Description of the condition
The hip joint is the articulation between the thigh bone (femur) and the pelvis. The term ‘hip fracture’ encompasses all fractures of the upper (proximal) part of the thigh bone (femur). Hip fractures are commonly divided into two types: intracapsular fractures, which represent those that occur within or proximal to the attachment of the hip joint capsule to the femur; and extracapsular, which represent fractures occurring outside or lower (distal) to the hip joint capsule (Parker 2010). Hip fracture is a common injury in the elderly population.
The majority of people undergo hip surgery following hip fracture (Uzoigwe 2012). The location of the fracture, stability and degree of comminution (number of pieces the bone breaks into) determine which operative procedure should be undertaken in order to repair the hip fracture. The aim of surgery, irrespective of the type of operation, is to reduce pain, facilitate early weight-bearing mobility to improve outcomes, and to facilitate independence in activities of daily living, such as bathing, dressing, and continence (Handoll 2009). A delay in surgical intervention is known to be a key factor in producing poorer outcomes (Vidal 2012).
The annual hip fracture incidence rate has been estimated as 1.29/1000 person-years in males and 2.24/1000 person-years in females (Adams 2012). This figure is likely to rise over the next few years as the population is increasing in age (Cummings 2002). It is the most common physical rehabilitation condition for older adults (Lenze 2007), seen in both those who are cognitively intact and those with all degrees of cognitive impairment, and is associated with significant pain and loss of independence and function (Morrison 2000). Thirty-three per cent to 37% of patients return to their prior level of function by six months, including those needing assistance, but only 24% are independent in locomotion at by six months (Magaziner 2002).
Dementia is a global loss of cognitive and intellectual functioning, which gradually interferes with social and occupational performance (Lieberman 2006; McGilton 2012). It is a common condition with a significant impact on society. Hip fracture is nearly three times more common in people with dementia than in people without dementia (Zhao 2012). It is expected that the incidence of patients with dementia and hip fracture will increase during the next 25 years (Adunsky 2003; Knapp 2007). Health and social care expenditure in England on people with dementia in the year following admission for fractured neck of femur has been estimated to be in excess of GBP 1 billion (GBP 1037 million in 2005 to 2006 prices), about GBP 0.4 billion higher than expenditure on those without dementia (Henderson 2007). This was estimated as equating to approximately GBP 34,200 per person per annum for those without dementia and GBP 40,300 per person per annum for people with dementia (Henderson 2007).
Description of the intervention
The provision of high-quality care for people following hip fracture has been identified as a major clinical need in the United Kingdom and elsewhere. This has been exemplified in the United Kingdom through the development of national guidelines (NICE 2011), the introduction of specific financial incentives for high-quality care through the 'Best Practice Tariff' (NICE 2011), and the national audit of standards of care provision to this population through the National Hip Fracture Database (National Hip Fracture Database 2013). For all hip fracture patients, initial management is usually provided in an acute hospital setting, where the person undergoes an operation for their hip fracture. Best practice often includes shared orthopaedic and geriatric (sometimes termed ortho-geriatric) care pre- and post-operatively to ensure that patients are medically fit for surgery and to monitor and manage any post-operative medical complications that may develop (Dy 2012). These may include pneumonia, anaemia, dehydration, pressure sores, or cardiovascular complications (Dy 2012; Jameson 2012). During the initial hip fracture admission, or index admission (Drummond 2005), health professionals such as nurses, pharmacists, occupational therapists, physiotherapists, social workers, and dieticians may be involved in the patient's recovery and rehabilitation (Kammerlander 2010; Stenvall 2012). Depending on their home circumstances and their post-operative functional capabilities, patients may be discharged directly to the residential setting they lived in, with or without community or out-patient rehabilitation, or may be transferred to an in-patient rehabilitation unit to receive continued multi-professional rehabilitation. Patients will remain in this rehabilitation setting until they are sufficiently independent to be discharged to their pre-admission residence or, if this is not achievable, they may be provided with residential or nursing home care (Hashmi 2004).
