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J Am Med Dir Assoc. Author manuscript; available in PMC 2017 March 01. Published in final edited form as: J Am Med Dir Assoc. 2016 March 1; 17(3): 200–205. doi:10.1016/j.jamda.2015.10.004.
Rehabilitation Interventions for Older Individuals with Cognitive Impairment Post Hip Fracture: A Systematic Review Barbara Resnick, PhD, CRNP, FAAN, FAANP [Professor], University of Maryland, School of Nursing, 655 West Lombard Street, Baltimore, Maryland 21201, Phone: 410 706 5178
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Lauren Beaupre, PT, PhD [Professor], Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada, T6G 2G4 Katherine S McGilton, RN, PhD [Senior Scientist], Toronto Rehabilitation Institute – UHN, Associate Professor, Lawrence S Bloomberg Faculty of Nursing, Toronto, Ontario, Canada M6K 2R7 Elizabeth Galik, PhD, CRNP, FAANP [Associated Professor], University of Maryland, School of Nursing, 655 West Lombard Street, Baltimore, Maryland 21201 Wen Liu, PhD, RN [Assistant Professor], University of Iowa
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Mark D. Neuman, MD, MSc [Assistant Professor of Anesthesiology and Critical Care, Assistant Professor of Medicine (Geriatrics)], Perelman School of Medicine at the University of Pennsylvania Ann L. Gruber-Baldini, PhD [Professor], Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201 Denise Orwig, PhD [Associate Professor], and Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201 Jay Magaziner, PhD, MSHyg [Professor] Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201
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Barbara Resnick: [email protected]; Elizabeth Galik: [email protected]
Abstract Purpose—Currently, most rehabilitation services for individuals who sustain a hip fracture are not designed to meet the complex needs of those who also have cognitive impairment. The goal of this review was to identify current best practices for rehabilitation in long term care settings and
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approaches to optimize outcomes among individuals with dementia and other cognitive impairments post hip fracture. Procedures—The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (the PRISMA Statement) was used to guide the review. Five electronic databases, including Pubmed, EMBASE, CINAHL (EBSCO), Medline (EBSCO) and PsycINFO (EBSCO), were searched for intervention studies published in English language journals. Studies were eligible if they focused on rehabilitation interventions post hip fracture among older individuals (≥ 65 years) with cognitive impairment who were living in or transferred to long-term care or post-acute/ rehabilitation settings post hip fracture. Studies were excluded if they did not enroll individuals with cognitive impairment, the study was descriptive without any intervention content, or the intervention components were only medication, surgical approach or medical treatment.
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Main Findings—A total of 4,478 records were identified, 1915 of which were duplicative, 2,563 were relevant based on title and after careful review seven studies were included. Two included studies were randomized controlled trials, one was a single group pre- and post-test, one a descriptive comparison between those with and without cognitive impairment, one a case controlled matched trial, one a nonequivalent groups trial, and one a case report. The interventions varied between manipulating the type and amount of exercise or testing multifactorial issues including environmental interventions and the use of an interdisciplinary team to address psychosocial factors, medication management, use of assistive devices, and specific preferences or concerns of the individuals.
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Conclusions—The evidence summarized in this review suggests that it is feasible to implement rehabilitation programs focused on individuals with cognitive impairment in post-acute care settings. Moreover, there was evidence to suggest that intensive rehabilitation and exercise activities are beneficial, although innovative approaches may be needed to engage individuals with cognitive impairment.
Introduction
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The prevalence of Alzheimer's disease or related dementias (referred to as dementia throughout) is increasing in most countries1 and hip fracture is a common acute health condition experienced by older adults. Recovery following a hip fracture tends to be particularly challenging for individuals with dementia2. Approximately 19% of all older individuals with hip fractures have dementia, and up to 40% of individuals with a hip fracture have some form of cognitive impairment, which may include dementia, delirium, mild cognitive impairment or other post-operative cognitive decline3. In addition, older individuals with dementia often have multiple chronic medical conditions4 contributing to the complexity of their care needs. Older individuals with dementia who sustain a hip fracture often have more complications and face increased risks of long term care admissions and higher mortality3. Currently, however, most rehabilitation services for individuals post-hip fracture are not designed to meet the complex needs of those with dementia. These individuals are not as likely to be exposed to intensive rehabilitation when compared with similar individuals without dementia5,6. Post-acute services are limited and dementia is believed to impede
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rehabilitation despite evidence suggesting that post-acute rehabilitation for these individuals is associated with a reduced risk of mortality and long-term care placement3. It is generally assumed that older individuals with cognitive impairment will not be able to participate in traditional rehabilitation programs and/or demonstrate progress and thus they are generally admitted to programs with less intensive rehabilitation. Individuals exposed to less intense programs were noted to have less favorable outcomes when compared to individuals exposed to high intensity programs3.
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There is, unfortunately, a paucity of research on optimal rehabilitation interventions for individuals with cognitive impairment after hip fracture in post-acute settings6-8. In addition, for those interventions that do include individuals with cognitive impairment there is limited information on the components of the intervention or the type of staff providing this care and their specific training. Health care staff in post-acute care rehabilitation settings are often inadequately trained or mentored to care for individuals with dementia or other types of cognitive impairment9. Research is needed to establish the best programs of care and strategies required to optimize the outcomes of this vulnerable group.
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There has been only one systematic review, a Cochrane review, published on rehabilitation care for individuals with dementia following hip fracture surgery10. The Cochrane review focused only on randomized and quasi-experimental controlled trials and considered the effectiveness of the care on individual and system related outcomes. Of the five studies included in the Cochrane review, most were small and at high risk of bias and thus there was insufficient evidence to determine the best ways to care for people with dementia following a hip fracture. In contrast to the prior Cochrane review, this systematic review focuses on the details of the different types of interventions for individuals with cognitive impairment post hip fracture in long-term care, post-acute and rehabilitation settings and the effectiveness of those interventions. The goal of this review was to identify current best practices for these individuals and help them return at least to baseline function and the least restrictive level of care.
