The Impact of Previous Strokes on the Rehabilitation of Elderly Patients Sustaining a Hip Fracture

Setting 

This retrospective chart survey comprised consecutive admissions between 1999 and 2004. The basic hypothesis was that a previous stroke could adversely affect the functional outcome of hip fracture patients compared with nonprevious stroke (NPS) patients. Therefore, the design of the study served to evaluate the functional outcome gain achieved by patients during the postacute care rehabilitation period.

This study was performed in an orthogeriatric ward. The nature and characteristics of this orthogeriatric facility have already been described in detail.20 Briefly, the ward admits elderly hip fracture patients directly from the emergency department. The ward integrates a multidisciplinary staff, and care is taken of patients’ surgical, medical, and rehabilitation needs in a single setting, from admission to discharge. The standard rehabilitation course is based on an interdisciplinary rehabilitative team approach, and staff members meet twice a week to evaluate the status of each patient. A treatment plan is established and monitored with the purpose of coordinating and integrating the various aspects of the staff activities (medical, nursing, physical and occupational therapy, social work, geriatric psychologist). These patients usually undergo a mean of 6 hours a week of physical and occupational therapy. The study was approved by the local institutional review board.

Participants 

The analyses included consecutive elderly patients with a primary diagnosis of hip fracture. Patients were admitted to the ward after pertrochanteric (extracapsular) or subcapital (intracapsular) hip fracture. There was no preselection of patients on clinical grounds. After surgery, patients were considered eligible for rehabilitation once they were in a stable medical condition enabling active rehabilitation treatment. Exclusion criteria included patients admitted for elective hip surgery because of osteoarthritis and a rehabilitation period shorter than 7 days (based on the assumption that the extent of rehabilitation in such a short period is limited and could distort results). Other exclusion criteria included the presence of other acute disabilities (eg, multiple trauma), postoperative unstable (non–weight-bearing) hip fractures, conservative hip fracture treatment, medical conditions preventing active rehabilitation (eg, cardiac failure with New York Heart Association functional capacity stage III or IV, severe chronic lung disease necessitating a constant use of oxygen), and transfer to acute care departments because of complications and/or death while being hospitalized in the ward. These exclusion criteria enabled us to exclude patients with either medical or functional conditions that would limit rehabilitation potential in advance. The presence of ischemic heart disease (manifested as stable or unstable coronary syndrome), diabetes mellitus, hypertension, hyperlipidemia, and atrial fibrillation had been established by a routine admission medical history obtained by an interview and a complete physical examination. All patients were evaluated for their cognitive level by the Mini-Mental State Examination (MMSE)21; however, the cognitive score was not used as an inclusion or exclusion parameter.

Validation of Previous Stroke Patients 

The presence of a previous stroke and NPS was determined after searching the hospital records indicating a discharge diagnosis of stroke (reviewed by the study physicians EHM, AA). To validate the diagnosis of a previous stroke, we studied all 51 medical charts of patients with a hip fracture and previous stroke. The documentation of a stroke by a computed tomography scan or magnetic resonance imaging was recorded in 50 patients, corresponding to a verification rate of 99%. A patient was considered eligible for possible validation as a stroke case whenever a medical record contained a discharge diagnosis code indicative of cerebrovascular disease (codes 430−438 of the International Classification of Diseases, Ninth Revision). In addition, a case was eligible as a previous stroke case if a review of the medical records revealed diagnostic brain imaging with cerebrovascular findings compatible with a stroke.

Functional Assessment 

The prefracture functional level was assessed as completely independent, minimally or partially dependent, or completely dependent in activities of daily living and functional movement activities. Each patient was evaluated twice (within 1wk of hip fracture surgery and at discharge) for level of disability by the FIM instrument. This tool is widely used to rate patients’ performances on 13 motor and 5 cognitive items. Total FIM scores range between 18 (reflecting complete functional dependency) and 126 (reflecting complete functional independence). In addition, we have separately calculated the motor FIM, which is highly sensitive to detect functional improvements.22 The motor FIM is composed of 13 motor items with scores ranging between 13 (minimum) and 91 (maximum).

Data Analysis 

Comparisons between previous stroke and NPS patients were performed on a list of clinical and functional measures by using t tests for continuous variables and chi-square tests for dichotomous variables. Linear regression analysis was performed to study simultaneously the independent relations among ages, sex, previous stroke, MMSE score, and prefracture function with the outcome of FIM gain (the difference between total FIM at discharge and at admission) and total FIM at discharge. A P value of .05 or less was considered to be statistically significant. All statistical analyses were performed by using SPSSa for Windows.

Study Limitations 

Possible limitations of our study result from its retrospective nature. This did not enable us to study the actual FIM score status (or, alternatively, the severity of neurologic disability) of the patients just before they had suffered their hip fractures. In addition, no data are available on the time interval between stroke onset and fracture, the laterality of stroke with regard to laterality of hip fracture, or whether the patient had a single or several strokes. Clearly, the relatively low number of previous stroke may have resulted in cell sizes too small to detect differences and could also affect the statistical analysis. Another limitation of our study results from the fact that stroke history was determined retrospectively by review of charts and brain imaging, and, thus, subjects might have been misclassified with regard to this predictor variable. However, our study is advantageous because it involved a substantial number of patients with a hip fracture and FIM-measured rehabilitation gains.