FUNCTIONAL RECOVERY AFTER HIP FRACTURE: SIX MONTHS FOLLOW-UP OF PATIENTS IN A MULTIDISCIPLINARY REHABILITATION PROGRAM

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1 Y.T. Dai, G.S. Huang, R.S. Yang, et al FUNCTIONAL RECOVERY AFTER HIP FRACTURE: SIX MONTHS FOLLOW-UP OF PATIENTS IN A MULTIDISCIPLINARY REHABILITATION PROGRAM Yu-Tzu Dai, Guey-Shiun Huang, Rong-Sen Yang, 1 Jau-Yih Tsauo, 2 and Li-Hwa Yang 3 Background and Purpose: Hip fracture is a major source of disability among the elderly. The purpose of this study was to evaluate the effects of an in-hospital multidisciplinary rehabilitation program (MRP) on basic activities of daily living (BADL) and mobility 6 months after hospital discharge in patients with hip fractures. Methods: A before and after quasi-experimental design was used. Subjects were recruited in a large teaching hospital in Taipei, Taiwan. The first 44 consecutive patients recruited received conventional care (control group). The next 50 consecutive patients received physical therapy, nursing-supervised practice of exercise, and discharge planning (intervention group). The 94 patients recruited were aged 60 years or older and were hospitalized to receive open reduction and internal fixation or arthroplasty. Subjects were assessed at admission, on the fourth operative day, on the day of discharge, and 6 months after discharge. Results: On average, subjects did not regain their prefracture functional score for BADL and mobility 6 months after discharge. The intervention versus control group had a lower incidence of functional decline in BADL (16.0% vs. 34.1%; p = 0.01) and mobility (48.0% vs. 75.0%; p = 0.01) 6 months after discharge. Subjects who were independent before fracture (odds ratio [OR], 12.24), did not receive MRP intervention (OR, 4.63), or who were female (OR, 5.24), were more likely to have a decline in function 6 months after discharge. Conclusion: An MRP had a continuous positive effect on hip-fracture patients, thus facilitating improved recovery in BADL and mobility 6 months after discharge. (J Formos Med Assoc 2002;101:846 53) Key words: hip fracture rehabilitation program functional outcomes predictors Functional decline after hip fracture is a common and devastating consequence of hip fracture in the elderly [1 3]. Previous studies have shown that patients with hip fractures run a high risk of functional loss in both ambulation (40 63% of patients) and independence in the activities of daily living (ADL; 51 75%) [2 5]. Only 22 to 67% of patients regain their prefracture walking ability 6 to 12 months after fracture, depending on the characteristics of the patients and the type of rehabilitation program they receive [5 8]. Most functional recovery occurs within 6 months of the fracture, but some patients start to decline after the first 6-month period [6, 9]. Studies have suggested that 6 months after the fracture is the best time for the assessment of optimal outcomes [6, 10]. The variables that are most commonly used to measure patient outcomes following hip fracture are ambulation, self-care (ADL), and social reintegration (living arrangement after discharge) [10]. Studies in various healthcare settings have had inconsistent results regarding the effects of rehabilitation programs. Some studies found positive and significant effects on patients functional recovery after hospital discharge [5, 11], while other studies found no School of Nursing, College of Medicine, National Taiwan University, and 3 Department of Nursing, National Taiwan University Hospital, Taipei; Department of 1 Orthopedics, National Taiwan University Hospital, Taipei; 2 Department of Physical Therapy, College of Medicine, National Taiwan University, Taipei. Received: 27 February Revised: 17 April Accepted: 4 June Reprint requests and correspondence to: Dr. Yu-Tzu Dai, Department of Nursing, College of Medicine, National Taiwan University Hospital, Jen-Ai Road, Section 1, Taipei 100, Taiwan. 846 J Formos Med Assoc 2002 Vol 101 No 12

