Details about each study's inclusion/exclusion criteria and the percentage of eligible patients who participated in the study are presented in Table 2. Eight of the eleven studies reported using consecutive admissions to the medical service in the study.37,38,40,41,43-46 Six studies reported the number of patients eligible for the study and the subsequent number who met study inclusion/exclusion criteria at the start of the study, though the exact reasons for exclusion were not fully reported in all studies. Inclusion rates vary widely from 95%37 and 91%40 to the very low values of 49.7%38 and 41%.42 Huusko et al42 had the lowest reported inclusion rate and the authors did not report reasons for participant exclusion, a finding that creates less confidence with the study's findings. High rates of eligible subject nonparticipation, particularly when reasons for exclusion are not presented, can lead to significant selection bias which impacts the generalizability of the results.
Multiple settings for inpatient rehabilitation care were evaluated in the articles: acute postsurgical care on a general orthopaedic ward40,43,46 and a specialized hip fracture service,37 stand alone rehabilitation hospitals,37,38,42,45 and specialized geriatric rehabilitation units within a tertiary care hospital.37,39,41 Three studies compared outcomes between 2 rehabilitation settings: 2 medical care models within the same acute care hospital,37 inpatient rehabilitation facilities versus skilled nursing facilities,44 and the randomized treatment to a geriatric ward in a tertiary care hospital or usual care in the local community hospital after surgery.42 The other studies followed cohorts of consecutive admissions to a single service.38-41,43,45-47
Only one study included the selection criteria used at the acute care hospital for referral and transfer to an inpatient rehabilitation facility.39 This study acknowledged a selection bias of choosing people who were felt would achieve a significant benefit from rehabilitation, were able to participate in therapy, and with a reasonable discharge plan in place prior to entering rehabilitation. The extent of the selection bias in the other studies is unknown and limits the generalizability of the findings.
Cognitive Impairment Assessment
Cognitive impairment was evaluated by multiple scales (Table 1). Additional measures included in these studies were depression measured using the Geriatric Depression Scale (GDS), severity of depression assessed using the Hamilton Depression Rating scale (Ham-D), and delirium using the Confusion Assessment Method (CAM).
The Mini-mental State Examination (MMSE) was the most common scale, being used in seven studies.38,40,42-46 The threshold score of the MMSE to indicate impairment was not consistent in these studies, making comparison of outcomes across studies difficult. Comparison of outcomes across all studies was difficult due to the use of different scales and thresholds to define the patients with cognitive impairment. A non-uniformity of the case definition for cognitive impairment can create dissimilar samples that impact the ability to compare findings between studies and to generalize study findings.
Additionally, none of the studies qualified cognitive status based on the timing of the diagnosis of cognitive impairment, for example pre-fracture dementia or postoperative delirium. Acute cognitive changes, for example delirium, may resolve over the inpatient rehabilitation time frame with subsequent improvement in function that may more closely resemble functional gains of people without cognitive impairment. Prefracture cognitive impairment indicates a chronic nature of the condition that may be exacerbated with the acute injury and not associated with an expectation of improvement in status over time. Three studies re-evaluated cognitive status at the end of the rehabilitation period,37,41,47 though data was not used to evaluate whether cognitive status changed over the duration of rehabilitation.
Several outcome measures were used: the Functional Independence Measure (FIM) as an aggregate score of the 2 subscales for motor function and cognitive function, and the motor subscale alone; the Barthel Index (BI); and the Elderly Mobility Scale (EMS). Six studies used the FIM making it the most common scale, 5 using the motor subscale alone and one study using the aggregate score.37,39,40,43,44,46 Derivations from the FIM score, specifically the FIM gain, FIM efficiency, Montebello Rehabilitation Factor Score (MRFS) efficiency and efficacy, were used in data analyses of these studies to quantify the magnitude of the rehabilitation effect. Activities of daily living (ADL) were used in 2 studies to evaluate function45,47, but only Moncada et al45 used a valid and reliable tool.
Seven studies have reported that patients with cognitive impairment were able to make functional gains after the inpatient rehabilitation.39-45 Absolute gains in function, the difference between the discharge and admission scores, were equal for impaired and nonimpaired. The relative gains, which take into account length of stay and a patient's specific potential for change based on the maximum possible FIM score the person can achieve creates a value from 0 to 1, were smaller in the cognitively impaired. The relative scores overcome a ceiling effect in high functioning individuals as their absolute gain is limited compared to the gain of individuals with a lower score.37
Two studies reported a definition for “successful rehabilitation,” though only one was specified a priori,40 using an MRFS efficacy ≥ 0.50, or at least a 50% improvement in function after hospital admission.37,40 The first study by Adunsky et al,37 “successful rehabilitation” was evaluated by admission FIM-cog scores divided into bands at 5-23, 24-32, and 33-35. The asymmetry of the score bands, post hoc analysis and lack of a threshold score for cognitive impairment make the interpretation of the results very challenging especially to translate the findings into clinical practice. The study by Heruti et al40 demonstrated absolute gains in function were independent of cognitive status though relative gains were less in patients with cognitive dysfunction (p < 0.001).
