FACTORS AFFECTING CARE OUTCOME IN OLDER PERSONS WITH HIP FRACTURES Rasa Valavičienė LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

Rasa Valavičienė

FACTORS AFFECTING CARE

OUTCOME IN OLDER PERSONS

WITH HIP FRACTURES

Doctoral dissertation Biomedical Sciences,

Nursing (10 B)

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Doctoral dissertation was prepared in the Department of Geriatrics of Lithuanian University of Health Sciences in 2007–2011.

Scientific Supervisor

Prof. Dr. Jūratė Macijauskienė (Lithuanian University of Health Sciences, Medical Academy, Biomedical Sciences, Nursing – 10 B). Consultants:

Assoc. Prof. Dr. Ami Hommel (Lund University, Sweden, Biomedical Sciences, Nursing – 10 B)

Prof. Dr. Alfredas Smailys (Lithuanian University of Health Sciences, Medical Academy, Biomedical Sciences, Medicine – 06 B)

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LIETUVOS SVEIKATOS MOKSLŲ UNIVERSITETAS

MEDICINOS AKADEMIJA

Rasa Valavičienė

VEIKSNIAI, DARANTYS ĮTAKĄ

VYRESNIO AMŢIAUS ŢMONIŲ,

PATYRUSIŲ ŠLAUNIKAULIO

KAKLO LŪŢĮ, GYDYMO

REZULTATAMS

Daktaro disertacija Biomedicinos mokslai, slauga (10 B) Kaunas, 2011

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Disertacija rengta 2007–2011 metais Lietuvos sveikatos mokslų universiteto Medicinos Akademijos Geriatrijos klinikoje.

Mokslinis vadovas

prof. dr. Jūratė Macijauskienė (Lietuvos sveikatos mokslų universitetas, Medicinos akademija, biomedicinos mokslai, slauga – 10 B)

Konsultantai:

doc. dr. Ami Hommel (Lundo universitetas (Švedija), biomedicinos mokslai, slauga –10 B)

prof. dr. Alfredas Smailys (Lietuvos sveikatos mokslų universitetas, Medicinos akademija, biomedicinos mokslai, medicina – 06 B)

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2.1 Registration of changes in the dynamics of patient functional outcomes and health-related quality of life results at 4 months and 1 year after the femoral neck fracture ...44 2.1.1 Data registration during the preoperative period ...44 2.1.2 Data registration during the postoperative period ...47 2.1.3. Patient data registration at 4-months follow-up after femoral neck fracture ...49 2.1.4 Patient data registration at the 1-year follow up after the femoral neck fracture ...51 2.2 Comparison of hip fracture patient care between Kaunas Clinics and Lund University Hospital ...51 2.3 Comparison of femoral neck fracture patients’ functional outcome and health-related quality of life in Kaunas Clinics and Lund University Hospital ..53 2.4 Statistical data analysis ...54 3. RESULTS ...55 3.1 Patients’ hip joint functioning and health-related quality of life after femoral neck fracture (first study) ...55

3.1.1 Patient characteristics and baseline data...55 3.1.2 Hip joint functioning and health-related quality of life results at the 4-month follow-up ...58 3.1.3 Changes in the dynamics of hip joint functioning and health-related quality of life at the 1-year follow up after the fracture ...62 3.2. Differences in patient care between Kaunas Clinics and Lund University Hospital (second study) ...68 3.3 Comparison of femoral neck fracture patient outcomes in Kaunas Clinics and Lund University Hospital (third study) ...71 3.3.1. A comparison of the results of the Hip fracture register forms in Kaunas Clinics and Lund University Hospital...73 3.3.2 The EQ-5D questionnaire results at the 4-month follow up in Kaunas Clinics and Lund University Hospital...75 4. DISCUSSION ...81 CONCLUSIONS ...96

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PRACTICAL AND SCIENTIFIC RECOMMENDATIONS ... 97

REFERENCES ... 98

LIST OF PUBLICATIONS ... 117

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ABBREVIATIONS

A&E – Admission and Emergency department ADL – Activities of Daily Living

ASA – American Society of Anaesthesiologists BMI – Body Mass Index

CI – Confidence Interval

EPUAP – European Pressure Ulcers Advisory Panel EQ-5D – The 5 Dimension Scale of the Euro-QoL FNF – Femoral Neck Fracture

HRQL – Health-related Quality of Life ICP– Interventional Care Pathway IF – Internal Fixation

LOS – Length of Stay

LUH – Lund University Hospital

MMSE – Mini Mental State Examination MNA – Mini Nutritional Assessment NHP – Nottingham Health Profile OHS – Oxford Hip Score

OR – Odds Ratio

p – Level of Significance PU – Pressure Ulcers QoL – Quality of Life

RCT – Randomized Controlled Trials

SAHFE – Standardized Audit of Hip Fracture in Europe SD – Standard Deviation

THA – Total Hip Arthroplasty VAS – Visual Analogue Scale

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INTRODUCTION

Hip fractures constitute a serious and common health problem among older adults from both individual and public health perspectives. The estimated risk of sustaining a femoral neck fracture (FNF) at 80 years of age is 20%, although at 90 years of age the risk increases up to 50% [47]. In 1990, 1.7 million FNFs occurred worldwide, and this number might increase up to 6.3 million FNFs per year by 2050 [53,113]. Patients with FNFs constitute an increasing health care problem; furthermore, FNFs affect patients’ daily living due to the trauma and reduced self-care abilities, and they increase the rate of mortality [213]. The treatment of these patients is associated with increasing costs due to complicated in-hospital treatments and the subsequent rehabilitation and nursing during the first year after the trauma. It is most important that the available resources are effectively used and that high quality care is provided.

A prospective systematic audit and a national register have been sugges-ted as being one of the best approaches for measuring and improving outcomes in FNFs’ [74,202]. The value of a register is in providing more accurate information about complications, risk factors and mortality, which help to improve hip fracture treatment and care [100]. Hip fracture registers ensure a unified system of registration, which is necessary for further comparisons of the data between different countries. Most hip fracture registers collect a standard dataset: data on the process and outcome during a patient’s acute stay, at 120 days after acute admission, and on any re-operations carried out within 4 months or an even longer follow-up period. Outcomes are divided into process outcomes, such as hospital stay, delays in surgery, re-operations and complications, and the more important final outcome measures, such as mortality, residual pain and the level of functioning regained.

Neither a detailed audit of patients with a hip fracture nor further analyses of the data have previously been undertaken in Lithuania. The State Patients Fund only collects data on the personal details, diagnosis, and types of treatment of patients. This information is insufficient for systematic analyses of the outcome of patients and the factors that affect it. Thus, the lack of knowledge about the outcomes of hip fracture patients and a dearth of existing research projects on the subject in Lithuania led to a prospective study of patients with hip fractures based on the Swedish National Hip Fracture register approach.

