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Should a dementia diagnosis be a barrier to an inpatient rehabilitation bed following a neck of femur fracture?

Patients who have sustained a neck of femur fracture have a higher mortality and morbidity rate than their non-affected peers. This study examines whether there is any difference in discharge outcomes between patients with and without a dementia diagnosis.

Patients who have sustained a neck of femur fracture have a higher mortality and morbidity rate than their non-affected peers. This study examines whether there is any difference in discharge outcomes between patients with and without a dementia diagnosis.

Abstract

Purpose: Given the increasing incidence of neck of femur (NOF) fractures worldwide along with the rising associated post-operative care costs, there is a requirement to identify services that maintain patients’ independence. Previous studies have shown inpatient post-operative rehabilitation services increase the chance of patients maintaining their independence.

Methods: We looked at National Hip Fracture Database data from a medium sized district general hospital in the UK between January 2016 and May 2019 to see if we could identify any difference in discharge outcomes from our post-acute inpatient rehabilitation hospitals between patients with and without a dementia diagnosis.

Results: We found no significant difference in length of stay, immediate readmissions to hospital or mortality at six months. We found an increased chance of admission to hospital six months post discharge in the dementia cohort (OR: 1.93; 95% CI: 1.17-3.18), in keeping with overall patient trends in literature. Importantly we did not find any significant difference in discharge to usual residence (OR: 0.75; 95% CI: 0.43-1.29) between these cohorts.

Conclusions: We conclude that a diagnosis of dementia should not be seen as a barrier to accessing post-acute inpatient rehabilitation care, in the presence of a specialist opinion that a patient will engage with the rehabilitation programme.

Introduction

Neck of femur (NOF), or hip, fracture incidence increases with age.1 As the life expectancy of the population increases, the incidence of hip fractures is likely to increase. In 2000 there were 1.6 million estimated hip fractures worldwide and this is expected to rise to 6.3 million by 2050.2

Patients who have sustained a neck of femur fracture have a higher mortality and morbidity rate than their non-affected peers.3 In particular, hip fracture patients experience a reduction in their ability to self-care, mobilise and perform their normal activities of daily living.4

This not only has an impact on these individuals’ quality of life but, given the need to support these people with long-term care, there are also large financial repercussions for healthcare funders. The 65,958 acute hip fractures in the UK and their associated post-operative care are estimated to have cost around £1 billion in 2017, equivalent to approximately 1% of the entire NHS budget.1

The post-operative management and outcomes of these patients has been improved by both the introduction of orthogeriatric services5 and by the recognised importance of early and continued multi-disciplinary team (MDT) involvement.6 Post-operative supportive care provided by the MDT should focus on optimising pain control, nutrition, physical therapy and multidisciplinary programmes aiming to regain pre-fracture mobility.7 Early identification of rehabilitation goals to facilitate a return to the home is a key component of this system.8

Patients lose around 50% of their strength in their fractured leg, when compared with their non-affected leg in the first few weeks post-surgery.9 Evidence from the national hip fracture database in the UK suggests that early mobilisation and ongoing regular physiotherapy input helps to improve strength and mobility at 30 days post discharge.10

This is reflected in the guidelines from the Chartered Society of Physiotherapists for rehabilitation of hip fracture patients.11 In particular the recommendations are that patients should receive physiotherapy totalling two hours per week until their goals have been met. This can be met either in the acute hospital setting, in a post-acute inpatient rehabilitation hospital, or at home with community therapists.

There is evidence suggesting that patients who receive post-acute inpatient rehabilitation have a greater level of independence on discharge.12 Selection of the correct post-acute discharge destination for individual patients is important in achieving their individual goals, and in providing a cost-effective service.

It is estimated that at least a third of patients who sustain a hip fracture have a degree of pre-existing cognitive impairment13 and delirium is common after hip fracture.14 Given the need for engagement with the physiotherapy programme in order to regain mobility, a dementia diagnosis may complicate functional rehabilitation and may be seen as a barrier to inpatient rehabilitation.

There is evidence of worse functional outcomes at six months in neck of femur fracture patients with a diagnosis of dementia.15 Similarly it has been identified as an independent predictor of poor outcomes in a cohort of 844 patients from an Australian teaching hospital.16 They did however conclude, based on observation that, if patients were able and motivated, functional gains could be made.

