Prevention and Clinical Management of Hip Fractures in Patients With Dementia

Abstract

Hip fractures and dementia increase exponentially with age, and patients who are afflicted by both conditions suffer significant morbidity and mortality. The aging of our population heightens the need to recognize the interaction of these conditions in order to improve our efforts to prevent hip fractures, provide acute care that improves outcomes, and provide secondary prevention and rehabilitation that returns patients to their previous level of functioning. Identification and treatment of vitamin D deficiency and osteoporosis and assessment and interventions to reduce falls in patients with dementia can significantly impact the incidence of first and subsequent hip fractures. Acute management of hip fractures that focuses on comanagement by orthopedic surgeons and geriatricians and uses protocol-driven geriatric-focused care has been shown to decrease mortality, length of hospitalization, readmission rates, and complications including delirium. Patients with mild-to-moderate dementia benefit from intensive geriatric rehabilitation to avoid nursing home placement. Recognizing the need to optimize primary and secondary prevention of hip fractures in patients with dementia and educating providers and families will lead to improved quality of life for patients affected by dementia and hip fractures.

Introduction

Hip fractures and dementia present a double challenge to the elderly. The frequency of both conditions increases exponentially with age and many individuals of advanced age are affected by both, leading to accelerated death for a significant number of patients and significant disability for survivors.^1,2 In 2005, hip fracture incidence was 21 per 10 000 women aged 65 to 69 years, compared with 325 per 10 000 women aged 85 to 100 years.³ One third of persons over 85 years have dementia.⁴ Patients with dementia are 2.7 times more likely to sustain a hip fracture than age- and sex-matched controls without dementia.⁵ Of all conditions that co-occur with hip fracture, dementia has been shown to add the largest amount to the total cost of care.⁶ As the population ages, the socioeconomic burden of hip fractures associated with dementia is expected to increase. This suggests a need to better understand the interaction of these conditions, so we can improve quality of life as well as control costs.

Dementia can complicate prevention and treatment at every stage of the care continuum for patients with hip fracture: from primary prevention, to acute management, to rehabilitation and post hip fracture care (see Figure 1 ). Osteoporosis and falls, 2 of the major risk factors for hip fractures, are common in patients with dementia.^7–10 Following a fracture, patients with dementia continue to be at higher risk of mortality than patients without dementia.¹¹ As a group, patients with hip fracture have a 5- to 8-fold increased risk of all-cause mortality during the first 3 months after a hip fracture.¹² In a prospective study of 311 cognitively impaired patients who had a hip fracture, 34% of women and 49% of men were not residing in their own home 24 months after hip fracture repair. In addition, the proportion of independent walkers with cognitive dysfunction decreased after 24 months.¹³

Figure 1.

Improving hip fracture prevention and outcomes in patients with dementia.

Despite the high financial and social costs of hip fractures and dementia, our understanding of the impact of dementia on hip fractures is sparse in some areas and absent in others. It is unclear whether the poor outcomes for patients with dementia are due to patient characteristics, practice patterns, or both. Furthermore, it is unclear whether practice changes could improve outcomes for patients with dementia. Should primary prevention, acute management, and secondary prevention for patients with dementia be augmented or specially tailored to their needs? This article will examine current knowledge of the effects of dementia on hip fractures prevention, treatment, and rehabilitation, focusing on practice patterns and identifying potential opportunities for improvement in care.

Methods

The following search strategy was used to identify relevant articles containing the evidence presented in this article. A PubMed search for medical subject heading “dementia” AND major subject heading “hip fractures” returned 91 articles. A similar search of PubMed clinical queries returned 65 articles. For subtopics, 4 PubMed clinical queries were conducted as follows: (1) “dementia” AND “osteoporosis,” returned 94 articles, (2) “dementia” AND “falls” returned 184 articles, (3) “dementia” AND “acute management” returned 25 articles, and (4) “dementia” AND “hip fractures” AND “rehabilitation” returned 30 articles. All abstracts were reviewed for relevance to the topic and the full text of all relevant abstracts were retrieved for further review. Combined, the searches resulted in 489 abstracts, with 72 redundant articles. Of the 417 abstracts, 149 were relevant to the subheadings of prevention, acute management, and rehabilitation. The bibliographies of relevant articles were reviewed for additional published works. This article is a synthesis of the relevant literature.

