Mum putting her best foot forward
Hip fracture is a really common injury in later life, but do we have reliable evidence to guide care and rehabilitation? Sarah Chapman takes a look.
“Mum’s fallen and broken her hip”. Heartsink words I didn’t want to hear, not just for the sorrow that my parent was in for a painful, difficult time in the short-term, but knowing too that this can be an injury with serious, long-term consequences. Thankfully, as a very fit 73 year old, Mum made a good recovery, though left with a rolling gait and a permanent dent in her confidence when moving outside.
A decade on, I dread it happening again, as for those who are frailer, older, the consequences can be catastrophic. There is an increased riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. of death following hip fracture; for survivors, poorer physical function can lead to loss of independence. Were Mum to break her hip again, she’d be one of the 40% of people with hip fracture who also have cognitive impairment or dementia; she’s also frail and under-nourished. These are all factors associated with poorer outcomesOutcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’..
People like my mum make up the majority of those with hip fracture; old and frail with multiple co-morbidities, quite probably including some form of cognitive impairment. It’s a really common injury, with a lifetime risk of 17.5% for white women and 6% for white men. Most need surgery, to reduce the risk of limb deformity and to speed recovery. We might expect, and certainly hope, that there is good evidence showing what works best when it comes to care and rehabilitation after hip fracture surgery. There are a number of Cochrane reviewsCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. which bring together the best available evidence on different aspects of rehabilitation and some have informed the NICE guideline on the management of hip fracture in adults. Let’s take a look.
Multidisciplinary rehabilitation
Care and rehabilitation after hip fracture surgery are increasingly in the hands of a multidisciplinary team, and this was explored in a Cochrane review. The populations and interventions of the 13 included studies varied considerably and did not allow for firm conclusions about effectivenessThe ability of an intervention (for example a drug, surgery, or exercise) to produce a desired effect, such as reduce symptoms.. However, in their helpful editorial from 2011 on rehabilitation of older people after hip fracture, Cochrane authors David Stott and Helen Handoll noted that both this review and a non-Cochrane, more general, review on inpatient rehabilitation for older people were generally supportive of co-ordinated multidisciplinary inpatient care. In the years since, we would hope that there have been new and better trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known., and the system of updating Cochrane reviews every few years allows for new evidence to be taken into account. It also means that other changes can be made to the reviews to increase their usefulness.
How can we best care for people with dementia?
There’s a lack of evidence on approaches to care for people with dementia and hip fracture
The Cochrane review on multidisciplinary rehabilitation is in the process of being updated, and this time people with dementia and hip fracture will be analysed as a subgroup. This may help to fill an important gap in the evidence on how best to care for this large group of people, as it’s not yet clear what’s best. Helen Handoll told me that people with dementia are under-represented in the trials currently included in the Cochrane reviews on hip fracture care, but that more recent trials, which will be considered for inclusion in the updated reviews, have included these patients.
A Cochrane review specifically looking at rehabilitation and care models for people with dementia after hip fracture surgery has been updated in February 2020. There is a little more evidence that in the earlier version I reported on when I wrote this blog in 2017, but not nearly enough.
The review has low-certaintyThe certainty (or quality) of evidence is the extent to which we can be confident that what the research tells us about a particular treatment effect is likely to be accurate. Concerns about factors such as bias can reduce the certainty of the evidence. Evidence may be of high certainty; moderate certainty; low certainty or very-low certainty. Cochrane has adopted the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) for assessing certainty (or quality) of evidence. Find out more here: https://training.cochrane.org/grade-approach evidence that for people with dementia enhanced care and rehabilitation following hip fracture surgery may reduce rates of postoperative delirium compared with usual care, and that compared with orthopaedic‐led management, geriatrician‐led management may lead to shorter hospital stays. Effects on other outcomes, including health-related quality of life and activities of daily living, remain uncertain. The review authors say that “determining the optimal strategies to improve outcomes for this growing populationThe group of people being studied. Populations may be defined by any characteristics e.g. where they live, age group, certain diseases. of patients should be a research priority”.
Getting mobile
Helping people to regain their mobility is, of course, an important aspect of care. The Cochrane review on this reveals the lack of reliable evidence on what works best. The most successful programmes have involved intensive, supervised and ongoing exercise, but the resource implications and the optimal format of these interventions remain unclear. Both this review and the review on multidisciplinary rehabilitation have been expanded to include post-discharge care and are being updated. More research is needed too on interventions that focus on social and psychological recovery, the gaps exposed by this Cochrane review.
Nutritional supplementation
Taking oral micronutrient supplements may help prevent complications after hip fracture surgery
With many older people under-nourished at the time of breaking a hip and subsequently not eating well whilst in hospital, this is an important area to address to aid recovery. The Cochrane review looking at this has very recently been updated and now includes 41 studies with nearly 4000 people. All the evidence was of low or very low quality and some interventions were explored in a single studyAn investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies.. The largest number of studies (18) looked at oral multinutrient supplements started before or soon after surgery and suggest that these may prevent complications (such as pressure ulcers, confusion and infection) in the first year after hip fracture, but have no clear effect on mortalitydeath.
Overall, the review raises more questions than the evidence can answer, or gives hints of that interventions may be promising, such as the use of dietetic assistants to help improve intake, but that need further scrutiny in well designed trials. The review authors note that there is no clear evidence that those who are malnourished are more likely to benefit from multi nutrient supplementation than those who aren’t, but that this may be down to limitations of the evidence, including the use of different definitions of malnutrition in individual trials. Many trials excluded people who were likely to be the most malnourished, such as those with dementia. Let’s hope future trials address these limitations so that we can fill some of these gaps in our knowledge.
Prevention is better than cure…
As well as better evidence on how best to promote recovery after hip fracture, we need to know how to prevent falls in the first place, and the Cochrane Bone, Joint and Muscle Trauma Group is on the case. Their review on preventing falls in older people living in the community, in particular, has robust evidence on the effectiveness of a number of approaches. However, like the trials in several of the hip fracture reviews, people with dementia are under-represented, one of the limitations we hope to see addressed in new trials. Owing to the size and complexity of this review, it is being split into separate reviews of the main interventions, rather than being updated in its current format. I’ll be watching this with interest, and doing what I can to keep Mum on her feet.
With thanks to Helen Handoll, Co-ordinating Editor of the Cochrane Bone, Joint and Muscle Trauma Group, for her insights on hip fracture evidence and to both Helen and the Group’s Managing Editor Lindsey Elstub, for keeping me up to date with plans for the hip fracture and falls reviews.
References may be found here.
Sarah Chapman has nothing to disclose.
Page last updated 05 March 2020
What I would say as an experienced nurse working in an intermediate community hospital environment is that I feel the loss of our beds will be detrimental to patients who fracture their hips. Their rehabilitation will be hampered and outcomes in the long term will prove more costly.