2 Rehabilitation Program for Hip-fracture Patients such effects [6, 12]. Little research on the long-term effects of in-hospital rehabilitation programs has been conducted in Taiwan s healthcare setting. Our previous study found that an in-hospital multidisciplinary rehabilitation program (MRP) had short-term benefits for patients with hip fractures [13]. The positive effects of the program included shorter hospital stay, lower occurrence of iatrogenic complications, and reduced decline in functional status at hospital discharge [13]. Whether or not the positive effects of this MRP on physical function are maintained after patients return to their family care setting remains unclear. This study aimed to examine: 1) the effects of the MRP on physical function, operationalized in terms of basic activities of daily living (BADL) and mobility; and 2) the predictors of functional decline 6 months after hospital discharge. Subjects and Methods Study participants This study used a before and after quasi-experimental design. All subjects were recruited consecutively in the orthopedic units of a large teaching hospital in Taipei, Taiwan. The hospital review committee approved this study after an evaluation of ethical considerations. From November 1998 to April 1999, we recruited 50 consecutively admitted patients as the intervention group for this study. These subjects all received operations on their hip fractures and were invited to participate in the MRP before and after surgery. All of these subjects received functional evaluation at home 6 months after hospital discharge. Inclusion criteria were: 1) age 60 years or older; 2) receiving a closed reduction under fluoroscopic guidance and internal fixation, or hemi-arthroplasty; and 3) ability to walk independently with or without an assistive device before hip fracture. Exclusion criteria were: 1) pathologic fracture; 2) multiple fractures; 3) unstable fracture; and 4) severe cognitive impairment assessed by the Mini-Mental State Examination [14] within 24 hours of admission (i.e., patients with a score of 18 were excluded). The same group of physicians and nurses cared for all of these patients. Subjects in the control group were selected from 106 patients of the control group of a previous study that focused on early outcome evaluation [13]. These 106 patients had been consecutively hospitalized due to hip fracture between November 1997 and October All of them received non-systematic instruction about range-of-motion (ROM) and muscle-strengthening exercises from nurses after surgical treatment. Subjects recruited in the last 6 months of the previous study period, from April 1998 to October 1998, received a visit and evaluation of physical function at home 6 months after hospital discharge. Only 45 of the 106 patients were followed up. One patient died of an asthma attack 4 months after discharge. Therefore, 44 of the 106 patients were included in the control group for this study. No significant differences were found in the demographic and clinical variables of these 44 patients compared to the other 61 patients not followed up after discharge (all p > 0.13). MRP protocol The detailed procedures of the MRP are described in our previous report [13]. Briefly, patients participated in the MRP during their hospital stay. The MRP included the following four components: 1) Preoperative instruction, and immediate postoperative commencement of in-bed mobilization by nursing staff; 2) Twenty-minute bedside mobility training every weekday provided by a student physiotherapist under faculty supervision. The mobility training included active ROM exercise of the lower extremity, including hip and knee flexion, and functional training such as ankle pumping, gluteal and quadriceps setting, turning, transferring and ambulation. With the surgeon s permission, each patient practiced weight bearing on the affected leg and ambulated as early as possible. 3) Participation in a mobility training program with instruction twice a day provided by a primary nurse until discharge. 4) Comprehensive discharge planning that included early assessment of needs for continuing care, adequate instruction for post-hospital care, care coordination and referral, and procurement of assistive devices. Data collection The head nurses of the orthopedic units referred eligible patients to a research assistant (RA). The RA explained to patients and families the purpose and procedures of the study, and the intervention program if a patient was a potential subject of the intervention group. Once a patient gave informed consent to participate, the RA assessed that patient s cognitive function and clinical variables within 24 hours of admission. Data about each patient s prefracture level of physical function were also collected from medical records. Complications and the level of physical function were assessed on the fourth day after surgery and on the day of discharge. Basic demographic data, site of hip fracture and type of surgery were recorded. Six months after hospital discharge, the RA visited patients at home and reassessed their physical function. Physical function was defined as the functional status of J Formos Med Assoc 2002 Vol 101 No

