Archives of Physical Medicine and Rehabilitation
Volume 88, Issue 7 , Pages 916-921, July 2007

Factors Affecting Short-Term Rehabilitation Outcomes of Disabled Elderly Patients With Proximal Hip Fracture

  • Avital Hershkovitz, MD, MHA

      Affiliations

    • Beit Rivka Geriatric Rehabilitation Center, Petach Tikva, Israel
    • Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
    • Corresponding Author InformationReprint requests to Avital Hershkovitz, MD, MHA, Beit Rivka Geriatric Rehabilitation Center, 4 Hachamisha St, Petach Tikva 49245, Israel
    • ,
  • Zulicha Kalandariov, MD

      Affiliations

    • Beit Rivka Geriatric Rehabilitation Center, Petach Tikva, Israel
    • ,
  • Vered Hermush, MD

      Affiliations

    • Beit Rivka Geriatric Rehabilitation Center, Petach Tikva, Israel
    • ,
  • Roni Weiss, MD

      Affiliations

    • Beit Rivka Geriatric Rehabilitation Center, Petach Tikva, Israel
    • ,
  • Shai Brill, MD, MPH

      Affiliations

    • Beit Rivka Geriatric Rehabilitation Center, Petach Tikva, Israel
    • Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Article Outline

Abstract 

Hershkovitz A, Kalandariov Z, Hermush V, Weiss R, Brill S. Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture.

Objective

To identify factors associated with postacute rehabilitation outcome of disabled elderly patients with proximal hip fracture.

Setting

Geriatric rehabilitation center.

Participants

One hundred thirty-three older patients.

Interventions

Not applicable.

Main Outcome Measures

FIM instrument, motor FIM score, absolute functional gain on the FIM and motor FIM scores, relative functional gain on the FIM and motor FIM scores, rate of improvement on the FIM and motor FIM scores, proportion of patients discharged to home, and length of stay (LOS).

Results

Mean FIM score improved by 14 points (22%) with a functional gain rate of .56 point per day. No significant differences (P>.05) were found between weight-bearing and non–weight-bearing patients regarding the above outcome measures. Functionally independent and cognitively intact patients achieved significantly better score changes and rates of improvement and showed a higher ability to extract their rehabilitation potential than dependent and cognitively impaired patients. Their LOSs were significantly shorter. Patients with latency time (time delay from fracture to operation) of more than 5 days and patients with a history of stroke had significantly longer LOSs. Mini-Mental State Examination score, albumin levels on admission, and prefracture functional status were the most important parameters associated with FIM discharge scores (r=.756) and relative functional gain on the FIM (r=.583). Depression was the most important factor associated with LOS in patients with weight-bearing instructions on admission. The presence of a caregiver was the significant predictive value variable for returning home.

Conclusions

Cognitive function, nutritional status, preinjury functional level, and depression were the most important prognostic factors associated with rehabilitation success of older patients with proximal hip fracture. Of these, depression and nutritional status are correctable, and early intervention may improve rehabilitation outcome.

Key Words: Frail elderly, Hip fractures, Rehabilitation, Treatment outcome

 

APPROXIMATELY ONE THIRD of the elderly population falls each year, and about 1% of these falls result in a hip fracture. Falls are associated with significant morbidity and mortality in the elderly, because they usually occur when the functional reserve or compensatory ability of older people is severely compromised.1 The 1-year mortality rate ranges from 14% to 36%.2, 3 Only half of hospitalized patients with hip fracture will return to the community, with only about a third regaining their former levels of function.2, 4, 5, 6

Successful inpatient rehabilitation accounts for most functional recovery in improving patients’ mobility and activities of daily living.6, 7 This extended process continues with patients’ discharge and further treatment in the community.

