Life after hip fracture - Impact of home rehabilitation versus conventional care and patients' experiences of the recovery process in a short- and long-term perspective

Aim In a short- and long-term perspective compare a geriatric home rehabilitation programme (HR) for patients with hip fracture with conventional care (CC), and to capture the patients experience of the consequences of the injury and their conceptions of what influences the recovery process. Method The thesis is based on two quantitative and two qualitative studies. The two quantitative studies were randomized and controlled, longitudinal intervention studies in which 102 community-dwelling elderly patients who had received either HR (n = 48) or CC (n = 54) were followed for one year after discharge. The HR programme, which started immediately after admission to hospital, included active participation from patients in setting goals and planning discharge. The programme was focused on encouraging the participants’ self-efficacy and exercising daily activities. Assessment of balance confidence, degree of independence and frequency of daily activities, health-related quality of life, mood, perceived recovery, and basic physical performance were made one month, six months and one year after hospital discharge. In the qualitative, phenomenographic studies 18 patients were interviewed one month and one year after discharge about how they experienced the consequences of the hip fracture and their conceptions of the recovery process. Results The main recovery for all participants took place during the first six months after discharge. The results show that those who had participated in the HR programme recovered faster than those who hade received CC. Additionally, in a longer perspective they were more confident and independent than the CC group, although the differences between the groups had diminished at one year. Only 14 persons in the HR group and five persons in the CC group considered themselves fully recovered after one year. The results from the interviews showed that the hip fracture caused social and existential cracks in the individuals’ lives. The hip fracture came unexpectedly and resulted in an experience of a changed body and a more restricted life. The interviewees experienced that they had increased difficulties to move and to manage independently. One reaction was that their pre-fracture self-view as being healthy and stable had been punctured by the injury. Although positive experiences, such as being satisfied with the recovery, were also expressed, many of the negative consequences remained or had even deepened one year after discharge. A dominating experience was that they were more cautious, afraid of further falls, and felt more sedentary and isolated than before the fracture. Conclusions The results show that the negative consequences of a hip fracture are substantial and long-lasting. However, the HR programme had a more significant impact than CC on the participants’ functioning and confidence, which was most evident in the early phase of the recovery. An essential task for health care should be to create continued possibilities for rehabilitation after discharge from hospital also in a longer perspective, and not primarily focus on the medical and physical needs. The patients’ experiences and psychological reactions that may follow a hip fracture should also be considered

For whom is a health-promoting intervention effective? Predictive factors for performing activities of daily living independently

BACKGROUND: Health-promoting interventions tailored to support older persons to remain in their homes, so-called "ageing in place" is important for supporting or improving their health. The health-promoting programme "Elderly Persons in the Risk Zone," (EPRZ) was set up for this purpose and has shown positive results for maintaining independence in activities of daily living for older persons 80 years and above at 1- and 2 year follow-ups. The aim of this study was to explore factors for maintaining independence in the EPRZ health-promoting programme.METHODS: Total of 459 participants in the original trial was included in the analysis; 345 in the programme arm and 114 in the control arm. Thirteen variables, including demographic, health, and programme-specific indicators, were chosen as predictors for independence of activities of daily living. Logistic regression was performed separately for participants in the health promotion programme and in the control arm.RESULTS: In the programme arm, being younger, living alone and self-rated lack of tiredness in performing mobility activities predicted a positive effect of independence in activities of daily living at 1-year follow-up (odds ratio [OR] 1.18, 1.73, 3.02) and 2-year, (OR 1.13, 2.01, 2.02). In the control arm, being less frail was the only predictor at 1-year follow up (OR 1.6 1.09, 2.4); no variables predicted the outcome at the 2-year follow-up.CONCLUSIONS: Older persons living alone - as a risk of ill health - should be especially recognized and offered an opportunity to participate in health-promoting programmes such as "Elderly Persons in the Risk Zone". Further, screening for subjective frailty could form an advantageous guiding principle to target the right population when deciding to whom health-promoting intervention should be offered.TRIAL REGISTRATION: The original clinical trial was registered at ClinicalTrials.gov. Identifier: NCT00877058 , April 6, 2009

Stakeholders' views and experiences of care and interventions for addressing frailty and pre-frailty:a meta-synthesis of qualitative evidence

Frailty is a common condition in older age and is a public health concern which requires integrated care and involves different stakeholders. This meta-synthesis focuses on experiences, understanding, and attitudes towards screening, care, intervention and prevention for frailty across frail and healthy older persons, caregivers, health and social care practitioners. Studies published since 2001 were identified through search of electronic databases; 81 eligible papers were identified and read in full, and 45 papers were finally included and synthesized. The synthesis was conducted with a meta-ethnographic approach. We identified four key themes: Uncertainty about malleability of frailty; Strategies to prevent or to respond to frailty; Capacity to care and person and family-centred service provision; Power and choice. A bottom-up approach which emphasises and works in synchrony with frail older people's and their families' values, goals, resources and optimisation strategies is necessary. A greater employment of psychological skills, enhancing communication abilities and tools to overcome disempowering attitudes should inform care organisation, resulting in more efficient and satisfactory use of services. Public health communication about prevention and management of frailty should be founded on a paradigm of resilience, balanced acceptance, and coping. Addressing stakeholders' views about the preventability of frailty was seen as a salient need

Health-promoting interventions for persons aged 80 and older are successful in the short term-results from the randomized and three-armed Elderly Persons in the Risk Zone study

Objectives: To examine the outcomes of the Elderly Persons in the Risk Zone study, which was designed to evaluate whether it is possible to delay deterioration if a health-promoting intervention is made when an older adult (=80) is at risk of becoming frail and whether a multiprofessional group intervention is more effective in delaying deterioration than a single preventive home visit with regard to frailty, self-rated health, and activities of daily living (ADLs) at 3-month follow-up. Design: Randomized, three-armed, single-blind, controlled trial performed between November 2007 and May 2011. Setting: Two urban districts of Gothenburg, Sweden. Participants: Four hundred fifty-nine community-living adults aged 80 and older not dependent on the municipal home help service. Intervention: A preventive home visit or four weekly multiprofessional senior group meetings with one follow-up home visit. Measurements: Change in frailty, self-rated health, and ADLs between baseline and 3-month follow-up. Results: Both interventions delayed deterioration of self-rated health (odds ratio (OR) = 1.99, 95% confidence interval (CI) = 1.12–3.54). Senior meetings were the most beneficial intervention for postponing dependence in ADLs (OR = 1.95, 95% CI = 1.14–3.33). No effect on frailty could be demonstrated. Conclusion: Health-promoting interventions made when older adults are at risk of becoming frail can delay deterioration in self-rated health and ADLs in the short term. A multiprofessional group intervention such as the senior meetings described seems to have a greater effect on delaying deterioration in ADLs than a single preventive home visit. Further research is needed to examine the outcome in the long term and in different contexts