The aim of our study was to investigate whether there was any difference in outcomes when looking at NOF fracture patients with and without dementia who were discharged to a post-acute inpatient rehabilitation hospital. Patients were identified following MDT assessment of their motivation and willingness to engage in a physical therapy programme in an inpatient rehabilitation hospital setting. We therefore hypothesised that there would be no difference in outcomes dependent on their dementia diagnosis status, and that an individual assessment was key in identifying patients who would benefit from the service.

Methods

All patients who were admitted with a neck of femur fracture to St Peter’s Hospital, an acute district general hospital in Surrey, UK, between 1st January 2016 and 31st May 2019 inclusively and had their admissions recorded in the National Hip Fracture Database. This database was used to identify those patients who had been discharged from St Peter’s Hospital, the acute hospital, to a post-acute inpatient rehabilitation hospital within this time period. The following outcomes were measured and compared between dementia and non dementia cohorts:

  • Length of stay (LOS) in acute hospital.
  • Length of stay (LOS) in rehabilitation hospital.
  • Readmission to acute hospital directly from rehabilitation hospital (direct readmissions).
  • Readmission to acute hospital within six months.
  • Discharge to usual residence from rehabilitation hospital.
  • Mortality at six months.

Length of stay data was compared between these two cohorts by calculating a mean length of stay and then by a P value with a two tailed T-test. Readmission, discharge destination and mortality data was compared using an odds ratio with 95% confidence interval.

Results

1,283 patients were admitted with a NOF fracture to St Peter’s (acute) Hospital between 1st January 2016 and 31st May 2019. Of these patients, 335 were discharged to a post-acute inpatient rehabilitation hospital. This means that 26.1% of our NOF fracture cohort had a spell of inpatient rehabilitation as part of their post-operative care. 95 of the 335 patients were male and 240 were female, with ages ranging between 60 and 101 years with an average age of 85.6 years old.

87 (26%) of the hip fracture patients who were transferred to an inpatient rehabilitation ward had a diagnosis of dementia on admission.

Table 1 shows the outcomes, defined above, of our cohort sorted into whether they had a dementia diagnosis or not. Table 2 shows patients’ residential setting on admission to the acute hospital. Table 3 shows the number of patients who were discharged back to their usual residence from the rehabilitation hospital, having been admitted from home or sheltered housing.

Variable

Dementia

No Dementia

Statistical significance

LOS acute (days)

12.8

12.0

P  = 0.395

LOS rehabilitation (days)

30.3

26.6

P = 0.144

Direct Readmission (n)

19 (21.8%)

39 (15.7%)

OR: 1.50 (95% CI: 0.81-2.76)

Readmission within 6 months (n)

40 (52.6%)

76 (30.6%)

OR: 1.93 (95% CI: 1.17-3.18)

Discharge to usual residence (n)

61 (70.1%)

188 (75.8%)

OR: 0.75 (95% CI: 0.43-1.29)

Mortality within 6 months (n)

2 (2.30%)

12 (4.84%)

OR: 0.46 (95% CI: 0.10-2.11)

Total (n)

87

248

OR = Odds ratio; 95% CI = 95% confidence interval.

Table 1: Post neck of femur fracture inpatient rehabilitation outcomes

Pre-Admission residential setting

Dementia

No Dementia

Statistical significance

Own home/Sheltered Housing (n)

70 (80.5%)

240 (96.8%)

OR: 0.14 (95% CI: 0.06 to 0.33)

Residential Care (n)

12 (13.8%)

7 (2.82%)

OR: 5.50 (95% CI: 2.09 to 14.5)

Nursing Care (n)

5 (5.74%)

1 (0.40%)

OR: 15.1 (95% CI: 1.73 to 131)

Total (n)

87

248

OR = Odds ratio; 95% CI = 95% confidence interval.

Table 2: Admission residential setting for patients undergoing inpatient rehabilitation post neck of femur fracture

 

Discharge Destination

Dementia

No Dementia

Statistical significance

Own home/Sheltered Housing (n)

47 (67.1%)

183 (76.3%)

OR: 0.64 (95% CI: 0.36-1.14)

Residential Care (n)

4 (5.71%)

10 (4.17%)

OR: 1.39 (95% CI: 0.42-4.59)

Nursing Care (n)

1 (1.43%)

3 (1.25%)

OR: 1.14 (95% CI: 0.12-11.2)

Acute Hospital (n)

17 (24.3%)

37 (15.4%)

OR: 1.76 (95% CI: 0.92-3.37)

Other (n)

1 (1.43%)

7 (2.92%)

OR: 0.48 (95% CI: 0.06-3.99)

Total (n)

70

240

OR = Odds ratio; 95% CI = 95% confidence interval

Table 3: Patients admitted from own home or sheltered housing discharge destination

