ABSTRACT
Objectives: To evaluate caregivers’ fear of post-fracture patients falling, we previously developed the Caregivers’ Fear of Falling Index (CFFI). In this study, we investigated the relationship between patient performance in activities of daily living (ADLs) and CFFI.
Methods: We surveyed 55 patients receiving home-visit rehabilitation after fall-related fracture and their primary caregivers. Participants (patient and caregiver pair) were divided into two groups based on patient performance in basic ADLs (BADLs) and instrumental ADLs (IADLs). ROC analysis was conducted to assess the usefulness of CFFI and Falls Efficacy Scale-International (FES-I) in determining declines in performance in BADLs and IADLs. Multivariate logistic regression analysis was performed to examine the association between CFFI and declining performance in BADLs and IADLs.
Results: ROC analysis showed that CFFI exhibited a higher accuracy than FES-I (AUC: 0.73 in BADLs, 0.77 in IADLs) as an indicator of reduced ADL performance. Multivariate logistic analysis adjusted for age, sex, and physical function showed that CFFI was associated with a decline in patients’ performance in IADLs (odds ratio, 0.92; 95% confidence interval, 0.85–0.99).
Conclusions: Caregivers’ fear of post-fracture patients falling was associated with a decline in patients’ performance in IADLs. These findings may serve as a guide for supporting caregivers of post-fracture patients.
INTRODUCTION
In the elderly, fall-related fractures have multifaceted impacts on their physical function and functional ability. The fractures for which falls are the most common mechanism of injury are hip fractures (over 75%),1) upper extremity fractures (97%), wrist fractures (100%),2) and spinal fractures (at least 30%).3) Among these, hip fractures result in reduced mobility4) and constitute a significant consequence for the elderly.5) Therefore, hip fractures frequently require long-term rehabilitation using care insurance. Previous studies reported that 17%–65% of patients with hip fractures showed a decrease in basic activities of daily living (BADLs) at 3 months postoperatively,6,7,8) and 14%–57% of patients continued to exhibit ADL impairment at 1 year postoperatively.9,10,11,12,13,14) Furthermore, 13%–18% of these patients required walking assistance.11,15) For instrumental activities of daily living (IADLs), 66%–82% of patients with hip fractures required assistance at 3 months postoperatively,6,16) and 43%–71% still required assistance at 1 year postoperatively.9,10,16) Furthermore, in the case of the elderly, hip fractures are not the only fractures that affect ADL performance. In a study of patients with spinal fractures, Gosch et al.17) reported that 69% of patients had achieved independence in BADLs at 4 months after discharge. In another study of spinal fractures in the elderly, BADLs were reduced at 1 year after spinal fracture with a 24% decrease mobility.18) Although BADLs in patients with upper extremity fractures do not decline as significantly as those with lower extremity fractures or spinal fractures, the performance capabilities of patients with upper extremity fractures also show clear declines.19,20) In addition, there are numerous fall risk factors present in patients with wrist fractures, and many patients are at high risk of recurrent falls.21) In elderly patients who show a decline in ADLs after a fall-related fracture, factors that contribute to this decline include advanced age, impaired physical function, and cognitive decline.10,14,22)
In the care of elderly patients with fractures, primary caregivers are likely to fear that the patients under their care may suffer further falls while performing activities. In Japan, 66% of primary caregivers are family members who live with care recipients, many of whom are spouses or children.23) A previous study of patients with hip fracture and their primary caregivers showed that the fear of further falls was higher in primary caregivers than in the patients themselves.24) Furthermore, it has been suggested that caregivers’ fear of further falls in post-fracture patients can affect the care burden of the primary caregiver.25) Therefore, understanding the concerns of primary caregivers in relation to post-fracture patients suffering further falls is important for the welfare of patients receiving care at home.
When compared with a patient’s own fear of falling, the fear held by the caregiver may have equal or greater potential to limit the patient’s performance in BADLs and IADLs. To date, the lack of a common indicator to assess these factors has hindered investigations into their interrelationships. Therefore, in a previous study, we identified key items necessary for evaluating caregivers’ fear of post-fracture patients falling and developed an evaluation index.26) In the current study, we used this evaluation index to investigate the relationship between caregivers’ fear of post-fracture patients falling and patients’ performance in daily living. Currently, it remains unclear whether differences in fracture sites affect the caregivers’ fear of post-fracture patients falling. During post-fracture recovery, the risk of further fractures caused by recurrent falls is elevated regardless of the initial fracture site.27) Therefore, it is possible that the actual occurrence of a fall, rather than the specific fracture site, could influence the concerns of caregivers in relation to post-fracture patients suffering further falls. This study aimed to clarify the influence of caregivers’ fear of post-fracture patients falling on patients’ ADL performance, encompassing various fracture sites.
MATERIALS AND METHODS
This cross-sectional study was conducted in accordance with the Declaration of Helsinki. The study protocol was reviewed and approved by the Institutional Review Board of the International University of Health and Welfare (No. 20-Im-027).
