SIMPOSIO Problematiche psicogeriatriche nel paziente fratturato. Giulio Pioli ASMN-IRCCS Reggio Emilia

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1 SIMPOSIO Problematiche psicogeriatriche nel paziente fratturato Giulio Pioli ASMN-IRCCS Reggio Emilia

2 Demenza come fattore di rischio di frattura AD case (N = 56,186, mean age 79.9 (SD 6.8) years, range years) Hazard ratios for hip fractures according to age at AD diagnosis Tolppanen et al. Incident Hip Fractures among Community Dwelling Persons with Alzheimer sdisease in a Finnish Nationwide Register-Based Cohort. PLoS ONE 2013

3 Pathogenic framework for dementia and hip fractures Friedman et al. Dementia and Hip Fractures: Development of a Pathogenic Framework for Understanding and Studying RiskGeriatric Orthopaedic Surgery & Rehabilitation 2010

4 Comorbidità prefrattura Emilia Romagna Survey Pooled analysis 974 subjects Età > 75 anni % 1 or more comorbidities Able to walk (with or without help). Some functional impairments in ADL or IADL % no comorbidity IADL = % bedridden Pioli et al. Time to surgery and rehabilitation resources affect outcomes in orthogeriatric units. Arch Gerontol Ger, 2012

5 Demenza come fattore di rischio dopo la frattura Population-based, retrospective cohort study. Ontario, Canada. 45,602 older adults had hip fractures Mortality community long term care Seitz et al. Effects of Dementia on Postoperative Outcomes of Older Adults With Hip Fractures. JAMDA 2014

6 Il paziente con frattura di femore e demenza Gestione delle fase acuta Controllo del dolore Tipo di anestesia Complicanze (delirium) Postoperative Cognitive Dysfunction Gestione della fase postacuta Il recupero funzionale nel paziente con demenza Tipo di riabilitazione Accesso ai servizi riabilitativi Rischio di istituzionalizzazione

7 Il controllo del dolore nei pazienti con frattura di femore e demenza Pain management Sieber et al. Postoperative Opioid Consumption and Its Relationship to Cognitive Function in Elderly Hip Fracture Patients. J Am Geriatr Soc. 2011

8 Il controllo del dolore nei pazienti con frattura di femore e demenza Nurses Assessment of Post-Operative Pain Management Rantala et al. Post-Operative Pain Management Practices in Patients with Dementia The Open Nursing Journal, 2012

9 Quale tipo di anestesia nel paziente con demenza Population-based, retrospective cohort study. Ontario, Canada. 20,973 older adults with dementia underwent hip fracture surgery Outcome nel paziente con demenza in base al tipo di anestesia Seitz et al. Postoperative Medical Complications Associated with Anesthesia in Older Adults with Dementia JAGS 2014

10 Quale tipo di anestesia nel paziente con demenza Retrospective review. 500 patients undergoing vascular surgical procedures. Rischio di delirium in base al tipo di anestesia Ellard,et al. Type of Anesthesia and Postoperative Delirium After Vascular Surgery Dementia JournalofCardiothoracicandVascularAnesthesia,2014

11 Seitz et al. A review of epidemiological evidence for general anesthesia as a risk factor for Alzheimer's disease. Progress in Neuro-Psychopharmacology & Biological Psychiatry 2013 Aumento del rischio di demenza dopo anestesia generale? Fifteen case control studies at the present time there is limited information to support the hypothesis of AD developing as a consequence of GA, although there are few high quality studies in this area.