Hospitals in several countries have adopted well-defined hip fracture care pathways for patients [43,48,75]. The aim of the introduction and use of

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care pathways in daily practice is to create a standardized delivery of health care and clinical management of patients in hospitals. This includes a detailed description of procedures and strategies for the care and management of femoral neck fracture patients from their arrival in the hospital until discharge. The majority of care pathways in this patient group are focused on fast-track schemes for admission and further surgery [75,99,174].

Lund University Hospital (LUH) in Sweden was one of the first hospitals in Europe where a hip fracture care pathway scheme was introduced (in 2003) and further developed [101]. In April 2007, “fast tracking” was introduced, where patients are directly admitted to the orthopaedic ward via the X-ray unit without attending the emergency department. The ample experience in hip fracture care at LUH was a determining factor in deciding to compare the care of hip fracture patients in Lithuania to that in Lund. Such a comparison aimed to identify the differences in care of hip fracture patient between the Lithuanian University of Health Sciences Hospital Kaunas Clinics (further – Kaunas Clinics; KC) and LUH. Thus, the effects and value of care pathways at LUH were compared to the care in Lithuania, where no care pathways for hip fracture patients have yet been introduced. Identifying differences in care are importance for developing hip fracture care algorithms in Lithuania.

Treatment methods and the care of patients with FNFs vary in different countries; such models are usually developed within the context of local cultures and health-care systems, therefore models that function well in one country will not necessarily provide the same results in another. Thus, the direct application of a treatment and care model from another country without an audit and outcome analysis may not be beneficial for the reasons described above.

At the moment, Lithuania does not have well-standardized schemes for the treatment of patients with FNFs. The lack of prospective studies investi-gating the outcomes of these patients impedes the introduction of effective models into clinical practice. A standardized prospective comparison has been efficient, and the results might change the treatment and care policies and provide more knowledge on the subject [46]. Thus, a comparison of patients with FNFs in Kaunas Clinics and LUH was performed regarding their care and outcome.

Aim of the research project – to estimate the factors affecting the outcome of patients with FNFs treated in Lithuania and Sweden and to audit patient care, assessing its importance regarding the outcome results.

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11 Tasks of the research project:

1. To identify factors affecting the functional outcome and quality of life in femoral neck fracture patients at the 4-month follow up.

2. To estimate the changes in functional outcome and quality of life in femoral neck fracture patients at 4 months and 1 year of follow up.

3. To compare the care of hip fracture patients in Kaunas Clinics and Lund University hospital and to identify differences in patient transportation and preoperative and postoperative time periods.

4. To compare the functional outcome and quality of life in femoral neck fracture patients treated in Kaunas Clinics and Lund University Hospital.

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Actuality, originality and practical value of the study

To the best of our knowledge, this is the first study in Lithuania to investigate the outcome and quality of life (QoL) of FNF patients according to the Hip Fracture Register model. The lack of prospective studies in the country has resulted in a shortage of reliably defined treatment methods, care models and nursing algorithms in this patient group. Thus, a prospec-tive and precise analysis including a 4-month and 1-year follow up was deemed important for providing knowledge and determining problems in the care of patients with FNFs. Despite the relatively low number of patients compared to those reported from national registers, our findings are important as they are the results of the first FNF audit study in the country.

No care pathways have been introduced for patients with FNFs in Lithuania. To the best of our knowledge, no audit studies investigating the care of these patients have been conducted in Lithuania either. A detailed analysis of the different aspects of care and a comparison with other coun-tries more experienced in hip fracture care would be beneficial for identifying the changes that need to be implemented in order to improve patient outcome after treatment.

Comparisons of patient outcomes between countries have been reported to be of great value in terms of identifying differences that could ultimately lead to further improvements in care [202,211]. We could not find any reports in the literature that used the same method to compare the outcome results of FNF patients in Lithuania with other countries. Using the same method in investigations of patients in Lithuania and Sweden has resulted in a more accurate dataset for comparison, thus providing more reliable results that can be used to create guidelines for the care of femoral neck fracture patients.

After we summarize our findings practical recommendations regarding the care and risk factors affecting patient outcomes will be provided to health-care providers. The knowledge of risk factors affecting patient outcomes will help in the creation of treatment and care guidelines that will help prevent undesirable events and complications and improve functional outcomes and QoL.

Our audit analysis and outcome results will create the prerequisite for the development of integrated care pathways for the treatment of femoral neck fracture patients in Lithuania. The implementation of care pathways and the subsequent detailed analyses will further improve care and thus the outcome of patients with femoral neck fractures.

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Our work demonstrates the value of research and audit studies and the importance of guidelines for the introduction of new treatment and care methods in countries where no detailed analyses or care pathways exist for FNF patients.

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1. LITERATURE REVIEW

1.1. Epidemiology of hip fracture

Hip fracture incidence and trends in the world. The incidence of hip fracture increases with age [148]. The estimated risk of sustaining a femoral neck fracture in women aged 80 years of age is 20%, although at 90 years of age the risk increases up to 50% [223]. The peak number of hip fractures occurs at 75 – 79 years of age for both sexes [112]. Nearly 75% of all hip fractures occur in women and about 25% occur in men for the population over 50 years of age [114,45,130131].

During the last century the incidence of hip fractures increased. Between 1990 and 2000 the incidence of hip fractures worldwide increased by almost 25% [112]. Approximately 1.6 million hip fractures occur worldwide each year and studies have shown that this number could reach between 4.5 million [81] and 6.3 million [53,113] by the year 2050.

Geographic and ethnic variations have been found in the incidence of hip fractures (Table 1.1.1). The highest hip fractures rates are seen in the United States. In Europe, the rate of incidence varies from northern to southern Europe, with the highest rates being in Sweden, Norway, Iceland and Denmark, with the lowest in France and Switzerland [54,94,111,118,130]. The incidence of hip fractures in Asia has also increased over recent years [149]. It is projected that more than 50% of all osteoporotic hip fractures worldwide will occur in Asia by the year 2050 because of a longer life expectancy and changes in the population [45,54,81,112]. The reasons for these geographic and ethnic variations in hip fracture distribution are hardly understood; however, genetic factors and environmental factors have been suggested as being responsible.

Some recent studies reported a decrease in hip fracture incidence in Europe and the USA [120,131,160]. A decrease in hip fracture incidence was also found for women but not for men [41,136]. The exact reasons and factors primarily responsible for the observed reduction in hip fractures in the population are still unknown and additional research is required to analyse this subject.