3 Y.T. Dai, G.S. Huang, R.S. Yang, et al patient s mobility and BADL. To reduce the attrition rate, patients were contacted every 2 months by telephone. The attrition rate was 1.06%. Instruments 1. A scale comprising the following five BADL: eating, grooming, dressing, bowel and bladder control, and bathing [15]. Each item was rated on a scale from 1 (totally dependent) to 5 (totally independent). The range of total scores was from 5 to 25 with a higher score indicating better physical function. Analysis of the data collected revealed a Cronbach s α of 0.80 and an interrater reliability of 0.93 for the BADL scale in the concurrent assessment. 2. A mobility scale comprising one transferring and one ambulation item [15]. Each item was rated on a scale from 1 (totally dependent) to 5 (totally independent). The range of total scores was from 2 to 10, with a higher score indicating greater mobility. Analysis of study data revealed a Cronbach s α of 0.93 and an interrater reliability of A detailed explanation of other instruments used for patient assessment during hospital stay is given in our previous report [13]. Statistical analysis SPSS Interactive Graphics 8.0 (SPSS Inc., Chicago, IL, USA) software was used to analyze the data. Two-tailed tests were used to determine probability values. Differences between the intervention and control groups were assessed using Student s t-test for continuous variables and χ 2 statistics for categorical data. Logistic regression analysis was employed to identify the predictors of functional decline in mobility from prefracture to 6 months after hospital discharge. 848 Results Patient characteristics The mean age of the 94 subjects was 76.4 years. There were 54 females (57.4%), and 60 subjects had received a primary school education or less. Surgery involved internal fixation in 54 subjects (57.4%), and hemiarthroplasty in the remaining 40 subjects (42.6%). Demographic and clinical variables did not differ significantly between the intervention and control groups (Table 1). Six months after hospital discharge, eight subjects in the control group were readmitted because of esophageal erosion (n = 1), duodenal ulcer (1), cataract (1), fever (1), fall (1), prosthetic dislocation (1), or loss of internal fixation (2). Two subjects in the intervention group were readmitted because of gastric ulcer (1) and bronchitis (1). The Figure shows the means of scores for the function of BADL and mobility for all 94 subjects at prefracture, fourth postoperative day, discharge day and 6 months after discharge. Subjects showed declines in function during the first 4 postoperative days, but had regained some function by the discharge day, and had further recovered in all functional variables 6 months after discharge. The percentage of subjects who regained prefracture levels of function regarding specific items of BADL and mobility were: continence 95.7%, eating 94.7%, grooming 89.4%, dressing 86.2%, bathing 74.5%, transferring 46.8%, and walking 53.2%. All items included in the assessment of BADL and mobility had a similar pattern of functional recovery, except for the mean score for eating, which was not reduced relative to the mean prefracture score. Functional outcomes The functional outcomes of the intervention group were assessed using: 1) the difference between the control and intervention groups in the score change of BADL and mobility between prefracture and 6 months after discharge; 2) the difference between the control and intervention groups in the change of BADL and mobility between discharge and 6 months after discharge; and 3) the percentage of functional decline in BADL between prefracture and 6 months after discharge. Comparison of the functional changes between prefracture and 6 months after discharge showed no significant decrease in BADL score change between the control and intervention groups, but a significant change in mobility 6 months after discharge was found (Table 2). The subjects in the intervention group had significantly less deterioration in mobility. The BADL scores of the two groups measured at the two time points were moderately correlated (control group r = 0.51, intervention group r = 0.76). Similar correlations were found in mobility scores measured prefracture and 6 months after discharge (control group, r = 0.57; intervention group, r = 0.49). These significant correlations indicated that subjects with better physical function before fracture had better physical function 6 months after discharge. Comparison of functional changes between discharge day and 6 months after discharge revealed no significant differences in BADL and mobility score changes between the control and intervention groups (Table 2). Further analysis of the percentage of functional decline from prefracture to 6 months after discharge using the χ 2 -test showed that significantly fewer subjects in the intervention than control group had a functional decline in bathing (p = 0.03), overall BADL (p = 0.01), transferring (p = 0.02), and mobility (p = 0.01) (Table 3). No significant difference was found between the intervention and control groups in the percentage J Formos Med Assoc 2002 Vol 101 No 12