Panel of ParticipantsParticipants included patients with a history of fall-related fractures and their primary caregivers. All patients met the following inclusion criteria: 1) past history of fall-related fracture of an upper extremity, a lower extremity, the spinal column, rib, or pelvis; 2) aged 65 years or older at the time of fracture; 3) less than 5 years since the time of the fracture to entry into the study; 4) the patient is not bedridden; 5) the primary caregiver was the spouse or a child of the patient and lived with the patient; 6) the primary caregiver showed no evidence of cognitive impairment; 7) the primary caregiver showed no evidence of psychiatric disorders (e.g., depression or anxiety neurosis); 8) all participants provided written consent to participate (after receiving verbal and written explanation of the study); and 9) receiving home-visit rehabilitation services during the study. Home-visit rehabilitation is one of the in-home rehabilitation services implemented under the long-term care insurance system in Japan. It is broadly categorized into home-visit rehabilitation and commuting rehabilitation services. The home-visit rehabilitation program is based on a comprehensive approach in the home environment and includes resistance training, gait exercises, and ADLs training, as necessary. In many cases, patients received one 40-min rehabilitation session per week. Data for this study were provided by International University of Health and Welfare Ichikawa Hospital, Ushiku Aiwa General Hospital, Home-visit Nursing Station Gratia, and Home-visit Nursing Station Ryugasaki. Subjects were evaluated from 1 July 2021 to 31 March 2023. The influence of fracture on patients’ physical function may vary with the type, location, and severity of the fracture. However, it remains unclear whether caregivers’ fear of patient falls varies according to the type of fracture. Therefore, we included patients with lower extremity fractures and those with fractures involving other body parts. Primary caregiver surveys were conducted within 1 week of patient evaluation.
Measurement of Caregivers’ Fear of Post-fracture Patients FallingCaregivers’ fear of post-fracture patients falling was assessed using the Caregivers’ Fear of Falling Index (CFFI). The CFFI is determined from a self-rated questionnaire that measures the fear of falling among primary caregivers of patients with fall-related fractures. The CFFI questionnaire utilizes 20 assessment items that were identified during our previous research. These items include not only the patient’s physical function and behavioral characteristics, but also the main caregiver’s home environment and behavioral characteristics.26) Each assessment item was rated on a four-point scale: 1, not at all applicable; 2, not very applicable; 3, somewhat applicable; 4, applicable; maximum score of 80 points. Because the questionnaire was targeted specifically at the primary caregiver, the caregiver and patient were explicitly identified at the beginning of the questionnaire as follows: “This questionnaire asks about you and the patient (name)”. As previously reported, the CFFI has good reliability with a Cronbach’s alpha of 0.904. Furthermore, its validity is supported by a moderate correlation with the Falls Efficacy Scale-International (FES-I) (r=0.432).28)
The FES-I is based on a self-administered questionnaire that asks patients to complete 16 items on a 64-point scale. The assessment items of the FES-I questionnaire encompass activities that are relevant to daily living and could potentially cause falls, such as taking a bath or shower, walking around the house, and getting in/out of a chair. As the respondents, the primary caregivers were asked to rate their confidence in the patients’ ability to perform each of these activities. The FES-I can also be used to evaluate caregivers’ fear of patients falling.24)
Measurement of Post-fracture Patients’ Performance in BADLs and IADLsThe Barthel Index (BI) was used to assess the performance of post-fracture patients in BADLs, whereas the Frenchay Activities Index (FAI) was used as a measure of IADLs. BI is based on performance in ten ADLs: feeding, dressing, transfers, grooming, toilet use, bathing, stair climbing, bowel control, bladder control, and mobility. Each item is rated on a scale of: “Independence”, “Partial assistance”, and “Assistance”, and the scores are summed to give a total score ranging from 0 to 100 (0, complete dependence; 100, complete independence). A score of 85 is considered to be the threshold for the transition to independence from requiring assistance.29) FAI is based on 15 items within the broad categories of domestic chores, hobbies, and occupation. FAI scores range from 0 to 45, with higher scores indicating that more IADLs are being performed. Previous studies have shown that FAI has good reliability and validity.30,31)
Other VariablesPatient data were obtained by rehabilitation personnel at each facility: age, sex, relationship with caregiver, long-term care-level, fracture site, comorbidities (hypertension, stroke, neurological degenerative disease, diabetes mellitus, malignant disease), Montreal Cognitive Assessment-Japanese version (MoCA-J), and Short Physical Performance Battery (SPPB). The long-term care level referred to the degree of care required of the care service, based on the assessment criteria of Japan’s long-term care insurance system. The long-term care level is divided into seven levels: requiring support 1 and 2, and requiring long-term care 1 to 5, depending on the level of care needed. In MoCA-J, a score below 26 indicates cognitive impairment.32) For SPPB, a score of 6 or lower indicates a high risk of falls.33)
Data AnalysisFor statistical analysis, the participants were divided into two groups for BADLs and two groups for IADLs. For BADLs, the decline group was defined as those with a BI score below 85, whereas that for IADLs was defined as an FAI score of less than 5, corresponding to the first quartile of the overall study subjects. The characteristics of the participants in the two groups were compared using the t-test, Mann–Whitney U test, or Chi-square test after evaluating normality and variance using the Shapiro–Wilk test. In ROC analysis, the area under the curve was calculated to evaluate the usefulness of determining the decline in performance in BADLs and IADLs for both CFFI and FES-I. In addition, ROC analysis was conducted to determine the optimal cutoff values. The logistic regression model was used to evaluate the influence of patients and CFFI on the scores for BADLs and IADLs, respectively. Covariables were adjusted in stages as follows: Model 1 used no adjustment (crude model); Model 2 was based on the crude model and used adjustments for age, sex, and SPPB (adjusted model). All statistical analysis was carried out using SPSS version 25 (IBM, Armonk, NY, USA). For all tests, P≤0.05 was considered significant; no correlation for multiple testing was performed.
