Hip fracture in older adults

rehab in cog impaired pts - prevalence of cog decline in hip fx - can they return to pre fx levels - pain

- 19% of older adults with hip fx have dementia - up to 40% have some type of cog decline post op - no consensus on what should be included in rehab - no uniformity to assess cog impairment - many studies exclude this group of people - research has shown that those with cog impairments can return to pre fx levels - pre fx functional impairment was more strongly associated with poor function and was main predictor of decline - cog impaired individuals are able to regain their mobility, suggests a need for post d/c targeted interventions -people with dementia received less drug based pain management than those without cog decline after hip fx - need to enhance pain assessment and management for these pts.

predictors of NOT regaining basic mobility 5 days post op and at d/c

- age more than 80 - low pre fx function - not completing PT in 1st day post op - low hg value on day 1 post op **sex and type of surgery were not significant. comorbidities and cog status were not included in the study**

7 themes - use of standardized assessments

- balancing clinical documentation and assessment to demonstrate need for intervention to progress pt - assess fall risk, balance, and cog.

category 1 - restrictions for everyday life

- being less mobile - difficulty with ADLs - dependent on ADs - being tired - less energy - concerned about falling again

strengthening and aerobic exercises post hip fx

- can use upper body cardio to help increase VO2 if they can't walk - strengthen 60 min/day supervised by PT with HEP during acute care with f/u calls had 25% lower fall rate - intense outpt care 6 mo of supervised PT for 45-90 min 3x/week had improved physical performance, functional status, strength, walking speed, and balance - 12 weeks of PRT improves strength and function - higher dose of exercise showed stronger effects on outcomes - focus on quad strength, DF strength, hip abductors - perturbation training - lateral side stepings

category 4 - performing every day activities

- doing everything that they did before - ceasing to do activities

things to consider when trying to maximize functional recovery

- exercise - nutrition - residential care - social support - depression - pharm management - motivation

7 themes - objective sof care

- facilitation of safe d/c home - maximize independence and equipping pt/caregiver with knowledge and skills, prevent falls - coming to terms with new self - assit pt and caregiver to reconcile individual's capacity. understand abilities, limitations, need for support to engage in meaningful activities at home. should be d/c planning early on; should educate on precautions, s/s of infection, transfers, bed mobility, ADs

7 themes - interdisciplinary collaboration

- give and take dynamic - sharing our info with the team - obtaining info of pt status from nurse, MD, PA, OT, etc. - other team members - geriatrician, geriatric nurse practitioner, social workers, neuropsych

weight bearing aftr hip fx

- immediate WBAT and early mobilization is encouraged within 48 hrs. - delayed ambulation leads to more complications, longer stays, and reduces the time for d/c to home.

strong evidence from AAOS hip fx guidelines

- interdisciplinary care program with mild to mod dementia to improve hip outcomes - supports intensive PT post d/c to improve functional outcomes

negatively associated factors for QOL following hip fracture in older adults

- low physical or psychological function before hip fracture - comorbidities - female - poor nutritional status - severe post surgical pain perception - longer duration of stay - post op complications - cog dysfunction

functional recovery following hip fracture

- many people continue to have limitations in functions a year after hip fracture - many are dependent in IADLS for up to 2 years post injury - depression, UE ADLs, cognition require 4 months of recuperation - 9 months for social function, IADLs, LE ADLs that peak at 12 months - recovery from hip fracture itself (bone/muscle) --> functional limitations in gait, balance, cognition, strength --> LE ADLs, IADLs, and social activities