Primary Prevention

Evaluation and management of osteoporosis and vitamin D deficiency can significantly reduce the risk of hip fractures in older adults. In addition, successful falls intervention may reduce the risk of hip fractures since most hip fractures are caused by a fall. The relationship between these risk factors is complex and is discussed further in the paper by Friedman, et al in this issue. In practice, there may be several missed opportunities for primary prevention of fractures, and these gaps may be accentuated in patients with dementia.

Osteoporosis

Osteoporosis remains widely underdiagnosed and undertreated in all patients, despite significant evidence-based advances in testing for and treating low bone mineral density (BMD).¹⁴ In one university-based academic geriatric practice, physicians were more likely to order BMD screening in younger patients without dementia who were independent in activities of daily living (ADL).¹⁵ This represents a missed opportunity for patients with dementia who are more likely to have a low BMD than their nondemented counterparts, and need treatment for osteoporosis.¹⁶

Treatment of osteoporosis in Alzheimer disease has been shown to be effective in preventing hip fractures. A study of 500 patients with Alzheimer disease with a mean Mini-Mental State Examination (MMSE) score of 16.5 (ie, moderate dementia), who were randomized to either risedronate with calcium and vitamin D, or calcium and vitamin D alone, showed a relative risk (RR) of hip fractures of 0.26 (95% CI, 0.10-0.69), a 74% risk reduction with the addition of the bisphosphonate. No serious side effects occurred: 2 patients experienced leukopenia, 1 had esophagitis, and 3 had abdominal pain in the risedronate group, and 3 patients in the control group developed transient abdominal pain.¹⁷

A survey of physicians' attitude toward prescribing a medication for osteoporosis in patients with dementia has not been documented, but it may be possible that physicians believe that patients with dementia are less likely to be compliant. Suboptimal compliance with a regimen of prescribed bisphosphonates in all patients is well documented. Only 45% of patients prescribed a bisphosphonate were still taking it at 1 year. Dementia is associated with other characteristics, such as advanced age, more comorbid conditions, and more medications for problems other than osteoporosis that are known to reduce compliance with osteoporosis medications.¹⁸ A consideration of yearly intravenous antiresorptive medications as opposed to oral regimens may be a reasonable approach in this population. Zoledronic acid reduced the risk of hip fractures by 41% in a double-blind, placebo-controlled trial of 3889 patients randomized to a single 15-minute infusion of zoledronic acid and 3876 patients randomized to placebo. Adverse events, including change in renal function, were similar in the 2 groups. However, caution should be used in patients with underlying cardiac abnormalities since serious atrial fibrillation occurred more frequently in the zoledronic group.¹⁹

Vitamin D

Vitamin D deficiency is very common in older adults and is seen even more commonly in older adults with dementia. In one study, the mean 25-OH vitamin D level in participants with dementia was 61 nmol/L, whereas it was 90 nmol/L in age- and sex-matched controls.²⁰ In addition, serum 25-OH vitamin D levels have been shown to decrease as the severity of dementia increases.²¹ Patients with Alzheimer disease have a lower intake of vitamin D and less sunlight exposure than patients who are cognitively intact, particularly in nursing home residents. In one study of nursing home residents, 83% of residents received less than the recommended daily allowance of vitamin D, and none of the 46 residents received 15 minutes or more of sunlight per week.^22,23 Vitamin D with calcium supplementation reduces hip fractures in frail older adults in institutional care.^24,25 Vitamin D and calcium has also been shown to reduce falls and improve muscle function in community-dwelling adults and to reduce falls in institutionalized elders.^26,27 Adequate levels of vitamin D are associated with multiple outcomes that can improve quality of life for older adults with dementia; therefore, routine screening is indicated, particularly in northern latitudes, older adults with darker complexion, and during winter months. Increased sunlight exposure could also prevent hip fractures in patients with dementia as discussed further in the paper by Friedman, et al in this issue.²⁸