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Table 1.1.1. Age-standardized hip fracture rates (per 100,000) across

different countries

Continent Country Men Women

North America USA, Minnesota state 201.6 511.5

United States 197.2 553.5

Europe England 143.6 418.2

Sweden 302.7 709.5

Norway 352 763.6

Oceania New Zealand 197 516

Australia 187.8 504.2

South America Mexico 98 169

Argentina 137 405

Africa Cameroon 43.7 52.1

Asia China, Beijing 87 97

Iran 127.3 164.6

Japan 99.6 368

Kuwait 216.6 316

Singapore 152 402

Hong Kong 193 484.3

Source: Dhanwal DK, Cooper C, Dennison EM. Geographic Variation in Osteoporotic Hip Fracture Incidence: The Growing Importance of Asian Influences in Coming Decades. J Osteoporos. 2010 (23).

Ageing and the incidence of hip fracture in Lithuania. Population ageing is one of the major issues being observed in Lithuania, similar to the situation in other European countries. Over the past 20 years in Lithuania the population has decreased due to high emigration and low birth rates. In 2009, there were 3339.4 thousand inhabitants in Lithuania, i.e. 18.7 thou-sand less than in 2008 [135]. The population aged over 60 years has increased from 668.3 thousand in 2000 to 690.8 thousand in 2008, despite a decrease in the total population in the country. The proportion of elderly people in the population increased during last decade. At the beginning of 2010, 20.9% of the population in Lithuania was aged 60 and older compared to 19% in 2000 [135].

There is a lack of long-term epidemiological data regarding patients with hip fractures in Lithuania. We only found one publication [127] that described, from an epidemiological point of view, patients with osteoporotic fractures treated in Kaunas Red Cross Hospital from 1991 to 1993. In this report the authors studied patients over 65 years of age who sustained Colles’ hip or vertebral fractures and were treated at this institution, which served the entire Kaunas Region at the time. The rate of fracture was calcu-lated per 1000 inhabitants over 65 and compared between 1991 and 1993.

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The authors noticed an increase in the hip fracture rate, which was 1.60/1000 for men and 3.09/1000 for women in 1991 and 4.70/1000 for men and 6.76/1000 for women in 1993. The authors described the importance of falls in relation to the fracture rate and reported an increase in the hip fracture rate of double for women and 2.9 times for men. A relationship between hip fracture incidence and the winter season was observed.

Although we could not find any more epidemiological reports in the lite-rature, some data were collected by the Lithuanian State Patients Fund, including personal information, the diagnosis and type of treatment method used in each particular case. Data about fractures have also been collected by the National Health Insurance Fund since 1999 and, similar to the previous epidemiological report, the tendency of a growing number of hip fractures in Lithuania can be observed. The epidemiological data regarding hip fractures in Lithuania from the State Patients Fund is presented in Table 1.1.2.

Table 1.1.2. Number of hip fractures in Lithuania in 2000-2009

Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Number of hip fractures 2780 3343 3614 3831 4031 4513 4668 4540 5032 5334 Mean age 66 65 64 65 63 64 63 64 65 65 Number of femoral neck fractures 1497 1663 1939 2148 2246 2421 2417 2280 2586 2783 Mean age 66 64 64 64 63 64 63 64 64 65

The increasing number of hip fractures in the population represents a growing problem for the health-care system, thus additional studies aimed at optimizing the care of these patients in Lithuania are required.

1.2. Femoral neck fracture classification

Hip fracture is a general description of several different types of proximal part femur fractures. There are two main types of hip fracture based on the anatomical location of the fracture line; the fracture is either located in the femoral neck (cervical or femoral neck fracture) or through or around the proximal femur in the region of the trochanter (intertrochanteric and subtrochanteric). The number of these types of fractures is about the same, although there is a slight predominance of cervical fractures (53 – 60%) [183,200].

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There are several classifications of femoral neck fracture: Arbeitsgemeinschaft für Osteosynthesefragen (AO), which is by the anatomical place of fracture [188]; Pauwels, based on the verticality of the fracture line [170]; and the Garden classification [73], which depends on the degree of displacement on frontal radiography. The Pauwels and AO classifications have little clinical relevance [30,200]. Cervical fractures are most commonly classified according to Garden. Garden I is an incomplete FNF fracture; itmay be impacted and in a valgus position. Garden II – com-plete FNF without displacement. Garden III – comcom-plete with partial displacement; bone fragments are still connected by a posterior retinacular attachment. Garden IV – complete FNF with full displacement (Figure 1.2.1, X-ray pictures from personal archive of the authors).

Figure 1.2.1. Femoral neck fracture classification according Garden Garden I

Garden II

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It is sometimes difficult to distinguish between Garden I and Garden II frac-tures, and Garden III and Garden IV fractures [68]. Because of this, classification into two groups is recommended: undisplaced fractures or minor dislocation (Garden I, Garden II) and displaced fractures (Garden III, Garden IV) [157,161]. About two-thirds of all femoral neck fractures are displaced [72,200].

In our study we used the Garden classification for hip fractures.

1.3. Treatment methods for femoral neck fracture

Patients with femoral neck fractures are treated operatively with either osteosynthesis or hip replacement. Conservative treatment is now rarely used because of a poor outcome and prolonged hospital stay [169]. There are no discussions about undisplaced femoral neck fracture treatment: they should be treated by internal fixation [25]. Internal fixation (IF) is also preferred in patients who are younger than 60 years age. However, the treatment of displaced femoral neck fractures in the elderly has been debated [21,22,103,177]: there are no well-defined algorithms in the literature regarding the treatment method that should be used for this patient group. Osteosynthesis is a less invasive form of surgery and is associated with a lower rate of postoperative mortality, lower blood loss and a lower infection rate compared to arthroplasty [21,141]. The latest meta-analyses [21,183] comparing arthroplasty with IF for displaced femoral neck fracture treatment in the elderly provide recommendations supported by well-defined scientific evidence.

A Cochrane review (2003) comparing IF and arthroplasty found no definite differences in pain or residual disability but confirmed an increased risk of re-operation on the hip after IF [171].

Another study by Rogmark and Johnell (2006) [183] investigated 14 randomized controlled trials (RCT) with a total of 2289 patients over 60 years of age treated between 1966 and 2004 comparing IF with arthroplasty. In all of the studies included, except one, the patients were followed for 2 years or longer to collect data on the complications, functional outcome, pain and mortality related to the surgical method. The authors reported that regardless of the type of IF the bone consolidation failure rate was 21– 57%, and re-operations were performed in 14 – 53% of all the cases. However, in nine studies where the patients were treated with total hip arthroplasty (THA) the failure rate was 4 – 11% and the re-operation rate was 2 – 8%. The corresponding numbers for hemiarthroplasty were 3 – 23% and 0 – 24%, respectively. In this meta-analysis the odds ratio (OR) for both major

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method-related complications and re-operations for primary arthroplasty versus osteosynthesis was 0.11 – 0.12, indicating that primary arthroplasty was the superior treatment method in these patients. Most of the RCTs found less pain and better functioning after cemented arthroplasty, particularly THA, compared to the outcome after IF. In summarizing this meta-analysis, which compared hip replacement with IF in displaced femoral neck fractures, it was clearly shown that there is an advantage to performing hip replacements. One concern was increased mortality in patients treated with total hip replacement [183]. After 30 days there was an OR of 1.30, but no significant difference in the mortality rate. After 1 year, the mortality rate was the same in patients who were treated with either IF or with total hip replacement.