Methods Data sources and search strategy
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The Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA Statement11 was used to guide this systematic review. Five electronic databases, including Pubmed, EMBASE, CINAHL (EBSCO), Medline (EBSCO) and PsycINFO (EBSCO), were searched for intervention studies published in English language journals. Other sources included Google Scholar and the reference lists from eligible studies. The keywords included: dementia, Alzheimer's disease, cognitive decline, cognitive impairment, hip fracture, and any matched individuals or MeSH terms. The search strategy for Pubmed is shown as an example in Table 1. Eligibility criteria and study selection Studies were included in the review based on the eligibility criteria defined by the Population, Intervention, Comparator, Outcomes, Timing and Setting of interest framework (PICOTS, Table 2)12. Eligible studies were those that focused on rehabilitation interventions post hip fracture among older individuals (≥ 65 years) with cognitive impairment who were
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living in or transferred to long-term care, rehabilitation or post-acute settings post hip fracture. Studies were excluded if they did not enroll individuals with cognitive impairment, the study was descriptive without any intervention content, or the intervention components were only medication, surgical approach or medical treatment. Based on eligibility criteria, studies were selected and assessed by three reviewers and included an initial screening by title and abstract; an assessment of the full-text for eligibility; and a review of the full-text for data abstraction and quality assessment. Individual reviewer results were compared and discrepancies were discussed to arrive at agreement for inclusion or exclusion.
Results Study characteristics
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As shown in Figure 1, a total of 4,478 records were identified; among these 1915 were duplicative. Preliminary review of titles and abstracts resulted in a remaining 2,563 relevant papers. From this group, 2,526 were excluded as they did not include individuals with cognitive impairment, were not focused on hip fracture, had no rehabilitation intervention, were review, commentary, or measurement focused, or were not done in rehabilitation settings. This left 37 potentially eligible papers from which 29 papers were excluded on closer review for the same reasons noted previously. A final total of seven studies were included for the review.
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Of the seven relevant studies, two were randomized controlled trials13,14, one was a single group pre- and post-test15, one was a descriptive comparison between those with and without cognitive impairment16, one was a case controlled matched trial17, one was a nonequivalent groups trial18,19, and one was a case report20. As described in Table 3, the interventions varied between manipulating the type and amount of exercise or testing multifactorial issues including environmental interventions and the use of an interdisciplinary team to address psychosocial factors, medication management, use of assistive devices, and specific preferences or concerns of the individuals.
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Exercise activities to augment rehabilitation were the major focus of the interventions in two of the studies13,20. In the Moseley study13 individuals were randomized to what was referred to as the HIGH group versus the LOW group. In addition to routine therapy, the HIGH group was exposed to weight-bearing exercise twice daily for 60 minutes for 16 weeks. Five weight-bearing exercises were included along with walking on a treadmill with partial body weight support using a harness or a walking program after discharge. Weight bearing exercises included stepping activities and sit to stand activities. These activities continued in the home although the frequency of the home visits decreased. The individuals in the LOW group also engaged in five exercises but these were done while sitting or lying and they walked using parallel bars or walking aids for 30 minutes daily for 4 weeks. The LOW group individuals were also followed at home for a 4 week period. In the case study report20, a body weight-supported treadmill activity was used with a severely cognitively impaired older woman post hip fracture. This involved stepping on a motorized treadmill while unloading a percentage of weight using a counterweight harness system. Manual assistance was provided to help her maintain upright posture and a normal
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gait pattern. Treadmill walking was done daily with the length of time increased to 40 minutes daily by the time of discharge. Three of the studies tested a team based approach to rehabilitation to augment what would otherwise be referred to as routine rehabilitation and therapy14,17,18. In the study by Huusko14, individuals were either sent to a specialized rehabilitation facility or usual care and rehabilitation. The intervention in the geriatric rehabilitation center involved care by a geriatrician, rehabilitation nurses, social worker, neuropsychology, and physiotherapists and occupational therapists. Advice, training and encouragement were provided along with appropriate medication management and therapies twice a day. There was a rehabilitation philosophy of care such that individuals were engaged in activities throughout the day. In addition there were 10 home visits after discharge home.
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McGilton tested similar interventions in two different studies using team approaches that focused specifically on the needs of cognitively impaired older adults. In the first study, which was a longitudinal feasibility retrospective design16, the intervention was referred to as the Assessment, Individual-Centered Goals, Treatment, Evaluation and Discharge (ACTED) model of care. The goal of this intervention was to provide rehabilitation to individuals with cognitive impairment based on individualized needs. Early admission to rehabilitation was encouraged; individualized assessments related to evaluating and optimizing remaining abilities; assessments for dementia, delirium and depression; development of individual centered goals; individualized timing of treatment and location; and staff education on how to manage the behavioral symptoms associated with dementia was provided. Building on this work, the subsequent intervention developed and tested by McGilton in a controlled trial18,19 was referred to as the Individual-Centered Rehabilitation Model including individuals with cognitive impairment (PCRM-CI). This was essentially the same approach as the ACTED and included five main components: routine rehabilitation services (daily one hour sessions of physical and occupational therapy five days a week); dementia management as needed, delirium prevention; education and support for the staff providing care to those with cognitive impairment; and education of the caregivers. Individualized goals were established during the first week of admission.
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The case controlled matched group trial by Rosler 17 likewise addressed management of individuals with cognitive impairment by augmenting the team approach and testing rehabilitation outcomes on a Cognitive Geriatric Unit. The unit incorporated environmental changes such as hidden exit doors, a loop track for free wandering, increased lighting, a unit based treatment room for therapy and a living and eating room to make it more home like. In addition, nurse staffing was increased and all staff were provided with education on Integrative Validation and psychiatric issues in dementia. Conversely, the study by Jones15 did not manipulate the rehabilitation/exercise activities provided to individuals but simply described the outcomes of routine rehabilitation between those with and without cognitive impairment. Routine rehabilitation in this study included physical therapy for approximately 1.5 hours a day and occupation therapy for approximately 1 hour per day, five days a week. The length of rehabilitation was generally three to six weeks.
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With the exception of the single case study20 which included an 82 year old woman with Alzheimer's disease [Mini-Mental State Examination (MMSE) score of 9/30], the remaining studies included older individuals post hip fracture with and without cognitive impairment. Specifically, McGilton et al.16,18,19 and Huusko et al.14 included all levels of cognitive status and deliberately compared outcomes between those with and without cognitive impairment using a cut off MMSE score of 23 and below as being indicative of cognitive impairment. Two of the studies included those with cognitive impairment unless the impairment was severe (defined as an MMSE of ≤ 14)15 or there was severe impairment with no caregiver available13. The study by Rosler 17 included a small sub-study analysis of those individuals with a diagnosis of dementia (mean MMSE =14.5, SD=6.4).