Falls

The annual incidence of falls is 40% to 60% in patients with dementia, compared with 20% to 30% in cognitively intact elderly patients.^7,29,30 Although the risk factors for falls in cognitively intact patients have been well studied, the risk factors for falls in patients with dementia are less well defined. There is evidence that environmental hazards, medications, cardiovascular conditions such as orthostatic hypotension, poor vision, and depression all contribute to falls in patients with dementia.^31,32 In addition, behavioral and psychological symptoms of dementia such as anxiety, confusion, and wandering have been shown to increase falls in nursing home residents, and in at least one study of 160 residents of 20 group dwellings for people with dementia living in northern Sweden.^33–35 The association between wandering and hip fractures is strong (odds ratio [OR] 6.9, 95%CI 1.66-28.6).³⁶ Symptomatic hypotension, which may be related to medication use, produced a hazard ratio of falls of 2.13 in the same study. Falls intervention trials for patients with dementia are needed to determine which risk factors are modifiable.

Interventions to modify risk factors have been successful in reducing falls by 30% in cognitively intact patients. Unfortunately, patients with dementia are underrepresented in fall intervention trials, limiting the evidence for developing targeted falls intervention for this group. A recent Cochrane review of falls intervention identified 111 randomized controlled trials (RCTs) in community dwelling adults and 41 RCTs in nursing home facilities and hospitals.³⁷ Participants with cognitive impairment were specifically excluded from 66 of the 111 studies in community-dwelling adults. In an additional 44 studies, cognitive impairment was not specified as an inclusion or exclusion criterium. In just one study, poor cognition was included as one of a number of fall risk factors indicating eligibility for inclusion.

Only 1 of 41 nursing home trials met the criteria for inclusion in the analysis and included patients with dementia.³² This trial used a multifactorial intervention based on risk factors that have been identified in cognitively intact patients. The study involved 274 patients who presented to an accident and emergency department after a fall. The mean MMSE score was 13, and a majority of patients resided in a nursing home. There was no difference in the proportion of patients who fell during a 1-year follow-up.

The incidence of falls in this group was 80%, which is higher than the 60% that has been estimated in community-dwelling patients with dementia. The group also had a high prevalence of gait and balance impairment, psychotropic and other culprit drugs, cardiovascular disease, and vision impairments. It is possible that the level of frailty in the participants of this study attenuated the effect of the intervention. Perhaps the pathophysiology of falls in frail patients with moderate-to-severe dementia is different from that seen in a general population, resulting in suboptimal targeting of risk factors.

In a falls intervention involving supervised exercise in patients living in institutionalized care, the hazard ratio for the risk of falling significantly increased in the subgroups classified as being frail, while the hazard ratio significantly decreased in the subgroups classified as being prefrail.³⁸ The subgroup of patients with dementia who would benefit from fall interventions has not yet been identified, but the negative study described above suggests that it is important to specifically identify modifiable falls risk factors in patients with dementia. It also suggests that less frail, community-dwelling patients with mild-to-moderate dementia may benefit most from falls intervention.³²

Acute Management of Hip Fractures

Following a hip fracture, patients with dementia are at higher risk of mortality and functional decline than those who are cognitively intact.^39,40 In an analysis of 7 million patients cared for in New York City hospitals between 1995 and 2000, the odds of hospital death for patients with dementia and hip fractures was 12% greater than the odds of death for those without dementia, after adjusting for age, gender, race, insurance status, comorbidities, and nursing home status.¹¹

Standard of Care

The treatment of choice for almost all hip fractures is surgical treatment for the preservation of function and reduction of pain. A very small minority of patients may be medically unfit for surgery and the risk of surgery may exceed the benefits. Several small studies of nonoperative treatment in medically unfit patients have been published, but methodological issues limit conclusions and interpretations of this data.^41–44 Once surgery is indicated, the goal of acute-care hospital treatment of patients with hip fractures including those with dementia is to achieve the following outcomes: short time to surgery, few or no complications, control of pain, and early mobilization for restoration of function and gait. The authors recommend that patient factors, fracture pattern, and surgeon experience dictate which surgical procedure is chosen to treat the fracture. The care of patients with hip fractures and severe dementia is discussed below.