4 Table 1. Demographic and clinical characteristics of hip-fracture patients on admission Rehabilitation Program for Hip-fracture Patients Variables Control group Intervention group p value (n = 44) (n = 50) Age (yr)* ± ± Sex 0.76 Male 18 (40.9%) 22 (44.0%) Female 26 (59.2%) 28 (56.0%) Level of education 0.84 Primary school or less 27 (61.4%) 33 (66.0%) High school 12 (27.3%) 11 (22.0%) College or higher 5 (11.4%) 6 (12.0%) Marital status 0.47 No spouse or partner 17 (38.6%) 23 (46.0%) With spouse or partner 27 (61.4%) 27 (54.0%) Previous history of fracture 0.70 No 40 (90.9%) 47 (94.0%) Yes 4 (9.1%) 3 (6.0%) Diagnosis of fracture 0.14 Femoral neck and above 26 (59.1%) 22 (44.0%) Peritrochanteric 18 (40.9%) 28 (56.0%) Surgical procedure 0.71 Internal fixation 22 (50.0%) 32 (64.0%) Hemi-arthroplasty 22 (50.0%) 18 (36.0%) Type of anesthesia 0.30 General 6 (13.6%) 3 (6.0%) Spinal 38 (86.4%) 47 (94.0%) BADL function 0.69 Independent 27 (61.4%) 31 (62.0%) Partially dependent 17 (38.6%) 19 (38.0%) Mobility 0.95 Independent 22 (50.0%) 27 (54.0%) Partially dependent 22 (50.0%) 23 (46.0%) BADL score* ± ± Mobility score* 8.91 ± ± Cognitive status* (MMSE score) ± ± *Mean ± standard error. The relationship between variables was examined using χ 2 -test for categorical data and t-test for interval data. Single, separated, divorced, or widowed; Fisher s exact test. BADL = basic activities of daily living; MMSE = mini-mental state examination. of functional decline in eating, grooming, dressing, continence and walking. Predictors of a decline in mobility The predictors of a functional decline in mobility from prefracture to 6 months postdischarge were further examined. The analysis of functional decline in BADL was not conducted due to a lack of significant change in the scores (Table 2). Univariate logistic regression analysis revealed that prefracture BADL, prefracture mobility, and grouping were predictors of a decline in mobility 6 months after discharge (Table 4). Multiple logistic regression analysis identified prefracture mobility, grouping, and female sex as predictors of mobility decline. Patients who were independent in mobility before hip fracture (odds ratio [OR], 12.24; 95% confidence interval [CI], ) or who did not receive MRP intervention (OR, 4.63; 95%, CI, ), and who were females (OR, 5.24; 95% CI, ) were more likely to have a functional decline 6 months after discharge. Other variables including age, iatrogenic complications during hospitalization, site of fracture, type of surgery, cognitive function, and independent BADL prefracture were not associated with a decline in mobility 6 months after discharge (Table 4). No significant predictor of functional decline in BADL 6 months after discharge was identified using multiple logistic regression analysis. Discussion This study found that an MRP successfully maintained the functional recovery in mobility and BADL in eld- J Formos Med Assoc 2002 Vol 101 No

5 Y.T. Dai, G.S. Huang, R.S. Yang, et al Mean score Continence Eating Grooming Dressing Figure. Trend in 6-month functional changes for patients with hip fractures (N = 94). Bathing Transferring Walking Prefracture 4th day postop. Discharge 6 months after discharge erly patients with hip fracture 6 months after hospital discharge. Subjects in the intervention group were 27% less likely to have a decline in mobility and 18% less likely to have a decline in BADL than subjects in the control group. In addition, patients with better physical function before the fracture had better physical function 6 months after hospital discharge. As shown in Table 3, the MRP significantly reduced the percentage of subjects with a decline in BADL; however, as shown in Table 2, the difference in the change of BADL score was not significant between the intervention and control groups. These seemingly contradictory findings are explained by the small magnitude of the functional decline in BADL