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With the exception of the Huusko study14, all of the studies focused on function and/or performance as the primary outcome, often including both physical and cognitive function. Functional measures included either the Barthel Index (BI) or the Functional Inventory Measure (FIM), both of which address basic activities of daily living. Other additional outcomes included gait and balance, walking speed, muscle strength, sit-to-stand time, and measures such as the Physical Performance and Mobility Examination and balance activities. In some studies, outcomes also included length of stay in rehabilitation and discharge location. The focus in the Huusko study was on length of stay, mortality and discharge location at three and twelve months post-surgery. Results of Individual Intervention Studies
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The descriptive study by Jones 15 included all levels of cognitive impairment with a mean MMSE score of 25.4 (SD=4.7) suggesting that the majority were considered to be cognitively intact. Overall the individuals did have some improvement in function based on the FIM, no improvement in cognitive function, and 85% were discharged back to the home setting while the remaining 15% remained in a nursing facility following discharge from rehabilitation. Interestingly there was no difference in FIM motor (i.e., function) scores between those who did versus did not go home. There were also no differences in length of stay based on cognitive status. In the McGilton study testing the ACTED model16, both those with and without cognitive impairment improved with regard to motor function and there was no improvement in either group with regard to cognitive function. Likewise there was no difference in length of stay (mean of 30 days) or discharge location noted between the two groups. The functional gain achieved by both groups was evaluated based on calculating functional gains per number of rehabilitation days.
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The study by McGilton testing the PCRM-CI versus usual rehabilitation noted that there was no difference between functional outcomes across both sites. Individuals in the PCRM-CI intervention were, however, more likely to return home after discharge than individuals who received routine rehabilitation. In the study by Rosler 17 comparing the effectiveness of the Cognitive Geriatric Unit with routine rehabilitation for those with cognitive impairment, it was noted that both groups improved functionally but gait and balance improved more for those on the Cognitive
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Geriatric Unit than for those on usual treatment units. The length of stay was actually a little longer for those on the treatment Cognitive Geriatric Unit versus routine care and there was no difference in discharge location. The Huusko study also tested a geriatric focused rehabilitation program and compared it to routine rehabilitation. Despite their increased focus on engaging individuals in rehabilitation activities throughout the course of the day, there was no significant difference between the intervention versus the routine care group with regard to length of stay in rehabilitation, mortality or discharge location.
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Results of the Mosely13 study testing rehabilitation augmented with additional exercises noted that, in the subsample of individuals with impaired cognition there was significantly greater improvement in walking speed, physical performance, the step test, balance, function, quality of life, falls self-efficacy and less pain. Further, individuals with cognitive impairment had a higher exercise rate (i.e., spent more time exercising) in the HIGH group when compared to those without cognitive impairment. Findings from the single case study by Bellelli20 noted that the 82 year old woman with severe dementia who was exposed to an individualized body weight-supported treadmill intervention had significant improvements in function at the time of discharge that were maintained over 6 months. It is important to note that this individual was not willing or able to participate in traditional rehabilitation and was resistive to the encouragement of the physical therapist and refused to walk. By day 12, however, she was back to her baseline cognitively and was willing to participate in the body weight-supported treadmill walking and was noted to “enjoy” the activity.
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With the exception of the case study 20 and the study by Moseley 13, these studies did not report on treatment fidelity or how engaged individuals were in intervention activities. For example, it was not indicated if the individual did all of the exercises recommended during a session, went to all sessions, or if he or she refused therapy or did not tolerate full therapy sessions.
Discussion
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Based on the small number of studies extracted for our review (n = 7), there continues to be limited evidence available to guide the development of interventions for individuals with cognitive impairment who have experienced a hip fracture and are living in or transferred to long-term care, rehabilitation or post-acute settings. Many studies exclude this group completely or only include those with cognitive impairment who are still able to live in the community. Notwithstanding, the evidence summarized in this review suggests that it is feasible to implement rehabilitation programs focused on individuals with cognitive impairment in post-acute care settings. Moreover, there was evidence to suggest that intensive rehabilitation and exercise activities are beneficial, although innovative approaches may be needed to engage individuals with cognitive impairment. Additional research is needed to better develop and test innovative approaches across the full spectrum of cognitive impairment.
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Major components of the programs reviewed included routine and daily physical and occupational therapy with various exercises and rehabilitation therapies. The key components in the programs reviewed focused on the need to assist older individuals with cognitive impairment to regain their strength and functional ability after a hip fracture. Most studies incorporated functional tasks/activities (e.g., bathing and dressing) into the rehabilitation programs as these were more likely to be familiar to the individual with cognitive impairment and thus more likely to be performed. There was little evidence, however, of innovative approaches that matched individual preferences for physical and functional activities. For example, some individuals might be willing to ride an exercise bike while others would be more comfortable with aquatic exercise, traditional walking or use of a treadmill.
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McGilton's18 research emphasized the need for training and skill development and support for staff as an integral part of the implementation success of the program. Providing direct care staff with easy access to primary care providers who have experience in geriatrics (e.g., adult/gerontological nurse practitioners; geriatricians) is essential and can influence the success of the interventions focused on individuals with cognitive impairment21.
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Although only limited evidence was found, all of the included studies uniformly support that rehabilitation appears beneficial for this sub-group of individuals across different settings and countries. Further there was no evidence that participation in any of the rehabilitation activities resulted in harm (e.g., no falls and no exacerbation of medical problems reported). Nor was there any evidence that individuals with cognitive impairment were unable to participate in the planned rehabilitation studies relative to those without cognitive impairment. Based on some of the approaches provided to optimize successful recovery for older individuals with cognitive impairment post hip fracture, it may be useful to incorporate the preferences of the individual20 and to use an interdisciplinary approach14,18.
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Most studies included individuals with and without cognitive impairment. These programs were not specifically developed to address rehabilitation for individuals with cognitive impairment and only focused on functional outcomes and physical performance rather than on cognitive performance. When only individuals with cognitive impairment were included in the study there was no consideration of level of impairment. Likewise, in these studies there was no differentiation between the three common presentations of cognitive impairment: dementia, delirium, and/or symptoms of depression. Although authors alluded to using approaches to facilitate individual engagement in their rehabilitation program through inter-individual interactions and environmental interventions17, they did not report on engagement (e.g., how long individuals participated in in therapeutic interventions; whether or not the individual went to therapy sessions easily or required encouragement). None of the studies incorporated previously reported effective interventions with individuals with cognitive impairment such as social support and engagement of caregivers 22. As shown in the work of Boltz et al. 22, family/caregiver participation can improve functional outcomes among older medical individuals with cognitive impairment. Based on the limited body of evidence noted in this review, there is an urgent need to develop interventions specifically focused on engaging individuals with cognitive
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impairment post hip fracture in rehabilitation. The goal of such programs is to optimize functional outcomes and assure return of these individuals to their highest level of physical function and social engagement regardless of where the ultimate discharge setting might be. We recommend the use of theoretically based approaches that are guided by the theory of self-efficacy 23 and those that address behavioral and psychological symptoms associated with cognitive impairment. The theory of self-efficacy is a behavior change theory suggesting that the stronger the individual's self-efficacy and outcome expectations, the more likely it is that he or she will initiate and persist with a given activity. Self-efficacy expectations are the individual's beliefs in his or her capabilities to perform a course of action to attain a desired outcome; outcome expectations are the beliefs that certain consequences will be produced by individual action. Efficacy expectations are dynamic and enhanced by four mechanisms: (1) successful performance of the activity; (2) verbal encouragement; (3) seeing like individuals perform the activity; and (4) elimination of unpleasant physiological and affective states associated with the activity. We have found repeatedly that the four sources of information suggested within the theory are effective in changing behavior among these individuals24-27.
