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Physiotherapy for people with dementia

This project is based on priorities highlighted by the James Lind Alliance to guide research into dementia care and is part of the The National Institute of Health Research (NIHR) Research Capacity in Dementia Care Programme (RCDCP) which aims to develop and evaluate interventions in dementia related care.

Lay Summary

Hip fracture is a common injury in the elderly and is usually caused by a fall. Typically surgery is required to repair the fracture often using implants including a combination of metal screws and plates attached to the thigh bone (femur). It is a significant operation and people frequently have other medical conditions making it a long and often difficult rehabilitation process. The aim of the rehabilitation is to try and enable the person to walk and live as independently as possible, however, they will regularly face ongoing difficulties. Hip fracture is more common in people with dementia and commonly their recovery is more difficult. This may be due to difficulty following instructions, or problems expressing their feelings.

Many healthcare professionals are involved in the rehabilitation of people with dementia who fracture their hip. Physiotherapists often have a significant role in the rehabilitation process, with the aim to try and improve the ability to walk again and participate in activities of everyday life. The rehabilitation process starts immediately after surgery and will continue often for many months in their own home or care home. However, despite this, there is little evidence to help support physiotherapists in the most effective ways to treat these people.

This project is aiming to explore the current evidence for physiotherapy treatments and determine the experiences of those involved, with the aim to develop an intervention to help improve the physiotherapy care of people with dementia who fracture their hip.

Background

Despite reported improvements in surgical technique for the repair of hip fractures [1], the recovery of people who sustain a hip fracture is often complex and involves a challenging interaction of physical, psychological and social factors [2]. Long-term functional recovery is frequently considered to be poor [3], and an estimated 27% to 59% of people move into permanent long-term care within the first year after fracture [4, 5].

The management of hip fractures can be more challenging if patients have dementia and it is estimated that people with dementia are 2.7 times more likely to sustain a hip fracture than sex- and age-matched controls without dementia [6]. In people with a diagnosed dementia, hip fractures are the third most common cause of admission into an acute setting [7] and lead to high levels of mortality [8] and morbidity [9]. It is estimated that, in the UK, 80,000 people will fracture their hip each year [10], costing £2.3 billion [11]. Of these, it is suggested that 40% will have coexisting dementia [10], which equates to approximately 32,000 people at a cost of £0.92 billion per year.

Why is this research needed?

It is suggested that people with dementia are frequently excluded from trials [12], with systematic reviews often excluding studies if the participants have any cognitive defects [13]. Concerns were recently raised by the British Orthopaedic Association (BOA) in conjunction with the Chartered Society of Physiotherapy (CSP) about poor management of people who fracture their hip [14]. This report highlighted, amongst other things, concern about the lack of emphasis placed on immediate post-operative physiotherapy. National guidance suggests people should be offered a physiotherapy assessment and mobilised on the day after surgery and seen at least daily after this.

The lack of evidence to support the physiotherapy intentions for people with dementia who fracture their hip has led to the development of this project.

Project aims

The aims of this project are as follows;

  1. To determine the current evidence base for physiotherapy interventions for people with dementia who fracture their hip
  2. Explore the experiences of physiotherapists treating people with dementia who fracture their hip
  3. Determine the experiences of patients with dementia who receive physiotherapy
  4. Determine what careers/next of kin felt about the physiotherapy treatment and how these could be improved

Following completion of these aims, it is anticipated that a complex intervention will be developed and the feasibility of this tested.

Project progress

A scoping review has been undertaken and was published in Physiotherapy in January 2017:

Hall AJ, Lang IA, Endacott R, Hall A, Goodwin VA. Physiotherapeutic interventions for people with dementia and hip fracture - a scoping review of the literature. Physiotherapy (2017)

Next steps

The following studies are planned to help guide the development of an intervention;

  1. “How do physiotherapists treat people with dementia who fracture their hip?” - A Grounded Theory qualitative study
  2. “What are the experiences of people with dementia and their carers of physiotherapy treatments?” – a qualitative study

If you’d like to learn more, please contact Abi Hall via Email

References

1. Royal College of Physicians. More patients surviving due to continued improvements in hip fracture care. 2014. https://www.rcplondon.ac.uk/press-releases/more-patients-surviving-due-continued-improvements-hip-fracture-care. Accessed 14/7/15.

2. McGilton KS, Davis AM, Naglie G, Mahomed N, Flannery J, Jaglal S et al. Evaluation of patient-centered rehabilitation model targeting older persons with a hip fracture, including those with cognitive impairment. BMC Geriatrics. 2013;13:136.

3. Heruti RJ, Lusky A, Barell V, Ohry A, Adunsky A. Cognitive status at admission: does it affect the rehabilitation outcome of elderly patients with hip fracture? Arch Phys Med Rehabil. 1999;80(4):432-6.

4. Leibson CL, Tosteson AN, Gabriel SE, Ransom JE, Melton LJ. Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. J Am Geriatr Soc. 2002;50(10):1644-50.

5. Fransen M, Woodward M, Norton R, Robinson E, Butler M, Campbell AJ. Excess mortality or institutionalization after hip fracture: men are at greater risk than women. J Am Geriatr Soc. 2002;50(4):685-90.

6. Melton LJ, Beard CM, Kokmen E, Atkinson EJ, O'Fallon WM. Fracture risk in patients with Alzheimer's disease. Journal of the American Geriatrics Society. 1994;42(6):614-9.

7. Natalwala A, Potluri R, Uppal H, Heun R. Reasons for hospital admissions in dementia patients in Birmingham, UK, during 2002-2007. Dement Geriatr Cogn Disord. 2008;26(6):499-505.

8. Braithwaite RS, Col NF, Wong JB. Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc. 2003;51(3):364-70.

9. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med. 1997;337(18):1279-84.

10. Mitchell P, Bateman, K. Dementia, falls and fractures. Integrated approaches to improve quality and reduce costs: Novartis2012.

11. Health Economics Research Centre. Dementia2010: The economic burden of dementia and associated research funding in the United Kingdom 2010., University of Oxford ftAsT;2010.

12. Mundi S, Chaudhry H, Bhandari M. Systematic review on the inclusion of patients with cognitive impairment in hip fracture trials: a missed opportunity? Canadian journal of surgery Journal canadien de chirurgie. 2014;57(4):E141-5.

 

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