IMPORTANCE Decision-making on management of proximal femoral fractures in frail patients with limited life expectancy is challenging, but surgical overtreatment needs to be prevented. Current... Show moreIMPORTANCE Decision-making on management of proximal femoral fractures in frail patients with limited life expectancy is challenging, but surgical overtreatment needs to be prevented. Current literature provides limited insight into the true outcomes of nonoperative management and operative management in this patient population. OBJECTIVE To investigate the outcomes of nonoperative management vs operative management of proximal femoral fractures in institutionalized frail older patients with limited life expectancy. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort studywas conducted between September 1, 2018, and April 25, 2020, with a 6-month follow-up period at 25 hospitals across the Netherlands. Eligible patientswere aged 70 years or older, frail, and institutionalized and sustained a femoral neck or pertrochanteric fracture. The term frail implied at least 1 of the following characteristicswas present: malnutrition (body mass index [calculated asweight in kilograms divided by height in meters squared] <18.5) or cachexia, severe comorbidities (American Society of Anesthesiologists physical status class of IV or V), or severe mobility issues (Functional Ambulation Category similar to 2). EXPOSURES Shared decision-making (SDM) followed by nonoperative or operative fracture management. MAIN OUTCOMES AND MEASURES The primary outcomewas the EuroQol 5 Dimension 5 Level (EQ-5D) utility score by proxies and caregivers. Secondary outcome measures were QUALIDEM (a dementia-specific quality-of-life instrument for persons with dementia in residential settings) scores, pain level (assessed by the Pain Assessment Checklist for Seniors With Limited Ability to Communicate), adverse events (Clavien-Dindo classification), mortality, treatment satisfaction (numeric rating scale), and quality of dying (Quality of Dying and Death Questionnaire). RESULTS Of the 172 enrolled patients with proximal femoral fractures (median [25th and 75th percentile] age, 88 [85-92] years; 135women [78%]), 88 opted for nonoperative management and 84 opted for operative management. The EQ-5D utility scores by proxies and caregivers in the nonoperative management group remained within the set 0.15 noninferiority limit of the operative management group (week 1: 0.17 [95% CI, 0.13-0.29] vs 0.26 [95% CI, 0.11-0.23]; week 2: 0.19 [95% CI, 0.10-0.27] vs 0.28 [95% CI, 0.22-0.35]; and week 4: 0.24 [95% CI, 0.15-0.33] vs 0.34 [95% CI, 0.28-0.41]). Adverse eventswere less frequent in the nonoperative management group vs the operative management group (67 vs 167). The 30-day mortality rate was 83%(n = 73) in the nonoperative management group and 25%(n = 21) in the operative management group, with 26 proxies and caregivers (51%) in the nonoperative management group rating the quality of dying as good-almost perfect. Treatment satisfaction was high in both groups, with a median numeric rating scale score of 8. CONCLUSIONS AND RELEVANCE Results of this study indicated that nonoperative management of proximal femoral fractures (selected through an SDM process) was a viable option for frail institutionalized patients with limited life expectancy, suggesting that surgery should not be a foregone conclusion for this patient population. Show less
Purpose To describe a guidance on the management of post-acute COVID 19 patients in geriatric rehabilitation. Methods The guidance is based on guidelines for post-acute COVID-19 geriatric... Show morePurpose To describe a guidance on the management of post-acute COVID 19 patients in geriatric rehabilitation. Methods The guidance is based on guidelines for post-acute COVID-19 geriatric rehabilitation developed in the Netherlands, updated with recent insights from literature, related guidance from other countries and disciplines, and combined with experiences from experts in countries participating in the Geriatric Rehabilitation Special Interest Group of the European Geriatric Medicine Society. Results This guidance for post-acute COVID-19 rehabilitation is divided into a section addressing general recommendations for geriatric rehabilitation and a section addressing specific processes and procedures. The Sect. "General recommendations for geriatric rehabilitation" addresses: (1) general