FIMS

- meausre pt's disabilities and level of assistance for ADLs - cost and training to administer test - 18 items - 13 motor, 5 cog - score range from 18 lowest to 126 highest - excellent test-retest reliability in older adults

survival rates follow hip fracture

- mortality doubles in men compared to women - both women and men who fracture hip are dying at higher rate due to infection compared to general population - but excess rate of death for men from infections are 2-3x higher than in women

posterior approach

- most common for total hips - less popular for ORIF of femoral neck fx - does not disrupt abductor mechanism - indications: hemiarthroplasty, total hip, ORIF posterior acetabular fx, OR of posterior hip dislocations, dependent drainage of hip sepsis and pedicle bone grafting - skin incision is 10 cm distal to the posterior superior iliac spine and extends laterally and distally to the greater troch - higher incidence of post op dislocation - risk of injury to sciatic nerve posterior hip precautions - hip flexion to 90, no IR, no add

category 3 - resources for recovery

- myself - own will and positive thinking - supporting and coaching - talking to others, home visits/phone calls, therapists boosting confiedence - technological support - fitbits, apple watches, etc.

how does type of fracture impact QOL after hip fracture?

- non displaced femoral neck fx with internal fix regained prefx health status - displaced femoral neck fx had worst health status in all time point - hemiarthroplasty is better than IF for displaced femoral neck fx - bipolar is better than unipolar hemiarthroplasty - total hip better than hemi, total hip better for displaced femoral neck fx

7 themes of high quality care for hip fx rehab

- objectives of care - the first 72 hours - 3 Ps- position, pain, precautions - use of standardized assessments - episode of care processes - facilitating insight into progress - interdisciplinary collaboration

s/s of hip fractures

- pain in groin and may refer distally - unable to bear weight -- not always. there may be worsening pain in butt or groin with WB. physical exam - stress or nondisplaced hip fx may have no obvious disformity - in supine, the LE is ER and shortened - unable to perform SLR - bruising rarely present intiailly - check distal pulses and sensation

7 themes - the first 72 hours

- practitioners identified that their initial interaction with the pt and family laid the foundation for the entire stay - build relationships - orient pt and family to rehab process to help with expectations - discuss findings of eval, collaborate care planning and initiate mobility -- do this with pt, family, nurse. *include recommendations for transfers, strategies to prevent adverse events, reinforce hip precautions and WB status

Other consequences of hip fracture

- re-fx - change in BMD - change in body comp - re-hospitalizations - community service use - care giver burden - complications - re-operations - cost effectiveness of pt focused/needs based care

4 categories that people can be in after hip fx - perspectives/their recovery process

- restrictions for everyday life - recovery process - resources for recovery - performing every day activity

anterolateral approach

- safely exposes the acetabulum and femoral neck - partial or complete detachment of abd mechanism - indications for this approach include: total hip replacement, hemiarthroplasty, ORIF of the femoral neck fx, synovial biopsy of the hip and biposy of femoral neck - skin incision starts at a point 2-3 cm posterior to the ASIS and is directed toward the mid portion of the greater troch. then it continues 10-15 cm along the axis of femur - risk of damage to superior gluteal nerve -- supplies glut med, min, and TFL

7 themes - facilitating insight into progress

- support the pts recognition of new self - importance of highlighting the pt's functional progress

moderate evidene from AAOS hip fx guideliens

- supports MRI for advanced imaging - does not support pre op traction - supports surgery within 48 hrs of admission - not delayed surgery due to aspirin or blood thinner use - supervised OT/PT across continuum of care - nutrition supplements of vit D and Ca++ after surgery - eval and treat for osteoporosis after hip fx

category 2 - recovery process

- trying and practicing and having successful experiences -- working on ADLs before d/c comforted them - limited trying and practicing and unsuccessful experiences - frustration and disappointment that they cannot do what they want

risk factors for falls

- weakness - balance deficits - gait decifit - visual deficit - mobility impairment - cog impairment - impaired functional status - postural hypotension

important key points

- women fx at higher rate than men, men are catching up - higher % of older adults don't get back to pre-fx levels - work on modifiable risk factors and know meds - radiographs first time eval, then MRI - surgery is better than no surgery - know hip precautions - get them up moving and weight bearing early - be apart of the team - cog impaired can return to pre-fx level - exercises can include UE/LE strengthening and aerobics - HEP should be comprehensive, structured, motivating and set them up for success - provide support and coaching when you can