RESULTS
Characteristics of ParticipantsThere were 55 participants (each participant being a patient and primary caregiver pair). The characteristics of the patients are presented in Table 1. The mean age of the patients at the time of study entry was 83.1 ± 9.0 years, and 35 (63.6%) were female. Of the 55 primary caregivers, 28 (50.9%) were spouses and 27 (49.1%) were children. The 55 fracture sites were classified as follows: 26 involved a lower extremity (47.2%), 15 were in the spinal column (27.5%), 8 involved an upper extremity (14.5%), and 6 were classified as other (10.9%). A total of 49 (89.1%) patients showed cognitive decline (MoCA-J score <26),25) and 32 (58.2%) had a high risk of falling (SPPB score ≤6.25) Among the participants, 22 (40.0%) showed a decline in performance in BADLs and 14 (25.5%) exhibited a decline in IADL performance. In both groups with declines in performance in BADLs and IADLs, the SPPB scores were significantly lower and CFFI scores were significantly higher.
Table 1. Characteristics of participants
| All subjects | BADLs | IADLs |
| Decline | No decline | P value | Decline | No decline | P value |
| Patients (n=55) |
| Number | 55 | ( | 100.0 | ) | 22 | ( | 40.0 | ) | 33 | ( | 60.0 | ) | | 14 | ( | 25.4 | ) | 41 | ( | 74.5 | ) | |
| Age (years) | 83.1 | ± | 9.0 | | 85.6 | ± | 6.4 | | 81.4 | ± | 10.2 | | 0.07 | 85.6 | ± | 6.4 | | 81.4 | ± | 10.2 | | 0.09 |
| Sex (female) | 35 | ( | 63.6 | ) | 19 | ( | 54.3 | ) | 16 | ( | 45.7 | ) | <0.01 | 10 | ( | 28.6 | ) | 25 | ( | 71.4 | ) | 0.48 |
| Relationship of caregiver | | | | | | | | | | | | | 0.23 | | | | | | | | | 0.49 |
| Spouse | 28 | ( | 50.9 | ) | 9 | ( | 32.1 | ) | 19 | ( | 67.9 | ) | 6 | ( | 21.4 | ) | 22 | ( | 78.6 | ) |
| Child | 27 | ( | 49.1 | ) | 13 | ( | 48.1 | ) | 14 | ( | 51.9 | ) | 8 | ( | 29.6 | ) | 19 | ( | 70.4 | ) |
| Required long-term care level |
| Requiring support 2 | 9 | ( | 16.4 | ) | 0 | ( | 0.0 | ) | 9 | ( | 100.0 | ) | 1 | ( | 11.1 | ) | 8 | ( | 88.9 | ) |
| Long-term care 1 | 9 | ( | 16.4 | ) | 1 | ( | 11.1 | ) | 8 | ( | 88.9 | ) | 0 | ( | 0.0 | ) | 9 | ( | 100 | ) |
| Long-term care 2 | 12 | ( | 21.8 | ) | 3 | ( | 25.0 | ) | 9 | ( | 75.0 | ) | 1 | ( | 8.3 | ) | 11 | ( | 91.7 | ) |
| Long-term care 3 | 14 | ( | 25.5 | ) | 12 | ( | 85.7 | ) | 2 | ( | 14.3 | ) | 8 | ( | 57.1 | ) | 6 | ( | 42.9 | ) |
| Long-term care 4 | 9 | ( | 16.4 | ) | 4 | ( | 44.4 | ) | 5 | ( | 55.6 | ) | 2 | ( | 22.2 | ) | 7 | ( | 77.8 | ) |
| Long-term care 5 | 2 | ( | 3.6 | ) | 2 | ( | 100.0 | ) | 0 | ( | 0.0 | ) | 2 | ( | 100.0 | ) | 0 | ( | 0.0 | ) |
| Fracture site |
| Upper extremity | 8 | ( | 14.5 | ) | 3 | ( | 37.5 | ) | 5 | ( | 62.5 | ) | 0 | ( | 0 | ) | 8 | ( | 100.0 | ) |
| Lower extremity | 26 | ( | 47.2 | ) | 8 | ( | 30.8 | ) | 18 | ( | 69.2 | ) | 6 | ( | 23.1 | ) | 20 | ( | 76.9 | ) |
| Spinal column | 15 | ( | 27.5 | ) | 10 | ( | 66.7 | ) | 5 | ( | 33.3 | ) | 7 | ( | 46.7 | ) | 8 | ( | 53.3 | ) |