requirements for post-acute COVID-19 rehabilitation and (2) critical aspects for quality assurance during COVID-19 pandemic. The Sect. "Specific processes and procedures", addresses the following topics: (1) patient selection; (2) admission; (3) treatment; (4) discharge; and (5) follow-up and monitoring. Conclusion Providing tailored geriatric rehabilitation treatment to post-acute COVID-19 patients is a challenge for which the guidance is designed to provide support. There is a strong need for additional evidence on COVID-19 geriatric rehabilitation including developing an understanding of risk profiles of older patients living with frailty to develop individualised treatment regimes. The present guidance will be regularly updated based on additional evidence from practice and research.Key summary pointsAim To describe a guidance on the management of post-acute COVID 19 patients in geriatric rehabilitation. Findings This guidance addresses general requirements for post-acute COVID-19 geriatric rehabilitation and critical aspects for quality assurance during the COVID-19 pandemic. Furthermore, the guidance describes relevant care processes and procedures divided in five topics: patient selection; admission; treatment; discharge; and follow-up and monitoring. Message This guidance is designed to provide support to care professionals involved in the geriatric rehabilitation treatment of post-acute COVID-19 patients. Show less
Scheffers-Barnhoorn, M.N.; Eijk, M. van; Schols, J.M.G.A.; Balen, R. van; Kempen, G.I.J.M.; Achterberg, W.P.; Haastregt, J.C.M. van 2021
Background: This study describes the process evaluation of an intervention developed to reduce fear of falling (FoF) after hip fracture, within an inpatient geriatric rehabilitation setting. This ... Show moreBackground: This study describes the process evaluation of an intervention developed to reduce fear of falling (FoF) after hip fracture, within an inpatient geriatric rehabilitation setting. This 'FIT-HIP intervention' is a multicomponent cognitive behavioral intervention, conducted by physiotherapists and embedded in usual care in geriatric rehabilitation in the Netherlands. A previous study (cluster randomized controlled trial) showed no beneficial effects of this intervention when compared to usual care. The aim of this study was to gain insight into factors related to the intervention process that may have influenced the effectiveness of the intervention.Methods: This process evaluation was conducted using an observational prospective study design. Based on quantitative and qualitative data derived from session logs, evaluation questionnaires and interviews, we addressed: 1] recruitment and reach; 2] performance according to protocol; 3] patients' adherence; and 4] opinions of patients and facilitators on the intervention. Participants in this study were: a) patients from 6 geriatric rehabilitation units, who were invited to participate in the intervention (39 adults aged ≥65 years with hip fracture and FoF) and; b) intervention facilitators (14 physiotherapists and 8 psychologists who provide coaching to the physiotherapists).Results: Thirty-six patients completed the intervention during inpatient geriatric rehabilitation. Apart from cognitive restructuring and telephonic booster (which was not provided to all patients), the intervention was performed to a fair degree in accordance with protocol. Patients' adherence to the intervention was very good, and patients rated the intervention positively (average 8.1 on a scale 0-10). Although most facilitators considered the intervention feasible, a limited level of FoF (possibly related to timing of intervention), and physiotherapists' limited experience with cognitive restructuring were identified as important barriers to performing the intervention according to protocol.Conclusions: The FIT-HIP intervention was only partly feasible, which may explain the lack of effectiveness in reducing FoF. To improve the intervention's feasibility, we recommend selecting patients with maladaptive FoF (i.e. leading to activity restriction), being more flexible in the timing of the intervention, and providing more support to the physiotherapists in conducting cognitive restructuring.Trial registration: Netherlands Trial Register: NTR5695 (7 March 2016).Keywords: Cognitive behavioral intervention; Fear of falling; Feasibility; Geriatric rehabilitation; Hip fracture; Process evaluation. Show less