To efficiently use rehabilitation time and resources assigned by health care providers, patients’ potential for functional recovery must be assessed. A physician should be able to recognize the major factors impinging on rehabilitation outcomes. Various factors have been reported to affect the rehabilitation outcomes of patients with hip fractures: sex, age, timing of surgery, cognitive and affective status, nutrition level, prefracture functional ability, comorbidity, and number of treatments.6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 Most studies, however, have examined a limited number of these factors, not always appraising their relationships.

The aim of the present study was to provide a broad evaluation of various prognostic factors affecting postacute rehabilitation outcomes of disabled elderly patients with proximal hip fracture.

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Methods 

Beit Rivka, a major (300-bed) postacute geriatric hospital, located in Petach Tikva, and affiliated with the Rabin Medical Center, Tel-Aviv University, Sackler Medical School, admits older patients from the center of Israel. All admitted patients carry full medical coverage provided by 4 health maintenance organizations (HMOs). The major health provider in Israel is Clalit General Health Services, servicing 75% of the elderly. Most patients are referred from main acute hospitals in Tel-Aviv and nearby cities. Half of these patients are admitted for rehabilitation after orthopedic surgery, stroke, and deconditioning due to prolonged hospitalization; 50% are admitted for medical care, encompassing treatment for severe pressure ulcers, management of advanced heart failure, terminal cancer, and nasogastric tube feeding, among others. The HMOs conform to the following admission criteria: age greater than 65 years, functionally dependent patients (2-men transfer), occasionally those without a social support system, or those living in an unfitted home environment, such as one without an elevator or narrow doorways to the toilet and bathroom.

The study was performed in a 60-bed rehabilitation department that admits mainly orthopedic patients. The multidisciplinary team provides medical, nursing, physical, occupational, speech, social work, and psychologic interventions.

The initial study population consisted of 149 elderly patients with hip fractures (47 subcapital, 102 intertrochanteric fractures) admitted during 2004. Sixteen patients were excluded from the final analysis (11 died, 5 were admitted to an acute hospital because of a worsening of their medical conditions). One hundred thirty-three patients completed the inpatient rehabilitation program. The male-to-female ratio was 27:106; the average age was 80.0±6.6 years for both sexes. Forty-three patients (32.3%) had a caregiver, and 52 (39.1%) had a high education level (≥10y). Functional level before the fracture was determined using the FIM instrument: dependent, 9 (6.8%) patients; partially dependent, 73 (54.9%) patients; and independent, 51 (38.3%) patients.25, 26, 27 Thirty-one (23.3%) patients were cognitively intact (Mini-Mental State Examination [MMSE] score >24); 50% had an MMSE score less than 20. Twenty-three of the 133 patients were admitted with non–weight-bearing instructions for 4 to 6 weeks.

The following outcome measures were used to measure the dependent variables. One, mean FIM discharge score was used to assess disability level. The FIM comprises 18 parameters, each rated on a scale of 1 to 7 according to the degree of assistance required to perform a specific activity in 3 domains: basic activities of daily living (BADLs) (8 parameters), mobility level (5 parameters), and cognitive function (5 parameters). Two, mean discharge score of the motor FIM, including 13 parameters of BADLs and mobility. Three, absolute functional gain on the FIM and motor FIM scores—that is, functional gain in scores or score changes (absolute functional gain = discharge score – admission score). Four, relative functional gain on the FIM and motor FIM scores. The Montebello Rehabilitation Factor Score16, 17, 28 is designed to overcome the problem of the ceiling effect and was used to calculate each patient’s specific potential for improvement. Relative functional gain is the absolute functional gain divided by the maximum score minus admission score. Five, rate of improvement, which is calculated as absolute functional gain divided by length of stay (LOS). Other parameters singled out were discharge destination (home vs nursing home) and LOS.

Independent factors potentially affecting rehabilitation outcome evaluated in this study were age, sex, education level, presence of caregiver, weight-bearing instructions, prefracture functional level, time delay from fracture to operation (latency time), albumin level on admission, comorbidity, cognitive functional level measured by the MMSE,29 and functional level on admission as measured by the FIM and motor FIM scores. Depression diagnosis was determined based on each patient’s medical history or, clinically, if a patient presented with depressive symptoms necessitating psychologic and/or pharmacologic intervention during the hospital stay.