Evidence-based medical care that includes a medical consultant in managing preoperative conditions and postoperative complications has been recommended to improve the standard of care in the United States.⁴⁵ An orthogeriatric model of care that employs comanagement of the patient by orthopedic surgeons and geriatricians improves outcomes for elderly patients.^46,47 This model is based on the principles of early evaluation of patients, daily comanagement, protocol-driven geriatric-focused care, and early discharge planning. Patients in this model of care have lower-than-predicted length of stay, reduced readmission rates, shorter time to surgery, low complication rates, and low mortality rates.

Time to Surgery

There is no evidence to suggest that, as a group, patients with dementia have longer time to surgery. One of the main medically related reasons for operative delay is stabilization of a medical condition, and patients with dementia are a heterogeneous group in terms of number and severity of preexisting medical conditions.⁴⁸ Early operative intervention is important to patients because it results in less pain, which in turn leads to lower incidence of delirium.⁴⁹ Operative delay of more than 48 hours for stable patients has also been shown to be an important predictor of length of stay and 1-year mortality after hip fracture.^48,50–56

Hospital Complications

Although several small studies have concluded that dementia does not predict postoperative complications overall, it is an independent risk factor for both preoperative and postoperative delirium.^57–59 In a study of 541 patients with hip fractures, cognitive impairment was an independent risk factor for the development of delirium with an adjusted RR of 3.6 (95% CI 1.8-7.2).⁶⁰ Patients who have postoperative delirium have significantly higher rates of mortality at 1 year, are less likely to recover their prefracture level of ambulation, and are more likely to show a decline in level of independence of basic ADL at 1-year follow-up.⁶¹

Several interventions have been shown to reduce the incidence of delirium in hip fracture patients. Using a proactive geriatric consultation in an RCT, Marcantonio et al reduced delirium by over one third from 50% in the usual care group to 32% in the intervention group.⁶² In addition, severe delirium was reduced from 29% in the usual care group to 12% in the intervention group. One case of delirium was prevented for every 5.6 patients in the geriatrics consultation group. Geriatric consultants made daily visits for the duration of the hospitalization and made targeted recommendations which were followed by the orthopedic team in an average of 77% of cases. The recommendations most frequently made and adhered to included transfusing to keep the patient’s hematocrit >30%; discontinuation of benzodiazepines, anticholinergics, and antihistamines; and discontinuing urinary catheter by postoperative day 2 with subsequent monitoring for and treatment of retention. The percentage of patients with prefracture dementia was 37% in the intervention group and 51% in the usual care group, P = .13. In a subgroup analysis, the intervention showed no benefit in patients with prefracture dementia or ADL impairment, most likely because of the small size of the subgroup.⁶²

Another approach that results in a low incidence of delirium (24%) is a geriatric fracture center program utilizing daily comanagement by a geriatrician and an orthopedic surgeon.⁴⁶ In this model, geriatricians are responsible for care management. In contrast, in the proactive geriatric consultation model, consultants made recommendations but did not write orders, and orders were followed on an average 77% of times. The percentage of patients with prefracture dementia was much higher in the comanagement model than in the geriatric consultant model.^46,62

Using a randomized placebo-controlled study, Kalisvaart et al examined the effectiveness of haloperidol prophylaxis on the incidence, severity, and duration of postoperative delirium in elderly hip-surgery patients at risk of delirium.⁶³ Haloperidol 1.5 mg/d or placebo was started preoperatively and continued for up to 3 days postoperatively. Proactive geriatric consultation was provided for all patients. The percentage of patients with postoperative delirium in the haloperidol and placebo treatment group was 15.1% and 16.5%, respectively (RR 0.91, 95% CI 0.6-1.3). Although haloperidol did not reduce the incidence of delirium, it had a positive effect on the severity and duration of delirium and reduced the number of days patients stayed in the hospital.