| Other | 6 | ( | 10.9 | ) | 1 | ( | 16.7 | ) | 5 | ( | 83.3 | ) | 1 | ( | 16.7 | ) | 5 | ( | 83.3 | ) |
| Comorbidities |
| Hypertension | 41 | ( | 74.5 | ) | 16 | ( | 72.7 | ) | 25 | ( | 75.7 | ) | 0.80 | 11 | ( | 78.5 | ) | 30 | ( | 73.1 | ) | 0.69 |
| Stroke | 12 | ( | 21.8 | ) | 3 | ( | 25.0 | ) | 9 | ( | 75.0 | ) | 0.23 | 2 | ( | 16.7 | ) | 10 | ( | 83.3 | ) | 0.43 |
| Neurodegenerative disease | 9 | ( | 16.4 | ) | 4 | ( | 44.4 | ) | 5 | ( | 55.6 | ) | 0.77 | 3 | ( | 33.3 | ) | 6 | ( | 66.7 | ) | 0.55 |
| Diabetes mellitus | 10 | ( | 18.2 | ) | 2 | ( | 20.0 | ) | 8 | ( | 80.0 | ) | 0.15 | 2 | ( | 20.0 | ) | 8 | ( | 80.0 | ) | 0.66 |
| Heart disease | 16 | ( | 29.1 | ) | 6 | ( | 37.5 | ) | 10 | ( | 62.5 | ) | 0.81 | 4 | ( | 25.0 | ) | 12 | ( | 75.0 | ) | 0.96 |
| Malignant disease | 8 | ( | 14.5 | ) | 3 | ( | 37.5 | ) | 5 | ( | 62.5 | ) | 0.88 | 1 | ( | 12.5 | ) | 7 | ( | 87.5 | ) | 0.36 |
| MoCA-J <26 | 49 | ( | 89.1 | ) | 21 | ( | 42.9 | ) | 28 | ( | 57.1 | ) | 0.22 | 1 | ( | 16.7 | ) | 5 | ( | 83.3 | ) | 0.60 |
| SPPB ≤6 | 32 | ( | 58.2 | ) | 21 | ( | 65.6 | ) | 11 | ( | 34.4 | ) | <0.01 | 1 | ( | 4.3 | ) | 22 | ( | 95.7 | ) | <0.01 |
| Caregivers (n=55) |
| CFFI | 44.5 | ± | 11.0 | | 50.0 | ± | 10.2 | | 40.8 | ± | 10.1 | | <0.01 | 52.4 | ± | 9.8 | | 41.7 | ± | 10.1 | | <0.01 |
| FES-I | 40.4 | ± | 13.3 | | 40.0 | ± | 13.6 | | 40.6 | ± | 13.3 | | 0.86 | 42.9 | ± | 11.9 | | 39.5 | ± | 13.8 | | 0.42 |
Data given as number (percentage) or mean ± standard deviation.
Requiring support 2, requires support with movements such as walking because of instability; Long-term care 1, requires assistance with daily activities such as bathing; Long-term care 2, requires support with movements including the act of standing up; Long-term care 3, cannot walk independently; Long-term care 4, requires assistance with all ADLs; Long-term care 5, completely dependent on care
The results of ROC analysis are shown in Fig. 1 The areas under the curve (AUCs) for BADLs and IADLs in CFFI were 0.73 (P<0.01) and 0.77 (P<0.01), respectively. In contrast, AUCs for BADLs and IADLs in FES-I were 0.53 (P=0.71) and 0.61 (P=0.24), respectively, indicating that CFFI has higher accuracy than FES-I as an indicator of reduced ADL performance. The cutoff points for CFFI to determine decline in performance in BADLs and IADLs for post-fracture patients were 42/43 (sensitivity: 77.3%, specificity: 60.6%) and 46/47 (sensitivity: 71.4%, specificity: 65.9%), respectively.
Results of Multivariate AnalysisThe results of the logistic regression model are shown in Table 2. In the crude model, the odds ratio (95% confidence interval; P value) for CFFI was 0.91 (0.86–0.97; P<0.01) for BADLs and 0.90 (0.83–0.97; P<0.01) for IADLs. In the adjusted model (adjusted for age, sex, SPPB score ≤6), the odds ratio was 0.95 (0.88–1.02; P=0.16) for BADLs and 0.92 (0.85–0.99; P=0.04) and IADLs. When FES-I was used as an explanatory variable, neither BADLs nor IADLs was significant in the crude model.