All of the above data were obtained from patients’ files. The various tests performed in the present study are part of the hospital’s routine patient care policy. FIM scores were determined during weekly meetings of the multidisciplinary team. Occupational therapists administered the MMSE test. Because this investigation was retrospective and evaluated unidentified patient information, it was exempt from review of the institutional review board of our institution.

Rehabilitation care included (1) 30 to 45 minutes of individual physical therapy (ie, improving transferring, walking the length of a room, climbing stairs, equilibrium, muscle strength, and joint range of motion [ROM]) 5 times a week; (2) 30 to 45 minutes of individual occupational therapy (BADLs and instrumental activities of daily living, cognitive evaluation and stimulation, safety education) 3 times a week; (3) 60 minutes of group exercise, 5 times a week, targeted to improve muscle strength, joint flexibility, and ROM; and (4) walking with a physiotherapy aide according to each patient’s needs. Weekly meetings were held with the multidisciplinary team to discuss whether to continue treatment and review progress. Although the HMOs encourage short LOSs (up to 20d), there are no definite time limitations.

Statistical analysis was performed with SPSSa for Windows. Following the suggestion of Cornwall et al,20 we combined the 2 hip fracture groups (subcapital and intertrochanteric). To achieve better agreement with a normal distribution, a logarithmic transformation of LOS was performed.

An independent-sample t test was used to present the significant differences between (1) weight-bearing versus non–weight-bearing patient groups, (2) 2 cognitive patient groups (MMSE score >24 vs MMSE score ≤24), (3) 2 groups of latency time (>5d vs ≤5d), and (4) neurologically intact versus neurologically impaired patient groups regarding outcome measures (discharge scores on the FIM and motor FIM, absolute functional gain, relative functional gain, LOS). The test was also used to present the significant difference between the 2 discharge destination patient groups (home vs nursing home) in relation to age, latency time, albumin level, and admission scores on the FIM, motor FIM, and MMSE.

One-way analysis of variance showed the difference between the 3 functional level patient groups (independent, partially dependent, dependent) in relation to our outcome measures. Correlations between age, latency time, albumin levels, admission scores on the FIM and motor FIM, MMSE score, and outcome measures were calculated by the Pearson correlation. Multivariate linear regressions were used to identify the most important factors predicting discharge scores on the FIM and motor FIM, relative functional gain on the FIM and motor FIM, and LOS. Logistic regression was used to find the most predictive variables for returning home. We applied the forward stepwise (likelihood ratio) procedure in selecting the variables for the regression model.

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Results 

Table 1 describes the rehabilitation outcomes of the studied population. During a mean rehabilitation period of 4 weeks, the mean FIM score increased from 62.5 to 76.0, an improvement of 14 points. The functional gain rate was .56 point per day. Similar results were obtained for the motor FIM score. Because the FIM and motor FIM scores are interrelated and manifest similar correlations with the independent variables, data presented in our tables and text pertain mainly to the FIM score.

Table 1. Results of Outcome Measures (N=133)
ParameterMean ± SDMinimumMaximum
FIM admission score62.5±19.221103
FIM discharge score76.4±23.921118
AFG on FIM13.9±10.6−1251
RFG on FIM0.25±0.19−0.210.74
RI on FIM0.56±0.47−0.442.13
LOS (d)33.2±21.47126

Abbreviations: AFG, absolute functional gain (discharge score – admission score); RFG, relative functional gain (AFG/[maximum score – admission score]); RI, rate of improvement (AFG/LOS); SD, standard deviation.

No significant differences (P>.05) were found between non–weight-bearing and weight-bearing patient groups regarding outcome measures (discharge score on the FIM, absolute functional gain, relative functional gain). Nevertheless, LOS was significantly longer in the non–weight-bearing group (54.1±32.9d vs 28.8±14.9d), with rate of improvement on the FIM significantly smaller (.36±.47 vs .60±.47 point/day).