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In addition, these programs need to identify the optimal timing of intervention components and the dosage of treatment required in terms of frequency, duration and intensity. It is not clear from our review how much time was spent in rehabilitation related therapy (physical, occupational and/or speech therapy), which activities were actually performed by the individual or the intensity of the activities performed. Likewise, the encouragement individuals received to practice functional tasks and physical activity outside of therapy sessions was not carefully considered (e.g., interactions with nursing, recreational staff, social workers). Activities such as walking individuals to and from the dining room or the bathroom, or engaging individuals in recreational/social activities can make a considerable contribution to performance outcomes. Our review demonstrated that individuals with cognitive impairment can participate in high intensity programs and achieve benefits. It is possible therefore, that increasing intensity, frequency and/or duration of therapeutic encounters might result in better outcomes and allow more individuals to return to community living after hip fracture. Seitz et al.,3 recently examined rehabilitation practices in a large Canadian province and found that those exposed to higher intensity approaches had better outcomes in terms of mortality and being able to return to community living.
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In summary, there are four fundamental barriers to advancing the field related to care of older individuals with cognitive impairment as identified in this review. First, there is no consensus on components that should be included in the rehabilitative programs for individuals post hip fracture with cognitive impairment. The ability to compare effects of the programs or interventions is difficult as they were all unique and the specific therapeutic components were not always well described. Second, there remains no uniform approach to determining how to engage this group of individuals to participate in rehabilitation. Hidden within these approaches are the specific skills and theoretically and evidence based techniques required of staff to rehabilitate individuals with cognitive impairment. The third barrier is the lack of uniformity in assessing cognitive impairment and differentiating
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cognitive impairment from what might be delirium or depression. This is important as the interventions required between these different conditions vary. Finally, the quality of reporting the treatment fidelity 28 and dose each individual receives within the rehabilitation programs requires more investigation. If our goal is to be individual centered and provide tailored interventions for individuals with cognitive impairment, knowledge of how to report this information is essential so researchers and clinicians can better evaluate the findings. Study Strengths and Limitations
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The strengths of this review include the broad search strategy employed followed by a very systematic evaluation of the available data. We identified all relevant studies (which was corroborated by the recent Cochrane review), and three reviewers assessed titles and abstracts. We synthesized our results in an unbiased way. Based on the sparse evidence retrieved, a clear gap in our current knowledge has been identified. However, there are also some limitations. Given the limited research in this area we were unable to draw any firm conclusions based on quantitative data. Rather, we looked more at the different types of approaches used and the impact of these approaches on individual outcomes. Despite the limited number of studies in this review, it was consistently noted that individuals post hip fracture with cognitive impairment participated in and benefitted from rehabilitation. Further we recommend that future research consider multimodal approaches and a broader evaluation of the impact of rehabilitation on individuals' recovery beyond physical function to include social participation and overall quality of life.
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This work has been supported through the Canadian Institute for Health Research as a New Investigator (Individual Oriented Research) and from Alberta Innovates Health Solutions; through the National Institute on Aging via K08 AG043548, R01 AG046217-01, NR013736-01A1, P30 AG028747, and R37 AG009901, R01 AG029315.
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26. Galik E, Resnick B, Hammersla M, Brightwater J. Optimizing function and physical activity among nursing home residents with dementia: Testing the impact of Function Focused Care. The Gerontologist. 2014; 54(6):11–20. 27. Galik EM, Resnick B, Gruber-Baldini A, Nahm ES, Pearson K, Pretzer-Aboff I. Pilot testing of the Restorative Care Intervention for the Cognitively Impaired. J Am Med Dir Assoc. 2008; 9(7):516– 22. [PubMed: 18755426] 28. Bellg A, Borrelli B, Resnick B, Hecht J, Minicucci DS, Ory M, et al. Czajkowski S. Enhancing treatment fidelity in health behavior change studies: Best practices and recommendations from the Behavior Change Consortium. Health Psych. 2004; 23(5):452–6.
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Figure 1. Flow Chart for Interventions among older adults with cognitive impairment post hip fracture
* Two articles described the same study, so the total number of studies included was 7.
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Table 1
Search strategy using Pubmed
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#1 “Alzheimer Disease”[Mesh] OR “Dementia”[Mesh] OR “Mild Cognitive Impairment”[Mesh] #2 Alzheimer OR cognition OR cognitive decline OR cognitive impairment OR dementia OR cognitive disorder #3 #1 OR #2 #4 “Hip Fractures”[Mesh] #5 hip fracture #6 #4 OR #5 # 7 #3 AND #6 Filters: Humans; English; Aged: 65+ years
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Table 2
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Eligibility criteria using PICOTS framework for interventions among older individuals with cognitive impairment post hip fracture
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Category
Criteria
Population of interest
-Older individuals(≥ 65 years old) with cognitive impairment post hip fracture (e.g., all or partial individuals had cognitive impairment; individuals with only moderate or mild cognitive impairment) -Excluded if none of the individuals had cognitive impairment or dementia.
Intervention of interest
-Any intervention for rehabilitation purpose (e.g., exercise training, functional training resistance training, mobility training, occupational or physical therapy, early rehabilitation) with any design (e.g., RCT, non-randomized controlled study, cohort, time series, case report, intervention protocols). -Excluded if there was no rehabilitation intervention or the intervention contents were only medication/pharmacy, surgical/medical approaches or treatments.
Comparator
-Any comparator, or none at all (e.g., placebo, no therapy, another active therapy, or no control therapy).
Outcome of interest
-Any individual outcomes (e.g., function, quality of life, balance, strength, gait, mood, ADLs, IADLs, falls, physical ability, delirium).
Timing
-Publication period: unlimited; Follow-up duration: unlimited.
