Original article
Relationship between dementia degree and gait ability after surgery of proximal femoral fracture: Review from Clinical Pathway with Regional Alliance data of rural region in Japan

https://doi.org/10.1016/j.jos.2016.03.005Get rights and content

Abstract

Background

Proximal femoral fracture (PFF) is one of the most serious injury-related problems in developed countries. Functional prognosis after operation for PFF is unsatisfactory, as a considerable number of patients cannot perform similar gait function before fracture. Postoperative gait function is a key in performing activities of daily living (ADL). It is well known that PFF patients with dementia result in worse prognosis compared to without dementia. It is believed that dementia affects gait function after operation. However, it is still unclear whether lost function recovers after dementia level improves.

Methods

Relationship between ADL and dementia of PFF patients after surgery was investigated using data of Clinical Pathway with Regional Alliance system. Functional Independence Measurement (FIM), revised version of Hasegawa's Dementia Scale (HDS-R), motivation for rehabilitation (MR), and gait status (GS) measured in acute and recovery institute (A-I and R-I) of 266 patients were analyzed with linear regression analysis. Degrees of patients' dementia were classified into three groups with HDS-R for ten points increment partition, and their average FIM and GS in R-I for groups were compared statistically with ANOVA. FIM gain and GS gain from A-I to R-I were compared statistically with chi-square test.

Results

FIM and HDS-R demonstrated significant regression with each of all other parameters (p < 0.01) for both A-I and R-I. The group with lowest HDS-R score demonstrated significant lower FIM gain and lower GS gain than groups with higher scores (p < 0.01). However, patients who demonstrated improvement in HDS-R at R-I demonstrated significant better GS gain (p < 0.05) even in the group with lowest HDS-R at A-I.

Conclusions

These results show that there is a very close correlation between patients' gait function and dementia and that it is necessary to control a patient's status not only for physical condition but also for mental status after PFF operation.

Introduction

The incidence of proximal femoral fracture (PFF) has been steadily increasing year by year in Japan in recent decades [1]. As the elderly population expands in Japan, fractures due to bone fragility have become a big social issue and health burden [2], [3], [4], [5]. One report showed 32.8% mortality within one year of PFF in the elderly over ninety years of age [6]. Not only does PFF undermine function and threaten lives, however its burgeoning incidence is fast becoming one of the most serious problems in progressed countries [1], [3], [4], [5], [6], [7]. The Clinical Pathway with Regional Alliance (CPRA) system has been implemented since 2006 with the aim of reducing health care costs in Japan. This system is built for regional medical institutions within the alliance, where patients have been treated in a systemic way. However, despite these efforts, a majority of patients are unable to return home or walk because of insufficient recovery in gait, as reported before CPRA [8], [9].

Dementia is also severe social problem in developed countries. It is well known that dementia is associated with sarcopenia and loss of ambulatory ability. Relationship between PFF and dementia is also widely established. However, little has been published whether dementia degree affect recovery after surgery for PFF. In this study, we investigated CPRA data for our region, and evaluated the influence of dementia, its severity, and other factors on functional recovery in activities of daily living (ADL) and gait function after surgery for PFF.

Section snippets

Methods

Of the approximately 100,000 people residing in the study region, 33% are elderly (i.e., above the age of 65). Within this region, the core hospital (i.e. the acute institution; AI) is the only institution, and the majority of PFF patients are referred to and treated and operated in it. Between April 2006 and March 2014, surgeries on 1316 fractures were performed in the AI within the CPRA, constituted approximately 99% of PFF patients in this area. Clinical data from the CPRA were also been

Results

Parameters that showed significant correlation with FIM at RI were FIM at AI, HDS-R at AI, HDS-R at RI, MR at RI, GM at AI, GM at RI, QF at AI, QF at RI, FL at RI, AB at RI, GS at AI, and GS at RI (P < 0.01). Neither PS at AI nor at RI demonstrated a significant correlation with FIM at RI (Table 2). FIM and HDS-R showed a significant strong correlation in both AI (R = 0.6517, P < 0.0001) and RI (R = 0.6934, P < 0.0001).

All HDS-R score groups were significantly different from each other in terms

Discussion

Fractures caused by bone fragility such as PFF and vertebral body fractures now constitute a major health problem in Japan [1], [2], [3], [4], [5]. Underlying issue of PFF is osteoporosis that causes not only in unilateral side, but also contralateral side PFF [14], [15]. Not only functional prognosis, but life expand is shorten because of comorbidity and immobility [4], [5], [6], [7], [8], [16], [17], [18].

Regional cohort studies of such fractures provide meaningful data for implementing

Conclusions

From these results, we conclude that ADL after surgery to treat proximal femoral fractures is very closely correlated with dementia, and that the severity of dementia influences patient motivation for undergoing rehabilitation, and therefore influences gait ability. During rehabilitation, patients make progress in terms of their gait ability when their dementia improves. However, if dementia does not improve, patients are expected to gain very little in terms of gait ability. Therefore,

Conflict of interest

None of the authors and their family have share income or property with any person.

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