items, even though there were a significant number of subjects with a functional decline. Our previous study found that the MRP exerted positive short-term effects on mobility at hospital discharge [13]. The findings of the current study indicate that the differential effect of the MRP lasted up to 6 months post-discharge. Table 2. Score changes in basic activities of daily living (BADL) and mobility between prefracture, discharge day, and 6 months after discharge Variable Control group Intervention group p value (n = 44) (n = 50) BADL 6 mo vs. prefracture 0.45 ± ± mo vs. discharge 5.32 ± ± Mobility 6 mo vs. prefracture 1.50 ± ± mo vs. discharge 2.73 ± ± Data expressed as mean ± standard error of the mean. Table 3. Associations between functional decline and intervention at 6 months after discharge Number of patients with decline Functional variable Control group Intervention group p value n = 44 (%) n = 50 (%) Eating 2 (4.5) 3 (6.0) 1.00* Grooming 6 (13.6) 4 (8.0) 0.51* Bathing 12 (27.3) 5 (10.0) 0.03 Dressing 8 (18.2) 5 (10.0) 0.25 Continence 1 (2.3) 3 (6.0) 0.62* BADL 15 (34.1) 8 (16.0) 0.01 Walking 23 (52.3) 21 (42.0) 0.32 Transferring 29 (65.9) 23 (46.0) 0.02 Mobility 33 (75.0) 24 (48.0) 0.01 *Fisher s exact test. BADL = basic activities of daily living. 850 J Formos Med Assoc 2002 Vol 101 No 12

6 Rehabilitation Program for Hip-fracture Patients Table 4. Logistic regression analysis of the predictors of mobility decline between prefracture and 6 months after discharge Variable OR Univariate p value OR Multivariate p value (95% CI) (95% CI) BADL prefracture < Mobility prefracture < Grouping Sex Age < 85 years Site of fracture (femoral neck and above) Type of surgery (ORIF) Complication (yes) Cognition impaired Reference group: independent mobility prefracture, intervention group, male sex. OR = odds ratio; CI = confidence interval; BADL = basic activities of daily living; ORIF = open reduction and internal fixation. Although the MRP did not have a significant impact on functional-score change between discharge day and 6 months after discharge, the analyses in Table 2, as well as the findings of our previous study [13], indicate that subjects in the intervention group had greater improvement in their mobility before discharge with comparatively less additional improvement after discharge. In contrast, subjects in the control group had less improvement in mobility before discharge, but more improvement after discharge, thus indicating a slower pace of recovery. The analysis of predictors of a decline in mobility found that patients who were independent in mobility prefracture, female, or who did not participate in the MRP during their hospital stay, were more likely to have a decline in mobility 6 months after hospital discharge. In the USA, about one-quarter of previously independent patients become partially dependent after hip fractures [8]. It is more difficult for an independent patient to regain full function than a partially dependent patient to return to their prefracture status [16]. In concurrence with previous studies [7, 9], patients with independent mobility before fracture in this study had more difficulty regaining totally independent walking 6 months after the fracture. It is easier for patients with hip fractures to regain an originally lower level of mobility than to regain total independence of mobility. Previous findings of sex as a predictor of functional recovery in hip-fracture patients were inconsistent. Some studies reported no association between sex and functional recovery [17 19]. Miller reported that male gender was a negative predictor of walking ability 12 months after a fracture [20]. Other studies found that female subjects were more likely to have a decline in ambulatory ability [21]. However, no study has reported on the association between sex and patients functional recovery. A recent study on the post-hospital care of disabled, Taiwanese elderly revealed that family caregiving expenses up to 2 months after hospital discharge were significantly different between males and females [22]. Compared with male patients, females were more likely to be discharged home and had higher caregiving expenditures. Males were more likely to receive unpaid care from their spouse or be discharged into a long-term care facility. These different care arrangements not only influence the level of expenditure, but might also influence quality of caregiving and patients functional recovery. Studies have shown that the children of elderly people needing care spend different amounts of time and money, depending on