Setting
-Individuals were recruited from or discharged to long-term care setting, assisted living, nursing home, geriatric centers, Alzheimer specialized center, skilled nursing facility; post-acute care rehabilitation unit in hospital setting). -Excluded if individuals were discharged from hospital or acute care settings to community or home-based setting after treatment.
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Huusko et al., 2000, Finland 14
Bellelli et al., 2006,
Italy20
Randomized controlled trial
Case report
Study Design
243 independently living patients with dementia (intervention: n=120 (79 with MMSE
J Am Med Dir Assoc. Author manuscript; available in PMC 2017 March 01. Published in final edited form as: J Am Med Dir Assoc. 2016 March 1; 17(3): 200–205. doi:10.1016/j.jamda.2015.10.004.
Rehabilitation Interventions for Older Individuals with Cognitive Impairment Post Hip Fracture: A Systematic Review Barbara Resnick, PhD, CRNP, FAAN, FAANP [Professor], University of Maryland, School of Nursing, 655 West Lombard Street, Baltimore, Maryland 21201, Phone: 410 706 5178
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Lauren Beaupre, PT, PhD [Professor], Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada, T6G 2G4 Katherine S McGilton, RN, PhD [Senior Scientist], Toronto Rehabilitation Institute – UHN, Associate Professor, Lawrence S Bloomberg Faculty of Nursing, Toronto, Ontario, Canada M6K 2R7 Elizabeth Galik, PhD, CRNP, FAANP [Associated Professor], University of Maryland, School of Nursing, 655 West Lombard Street, Baltimore, Maryland 21201 Wen Liu, PhD, RN [Assistant Professor], University of Iowa
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Mark D. Neuman, MD, MSc [Assistant Professor of Anesthesiology and Critical Care, Assistant Professor of Medicine (Geriatrics)], Perelman School of Medicine at the University of Pennsylvania Ann L. Gruber-Baldini, PhD [Professor], Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201 Denise Orwig, PhD [Associate Professor], and Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201 Jay Magaziner, PhD, MSHyg [Professor] Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201
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Barbara Resnick: [email protected]; Elizabeth Galik: [email protected]
Abstract Purpose—Currently, most rehabilitation services for individuals who sustain a hip fracture are not designed to meet the complex needs of those who also have cognitive impairment. The goal of this review was to identify current best practices for rehabilitation in long term care settings and
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approaches to optimize outcomes among individuals with dementia and other cognitive impairments post hip fracture. Procedures—The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (the PRISMA Statement) was used to guide the review. Five electronic databases, including Pubmed, EMBASE, CINAHL (EBSCO), Medline (EBSCO) and PsycINFO (EBSCO), were searched for intervention studies published in English language journals. Studies were eligible if they focused on rehabilitation interventions post hip fracture among older individuals (≥ 65 years) with cognitive impairment who were living in or transferred to long-term care or post-acute/ rehabilitation settings post hip fracture. Studies were excluded if they did not enroll individuals with cognitive impairment, the study was descriptive without any intervention content, or the intervention components were only medication, surgical approach or medical treatment.
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Main Findings—A total of 4,478 records were identified, 1915 of which were duplicative, 2,563 were relevant based on title and after careful review seven studies were included. Two included studies were randomized controlled trials, one was a single group pre- and post-test, one a descriptive comparison between those with and without cognitive impairment, one a case controlled matched trial, one a nonequivalent groups trial, and one a case report. The interventions varied between manipulating the type and amount of exercise or testing multifactorial issues including environmental interventions and the use of an interdisciplinary team to address psychosocial factors, medication management, use of assistive devices, and specific preferences or concerns of the individuals.
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Conclusions—The evidence summarized in this review suggests that it is feasible to implement rehabilitation programs focused on individuals with cognitive impairment in post-acute care settings. Moreover, there was evidence to suggest that intensive rehabilitation and exercise activities are beneficial, although innovative approaches may be needed to engage individuals with cognitive impairment.
Introduction
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The prevalence of Alzheimer's disease or related dementias (referred to as dementia throughout) is increasing in most countries1 and hip fracture is a common acute health condition experienced by older adults. Recovery following a hip fracture tends to be particularly challenging for individuals with dementia2. Approximately 19% of all older individuals with hip fractures have dementia, and up to 40% of individuals with a hip fracture have some form of cognitive impairment, which may include dementia, delirium, mild cognitive impairment or other post-operative cognitive decline3. In addition, older individuals with dementia often have multiple chronic medical conditions4 contributing to the complexity of their care needs. Older individuals with dementia who sustain a hip fracture often have more complications and face increased risks of long term care admissions and higher mortality3. Currently, however, most rehabilitation services for individuals post-hip fracture are not designed to meet the complex needs of those with dementia. These individuals are not as likely to be exposed to intensive rehabilitation when compared with similar individuals without dementia5,6. Post-acute services are limited and dementia is believed to impede
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rehabilitation despite evidence suggesting that post-acute rehabilitation for these individuals is associated with a reduced risk of mortality and long-term care placement3. It is generally assumed that older individuals with cognitive impairment will not be able to participate in traditional rehabilitation programs and/or demonstrate progress and thus they are generally admitted to programs with less intensive rehabilitation. Individuals exposed to less intense programs were noted to have less favorable outcomes when compared to individuals exposed to high intensity programs3.
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There is, unfortunately, a paucity of research on optimal rehabilitation interventions for individuals with cognitive impairment after hip fracture in post-acute settings6-8. In addition, for those interventions that do include individuals with cognitive impairment there is limited information on the components of the intervention or the type of staff providing this care and their specific training. Health care staff in post-acute care rehabilitation settings are often inadequately trained or mentored to care for individuals with dementia or other types of cognitive impairment9. Research is needed to establish the best programs of care and strategies required to optimize the outcomes of this vulnerable group.
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There has been only one systematic review, a Cochrane review, published on rehabilitation care for individuals with dementia following hip fracture surgery10. The Cochrane review focused only on randomized and quasi-experimental controlled trials and considered the effectiveness of the care on individual and system related outcomes. Of the five studies included in the Cochrane review, most were small and at high risk of bias and thus there was insufficient evidence to determine the best ways to care for people with dementia following a hip fracture. In contrast to the prior Cochrane review, this systematic review focuses on the details of the different types of interventions for individuals with cognitive impairment post hip fracture in long-term care, post-acute and rehabilitation settings and the effectiveness of those interventions. The goal of this review was to identify current best practices for these individuals and help them return at least to baseline function and the least restrictive level of care.