Referencing ADL function to ability one month prior to the fracture, the total number of independent ADLs decreased from 5.4 to 3.8 at 6 weeks postsurgery, a statistically significant effect, p < 0.001, that was independent of cognitive status.45 Unfortunately, this study only looked at short-term outcomes and did not follow up participants for a sufficient time frame to evaluate recovery of function. vanDortmont et al47 found the majority of patients were independent in ADLs at the end of rehabilitation. However these results need to be viewed with caution as the measurement tool has not been adequately tested for reliability or validity as a measure of ADL function for older people and there was no statistical analysis accompanying this result.
Length of Stay (LOS)
Discharge criteria to determine attainment of maximal function during rehabilitation was reported in only one study.46 Four studies reported LOS by cognitive status while 5 studies reported a combined average LOS for all study participants. Three studies reported no significant difference in the average LOS between cognitively impaired and intact groups during the acute hospital stay.41,45,46 The average LOS in the acute hospital setting prior to transfer to an inpatient rehabilitation facility varied widely from 6.6 days,45 16 days,41 and 84.5 days46 respectively.
In the subacute rehabilitation phase, a statistically significant decrease in LOS was found for mild and moderately cognitively impaired participants in the intervention group of the RCT.42 The LOS ranged from 29 to 47 days in the intervention group to a range of 46 to 147 days in the control group. The median MMSE scores showed a statistically significant difference between the intervention and control groups at 23 versus 20, p < 0.001, even though subjects were randomly allocated into the groups. Results are conflicting for studies following a case-series through a single rehabilitation model. Rolland et al46 found no statistically significant difference in average LOS across 3 cognitive groups with values ranging between 47.7 to 66.2 days for inpatient subacute rehabilitation. In contrast, Moncada et al45 found a statistically significant difference, p < 0.001, in the LOS. Patients with cognitive impairment had a longer LOS at 18 days compared to patients who were cognitively intact at 10 days during the acute postoperative period. The lack of standardized discharge criteria from rehabilitation for all studies meant we were unable to make direct comparison of results across studies.
Place of residence upon discharge was another outcome measure included in 3 studies.39,42,47 These studies focused on the ability of participants residing independently in the community pre-fracture to return to community living upon discharge from rehabilitation. Only one study limited participation entirely to community dwelling elderly.42 Goldstein et al39 had a heterogeneous population comprised of people who resided in the community, personal care homes, intermediate nursing facilities, and nursing home. The study by vanDortmont et al47 contained community dwelling older adults in the cognitively intact group while 92.3% of the small cognitively impaired group came from psychogeriatric institutions. In the study by Huusko et al,42 a greater percentage of the cognitively impaired patients receiving the structured inpatient rehabilitation program returned to community living, 91%, compared to the control group, 63%. The other studies included in this review did not report the place of residence prior to fracture for the study participants.37,38,40,41,43-46
No detailed information about the rehabilitation interventions was included in the studies.43-47 The most common practice was to report the number of hours of rehabilitation that patients received per day or per week.37-39 Only one study reported on weight bearing status of participants postsurgery and specifically included the provision that if patients were unable to adhere to weight bearing restrictions than they would be allowed mobilization without restriction.42 Cognitive impairment was found to negatively influence the ability of individuals ability to participate in rehabilitation sessions either through a reduction in the total number of sessions or in the level of participation in each session.38,43 However, there is not enough evidence or information to guide selection and inclusion of specific physical therapy rehabilitation interventions to optimize outcomes in this patient population.
Level of Evidence Recommendations
After the surgical repair of a hip fracture, patients with mild to moderate cognitive impairment benefit from participation in a multidisciplinary inpatient rehabilitation program was assigned a Grade B recommendation.42 The more general statement that people with cognitive impairment demonstrate functional gains in the acute and subacute phases of an inpatient rehabilitation program though with possible longer length of stay merits a Grade C recommendation.39-41,43-45 No recommendations can be made specific to physical therapy interventions as the literature does not provide sufficient detail.
The methodological quality of studies included in this systematic review was fair to poor. The levels of evidence rating derived from the studies included in this systematic review must be interpreted with caution due to the low methodological quality of the studies. The recommendations are primarily derived from the study by Huusko et al,42 and there are conflicting opinions in the literature about the quality of recommendations that can be obtained from the study. A recent systematic review of physical therapy interventions in hip fracture rehabilitation assigned this study's results a Grade A recommendation,47 while the Cochrane Review on inpatient rehabilitation for proximal femoral fractures in older adults had significant concerns and felt the subgroup analysis by cognitive status was inappropriate.49 The present Grade B level of recommendation takes into consideration the possibility of moderate to high risk of error in the study results as outlined by the Cochrane review. There is consistent Grade C evidence to support the more general recommendation that patients with cognitive impairment can demonstrate functional gains during inpatient rehabilitation.39-41,43-45
Comparison across studies is limited by the heterogeneity of the samples and clinical measures used to assess both cognitive status and functional ability. In the assessment of cognitive status, the use of multiple scales and multiple threshold values created problems in identifying the study population with cognitive impairment. Previous research has demonstrated the choice of diagnostic system has a dramatic impact on the prevalence estimates of dementia.50 This heterogeneity does not allow for any certainty that the same patient populations are being designated as cognitively impaired between studies thereby limiting the generizability of the findings or the ability to make firm recommendations.
