認知症の大腿骨近位部骨折への多職種介入プログラム

認知症のある大腿骨近位部骨折患者にも多職種介入プログラムは予後を改善させるというRCTのサブグループ解析論文を紹介します。

Stenvall M, Berggren M, Lundström M, Gustafson Y, Olofsson B. A multidisciplinary intervention program improved the outcome after hip fracture for people with dementia--subgroup analyses of a randomized controlled trial. Arch Gerontol Geriatr. 2012 May-Jun;54(3):e284-9.

大腿骨近位部骨折患者の30-50%に認知症を認めます。多職種介入プログラムは、スタッフ教育、個別のケア計画とリハ、積極的予防、術後合併症（特にせん妄）の検索と治療で構成されています。CGA（comprehensive geriatric assessment）を用いています。

結果ですが、尿路感染症、栄養障害、せん妄、転倒といった術後合併症が有意に少ないという結果でした。4か月後の歩行能力、12ヶ月後のADLも有意に高かったです。以上より、認知症があっても多職種介入プログラムは有効であり、認知症を理由に除外すべきではないという結論です。

これは日本の回復期リハ病棟にも当てはまるかもしれません。認知症の有無で回復期リハ病棟の入院審査を左右させてはいけないというメッセージ・エビデンスのように聞こえます。ただ、サブグループ解析ですので、エビデンスレベルとしては十分とは言えませんが。

Abstract

BACKGROUND:

People with cognitive impairment and dementia have a poor outcome after a hip fracture surgery, about 30-50% of all those who sustain a hip fracture have dementia. Therefore the aim was to investigate whether a multidisciplinary postoperative intervention program could reduce postoperative complications and improve functional recovery among people with dementia.

METHODS:

A randomized controlled trial with subgroup analyses among patients with dementia. Sixty-four patients with femoral neck fracture, aged ≥70 years at Umeå University Hospital, Sweden. The intervention consisted of staff education, individualized care planning and rehabilitation, active prevention, detection and treatment of postoperative complications, especially delirium. The staff worked in teams to apply comprehensive geriatric assessment, management and rehabilitation, including a follow-up at 4 months postoperatively. The control group followed conventional postoperative routines.

RESULTS:

There were fewer postoperative complications in the intervention group such as urinary tract infections, p=0.001; nutritional problems, p=0.025; postoperative delirium, p=0.002; falls, p=0.006. At 4 months a larger proportion in the intervention group had regained their previous independent indoor walking ability performance, p=0.005. At 12 months a larger proportion in the intervention group had regained the activities of daily living (ADL) performance level they had before the fracture, p=0.027.

CONCLUSION:

This study demonstrates that patients with dementia who suffer a hip fracture can benefit from multidisciplinary geriatric assessment and rehabilitation and should not be excluded from rehabilitation programs.