Don’t Worry and Be Positive: What helps the most in functional recovery one year after hip fracture? An exit interview

Abstract

Hip fractures cause significant mortality, morbidity, and disability among older adults ( Latham, Jette, Warren & Wirtalla, 2006; Frihagen, Nordsletten & Madsen, 2007; Hershkovitz, Kalandariov, Hermush, Weiss & Brill, 2007; Press, Grinshpun, Berzak, Friger & Clarfield, 2007) account for 266,000 hospital discharges (Department of Health and Human Services 2007) and 600,000 nursing home admissions, and cost Medicare 2.8 billion dollars each year (Schneider & Guralnik, 1990; Latham, Jette, Warren & Wirtalla, 2006;Titler, Dochterman, Kim, Kanak, Shever, Picone, Everett & Budreau, 2007). More than four percent of hip fracture patients die during initial hospitalization and 18 to 33 percent will die within a year of fracture (Schroder & Erlandsen, 1993; Pitto, 1994; Latham, Jette, Warren & Wirtalla, 2006; Frihagen, Nordsletten & Madsen, 2007; Hershkovitz, Kalandariov, Hermush, Weiss & Brill, 2007); between 26 and 65 percent of patients lose their ability to walk or do not recover their pre-fracture ambulatory status within the year following their fracture (Koval & Zuckerman, 1994; Wolinsky, Fitzgerald, & Stump, 1997; Binder, Brown, Sinacore, Steger-May, Yarasheski & Schechtman, 2004; Latham, Jette, Warren & Wirtalla, 2006; Hershkovitz, Kalandariov, Hermush, Weiss & Brill, 2007).

The compromised mobility and self-care ability affect not only the individual’s functional independence, but also the family and society as a whole. The older population in the U.S. is expected to reach 71.5 million in 2030 when all baby boomers will have turned 65 (U.S. Census Bureau, 2004). Given that hip fracture is associated with increasing age, the incidence of hip fracture is bound to increase. The healthcare cost and ability of society to provide needed care to older persons with hip fracture is a crucial healthcare issue.

Studies focusing on hip fracture rehabilitation and functional outcomes can be categorized into three groups. The first group, clinical research, focused on surgical treatments (e.g., internal fixation vs. heimiarthoplasty) or rehabilitation (rehabilitation hospital vs. SNF rehabilitation) on selected functional outcomes during the acute care and post-acute hospitalization period (Young, German, Brant, Kenzora & Magaziner, 1996; Rodriguez-Merchan, 2002; Isotalo, Rantanen, Aarimaa, & Gullichsen, 2002; Latham, Jette, Warren & Wirtalla, 2006; Hershkovitz, Kalandariov, Hermush, Weiss & Brill, 2007). These types of studies have helped our understanding on which treatment modality would produce better functional recovery, such as mobility or activities of daily living (ADLs). The second type are epidemiological studies which mainly focus on hip fracture prevalence and incidence rates, postacute care mortality and disability rates one year after hip fracture, or postacute care discharge location (Young, Brant, German, Kenzora, & Magaziner, 1997; Magaziner et al., 2000; Ingemarsson, Frandin, Mellstrom, & Moller, 2003; Rosell & Parker, 2003; Latham, Jette, Warren & Wirtalla, 2006; Chevalley, Guilley, Herrmann, Hoffmeyer, Rapin & Rizzoli, 2007). These studies provide valuable information for policy makers and healthcare providers to make informed decision on health manpower planning and scarce health resources allocation. The third type are outcome evaluations studies. Outcome studies primarily center on factors associated with functional recovery, including sociodemographics (e.g., age, gender, income, marital status), health status (e.g., osteoporosis, diabetes), functional status (e.g., mobility, activities of daily living), and social support (e.g., frequency of contacts with children, friends) (Young et al., 1996; Adunsky, Lusky, Arad, & Heruti, 2003; Boonen et al., 2004; Kristensen, Foss & Kehlet, 2007; Grinshpun, Berzak, Friger & Clarfield, 2007). Study results on determinants were very useful and played important roles in shaping or modifying treatment methods and interventions to foster functional recovery.

Findings from these clinical, epidemiological, outcome evaluation studies have improved our understanding of the hip fracture functional recovery process and associated outcomes. However, most of these studies come from the perspective of clinicians or researchers, but not patients themselves. Hip fracture patients--the victims and the key players in the recovery process--often did not have the opportunity to contribute their ideas as to what helped them the most in their functional recovery one year after hip fractures. The desire to better understand why some hip fracture survivors return to their prefracture function and others do not lead this study to explore factors associated with functional recovery from patients’ perspective.

Methods

The goal of this research study was to explore the perceptions of older adults about their functional recovery one year post hip fracture. This study was part of a larger longitudinal study entitled, “Rehabilitation and Functional Recovery after Hip Fracture (Reheb&Hipfx)” funded by a National Institutes on Aging grant. The major goals of the Reheb&Hipfx study were to explore the effectiveness of post-acute rehabilitation on functional recovery and on the costs incurred during recovery among elderly hip fracture patients.