There are conflicting findings for the impact of cognitive status on the length of stay in a subacute inpatient rehabilitation program. Potential sources for this variation include the lack of defined discharge criteria, uncertainty that the study samples have patients with similar levels of cognitive impairment and potential differences in clinical practice between countries. Greater information was required from these studies on the criteria used to discharge people from rehabilitation.
Regardless of the cognitive status of older adults following surgery for a hip fracture, there is limited evidence from the literature supporting coordinated multidisciplinary inpatient rehabilitation.48,49,51 Considering the high prevalence of cognitive impairment in this population,15 this subgroup of patients represents an area with great potential and need for further research. Specifically there is a need to identify patient characteristics and treatment interventions that lead to successful outcomes and address the cognitive and behavioural symptoms that can create barriers to rehabilitation. There is also a need to increase attention to the prevention of acute cognitive changes, such as delirium, as even transient acute cognitive changes can increase the risk of poorer functional outcomes.15 Additionally, the timing of onset of cognitive changes is important from both a research and clinical perspective. Importantly acute cognitive changes may resolve over the time frame a patient is receiving inpatient rehabilitation such that cognitive ability after surgery may not reflect potential functional outcomes.
None of the included studies supplied sufficient detail to allow for the evaluation of specific rehabilitation interventions, their frequency with respect to prescriptive information on the number of repetitions of a given exercise or the frequency of performing the exercise over a week duration, duration or progression. Future research is required to define the specific rehabilitation interventions that successfully overcome the cognitive and behavioural symptoms that impact the ability of thispopulation to participate optimally in rehabilitation interventions. Treatment approaches that are successful in the cognitively intact may be unsuccessful in the cognitively impaired, so more specific information about interventions and modifications that are employed at the program level as well as at the physical therapy level merit further investigation. It is also difficult to isolate the independent contribution of a single intervention, eg, physical therapy treatment, from other disciplines within a multidisciplinary program, therefore well-designed studies are need to address this area. Additionally, further research is also required to determine the optimal time frame for recovery to occur, especially if rehabilitation is on a trial basis;52 the clinical significance of gains with respect to care needs for the individual and caregivers; and the maintenance of functional gains upon discharge from rehabilitation.
Additional areas for improvement in future research identified from this systematic review include a complete reporting of both inclusion and exclusion criteria for study participants as well as a demographic, and pre-fracture cognitive and physical function of all participants. Importantly there needs to be standardization of cognitive assessment, both for the method used and the threshold values used to denote impairment to allow comparison across studies. The assessment of cognition also needs to take into account the timing of the diagnosis and any change in the cognitive status from pre-fracture levels.
A clear identification of criteria used at the acute hospital stage for referral to and acceptance into inpatient rehabilitation is needed. The potential selection bias of picking only the best possible candidates will over-estimate treatment effects and a lack of criteria used on this issue limits fully describing the characteristics of people who will and will not benefit from rehabilitation. Prefracture place of residence of patients is important information as discharge destination is not an informative outcome if a change in status cannot be determined. Additionally, people living in supported accommodation or institutional setting represent a more frail population with possibly limited potential to make gains in function compared to people who were living in the community pre-fracture.
Weight bearing status may impact the ability to make functional gains and may increase length of stay if these restrictions directly impact a person's ability to safely return home regardless of cognitive status. Additionally, the cognitively impaired may be particularly challenged to mobilize with weight bearing restrictions. Therefore, it is important to include information on the type of fracture, type of fixation, weight bearing restrictions, co-morbid medical conditions and provisions that will facilitate mobilization if a person is unable to adhere to or physically unable to manage mobilizing with less than full weight bearing status.
There are several limitations in this systematic review. First, randomized controlled trials are considered the primary means of demonstrating treatment efficacy and this systematic review found only one RCT.42 The strength of recommendations derived from this study is limited due to concerns about the data analysis for the subgroup of cognitively impaired patients. Second, the majority of studies supporting inpatient rehabilitation after hip fracture in the cognitively impaired are prospective case series and provide limited evidence to support efficacy. Further limitations may include small sample sizes and poor methodological quality of the studies which highlight the need for further research.
Due to the limitations in the studies identified for this systematic review the recommendations should be regarded with caution. The first recommendation is that cognitively impaired older patients with hip fracture are most likely to demonstrate gains in function from participation in an inpatient rehabilitation program in the acute and subacute recovery phases after surgery. Second, group participation in an inpatient rehabilitation program for the cognitively impaired may require a longer length of stay compared to the cognitively intact which is offset by the benefit that more cognitively impaired older adults might be able to return to community living after this type of intervention. Third, our findings highlight the need for well-designed clinical trials adequately powered to detect clinically meaningful results with valid outcome measures to improve care for this patient group.
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Keywords:© 2009 Lippincott Williams & Wilkins, Inc.
systematic review; rehabilitation; hip fracture; older adults; dementia/cognitive impairment