Similarly to Rogmark and Johnell, Dai et al. [49] analysed 19 RCTs involving a total of 3505 patients from 1996 to 2000. Their results were similar to those of previous studies and they concluded that, compared with internal fixation, arthroplasty can not only reduce the re-operation rate, but it can also decrease the incidence of complications without increasing mortality.

In summary we can state that evidence shows a better outcome when arthroplasty is chosen as the primary treatment method for displaced FNFs in the elderly. For a healthy, independent, cognitively intact 70 to 80-year-old individual there is evidence-based data supporting the use of a primary THA. Internal fixation for the treatment of femoral neck fractures could be used in undisplaced fractures or for younger patients.

1.4. Instruments for measuring the outcome of femoral neck fracture patients

One of the primary objectives of the health-care system is to have older adults recover from hip fracture and regain functional independence or pre-fracture status [201]. However, researchers who investigated functional outcomes after hip fractures have reported that 25 – 75% of patients will never reach their pre-fracture status [42,142,173,220].

Recovery after trauma is a complex issue. Reports from the scientific literature suggest that recovery has a predominant functional restorative focus, although the outcome of recovery is also influenced by physical functioning and psychosocial factors; the authors suggest a wide scope of analysis for factors influencing recovery [91]. Healee et al. (2011) suggested a scheme for a more detailed analysis of patient outcome after femoral neck fracture [91]. Three main components for outcome analysis

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were suggested: functional outcome recovery from a professional point of view, a quality of life evaluation and an analysis of complications mainly related to ageing. A graphical representation of the approaches suggested for the evaluation of patients with femoral neck fractures is presented in Figure 1.4.1.

Figure 1.4.1. The components of analysis of patients’ outcomes after

hip fracture surgery

Source: Healee DJ, McCallin A, Jones M. Older adult’s recovery from hip fracture: A literature review. International Journal of Orthopaedic and Trauma Nursing. 2011,15(1):18-28 [91].

It is obvious that each of these components is important and requires special attention when a detailed outcome analysis is performed for this patient group.

1.4.1. Functional outcome measurement methods

Functional recovery outcome measures in studies evaluating FNF patients generally include their mobility, activities of daily living, levels of dependence, walking ability and self-care ability compared to their pre-fracture status or changes in outcome during the last few years. However, there is an increasing need for sensitive and reproducible outcome measurement after hip surgery. We could not find any instruments dedicated to evaluating hip function outcomes after FNF in the literature. Researchers use general hip function measurement methods to analyse hip function outcomes after trauma.

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The following questionnaires are most frequently used for functional outcome analysis in patients after FNF:

 Oxford Hip Score (OHS) [51]: developed in 1996, this is a joint specific patient-centred outcome measure;

 Harris Hip Score (HHS) [90,189]: developed in 1969, this is used to assess outcomes following total hip arthroplasty;

 The Western Ontario and McMaster University Osteoarthritis Index (WOMAC) [18]: this is a self-administered disease-specific health status measure for osteoarthritis of the hip or knee; it has been validated for osteoarthritis in the lower extremities and for evaluating outcomes after total hip replacement;

 Charnley score [40]: was devised in 1972 to be used for assessments performed by surgeons.

The main questionnaires for these outcome measurements and their strengths and weaknesses are presented in Table 1.4.1.1.

The one of newest instruments that has recently been reported in the literature for evaluating functional and health-related quality of life (HRQL) in patients with hip osteoarthritis or another disability is the Hip Disability and Osteoarthritis Outcome Score (HOOS) [158]. This is a simple self-administered instrument developed as an extension of the WOMAC [123]. The HOOS includes five subscales: pain, other symptoms, activities of daily living (ADL), sport and recreation (SP) and hip-related quality of life. The original version of the HOOS was shown to be valid, reliable and responsive in hip OA patients and is considered useful for evaluating patient-relevant outcomes and for evaluating patients after surgery [123,158]. The HOOS questionnaire was also validated and used in a Lithuanian population [198]. Good responsiveness and reliability of the HOOS and a validation for the Lithuanian language were the main reasons for deciding to use this particular questionnaire in our study.

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Table 1.4.1.1. The strengths and weaknesses of measuring

instruments for outcome evaluation in patients with femoral neck fractures

Scoring system

Categories Score Strength Weaknesses

Charnley [40]

Pain Mobility Abilit y to walk Not cumulati-ve (0-6) Simple reproducible easy to use Clinical bias Harris Hip Score [90] Pain (0–44) Function (0–47) Level of activit y (0–9) Cumula-tive (0–100) Less sensitive to a patient's subjective bias Age/health not accounted for clinician bias Oxford Hip Score [51] 12 questions pain & functional ability (each 0– 4) Cumulati ve (0–48) Easy to use independent of clinicians, consistent, reproducible Pain questions ambiguous co-morbidities not accounted WOMAC [18]

24 questions: pain (5), stiffness (2) physical function (17). Each rated 0 (extreme) to 4 (none) Cumula-tive 0 (worst) to 100 (best) Valid, reliable Statistician needed Influenced by factors other than lower extre-mity disease Source: Ahmad MA, Xypnitos FN, Giannoudis PV. Measuring hip outcomes: common scales and checklists. Injury. 2011; 42(3):259-264 [2].

Recognizing the importance of being able to compare the results between different studies, a unified scoring system for outcome evaluation in patients with femoral neck fractures would be an advantage.

1.4.2. Quality of life questionnaires for the evaluation of femoral neck fracture patients

Recovery from hip fracture is affected by more than just physical changes and functioning of the hip. An increasing number of reports in the literature state that quality of life measures should be used more often to evaluate health-care interventions [206].

“Quality of life is defined as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standard and concerns. It is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, and their

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relationship to salient features of their environment” [196]. However, we also have to recognize that it is sometimes difficult to use quality of life questionnaires for older people because of the changes in their cognitive functioning, as reported by Boonen (2004), who, in his study, reported that only 51% of the patients included, who were considerably younger, had a significantly lower level of cognitive impairment and better functional status and were able to complete the SF-36 questionnaire upon discharge and after 1 year [31]. Special questionnaires are available for patients with cognitive impairment in order to evaluate their QoL.

Quality of life is a “health status” [212] that is measured in three dimensions: functionally, psychologically and in terms of social health. A quality of life assessment can display the impact of an injury on other areas of life from the patient’s perspective.

