simposio problematiche psicogeriatriche nel paziente ... · asmn-irccs reggio emilia. demenza come...

SIMPOSIO

Problematiche

psicogeriatriche nel paziente

fratturato

Giulio Pioli

ASMN-IRCCS

Reggio Emilia

Demenza come fattore di rischio di frattura

AD case (N = 56,186, mean age 79.9 (SD 6.8) years, range 42–101 years)

Tolppanen et al. • Incident Hip Fractures among Community Dwelling Persons with Alzheimer’sDisease in a Finnish Nationwide Register-Based Cohort. PLoS ONE 2013

Hazard ratios for hip fractures according to age at AD diagnosis

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

Comorbidità prefrattura

Emilia Romagna Survey Pooled analysis 974 subjects Età > 75 anni

4-5 % bedridden 11-14 % no comorbidity IADL = 8

80-85 % 1 or more comorbidities Able to walk (with or without help). Some functional impairments in ADL or IADL

Pioli et al. • Time to surgery and rehabilitation resources affect outcomes in orthogeriatric units. Arch Gerontol Ger, 2012

Demenza come fattore di rischio dopo la frattura

Population-based, retrospective cohort study. Ontario, Canada. 45,602 older adults had hip fractures

Seitz et al. • Effects of Dementia on Postoperative Outcomes of Older Adults With Hip Fractures. JAMDA 2014

community long term care

Mortality

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

Il controllo del dolore nei pazienti con frattura di femore e demenza

Sieber et al. • Postoperative Opioid Consumption and Its Relationship to Cognitive Function in Elderly Hip Fracture Patients. J Am Geriatr Soc. 2011

Pain management

Il controllo del dolore nei pazienti con frattura di femore e demenza

Rantala et al. • Post-Operative Pain Management Practices in Patients with Dementia The Open Nursing Journal, 2012

Nurses’ Assessment of Post-Operative Pain Management

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

Seitz et al. • Postoperative Medical Complications Associated with Anesthesia in Older Adults with Dementia JAGS 2014

Outcome nel paziente con demenza in base al tipo di anestesia

Quale tipo di anestesia nel paziente con demenza

Retrospective review. 500 patients undergoing vascular surgical procedures.

Ellard,et al. • Type of Anesthesia and Postoperative Delirium After Vascular Surgery Dementia JournalofCardiothoracicandVascularAnesthesia,2014

Rischio di delirium in base al tipo di anestesia

Aumento del rischio di demenza dopo anestesia generale ?

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

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.

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

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

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. 2014 )

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

Steinmetz et al. • Is postoperative cognitive dysfunction a risk factor for dementia? A cohort follow-up study British Journal of Anaesthesia 2013

HR 1.50 (0.51–4.44)) HR 1.16 (0.48–2.78)

Postoperative Cognitive Dysfunction nel paziente ortopedico

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

69 patients aged 65 years or older undergoing major noncardiac surgery

(88% elective orthopedic surgery) MMSE 28 ± 1.4

Multivariate logistic regression

Incidenza a 3 mesi, 15.9%

Postoperative Cognitive Dysfunction nella frattura di femore

Bitsch et al. • Acute cognitive dysfunction after hip fracture: frequency and risk factors in an optimized, multimodal, rehabilitation program. Acta Anaesthesiol Scand 2006

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

Postoperative Cognitive Dysfunction nella frattura di femore

Bitsch et al. • Acute cognitive dysfunction after hip fracture: frequency and risk factors in an optimized, multimodal, rehabilitation program. Acta Anaesthesiol Scand 2006

100 unselected hip fracture patients treated in a optimized, multimodal regimen

MMSE at admission and postoperative day 2,4,7

Orthogeriatric intervention on patients with dementia

Umea˚ University Hospital, Sweden RCT on patients aged 70 years or older

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

Subgroup analyses on patients with dementia (64%) Postoperative complications

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

Il recupero funzionale nel paziente con demenza

Uriz-Otano et al • Factors Associated With Short-Term Functional Recovery in Elderly People With a Hip Fracture. Influence of Cognitive Impairment. JAMDA 2014

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.

Il recupero funzionale nel paziente con demenza

Uriz-Otano et al • Factors Associated With Short-Term Functional Recovery in Elderly People With a Hip Fracture. Influence of Cognitive Impairment. JAMDA 2014

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.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

dead

walking performance lower than prefracture

walking performance similar to prefracture

3 m 12 m 6 m 3 m 12 m 6 m 3 m 12 m 6 m

Perc

ent of

the w

hole

sam

ple

Group 2

Mobile indoors

Group 1

Mobile outdoors

Group 3

Mobile with help

Recupero del cammino dopo la frattura di femore

Pioli et al • (Submitted) 2015

Emilia Romagna Survey Pooled analysis 774 subjects (excluded bed-ridden before fracture) Età > 75 anni



Emilia Romagna Survey Pooled analysis 774 subjects (excluded bed-ridden before fracture), Età > 75 anni

