Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery

摘要

BackgroundudHip fracture is a major fall-related injury which causes significant problems for individuals, their family and carers. Over 40% of peopleudwith hip fracture have dementia or cognitive impairment, and their outcomes after surgery are poorer than those without dementia. Itudis not clear which care and rehabilitation interventions achieve the best outcomes for these people.udObjectivesud(a)To assess the effectiveness ofmodels of care including enhanced rehabilitation strategies designed specifically for peoplewith dementiaudfollowing hip fracture surgery compared to usual care.ud(b) To assess the effectiveness for people with dementia ofmodels of care including enhanced rehabilitation strategies which are designedudfor all older people, regardless of cognitive status, following hip fracture surgery compared to usual care.udSearch methodsudWe searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group Specialised Register,udup to and including week 1 June 2014 using the terms hip OR fracture OR surgery OR operation OR femur OR femoral.udSelection criteriaudWe include randomised and quasi-randomised controlled clinical trials (RCTs) evaluating the effectiveness for people with dementiaudof any model of enhanced care and rehabilitation following hip fracture surgery compared to usual care.udData collection and analysisudTwo review authors working independently selected studies for inclusion and extracted data. We assessed the risk of bias of includedudstudies.We synthesised data only ifwe considered studies sufficiently homogeneous in terms of participants, interventions and outcomes.udWe used the GRADE approach to rate the overall quality of evidence for each outcome.udMain resultsudWe included five trials with a total of 316 participants. Four trials evaluated models of enhanced interdisciplinary rehabilitation andudcare, two of these for inpatients only and two for inpatients and at home after discharge. All were compared with usual rehabilitationudand care in the trial settings. The fifth trial compared outcomes of geriatrician-led care in hospital to conventional care led by theudorthopaedic team. All papers analysed subgroups of people with dementia/cognitive impairment from larger RCTs of older peopleudfollowing hip fracture. Trial follow-up periods ranged from acute hospital discharge to 24 months post-discharge.udWe considered all of the studies to be at high risk of bias in more than one domain. As subgroups of larger studies, the analysesudlacked power to detect differences between the intervention groups. Further, there were some important differences in the baselineudcharacteristics of the participants in experimental and control groups. Using the GRADE approach, we downgraded the quality of theudevidence for all outcomes to ’low’ or ’very low’.udNo study assessed our primary outcome (cognitive function) nor other important dementia-related outcomes including behaviour andudquality of life. The effect estimates for most comparisons were very imprecise, so it was not possible to draw firm conclusions from theuddata. There was low-quality evidence that enhanced care and rehabilitation in hospital led to lower rates of some complications andudthat enhanced care provided across hospital and home settings reduced the chance of being in institutional care at three months postdischargeud(Odds Ratio (OR) 0.46, 95% confidence interval (CI) 0.22 to 0.95, 2 trials, n = 184), but this effect was more uncertainudat 12 months (OR 0.90, 95% CI 0.40 to 2.03, 2 trials, n = 177). The effect of enhanced care and rehabilitation in hospital andudat home on functional outcomes was very uncertain because the quality of evidence was very low from one small trial. Results onudfunctional outcomes from other trials were inconclusive. The effect of geriatrician-led compared to orthopaedic-led management onudthe cumulative incidence of delirium was very uncertain (OR 0.73, 95% CI 0.22 to 2.38, 1 trial, n = 126, very low-quality evidence).udAuthors’ conclusionsudThere is currently insufficient evidence to draw conclusions about how effective the models of enhanced rehabilitation and care afterudhip fracture used in these trials are for people with dementia above active usual care. The current evidence base derives from a smalludnumber of studies with quality limitations. This should be addressed as a research priority to determine the optimal strategies to improveudoutcomes for this growing population of patients.