Hip Fracture Rehabilitation in Persons with Dementia: How Much Should We Invest?
Friday, September 5, 2008 - 17:54
INTRODUCTION Hip fractures often have very serious consequences for older adults with dementia, including higher risk for developing delirium and a higher mortality rate, than they have for more cognitively intact individuals.1,2 Shen et al3 and Takayama et al4 found poor quality of life and recovery rate results following hip fracture surgery for those with dementia. Although Toussant and Kohia’s5 literature review found several studies demonstrating the benefit of physical rehabilitation in persons with dementia, many of these patients with hip fracture are deemed poor candidates for rehabilitation due to cognitive difficulties in following directions.6 Some studies, however, found that dementia does not complicate recovery and functional gain post–hip fracture in those who were mobile before the fracture.7,8 Ishida and colleagues9 found that in persons over age 90, walking ability decreased during the first year after discharge from hip fracture surgery. This study also found that walking ability is a predictor of survival in this population. Hamman10 reported that patients with hip fractures and Alzheimer’s disease were happier walking than using a wheelchair, and found that several months after an average 10-week rehabilitation, most patients were still ambulating. She suggests that while rehabilitation may take longer in those with Alzheimer’s disease, it nevertheless improves quality of life. The following case demonstrates the issues involved in providing resources for the rehabilitation of persons with dementia. The report was written by the son of a woman with dementia who suffered a hip fracture while residing in a nursing home. The results of this story were independently verified by one of the authors of this paper who had established a relationship with this family through previous research studies. CASE PRESENTATION: THE PATIENT’S SON’S ACCOUNT “Life begins, again, at 90. The good news was that my mother’s broken hip would probably heal. The bad news was (according to one doctor) that she would probably never walk again and would be dead within a year. “About a year ago, it was discovered that my mother had a serious hip fracture. The top part of the leg bone that fits into the pelvis was completely sheared off and detached. I believe it is called an oblique, comminuted fracture of the trochanter. Her hip was repaired by joining the two segments of bone with a metal pin. However, the ball of the trochanter was inserted back into the pelvis at an awkward angle that resulted in her knee facing inward toward the opposite leg. According to the orthopedic surgeon, this was done to keep the femur from coming out of the joint. Also, some bone had to be removed, and one leg was now shorter than the other. “Favorable factors for her recovery were that it was a clean break, and that she was in good physical health and loved to walk. Factors against recovery were: • 90 years old • Alzheimer’s disease, reduced cognitive level • Anesthesia, residual effects, including disorientation; could last 6 months • Torsion of her leg, making it very difficult to walk with one leg turned inward • One leg shorter than the other • Decubitus sores on her ankle and heel “The hard reality was that if my mother could not, or would not, respond to the words of the physical therapists to get up and start walking, she would be assigned to a nonmobile ward. This meant that her bones and muscles would degenerate, she would continue to get bedsores, and she probably would die within a year. “The physical therapy department evaluated her, concluded that she would never walk again, and consigned her to the immobility ward. “While watching the evaluation, I had determined that the initial warm-up procedure had caused my mother so much pain that she was afraid of putting more weight on her leg by standing. The physical therapists didn’t want to lift her into an erect position without her consent. Also, given her restricted cognitive level, it was hard to reason with her. “I decided to try to get her up myself. I simply said to her, “Okay Ma, let’s get up,” and then proceeded to help her up. Once she was on her feet, I helped her to enter the parallel bars. The rest is history. My brother and I continued to help her up, support her, and walk with her for over a year. We talked, played music, and sang while we walked. She progressed from the parallel bars to a walker, to a Merry Walker® (a device that has wheels, a seat, and support bars), to walking on her own without mechanical assistance. When she walks without the Merry Walker, I make sure to hold her arm, just in case she should need support. Her general health, cognitive level, weight, and strength have all improved greatly. We are actually at the point today where either my brother or I walk with her an hour a day, up and down fairly steep hills outside of the nursing home. When we are not there, she walks by herself in the nursing home using the Merry Walker. The staff say that they have never seen such an amazing recovery. “We could not have proceeded this far without the enthusiastic help of a wonderful physical