Annals of Long Term Care

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.