There are no disease- or population-specific measures or well-defined recommendations for evaluating patient quality of life after FNF. The most commonly used measures for quality of life in patients with FNFs are the Short Form-36 (SF-36) [218,219], the Nottingham Health Profile (NHP) [106] and the EuroQol (EQ-5D) [35]. Although all these questionnaires evaluate patient quality of life, there are certain differences between them.

Van Balen et al. observed 208 elderly hip fracture patients over a 4 month follow-up period after hospitalization. The NHP was used to evaluate patient health-related quality of life (HRQL). The author reported that the NHP was an excellent instrument that covered a wider range of psychological health dimensions (emotion, pain, energy and sleep), although it did not perform well in assessing social functioning [212].

The EQ-5D questionnaire is shorter and simpler compared to the SF-36 and the NHP, but it can reproduce a similar responsiveness compared to the others. Tidmark et al. [203] evaluated the responsiveness of the EQ-5D and Short Form-36 (SF-36) instruments regarding their ability to capture clinically important changes in 110 elderly patients with a displaced FNF and the absence of severe cognitive dysfunction. The scores showed good agreement with those of age-matched Swedish reference populations. The results showed high responsiveness for both the EQ-5D and the SF-36, and the authors concluded that both instruments are suitable for use as outcome measures in elderly hip fracture patients.

In other study Tidermark et al. (2002) investigated the functional outcome and HRQL according to EQ-5D after a femoral neck fracture in patients 65 years of age without severe cognitive dysfunction, who, preoperatively, had lived independently and walked unaided. The questionnaire response rate was 89 – 100%. The authors concluded that the

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EQ-5D is an easy-to-use instrument for evaluating outcome, even for elderly patients with FNF [206].

The same author, in a subsequent study (2007), evaluated the internal and external responsiveness and overlap of changes in scores of the EQ-5D and the NHP, investigating 60 patients with FNF treated with IF. The main finding of this study was that both the EQ-5D and the NHP showed good internal responsiveness in elderly hip fracture patients, as expressed by the high and significant change in scores and the large standardized response mean among patients with displaced fractures. When both instruments were used simultaneously, it was found that the EQ-5D alone was almost as effective as the combination of both instruments. The response rate for both instruments was 98% for both assessments. This high figure indicates that both questionnaires are easy to complete. The authors preferred to use the EQ-5D on the global health status evaluation because of its better responsiveness compared to more comprehensive instruments, such as the NHP and the SF-36 [204].

The EQ-5D can also be used in health economic evaluations [204]. The EQ-5D was found to be useful in those with cognitive failure, with the possible exception of the visual analogue scale of EQ-5D [71].

Based on this information, we used the EQ-5D questionnaire to evaluate the HRQL, which was validated for the Lithuanian language by questionnaire’s authors.

Traditionally the end results of joint replacement were based on morbidity/mortality rates and operative complications. Studies on hip fracture recovery should ensure that patient satisfaction is also analysed. In a literature review, Healee et al. concluded that this knowledge has the potential to improve recovery outcomes for the older adult, update clinicians’ knowledge and improve the continuum of care for people with hip fracture through on-going research [91].

The modern approach to outcomes following orthopaedic surgery changed from the success or failure of implants to patient satisfaction and the quality of life achieved, as was the case in our study. The currently available outcome measures all have limitations and do not individually fulfil these requirements, thus a combination (functional status and quality of life) of health outcome measures are used.

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1.5. Factors affecting the outcome of femoral neck fracture patients

Many studies have attempted to determine potential outcome predictors in hip fracture patients and to distinguish the most important ones. Evidence-based changes are made in surgical techniques, perioperative management and functional rehabilitation programmes with the aim of improving quality of care, recovery outcomes and patient satisfaction. However, there is a wide spectrum of complications that influence the outcome of these patients.

1.5.1. Impact of implant type and dislocation on quality of life of patients with femoral neck fractures

Up until now there have been no well-defined indications in the literature regarding the type of treatment that should be used in FNF patients. We previously mentioned that there is evidence to show better functional outcomes when arthroplasty is chosen as the primary treatment for displaced FNFs in the elderly. Similar results were observed when evaluating HRQL in FNF patients treated with either IF or total hip replacement. The methods of treatment and their relationship to HRQL are shown in Table 1.5.1.1.

Table 1.5.1.1. The health related quality of life of patients with hip

fracture depending on method of surgery

Author Year Treatment methods,

number of patients Quality of life questionnaire The difference of HRQL R. Blomfeldt [27] 2007 Bipolar hip replacement, n=60 Total hip replacement, n=60

EQ-5D Difference non significant F.Frihagen [71] 2007 Osteosynthesis, n=112 Bipolar hip replacement, n=110 EQ-5D HRQL improvement after hip replacement, p=0.03 R. Blomfeldt [28] 2005 Osteosynthesis, n=53 Total hip replacement, n=49 EQ-5D HRQL improvement after hip replacement, p<0.005 R. Blomfeldt [29] 2005 Osteosynthesis, n=30 Unipolar hip replacement, n=30 EQ-5D HRQL improvement after osteosynthesis, p<0.001

F.J Raia [179] 2003 Unipolar hip replacement, n=60 Bipolar hip replacement, n=55

SF-36 Difference non significant

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In summary, in the literature, we found data indicating that hip replacement (independent of the method used) assures a better HRQL compared to IF. Dislocation of the prosthesis remains a significant clinical problem. There are very few reports on its influence on functioning and HRQL in patients with femoral neck fracture. Enocson and colleagues investigated 319 consecutive patients with displaced femoral neck fractures who were treated with a primary arthroplasty to evaluate factors affecting outcome during the first 12 months following surgery [62]. A recurrent dislocation of the hip prosthesis in patients with femoral neck fractures resulted in persistent deterioration in HRQL, while patients with a single dislocation only experienced a temporary deterioration.

1.5.2. Impact of dementia and delirium on the outcome of patients with femoral neck fracture

Incidence of dementia and delirium and risk factors. A high proportion of older in-patients have dementia syndrome. The occurrence of dementia varies from 2.8% to 63% [155]. Dementia is common among older adults with hip fractures. The estimated prevalence of dementia in patients with hip fractures was 19.2% [186]. People with dementia need special care in hospitals and additional financial and human resources [110]. The pre-valence of dementia and delirium increases with age [110].

There are a few clinical subtypes of delirium: hyperactive (agitation, confusion, mood lability, psychotic symptoms), hypoactive delirium (lethar-gy, apathy and confusion), mixed (features of both increased and decreased psychomotor activity) and unclassified (psychomotor activity is normal) and its onset can occur at any time from a few days to a few weeks following surgery [185].