12 Anestesia ed intervento come fattori di rischio per la demenza? Taiwan. Nationwide Population-Based Cohort Study. 7-year follow-up period Chen et al. Risk of dementia after anaesthesia and surgery. The British Journal of Psychiatry 2014

13 Aumento del rischio di demenza dopo frattura? Taiwan. Nationwide Population-Based Cohort Study. 12-year follow-up period Tsai et al. Fracture as an Independent Risk Factor of Dementia. Medicine 2014

14 Postoperative Cognitive Dysfunction (POCD) Alterazioni cognitive di nuova insorgenza che compaiono dopo una procedura chirurgica. Per la diagnosi è richiesta la valutazione psicometrica prima e dopo l intervento. Incidenza per gli interventi maggiori non cardiaci circa il 40% nei pazienti dopo i 60 anni, 12-13% a 3 mesi Transitoria. Comparsa immediata dopo l intervento, risoluzione da 3 mesi ad 1 anno. Associata ad una più elevata mortalità HR 1.63 (Steinmetz et al. Anesthesiology 2009, Monk et al Anesthesiology 2008) Fattori di rischio (da Rundshagen Postoperative Cognitive Dysfunction. Dtsch Arztebl Int )

15 Steinmetz et al. Is postoperative cognitive dysfunction a risk factor for dementia? A cohort follow-up study British Journal of Anaesthesia 2013 Postoperative Cognitive Dysfunction (POCD) Fattore di rischio per lo sviluppo di demenza? 686 patients with a median age of 67, follow up 11.1 yr HR 1.16 ( ) HR 1.50 ( ))

16 Postoperative Cognitive Dysfunction nel paziente ortopedico 69 patients aged 65 years or older undergoing major noncardiac surgery (88% elective orthopedic surgery) MMSE 28 ± 1.4 Incidenza a 3 mesi, 15.9% Multivariate logistic regression Shoair et al Incidence and risk factors for postoperative cognitive dysfunction in older adults undergoing major noncardiac surgery: A prospective study. J Anaesthesiol Clin Pharmacol. 2015

17 Postoperative Cognitive Dysfunction nella frattura di femore 100 unselected hip fracture patients treated in a optimized, multimodal regimen MMSE at admission and postoperative day 2,4,7 32% developed a significant post-operative decline in cognitive dysfunction, and 18% a major decline (at least 50% reduction in MMSE) Possibili fattori di rischio sulla base delle differenze fra i 2 gruppi No: co-patologie cardiovascolari, diabete, polmonari o renali tipo di anestesia, durata dell intervento, trasfusioni intraoperatorie Si: diagnosi di demenza, uso di antipsicotici, complicanze postoperatorie maggiori soprattutto cardiache ed insufficienza renale, numero totale trasfusioni Bitsch et al. Acute cognitive dysfunction after hip fracture: frequency and risk factors in an optimized, multimodal, rehabilitation program. Acta Anaesthesiol Scand 2006

18 Postoperative Cognitive Dysfunction nella frattura di femore 100 unselected hip fracture patients treated in a optimized, multimodal regimen MMSE at admission and postoperative day 2,4,7 Bitsch et al. Acute cognitive dysfunction after hip fracture: frequency and risk factors in an optimized, multimodal, rehabilitation program. Acta Anaesthesiol Scand 2006

19 Orthogeriatric intervention on patients with dementia Umea University Hospital, Sweden RCT on patients aged 70 years or older Subgroup analyses on patients with dementia (64%) Postoperative complications Stenvall et al. A multidisciplinary intervention program improved the outcome after hip fracture for people with dementia Subgroup analyses of a randomized controlled trial. Arch Gerontol Ger 2014

20 Il paziente con frattura di femore e demenza Gestione delle fase acuta Controllo del dolore Tipo di anestesia Complicanze (delirium) Postoperative Cognitive Dysfunction Gestione della fase postacuta Il recupero funzionale nel paziente con demenza Tipo di riabilitazione Accesso ai servizi riabilitativi Rischio di istituzionalizzazione

21 Il recupero funzionale nel paziente con demenza Orthogeriatric rehabilitation ward. Prospective cohort study. 314 older adults (> 65 years) admitted for rehabilitation after a hip operation Recovery of activities of daily living and walking ability. Uriz-Otano et al Factors Associated With Short-Term Functional Recovery in Elderly People With a Hip Fracture. Influence of Cognitive Impairment. JAMDA 2014