Table 2. Results of multivariate analysis
| Model 1 (crude model) | Model 2 (adjusted model) |
| OR | 95% CI | P value | OR | 95% CI | P value |
| BADLs |
| CFFI | 0.91 | 0.86–0.97 | <0.01 | 0.95 | 0.88–1.02 | 0.16 |
| IADLs |
| CFFI | 0.90 | 0.83–0.97 | <0.01 | 0.92 | 0.85–0.99 | <0.05 |
Model 2 adjusted for age, sex, SPPB score ≤6
DISCUSSION
This study investigated the relationship between caregivers’ fear of post-fracture patients falling and the decline in performance of home-visit rehabilitation patients who previously experienced fall-related fractures. The results indicated that caregivers’ fear of patients falling did not act as an independent factor for patients’ BADLs, but it was a significant variable for their IADLs, even after adjusting for age, sex, and physical function. To the best of our knowledge, this study is the first to demonstrate the potential association between caregivers’ fear of post-fracture patient falling and a decline in performance in patients’ daily activities.
The existence of a relationship between the performance in daily activities of care recipients and the psychological background of caregivers has been suggested in previous studies. Based on interviews with caregivers, Faes et al.34) reported that falls have significant physical and psychological impacts on both patients and family caregivers, leading to concerns about subsequent declines in patient activity. However, this study is the first to demonstrate the potential association between caregivers’ fear for post-fracture patients and decreased performance of the patients. Our newly developed CFFI includes items related not only to a patient’s physical function but also to the caregiver’s environment and psychological background.26) In particular, IADLs have been reported to be influenced not only by physical function but also by lifestyle factors,35) and the influence of these factors may reflect the relationship with IADLs. In addition, previous studies reported that difficulty in performing IADLs increases the risk of falls more than difficulty in performing BADLs,36) and primary caregivers may not always recommend performing IADLs.
This study recruited patients receiving home-visit rehabilitation as the target participants. The activity levels of hospitalized patients are managed and adjusted by medical professionals, whereas the activity levels of patients living at home are entrusted to themselves or their families. Therefore, in the case of patients living at home, the psychological state of the primary caregiver is considered to have a significant impact on the patient’s performance in daily activities. This study included patients with various fracture sites, including fractures of the lower extremities, spinal column, and upper extremities. Although the impact on physical function may vary depending on the location of the fracture, the study specifically focused on home-visit rehabilitation patients with reduced activity levels. Even after adjusting for physical function, the results still indicated a potential association between caregivers’ fear of post-fracture patients’ falling and a decline in patients’ activities. Furthermore, the participants of the current study had relatively low levels of physical and cognitive functioning when compared with the total population of community-dwelling elderly citizens, based on previous studies.32,37,38,39) Regarding the ADL measures used in this study, BADLs were assessed using the Barthel Index, and a decline in performance was defined as a BI below 85.16) In contrast, IADLs were assessed using FAI, and a decline in performance was defined as an FAI score lower than 5. A previous study suggested that poor physical function increases the physical burden on caregivers,40) and the research findings may be specific to a subgroup of patients who have a poor level of activity even among those who live at home.
Although previous studies have reported a correlation between functional ability and cognitive function, this study found no clear correlation between a decline in performance (as defined in this study) and cognitive decline. All participants in this study received home-visit rehabilitation and showed lower physical and cognitive functions than similarly aged community-dwelling citizens.32,37,38,39) In fact, 89% of participants scored below 26 points on MoCA-J, which is an indicator of cognitive decline. Although this study did not identify a clear relationship between cognitive decline and declines in performance in BADLs and IADLs, the impact of cognitive decline on the functional ability of the elderly is significant.41,42,43) It is desirable to further investigate this issue by expanding the scope of the study to consider the influence of cognitive function.
This study has some limitations. First, this study focused on patients receiving home-visit rehabilitation as the target population. Although a wider range of participants was considered when planning the study, it was anticipated that communication with primary caregivers, especially patients’ families, would be difficult if inpatients were selected as participants under the circumstances of the COVID-19 pandemic. Furthermore, limited visitation by patients’ family members could significantly alter the results. By narrowing the target group to patients receiving home-visit rehabilitation, it is possible that the participants in this study had lower functional levels than a general population with fall-related fractures. Second, the elapsed time from fracture to actual measurement was not standardized. In this study, the length of time from fracture to the resumption of ADLs varied among the participants because the start time of home-visit rehabilitation differed for each participant. As a result, the experience of patients and primary caregivers during home-visit rehabilitation may have affected the results. Third, this study did not consider the contents of the rehabilitation programs. Given that rehabilitation programs may differ in content, focus, and intensity, some types of rehabilitation may be more effective than others in reducing caregivers’ fear of fall-related fracture.44) Therefore, future research should investigate the impact of different rehabilitation programs on caregivers’ fear of fall-related fractures and should consider the content of rehabilitation as a potential moderator of such fears.