the sex of the parent that needs care [23]. In addition, older women receive more social support and provide more help to children in meal preparation and cleaning than older men. Adult children may therefore feel a stronger filial obligation to their mothers because their mothers usually provide more help and care to family members [23]. It has been reported that patients with advanced age (> 85 yr) or cognitive impairment are more likely to have a functional decline in ADL and ambulatory ability postfracture [6, 8, 18, 21, 24]. In conflict with the findings of previous studies, this study did not find that age and cognitive function were predictors of mobility recovery. Insufficient sample size could have been responsible for the only marginally significant (p = 0.07) p value in the relationship between age and decline in mobility. In-hospital clinical variables such as site of fracture, type of surgery, and presence of complications were not associated with a decline in mobility 6 months after hospital discharge. These findings concur with other studies on the predictors of functional recovery 6 to 12 months after discharge [17, 24]. Few subjects in this study were re-hospitalized. There was inadequate statistical power to test the association between readmission J Formos Med Assoc 2002 Vol 101 No

7 Y.T. Dai, G.S. Huang, R.S. Yang, et al and mobility. Some studies have found that readmission hampers a patient s functional recovery [8]. Inhospital clinical variables tended to be the predictors of mortality rather than the predictors of walking ability between 6 and 12 months after hip fracture [1, 10]. Before hip fracture, all subjects in the current study resided in their own home, could walk independently or with assistive devices, and had no severe cognitive impairment. They had a mean age of 76.4 years. The subjects of this study represented a younger and healthier population than most of the populations in previous studies [6, 12, 18]. Because the instruments used to measure function in this study were different from those of other studies, comparison across research findings is complex and difficult. The percentage of our subjects who regained function seems lower than that reported in previous studies of older and frailer populations [6, 8]. Most subjects in this study visited orthopedic outpatient clinics, but did not receive post-hospital rehabilitation therapy. Sherrington and Lord [11] reported that a home-based rehabilitation program had a positive effect on patients physical function after hospital discharge. Evidence suggests that the settings and intensity of post-hospital rehabilitation are important factors influencing functional recovery in patients with hip fracture [3, 25]. Six months after hospital discharge, patients with hip fractures who received home health care regained more function than those treated in rehabilitation facilities or at home without formal care [3]. Kramer et al found that the chance of patients with hip fractures returning to the community was similar whether the patients were admitted to rehabilitation hospitals or nursing homes [25]. These findings suggest that a continuing rehabilitation program might be more cost-effective for patients with hip fractures than an intensive rehabilitation program at a rehabilitation facility. It is unknown whether subjects in our intervention group reached their maximal possible functional recovery with an in-hospital MRP. Further studies to examine whether receiving a home rehabilitation program would further reduce functional decline are warranted. In the current study, follow-up data after hospital discharge were obtained by home visits and direct patient contact. Direct contact is more reliable than the telephone interviews used in most previous studies [4, 8, 19]. In addition, the findings showing the effectiveness of the MRP are more convincing because a control group was used to examine the outcomes. Despite these strengths, three limitations of this study need to be mentioned. First, changes in hospital practice or policy during the period of data collection might have confounded the analysis of this before and after study. Analysis of possible confounding factors 852 showed that the average length of hospital stay during the first and second period of this study was similar (11.71 vs d), and no significant change in healthcare practice or hospital policy was noted. A trend analysis on outcome indicators did not suggest that a time effect could have been caused by a change of practice. Second, bias might have resulted from a lack of