Grund, S.; Caljouw, M.A.A.; Haaksma, M.L.; Gordon, A.L.; Balen, R. van; Bauer, J.M.; ... ; COGER STUDY SUBGRP EUGMSS IG GR 2021
Objectives There is insufficient knowledge about the functional and medical recovery of older people infected with SARS-CoV-2. This study aims to gain insight into the course of functional and... Show moreObjectives There is insufficient knowledge about the functional and medical recovery of older people infected with SARS-CoV-2. This study aims to gain insight into the course of functional and medical recovery of persons who receive geriatric rehabilitation (GR) following SARS-CoV-2 infection across Europe. Special attention will be paid to the recovery of activities of daily living (ADL) and to the GR services offered to these patients. Design A multi-center observational cohort study. Setting and participants This study will include several European countries (EuGMS member states) each providing at least 52 comparable routine datasets (core dataset) of persons recovering from a SARS-CoV-2 infection and receiving geriatric rehabilitation. The routine data will be anonymously collected in an online CASTOR database. The ethical regulations of each participating country will be followed. Primary outcome ADL functioning. Secondary outcomes Length of stay, discharge destination, hospital readmission and mortality. Other variables that will be collected are quality of life, treatment modalities, complications, cognition, frailty, mood/anxiety, BMI, nutrition and pain. All variables will be reported at admission and compared with follow-up scores (discharge, 6 weeks and 6 months follow-up). Conclusion This study will explore the effect of geriatric rehabilitation on post-COVID-19 patients, especially on ADL recovery, and the variety of geriatric rehabilitation services across Europe. Information from this study may help improve recovery of older persons infected with SARS-CoV-2 and improve geriatric rehabilitation services in the ongoing COVID-19 pandemic. Show less
Scheffers-Barnhoorn, M.N.; Sharma-Virk, M.; Balen, R. van; Eijk, M. van; Achterberg, W.P. 2021
Objectives: Coping strategies may play an important role as facilitator or barrier for functional recovery after hip fracture. This study explored 1] active and passive coping strategies in hip... Show moreObjectives: Coping strategies may play an important role as facilitator or barrier for functional recovery after hip fracture. This study explored 1] active and passive coping strategies in hip fracture patients within inpatient geriatric rehabilitation (GR) 2] the association of these coping strategies with depression, anxiety, pain and health-related quality of life (HRQoL).Method: Secondary data analysis (FIT-HIP trial). Participants were patients with hip fracture, aged 65+ years, admitted to post-acute GR units. Coping was assessed using the 'Active Tackling' and 'Passive Reacting' subscale of Utrecht Coping List (UCL). Depression, anxiety, pain and HRQoL was assessed using GDS-8, HADS-A, NPRS and EQ5D-VAS. Based on UCL norm tables - for both subscales - we dichotomized the group into (extremely) high use of this coping strategy i.e. 'predominantly active coping' (PAC), and 'predominantly passive coping' (PPC); versus their corresponding 'residual groups', i.e. the remaining participants.Results: 72 participants were included. Participants mostly used active coping (PAC: 33.3%), however those engaging in passive coping (23.6%) had significantly more depression and anxiety symptoms (GDS-8 ≥ 3: 31.1% respectively 9.1%, p = 0.040; HADS-A ≥ 7: 58.8% vs 10.9%; p = 0.00).Conclusion: Active tackling and passive reacting coping strategies are used by up to one-third of patients with recent hip fracture. Passive coping was associated with more symptoms of depression and anxiety, which in turn may influence rehabilitation negatively. Screening of (passive) coping strategies could contribute to prompt identification of hip fracture patients at risk for negative health outcomes.Keywords: 2016); Coping (strategies); Netherlands Trial Register: NTR5695 (March 7; geriatric rehabilitation; hip fracture. Show less