CONCLUSION
The results of this study suggest that caregivers’ excessive fear of post-fracture patients falling is associated with a decline in the IADLs of these patients. These findings indicate that both patients and primary caregivers require guidance in supporting the daily activities of post-fracture patients. Future investigations using larger samples and longitudinal studies are needed to confirm the findings of this study.
ACKNOWLEDGMENTS
The authors thank the rehabilitation therapists of International University of Health and Welfare Ichikawa Hospital, Ushiku Aiwa General Hospital, the Home-visit Nursing Station Gratia, and the Home-visit Nursing Station of Ryugasaki for their contributions to data collection.
CONFLICTS OF INTEREST
The authors declare no conflict of interest.
REFERENCES
- 1. Aharonoff GB, Dennis MG, Elshinawy A, Zuckerman JD, Koval KJ: Circumstances of falls causing hip fractures in the elderly. Clin Orthop Relat Res 1998;348:10–14. PMID:9553527, DOI:10.1097/00003086-199803000-00004
- 2. Palvanen M, Kannus P, Parkkari J, Pitkäjärvi T, Pasanen M, Vuori I, Järvinen M: The injury mechanisms of osteoporotic upper extremity fractures among older adults: a controlled study of 287 consecutive patients and their 108 controls. Osteoporos Int 2000;11:822–831. PMID:11199185, DOI:10.1007/s001980070040
- 3. Cooper C, Atkinson EJ, O’Fallon WM, Melton JL, III Incidence of clinically diagnosed vertebral fractures: a population‐based study in Rochester, Minnesota, 1985–1989. J Bone Miner Res 1992;7:221–227. PMID:1570766, DOI:10.1002/jbmr.5650070214
- 4. Fleig L, McAllister MM, Brasher P, Cook WL, Guy P, Puyat JH, Khan KM, McKay HA, Ashe MC: Sedentary behavior and physical activity patterns in older adults after hip fracture: a call to action. J Aging Phys Act 2016;24:79–84. PMID:25950867, DOI:10.1123/japa.2015-0013
- 5. Zidén L, Wenestam CG, Hansson-Scherman M: A life-breaking event: early experiences of the consequences of a hip fracture for elderly people. Clin Rehabil 2008;22:801–811. PMID:18728133, DOI:10.1177/0269215508090204
- 6. Ganczak M, Chrobrowski K, Korzeń M: Predictors of a change and correlation in activities of daily living after hip fracture in elderly patients in a community hospital in Poland: a six-month prospective cohort study. Int J Environ Res Public Health 2018;15:95. PMID:29316721, DOI:10.3390/ijerph15010095
- 7. Ariza-Vega P, Jiménez-Moleón JJ, Kristensen MT: Change of residence and functional status within three months and one year following hip fracture surgery. Disabil Rehabil 2014;36:685–690. PMID:23919643, DOI:10.3109/09638288.2013.813081
- 8. Koval KJ, Skovron ML, Aharonoff GB, Zuckerman JD: Predictors of functional recovery after hip fracture in the elderly. Clin Orthop Relat Res 1998;348:22–28. PMID:9553529, DOI:10.1097/00003086-199803000-00006
- 9. Shah MR, Aharonoff GB, Wolinsky P, Zuckerman JD, Koval KJ: Outcome after hip fracture in individuals ninety years of age and older. J Orthop Trauma 2001;15:34–39. PMID:11147685, DOI:10.1097/00005131-200101000-00007
- 10. Ishidou Y, Koriyama C, Kakoi H, Setoguchi T, Nagano S, Hirotsu M, Yamamoto T, Yokouchi M, Komiya S: Predictive factors of mortality and deterioration in performance of activities of daily living after hip fracture surgery in Kagoshima, Japan. Geriatr Gerontol Int 2017;17:391–401. PMID:26822837, DOI:10.1111/ggi.12718
- 11. Konda SR, Dedhia N, Ranson RA, Tong Y, Ganta A, Egol KA: Loss of ambulatory level and activities of daily living at 1 year following hip fracture: can we identify patients at risk? Geriatr Orthop Surg Rehabil 2021;12:21514593211002158. PMID:33868763, DOI:10.1177/21514593211002158
- 12. Mariconda M, Costa GG, Cerbasi S, Recano P, Orabona G, Gambacorta M, Misasi M: Factors predicting mobility and the change in activities of daily living after hip fracture: a 1-year prospective cohort study. J Orthop Trauma 2016;30:71–77. PMID:26817573, DOI:10.1097/BOT.0000000000000448
- 13. Umehara T, Tanaka R, Nagao S, Tomiyama D, Kawabata Y, Nagano Y, Takeuchi Y, Kakehashi M: Efficient predictors for the decline of activities of daily living in patients with hip fracture one year after surgery: a multicenter prospective cohort study. J Back Musculoskeletal Rehabil 2020;33:553–560. PMID:32444533, DOI:10.3233/BMR-181126