Over the past 15 years, developments in the management of people with hip fracture have been advanced (Cameron 2000). This has particularly been seen for those with dementia, who have specific and complex care needs (Cameron 2000; Dy 2012). Over this period, research reports and subsequent clinical guidelines have recommended a number of interventions to improve outcomes for this group of patients (NICE 2011). These have included specific medical management by an ortho-geriatrician on specified hip-fracture wards, which is considered to enhance inter-disciplinary team working; improvement of communication between health and social agencies (Kammerlander 2010; Stenvall 2012); provision of dedicated functional rehabilitation interventions across acute hospital and community rehabilitation settings (Al-Ani 2010; Huusko 2000); monitoring of post-operative complications including pressure sores (Söderqvist 2007); and optimisation of nutritional levels for this group of patients (Hershkovitz 2010). Specific rehabilitation strategies for this population have included enhanced rehabilitation with respect to orientation to the environment, clues, reminiscence and structured, familiarised routines. Such interventions can be delivered in a variety of healthcare and domiciliary settings.
How the intervention might work
The interventions that have been proposed to improve the management of people with dementia who have suffered a hip fracture have been advocated to improve communication between healthcare professionals and provide generic and wider healthcare expertise than may conventionally be found on an orthopaedic ward or in a rehabilitation setting (Söderqvist 2007). Recommended interventions have also included specifically targeting interventions and resources for this population, who have greater and more complex healthcare needs (Söderqvist 2007). These factors are acknowledged as possible explanations why a specific, targeted management programme for people with dementia following hip fracture may be advantageous over conventional, non-specific post-operative management (Handoll 2009).
Why it is important to do this review
More than three quarters of a million people in the UK have dementia. One in four National Health Service (NHS) beds are occupied by someone with dementia. Fractured hips and falls are the commonest reasons for hospital admission. People with dementia who sustain a hip fracture have more complex health problems with complications, disabilities, and social needs. Whilst previous reviews have examined the rehabilitation of people following hip fracture, none have specifically assessed the specialist rehabilitation strategies for those who have dementia. Since this population has complex care needs, and makes a major demands on healthcare services, this focused review of the literature is warranted.
In this population, factors such as depression, motivation, pain, and cognitive impairment have been cited as impacting on clinical outcomes (Lenze 2007). Pain has been acknowledged as a particular problem since if pain management is inadequate, due to poor assessment, negative post-operative outcomes and complications such as pneumonia, atrophy, and thromboembolism can occur (Egbert 1996; Feldt 1998; Morrison 1998). These factors may adversely impact on the ability of a person to return to functional independence, the discharge destination, the length of their in-patient hospital stay and rehabilitation requirements. The resulting negative consequences, therefore, have a health economic impact, at a personal and a systems level. People who sustain a hip fracture and have dementia experience longer hospitalisations with poorer outcomes, such as higher mortality and morbidity rates, and have a greater risk of requiring nursing home placement and poorer functional recovery (Gruber-Baldini 2003; Magaziner 1990; Steiner 1997). However, whilst various interventions have been supported for the targeted rehabilitation of people with dementia who experience a hip fracture (Al-Ani 2010; Huusko 2000), these are more expensive than conventional post-operative management following hip fracture (Lenze 2007). More evidence is needed on the relationship between the processes and outcomes of post-operative care, length of stay, and costs in the general population of hip fracture patients (Hunt 2009), and in particular in the subpopulation of people with dementia (Henderson 2007). Decisions as to whether to allocate limited health and social care resources to these new interventions can be informed by economic evaluation, the comparative analysis of outcomes and the costs of alternative treatment programmes (Drummond 2005).
Previous reviews have examined the literature on the use of management strategies for people with dementia who experience a hip fracture (Allen 2012; Handoll 2009). These have focused on clinical and functional outcomes. No reviews have specifically assessed the impact of such management programmes on behavioural, cognitive, or dementia-related outcomes for this population, nor on the relationship between these outcomes and resource use and costs. The purpose of this review is therefore to answer these important questions.