Frailty Intervention in Postoperative Hip Fracture Inpatients

Condition(s) studied

Investigational drug(s) / intervention(s)

Exercise Intervention: This arm will include and exercise and nutritional intervention in addition to usual postoperative hip fracture care. The exercise program will be delivered 3-5 times per week, each session lasting between 20-30 minutes depending on patient tolerance. The program will be progressed gradually between sessions and be guided by patient tolerance. The program will involve bed/ chair-based aerobic and resistance training (using an arm crank ergometer, resistance bands and ankle weights). The program will be delivered over the entire length of a patient's hospital stay up to a duration of 6 weeks for prolonged stays. All patients will undergo baseline assessments including assessment of level of frailty, pre-fracture level of mobility \& function, postoperative mobility, nutritional status/ screening, grip strength and level of pain.

Usual Care: This arm will assess all aspects of usual postoperative hip fracture care which will include multidisciplinary team assessment which include physiotherapists, occupational therapists, dieticians as well as specialist nurses and doctors working as part of the orthogeriatric team (falls and bone health assessment). They will receive daily physiotherapy training starting on the first postoperative day which will include mobility, balance, strength and gait training. This group will also receive additional protein supplementation in the form of a nutritional supplement twice daily as part of usual postoperative hip fracture care. All patients will undergo baseline assessments including assessment of level of frailty, pre-fracture level of mobility \& function, postoperative mobility, nutritional status/ screening, grip strength and level of pain. All patients will be asked to maintain a three-day food diary to monitor their protein intake.

Nutritional Intervention: The nutritional intervention will take the form of a protein fortified evening snack administered by nursing staff (additional 20g of protein).

Study summary

Hip fracture is a big health concern in older adults, and can lead to increased risk of death, reduced level of independence \& mobility, reduced quality of life, and higher likelihood of admission to nursing homes. Frailty is a medical condition associated with ageing that results in a reduced ability to do daily tasks. A frail older adult is also less able to recover well from conditions that may affect their wellbeing (for example, infections, falls resulting in injuries or hospital admissions). Frailty is common in older adults with hip fractures.

There has been increasing research showing that frailty can be slowed down and improved by a combination of nutritional supplementation and exercise. However, most of the research in this area has been in frail older adults living at home or in nursing homes. The exercise or nutritional programs in these studies tend to be carried out over weeks or months. There are very few studies looking at older adults in hospital and how exercise and nutrition help with frailty over shorter periods of time, even more so in patients who have sustained an injury.

There is, however, very little research in hospital based frailty programs in older patients who have suffered major trauma. It is well known that standing up and starting to walk soon after a hip fracture improves time to recovery, reduces hospital length of stay and death. Hence, physiotherapy on the first day after hip fracture surgery is now recommended. However, there needs to be more research to aid in developing physiotherapy and exercise programs that are safe and doable in the care of hip fracture patients despite limited resources in our healthcare system.

Similarly, although malnutrition is common in frail older adults with hip fractures, the benefits of nutritional supplementation in these patients is not fully understood. It is known that having a hip fracture puts a person at risk of muscle breakdown and increasing protein intake is recommended to help reduce this risk. Research on exercise and nutrition based frailty programs specific to hip fracture patients is strongly needed, specifically the development of that are doable and safe in the hospital setting that can help improve outcomes in hip fracture patients after surgery.

The investigators believe that a multicomponent exercise and nutrition based frailty program will be safe, doable and acceptable in frail older adults after hip fracture surgery.

Eligibility

Primary outcome measure(s)

• Eligibility Rate — Through study completion, an average of 6 months
  Patients eligible for inclusion/ total number of admissions
• Recruitment Rate — Through study completion, an average of 6 months
  Recruited patients/ Patients eligible for inclusion
• Number of drop outs — Through study completion, an average fo 6 months
  Number of participant dropouts after recruitment into study
• Number of intervention related adverse events — Through study completion, an average of 6 months
  Musculoskeletal injury/ pain, nausea, vomiting, aspiration, constipation etc.
• Compliance to prescribed duration of exercise sessions — Through completion of intervention, an average of 3 weeks up to a maximum of 6 weeks
  Percentage of sessions achieving 25 minutes of training
• Patient Acceptability of Intervention — Through study completion, an average of 6 months
  Survey utilising open ended questions and 5 point Likert Scales (Strongly Agree, Agree, Neither Agree nor Disagree, Disagree, Strongly Disagree) will be used to evaluate patient satisfaction of the intervention.
• Nursing staff acceptability of intervention delivery — Through study completion, an average of 6 months
  Survey utilising open ended questions and 5 point Likert Scales (Strongly Agree, Agree, Neither Agree nor Disagree, Disagree, Strongly Disagree) will be used to evaluate patient satisfaction of the intervention.
• Compliance with prescribed intensity — Through completion of intervention, an average of 3 weeks up to a maximum of 6 weeks
  Percentage of sessions completed at Borg Scale score 4-6
• Attendance rate — Through completion of intervention, an average of 3 weeks up to a maximum of 6 weeks
  Number of completed sessions/ number of planned sessions
• Compliance rate to prescribed nutritional intervention — Through completion of intervention, an average of 3 weeks up to a maximum of 6 weeks
  Number of supplements taken/ number prescribed

Trial sites (1)