Key summary pointsAim The consensus statement about core principles and future priorities of geriatric rehabilitation has the aim to help healthcare providers which need strategies to support older... Show moreKey summary pointsAim The consensus statement about core principles and future priorities of geriatric rehabilitation has the aim to help healthcare providers which need strategies to support older people who have experienced functional decline. Findings Geriatric rehabilitation is now defined in a way that is compatible with existing service models across Europe. Message This consensus statement can provide a starting point for further development of geriatric rehabilitation.Purpose In response to the growing recognition of geriatric rehabilitation and to support healthcare providers which need strategies to support older people with frailty who have experienced functional decline, we developed a consensus statement about core principles and future priorities for geriatric rehabilitation. Methods We used a three-stage approach to establish consensus-preparation, consensus and review. Results The consensus statement is grouped under 11 headings from (1) "Definition of GR" to (11) "Effective strategies to develop GR in Europe", which define geriatric rehabilitation in a way that is compatible with existing service models across Europe. Additionally future goals around research and education are highlighted. Conclusion The definitions of the consensus statement can provide a starting point for those wishing to further develop geriatric rehabilitation in their jurisdiction and help to develop strategic alliances with other specialties, serving as a basis for a pan-European approach to geriatric rehabilitation. Show less
Kabboord, A.D.; Godfrey, D.; Gordon, A.L.; Gladman, J.R.F.; Eijk, M. van; Balen, R. van; Achterberg, W.P. 2020
Background In the inpatient rehabilitation of older patients, estimating to what extent the patient may functionally recover (functional prognosis), is important to plan the rehabilitation... Show moreBackground In the inpatient rehabilitation of older patients, estimating to what extent the patient may functionally recover (functional prognosis), is important to plan the rehabilitation programme and aid discharge planning. Comorbidity is very common in older patients. However, the role of comorbidity in making a functional prognosis is not clearly defined. The aim of this study was to investigate a modified and weighted Functional Comorbidity Index (w-FCI) in relation to functional recovery and compare its predictive performance with that of the Charlson comorbidity index (CCI) and the original Functional Comorbidity Index (FCI). Methods The COOPERATION study (Comorbidity and Outcomes of Older Patients Evaluated in RehabilitATION) is a prospective observational cohort study. Data of patients that were admitted in an inpatient geriatric rehabilitation facility in the UK between January and September 2017, were collected. The outcome measures were: the Elderly Mobility Scale (EMS) and Barthel index (BI) at discharge, EMS gain/day and BI gain/day. Baseline comorbidity was assessed using the CCI, the FCI and the w-FCI. Correlations, receiver operating curves (ROC), and multiple linear regression analyses were performed. The models were adjusted for age, gender and EMS or BI on admission. Results In total, 98 patients (mean age 82 years; 37% male) were included. The areas under the ROC curves of the w-FCI (EMS at discharge: 0.72, EMS gain/day: 0.72, BI at discharge: 0.66 and BI gain/day: 0.60) were higher than for the CCI (0.50, 0.53, 0.49, 0.44 respectively) and FCI (0.65, 0.55, 0.60, 0.49 respectively). The w-FCI was independently associated with EMS at discharge (20.7% of variance explained (PVE), p < 0.001), EMS gain/day (11.2PVE, p < 0.001), and BI at discharge (18.3 PVE, p < 0.001). The FCI was only associated with EMS gain/day (3.9 PVE, p < 0.05). None of the comorbidity indices contributed significantly to BI gain/day (w-FCI: 2.4 PVE, p > 0.05). Conclusions The w-FCI was predictive of mobility & function at discharge and mobility gain per day, and outperformed the original FCI and the CCI. The w-FCI could be useful in assessing comorbidity in a personalised way and aid functional prognosis at the start of rehabilitation. Show less