22 Il recupero funzionale nel paziente con demenza Orthogeriatric rehabilitation ward. Prospective cohort study. 314 older adults (> 65 years) admitted for rehabilitation after a hip operation Conclusion: Previous walking ability and the presence of complications, such as pressure ulcers or delirium, play a greater role in functional recovery than cognitive impairment. Not considering these aspects could lead to an overestimation of the impact of cognitive impairment in the recovery of these patients. Uriz-Otano et al Factors Associated With Short-Term Functional Recovery in Elderly People With a Hip Fracture. Influence of Cognitive Impairment. JAMDA 2014

23 Percent of the whole sample Recupero del cammino dopo la frattura di femore Emilia Romagna Survey Pooled analysis 774 subjects (excluded bed-ridden before fracture) Età > 75 anni 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Group 1 Mobile outdoors Group 2 Mobile indoors Group 3 Mobile with help 3 m 6 m 12 m 3 m 6 m 12 m 3 m 6 m 12 m dead walking performance lower than prefracture walking performance similar to prefracture Pioli et al (Submitted) 2015

24 Recupero del cammino dopo la frattura di femore Emilia Romagna Survey Pooled analysis 774 subjects (excluded bed-ridden before fracture), Età > 75 anni Prefracture walking recovery at 6 month cognitively healthy moderate cognitive impairment severe cognitive impairment Mobile outdoors Mobile indoors Mobile with help * # Pioli et al (Submitted) 2015

25 Recupero del cammino dopo la frattura di femore Emilia Romagna Survey Pooled analysis 774 subjects (excluded bed-ridden before fracture), Età > 75 aa Prefracture walking recovery at 6 month Mobile outdoor Mobile indoor Mobile with help HR (95%CI) p-value HR (95%CI) p-value HR (95%CI) p-value Age (year) <80 ref Ref ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Male Gender 2.59 ( ) ( ) ( ) Charlson Indesx (score) ) ( ) ( ) Copgnitive impairment No ref Ref Mild-moderate 1.12 ( ( ) ( ) Severe na 0.27 ( ) ( ) APS (score) 0.88 ( ) ( ) ( ) ADL (score) 1.06 ( ) ( ) ( ) IADL (score) 1.24 ( ) ( ) ( ) walking devices 0.35 ( ) ( ) ( ) Albumin at admission < 3.2 g/dl 0.47 ( ) ( ) ( ) Vitamin D Lower tertile ref ref ref intermediate tertile 1.81 ( ) ( ) ( ) Upper tertile 2. 9 ( ) ( ) ( ) Delirium 0.48 ( ) ( ) ( ) Surgery within 48 hrs 0.95 ( ) ( ) ( ) Pioli et al (Submitted) 2015

26 Recupero funzionale nella demenza Muir et al. The impact of cognitive impairment on rehabilitation outcomes in elderly patients admitted with a femoral neck fracture: a systematic review. J Geriatr Phys Ther CONCLUSION: There is some evidence that older adults with cognitive impairment who receive intensive inpatient rehabilitation after surgical repair of a hip fracture may be able to gain comparable benefit in physical function as cognitively intact patients. There is not enough information to guide recommendations of specific physical therapy interventions to optimize outcomes in this patient population. Further work is needed. Allen et al. Rehabilitation in Patients with Dementia Following Hip Fracture: A Systematic Review. J Physiotherapy Canada 2012 CONCLUSIONS: People with mild or moderate dementia may show improved function and ambulation and decreased fall risk after rehabilitation post hip fracture, similar to gains achieved by those without dementia. More research is required to ascertain the effect of rehabilitation in people with moderate to severe dementia, including those residing in continuing-care settings.

