75 (0.3) 47.0 (23.0) 88/39
0.630 0.296 0.035a 0.026a 0.406 0.619 0.010b 0.075 0.399
Data are shown as mean (standard deviation) or number. Comparison between groups was performed with the W2 test for sex, orthopedic treatment, and destination upon discharge and the t test for all other variables. a P G 0.05. b P G 0.01. ROM, range of motion.
and efficiency of rehabilitation (based on motorFIM score). These findings indicate that, after a rehabilitation program, patients with neuropsychiatric symptoms can have a similar functional outcome as that of patients without neuropsychiatric symptoms. However, neuropsychiatric symptoms have a negative impact on hip fracture rehabilitation and slow down the rehabilitation program. Thus, patients with neuropsychiatric symptoms require a longer period of rehabilitation with a consequent longer LOS. These findings are consistent with those of Lenze et al.,11 who found that hip fracture patients with depression, amotivation, or mild-to-moderate cognitive impairment have similar outcomes as those of nondepressed, motivated, and cognitively intact elderly when they were treated in inpatient rehabilitation facilities,11 and with Holmes and House4 and Hershkovitz et al.,20 who showed that delirium and depressive symptoms are independently www.ajpmr.com
associated with a longer length of hospital stay in hip fracture patients. Conversely, the findings of this study are in disagreement with those of Mossey et al.,6 Edlund et al.,7 Marcantonio et al.,8 and JuliebL et al.9 Edlund et al.,7 Marcantonio et al.,8 and JuliebL et al.9 reported that hip fracture patients who developed delirium preoperatively or postoperatively were more functionally impaired than those remaining lucid.7Y9 Mossey et al.6 reported that older people with hip fracture with few depressive symptoms were three times more likely to achieve independence in walking and nine times more likely to return to their prefracture level of function than those with more depressive symptoms.6 However, there are differences between this study and those of the abovementioned authors. All the abovementioned studies analyzed patients with delirium or depression only,6Y9 whereas this study analyzed patients with a wider range of neuropsychiatric symptoms, using the NPI to evaluate Outcomes in Patients with Hip Fracture
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neuropsychiatric symptoms, which considers 12 neuropsychiatric symptoms (among which depression and delirium are also included). Moreover, in the studies of Edlund et al.,7 Mossey et al.,6 and JuliebL et al.,9 patients with delirium and depression were more cognitively impaired than those without neuropsychiatric symptoms.6,7,9 This may have influenced their findings because cognitive impairment is an independent risk factor of poor outcome in hip fracture patients.20Y23 In this study, efficiency in terms of motor-FIM was lower in the patients with than in those without neuropsychiatric symptoms. An explanation for this finding might be that neuropsychiatric symptoms reduce patients’ participation in the rehabilitation treatment, thus prolonging their LOS in rehabilitation.22 Indeed, efficiency represents the mean increase per day obtained by therapy and is inversely related to LOS. In this study, efficiency in motorFIM was related to depression, euphoria/elation, apathy, and irritability, that is, conditions that may reduce the patient’s participation in rehabilitation treatment.22 Indeed, Lenze et al.22 found that depressed patients, as well as those who were not depressed, had a poor functional outcome of rehabilitation because they were unable to participate in their therapy sessions. Moreover, the low efficiency of motor-FIM of patients with neuropsychiatric symptoms might cause the beginning of other neuropsychiatric symptoms. Some studies in the literature7,9,24 reported that patients who develop delirium and neuropsychiatric symptoms have higher impairment of activities of daily living. In this study, LOS was more than 30 days in both groups, being significantly longer in the patients with neuropsychiatric symptoms. Moreover, in the current study, LOS lasted more than that reported by Hershkovitz et al.20 and Munin et al.25 This result might be explained by the higher intensity of the rehabilitation program reported in the abovementioned studies,20,25 with respect to the lower rehabilitation program intensity of this study. Rehabilitation intensity is a variable that significantly influences functional outcomes in hip fracture patients.11 Lenze et al.11 showed that hip fracture patients with depression, amotivation, or mild-to-moderate cognitive impairment treated in inpatient rehabilitation facilities had significantly better functional outcomes than those of patients treated in lesser-intensity skilled nursing home facilities. In the present study, the patients with neuropsychiatric symptoms had, at admission, lower
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motor- and total-FIM scores than those of the patients without neuropsychiatric symptoms, but gain and effectiveness in motor-FIM were not different at the end of rehabilitation. In addition, although the patients with and without neuropsychiatric symptoms had low MMSE scores at admission, both groups had a good functional improvement. These findings indicate that functional benefits of rehabilitation after hip fracture are not influenced by neuropsychiatric symptoms and support the assertion that functional benefit of rehabilitation is not diminished by impairments in cognition.11,26 The association between neuropsychiatric symptoms and poorer rehabilitation outcome suggests that treatment of all neuropsychiatric symptoms is important in the management of hip fracture patients. The current prophylactic treatment of neuropsychiatric symptoms consists of both pharmacologic treatment and nonpharmacologic interventions, the latter seeming to be more effective.27,28 The definitive treatment of neuropsychiatric symptoms depends on the identification and correction of the underlying etiology.29 Reports in the literature suggest that in patients with significant prefracture impairment, the stress related to hip fracture and its surgical repair may be sufficient in itself to precipitate delirium, despite otherwise optimal management,24 and delirium is preventable in general medical practice using a unit-based multifactorial intervention30,31 including obligatory supplemental oxygen already in the ambulance, intravenous fluids and blood transfusion to maintain normal circulatory and oxygen delivery, adequate pain treatment, reduction of antiemetics and anticholinergics, extra nutrition, and improved transfer logistics.30 All these interventions may be useful also for other neuropsychiatric symptoms. Despite these considerations, the present study has some limitations. First of all, it was not a population-based study (the patients were referred to the authors by general hospitals), and, therefore, not all hip fracture patients were represented. Second, the authors analyzed only some risk factors of psychiatric symptoms. Moreover, the authors considered psychiatric symptoms as a comorbidity and did not estimate by specific scales, administered to family members, the prefracture psychiatric impairment of the patients. This could be useful to better investigate the role of psychiatric symptoms in hip fracture patients. In conclusion, this study highlights that neuropsychiatric symptoms are present in 74% of the hip fracture patients. Such symptoms slow down the rehabilitation program and lower the rehabilitation efficiency in hip fracture patients. The NPI may be
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useful to detect and assess the wide variety of neuropsychiatric symptoms present in hip fracture patients. Knowledge of neuropsychiatric symptoms and diagnostic skills to identify and implement optimal treatment of these symptoms are hence of major importance in the management of patients with hip fracture. ACKNOWLEDGMENTS
The authors thank Rosemary Allpress for editing the manuscript. REFERENCES
15. Sheikh JI, Yesavage JA, Brooks JO III, et al: Proposed factor structure of the Geriatric Depression Scale. Int Psychogeriatr 1991;3:23Y8 16. Miller DW, Hahn JF: General methods of clinical examination. In: Youmans JR (ed). Neurological Surgery, ed 4. Philadelphia, WB Saunders, 1996, pp 31Y2. 17. Shah S, Vanclay F, Cooper B: Efficiency, effectiveness and duration of stroke rehabilitation. Stroke 1990;21:241Y6 18. Bitsch M, Foss N, Kristensen B, et al: Pathogenesis of and management strategies for postoperative delirium after hip fracture: A review. Acta Orthop Scand 2004; 75:378Y89
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