AimsTo investigate the reliability of a weighted version of the Functional Comorbidity Index (w-FCI) compared with that of the original Functional Comorbidity Index (FCI) and to test its usability....Show moreAimsTo investigate the reliability of a weighted version of the Functional Comorbidity Index (w-FCI) compared with that of the original Functional Comorbidity Index (FCI) and to test its usability.Patients and methods Sixteen physicians collected data from 102 residents who lived in 16 different nursing homes in the Netherlands. A multicentre, prospective observational study was carried out in combination with a qualitative part using the three-step test interview, in which participants completed the w-FCI while thinking aloud and being observed, and were then interviewed afterward. To analyse inter-rater reliability, a subset of 41 residents participated. The qualitative part of the study was completed by eleven elderly care physicians and one advanced nurse practitioner.Measurements The w-FCI was composed of the original FCI supplemented with a severity rating per comorbidity, ranging from 0 (disease absent) to 3 (severe impact on daily function). The w-FCI was filled out at baseline by 16 physicians and again 2 months later to establish intra-rater reliability (intraclass correlations; ICCs). For inter-rater reliability, four pairs of raters completed the w-FCI independently from each other.Results The ICCs were 0.90 (FCI) and 0.94 (w-FCI) for intra-rater reliability, and 0.61 (FCI) and 0.55 (w-FCI) for inter-rater reliability. Regarding usability of the w-FCI, five meaningful themes emerged from the qualitative data: 1) sources of information; 2) deciding on the presence or absence of disease; 3) severity of comorbidities; 4) usefulness; and 5) content.Conclusion The intra-rater reliability of the FCI and the w-FCI was excellent, whereas the inter-rater reliability was moderate for both indices. Based on the present results, a modified w-FCI is proposed that is acceptable and feasible for use in older patients and requires further investigation to study its (predictive) validity. Show less
Scheffers-Barnhoorn, M.N.; Eijk, M. van; Haastregt, J.C.M. van; Schols, J.M.G.A.; Balen, R. van; Geloven, N. van; ... ; Achterberg, W.P. 2019
Objectives: Fear of falling (FoF) is common after hip fracture and can impede functional recovery because of activity restriction. The Fear of falling InTervention in HIP fracture geriatric... Show moreObjectives: Fear of falling (FoF) is common after hip fracture and can impede functional recovery because of activity restriction. The Fear of falling InTervention in HIP fracture geriatric rehabilitation (FIT-HIP intervention) was designed to target FoF and consequently to improve mobility. The aim of this study was to evaluate the effect of the FIT-HIP intervention in patients with FoF in geriatric rehabilitation (GR) after hip fracture.Design, setting, and participants: This cluster-randomized controlled trial was performed in 11 post-acute GR units in the Netherlands (2016-2017). Six clusters were assigned to the intervention group, 5 to the usual care group. We included 78 patients with hip fracture and FoF (aged ≥65 years; 39 per group).Intervention(s): The FIT-HIP intervention is a multicomponent cognitive behavioral intervention conducted by physiotherapists, embedded in usual care in GR. The FIT-HIP intervention was compared to usual care in GR.Measurements: FoF was assessed with the Falls Efficacy Scale-International (FES-I) and mobility, with the Performance Oriented Mobility Assessment (POMA). Data were collected at baseline, discharge, and 3 and 6 months postdischarge from GR. Primary endpoints were change scores at discharge. Linear mixed models were used to evaluate the treatment effect.Results: No significant between-group differences were observed for primary outcome measures. With the usual care group as reference, the FES-I estimated difference between mean change scores was 3.3 [95% confidence interval (CI) -1.0, 7.5, P = .13] at discharge from GR; -4.1 (95% CI -11.8, 3.6, P = .29) after 3 months; and -2.8 (95% CI -10.0, 4.4, P = .44) after 6 months. POMA estimated difference was -0.3 (95% CI -6.5, 5.8, P = .90).Conclusion/implications: The FIT-HIP intervention was not effective in reducing FoF. Possibly FoF (shortly) after hip fracture can to some extent be appropriate. This may imply the study was not able to accurately identify and accordingly treat FoF that is maladaptive (reflective of disproportionate anxiety). Show less
Kabboord, A.D.; Eijk, M. van; Buijck, B.I.; Koopmans, R.T.C.M.; Balen, R. van; Achterberg, W.P. 2018
