Dementia does not prevent the restoration of safe gait after hip fracture.

Abstract

To the Editor: We read with interest the paper published in the Journal regarding the functional outcome of cognitively impaired hip fracture patients treated in a Geriatric Rehabilitation Unit.1 We would like to contribute further to this topic by discussing the data gathered in our Geriatric Evaluation and Rehabilitation Unit. During the past year, 69 older patients with hip fractures (mean age 81.7 ± 7.8, 88% women, 8.3% of all new admissions) have been admitted to our ward for rehabilitation. All patients underwent diagnostic, therapeutical, and rehabilitative procedures. Twenty-six patients had severe cognitive impairment (MMSE < 18),2 and 42 (60.9%) were malnourished (i.e., Prognostic Nutritional Index > 40).3 None of the patients had active medical conditions that contraindicated physical rehabilitation, i.e., active medical conditions that in the judgment of the physician precluded participation in physical therapy. Patients took part in one daily rehabilitation session, lasting 30 to 45 minutes each day, 5 days per week. Sessions took place in the gymnasium except for those unable to walk who received physical therapy in their own rooms. Patients were discharged when the rehabilitation team judged that the maximal effect of rehabilitation had been reached. The mean ± SD length of stay was 42.2 ± 21.9 days. The efficacy of the rehabilitative treatment was estimated by the difference between the Tinetti scale4 score at discharge (population mean ± SD = 14.1 ± 7.8) and on admission (3.2 ± 3.7). For the purpose of this study, the Tinetti scale on admission was stratified into three levels corresponding to patients unable to sit steadily and safely but rather leaning or sliding when placed in an armless chair (Tinetti score = 0), patients able only to sit steadily and safely (Tinetti score = 1), and patients with better balance and gait function (Tinetti score of 2 or higher). We defined motor independence and safe gait by a Tinetti score of ≥18. This endpoint was reached by 28 patients (40.6%) and was found to be less likely in patients with poorer functional status on admission, very old age, and malnutrition. Dementia was not associated with lower likelihood of reaching the endpoint (see Table 1). However, demented patients were not able to reach Tinetti scores as high as their nondemented peers (see Figure 1). . Tinetti scores on discharge compared with scores on admission in 69 demented older hip fracture patients. We hypothesize that cognitive deficits exert an overall negative effect that could manifest itself through increased rehabilitation time (we are actually measuring the parameter). However, the data suggest that basic learning processes (body awareness) in demented patients are maintained (in fact, the ability to reach the threshold of motor independence is not impaired by dementia).