Health-related Quality of Life (QoL) is recognised as an important measure of health status that may be used for evaluating disease and health care services [26]. It is a broad, multidimensional construct that includes domains such as physical, psychological, and social functionality [27] and which permits to identify specific aspects of QoL and target necessary intervention.

Some patients suffer from QoL [28] and wellbeing loss [29] while others move to nursing home facilities [30]. According to Rasmussen and colleagues [31], wellbeing and self-efficacy are resources for both health and illness to be taken into account when exploring ways of promoting possibilities of recovery. The importance of patients’ perception of the care they receive has been highlighted in the literature over the past few years [32]. Without QoL data, the burden of osteoporotic fractures is likely to be underestimated [33]. The EQ-5D has been recommended for the assessment of QoL in elderly patients [34]. Although this instrument shows good psychometric properties in elderly patients, assessing the QoL of cognitively impaired patients is difficult. In people with mild and moderate dementia, this tests yield good validity and good-to-average test–retest reliability for the descriptive system, but not for the Visual Analogue Scale (VAS), which is a part of this questionnaire. Proxy assessment is, in some cases, the only way to gather information regarding QoL, when patients are unable to respond. Family caregivers have a tendency to overestimate health limitations concerning less visible items (pain and anxiety/depression). Very frequently, health-care professionals rate patients at the same level for all five domains (some problems with everything). No consensus has been reached as to the most appropriate proxy to apply, but proxy assessment of EQ-5D seems, in our opinion, to be the best option when assessing QoL in patients with severe dementia. QoL should be assessed using the EQ-5D method upon admission to determine pre-fracture QoL and in post-admission 90-day and 1-year follow-ups. In patients affected by severe dementia, EQ-5D should be completed by a proxy, if one is available [35].

Fear of falling is linked to self-efficacy. Self-efficacy is the belief people have about their capability to perform certain tasks [36].

After hip fracture, older people have reported that their lives have changed physically, personally and socially [37]. McMillan and colleagues [38] conducted interviews 3 months after discharge from hospital and found that during hip fracture rehabilitation, older people struggled to take control of their future lives by trying to balance risk-taking and help-seeking. The interviewees were aware that, on the one hand, it might prove risky to move around and that they were afraid of falling but, on the other, they wanted to be active and were trying to do things. They were determined to regain independence. In order to make progress, some of the interviewees stressed the importance of giving information to patients and to include them in talks regarding their progress. In the patient follow-up, FOF should be assessed 90 days after admission.

In the HF patients, pain should be assessed, initially, during EQ-5D test; however, as we said before, the VAS used by EQ-5D is not reliable in cognitively impaired patients [34]. Therefore, VAS within EQ-5D rates overall body pain, while we are also interested in the pain at the site of the fracture. The Verbal Rating Scale (VRS) performs well in cases of patients with dementia, and it is more informative regarding fracture-site pain [39]. Liem and colleagues [35] agree that this test should be used on the second day after surgery – or, in cases of conservative treatment, the second day after admission – and at 90 days and 1 year after admission.

Activities of daily living (ADLs) are an important health outcome in the orthogeriatric population. Recovery of pre-fracture health and functional levels is one of the main goals in hip fracture management. Therefore, it is important to assess deterioration in functional level over time. The literature provides a vast selection of ADL measurement tools, but the Katz Activities of Daily Living Scale [40], is the most widely used. In many cases, it may prove difficult to assess pre-injury ADL’s accurately at the time of admission. In such cases, we suggest consulting a proxy, who will typically be a family member, friend or caregiver. ADLs should be assessed upon admission to evaluate pre-fracture status. During patient follow-up, ADLs should be assessed after 90 days and 1 year after admission.

Delirium in hip-fracture patients usually occurs during the 2–5 days following surgery. It is common in elderly hip fracture patients, occurring in 10–61 % of cases [41]. It can represent a difficult clinical condition to assess, as fluctuation of symptoms can lead to failure to recognise its onset [42]. Dementia and cognitive decline, measured by MMSE, were found to be independent risk factors for delirium [43]. The Confusion Assessment Method (CAM) [44] is a reliable and valid measure of delirium in the general medical and surgical population. The CAM focuses on four features: (i) acute change in mental status with a fluctuating course, (ii) inattention, (iii) disorganised thinking, and (iv) altered level of consciousness. It is a valuable test by which to assess delirium, should be assessed upon admission to evaluate the pre-fracture status and on discharge after acute hospitalisation.

