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- Karlsson, Åsa, 1972-
(författare)
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Team-based home rehabilitation after hip fracture in older adults : effects, experiences and impact of dementia
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BACKGROUND: For an older adult a hip fracture may be a traumatic and life-changing event and has shown to be associated with reduced health-related quality of life, disability and increased mortality. Previous rehabilitation studies have often excluded older adults with cognitive impairment and those living in residential care facilities, groups with an additional risk of poor outcome. Moreover, there are few randomized controlled trials that have evaluated interdisciplinary home rehabilitation after hip fracture. These studies did not include older adults with severe cognitive impairment or dementia, those with serious medical conditions, or those living in residential care.OBJECTIVE: The aim of the thesis was to investigate the effects of early discharge followed by geriatric interdisciplinary home rehabilitation (GIHR) for older adults with hip fracture, and specifically among those with dementia, compared to in-hospital geriatric care according to a multifactorial rehabilitation program. An additional aim was to explore how older adults experienced their rehabilitation and recovery during the year following the fracture.METHODS: The thesis evaluated a randomized controlled trial that included 205 participants with hip fracture, 70 years or older, living in ordinary housing or residential care facilities. In hospital, both the GIHR and control groups received care and rehabilitation according to a multifactorial rehabilitation program, but with the aim of early discharge for the GIHR group. The individually designed GIHR intervention focused on walking ability indoors and outdoors, independence in activities of daily living (ADL), and multifactorial fall prevention during a maximum period of 10 weeks. Participants were assessed in-hospital and at 3- and 12-month follow-up visits. Independence in walking and use of walking aids was assessed via an interview along with gait speed tests. Independence in ADL was measured using the Barthel ADL Index, and the ADL Staircase including the Katz ADL Index, and hospital length of stay (LOS) was recorded from medical charts. The effects of GIHR intervention among participants with dementia were investigated in a post hoc subgroup analysis where additional outcomes were falls, mortality and readmissions between discharge and 12 months. Individual interviews were conducted with 20 selected participants just after the 12-month follow-up. Data were analysed using qualitative content analysis.RESULTS: The postoperative hospital LOS was significantly reduced by a median of six days in the GIHR group compared to the control group, although not significantly reduced in the GIHR group for participants with dementia. Binary logistic regression analyses revealed no significant differences between the GIHR and control groups regarding independent walking ability, the ability to walk without a walking device, or independence in ADL at 3 and 12 months. Gait speed was comparable between the two groups at 3 and 12 months. At 12 months, 56% in the GIHR group and 58% in the control group had recovered their prefracture walking ability, and 41% vs. 42% in GIHR and control groups, respectively, had regained their prefracture Barthel ADL Index score. Interaction analyses showed that the GIHR group vs. the control group had comparable effects on walking ability and ADL at 3 and 12 months, and on falls and mortality between discharge and 12 months, regardless of whether the participants had dementia or not (P≥0.05 for all). The number of readmissions and hospital days after discharge was comparable between GIHR and control groups for participants with dementia. Overall, dementia was associated with significantly impaired walking ability and greater dependence in ADL at 3 and 12 months and with increased risk of falling and increased mortality between discharge and 12 months compared to participants without dementia. The interviews revealed that access to rehabilitation, provided by skilled staff, and support from others were important for participants’ well-being and recovery. Participants experienced a fundamental change in their self-image after the fracture, and faced a number of difficulties, but strove for independence and used adaptive strategies to find contentment in their lives.CONCLUSIONS: In older adults with hip fracture, early discharge followed by interdisciplinary home rehabilitation significantly reduced postoperative hospital LOS. Functional recovery during the year following the fracture was nevertheless comparable to in-hospital geriatric care according to a multifactorial rehabilitation program. The GIHR intervention seems to be appropriate also for older adults with dementia since the effects were not different in this subgroup, except for postoperative hospital LOS, which was not significantly reduced in the GIHR group for participants with dementia. Further studies with larger samples are needed to validate these results. Overall, dementia was associated with a substantial negative impact on the outcomes. According to participants’ experiences, receiving rehabilitation and support after the hip fracture seems crucial for successful recovery. Negative psychological reactions were common, suggesting that future interventions should consider both physical and psychological aspects. Different rehabilitation alternatives were appreciated by the participants. Rehabilitation should thus be customised to suit wishes and needs of older adults and may accordingly be carried out in different settings, where rehabilitation in the home can be one suitable alternative. The findings of this thesis indicate that geriatric interdisciplinary home rehabilitation after hip fracture can be an alternative and a complement to in-hospital care and rehabilitation for older adults with and without dementia.