Pain Control

Optimizing pain control improves quality of life, reduces risk of delirium, and can improve functional recovery. Morrison et al demonstrated that patients with dementia who received the equivalent of less than 10 mg of morphine sulfate per day were more likely to develop delirium than patients who received more analgesic (RR 4.0 95% CI 1.6-10.4).⁶⁴ The study also demonstrated that opioids, other than meperidine, do not precipitate delirium in patients with acute pain. In the same study, cognitively intact patients with higher pain scores at rest had significantly longer hospital stays and were less likely to be ambulating 3 days after surgery.⁶⁴ If this relationship between pain and functional recovery holds true for patients with dementia, they may be at particularly high risk if they are not able to express pain and thereby obtain optimal treatment for it.

Early Mobilization

Early mobilization is important for minimizing complications like venous thromboembolism, pneumonia, and pressure sores.⁶⁵ A delay in getting the patient out of bed leads to poor functional recovery and worse 6-month survival.^66,67 In a multivariate analysis, Barone et al evaluated patient characteristics and in-hospital factors that affect immediate weight bearing and early ambulation (IWB-EA) in 469 patients who had hip fracture repair. Neither cognitive impairment nor high comorbidity significantly affected patients' adherence to an IWB-EA protocol. The day of surgery, for example, preholiday or not, was the only variable influencing the patient’s adherence to the IWB-EA protocol and probably related to the reduction in available resources during the weekend and on holidays. This study suggests that IWB-EA is feasible in patients with dementia.⁶⁸

Individualized Treatment

The patient with hip fracture and dementia is part of a heterogeneous group in terms of severity of cognitive impairment, functional status, and burden of comorbidity. Generally accepted guidelines for prevention of functional decline and short-term clinical improvements are appropriate for most patients with dementia. In patients with severe dementia and limited life expectancy individualized care should reflect the preferences of patients, families, and physicians and their judgments about the burdens and benefits of treatment. Successful operative treatment may reduce pain and facilitate nursing care. On the other hand, marginal benefit from surgical repair may be gained by the patient with a stable fracture, immobility, and minimal or no pain. Clinical decisions for nonoperative care in this type of patient is made with little support from the literature. An extensive literature review has not revealed a paper describing patient characteristics that dictate conservative treatment in medically stable patients with dementia.

Post Hip Fracture Care

Appropriate post hip fracture management including rehabilitation and secondary prevention of osteoporosis and falls can ensure optimal recovery after hip fracture repair and prevent subsequent fractures. Following the first hip fracture, the rate of a second hip fracture in women increases 6-fold from 3.6 to 20 per 1000 person years and in men 9-fold from 1.6 to 15 per 1000 person years.⁶⁹ Patients with dementia are at increased risk of a second hip fracture. In a prospective study of 714 patients, the OR for a second hip fracture was 3.07 (95% CI 1.58-5.96) for those with dementia versus those without.⁷⁰ In another prospective study of 384 patients with dementia, the risk of a second hip fracture was 1.87 higher (95% CI 1.02-3.41) after 3 years of follow-up.⁷¹

Treatment of Osteoporosis

Despite the heightened importance of diagnosing and treating osteoporosis after hip fracture, the rate of osteoporosis treatment in all patients with previous fractures remains low.^72–76 In a study of 318 hospitals in the United States and 51 386 patients hospitalized for repair of a hip fracture, 6.6% of patients received calcium and vitamin D at any time after the procedure and 7.3% received an antiresorptive medication; however, only 2% were prescribed both.⁷⁷ In a large group of 10 279 patients with a previous hip fracture, the increase in the use of osteoporosis medication during the 6 months after the fracture compared with the 6 months before the fracture was small, averaging 3% during the study period from 1995 to 2000.⁷⁸ In an extension of that study looking at prescribing patterns from 1995 to 2004, new users of osteoporotic drugs 6 months after hip fracture increased from 4% in 1995 to 17% in 2002, without subsequent increase through 2004.⁷⁹ This very low percentage of new users of osteoporotic drugs after hip fractures is seen despite evidence that antiresorptive agents produce a 26% reduction in the rate of recurrent hip fractures,⁸⁰ and calcium and vitamin D3 have been shown to decrease the number of hip fractures by 43% when compared with placebo.⁸¹ Fracture patients who also have dementia are even less likely to be treated for osteoporosis compared with patients who are cognitively intact (OR 0.39, 95% CI 0.21-0.74).^82,83

