Many Ontarians with dementia do not get rehabilitative care following hip fracture surgery; linked to more LTC admissions, mortality

Up to 40 per cent of older Ontarians with dementia receive no formal rehabilitation services following hip fracture surgery, and are more likely to be admitted to long-term care or die within a year compared to those who do receive rehabilitative care, says a new study from the Institute for Clinical Evaluative Sciences (ICES).

Published today in the Journal of the American Geriatrics Society, this study is one of the largest to date to examine rehabilitation rates and outcomes in older adults with dementia who undergo hip fracture surgery.

“We found that approximately 40 per cent of older adults with dementia who underwent hip fracture surgery did not get post-operative rehabilitation,” says Dallas Seitz, an adjunct scientist at ICES who is assistant professor in the Department of Psychiatry at Queen's University. “Two-thirds of these people ended up in long-term care within a year, and over 40 per cent had died. However, for people who received rehabilitative care, the outcomes were much better.”

Previous studies have established that older adults who experience hip fracture surgery do better if they receive rehabilitative care. However, for people with dementia, there has been less use of post-surgical rehabilitative care, and studies have been less clear about its relative benefits.

The researchers looked at the anonymized health records of 11,200 community-dwelling older Ontarians with dementia who underwent hip fracture surgery between 2003 and 2011. Participants were categorized into groups based on types of rehabilitation, ranging from no rehabilitation to complex continuing care, home-care based rehabilitation, and inpatient rehabilitation. The researchers then followed these records over time to see how many people were admitted to long-term care, as well as other health outcomes ranging from falls and new fractures to death.

To limit selection bias, the researchers chose to study only patients who were living in the community (generally independently) at the time of their hip surgery, as this indicates that the dementia in these individuals was likely not severe at outset. The mean age of the four groups was similar, ranging from 83.9 to 85.35 years old. The groups’ burden of comorbidities was also roughly similar, as were the number of physician visits and hospitalizations leading up to injury, indicating that no group was overwhelmingly more sick than the others. Where there were differences between the groups noted, these were later adjusted for in the statistical analysis.

Among the study’s findings:

• A total of 4,494 (40 per cent) people did not receive any rehabilitation. 2,474 (22 per cent) received complex continuing care, 1,157 (10 per cent) received home-care based rehabilitation and 3,075 (27 per cent) received inpatient rehabilitation.
• After one year, two-thirds (63 per cent) of individuals in the “no rehabilitation” group had been admitted to long-term care, compared to roughly half for those receiving complex continuing care and roughly one quarter of those receiving rehabilitation at home or in hospital.
• After three years, the differences were less pronounced but still present, with three quarters of individuals in the no rehabilitation group admitted to long-term care, compared to 68 per cent of individuals receiving rehabilitation in complex continuing care, 42 per cent in inpatient care and 43 per cent of those receiving home-based rehabilitative care.
• Mortality at one year was 44 per cent among individuals in the no rehabilitation group, 31 per cent for complex continuing care, 13 per cent for inpatient care and 15 per cent for home-based rehabilitation.
• After three years, the proportion of individuals who had died was 65 per cent in the no rehabilitation group, 56 per cent in the complex continuing care group, 35 per cent in inpatient care, and 39 per cent in home-based rehabilitation.
• Individuals receiving surgery in rural hospitals had lower use of inpatient rehabilitative care and higher rates of subsequent long-term care admission compared to those in urban settings.

Seitz notes that while the study showed a very strong association between rehabilitation and outcomes, the results should be interpreted with some caution as some of the factors that might have led clinicians to select certain patients for different types of rehabilitation may have led to an overestimation of the benefits. “Large randomized controlled trials would be an ideal way to test this association, however these have not been conducted to date,” says Seitz. ”Our study is one of the largest so far to examine rehabilitation rates and outcomes following hip fracture surgery for patients with dementia. As this is a highly vulnerable group at increased risk of falls and fractures, it is very important that patients, families, care providers and health planners use this information to guide choices in supporting the individual’s health and quality of life.”

“Rehabilitation of older adults with dementia after hip fracture” was published today in the Journal of the American Geriatrics Society.

Author block: Dallas P. Seitz, Sudeep S. Gill, Peter C. Austin, Chaim M. Bell, Geoffrey M Anderson, Andrea Gruneir, Paula A. Rochon.

The Institute for Clinical Evaluative Sciences (ICES) is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy. For the latest ICES news, follow us on Twitter: @ICESOntario

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