Delirium is common in elderly patients after cardio surgery and orthopaedic surgery [185]. Postoperative delirium has been reported to be a common complication after femoral neck fractures, affecting from 4% to 60% of patients [36,56,185], whereas in elective THA the incidence was reported to be 3.6 – 28.3% [36].Cognitive impairment, indoor injury, fever, and longer time from admission to surgery were reported as significant risk factors for preoperative delirium in patients with FNF [115]. Similarly, cognitive impairment, indoor injury, and a body mass index (BMI) of less than 20 were found to be significant risk factors for postoperative delirium [115]. This is in contrast to the results of Bitsch et al., who reviewed 12

studies and reported that only older age and dementia showed strong associations with perioperative delirium [24]. The authors also concluded

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that further research studies are required to determine the definitive factors that significantly affect the development of delirium in femoral neck fracture patients.

Demographic characteristics such as old age, male gender, dementia, cognitive impairment, history of delirium, functional dependence, immobility, visual and hearing impairment, dehydration, malnutrition, seve-re illness, fractuseve-re or trauma and the use of psychoactive or many drugs aseve-re reported to be predisposing factors for delirium [110]. Also, many factors precipitate the development of delirium, i.e. psychological stress, fatigue, immobilization, sleep, sensory deprivation or sensory overload, electrolyte imbalance, medications such as opioids, sedative hypnotics and anticholinergics, metabolic disturbance, alcohol withdrawal, drug toxicity, sensory problems, urinary retention, environmental changes and psycho-social factors [42]. Due to the large number of predisposing and preci-pitating factors it is difficult to manage delirium after FNF, and a lot of strategies for its prevention and care have been tested and are discussed in the literature.

Oliver et al. (2004) reported that, in some cases, delirium can exist before the trauma and can even be an aetiological factor for the trauma, related to a previous medical illness or medication. Thus, postoperative delirium could therefore be subsequent to a preoperative cause, as a result of the operation itself or secondary to factors influencing recovery, such as postoperative complications and medication [162].

However, the exact pathophysiology leading to delirium after hip fracture surgery still remains to be clarified and no single drug or surgical regimen has been proven to be preventive.

Delirium and dementia in relation to the outcome of femoral neck fracture patients. Delirium is a devastating complication in patients with FNF, with associated negative consequences such as impaired recovery, increased mortality, prolonged hospital stay, complications, impaired rehabilitation and the risk of institutionalization [110,115,144,145,163]. However, the reports in the literature regarding the relationship between delirium and increased mortality are becoming controversial. One recent report in the literature by Juliebo et al. (2010) on a prospective observational study with 331 hip fracture patients revealed no association between delirium and mortality; however, patients with pre-fracture dementia had an increased risk of death from stroke [116].

When analysing the recent reports in the literature we discovered that delirium was recognized as a predictor for the development of dementia after FNF surgery [125,140]. Lundstrom et al. (2003) investigated 78

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demented patients aged 65 and older who were operated on for FNF. The patients were followed for 5 years: 30 out of 78 (38.5%) FNF patients, who had no previous dementia, developed dementia within a 5-year period; and 20 out of 29 (69%) patients who were delirious postoperatively developed dementia compared to 10 out of 49 (20%) who were not delirious during their hospital stay (p<0.001). The authors concluded that delirium in non-demented FNF patients is a risk factor for the development of dementia later on [140].

The results from the study by Krogseth et al. (2011) are in agreement with those of Lundstrom et al. These authors investigated 106 elderly hip fracture patients who were free from pre-fracture dementia. Cognition was measured after 6 months, using five validated cognitive tests: 29/106 pa-tients (27%) developed delirium in the acute phase. In the delirious group, 11/29 (38%) fulfilled the criteria of dementia after 6 months compared to 5/77 (7%) in the group without delirium (p<0.001). They concluded that delirium was the strongest predictor of dementia within 6 months after the trauma [125].

Recognition and prevention of delirium in patients with femoral neck fractures. Delirium is easily recognized in acutely agitated patients (hyperactive delirium), but a high level of suspicion and experience is necessary to detect hypoactive delirium. Studies report that between a third and two-thirds of delirium goes unrecognized in clinical practice [108,185].

The British Geriatrics Society (BGS) recently produced clinical guidelines to improve the prevention, diagnosis and management of delirium in older people in hospital [176]. In these guidelines, the diagnosis of delirium is helped by screening for cognitive impairment upon admission using the Abbreviated Mental Test or the Mini-Mental State Examination (MMSE) followed by the Confusion Assessment Method (CAM) screening instrument [107,109]. The CAM is a well-validated diagnostic rating scale that has been tested and found to be a sensitive, specific, reliable and easy-to-use instrument for the identification of delirium [109]. The CAM is the most frequently used method for detecting delirium in FNF patients [36].

Preventing delirium is the most effective strategy for reducing its frequency and related complications in FNF patients during the peri-operative period. Successful preventive strategies include multicomponent approaches for reducing risk factors [110]. An RCT involving patients who had hip fractures showed the effectiveness of a multicomponent strategy for geriatric consultation that targeted 10 domains: oxygen delivery to the brain, fluid and electrolyte balance, pain management, a reduction in the use of psychoactive drugs, bowel and bladder functioning, nutrition, early

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mobilization, the prevention of postoperative complications, appropriate environmental stimuli and the treatment of symptoms of delirium [145].

The use of a multi-factorial intervention programme in elderly hip fracture patients who are cognitively intact upon admission can reduce the incidence of delirium during hospitalization by 35% [26]. Although these interventions are generally used in the majority of Western European countries, there are no well-established or accepted guidelines for reco-gnizing and preventing delirium after FNF in Lithuania. The implement-tation of previously described multi-factorial programmes for detecting and treating delirium in Lithuania would be beneficial in terms of reducing rates of complications and mortality.

In summary, we can conclude that delirium occurs more commonly in FNF patients after THA than after elective arthroplasty, and that it is often underdiagnosed. Delirium, as a complication and condition in FNF patients, has a negative influence on their short and long-term outcome results. However, delirium is not inevitable in this group of patients and the use of up-to date screening, recognition and prevention instruments for delirium is beneficial in clinical practice with FNF patients.

1.5.3. Impact of pressure ulcers on the outcome of patients with femoral neck fractures

Patients with FNFs are at risk of developing pressure ulcers (PU), which are a frequent complication in this group of patients [105]. The incidence of PUs varies between 8.8% and 55% [16,84] and they remain an unsolved problem in patients with hip fractures despite good knowledge about the risk factors and different preventions used in health-care institutions. Pressure ulcers can develop at any time during care, from hip-fracture patient arrival to discharge from hospital, but the majority of fracture-related PUs are reported to appear within 2 – 4 days after surgery [105].

Pressure ulcer risk assessment tools. The best strategy for avoiding PUs is prevention, thus the use of an appropriate instrument for the assessment and calculation of risk is important; however, there is no evidence showing that the use of risk assessment scales decreases pressure ulcer incidence [5,167]. Two main assessment scales (Modified Norton Scale and Braden Scales) are most frequently used for patients with femoral neck fracture.