Depression is the most common hip-fracture-related psychological disorder, although it is frequently difficult to assess it [45]. An independent relationship was found to exist between low functional capacity and depression symptoms in the elderly [46]. In elderly people who cannot walk well enough to perform daily living activities, social isolation often occurs and social isolation is in itself a risk factor for depression [47]. Therefore, we can say that a vicious circle of low ADL is created between pre-existing depression and an increase in depression that feelings of inadequacy when performing daily activities can produce. The Geriatric Depression Scale (GDS) may be a valuable instrument by which to assess depression [48]. Depression was observed more often in females and those who had lost their spouses [11]. Depression should be assessed upon admission to evaluate its pre-fracture status. During patient follow-up, it should be assessed after 90 days, 1 and 2 years from the date of admission.

Some studies suggest that cognitive impairment, found in 31–88 % of elderly patients experiencing hip fracture, is a predictor of poor functional recovery after hip-fracture surgery [13]. Furthermore, pre-fracture cognitive impairment is also associated [4] with higher mortality rates. The Mini Mental State Examination (MMSE) [49] may prove to be a valuable instrument for the assessment of cognitive impairment. Cognitive impairment should be assessed upon admission to evaluate the pre-fracture status.

The concept of subjective well-being (SWB) is multi-component by nature. It is affected by positive (i.e., happiness), negative (i.e., depressive symptoms) and cognitive components (i.e., life satisfaction). Its multiple components are affected by different sets of social determinants and develop differently at successive life stages [51]. High care-demand levels may affect multiple aspects of caregivers’ lives, including free time, social life, emotional and physical health as well as personal development. These subjectively defined stressors are also called caregiver burden. Perceived caregiver burden may adversely affect their self-esteem and their sense of competency as a caregiver [20]. These might cause caregivers to suffer from higher levels of depressive symptoms and become less satisfied with their lives. In other words, multidimensional caregiver burdens may play a mediatory role in the association between objective primary stressors and caregivers’ SWB. The Psychological General Well-Being Index (PGWBI) [52] can prove to be a valuable test for the investigation of patients’ and caregivers’ psychological wellbeing. Psychological wellbeing should be assessed after admission and at 90 days and 1 year after admission.

Informal caregivers have to cope with physical, psychological and social stressors that affect their health conditions and quality of life negatively [50]. Over the last 30 years researchers have paid special attention to the investigation and assessment of burden [51]. The Caregiver Burden Inventory (CBI) [53] provides information regarding both the Objective Burden (OB) – the time and commitment caregivers devote to caring activities daily – and the Subjective Burden (SB) – perceived lack of everyday opportunities, fatigue, physical problems, issues related to socialisation and participation, and how they feel toward the care-recipient. Caregiver burden is an all-encompassing term used to describe the physical, emotional, and financial responses of a caregiver to the changes and demands caused by providing help to another person with a physical or mental disability [54]. Increasing numbers of studies have examined the caregiver-burden phenomenon, the lack of support given to caregivers and interventions focused on relieving caregiver burden; this increase is probably due in part to greater evidence of caregiver burden being a determining factor in the quality of life (QoL) of caregivers. Several studies have revealed an association between the characteristics of patients and caregivers and caregivers’ QoL, with caregiver burden serving as an important predictor of QoL. Caregiver burden has also been used as an outcome variable rather than a predictor [55], suggesting that caregiver burden and QoL are closely related. Thus, caregiver burden seems to be a potential moderator of the associations between patients’ and caregivers’ characteristics and caregivers’ QoL. Some studies have shown that caregivers of elderly people suffering from hip fracture experienced multidimensional burden, including tiredness, emotional distress and role conflicts [21, 22]. Many caregivers assume the caregiver role with little or no preparation and have to learn to deal with several aspects of care in a very short time. Often caregivers do not know what to expect during hip fracture recovery. They face situations where they have to address various care-related tasks, such as arrangement of rehabilitation services and assistive devices. These situations become more stressful when the caregivers have to juggle their own work and family lives. The care burden related to hip fracture, an acute injury, may decrease over time; however, it is often prolonged over 12 months or more [56]. Caregivers tend to experience the greatest stress during the first 2 months after fracture, the stress being associated with increased care demands and costs. Family caregivers of hip-fractured patients were reported as experiencing moderate burden [22]. Furthermore, the caregiver’s burden was negatively related to the physical function of older patients with hip fracture. On the other hand, social support has been associated with a diminution of the caregiver burden [23]. The caregiver’s burden should be assessed after admission as well as at 90 days and 1 year after admission.