ASSESSMENT OF MOBILITY AND ADL DEPENDENCE FOLLOWING HIP FRACTURE SURGERY

Field: Medicine (Health Sciences)

To the Editor: With the proportion of older people increasing, fractures of the proximal femur represent a major and growing health care problem in our society. Despite the use of advanced treatment procedures, the mortality rate remains significant,1 and a majority of patients will never recover completely in terms of ambulatory capacity2–4 and activity of daily living functions. Not much is known, however, about what happens to these patients during admission to the hospital, and for which patients a geriatric intervention should be attempted. In this study, the geriatric consultation liaison service (CL-service) followed 50 consecutive hip fracture patients, who were 65 years of age and older who were admitted to the Leyenburg Hospital for surgical repair of a fractured hip, during their hospital stay to identify the discharge pattern and changes in mobility and ADL dependence. We also determined the factors that are important in predicting functional recovery. During admission, information was obtained on pre-fracture status, and the occurrence of postoperative complications was recorded. Two screening instruments were used for the weekly follow-up (up to a maximum of 8 weeks): the Gotfries, Brdgne and Steen (GBS) scale5 and the SIVIS validity scale.6 The SIVIS validity scale is a well validated Dutch screening instrument that measures dependence in ADL and mobility. Furthermore, the Help index, an index score correlated to the time span needed for assistance with ADL functions and ambulation, can be calculated from the SIVIS validity items. The population in our study contained a high percentage of woman (86%) and had a mean age of 82.2 years (SD 7.9). The majority of our subjects (90%) did not need any personal assistance when walking before the fracture. Only 10% of our population were already known to be cognitively impaired before admission. Mean length of hospital stay (LOS) was 25.8 days. Postoperative somatic complications were present in 42% of patients, with a mean LOS of 35.1 days and postoperative delirium in 12% with a mean LOS of 51.3 days. These findings are consistent with earlier reports that proved the presence of in-hospital complications to be strongly associated with a long hospitalization time.7 Five patients (10%) died in the hospital; of the survivors, 58% eventually went back to their original residences, 80% of them being discharged as early as in the fifth week. The other survivors (42%) were discharged to a nursing home or a geriatric department. To determine the factors associated with LOS and functional outcome, multiple regression analysis was performed (Table 1). The variables sex, consultation of a geriatrician during admission, and postoperative psychiatric complications did not contribute significantly to any of the multivariate models. According to our results, pre-fracture ambulatory dependence and pre-existent psychiatric illness (including cognitive impairment) were the two most important factors in predicting ambulatory dependence, ADL dependence, and the Help index on discharge. It is already well known that cognitive impairment is highly predictive of poor postoperative ambulation and ADL functioning. This factor has been found in all reports on this subject.2–4, 8 The importance of pre-fracture physical function in predicting walking ability and/or ADL function was already emphasized in some reports.3,4 Older age proved to be highly predictive of impaired mobility on discharge, but not of ADL dependence on the Help index. Living alone (without a spouse) before admission and living at home before admission were correlated with a better outcome. The explanation for this finding may be that older people who are still able to live alone and/or in their own houses are healthier and thus more independent in ambulation and ADL activities. To answer the question to which patients admitted with a fractured hip should a geriatric intervention be targeted, we recommend focusing on patients with pre-existent walking disability or patients with psychiatric illness/cognitive impairment. Several reports on the subject of joint orthopedic-geriatric management have promising results.9 The results of our study may improve the efficiency of case-finding procedures for a geriatric CL-service by using a biopsychosocial assessment procedure in which relevant risk factors are obtained.