Treatment with bisphosphonates is recommended as the standard of care for secondary prevention of fractures. Many reasons exist for low rates of osteoporosis treatment post hip fracture and may include lack of awareness of potential benefits of treatment among physicians and patients. Patients with cognitive impairment have additional factors that may discourage osteoporosis treatment. These include perceived risk of complications with other medications, lack of adherence with treatment, and shorter life expectancy.⁸⁴

Assessment and Treatment of Falls

Most hip fractures occur as a result of a fall and many patients will fall again after sustaining a hip fracture. Secondary prevention of hip fracture, therefore, must include an assessment of risk factors leading to falls. In a community-dwelling hip fracture cohort of 178 persons, 42% fell before the hip fracture and 20% were recurrent fallers. In the same cohort in the year after hip fracture, 56% fell at least once, 28% had recurrent falls, 30% were injured, 12% sustained a new fracture, and 5% sustained a new hip fracture.⁸⁵ Multivariate analyses identified older age, congestive heart failure, poorer quality of life and nutritional status, and factors associated with dementia, as independent risk factors for recurrent and injurious falls. In this study, every 10 nmol/L increase in serum vitamin D level was associated with an 87% decrease in both recurrent fall risk and all fall-related injuries risk, in agreement with evidence that vitamin D supplementation prevents falls and fractures.^25,27,86

In Sweden, a postoperative, multidisciplinary intervention program including assessment and treatment of fall risk factors successfully prevented inpatient falls and injuries during in-hospital rehabilitation, even in patients with dementia.⁸⁷ Twelve patients fell 18 times in the intervention group compared with 26 patients suffering 60 falls in the control group. Only 1 patient with dementia fell in the intervention group compared with 11 in the control group. The intervention included active prevention and treatments of delirium and pain, discontinuation of urinary catheter 24 hours postoperatively, screening for urinary retention, calcium and vitamin D supplementation when indicated, and nutritional and protein drinks provided daily. A subsequent study to evaluate whether the program described above had any continuing effect after discharge showed no statistically significant effect of the program after discharge.⁸⁸ The authors concluded that fall prevention must be part of routine inpatient care in fall-prone elderly individuals.

Falls risk factor reduction must be part of a comprehensive approach to secondary prevention of hip fractures. However, as is the case with dementia and falls in primary prevention, more studies are needed to identify fall prevention strategies that will be effective in cognitively impaired individuals who have sustained a hip fracture.

Dementia and Depression

Elderly hip fracture patients with both dementia and depression are at risk of death and functional decline from the additive effects of these 2 conditions. In a cohort of 211 patients with hip fracture, those with both depression and dementia had significantly lower 12-month survival compared with patients with dementia only. The hazard ratio for mortality was 8.7 (95% CI 1.5-48.5) versus 3.4 (95% CI 0.5-24.0) in patients with dementia only, after adjusting for age, other comorbidities, use of antidepressants, and functional status at discharge.⁸⁹ Givens et al showed that the stepwise addition of cognitive impairment, depressive symptoms, and delirium to a patient’s preexisting risk was associated with an increase in the odds of ADL decline, decline in ambulation, and nursing home admission or death.⁹⁰ Identification of depressive symptoms in demented hip fracture patients is important to provide adequate treatment if indicated and to inform clinicians, families, and caregivers of the need for follow-up and continuity of care after rehabilitation.

The US National Institute of Mental Health has developed criteria for the diagnosis of depression in individuals with Alzheimer disease.⁹¹ Depression is diagnosed by the presence of 3 or more symptoms that cause clinically significant distress or disruption in functioning during the same 2-week period. The symptoms must include either (1) a depressed mood or (2) decreased positive affect, as well as the following: social isolation or withdrawal; disruption in appetite; disruption in sleep; psychomotor changes; irritability; fatigue or loss of energy; feelings of worthlessness, hopelessness, excessive or inappropriate guilt; and recurrent thoughts of death; suicidal ideation, plan, or attempt. The symptoms should not occur in the context of delirium, be attributable to a medication, or be due to another medical condition such as schizophrenia or anxiety disorder.