Methods Data sources and search strategy
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The Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA Statement11 was used to guide this systematic review. Five electronic databases, including Pubmed, EMBASE, CINAHL (EBSCO), Medline (EBSCO) and PsycINFO (EBSCO), were searched for intervention studies published in English language journals. Other sources included Google Scholar and the reference lists from eligible studies. The keywords included: dementia, Alzheimer's disease, cognitive decline, cognitive impairment, hip fracture, and any matched individuals or MeSH terms. The search strategy for Pubmed is shown as an example in Table 1. Eligibility criteria and study selection Studies were included in the review based on the eligibility criteria defined by the Population, Intervention, Comparator, Outcomes, Timing and Setting of interest framework (PICOTS, Table 2)12. Eligible studies were those that focused on rehabilitation interventions post hip fracture among older individuals (≥ 65 years) with cognitive impairment who were
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living in or transferred to long-term care, rehabilitation or post-acute settings post hip fracture. Studies were excluded if they did not enroll individuals with cognitive impairment, the study was descriptive without any intervention content, or the intervention components were only medication, surgical approach or medical treatment. Based on eligibility criteria, studies were selected and assessed by three reviewers and included an initial screening by title and abstract; an assessment of the full-text for eligibility; and a review of the full-text for data abstraction and quality assessment. Individual reviewer results were compared and discrepancies were discussed to arrive at agreement for inclusion or exclusion.
Results Study characteristics
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As shown in Figure 1, a total of 4,478 records were identified; among these 1915 were duplicative. Preliminary review of titles and abstracts resulted in a remaining 2,563 relevant papers. From this group, 2,526 were excluded as they did not include individuals with cognitive impairment, were not focused on hip fracture, had no rehabilitation intervention, were review, commentary, or measurement focused, or were not done in rehabilitation settings. This left 37 potentially eligible papers from which 29 papers were excluded on closer review for the same reasons noted previously. A final total of seven studies were included for the review.
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Of the seven relevant studies, two were randomized controlled trials13,14, one was a single group pre- and post-test15, one was a descriptive comparison between those with and without cognitive impairment16, one was a case controlled matched trial17, one was a nonequivalent groups trial18,19, and one was a case report20. As described in Table 3, the interventions varied between manipulating the type and amount of exercise or testing multifactorial issues including environmental interventions and the use of an interdisciplinary team to address psychosocial factors, medication management, use of assistive devices, and specific preferences or concerns of the individuals.
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Exercise activities to augment rehabilitation were the major focus of the interventions in two of the studies13,20. In the Moseley study13 individuals were randomized to what was referred to as the HIGH group versus the LOW group. In addition to routine therapy, the HIGH group was exposed to weight-bearing exercise twice daily for 60 minutes for 16 weeks. Five weight-bearing exercises were included along with walking on a treadmill with partial body weight support using a harness or a walking program after discharge. Weight bearing exercises included stepping activities and sit to stand activities. These activities continued in the home although the frequency of the home visits decreased. The individuals in the LOW group also engaged in five exercises but these were done while sitting or lying and they walked using parallel bars or walking aids for 30 minutes daily for 4 weeks. The LOW group individuals were also followed at home for a 4 week period. In the case study report20, a body weight-supported treadmill activity was used with a severely cognitively impaired older woman post hip fracture. This involved stepping on a motorized treadmill while unloading a percentage of weight using a counterweight harness system. Manual assistance was provided to help her maintain upright posture and a normal
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gait pattern. Treadmill walking was done daily with the length of time increased to 40 minutes daily by the time of discharge. Three of the studies tested a team based approach to rehabilitation to augment what would otherwise be referred to as routine rehabilitation and therapy14,17,18. In the study by Huusko14, individuals were either sent to a specialized rehabilitation facility or usual care and rehabilitation. The intervention in the geriatric rehabilitation center involved care by a geriatrician, rehabilitation nurses, social worker, neuropsychology, and physiotherapists and occupational therapists. Advice, training and encouragement were provided along with appropriate medication management and therapies twice a day. There was a rehabilitation philosophy of care such that individuals were engaged in activities throughout the day. In addition there were 10 home visits after discharge home.
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McGilton tested similar interventions in two different studies using team approaches that focused specifically on the needs of cognitively impaired older adults. In the first study, which was a longitudinal feasibility retrospective design16, the intervention was referred to as the Assessment, Individual-Centered Goals, Treatment, Evaluation and Discharge (ACTED) model of care. The goal of this intervention was to provide rehabilitation to individuals with cognitive impairment based on individualized needs. Early admission to rehabilitation was encouraged; individualized assessments related to evaluating and optimizing remaining abilities; assessments for dementia, delirium and depression; development of individual centered goals; individualized timing of treatment and location; and staff education on how to manage the behavioral symptoms associated with dementia was provided. Building on this work, the subsequent intervention developed and tested by McGilton in a controlled trial18,19 was referred to as the Individual-Centered Rehabilitation Model including individuals with cognitive impairment (PCRM-CI). This was essentially the same approach as the ACTED and included five main components: routine rehabilitation services (daily one hour sessions of physical and occupational therapy five days a week); dementia management as needed, delirium prevention; education and support for the staff providing care to those with cognitive impairment; and education of the caregivers. Individualized goals were established during the first week of admission.
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The case controlled matched group trial by Rosler 17 likewise addressed management of individuals with cognitive impairment by augmenting the team approach and testing rehabilitation outcomes on a Cognitive Geriatric Unit. The unit incorporated environmental changes such as hidden exit doors, a loop track for free wandering, increased lighting, a unit based treatment room for therapy and a living and eating room to make it more home like. In addition, nurse staffing was increased and all staff were provided with education on Integrative Validation and psychiatric issues in dementia. Conversely, the study by Jones15 did not manipulate the rehabilitation/exercise activities provided to individuals but simply described the outcomes of routine rehabilitation between those with and without cognitive impairment. Routine rehabilitation in this study included physical therapy for approximately 1.5 hours a day and occupation therapy for approximately 1 hour per day, five days a week. The length of rehabilitation was generally three to six weeks.
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With the exception of the single case study20 which included an 82 year old woman with Alzheimer's disease [Mini-Mental State Examination (MMSE) score of 9/30], the remaining studies included older individuals post hip fracture with and without cognitive impairment. Specifically, McGilton et al.16,18,19 and Huusko et al.14 included all levels of cognitive status and deliberately compared outcomes between those with and without cognitive impairment using a cut off MMSE score of 23 and below as being indicative of cognitive impairment. Two of the studies included those with cognitive impairment unless the impairment was severe (defined as an MMSE of ≤ 14)15 or there was severe impairment with no caregiver available13. The study by Rosler 17 included a small sub-study analysis of those individuals with a diagnosis of dementia (mean MMSE =14.5, SD=6.4).