Table 2 presents correlation coefficients of various parameters and outcome measures. We found that physical and cognitive functions on admission were associated with discharge functional status, rate of improvement, ability of patients to extract their rehabilitation potentials, and LOS; albumin levels on admission were associated with discharge functional status and LOS; latency was associated with LOS (when log transformed); and age was unassociated with any of the outcome measures.

Table 2. Correlations Between Various Parameters and Outcome Measures
Outcome MeasuresAgeLatencyAlbuminFIM Admission ScoreMMSE Score
FIM discharge−.038−.176.253.902.691
P.661.053.003<.001<.001
AFG on FIM−.046.006.093.217.279
P.599.946.289.012.002
RFG on FIM−.076−.064.184.523.494
P.383.481.034<.001<.001
RI on FIM−.127−.100.164.429.371
P.146.272.061<.001<.001
LOS.075.172−.250−.407−.324
P.390.058.004<.001<.001
Log-transformed LOS.096.179−.201−.438−.301
P.271.048.021<.001.001

NOTE. Values are Pearson correlation coefficients and P values.

Functionally independent and cognitively intact patients achieved significantly better functional levels at discharge (FIM and motor FIM scores), achieved significantly better score changes and rates of improvement, and presented a higher ability to extract their rehabilitation potentials. Their LOSs were significantly shorter (table 3). LOS was significantly longer in patients with a latency time of more than 5 days and patients with a history of stroke.

Table 3. Distribution of Outcome Measures According to Preinjury Functional Level, Cognitive Function, Latency Time, and Stroke History
ParametersFIM DischargeAFG on FIMRFG on FIMRI on FIMLOSLog-Transformed LOS
Prefracture function
Independent90.1±20.016.4±9.90.34±0.190.75±0.4928.5±20.03.20±0.56
Partially dependent71.4±20.913.9±10.90.21±0.170.47±0.4435.9±20.63.40±0.52
Dependent39.8±10.04.6±5.30.04±0.060.21±0.2538.9±30.73.80±0.60
P<.001.007<.001<.001.116.024
Cognitive function
MMSE score >2497.3±13.518.9±7.90.41±0.160.91±0.3922.7±7.93.10±0.38
MMSE score ≤2472.1±21.513.1±11.10.21±0.180.47±0.4637.5±23.83.50±0.58
P<.001.008<.001<.001.001.001
Latency (d)
≤578.7±23.414.4±10.00.26±0.190.61±0.4830.8±19.73.30±0.54
>565.7±27.515.6±13.90.23±0.220.46±0.3943.7±29.43.60±0.53
P.051.693.576.248.0300.20
Stroke history
No77.9±23.914.2±10.20.26±0.190.59±0.4931.1±20.83.30±0.55
Yes69.9±23.312.9±12.30.21±0.210.39±0.3542.7±21.53.60±0.48
P.132.570.199.054.014.002

NOTE. Values are mean ± SD.

Patients discharged home had a significantly higher level of physical and cognitive function on admission and at discharge versus patients discharged to nursing homes (admission FIM score, 66.1 vs 52.3; admission motor FIM score, 41.6 vs 33.1; discharge FIM score, 81.7 vs 61.7; discharge motor FIM score, 56.7 vs 42.6; MMSE score, 20.7 vs 17.4). Age, latency time, and albumin levels on admission did not differ between the 2 patient groups (table 4).

Table 4. Comparison of Data for Patients Discharged Home (n=98) and for Those Discharged to Nursing Homes (n=35)
DischargeAgeLatencyAlbuminFIM Admission ScoreFIM Discharge ScoreMMSE Score
Home79.8±6.82.2±2.23.5±0.466.1±18.081.7±21.620.7±6.7
Nursing home80.1±5.92.9±3.53.4±0.552.3±19.261.7±24.317.4±4.7
P.464.161.163<.001<.001.001

NOTE. Values are mean ± SD.

