Original Study
Effects of High-Intensity Progressive Resistance Training and Targeted Multidisciplinary Treatment of Frailty on Mortality and Nursing Home Admissions after Hip Fracture: A Randomized Controlled Trial

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Abstract

Rationale

Excess mortality and residual disability are common after hip fracture.

Hypothesis

Twelve months of high-intensity weight-lifting exercise and targeted multidisciplinary interventions will result in lower mortality, nursing home admissions, and disability compared with usual care after hip fracture.

Design

Randomized, controlled, parallel-group superiority study.

Setting

Outpatient clinic

Participants

Patients (n = 124) admitted to public hospital for surgical repair of hip fracture between 2003 and 2007.

Intervention

Twelve months of geriatrician-supervised high-intensity weight-lifting exercise and targeted treatment of balance, osteoporosis, nutrition, vitamin D/calcium, depression, cognition, vision, home safety, polypharmacy, hip protectors, self-efficacy, and social support.

Outcomes

Functional independence: mortality, nursing home admissions, basic and instrumental activities of daily living (ADLs/IADLs), and assistive device utilization.

Results

Risk of death was reduced by 81% (age-adjusted OR [95% CI] = 0.19 [0.04–0.91]; P < .04) in the HIPFIT group (n = 4) compared with usual care controls (n = 8). Nursing home admissions were reduced by 84% (age-adjusted OR [95% CI] = 0.16 [0.04–0.64]; P < .01) in the experimental group (n = 5) compared with controls (n = 12). Basic ADLs declined less (P < .0001) and assistive device use was significantly lower at 12 months (P = .02) in the intervention group compared with controls. The targeted improvements in upper body strength, nutrition, depressive symptoms, vision, balance, cognition, self-efficacy, and habitual activity level were all related to ADL improvements (P < .0001–.02), and improvements in basic ADLs, vision, and walking endurance were associated with reduced nursing home use (P < .0001–.05).

Conclusion

The HIPFIT intervention reduced mortality, nursing home admissions, and ADL dependency compared with usual care. Australian New Zealand Clinical Trials Registry (ACTN12605000164695).

Section snippets

Trial Design

This was a randomized, parallel-group superiority trial with an intention-to-treat analytic strategy, irrespective of dropout or discontinuation of intervention.31 There were no missing data for primary outcomes of mortality and nursing home admissions, and missing data for other primary outcomes were handled via imputation as recommended.32 We conducted blinded assessment of 2 disability outcomes: the Functional Independence Measure (FIM)33 and the Assessment of Living Skills and Resources

Flow of Participants

Participants were recruited between February 2003 and April 2007, closing when funding ceased. All but one hip fracture patient admitted during recruitment (773/774; 99.9%) were assessed for eligibility, and 47% (124) of the 262 potentially eligible hip fracture patients consented (Figure 1). Hip fracture patients who were ineligible (n = 512), eligible but refused (n = 138), and consented (n = 124) were similar in age (79, 80, and 79 years, respectively; P = .79) and gender (67%, 67%, and 69%

Interpretation

One year of high-intensity progressive resistance training combined with a targeted multifactorial intervention directed at major predictors of frailty reduced mortality and nursing home use over 12 months by more than 80% after hip fracture. Additionally, independence in toileting and transferring and assistive device usage were significantly improved by HIPFIT compared with usual care.

Notably, usual care included inpatient orthogeriatric and allied health consultation, followed by 6 to 12

Conclusions

We have shown for the first time that provision of 12 months of supervised high-intensity progressive resistance training, with simultaneous targeting and treatment of other deficits related to frailty in a typical hip fracture cohort is feasible and effective. The HIPFIT intervention resulted in statistically significant and clinically meaningful reductions in mortality, nursing home use, ADL dependency, and assistive device usage. Rehabilitation withdrawn when prefracture levels of mobility

Acknowledgments

We are grateful for the assistance of Associate Professor Cherry Russell for acquisition of funding and study design and intervention implementation, the Ophthalmology Department of Royal Prince Alfred Hospital for assessments and treatment provided, Ms Amanda Eames for participant recruitment and training, to Helen Badge and Louise Cowles for blinded outcome assessments, to Michael Baker for statistical assistance, to the staff of Royal Prince Alfred and Balmain Hospitals for assistance with

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      Studies that reported the means and SDs of functional outcomes described in table 1 for both the control and intervention groups were included in this analysis. Standardized mean differences (SMDs) between groups and the SE in the estimate of the SMD were calculated.32-52 The regression coefficient and associated 95% CI were reported, along with I2 and adjusted R2 values to determine what degree the variables included in the model explained the variance in trial outcomes.

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    This work was carried out at the Exercise Health and Performance Research Group, Faculty of Health Sciences, University of Sydney.

    This study was funded by the Australian National Health and Medical Research Council (NH&MRC), project grant 211226, administered by The University of Sydney. The funding organization and the University of Sydney had no role in the design and conduct of the study; nor in the collection, management, analysis, and interpretation of the data; nor in preparation, writing, review, decision to submit for publication or approval of the manuscript. There was complete independence of researchers from funders and sponsors; and all researchers had complete access to all the data.

    Ethics approval was granted by the University of Sydney Human Research Ethics Committee and Sydney South West Area Health Service Ethics Review Committee in 2002. This trial was registered with the Australian New Zealand Clinical Trials Registry (ACTN12605000164695).

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