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With the exception of the Huusko study14, all of the studies focused on function and/or performance as the primary outcome, often including both physical and cognitive function. Functional measures included either the Barthel Index (BI) or the Functional Inventory Measure (FIM), both of which address basic activities of daily living. Other additional outcomes included gait and balance, walking speed, muscle strength, sit-to-stand time, and measures such as the Physical Performance and Mobility Examination and balance activities. In some studies, outcomes also included length of stay in rehabilitation and discharge location. The focus in the Huusko study was on length of stay, mortality and discharge location at three and twelve months post-surgery. Results of Individual Intervention Studies
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The descriptive study by Jones 15 included all levels of cognitive impairment with a mean MMSE score of 25.4 (SD=4.7) suggesting that the majority were considered to be cognitively intact. Overall the individuals did have some improvement in function based on the FIM, no improvement in cognitive function, and 85% were discharged back to the home setting while the remaining 15% remained in a nursing facility following discharge from rehabilitation. Interestingly there was no difference in FIM motor (i.e., function) scores between those who did versus did not go home. There were also no differences in length of stay based on cognitive status. In the McGilton study testing the ACTED model16, both those with and without cognitive impairment improved with regard to motor function and there was no improvement in either group with regard to cognitive function. Likewise there was no difference in length of stay (mean of 30 days) or discharge location noted between the two groups. The functional gain achieved by both groups was evaluated based on calculating functional gains per number of rehabilitation days.
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The study by McGilton testing the PCRM-CI versus usual rehabilitation noted that there was no difference between functional outcomes across both sites. Individuals in the PCRM-CI intervention were, however, more likely to return home after discharge than individuals who received routine rehabilitation. In the study by Rosler 17 comparing the effectiveness of the Cognitive Geriatric Unit with routine rehabilitation for those with cognitive impairment, it was noted that both groups improved functionally but gait and balance improved more for those on the Cognitive
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Geriatric Unit than for those on usual treatment units. The length of stay was actually a little longer for those on the treatment Cognitive Geriatric Unit versus routine care and there was no difference in discharge location. The Huusko study also tested a geriatric focused rehabilitation program and compared it to routine rehabilitation. Despite their increased focus on engaging individuals in rehabilitation activities throughout the course of the day, there was no significant difference between the intervention versus the routine care group with regard to length of stay in rehabilitation, mortality or discharge location.
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Results of the Mosely13 study testing rehabilitation augmented with additional exercises noted that, in the subsample of individuals with impaired cognition there was significantly greater improvement in walking speed, physical performance, the step test, balance, function, quality of life, falls self-efficacy and less pain. Further, individuals with cognitive impairment had a higher exercise rate (i.e., spent more time exercising) in the HIGH group when compared to those without cognitive impairment. Findings from the single case study by Bellelli20 noted that the 82 year old woman with severe dementia who was exposed to an individualized body weight-supported treadmill intervention had significant improvements in function at the time of discharge that were maintained over 6 months. It is important to note that this individual was not willing or able to participate in traditional rehabilitation and was resistive to the encouragement of the physical therapist and refused to walk. By day 12, however, she was back to her baseline cognitively and was willing to participate in the body weight-supported treadmill walking and was noted to “enjoy” the activity.
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With the exception of the case study 20 and the study by Moseley 13, these studies did not report on treatment fidelity or how engaged individuals were in intervention activities. For example, it was not indicated if the individual did all of the exercises recommended during a session, went to all sessions, or if he or she refused therapy or did not tolerate full therapy sessions.
Discussion
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Based on the small number of studies extracted for our review (n = 7), there continues to be limited evidence available to guide the development of interventions for individuals with cognitive impairment who have experienced a hip fracture and are living in or transferred to long-term care, rehabilitation or post-acute settings. Many studies exclude this group completely or only include those with cognitive impairment who are still able to live in the community. Notwithstanding, the evidence summarized in this review suggests that it is feasible to implement rehabilitation programs focused on individuals with cognitive impairment in post-acute care settings. Moreover, there was evidence to suggest that intensive rehabilitation and exercise activities are beneficial, although innovative approaches may be needed to engage individuals with cognitive impairment. Additional research is needed to better develop and test innovative approaches across the full spectrum of cognitive impairment.
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Major components of the programs reviewed included routine and daily physical and occupational therapy with various exercises and rehabilitation therapies. The key components in the programs reviewed focused on the need to assist older individuals with cognitive impairment to regain their strength and functional ability after a hip fracture. Most studies incorporated functional tasks/activities (e.g., bathing and dressing) into the rehabilitation programs as these were more likely to be familiar to the individual with cognitive impairment and thus more likely to be performed. There was little evidence, however, of innovative approaches that matched individual preferences for physical and functional activities. For example, some individuals might be willing to ride an exercise bike while others would be more comfortable with aquatic exercise, traditional walking or use of a treadmill.
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McGilton's18 research emphasized the need for training and skill development and support for staff as an integral part of the implementation success of the program. Providing direct care staff with easy access to primary care providers who have experience in geriatrics (e.g., adult/gerontological nurse practitioners; geriatricians) is essential and can influence the success of the interventions focused on individuals with cognitive impairment21.
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Although only limited evidence was found, all of the included studies uniformly support that rehabilitation appears beneficial for this sub-group of individuals across different settings and countries. Further there was no evidence that participation in any of the rehabilitation activities resulted in harm (e.g., no falls and no exacerbation of medical problems reported). Nor was there any evidence that individuals with cognitive impairment were unable to participate in the planned rehabilitation studies relative to those without cognitive impairment. Based on some of the approaches provided to optimize successful recovery for older individuals with cognitive impairment post hip fracture, it may be useful to incorporate the preferences of the individual20 and to use an interdisciplinary approach14,18.