BackgroundOlder patients often have multiple comorbidities and are susceptible to develop intercurrent diseases during rehabilitation. This study investigates intercurrent diseases and associated... Show moreBackgroundOlder patients often have multiple comorbidities and are susceptible to develop intercurrent diseases during rehabilitation. This study investigates intercurrent diseases and associated factors in patients undergoing geriatric stroke rehabilitation, focussing on pre-existing comorbid conditions, overall comorbidity and baseline functional status.Materials and MethodsThis multicentre prospective cohort study included 15 skilled nursing facilities. Data were collected at baseline and at discharge. The primary outcome measures were presence and number of intercurrent diseases, and secondary their impact on change in rehabilitation goals or length of stay was examined. Comorbidity was assessed with the Charlson index, and functional status with the Barthel index (BI).ResultsOf the 175 included patients, 51% developed an intercurrent disease. A lower baseline BI, a higher Charlson index, presence of diabetes mellitus (DM) and kidney disease were related to the occurrence of an intercurrent disease (p<0.05). Moreover, a lower BI, a higher Charlson index, and particularly the presence of DM were independently associated. If both comorbidity and a lower baseline functional status were present, the odds ratio (95%CI) of developing intercurrent diseases was 6.70 [2.33-19.2], compared to 1.73 [0.52-5.72] (comorbidity only) and 1.62 [0.53-4.94] (only BI ≤14).ConclusionsOn admission, functional impairments and comorbidity (particularly diabetes) independently contribute to developing intercurrent diseases during geriatric stroke rehabilitation. Therefore, routine evaluation of comorbidity and functional status at the start of rehabilitation helps to identify patients at risk. Particular attention should be paid to patients with DM to prevent the occurrence of intercurrent diseases and support optimal functional recovery. Show less
Background: Hip fracture is a common injury in the geriatric population. Despite surgical repair and subsequent rehabilitation programmes, functional recovery is often limited, particularly in... Show moreBackground: Hip fracture is a common injury in the geriatric population. Despite surgical repair and subsequent rehabilitation programmes, functional recovery is often limited, particularly in individuals with multi-morbidity. This leads to high care dependency and subsequent use of healthcare services. Fear of falling has a negative influence on recovery after hip fracture, due to avoidance of activity and subsequent restriction in mobility. Although fear of falling is highly prevalent after hip fracture, no structured treatment programme is currently available. This trial will evaluate whether targeted treatment of fear of falling in geriatric rehabilitation after hip fracture using a multi-component cognitive behavioural intervention (FIT-HIP), is feasible and (cost) effective in reducing fear of falling and associated activity restriction and thereby improves physical functioning.Methods/design: This multicentre cluster randomised controlled trial will be conducted among older patients with hip fracture and fear of falling who are admitted to a multidisciplinary inpatient geriatric rehabilitation programme in eleven post-acute geriatric rehabilitation units. Fifteen participants will be recruited from each site. Recruitment sites will be allocated by computer randomisation to either the control group, receiving usual care, or to the intervention group receiving the FIT-HIP intervention in addition to usual care. The FIT-HIP intervention is conducted by physiotherapists and will be embedded in usual care. It consists of various elements of cognitive behavioural therapy, including guided exposure to feared activities (that are avoided by the participants). Participants and outcome assessors are blinded to group allocation. Follow-up measurements will be performed at 3 and 6 months after discharge from geriatric rehabilitation. (Cost)-effectiveness and feasibility of the intervention will be evaluated. Primary outcome measures are fear of falling and mobility.Discussion: Targeted treatment of fear of falling may improve recovery and physical and social functioning after hip fracture, thereby offering benefits for patients and reducing healthcare costs. Results of this study will provide insight into whether fear of falling is modifiable in the (geriatric) rehabilitation after hip fracture and whether the intervention is feasible.Trial registration: Netherlands Trial Register: NTR 5695 Show less
