1. Bradford, Natalie K.

Article Content


Hip fractures are a common injury in elderly people, usually caused by a fall. Hip fractures are more common in people with dementia, and rehabilitation may be complicated by additional problems such as increased confusion, pressure ulcers, and chest infections. As a result, this group of people is more likely to have higher mortality, to be admitted to long-term care, and to have a higher demand for health and social care expenditure (Henderson, Malley, & Knapp, 2007). With the aging population, it is expected that over the next 25 years, the number of people with dementia and hip fracture will increase substantially (Knapp & Privette, 2007). Over the last 15 years, advances in the management of people with hip fracture have changed practice so that greater emphasis is now placed on postoperative physiotherapy, occupational therapy, and multidisciplinary and integrated care packages. Clinical guidelines recommend a number of interventions to improve outcomes (NICE, 2011), including specific management practices, interdisciplinary team work, communication between health and social agencies, and provision of dedicated functional rehabilitation interventions across acute hospital and community settings. However, the overall effectiveness of such care has not been assessed and the benefit remains uncertain. For people with dementia, it may be better to draw on best practice dementia care. With one in four beds occupied by someone with dementia, and hip fractures being the commonest reason for hospital admission, there is a need to have a focused review on this topic. Decisions of whether to allocate limited health and social care resources to interventions should be evidence based.



Objectives of this study were (1) to assess the effectiveness of models of care including enhanced rehabilitation strategies designed specifically for people with dementia following hip fracture surgery compared with usual care and (2) to assess the effectiveness for people with dementia of models of care including enhanced rehabilitation strategies that are designed for all older people, regardless of cognitive status, following hip fracture surgery compared with usual care.



This review considered randomized, quasi-randomized, and cluster randomized controlled trials published in any language that evaluated the effectiveness for people with dementia of any model of enhanced care and rehabilitation following hip fracture surgery compared with usual care. The population included adults 65 years or older, who had any form of dementia, and had undergone surgery to repair a hip fracture. Interventions consisted of any model of care that involved advanced rehabilitation intended to improve outcomes delivered in acute hospital environments, community health or rehabilitation centers, or in people's home and residences. The primary outcome measure was cognitive function as assessed using a validated scale. Secondary outcomes included functional performance, behavior, quality of life, and pain (all measured by validated scales); mortality; complications; use of resources; and costs of hospitalization. A wide range of electronic databases, journals, and gray literature was searched in accordance to Cochrane's recommendations. Data collection and analysis were undertaken in accordance with Cochrane's recommendations. All included studies were evaluated for quality and risk of bias. Outcomes were reported using mean differences and odds ratio (OR) with 95% confidence intervals (CIs).



Five trials with a total of 316 participants were included (Huusko, Karppi, Avikainen, Kautiainen, & Sulkava, 2000; Marcantonio, Flacker, Wright, & Resnick, 2001; Shyu et al., 2012; Stenvall, Berggren, Lundstrom, Gustafson, & Olofsson, 2012; Uy, Kurrle, & Cameron, 2008). Four trials evaluated models of enhanced interdisciplinary rehabilitation and care and compared usual rehabilitation and care in the trial settings. The fifth trial compared outcomes of geriatrician-led care in hospital with conventional care led by the orthopaedic team. All articles analyzed subgroups of people with dementia/cognitive impairment from larger populations of older people following hip fracture.


All studies were considered to be at high risk of bias. No study assessed the primary outcome (cognitive function). The effect estimates for most comparisons were very imprecise, so it was not possible to draw firm conclusions from the data. There was low-quality evidence that enhanced care and rehabilitation in hospital led to lower rates of some complications and that enhanced care provided across hospital and home settings reduced the chance of being in institutional care at 3 months postdischarge (OR = 0.46; 95% CI [0.22, 0.95], two trials, n = 184).



This review found that the current evidence is insufficient to determine the best care for people with dementia after hip fracture. There was limited research available on this topic, with no care models designed specifically for people with dementia. For almost all outcomes, results were inconclusive because the studies were too small and of low quality. Further research is needed to establish what the best strategies are for improving the care for people with dementia following hip fracture.


Implications for Practice

The optimal rehabilitation and care model for this population is unclear. Given the rising need to provide care for people with dementia following hip fracture, there is a need for more research in this area. Nurses in this field are encouraged to consider the importance of evaluating the benefits of dementia-focused interventions such as reminiscence therapy, using familiar routines, provision of cues, and assistive technologies. Nursing is an important profession involved in the care of this population and, with other members of the multidisciplinary team, is well placed to design and participate in research in this area.




Henderson C., Malley J., Knapp M. (2007). Maintaining good health for older people with dementia who experience fractured neck of femur. London, England: National Audit Office, Personal Social Services Research Unit, London School of Economics and Political Science. [Context Link]


Huusko T. M., Karppi P., Avikainen V., Kautiainen H., Sulkava R. (2000). Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: Subgroup analysis of patients with dementia. BMJ, 321(7269), 1107-1111. [Context Link]


Knapp M., Privette A. (2007). Dementia UK Alzheimer's Society. London, England: Alzheimer's Society. [Context Link]


Marcantonio E. R., Flacker J. M., Wright R. J., Resnick N. M. (2001). Reducing delirium after hip fracture: A randomized trial. Journal of the American Geriatric Society, 49(5), 516-522. [Context Link]


NICE. (2011). Hip fracture: The management of hip fracture in adults. Retrieved May 31, 2015, from [Context Link]


Shyu Y. I., Tsai W. C., Chen M. C., Liang J., Cheng H. S., Wu C. C., Chou S. W. (2012). Two-year effects of an interdisciplinary intervention on recovery following hip fracture in older Taiwanese with cognitive impairment. International Journal of Geriatric Psychiatry, 27(5), 529-538. [Context Link]


Smith T. O., Hameed Y. A., Cross J. L., Henderson C., Sahota O., Fox C. (2015). Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery. Cochrane Database of Systematic Reviews, 6. Retrieved from


Stenvall M., Berggren M., Lundstrom M., Gustafson Y., Olofsson B. (2012). A multidisciplinary intervention program improved the outcome after hip fracture for people with dementia-Subgroup analyses of a randomized controlled trial. Archives of Gerontology and Geriatrics, 54(3), 284-289. [Context Link]


Uy C., Kurrle S. E., Cameron I. D. (2008). Inpatient multidisciplinary rehabilitation after hip fracture for residents of nursing homes: A randomised trial. Australasian Journal on Ageing, 27(1), 43-44. [Context Link]