The Rehabilitation of Patients with Dementia After Hip Fracture
To the Editor:
“They can be happy or sad, in pain or not in pain, content or disturbed.” These alternatives in the conditions of old persons affected by dementia give a heavy responsibility to providers of medical and rehabilitative services. In this perspective, we really enjoyed the article “Hip Fracture Rehabilitation in Persons with Dementia: How Much Should We Invest?” by Dr. Davis et al,1 and we would like to contribute to the topic with personal reflections.
Although demented subjects are well-known to need specific clinical approaches,2-3 the rehabilitation of these individuals after hip fracture (HF) usually follows interventions and procedures derived from the rehabilitative programmes for nondemented subjects. In primis, the criteria adopted to establish the functional prognosis after HF are not adequately studied in demented subjects, taking into account variables that are supposed, but not confirmed, to predict their motor recovery. As an example, in the case described by Davis et al,1 the physiotherapist assigned the patient to a nonmobile ward on the basis of his perception of a poor participation in the rehabilitative program and of a negative result to his standard functional assessment (“she refused to get up and start walking at demand”). Both perceptions were lacking formal scientific evidence. These observations are in line with previous studies showing that comorbidity and severity of cognitive impairment are significantly related to the intensity of in-hospital rehabilitation,4-5 that, in turn, is related to functional recovery.6 In particular, higher comorbidity has been found to be associated with a lower level of complexity of the rehabilitative interventions among in-hospital elderly patients,4 while poor cognitive status was a predictor of fewer procedures per session performed by physical therapists during rehabilitation5 and poor participation in the entire rehabilitative program6 among HF patients.
We think that novel rehabilitative procedures have to be offered to severely demented patients, taking into the account some crucial questions, summarized as follows:
•The Communicative Bias: It is necessary to use a communicative approach that bypasses the traditional verbal channel. In the case described by Davis and colleagues,1 the patient accepted getting up and starting to walk in response to the son’s but not to the physical therapist’s invitation. This suggests that the tone of the voice and the nonverbal expressions may play a significant role in stimulating the participation of the very demented subjects to participate in the rehabilitative program.
•The Deficit in Attentive and Executive Functions: The rehabilitative procedures directly focusing on specific uni-tasks and a reduction of possible environmental interferences should be preferred for these subjects in order to optimize the time spent in rehabilitation. Furthermore, it might be useful to overcome programming difficulty that these patients frequently show when they have to learn new complex motor strategies, such as use of walking aids. In this direction, we have previously described the case of a very elderly subject with severe dementia and HF who improved walking after a training with the body-weight supported treadmill, when other approaches failed.7
•The Physical Exhaustilibity: Because many demented subjects are noncompliant in prolonging their physical efforts in a unique session, it should be plausible to subdivide the rehabilitative session in multiple short-duration subsessions.
•Delirium: Demented patients are well-known to be more prone than nondemented subjects to develop delirium in response to acute medical illnesses,8 strongly interfering with functional outcomes.9 This requires a continuous clinical attention by physicians and healthcare providers, and suggests that geriatricians should be directly involved in the clinical surveillance of the health status of HF demented subjects.
•The Geriatric Assessment: A complete evaluation of the patients affected by dementia is needed to detect the potential rehabilitative capacity. In particular, it is imperative to detect usually neglected events, such as the “fear of falling syndrome” that commonly develops in these individuals after HF.10
•Rehabilitation is a complex task needing a general involvement of the patients for a longer period than that formally dedicated to rehabilitative procedures. For this purpose, we must also create a positive environment both inside and outside the hospitals, where healthcare professionals may give their personal contribution to the well being of patients.
•A geriatric cultural background is important to avoid an “ageistic reflex” in front of very old persons with dementia and HF. If we like to provide for these patients the ability to thrive, we must link the classical geriatrics with a humanitarian attitude. In this perspective, the first step at the moment of hospital admission for rehabilitation is extremely important to start a positive reaction chain, even in clinical conditions apparently desperate. On this line, it would be important to teach young students that working with patients at borderline with failure to thrive is a professional opportunity more interesting than easy traditional care.
•Family remains a very important support to the elderly, even when admitted to a nursing home. Unfortunately the changes of the family structure with a decreasing number of daughters and sons will make critical in the next future––at least in our country––providing informal support to elderly in their needs. Thus, we should dedicate attention to families to allow them giving the maximum possible amount in caregiving.