blinding of outcome assessors, although the high inter-rater reliability in functional measurement should decrease doubt about the potential for biased assessment. Lastly, instead of random assignment, a consecutive sampling was used in this study. This study found that an MRP had not only shortterm effects [13] but also long-term effects on the improvement in physical function in patients with hip fractures. Earlier discharge from hospital in the intervention than control group facilitated a better recovery in BADL and mobility 6 months after hospital discharge. Patients with independent mobility before fracture, those patients who did not receive the MRP, or females, were less likely than others to regain prefracture mobility within 6 months of discharge. ACKNOWLEDGMENTS: The authors would like to thank the nurses and orthopedic surgeons of the orthopedic units, as well as students of the Department of Physical Therapy of National Taiwan University for their assistance. They would also like to thank the National Science Council of the Republic of China for its supporting grants (NSC B and NSC B ), which made this study possible. References 1. Hannon EL, Magaziner J, Wang JJ, et al: Mortality and locomotion 6 months after hospitalization for hip fracture. JAMA 2001;285: Craik RL: Disability following hip fracture. Phys Ther 1994;74: Kane RL, Chen Q, Finch M, et al: Functional outcomes of posthospital care for stroke and hip fracture patients under Medicare. J Am Geriatr Soc 1998;46: Fox KM, Magaziner J, Hebel JR, et al: Intertrochanteric versus femoral neck fractures: differential characteristics, treatment, and sequelae. Journal of Gerontology Medical Sciences 1999;12:M Reid J, Kennie DC: Geriatric rehabilitative care after fractures of the proximal femur: one year follow up of a randomized clinical trial. BMJ 1989;299: Jette AM, Harris BA, Cleary, PD, et al: Functional recovery after hip fracture. Arch Phys Med Rehabil 1987;68: Kitamura S, Hasegawa Y, Suzuki S, et al: Functional outcome after hip fracture in Japan. Clin Orthop Relat Res 1998;348: J Formos Med Assoc 2002 Vol 101 No 12

8 Rehabilitation Program for Hip-fracture Patients 8. Magaziner J, Simonsick EM, Kashner M, et al: Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. Journal of Gerontology Medical Sciences 1990;45:M Fox KM, Hawkes WG, Magaziner J, et al: Markers of failure to thrive among older hip fracture patients. J Am Geriatr Soc 1996;44: Ahmad LA, Eckhoff DG, Kramer AM: Outcome studies of hip fractures: a functional viewpoint. Orthop Review 1994; 23: Sherrington C, Lord SR: Home exercise to improve strength and walking velocity after hip fracture: a randomized controlled trial. Arch Phys Med Rehabil 1997;78: Cameron ID, Lyle DM, Quine S: Accelerated rehabilitation after proximal femoral fracture: a randomized controlled trial. Disabil Rehabil 1993;15: Dai YT, Huang GS, Yang RS, et al: Effectiveness of a multidisciplinary rehabilitation program in elderly patients with hip fractures. J Formos Med Assoc 2001;100: Folstein MF, Folstein SE, McHugh PR: Mini mental state: a practical method for the cognitive state of patients for the clinician. J Psychiatr Res 1975;12: Chiu CJ, Wang SH: Self-care in the aged and its related factors. Kaohsiung J Med Sci 1989;3: Cooper C: The crippling consequences of fractures and their impact on quality of life. Am J Med 1997;103:12S 9S. 17. Marottili RA, Berkman LF, Cooney LM: Decline in physical function following hip fracture. J Am Geriatr Soc 1992; 40: Parker MJ, Palmer CR: Prediction of rehabilitation after hip fracture. Age Aging 1995;24: Koval KJ, Skovron ML, Aharonoff GB, et al: Ambulatory ability after hip fracture. Clin Orthop 1995;310: Miller CW: Survival and ambulation following hip fracture. J Bone Joint Surg Am 1978;60: Clayer MT, Bauze RJ: Morbidity and mortality following fractures of the femoral neck and trochanteric region: analysis of risk factors. J Trauma 1989;29: Dai YT, Wu SC, Oung RH, et al: The study of the needs for post-hospitalization care. Unpublished research report to Department of Health, Republic of China, Taipei, Taiwan 2001; Ingersoll-Dayton B, Starrels ME, Dowler D: Caregiving in parents and parents-in-law: is gender important? Gerontologist 1996;36: Mossey JM, Mutran E, Knott K, et al: Determinants of recovery 12 months after hip fracture: the importance of psychosocial factors. Am J Public Health 1989;79: Kramer AM, Steiner JF, Schlenker RE, et al: Outcomes and costs after hip fracture and stroke: a comparison of rehabilitation setting. JAMA 1997;277: J Formos Med Assoc 2002 Vol 101 No