therapist. She ordered a special boot so that my mother could walk, even with the bedsores on her foot. She cheerfully and conscientiously worked with us during the initial phases of the rehabilitation. When my brother and I left town for a month, she kept walking my mother on her own time and without pay. This was critical to my mother’s continued recovery, since she had not as yet progressed to using the Merry Walker to the point where she could walk or sit at her own convenience. “Unfortunately, the regular staff did not have time to walk her on a regular basis, even though the physical therapy department prescribed it. We have heard and seen that this is the rule rather than the exception. At best, the aides walked her from the wheelchair to the dining room, a total of a few minutes a day. “From the rehabilitation process, I derived the following observations and thoughts that might be helpful to others: 1. The single most important step to getting people to walk again after hip surgery is the first step. The way the system is now set up, that first step may never be taken if the patient does not give his or her verbal assent to the physical therapists. 2. The greatest impediment to getting that verbal assent is pain. 3. Another problem with getting a verbal response can occur if the patient is cognitively impaired due to Alzheimer’s disease, anesthesia, etc. 4. The patient should be walked for as long and as frequently as possible. A way must be found to continue walking the patient after the physical therapy staff members turn the task over to the regular staff. 5. Rehabilitation sessions should be scheduled for times when the patient is receptive. 6. Various techniques such as music and singing should be used to help motivate the patient to move. 7. Various modalities to minimize pain during the therapy, such as drugs or special footwear, should be used. My guess is that a weight-bearing lift and harness would be especially useful, as it could both prevent pain and increase balance. “The powers-that-be can calculate the cost/benefit factors of implementing these proposals. From a personal standpoint, it is a wonderful thing to have my mother alive and walking again at 91 years of age.” DISCUSSION This case demonstrates the success of persistent rehabilitative efforts in enhancing and recovering quality of life for a person with dementia. Whereas it is assumed that persons with dementia have a lower quality of life, this is not necessarily true. They can be happy or sad, in pain or not in pain, content or disturbed. That distinction in quality is as meaningful to them as it is to the cognitively intact, because this is life as they experience it. The patient in this case regained not only her walking ability but her quality of life, a fact that was demonstrated by her general demeanor, weight gain, and overall “success in thriving,” as opposed to the alternative anticipated without rehabilitation, “failure to thrive.”11,12 Indeed, this woman had all four syndromes associated with poor outcome and failure to thrive: impaired physical functioning because of the fracture, rapid weight loss, depressed affect, and cognitive impairment.11 Three of these could be attributed to the immobility and hip pain resulting from the hip fracture. This case raises the question, “Who is responsible for providing the ability to thrive?” In this example, neither the nursing home, the staff on the unit, nor the physical therapy department provided the resources necessary to assure quality of life for this woman. This probably involves administrative issues (ie, delegation of existing resources), an erroneous fatalistic conceptualization (ie, the physical therapy department’s determination that this woman’s prognosis precluded future walking), and insufficient resources on all levels. Sarkisian and Lachs12 pose the question, “How aggressively should more resource-intensive strategies for less easily modifiable contributors be pursued? This is a central clinical, ethical, and policy issue in geriatric medicine.” In this case, the patient’s sons provided an intervention for an hour a day over the course of a year to achieve this goal. It was the sons who were able to identify the various sources of the problem: the physical help required, the psychological strategy needed to work with her, and the need to address the pain. As a society, it behooves us to reconsider the current state of affairs. Is it possible to change the systemic problem that caused all existing responsible parties in the nursing home to give up on the rehabilitation of this woman? This is both a resource question for Medicare/Medicaid, a resource distribution question for any nursing home, and a discipline question for rehabilitation professionals. Furthermore, is it possible to utilize and educate other resources, such as volunteers, students who have to provide community service, music therapists, music students, and others, to help those patients who do not have devoted sons or daughters? These are some of the issues that need to be examined in order to assure quality of life for those who live with dementia. The authors report no relevant financial relationships.
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