Intensive In-Hospital Rehabilitation After Hip Fracture Surgery and Activities of Daily Living in Patients With Dementia: Retrospective Analysis of a Nationwide Inpatient Database

Published:August 14, 2019DOI:



      To examine the effects of earlier, more frequent, and larger daily amounts of postoperative rehabilitation on activities of daily living (ADL) after hip fracture surgery in patients with dementia.


      Retrospective cohort study.


      A total of 1053 acute-care hospitals.


      Patients aged ≥65 years with dementia at admission underwent hip fracture surgery and received postoperative rehabilitation from April 1, 2014 to March 31, 2016 (N=43,206).


      Three rehabilitation variables as key independent variables: (1) the interval from surgery to starting rehabilitation (days); (2) the frequency of postoperative rehabilitation (days per week); and (3) the average daily units of postoperative rehabilitation (minutes per daily rehabilitation).

      Main Outcome Measure

      ADLs based on the Barthel Index (BI) at discharge from acute-care hospitals.


      In the multivariable linear regression analysis, delayed rehabilitation was significantly associated with a lower BI at discharge (for each day of the interval increase, BI at discharge was 0.38 lower; 95% confidence interval [CI], 0.21-0.54), and a significant increase in the BI at discharge was observed in patients who underwent more frequent rehabilitation (BI [95% CI] was 2.62 [0.99-4.25], 5.83 [4.28-7.38], 7.56 [5.95-9.16], and 9.16 [7.34-10.97] higher for frequencies of 3.1-4.0, 4.1-5.0, 5.1-6.0, and >6.0 days per week, respectively) and larger daily amounts of rehabilitation (4.37 [3.69-5.06] and 6.60 [5.63-7.57] higher for 40-59 and ≥60 minutes per day, respectively).


      These results suggest that earlier, more frequent, and larger daily amounts of postoperative rehabilitation in acute-care hospitals are independently associated with better recovery in ADL at discharge from acute-care hospitals after hip fracture surgery in patients with dementia.


      List of abbreviations:

      ADL (activities of daily living), BI (Barthel Index), CI (confidence interval), ICD-10 (International Classification of Diseases, Tenth Revision)
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        • Seitz D.P.
        • Adunuri N.
        • Gill S.S.
        • Rochon P.A.
        Prevalence of dementia and cognitive impairment among older adults with hip fractures.
        J Am Med Dir Assoc. 2011; 12: 556-564
        • Ferri C.P.
        • Prince M.
        • Brayne C.
        • et al.
        Global prevalence of dementia: a Delphi consensus study.
        Lancet (London, England). 2005; 366: 2112-2117
        • Muir S.W.
        • Yohannes A.M.
        The impact of cognitive impairment on rehabilitation outcomes in elderly patients admitted with a femoral neck fracture: a systematic review.
        J Geriatr Phys Ther. 2009; 32: 24-32
        • Allen J.
        • Koziak A.
        • Buddingh S.
        • Liang J.
        • Buckingham J.
        • Beaupre L.A.
        Rehabilitation in patients with dementia following hip fracture: a systematic review.
        Physiother Can. 2012; 64: 190-201
        • Stenvall M.
        • Berggren M.
        • Lundstrom M.
        • Gustafson Y.
        • Olofsson B.
        A multidisciplinary intervention program improved the outcome after hip fracture for people with dementia--subgroup analyses of a randomized controlled trial.
        Arch Gerontol Geriatr. 2012; 54: e284-e289
        • Jones C.A.
        • Jhangri G.S.
        • Feeny D.H.
        • Beaupre L.A.
        Cognitive status at hospital admission: postoperative trajectory of functional recovery for hip fracture.
        J Gerontol A Biol Sci Med Sci. 2017; 72: 61-67
        • Smith T.O.
        • Hameed Y.A.
        • Cross J.L.
        • Henderson C.
        • Sahota O.
        • Fox C.
        Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery.
        Cochrane Database Syst Rev. 2015; 6CD010569
        • Kronborg L.
        • Bandholm T.
        • Palm H.
        • Kehlet H.
        • Kristensen M.T.
        Effectiveness of acute in-hospital physiotherapy with knee-extension strength training in reducing strength deficits in patients with a hip fracture: a randomised controlled trial.
        PLoS One. 2017; 12e0179867
        • Kimmel L.A.
        • Liew S.M.
        • Sayer J.M.
        • Holland A.E.
        HIP4Hips (high intensity physiotherapy for hip fractures in the acute hospital setting): a randomised controlled trial.
        Med J Aust. 2016; 205: 73-78
        • Hebert-Davies J.
        • Laflamme G.Y.
        • Rouleau D.
        • HEALTH and FAITH investigators
        Bias towards dementia: are hip fracture trials excluding too many patients? A systematic review.
        Injury. 2012; 43: 1978-1984
        • Mahoney F.I.
        • Barthel D.W.
        Functional evaluation: the Barthel Index.
        Md State Med J. 1965; 14: 61-65
        • Noda H.
        • Yamagishi K.
        • Ikeda A.
        • Asada T.
        • Iso H.
        Identification of dementia using standard clinical assessments by primary care physicians in Japan.
        Geriatr Gerontol Int. 2018; 18: 738-744
        • Meguro K.
        • Tanaka N.
        • Kasai M.
        • et al.
        Prevalence of dementia and dementing diseases in the old-old population in Japan: the Kurihara Project. Implications for long-term care insurance data.
        Psychogeriatrics. 2012; 12: 226-234
        • Arai H.
        • Sumitomo K.
        • Sakata Y.
        • Daidoji K.
        • Takase T.
        • Toyoda T.
        Disease state changes and safety of long-term donepezil hydrochloride administration in patients with Alzheimer's disease: interim results from the long-term, large-scale J-GOLD study in Japan.
        Psychogeriatrics. 2016; 16: 107-115
        • Quan H.
        • Li B.
        • Couris C.M.
        • et al.
        Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries.
        Am J Epidemiol. 2011; 173: 676-682
        • Hubbard A.E.
        • Ahern J.
        • Fleischer N.L.
        • et al.
        To GEE or not to GEE: comparing population average and mixed models for estimating the associations between neighborhood risk factors and health.
        Epidemiology. 2010; 21: 467-474
        • Sheehan K.J.
        • Williamson L.
        • Alexander J.
        • et al.
        Prognostic factors of functional outcome after hip fracture surgery: a systematic review.
        Age Ageing. 2018; 47: 661-670
        • Aloisio K.M.
        • Micali N.
        • Swanson S.A.
        • Field A.
        • Horton N.J.
        Analysis of partially observed clustered data using generalized estimating equations and multiple imputation.
        Stata J. 2014; 14: 863-883
        • Seitz D.P.
        • Gill S.S.
        • Austin P.C.
        • et al.
        Rehabilitation of older adults with dementia after hip fracture.
        J Am Geriatr Soc. 2016; 64: 47-54
        • Bentler S.E.
        • Liu L.
        • Obrizan M.
        • et al.
        The aftermath of hip fracture: discharge placement, functional status change, and mortality.
        Am J Epidemiol. 2009; 170: 1290-1299
        • Penrod J.D.
        • Boockvar K.S.
        • Litke A.
        • et al.
        Physical therapy and mobility 2 and 6 months after hip fracture.
        J Am Geriatr Soc. 2004; 52: 1114-1120
        • Siu A.L.
        • Penrod J.D.
        • Boockvar K.S.
        • Koval K.
        • Strauss E.
        • Morrison R.S.
        Early ambulation after hip fracture: effects on function and mortality.
        Arch Intern Med. 2006; 166: 766-771
        • Oldmeadow L.B.
        • Edwards E.R.
        • Kimmel L.A.
        • Kipen E.
        • Robertson V.J.
        • Bailey M.J.
        No rest for the wounded: early ambulation after hip surgery accelerates recovery.
        ANZ J Surg. 2006; 76: 607-611
        • National Clinical Guideline Centre
        The management of hip fracture in adults.
        (Available at:) (Accessed June 20, 2019)
        • Thomas S.
        • Mackintosh S.
        • Halbert J.
        Determining current physical therapist management of hip fracture in an acute care hospital and physical therapists' rationale for this management.
        Phys Ther. 2011; 91: 1490-1502

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