- 14. Córcoles-Jiménez MP, Villada-Munera A, del Egido-Fernández MÁ, Candel-Parra E, Moreno-Moreno M, Jiménez-Sánchez MD, Piña-Martínez A: Recovery of activities of daily living among older people one year after hip fracture. Clin Nurs Res 2015;24:604–623. PMID:25796268, DOI:10.1177/1054773815573261
- 15. Shyu YI, Chen MC, Wu CC, Cheng HS: Family caregivers’ needs predict functional recovery of older care recipients after hip fracture. J Adv Nurs 2010;66:2450–2459. PMID:20722808, DOI:10.1111/j.1365-2648.2010.05418.x
- 16. Moerman S, Mathijssen NM, Tuinebreijer WE, Nelissen RG, Vochteloo AJ: Less than one‐third of hip fracture patients return to their prefracture level of instrumental activities of daily living in a prospective cohort study of 480 patients. Geriatr Gerontol Int 2018;18:1244–1248. PMID:30004174, DOI:10.1111/ggi.13471
- 17. Gosch M, Druml T, Nicholas JA, Hoffmann-Weltin Y, Roth T, Zegg M, Blauth M, Kammerlander C: Fragility non-hip fracture patients are at risk. Arch Orthop Trauma Surg 2015;135:69–77. PMID:25412880, DOI:10.1007/s00402-014-2115-4
- 18. Theander E, Jarnlo GB, Ornstein E, Karlsson MK: Activities of daily living decrease similarly in hospital-treated patients with a hip fracture or a vertebral fracture: a one-year prospective study in 151 patients. Scand J Public Health 2004;32:356–360. PMID:15513668, DOI:10.1080/14034940410026912
- 19. Madhok R, Green S: Longer term functional outcome and societal implications of upper limb fractures in the elderly. J R Soc Health 1993;113:179–180. PMID:8410908, DOI:10.1177/146642409311300405
- 20. González N, Aguirre U, Orive M, Zabala J, García-Gutiérrez S, Las Hayas C, Navarro G, Quintana JM: Health-related quality of life and functionality in elderly men and women before and after a fall-related wrist fracture. Int J Clin Pract 2014;68:919–928. PMID:24666925, DOI:10.1111/ijcp.12410
- 21. Dewan N, MacDermid JC, Grewal R, Beattie K: Risk factors predicting subsequent falls and osteoporotic fractures at 4 years after distal radius fracture—a prospective cohort study. Arch Osteoporos 2018;13:32. PMID:29558002, DOI:10.1007/s11657-018-0445-5
- 22. Beloosesky Y, Grinblat J, Epelboym B, Weiss A, Grosman B, Hendel D: Functional gain of hip fracture patients in different cognitive and functional groups. Clin Rehabil 2002;16:321–328. PMID:12017519, DOI:10.1191/0269215502cr497oa
- 23. Kusaba T, Sato K, Fukuma S, Yamada Y, Matsui Y, Matsuda S, Ando T, Sakushima K, Fukuhara S: Influence of family dynamics on burden among family caregivers in aging Japan. Fam Pract 2016;33:466–470. PMID:27450988, DOI:10.1093/fampra/cmw062
- 24. Shen J, Hu F, Liu F, Tong P: Functional restriction for the fear of falling in family caregivers. Medicine (Baltimore) 2015;94:e1090. PMID:26166092, DOI:10.1097/MD.0000000000001090
- 25. Kuzuya M, Masuda Y, Hirakawa Y, Iwata M, Enoki H, Hasegawa J, Izawa S, Iguchi A: Falls of the elderly are associated with burden of caregivers in the community. Int J Geriatr Psychiatry 2006;21:740–745. PMID:16858745, DOI:10.1002/gps.1554
- 26. Kakehi T, Tamura N, Zenta M, Suzuki Y, Nakajima K, Wada H, Ishimori T, Bessho M, Kakuda W: Proposal of index to evaluate caregivers’ fear of care recipient falls. Int J Rehabil Res 2022;45:366–369. PMID:35942635, DOI:10.1097/MRR.0000000000000543
- 27. Kanis JA, Johansson H, Odén A, Harvey NC, Gudnason V, Sanders KM, Sigurdsson G, Siggeirsdottir K, Fitzpatrick LA, Borgström F, McCloskey EV: Characteristics of recurrent fractures. Osteoporos Int 2018;29:1747–1757. PMID:29947869, DOI:10.1007/s00198-018-4502-0
- 28. Kakehi T, Zenta M, Ishimori T, Tamura N, Wada H, Bessho M, Kakuda W: Reliability and validity of caregivers’ fear of falling index when caring for home-based rehabilitation patients with fall-related fractures. Ann Rehabil Med 2023;47:300–306. PMID:37644719, DOI:10.5535/arm.23052
- 29. Di Monaco M, Castiglioni C, Di Carlo S: Lean mass and functional recovery in men with hip fracture: a short-term prospective pilot study. Am J Phys Med Rehabil 2018;97:401–406. PMID:29206665, DOI:10.1097/PHM.0000000000000875