The Norton scale was the first pressure ulcer risk assessment scale described in the scientific literature in 1969 [101]. This scale was modified and tested [58,59]. It includes seven subscales: mental condition, physical

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activity, mobility, food intake, fluid intake, incontinence and general physical condition, each consisting of four items. Each item has a score ranging from 1 to 4, (1 – lack of function, 4 – normal function). Patients are at risk when the score is below or equal to 20 points, where a lower number of points indicates a greater risk of PUs. The Modified Norton Scale was suggested as valuable tool for nurses, for both identifying patients at risk and acting as a guide for nursing interventions [84].

Other authors proposed using the Braden Scale, which has the best balance between sensitivity and specificity and the best risk estimate [167,134]. The Braden scale was developed in 1984 in the USA. It has six subscales for evaluating sensory perception, skin moisture, patients’ acti-vity, mobility, nutrition, friction and shear. Each variable is rated from 1 to 4, except for friction and shear, which are rated from 1 to 3. The risk for PU development is increased when the total score is equal to or below 16.

In a systematic review, Pancorbo-Hidalgo et al. (2006) investigated the effectiveness of risk assessment scales for pressure ulcer prevention, the degree of validation of these scales and their effectiveness as indicators of PU development. The authors concluded that both the Braden and Norton Scales are more accurate than nurses’ clinical judgment in predicting pressure ulcer risk [167].

Baath et al. (2008) examined the reliability between and among registered and enrolled nurses using the Modified Norton Scale, Pressure Ulcer Card and Short Form-Mini Nutritional Assessment. They concluded that the Modified Norton Scale and Short Form Mini-Nutritional Assessment were reasonably understandable and easy to use in daily clinical practice. Therefore, it seems possible for nurses to perform PU risk assessments using these tools [10].

In summary, we can state that the use of reliable and valid assessment tools is important in clinical practice for identifying patients at risk of PUs.

Pressure ulcers in relation to outcome in patients with FNFs. From the health-care perspective, patients with PUs require significantly more nursing time, a prolonged length of stay in hospital or rehabilitation units, more health-care resources after discharge and greater overall treatment costs [3,4]. The negative impact on patients is pain, discomfort, restricted life and the impact on the people that care for them [102]. Overall, it negatively influences their quality of life [69,77,207].

The aetiology of PUs appears to be multifactorial in origin and is often a result of multiple pathologies; this could explain the strong relationship already noted between old age and the formation of PUs [57,133]. Although the common risk factors for pressure ulcer development are known,

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researchers are investigating the factors that affect PU development in FNF patients in order to create new guidelines for their prevention. One major problem for researchers is that the comprehensiveness and quality of nurses’ documentation of pressure ulcers is often unsatisfactory [11,84]. Two main risk factors such as older age [83,105] and length of time on the operating table [105] have been reported to increase the risk of PU development.

Haleem et al. (2007) prospectively investigated data collected from 4654 consecutive FNF patients admitted to a single unit. Older age, diabetes, impaired mobility, higher American Society of Anaesthesiologists (ASA) grade, low haemoglobin levels and lower mental test score were found to be factors that increase the risk of developing PUs [88]. The incidence of pressure ulcers is also increasing in hip fracture patients with severe cogni-tive dysfunction [191].

Rademakers et al. (2007) investigated pressure ulcers and prolonged hospital stay in 722 hip fracture patients. The author reported that time-to-surgery was an independent predictor of postoperative pressure ulcer development and prolonged hospital stay. The data suggests that the imple-mentation of an early surgery protocol following admission for hip fractures could reduce both postoperative complications and overall hospital stay [178].

Furthermore, Simunovic et al. (2010), in a systematic review and meta-analysis, investigated the effect of early surgery on common postoperative complications among elderly patients with hip fractures. The authors concluded that early surgery was associated with lower rates of PUs (RR 0.48,95% CI 0.34 – 0.69, p<0.001) [187].

The large Pan-European Pressure Ulcers Study [134] was performed to identify intrinsic and extrinsic risk indicators for PU development in patients with hip fracture. The study included 635 patients from six European countries. The patients were followed from the Accident and Emergency Department until discharge or seven days. The risk factors significantly correlated with PUs at discharge were age ≥ 71, dehydration, moist skin and the total Braden score and subscores for friction, nutrition and sensory perception. Statistically significant co-morbid conditions correlated with the development of PUs were diabetes and pulmonary disease. However, contrary to previous studies the authors reported that waiting time for surgery and the duration of surgery were not significantly correlated with the development of PUs. They found that warming or no warming preoperatively, the type of anaesthesia, traction and the type of fracture were insignificant.

We discovered few reports in the literature investigating the role of nutrition in pressure ulcer development in patients with hip fractures. In an

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interventional study with hip fracture patients, Olofsson et al. (2006) reported that nutritional supplementation might have contributed to the decrease found in the incidence of PUs [164]. Similarly, in her study of 478 patients, Hommel (2007) investigated the effects of an improved care intervention in relation to nutritional status and PUs. The number of patients who developed PUs during their stay in hospital was reduced by 50%. The author concluded that it was possible to reduce the development of hospital-acquired PUs among elderly patients with a hip fracture, even in patients with a poor pre-fracture nutritional status [98].

These days PUs are not seen as a result of poor nursing but are accepted as an indicator of quality of care [17,101,126].

In summary, the assessment and management of PUs requires a com-prehensive and multidisciplinary approach. Special attention is needed for patients older than 70 years of age with FNFs. Not all risk factors, such as old age, co-morbidities and poor mental status, can be eliminated by health-care professionals; however, if appropriate preventive measures are used the majority of PUs can be avoided. Applying appropriate and correctly used methods of risk assessment, reducing the time to surgery and adding some nutritional support and low-pressure support helps to prevent PU development. These care pathways should become the standard of care for patients admitted with hip fractures. The implementation of this policy could improve clinical outcome and reduce the overall costs in the treatment of femoral neck fracture patients. We found no scientific reports on pressure ulcers in FNF patients in Lithuania.

1.5.4. Impact of malnutrition on the outcome of patients with femoral neck fractures

Malnutrition is common in hip fracture patients [60,38,139]. Studies show that elderly patients after surgery for hip fracture have one of the highest rates of severe malnutrition; the average risk of malnutrition in the different studies ranged from 13% to 63% [39,194]. Protein-energy mal-nutrition has been reported as an important determinant of the clinical outcome in FNF patients [61,139]. Malnutrition affects many bodily systems and causes muscle wastage, mental apathy and impaired cardiac functioning. This leads to impaired mobility and increased risk of complications, morbidity and mortality [42,104,105]. Malnutrition is also linked to an impaired immune response, leading to an increased risk of infections postoperatively [42]. Some reports in the literature state that men with hip fractures had a poorer nutritional status than women and this might

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be related to the greater incidence of death in men reported during the first 3 months after FNF [39].