Discussion

There is no statistically significant difference between patients with or without a dementia diagnosis in the majority of our measured outcomes. The only statistically significant difference observed in our study population was that patients with dementia were more likely to be readmitted to hospital within six months of discharge from the rehabilitation hospital (OR: 1.93; 95% CI: 1.17-3.18). This is also true of the general population, where patients with dementia are more frequently admitted to hospital, regardless of physical comorbidities.17

One of the main aims of inpatient rehabilitation services is to enable people to return to their own home environment on discharge and to reduce the chances of a new need for institutional care. The fact that there is no significant difference in patients’ discharge to usual residence between the dementia and non-dementia groups (OR: 0.75; 95% CI 0.43-1.29) suggests that both groups benefit similarly from inpatient rehabilitation in this regard.

This outcome was calculated using discharge destination from the rehabilitation hospital, and therefore excluded any patients who were directly readmitted to the acute hospital before being successfully discharged to their normal residence from the second acute hospital admission. We may therefore expect that a slightly higher percentage of both cohorts were eventually successfully transferred to their usual residence on discharge from the hospital.

On admission patients with dementia were statistically less likely to be living in their own home or in sheltered housing (OR: 0.14; 95% CI: 0.06-0.33) and were more likely to be in both residential (OR: 5.50; 95% CI: 2.09-14.5) and nursing (OR: 15.1; 95% CI: 1.73-131) care facilities than the rest of their cohort.

This reflects the increased frailty of dementia patients and yet, despite this, our data suggests they benefit similarly to the rest of their cohort from inpatient rehabilitation services post hip fracture. This is supported by the fact that patients with dementia who were admitted from home, and therefore stood the most to gain from rehabilitation services in terms of reducing need for institutional care, had no significant difference in successful discharge back to normal residence (OR: 0.64; 95% CI: 0.36-1.14).

Whilst there is no significant intra-group difference in direct readmissions to the acute hospital we do see a relatively large proportion of patients being readmitted (17.3% in total). This could be a sign of the frailty of the NOF fracture patient cohort as a whole, or could indicate that patients are either being transferred to the rehabilitation facility whilst they have ongoing acute medical care needs. It could also indicate that there is not enough capacity for acute medical care at the rehabilitation hospital.

Given the known risk of delirium and worsening confusion when patients are moved, as well as the additional costs incurred with readmissions and transfers, looking at interventions to reduce this readmission rate could be of importance for improved patient experience and for reducing cost of this service.

Limitations

The lack of final discharge destination follow up of the patients who are readmitted to the acute hospital from the post-acute inpatient rehabilitation hospital is the main limitation of this study.

Another limitation of our study is that the population of our hospital catchment area is relatively affluent and therefore these findings may not be representative of the rest of the UK or of the worldwide population. Larger samples involving multiple centres might be better able to analyse any population wide differences.

Conclusion

In patients who were discharged from St Peter’s Hospital to post-acute rehabilitation hospitals to continue their ongoing recovery from neck of femur fractures there was no statistically significant difference in length of stay, readmission rate, mortality within six months or discharge to usual residence between patients with a dementia diagnosis and those without.

We therefore conclude that a diagnosis of dementia should not be seen as a barrier to accessing inpatient rehabilitation care, in the presence of a specialist opinion that a patient will engage with the programme, as these patients benefit similarly from the service.


Authors

  • Henry Sergeant, Foundation trainee, Department of Medicine, Ashford and St Peter’s Hospitals NHS Foundation Trust, Guildford Road, Chertsey, Surrey
  • Michael Wood, Medical Director, Central Surrey Health, 4th Floor, Dukes Court, Woking
  • Olwen Revill, Evidence Specialist, Knowledge Service, Clinical Education, Ashford and St Peter’s Hospitals NHS Foundation Trust, Guildford Road, Chertsey, Surrey
  • Carley Allen, Clinical lead for Orthopaedic Inpatient Physiotherapy and Occupational Therapy, Ashford and St Peter’s Hospitals NHS Foundation Trust, Guildford Road, Chertsey, Surrey
  • Peter Enwere, Consultant Geriatrician, Senior Adult Medical Service, Ashford and St Peter’s Hospitals NHS Foundation Trust, Guildford Road, Chertsey, Surrey
  • Kefai Yeong, Consultant geriatrician, St Peter’s Hospital
  • Radcliffe Lisk, Consultant Geriatrician, Senior Adult Medical Service, Ashford and St Peter’s Hospitals NHS Foundation Trust, Guildford Road, Chertsey, Surrey
  • Rashid Mahmood, Consultant Geriatrician, Senior Adult Medical Service, Ashford and St Peter’s Hospitals NHS Foundation Trust, Guildford Road, Chertsey, Surrey, [email protected]

Declarations: The authors have no conflicts of interest to declare that are relevant to the content of this article.