Table 5 shows the results of the multiple regression analysis identifying admission and rehabilitation predictors of the FIM discharge score. Increasing cognitive levels were strongly associated with increasing FIM discharge score, followed by increasing albumin levels on admission and higher prefracture functional status. Demographic parameters (age, sex, education level, family status), comorbidity, and latency time were not associated with FIM discharge score. The 3 significant characteristics accounted for 57.2% of the variance in FIM discharge score (r=.756).

Table 5. Multiple Linear Regression Analysis of Significant Admission and Rehabilitation Predictors of Discharge FIM⁎
PredictorsStandardized CoefficientStandard ErrorP
MMSE score.5710.249<.001
Albumin level.2503.646<.001
Prefracture functional level.2062.771.005

⁎r2=.572.

Depression followed by MMSE score and albumin level were the most important factors affecting LOS in patients with weight-bearing instructions on admission. Multiple regression analysis regarding LOS is presented in table 6. Although depression was strongly associated with longer LOS, increasing cognitive and albumin levels on admission were strongly associated with shorter LOS (r=.435).

Table 6. Multiple Linear Regression Analysis of Significant Admission and Rehabilitation Predictors of LOS⁎
PredictorsStandardized CoefficientStandard ErrorP
Depression.2840.297.004
MMSE score−.2660.214.007
Albumin level−.2173.730.026

⁎r2=.189.

Logistic regression presented 2 variables with significant predictive value for returning home on termination of the rehabilitation program: the presence of a caregiver (odds ratio [OR], 8.881; 95% confidence interval [CI], 1.755–44.947) and the MMSE score (OR=1.112; 95% CI, 1.027–1.203). Depression had a significant negative predictive value (OR=0.298; 95% CI, 0.106–0.839).

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Discussion 

Hip fracture is among the most common traumatic events among the elderly, leading to significant mortality and morbidity. As the population ages, more people will require rehabilitation services. Many posttraumatic disabled elderly patients are unable to receive home-based rehabilitation services because of lack of social support or unfitted home environment. Consequently, the role of postacute geriatric rehabilitation in geriatric hospitals and skilled nursing facilities is expected to expand. The goals of the multidisciplinary team are to achieve significant functional improvement mainly in mobility, enabling these patients to return home in a relatively short period. These tasks are difficult to achieve, because the admitted patients often suffer from extended comorbidity and impaired cognitive abilities.

In the present study, we examined several prognostic factors for 3 major aspects of rehabilitation in disabled elderly patients with proximal hip fracture: functional gain, discharge destination, and LOS. The value of early prediction of rehabilitation outcome after hip fracture is important for several reasons: it may assist in coordinating patients’ and caregivers’ expectations, efficiently allocating resources, and planning advanced care.30

We found that functional gain was associated with cognitive function level, followed by albumin level on admission and preinjury functional level. Discharge destination was highly associated with the presence of a caregiver, followed by depression and cognitive ability. Surprisingly, LOS was mainly associated with depression. Cognitive function level and albumin levels had only secondary prognostic values.

The relationship between cognitive function and rehabilitation outcome in elderly patients has been acknowledged in several studies,16, 17, 31, 32, 33, 34, 35, 36, 37, 38, 39 showing better discharge functional level among cognitively intact patients. This does not necessarily imply that cognitively impaired patients do not benefit from a rehabilitation program, but rather that their performances will be downgraded. This was clearly illustrated in our study, in which 61% of our patients were functionally dependent before the injury; 74% were cognitively impaired. Not surprisingly, their outcome measure scores (mean admission and discharge FIM scores, absolute functional gain) were less favorable compared with populations manifesting better physical and cognitive functions on admission (62 vs 73–79; 76 vs 87–98; 13 vs 16–21, respectively).4, 9, 12, 17, 40 Rate of improvement in FIM was also slower (0.5 vs 2 points/day).4 Nevertheless, even with lower functional capacity, considerable improvement was shown in almost all outcome parameters within a relatively short period of time (4wk).

