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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.
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.
Despite reported improvements in surgical technique for the repair of hip fractures , the recovery of people who sustain a hip fracture is often complex and involves a challenging interaction of physical, psychological and social factors . Long-term functional recovery is frequently considered to be poor , 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 . In people with a diagnosed dementia, hip fractures are the third most common cause of admission into an acute setting  and lead to high levels of mortality  and morbidity . It is estimated that, in the UK, 80,000 people will fracture their hip each year , costing £2.3 billion . Of these, it is suggested that 40% will have coexisting dementia , which equates to approximately 32,000 people at a cost of £0.92 billion per year.
It is suggested that people with dementia are frequently excluded from trials , with systematic reviews often excluding studies if the participants have any cognitive defects . 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 . 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.
The overall aim of the project is to;
Develop an evidence based physiotherapy intervention for the treatment of people with dementia following hip fracture, to determine whether it is feasible to deliver and whether it is acceptable to patients and physiotherapists
In order to achieve this overarching aim, several objectives were set:
The MRC’s guidance suggests that the initial phase of development of complex interventions requires the identification of relevant, existing evidence base . A scoping review summarised the current available evidence for physiotherapy interventions for people with dementia who fracture their hip as well as seeking to identify gaps in the literature. A systematic search of thirteen databases was undertaken with articles being included if they described an intervention which was considered within the scope of a physiotherapist and targeted those with both a hip fracture and dementia. A narrative summary was then undertaken to describe the current state of the literature. The findings of the scoping review suggested that there was limited evidence to guide physiotherapists in the management of people with dementia who fracture their hip. No evidence was found about perceptions or experiences of patients in this group or of the physiotherapists involved in their care. It was concluded that further empirical research was needed to develop and evaluate physiotherapy interventions for people with dementia who fracture their hip.
The scoping review highlighted the lack of understanding around complex factors such as social, environmental and contextual components. Therefore qualitative methodologies were designed in order to allow the creation of new primary data. A qualitative study undertaken with physiotherapists exploring the experiences off treating people with dementia who fracture their hip. Semi-structured interviews with physiotherapists were undertaken in order to gain an in-depth understanding of how they manage this population. Physiotherapists were recruited from all over the UK and a purposive sampling strategy was employed. Thematic analysis was utilised.
Physiotherapists felt significant pressures and challenges regarding many aspects of the management of this population. It was concluded that interventions for the management of people with dementia and hip fracture need to consider that a traditional biomedical physiotherapy approach may not be the most appropriate approach to use with this population.
A second qualitative study exploring the experiences of people with dementia (and their carers) of receiving physiotherapy, with the aim to determine whether a biomedical approach was appropriate for this population. Semi-structured interviews were undertaken with eleven people with dementia or their carers between September 2016 and January 2017. Carers were also recruited carers to explore their involvement in the intervention. Thematic analysis was used to analyse the data. The results suggested that people experienced a biomedical approach from physiotherapy and the lack of a person-centred care approach was evident.
A small scale feasibility study was designed following completion of the qualitative work in order to test the feasibility and acceptability of the intervention. Data collection is currently underway for this phase of the project.
The following studies are planned to help guide the development of an intervention;
Hall A, Goodwin V, Lang I, Endacott R (2016). Physiotherapeutic interventions for people with dementia and hip fracture - a scoping review of the literature. Physiotherapy, 102, p.e187.
Hall AJ, Watkins R, Lang IA, Endacott R, Goodwin VA (2017). The experiences of physiotherapists treating people with dementia who fracture their hip. BMC geriatrics, 17(1), p.91.
Hall AJ, Burrows L, Lang IA, Endacott R, Goodwin VA (2018). Are physiotherapists employing person-centred care for people with dementia? An exploratory qualitative study examining the experiences of people with dementia and their carers. BMC Geriatrics 18 (63)
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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