- 30. Wade DT, Legh-Smith J, Hewer RL: Social activities after stroke: measurement and natural history using the Frenchay Activities Index. Int Rehabil Med 1985;7:176–181. PMID:4093249, DOI:10.3109/03790798509165991
- 31. Turnbull JC, Kersten P, Habib M, McLellan L, Mullee MA, George S: Validation of the Frenchay Activities index in a general population aged 16 years and older. Arch Phys Med Rehabil 2000;81:1034–1038. PMID:10943751, DOI:10.1053/apmr.2000.7162
- 32. Fujiwara Y, Suzuki H, Yasunaga M, Sugiyama M, Ijuin M, Sakuma N, Inagaki H, Iwasa H, Ura C, Yatomi N, Ishii K, Tokumaru AM, Homma A, Nasreddine Z, Shinkai S: Brief screening tool for mild cognitive impairment in older Japanese: validation of the Japanese version of the Montreal Cognitive Assessment. Geriatr Gerontol Int 2010;10:225–232. PMID:20141536, DOI:10.1111/j.1447-0594.2010.00585.x
- 33. Veronese N, Bolzetta F, Toffanello ED, Zambon S, De Rui M, Perissinotto E, Coin A, Corti MC, Baggio G, Crepaldi G, Sergi G, Manzato E: Association between Short Physical Performance Battery and falls in older people: the Progetto Veneto Anziani Study. Rejuvenation Res 2014;17:276–284. PMID:24387140, DOI:10.1089/rej.2013.1491
- 34. Faes MC, Reelick MF, Joosten-Weyn Banningh LW, Gier M, Esselink RA, Olde Rikkert MG: Qualitative study on the impact of falling in frail older persons and family caregivers: foundations for an intervention to prevent falls. Aging Ment Health 2010;14:834–842. PMID:20635232, DOI:10.1080/13607861003781825
- 35. Tomioka K, Kurumatani N, Hosoi H: Association between social participation and 3‐year change in instrumental activities of daily living in community‐dwelling elderly adults. J Am Geriatr Soc 2017;65:107–113. PMID:27673582, DOI:10.1111/jgs.14447
- 36. Tornero-Quiñones I, Sáez-Padilla J, Espina Díaz A, Abad Robles MT, Sierra Robles Á: Functional ability, frailty and risk of falls in the elderly: relations with autonomy in daily living. Int J Environ Res Public Health 2020;17:1006. PMID:32033397, DOI:10.3390/ijerph17031006
- 37. Beckmann M, Bruun-Olsen V, Pripp AH, Bergland A, Smith T, Heiberg KE: Recovery and prediction of physical function 1 year following hip fracture. Physiother Res Int 2022;27:e1947. PMID:35332627, DOI:10.1002/pri.1947
- 38. Sugie M, Harada K, Nara M, Kugimiya Y, Takahashi T, Kitagou M, Kim H, Kyo S, Ito H: Prevalence, overlap, and interrelationships of physical, cognitive, psychological, and social frailty among community-dwelling older people in Japan. Arch Gerontol Geriatr 2022;100:104659. PMID:35190333, DOI:10.1016/j.archger.2022.104659
- 39. Hao W, Zhao W, Kimura T, Ukawa S, Kadoya K, Kondo K, Tamakoshi A: Association of gait with global cognitive function and cognitive domains detected by MoCA-J among community-dwelling older adults: a cross-sectional study. BMC Geriatr 2021;21:523. PMID:34600495, DOI:10.1186/s12877-021-02467-5
- 40. Riffin C, Van Ness PH, Wolff JL, Fried T: Multifactorial examination of caregiver burden in a national sample of family and unpaid caregivers. J Am Geriatr Soc 2019;67:277–283. PMID:30452088, DOI:10.1111/jgs.15664
- 41. Owens WD, Felts JA, Spitznagel EL, Jr ASA physical status classifications: a study of consistency of ratings. Anesthesiology 1978;49:239–243. PMID:697077, DOI:10.1097/00000542-197810000-00003
- 42. Ryg J, Rejnmark L, Overgaard S, Brixen K, Vestergaard P: Hip fracture patients at risk of second hip fracture: a nationwide population-based cohort study of 169,145 cases during 1977–2001. J Bone Miner Res 2009;24:1299–1307. PMID:19257816, DOI:10.1359/jbmr.090207
- 43. Egan M, Jaglal S, Byrne K, Wells J, Stolee P: Factors associated with a second hip fracture: a systematic review. Clin Rehabil 2008;22:272–282. PMID:18057086, DOI:10.1177/0269215507081573
- 44. Cheng HY, Chair SY, Chau JP: Effectiveness of a strength-oriented psychoeducation on caregiving competence, problem-solving abilities, psychosocial outcomes and physical health among family caregiver of stroke survivors: a randomised controlled trial. Int J Nurs Stud 2018;87:84–93. PMID:30059815, DOI:10.1016/j.ijnurstu.2018.07.005