27 Recupero funzionale nella demenza RCT. 243 independently living patients Intervention: dedicated geriatric ward, multiprofessional team, physiotherapy sessions twice a day, and daily activities were practised throughout the day with the nurses, occupational therapy Control 100 Independent living at 3 month 100 Independent living at 1 year Huusko et al. Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia. BMJ 2000

28 Barone et al. An Analysis of the Feasibility of Home Rehabilitation. Arch Phys Med Rehabil 2006 Giusti et al. Rehabilitation After Hip Fracture In Patients With Dementia. JAGS 2007 Recupero funzionale nella demenza Galliera hospital. Community-dwelling older adults (N199) aged 70 years or older Variations of the Barthel Index From Prefracture Levels P=.01 Home-Based Rehabilitation (n.99) Subgroup with SPMSQ <8 Institutional-Based Rehabilitation ( n.100) Subgroup with SPMSQ <8

29 Recupero funzionale nella demenza Longitudinal study (n 231). Data were collected within 72 hours of admission to and before discharge from the postacute rehabilitation facilities and at 2, 6, and 12 months following postacute rehabilitation discharge Young et al. Longitudinal Functional Recovery After Postacute Rehabilitation in Older Hip Fracture Patients. J Am Med Dir Assoc 2011

30 Extended Multidisciplinary Rehabilitation 124 soggetti operati per frattura di femore dopo la riabilitazione standard RCT - Intervento: terapia fisica ad incremento progressivo (2 volte la settimana in strutture riabilitative) per 12 mesi. Controllo telefonico mensile più visita geriatrica mensile - Controllo. Terapia standard compreso l intervento ortogeriatrico in fase acuta, la riabilitazione standard e interventi successivi se richiesti. % ADL. Variazione media a 12 mesi rispetto al valore prefrattura P <0.04 P < ,5 intervento controllo -1 P = ,5 Singh et al. Effects of High-Intensity Progressive Resistance Training and Targeted Multidisciplinary Treatment of Frailty on Mortality and Nursing Home Admissions after Hip Fracture. JAMDA 2012

31 Recupero funzionale nella demenza Multicenter study of the Stockholm Hip Fracture Group with cognitive impairment (known dementia or low [0 2 points] score) in Short Portable Mental Status Questionnaire [0 10 points]) and able to walk before the fracture. Al-Ani et al. Does Rehabilitation Matter in Patients With Femoral Neck fracture and Cognitive Impairment? Arch Phys Med Rehabil 2010

32 Post-discharge site of care 411 Patients living at home before fracture (excluded bed-ridden before fracture and with restricted weight-bearing after surgical repair) Rehabilitation facilities Home Long-term care Independent walk before fracture cognitively intact mild to moderate CI severe CI 33% 77% 73% 22% 10% 12% 34% 13% 15% Walking with help before fracture cognitively intact mild to moderate CI 26% 44% 53% 33% 22% 21% severe CI 14% 54% 32% Bendini et al. Equality in access to rehabilitation after hip fracture: a prospective observational study 3 FFN Global Congress. Madrid 2014

33 Demenza come fattore di rischio dopo la frattura Risk factors known at admission for failing to return to their own home Vochteloo et al. Risk factors for failure to return to the pre-fracture place of residence after hip fracture. Arch Orthop Trauma Surg 2014

34 Take home message Patients with cognitive impairment and hip fracture Long term outcomes Il paziente con fratture di femore e deterioramento cognitivo ha maggiori probabilità di avere risultati negativi rispetto alla popolazione generali con frattura di femore. L approccio multidimensionale di tipo ortogeriatrico che include la precocità dell intervento chirurgico e della mobilizzazione, l intervento nutrizionale, la prevenzione delle complicanze, l ottimizzare dei livelli di emoglobina e dei fluidi, è in grado di migliorare gli outcome soprattutto dei pazienti più fragili compresi quelli con deterioramento cognitivo. I pazienti con deterioramento cognitivo, almeno lieve-moderato, hanno le stesse probabilità di recupero funzionale dei pazienti integri dal punto di vista cognitivo e non dovrebbero essere esclusi dai servizi riabilitativi,