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Most studies included individuals with and without cognitive impairment. These programs were not specifically developed to address rehabilitation for individuals with cognitive impairment and only focused on functional outcomes and physical performance rather than on cognitive performance. When only individuals with cognitive impairment were included in the study there was no consideration of level of impairment. Likewise, in these studies there was no differentiation between the three common presentations of cognitive impairment: dementia, delirium, and/or symptoms of depression. Although authors alluded to using approaches to facilitate individual engagement in their rehabilitation program through inter-individual interactions and environmental interventions17, they did not report on engagement (e.g., how long individuals participated in in therapeutic interventions; whether or not the individual went to therapy sessions easily or required encouragement). None of the studies incorporated previously reported effective interventions with individuals with cognitive impairment such as social support and engagement of caregivers 22. As shown in the work of Boltz et al. 22, family/caregiver participation can improve functional outcomes among older medical individuals with cognitive impairment. Based on the limited body of evidence noted in this review, there is an urgent need to develop interventions specifically focused on engaging individuals with cognitive
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impairment post hip fracture in rehabilitation. The goal of such programs is to optimize functional outcomes and assure return of these individuals to their highest level of physical function and social engagement regardless of where the ultimate discharge setting might be. We recommend the use of theoretically based approaches that are guided by the theory of self-efficacy 23 and those that address behavioral and psychological symptoms associated with cognitive impairment. The theory of self-efficacy is a behavior change theory suggesting that the stronger the individual's self-efficacy and outcome expectations, the more likely it is that he or she will initiate and persist with a given activity. Self-efficacy expectations are the individual's beliefs in his or her capabilities to perform a course of action to attain a desired outcome; outcome expectations are the beliefs that certain consequences will be produced by individual action. Efficacy expectations are dynamic and enhanced by four mechanisms: (1) successful performance of the activity; (2) verbal encouragement; (3) seeing like individuals perform the activity; and (4) elimination of unpleasant physiological and affective states associated with the activity. We have found repeatedly that the four sources of information suggested within the theory are effective in changing behavior among these individuals24-27.
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In addition, these programs need to identify the optimal timing of intervention components and the dosage of treatment required in terms of frequency, duration and intensity. It is not clear from our review how much time was spent in rehabilitation related therapy (physical, occupational and/or speech therapy), which activities were actually performed by the individual or the intensity of the activities performed. Likewise, the encouragement individuals received to practice functional tasks and physical activity outside of therapy sessions was not carefully considered (e.g., interactions with nursing, recreational staff, social workers). Activities such as walking individuals to and from the dining room or the bathroom, or engaging individuals in recreational/social activities can make a considerable contribution to performance outcomes. Our review demonstrated that individuals with cognitive impairment can participate in high intensity programs and achieve benefits. It is possible therefore, that increasing intensity, frequency and/or duration of therapeutic encounters might result in better outcomes and allow more individuals to return to community living after hip fracture. Seitz et al.,3 recently examined rehabilitation practices in a large Canadian province and found that those exposed to higher intensity approaches had better outcomes in terms of mortality and being able to return to community living.
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In summary, there are four fundamental barriers to advancing the field related to care of older individuals with cognitive impairment as identified in this review. First, there is no consensus on components that should be included in the rehabilitative programs for individuals post hip fracture with cognitive impairment. The ability to compare effects of the programs or interventions is difficult as they were all unique and the specific therapeutic components were not always well described. Second, there remains no uniform approach to determining how to engage this group of individuals to participate in rehabilitation. Hidden within these approaches are the specific skills and theoretically and evidence based techniques required of staff to rehabilitate individuals with cognitive impairment. The third barrier is the lack of uniformity in assessing cognitive impairment and differentiating
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cognitive impairment from what might be delirium or depression. This is important as the interventions required between these different conditions vary. Finally, the quality of reporting the treatment fidelity 28 and dose each individual receives within the rehabilitation programs requires more investigation. If our goal is to be individual centered and provide tailored interventions for individuals with cognitive impairment, knowledge of how to report this information is essential so researchers and clinicians can better evaluate the findings. Study Strengths and Limitations
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The strengths of this review include the broad search strategy employed followed by a very systematic evaluation of the available data. We identified all relevant studies (which was corroborated by the recent Cochrane review), and three reviewers assessed titles and abstracts. We synthesized our results in an unbiased way. Based on the sparse evidence retrieved, a clear gap in our current knowledge has been identified. However, there are also some limitations. Given the limited research in this area we were unable to draw any firm conclusions based on quantitative data. Rather, we looked more at the different types of approaches used and the impact of these approaches on individual outcomes. Despite the limited number of studies in this review, it was consistently noted that individuals post hip fracture with cognitive impairment participated in and benefitted from rehabilitation. Further we recommend that future research consider multimodal approaches and a broader evaluation of the impact of rehabilitation on individuals' recovery beyond physical function to include social participation and overall quality of life.
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This work has been supported through the Canadian Institute for Health Research as a New Investigator (Individual Oriented Research) and from Alberta Innovates Health Solutions; through the National Institute on Aging via K08 AG043548, R01 AG046217-01, NR013736-01A1, P30 AG028747, and R37 AG009901, R01 AG029315.
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Figure 1. Flow Chart for Interventions among older adults with cognitive impairment post hip fracture
* Two articles described the same study, so the total number of studies included was 7.
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Table 1
Search strategy using Pubmed
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#1 “Alzheimer Disease”[Mesh] OR “Dementia”[Mesh] OR “Mild Cognitive Impairment”[Mesh] #2 Alzheimer OR cognition OR cognitive decline OR cognitive impairment OR dementia OR cognitive disorder #3 #1 OR #2 #4 “Hip Fractures”[Mesh] #5 hip fracture #6 #4 OR #5 # 7 #3 AND #6 Filters: Humans; English; Aged: 65+ years
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Table 2
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Eligibility criteria using PICOTS framework for interventions among older individuals with cognitive impairment post hip fracture
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Category
Criteria
Population of interest
-Older individuals(≥ 65 years old) with cognitive impairment post hip fracture (e.g., all or partial individuals had cognitive impairment; individuals with only moderate or mild cognitive impairment) -Excluded if none of the individuals had cognitive impairment or dementia.
Intervention of interest
-Any intervention for rehabilitation purpose (e.g., exercise training, functional training resistance training, mobility training, occupational or physical therapy, early rehabilitation) with any design (e.g., RCT, non-randomized controlled study, cohort, time series, case report, intervention protocols). -Excluded if there was no rehabilitation intervention or the intervention contents were only medication/pharmacy, surgical/medical approaches or treatments.
Comparator
-Any comparator, or none at all (e.g., placebo, no therapy, another active therapy, or no control therapy).
Outcome of interest
-Any individual outcomes (e.g., function, quality of life, balance, strength, gait, mood, ADLs, IADLs, falls, physical ability, delirium).
Timing
-Publication period: unlimited; Follow-up duration: unlimited.
Setting
-Individuals were recruited from or discharged to long-term care setting, assisted living, nursing home, geriatric centers, Alzheimer specialized center, skilled nursing facility; post-acute care rehabilitation unit in hospital setting). -Excluded if individuals were discharged from hospital or acute care settings to community or home-based setting after treatment.
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Huusko et al., 2000, Finland 14
Bellelli et al., 2006,
Italy20
Randomized controlled trial
Case report
Study Design
243 independently living patients with dementia (intervention: n=120 (79 with MMSE