Treatment with an antidepressant is well tolerated by elderly people and can be as effective as in younger adults.^92–95 Practice guidelines issued in 2007 by the Work Group on Alzheimer’s Disease and Other Dementias of the American Psychiatric Association currently support selective serotonin reuptake inhibitors (SSRIs) as the first pharmacological treatment of choice for depression in dementia, since SSRIs tend to be better tolerated than other antidepressants.⁹⁶ The initial dose should be low, but the final dose should be similar to those used in young adults. If the patient cannot tolerate higher therapeutic doses, trials of alternative antidepressants such as bupropion, venlafaxine, and mirtazipine may be considered.⁹⁶

Rehabilitation

Although dementia may be a main contributor to functional dependence in community-dwelling elders, existing evidence suggests that patients with mild-to-moderate dementia benefit from rehabilitation and are often able to return to the community. An RCT compared outcomes of intensive geriatric rehabilitation versus rehabilitation at usual care hospitals in 248 independently living patients with hip fractures. The highlights of the program included common rehabilitation interventions such as providing advice, training, and encouragement and listening to patients' concerns as well as drug treatment, physiotherapy twice daily, and occupational therapy. All patients who were discharged to independent living had 10 home visits from the physiotherapists.

In this study, the median hospital stay of patients with mild dementia (MMSE score 18-23) was 29 days in the intervention group and 46 days in the control group.⁹⁷ In addition, 91% in the intervention group were living independently at 3 months compared with 67% in the control group (P = .009). The median length of hospital stay of the patients with moderate dementia (MMSE score 12-17) was 47 days in the intervention group and 147 days in the control group (P = .04). In addition, 63% of patients with moderate dementia were living independently at 3 months compared to 17% in the control group (P = .009). There were no significant differences in the lengths of hospital stay of patients with severe dementia (MMSE 0-11) and patients with normal MMSE scores. These results are comparable with the results of a prospective longitudinal study in a specialized geriatric rehabilitation program.⁹⁸

Not surprisingly, severe cognitive impairment predicts less successful return to independent living, but it is encouraging that patients with mild-to-moderate impairment are able to benefit from intensive postfracture geriatric rehabilitation and avoid nursing home placement. After a recent systematic review of the literature, Muir and Yohannes concluded that there is some evidence that patients with cognitive impairment who receive intensive inpatient rehabilitation after surgical repair of a hip fracture may be able to obtain physical function benefits that are comparable with cognitively intact patients.⁹⁹ Hospital rehabilitation or acute rehabilitation is not typical in the United States, where subacute rehabilitation is more common.

Conclusions

Patients with dementia are at very high risk of hip fractures in part because of their prevalence of vitamin D deficiency, osteoporosis, and falls. Current clinical practice regarding identification and treatment of vitamin D and osteoporosis in patients with dementia both before and after a hip fracture is not optimal, despite substantial evidence supporting the treatment of osteoporosis in this group. Risk factors for falls in patients with dementia need to be better defined so that randomized controlled interventions can be designed. Limited but good evidence has shown that interventions in frail patients with dementia targeting risk factors that have been identified in cognitively intact patients do not reduce fall risk in patients with dementia. Patients with mild dementia may benefit more from falls intervention than individuals with severe dementia.

Acute management of hip fracture patients that incorporates orthogeriatric comanagement and evidence-based protocol-driven care has been shown to decrease mortality, length of stay, complications, and readmission in all patients including those with dementia. Intensive geriatric rehabilitation versus usual care in patients with mild-to-moderate dementia results in a greater likelihood of patients returning to their previous residence and avoiding nursing home admission. A better understanding of the barriers to optimal primary and secondary prevention of hip fractures and subsequent education of providers and patients on those barriers can impact the burden of hip fracture mortality and morbidity in patients with dementia.