An analysis of the feasibility of home rehabilitation among elderly people with proximal femoral fractures

Objective: To evaluate the feasibility and predictors of success of home-based rehabilitation (HBR) in older adults after hip fracture. Design: Prospective inception cohort study with 12 months of follow-up. Setting: Acute and subacute care with follow-up in a community setting in Italy. Participants: Community-dwelling older adults (N = 199) aged 70 years or older, discharged from an acute orthopedic unit after repair of a nontraumatic proximal femoral fracture. Interventions: Patients' choice of pursuing HBR or institutional-based rehabilitation (IBR). Main Outcome Measures: Proportion of subjects discharged home for rehabilitation. Rates of institutionalization assessed at 3, 6, and 12 months postdischarge. Mean changes of the Barthel Index from baseline and proportion of subjects who regained their prefracture levels of function at the time of follow-up in the 2 intervention groups (HBR, IBR). Results: Ninety-nine (49.7%) patients chose HBR, and the rest (50.3%) were discharged to a rehabilitation facility. With regard to the baseline characteristics, the 2 patient groups (HBR, IBR) differed with respect to living arrangement (P <= .001), prefracture functional status in basic (Barthel Index, P = .033; Katz Index, P = .041) and instrumental activities of daily living (IADLs) (P = .041), and occurrence of delirium (P = .022). During the follow-up, the number of subjects institutionalized at 3, 6, and 12 months was 52, 26, and 22, respectively. In the multiple logistic regression model, the only significant variable affecting the choice of IBR at discharge was the absence of relatives at home (odds ratio [OR], 6.7; 95% confidence interval [CI], 3.33-13.46; P <= .001), whereas a prefracture functional impairment in more than 3 IADLs (at 12 mo: OR = 3.99; 95% CI, 1.57-10.18; P = .004), the absence of relatives at home (at 12mo: OR = 8.81; 95% CI, 2.47-31.46; P = .001), and delay to surgery longer than 3 days (at 12 mo: OR = 5.51; 95% CI, 1.28-23.81; P = .022) resulted in significant risk factors for longterm institutionalization. Compared with subjects who received traditional rehabilitation, those discharged home showed-after controlling for prefracture Barthel Index score, IADLs, cognitive status and age-a slightly lower functional decline and a higher rate of recovery during the follow-up (mean change in Barthel Index score +/- standard deviation at 12mo: HBR, -11.2 +/- 24.7 vs IBR, -23.7 +/- 28.5; P=.015). Conclusions: In an unselected population of hip-fractured older adults previously living in the community, HBR seems to be a feasible alternative to IBR in those subjects living with relatives.