A fractured hip sends a person with dementia into a hospital system that often worsens their confusion, mobility, and health. This programme aims to redesign that entire experience by building and testing an Enhanced Recovery Pathway (ERP) specifically for these patients. The problem is stark: people with dementia admitted for hip fracture face higher rates of complications such as delirium, and their hospital stay can accelerate long-term decline. Yet there is almost no research on complex, coordinated care pathways tailored to their needs. Current best practice is undefined, and staff training and hospital culture are not set up to deliver it. If the ERP works, it could change how every NHS hospital handles these admissions. The pathway—developed with patients, carers, and clinicians—will include a training manual to shift ward culture and ensure consistent, dementia-aware care. A pilot study in ten hospitals will test whether the approach is clinically effective and cost-effective, providing the data needed for a definitive large-scale trial. Success would mean fewer complications, better recovery, and lower costs for a vulnerable group that currently falls through the cracks of standard surgical care.
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This programme, which is consistent with the MRC Framework for Complex Interventions (1), aims to improve hospital care for people with dementia (PwD) admitted with a fractured hip. We will develop and examine the feasibility, acceptability and potential clinical and cost effectiveness of an Enhanced Recovery Pathway (ERP). Objectives: 1. Establish current best practice from a systematic review and the perspectives of service users, carers, health care professionals, health service managers and experts in the field (Work Package (WP) 1) 2. Define an optimised care pathway- the ERP (WP 1). 3. Determine the staff training and cultural/organisational changes required to implement and maximise adherence to the ERP in hospital settings (WP 2). 4. Produce a training manual promoting cultural and organisational changes and maximising ERP adherance (WP 2). 5. Undertake a pilot study to assess the clinical and cost effectiveness of the ERP to inform a future large Randomised Controlled Trial (RCT) (WP 3). 6. Disseminate and definitive trial bid development (WP 4). BACKGROUND PwD with a fractured hip often have complications but can achieve comparable outcomes to patients without dementia (3-6). There is a need to optimise inpatient care for PWD and explore models of re-ablement to improve outcomes and reduce costs (6). IMPORTANCE Hospital care for PwD is a high priority as admission often worsens health and increases risks of complications e.g delirium (7, 8). NEED FOR RESEARCH Research is needed to define a system of care for cognitively impaired patients including rehabilitation, which aims to prevent undue decline. PAST AND CURRENT RESEARCH There has been very limited research in PWD and hip fracture particularly in complex interventions. WORK UNDERTAKEN Members of the team have undertaken systematic reviews on the management of delirium and significantly contributed to NICE guidance on hip fracture, delirium and dementia. We have presented PERFECTED to consumer groups, clinicians, hospital managers and commissioners. The project was reviewed by carers and patients from the Alzheimer s Society and Dementia UK and strongly endorsed. RESEARCH PLANS WP 1: We will establish best practice in the care of PwD with hip fracture by systematically reviewing the literature, observing practice, surveying care, and eliciting stakeholders views. Key components will form the Enhanced Recovery Pathway (ERP) and an audit checklist. WP 2: We will produce a training manual reflecting and supporting changes in working culture and organisation to ensure wards put the ERP into practice as faithfully as possible. This will be developed through 3 cycles of action research consisting of audits of practice, feedback to clinical staff and development of practice, which will inform the content and structure of the Manual. WP 3: We will conduct a cluster, randomised, controlled, pilot study in 10 hospitals to test for preliminary evidence of clinical effectiveness and cost-effectiveness. It will gather data to inform recruitment, select appropriate outcome measures and allow a sample size calculation for a definitive RCT. WP 4: Disseminate findings and develop definitive RCT proposal. RESEARCH TEAM The highly interdisciplinary team has recognised experts in all required domains: in dementia, delirium, hip fracture acute care and rehabilitation, development and evaluation of complex interventions, nursing research, occupational therapy, physiotherapy, behaviour change and organisational change theory, health economics, statistics, clinical trials, quantitative and qualitative research methods, workforce planning and NHS management. RESEARCH ENVIRONMENT The University of East Anglia has fifteen years of health services research with high impact outputs (e.g in The Lancet), using multi-methods research, RCTs, systematic reviews, qualitative and health economic studies. We will be supported by a UKCRC registered Clinical Tr
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