0

10

20

30

40

50

60

70

80

90

100

Mobile outdoors Mobile indoors Mobile with help

cognitively healthy

moderate cognitive impairment

severe cognitive impairment

*

#

Prefracture walking recovery at 6° month



Emilia Romagna Survey Pooled analysis 774 subjects (excluded bed-ridden before fracture), Età > 75 aa

Mobile outdoor Mobile indoor Mobile with help

HR (95%CI) p-value HR (95%CI) p-value HR (95%CI) p-value Age (year) 0.000 0.518 0.673

<80 ref Ref 80-84 0.84 (0.40-1.74) 0.635 1.90 (0.71-5.09) 0.201 1.13 (0.27-4.80) 0.869 85-89 0.23 (0.09-0.55) 0.001 1.10 (0.40-3.06) 0.850 0.87 (0.17-4.44) 0.862 ≥90 0.07 (0.01-0.36) 0.001 1.03 (0.37-2.84) 0.958 2.08 (0.47-9.25) 0.335

Male Gender 2.59 (1.18-5.65) 0.017 0.81 (0.30-2.21) 0.679 0.27 (0.06-1.30) 0.102 Charlson Indesx (score) 0.69 0.54-0.87) 0.002 1.01 (0.82-1.25) 0.914 0.86 (0.66-1.12) 0.270 Copgnitive impairment 0.159 0.100 0.932

No ref Ref Mild-moderate 1.12 (0.53 0.762 0.67 (0.29-1.58) 0.365 0.43 (0.03-5.79) 0.754 Severe na 0.27 (0.08-0.90) 0.033 0.38 (0.02-6.35) 0.963

APS (score) 0.88 (0.73-1.05) 0.162 0.97 (0.84-1.13) 0.723 1.06 (0.82-1.38) 0.647 ADL (score) 1.06 (0.61-1.84) 0.834 1.46 (1.07-2.00) 0.017 1.54 (1.03-2.32) 0.037 IADL (score) 1.24 (1.01-1.53) 0.042 1.03 (0.82-1.29) 0.824 1.37 (0.77-2.424) 0.289 walking devices 0.35 (0.15-0.83) 0.016 0.76 (0.38-1.54) 0.449 2.42 (0.77-7.63) 0.130

Albumin at admission < 3.2 g/dl 0.47 (0.22-0.99) 0.049 0.82 (0.36-1.86) 0.635 0.81 (0.29-2.36) 0.703

Vitamin D 0.050 0.010 0.793

Lower tertile ref ref ref intermediate tertile 1.81 (0.76-4.28) 0.180 2.81 (1.21-6.51) 0.016 0.81 (0.22-3.05) 0.523

Upper tertile 2. 9 (1.23-6.85) 0.015 3.66 (1.47-9.11) 0.005 1.03 (0.27-3. 90) 0.496

Delirium 0.48 (0.21-1.10) 0.084 0.99 (0.43-2.29) 0.978 0.36 (0.11-1.22) 0.100 Surgery within 48 hrs 0.95 (0.49-1.84) 0.870 1.07 (0.52-2.21) 0.860 1.53 (0.48-4.84) 0.468

Prefracture walking recovery at 6° month

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. 2009

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.


RCT. 243 independently living patients

Huusko et al. Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia. BMJ 2000

0

20

40

60

80

100

0-11 12-17 18-23 24-30

0

20

40

60

80

100

0-11 12-17 18-23 24-30

Independent living at 3 month Independent living at 1 year

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


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

Galliera hospital. Community-dwelling older adults (N199) aged 70 years or older

Variations of the Barthel Index From Prefracture Levels

Home-Based Rehabilitation (n.99)

Institutional-Based Rehabilitation ( n.100)

P= .01

Subgroup with SPMSQ <8

Subgroup with SPMSQ <8


Young et al. Longitudinal Functional Recovery After Postacute Rehabilitation in Older Hip Fracture Patients. J Am Med Dir Assoc 2011

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

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.

P <0.04

P <0.01

%

-1,5

-1

-0,5

0

intervento controllo

ADL. Variazione media a 12 mesi

rispetto al valore prefrattura

P = 0.02

Extended Multidisciplinary Rehabilitation

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


Al-Ani et al. Does Rehabilitation Matter in Patients With Femoral Neck fracture and Cognitive Impairment? Arch Phys Med Rehabil 2010

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.

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)

77%

73%

33%

44%

26%

14%

10%

12%

22%

33%

53%

54%

13%

15%

34%

22%

21%

32%

Independent

walk before

fracture

Walking with

help before

fracture

cognitively

intact

mild to

moderate CI

severe

CI

cognitively

intact

mild to

moderate CI

severe

CI

Rehabilitation

facilities Home Long-term

care

Bendini et al. Equality in access to rehabilitation after hip fracture: a prospective observational study 3° FFN Global Congress. Madrid 2014

Demenza come fattore di rischio dopo la frattura

Vochteloo et al. • Risk factors for failure to return to the pre-fracture place of residence after hip fracture. Arch Orthop Trauma Surg 2014

Risk factors known at admission for failing to return to their own home

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,

simposio problematiche psicogeriatriche nel paziente ... · asmn-irccs reggio emilia. demenza come...

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