•Finally, in dealing with these clinical problems we must consider that a Real-World Medicine is as important as Evidence-Based Medicine; the latter alone will never be able to give answers to the peculiar problems of very frail elderly subjects.
Giuseppe Bellelli, MD, and Marco Trabucchi, MD Drs. Bellelli and Trabucchi are from the Geriatric Research Group, Brescia, Italy; Dr. Bellelli is also at the Rehabilitation and Aged Care Unit “Ancelle della Carità” Hospital, Cremona, Italy; and Dr. Trabucchi is also at the Tor Vergata University, Rome.
References
1. Davis E, Biddison J, Cohen-Mansfield J. Hip fracture rehabilitation in persons with dementia: How much should we invest? Annals of Long Term Care: Clinical Care and Aging 2007;15(3):19-21.
2. Teri L, McCurry SM, Buchner DM, et al. Exercise and activity level in Alzheimer’s disease: A potential treatment focus. J Rehabil Res Dev 1998;35(4):411-419.
3. Bianchetti A, Ranieri P, Margiotta A, Trabucchi M. Pharmacological treatment of Alzheimer’s disease. Aging Clin Exp Res 2006;18(2):158-162.
4. Bellelli G, Guerini F, Bianchetti A, et al. Medical comorbidity and complexity of the rehabilitative procedures for older patients with functional impairments. J Am Geriatr Soc 2002;50(12):2095-2096.
5. Bellelli G, Frisoni GB, Pagani M, et al. Does cognitive performance affect physical therapy regimen after hip fracture surgery? Aging Clin Exp Res 2007;19(2):119-124.
6. Lenze EJ, Munin MC, Dew MA, et al. Adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture. Int J Geriatr Psychiatry 2004;19(5):472-478.
7. Bellelli G, Guerini F. Trabucchi M. Body weight-supported treadmill in the physical rehabilitation of severely demented subjects after hip fracture: A case report. J Am Geriatr Soc 2006; 54(4):717-718.
8. Young J, Inouye SK. Delirium in older people. BMJ 2007;334(7598):842-846.
9. Speciale S, Bellelli G, Lucchi E, Trabucchi M. Delirium and functional recovery in elderly patients. J Gerontol A Biol Sci Med Sci 2007;62(1):107-108.
10. Oude Voshaar RC, Banerjee S, Horan M, et al. Fear of falling more important than pain and depression for functional recovery after surgery for hip fracture in older people. Psychol Med 2006;36(11):1635-1645.
Response from the author:
Dear Dr. Bellelli and Dr. Trabucchi:
Thank you for your perceptive and constructive remarks. They obviously reflect years of experience and innovative thinking.
At this point in time, my primary focus is to get post-operative hip fracture patients with dementia on their feet and to get those feet moving. If they don't take the first step, they will never walk!
Physical therapists simply do not have the time nor the financial go-ahead from Medicare to continue physical therapy if a patient is unresponsive. Unfortunately, as you mention, fear of falling, pain, and disorientation make it likely that post-hip fracture patients will resist getting up and trying to walk. As your case study suggests, it would seem that some sort of body weight− bearing device to help in lifting and supporting hip fracture patients while undergoing therapy would be very helpful.
Along these lines, we are seeking funding for a comprehensive clinical study of the effect of body weight support (BWS) devices in restoring mobility to hip fracture patients with dementia. It would be especially interesting to see if such a device could make a difference for people who are evaluated as physically able to walk but unresponsive or uncooperative in their interactions with the physical therapist.
As has been demonstrated in our case study of my mother, aged hip fracture patients with dementia and other risk factors can attain full mobility. Two years have elapsed since my mother's accident. She can now walk for two hours straight, with no assistance whatsoever, at a fairly rapid pace. She laughs, she dances, and relates to people she meets.
Walking has vastly increased her quality of life, not to mention the quality of life for her family, friends, and nursing assistants who enjoy interacting with her. A video of my mother determinedly walking through the halls of the nursing home may be viewed on the Internet at: https://www.hope.webstuff.org/.
One last thought. My mother regained mobility because my brother and I came in every day and walked her. The 15-30 minutes of physical therapy she received several times a week simply was not adequate. When she was returned to her ward she was confined to her wheelchair. Nursing assistants simply had no time to walk her. Only when my mother progressed to the extent where she could be placed in a rolling walker with a seat was she able to walk at will. Once again, if we had not gotten her to that point, she wouldn't have walked. Thank you again for your insightful remarks.
Sincerely,
Elliot Davis, PhD
Dr. Davis is retired from the State University of New York at Buffalo.