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| 2. |
- Sondell, Anna, 1968-
(författare)
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Exercise and team rehabilitation in older people with dementia : applicability, motivation and experiences
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The world’s population is aging. With the growing population of older people, dementia disorders are becoming increasingly common. Dementia disorders are progressive and include impairments in cognitive and physical function, which lead to increased risks of inactivity, falls, fractures, and comorbidity. Dementia is also the leading cause of dependency in activities of daily living. Therefore, rehabilitation including exercise is needed for this population. To obtain optimal effects on the functional ability of older people, exercise should be task specific, functional, performed at high intensity at sufficient frequency and duration, and include both balance and strength training. Motivation to participate is important for exercise program participation, the fulfillment of exercise recommendations and facilitation of motor learning in order to achieve exercise response. However, exercise recommendations for older people are based mainly on findings from studies conducted with people without dementia. Exercise may be challenging for some people with dementia due to complicating symptoms, such as cognitive deficits, depression, apathy or lack of motivation, and behavioral and psychological symptoms of dementia (BPSD). Studies exploring the applicability of exercise programs have been called for to optimize exercise programs; knowledge about motivation is lacking, and how this together influences exercise response in this group. Additionally, dementia disorders significantly affect all aspects of life for the affected persons and their informal caregivers, friends, and family members in their immediate networks. Furthermore, the care and rehabilitation needs of community-dwelling people with dementia must be considered due to the decreasing proportion of nursing home residents in Sweden today. Scientific knowledge and clinical experiences regarding the use of interdisciplinary team rehabilitation for people with dementia are limited, despite the urgent need for rehabilitation and its proven effects after events such as hip fracture. The effects of person-centered multidimensional interdisciplinary rehabilitation programs for people with dementia, including education and counseling for informal primary caregivers, have not been evaluated and need to be explored.The overall aim of the thesis was to evaluate exercise and team based rehabilitation among older people with dementia. Specifically, the objectives were to evaluate motivation to participate in and applicability of a high-intensity functional exercise program, and to explore participants’ experiences with a multidimensional interdisciplinary team rehabilitation program including high-intensity functional exercise, among older people with dementia.In the Umeå Dementia and Exercise (UMDEX) study, a cluster-randomized controlled trial including 186 people with dementia in nursing homes, the effects of the High-Intensity Functional Exercise (HIFE) Program and a seated social activity, both lasting for 45 minutes and held five times fortnightly for 4 months, were compared. Participants’ motivation to go to activity sessions and motivation during sessions were assessed using a five-point Likert scale. The applicability of the exercise program (with regard to attendance, achieved intensity, and adverse events) was assessed with a focus on dementia type and reasons for non-attendance and for not achieving high intensity, based on exercise diary data. Balance exercise response was investigated using the Berg Balance Scale, assessed at baseline and 4 month follow-up. In the Multidimensional InterDisciplinary Rehabilitation in Dementia (MIDRED) study, a randomized controlled study, a person-centered multidimensional interdisciplinary rehabilitation program for community-dwelling older people with dementia, including education and counseling for informal primary caregivers, was evaluated. With the aim of exploring experiences with program participation, 16 participants with dementia were interviewed and data were analyzed using qualitative content analysis.The UMDEX study showed that motivation during activities was quite high, with no overall difference between groups; over time, however, motivation increased in the exercise group and decreased in the social activity group. Motivation during activity sessions was greater than motivation to go to sessions in both groups. The exercise program was applicable, with high attendance rates, moderate to high intensity achieved, and the occurrence of only minor and temporary adverse events. Dementia subtype, low motivation, pain, and presence of BPSD seemed to affect applicability. The exercise response varied widely, with many participants showing improved balance after the intervention. The applicability of the exercise program and motivation did not seem to be associated with paramount balance response. Four categories emerged from the MIDRED study analysis: being empowered through challenges; gaining insight, motives and rising concerns about the future; to participate is worthwhile, if you are seen; and togetherness in prosperity and adversity.In conclusion, for older people with dementia living in nursing homes, who have a high prevalence of medical conditions and functional limitations, motivation to participate in a high-intensity exercise program was high and did not differ from motivation to participate in a less physically demanding social activity. The exercise program seems to be applicable with regard to attendance, achieved intensity, and adverse events. The prediction of balance exercise response based on program applicability and participant motivation does not seem to be possible. The promotion of strategies to encourage people with dementia to join exercise groups is of great importance, and more knowledge about strategies is needed to overcome low pre-exercise motivation levels. An interdisciplinary rehabilitation program for community-dwelling older people seems feasible, according to reported experiences. The participants had positive experiences and perceived improvement and empowerment due to the rehabilitation, which can influence well-being in daily life in this population. The results of this research support the inclusion of this population in team rehabilitation and high-intensity functional exercise programs.
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