References

  1. Royal College of Physicians. National Hip Fracture Database Annual Report 2019.; 2019.
  2. Cooper C, Cole Z, Holroyd C, et al. Secular trends in the incidence of hip and other osteoporotic fractures and the IOF CSA Working Group on Fracture Epidemiology Europe PMC Funders Group. Osteoporos Int. 2011;22(5):1277-1288. doi:10.1007/s00198-011-1601-6.Secular
  3. Lisk R, Yeong K. Reducing mortality from hip fractures: a systematic quality improvement programme. BMJ Qual Improv Reports. 2014;3(1):u205006.w2103. doi:10.1136/bmjquality.u205006.w2103
  4. Amarilla-Donoso FJ, López-Espuela F, Roncero-Martín R, et al. Quality of life in elderly people after a hip fracture: A prospective study. Health Qual Life Outcomes. 2020;18(1):1-10. doi:10.1186/s12955-020-01314-2
  5. Tarazona-Santabalbina FJ, Ojeda-Thies C, Rodríguez JF, Cassinello-Ogea C, Caeiro JR. Orthogeriatric management: Improvements in outcomes during hospital admission due to hip fracture. Int J Environ Res Public Health. 2021;18(6):1-29. doi:10.3390/ijerph18063049
  6. Sekeitto AR, Sikhauli N, van der Jagt DR, Mokete L, Pietrzak JRT. The management of displaced femoral neck fractures: a narrative review. EFORT Open Rev. 2021;6(2):139-144. doi:10.1302/2058-5241.6.200036
  7. Little Z, Griffiths B, Khan H. Hip Fracture.; 2020. https://bestpractice.bmj.com/topics/en-gb/3000105. Accessed May 20, 2021.
  8. National Institute for Health Research. Specialist Hip Fracture Services Linked to Fewer Deaths in South Central Region.; 2017. doi:10.3310/signal-000369
  9. Lee K-J, Um S-H, Kim Y-H. Postoperative Rehabilitation after Hip Fracture: A Literature Review. Hip Pelvis. 2020;32(3):125. doi:10.5371/hp.2020.32.3.125
  10. Su B, Newson R, Soljak H, Soljak M. Associations between post-operative rehabilitation of hip fracture and outcomes: national database analysis (90 characters). BMC Musculoskelet Disord. 2018;19(1):1-9. doi:10.1186/s12891-018-2093-8
  11. Chartered society of Physiotherapists (CSP). Hip Fracture Rehabilitation in Physiotherapy Practice.; 2018. https://www.csp.org.uk/publications/hip-fracture-rehabilitation-physiotherapy-practice. Accessed May 20, 2021.
  12. Young J, Green J, Forster A, et al. Postacute care for older people in community hospitals: A multicenter randomized, controlled trial. J Am Geriatr Soc. 2007;55(12):1995-2002. doi:10.1111/j.1532-5415.2007.01456.x
  13. Chammout G, Kelly-Pettersson P, Hedbeck CJ, et al. Primary hemiarthroplasty for the elderly patient with cognitive dysfunction and a displaced femoral neck fracture: a prospective, observational cohort study. Aging Clin Exp Res. 2020;33(5):1275-1283. doi:10.1007/s40520-020-01651-8
  14. Lisk R, Yeong K, Enwere P, et al. Associations of 4AT with mobility, length of stay and mortality in hospital and discharge destination among patients admitted with hip fractures. Age Ageing. 2020;49(3):411-417. doi:10.1093/ageing/afz161
  15. Yoon SH, Kim BR, Lee SY, Beom J, Choi JH, Lim J. Influence of comorbidities on functional outcomes in patients with surgically treated fragility hip fractures: a retrospective cohort study. 2021:1-11.
  16. Low S, Wee E, Dorevitch M. Impact of place of residence, frailty and other factors on rehabilitation outcomes post hip fracture. Age Ageing. 2021;50(2):423-430. doi:10.1093/ageing/afaa131
  17. Shepherd H, Livingston G, Chan J, Sommerlad A. Hospitalisation rates and predictors in people with dementia: A systematic review and meta-analysis. BMC Med. 2019;17(1):1-13. doi:10.1186/s12916-019-1369-7

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