The results of the present study clearly show that depression is an important prognostic factor of rehabilitation outcome. Depressed patients achieved less functional gain, had longer LOSs, and had lower likelihood of returning home after completion of the rehabilitation program. Our results concur with previous studies4, 41, 42 showing that depression negatively influences rehabilitation outcomes and increases morbidity and mortality. Depression is highly prevalent among elderly patients with hip fracture, yet it is often unrecognized and undertreated,43 especially among cognitively impaired patients who have limited self-expressive abilities. Screening for depression in elderly patients with hip fractures is therefore imperative, because this is a treatable condition. Early and proper management of depression may improve patients’ rehabilitation participation and, as a result, their rehabilitation outcomes.4 Further studies are needed to shed light on this issue.

Preinjury functional level and absence of a caregiver are also known to be predictive factors of rehabilitation outcome (in terms of a lower rate of functional improvement), longer LOS, and high rate of institutionalization.20, 30, 44, 45, 46 The small functional gain and high rate of institutionalization (26.3%) in our studied patient group are in accordance with the fact that most of our patients were functionally impaired and of poor socioeconomic status.

Other significant factors associated with rehabilitation outcome were latency time, preinjury stroke, and albumin levels on admission. A delayed (>5d) operation time and preinjury stroke were associated with a longer LOS. This is supported by other studies15, 20 showing that early surgical intervention was associated with better functional outcome, lower mortality rate, shorter LOS, and better quality of life. Our finding that neurologically impaired patients with hip fracture can achieve functional improvement as a result of a rehabilitation program is encouraging. However, clinicians should be aware that the LOSs are longer, because these patients need an extended program to extract their rehabilitation potentials.10, 11

Low albumin levels on admission were associated with less favorable functional outcome and longer LOS. Undernutrition was previously described as relating to prolonged rehabilitation time and higher mortality rate after hip fracture.19, 47, 48 More data are needed, however, to determine if high protein and energy supplementation reduce unfavorable outcomes in patients recovering from hip fracture.18, 19

Finally, the age of most of our patients ranged between 75 to 85 years, which may explain why age was not found to affect rehabilitation outcome in our study as opposed to others.8, 12

The present study suggests that impaired cognitive function may negatively affect functional gain in disabled elderly patients with proximal hip fracture. It should not, however, preclude rehabilitation, because these patients can improve in mobility and may return home if there is a supportive living environment. Rehabilitation process may be more efficient if correctable factors such as depression and nutritional status are screened on admission and thus treated.

Study Limitations 

The limitations of our study are as follows. Only short-term rehabilitation outcomes were measured. We did not follow up with our patients after discharge; therefore, information regarding further functional gain was lacking. The FIM was used to present the functional gain in our disabled population. Because mobility is the most important functional achievement in patients with hip fractures, the use of more specific mobility outcome measures may improve benefit (ie, a timed walking test).49, 50 The study population consisted of patients from a single rehabilitation department. The generalizability of the study’s results needs further confirmation.

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Conclusions 

Disabled elderly patients with proximal hip fractures can improve, especially in their mobility, when participating in a postacute rehabilitation program wherein their rehabilitation potentials can be efficiently assessed and extracted. Cognitive function, nutritional status, preinjury functional level, and depression were the most important factors associated with the rehabilitation success of these patients. Two factors—depression and nutritional status—are treatable, and consequently, early intervention may improve rehabilitation outcome.

Supplier

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Acknowledgments 

We thank Ilana Gelernter, MA (Department of Statistics, Tel-Aviv University), for assistance with data analysis and Phyllis Curchack Kornspan for her editing services.

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  • a Version 10.01; SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

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PII: S0003-9993(07)00257-2

doi:10.1016/j.apmr.2007.03.029

Archives of Physical Medicine and Rehabilitation
Volume 88, Issue 7 , Pages 916-921, July 2007

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