Nutritional assessment in femoral neck fracture patients. It has been shown that malnutrition remains under-reported and often poorly documented in hospitals [14]. It has been recognized that perioperative complications and cognitive impairment are independent risk factors for malnutrition during the perioperative phase [12,67]. If these factors are pre-sent in FNF patients, increased nutritional support is necessary. Thus, the recognition of malnutrition is of great importance.

Several nutritional screening tools are appropriate for hospitalized patients: the Malnutrition Universal Screening Tool (MUST), Nutritional Risk Screening (NRS), the Short Nutritional Assessment Questionnaire (SNAQ), the Malnutrition Screening Tool, the Subjective Global Assessment (SGA) and the Mini Nutritional Assessment questionnaire (MNA) [6].

The Mini Nutritional Assessment questionnaire is a non-invasive and validated questionnaire specifically developed for evaluating the nutritional status among elderly patients (≥ 65 years) in hospitals, nursing homes and the community [79]. The MNA is an 18-item clinical tool consisting of four items: anthropometric measurements (BMI, mid-arm and calf circum-ference, and weight loss), global evaluation (lifestyle, medication, mobility, presence of acute stress and presence of dementia or depression), dietary assessment (number of meals consumed, food and fluid intake, and feeding autonomy), and subjective self-assessment (self-perception of health and nutrition), that uses a points-based scoring system to determine whether or not a patient is at risk of, or suffering from, malnutrition. The results are classified into three groups: malnourished (score < 17), at risk of malnutri-tion (score at ≥ 17 and ≤ 23.5) and well-nourished (score ≥ 24), with a maxi-mum of 30 points.

The MNA has gained worldwide acceptance and has shown a high prevalence of malnutrition in different settings, except for the community [117]. It has been reported that the MNA is a sensitive, specific and accurate tool for identifying the risk of nutrition [80] and the European Society for Parenteral and Enteral nutrition recommends the MNA for screening of the elderly [124]. However, a recent study of Bouer et al. (2008) reports that due to patients’ communication and comprehension deficits the MNA could only be used in 66.1% of the population [15].

The Mini Nutritional Assessment (MNA) questionnaire has been validated for use in Lithuania and is currently used for dietary assessments in patients with malnutrition [210]. Despite the use of the MNA

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questionnaire in various clinical areas we could not find any reports in the literature regarding use of this nutritional assessment method for FNF patients in Lithuania.

Nutritional support in femoral neck fracture patients. There is increasing evidence in the literature supporting the use of oral nutritional supplements in clinical practice, particularly in acutely ill and older patients [193]. However, the efficiency of nutritional support programmes in routine clinical practice in older patients with femoral neck fractures is still con-troversial.

Tidermark et al. (2004) found a correlation between a protein-rich liquid supplementation, alone or in combination with the anabolic steroid nandrolone decanoate, with body composition, activities of daily living (ADL) status and health-related quality of life (HRQL) in 59 FNF patients, where 20 patients were treated with a protein-enriched diet, 19 patients received intramuscular injections of nandrolone decanoate three times per day in addition to a protein-enriched diet, and a third group of 20 patients was as used as a control with standard nutrition. In addition, all patients received vitamin D and calcium. The HRQL was assessed using the EQ-5D questionnaire at 6 and 12 months after the trauma. The authors concluded that besides the protein-enriched diet, intramuscular injections of nandrolone decanoate in the femoral neck fracture patients group was associated with a better HRQL compared to other two groups. However, no statistically significant difference in HRQL was observed between the patients with a protein-enriched diet and patients with standard nutrition at 6 and 12 months after surgery [205].

Eneroht et al. (2006) performed a prospective RCT and evaluated the role of additional nutritional supplementations on the rate of FNF-related complications. The control group (n = 40) was given ordinary hospital food and beverages; the intervention group (n = 40) also was administered with a 1000 kcal daily intravenous supplement for 3 days, followed by a 400 kcal oral nutritional supplement for 7 days. The daily fluid and energy intake during the first 10 days of hospitalization and fracture-related complications up to 4 months were recorded. The authors reported that the risk of fracture- related complications was greater in the control group (70%) than in the intervention group (15%). Four patients in the control group died within 120 postoperative days. They concluded that a comprehensive, balanced nutritional supplement resulted in lower complication and mortality rates at 120 postoperative days [61].

Avenell and Handoll (2003) performed a systematic review of rando-mized and quasi-randorando-mized trials from 1966 to 2002 in people aged

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65 years or older and evaluated whether or not protein and energy supple-mentation influences recovery after hip fracture. It was concluded that oral protein and energy supplementation after hip fracture might reduce the rate of unfavourable outcomes [9]. This systematic review has been updated a few times (2004, 2005, 2006, 2010) and the last systematic review [7] reported that weak evidence exists for the effectiveness of protein and energy feeds, but it was concluded that there is a need for more adequately sized randomized trials on this subject, with a robust methodology.

In summarizing the findings described above we can suggest that addi-tional nutrition in FNF patients may have an effect on the outcome, although evidence regarding the effectiveness of different interventions is weak because there are too few well-designed RCTs. Malnutrition first requires a malnourished patient to be identified via either screening or assessment. A nutritional evaluation should be performed immediately after admission. A nutritional assessment using the MNA can be easily completed by health-care professionals upon admission to hospital for the early detection of the risk of malnutrition. If malnutrition is diagnosed in FNF patients upon admission to a health-care institution, adequate nutrition with some addi-tional support may reduce the rates of complication.

1.5.5. Impact of complications and co-morbidities on the outcome of patients with femoral neck fractures

It has been recognized that there are many factors that can influence the outcome in FNF patients. It has been reported that older age, male gender, a lower Barthel Index score, worse pre-injury mobility, and higher ASA score predict a poorer outcome in this patient group [19,221]. Certain co-morbidities such as cardiovascular disease, glucose tolerance impairment and pulmonary dysfunction also indicate a poorer functional prognosis [42,146,181]. Additionally, Gruson (2002) observed in his study that length of hospital stay and mortality rate at 6 and 12 months were significantly greater for patients who were anaemic upon admission. He suggested that patients at risk of poor outcomes after hip fracture could be identified by assessing haemoglobin levels upon hospital admission [78].

Although many studies have reported a direct correlation between a higher number of co-morbidities and increased mortality in patients with hip fracture, some reports showed that the major cause of death was linked to

the fracture event but not to a pre-existing co-morbidity. Farahmand et al.

(2005) investigated the impact of co-morbidity in a population-based set of 2245 hip fracture cases and 4035 randomly selected population-based controls among women from 50 to 81 years old. Increased mortality was

FACTORS AFFECTING CARE OUTCOME IN OLDER PERSONS WITH HIP FRACTURES Rasa Valavičienė LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

Rasa Valavičienė