ACR appropriateness criteria for radiographs

acute hip pain - suspected hip fx variant 1 - middle aged/elderly - xrays - AP/cross lateral hip views and AP pelvis variant 2 - middle ages/elderly - negative or indeterminate xrays calls for MRI of hip without contrast 37% of missed hip fx can be detected on MRI

epidemiology of hip fractures

almost all hip fractures are adults over 65, average age is 80 years, and women experience 80% of fractures

early mobilization in hip fracture

early mobilization improves pt outcomes, including functional recovery and mortality rate. delayed ambulation is associated with development of new onset delirium, post op pneumonia, and increased LOS.

extracapsular vs intracapsular hip fractures

extra - intertrochanteric and subtrochanteric. large amount of cancellous bone and good blood supply. typically heals well although subtroch has higher rates of impact device failure intra - femoral head and neck. little cancellous bone and relatively poor blood supply. higher incidence of AVN, nonunion, malunion and degenerative changes

AAOS recommendations for types of surgeries - femoral neck fx - stable intertrochanteric fx - unstable intertrochantertic fx - displaced femoral neck fx - subintertrochanteric fx

femoral neck - operative fix with stable, hemiarthroplasty or THA in unstable. stable intertroch - hip screw or cephalomedullary device unstable intertroch - cephalomedullary device displaced femoral neck - arthroplasty subintertroch - cephalomedullary device

anterior approach - indications - precautions

indications: open reduction of congenitla dislocation of the hip, synovial biopsy, hemiarthroplasty, pelvic osteotomies, total hip replacement and joint drainage and irrigation for infection skin incision is made from middle of iliac crest and carried anteriorly to the ASIS. From there, the incision is carried distally and slightly laterally for 8-10 cm. - avoid disruption of abduction - rec fem is detached precautions - avoid extension

cumulated ambulation score

level of basic mobility - valid and reliable to predict ST post op outcome in relation to one month mortality, DC to own home, and larger medical complications after hip fx - ability to get in/out of bed, rise from chair, walk around indoor with AD - each item is 0-2, higher is better - score for each day - more than 9/18 for POD 1-3 is predictive of d/c in 14 days to own home, 30 day survival, and not experiencing major medical complications

after surgery - medications - compression

meds - antibiotics, thromboembolic prophylaxis, vit D, Ca++, bisphosphates use of intermittent pneumatic compression - routine use of graduated compression stockings not recommended for those who can take anticoagulants -- want them up and walking instead of using stockings

testing cog function

mini mental state exam - >24/30 normal - 15-23/30 mod impairment - <15/30 severe impairment MOCA - >26/30 no impairments

risk factors for hip fractures - non-modifiable - modifiable

non-modifiable - age/sex. women >85 are 10x more likely to have a hip fx compared to 60-69 y/o. also family history or prior hip fracture modifiable - falls decreased BMD, reduced level of activity, chronic medican use, smoking

7 themes - pain, positioning, precautions

pain - limits participation; role is to collaborate with pt and nursing to identify optimal times for rehab based on pain med schedule, contacting MD/nurse if pain interferes with therapy. positioning and compliance with precautions that mitigate pain - education, training, and reinforcement

who is nonsurgical intervention reserved for?

patients with - severe disability - major uncorrectable diseases of lung/heart - who are non-ambulatory - at the end stages of terminal illness - impacted stable fx

new mobility score

pre-fx functional level - reliable and valid predictor of one year mortality and function outcome 6 mo after hip fx - score consists of rating pt ability to walk indoor, outdoor and when shopping - 0-3 per question, total score 9 - higher is better

HEP for hip fx

studied HEP included: - 5x/week, 2 strength, 3 aerobic - warm up - ROM, flexibility - strength training- 11 exercises for UE and LE - aerobic exercise - safety assessments - motivation component - hip fx book, exercise calendar ** study found that older adulst can participate in HEP after hip fx.

surgical or nonsurgical management for hip fx?

surgery after hip fx is most viable option - pts tx non-op had higher risk of mortality compared to those who had an operation.

what types of medications can cause issues with calcium absorption

thyroid meds, diuretics, acid reflux, long term use of steroids