Results

Participants who were satisfied with their functional recovery (n=53) shared their experiences of factors that facilitated functional recovery; those who were not satisfied (n=9) shared their experiences of factors that hindered recovery. The other two themes were system recommendations to facilitate functional recovery and intrinsic or peer advice to future hip fracture patients on factors that facilitate functional recovery.

Discussion

This study provided insight from the patients’ perspectives through the use of in-person interviews 12 months following post-acute inpatient rehabilitation. Overall, the participants in this study had a positive experience with rehabilitation and attributed their successful recovery to exposure to physical therapy and occupational therapy. The patients recognized and acknowledged that it was the rehabilitation experience that helped them return to their prefracture function and mobility. This finding adds important information to the benefit of the rehabilitation experience from patients’ perspectives. Previous studies on determinants related to functional recovery at one year following hip surgery varies. These include increasing age, comorbidities, lengthy acute hospital stay, chronic or acute cognitive deficits and depressive symptomatology while hospitalized, worse prefracture ADL and IADL, unsteady gait, discharge to institution (Young et al., 1997; Koot et al., 2000). These studies did not include rehabilitation as a significant predictor of functional recovery.

Exposure to rehabilitation alone, however, may not be sufficient to result in an optimal recovery process. Participants in this study also attributed their functional recovery to professional care by their surgeons and support and encouragement from other professional staff. The rehabilitation setting and staff within the rehabilitation setting promote and encourage the rehabilitation process throughout all care activities (Resnick, Slocum, Ra, & Moffett, 1996). In addition, the environment needed to be one that was conducive to recovery. Assuring older adults post hip fracture that they are in a safe environment with grab bars and hand rails to facilitate function, where personal items are easily accessible, and pathways are uncluttered and well lit is important in facilitating optimal functional activities.

Participants in this study reiterated the importance of self-determination and their own personal desires to get better and to recover. This has been noted previously among older adults in rehabilitation settings (Resnick, 2002) and in the Exercise Plus Program following hip fracture (Resnick et al., 2005). Self-determination, as defined by Deci and Ryan (Deci & Ryan, 1985, p.38), is the “capacity to choose and to have those choices be the determinants of one’s action”; perceived self-efficacy (Bandura, 2004) is a person’s belief that personal action can succeed in bringing about desired changes. In this study, patients stressed mental attitude that “determination to walk again,” “determination to learn and improve,” a “positive attitude,” and a “never give up” frame of mind helped in their post-acute functional recovery. Self-determination and perceived self-efficacy may propel the individual to do more exercise and be more cooperative with instructions given by health professionals, hence, better functional recovery.

In addition to being determined, the participants in this study described being resilient in the face of the acute hip fracture. Resilience has been described as an individual’s capacity to make a “psycho-social comeback in adversity” (Kadner, 1989). Resilience in women older than 85 is defined as the ability to achieve, retain, or regain a level of physical or emotional health after devastating illness or loss (Felten & Hall, 2001). Resilient individuals tend to manifest adaptive behavior, especially with regard to social functioning, morale, and somatic health (Wagnild & Young, 1990), and are less likely to succumb to illness (O’Connell & Mayo, 1988; Caplan, 1990). Older women who have successfully recovered from orthopedic or other stressful events have been noted to describe themselves as resilient and determined (Felten, 2000; Felten & Hall, 2001). Community-dwelling older adults who are resilient were noted to have better function, mood, and quality of life than those who were less resilient (Glantz & Johnson, 1999; Wagnild, 2003; Hardy, Concato & Gill, 2004). Stressful events such as hip fractures are actually perceived differently by those who consider themselves to be resilient (Hardy, Concato, & Gill, 2002). This variation in response to stressful events further supports the importance of resilience with regard to recovery of function and willingness to engage in activities such as rehabilitation to regain and maintain optimal health following a hip fracture.

Following professional care and self-determination, patients described social support from family and friends as playing a significant role in helping their functional recovery. This finding confirms previous studies that social support is independently associated with better functional recovery among elderly hip fracture patients (Roberto, 1992; Young et al., 2005). Better understanding of social support mechanisms at home and in communities can facilitate functional recovery. Support mechanisms and resources available to patients are important and should be an integrating part of post-acute care discharge planning.

Participants who were not satisfied with their functional recovery at one year reported that factors hindering their functional recovery included older age, medical complications, comorbidities, and unpleasant sensations such as pain. Modifiable barriers such as unpleasant sensations should be anticipated and addressed to optimize the rehabilitation process. Likewise, attempts should be made to prevent commonly noted adverse events post fracture, such as deep vein thrombosis, pressure ulcers, pneumonia, and urinary tract infections, through early mobilization and medical management with anticoagulation as appropriate to the individual patient.

When asked about what might improve functional recovery for hip fracture patients, participants in this study unanimously reported that more information about the rehabilitation process post hip fracture and increasing and extending physical therapy and occupational therapy at post-acute inpatient settings would be beneficial. It is possible that these individuals needed the ongoing support, encouragement, and confidence-building they received from the professional staff in the rehabilitation setting. Several recent studies have tested the impact of home-based exercise programs following hip fracture (Resnick, Magaziner, Orwig & Zimmerman, 2002; Mangione & Palombaro, 2005), and the participants in these studies were willing to engage in additional exercise activities following discharge from rehabilitation.

Participants in this study were optimistic in their advice to other patients post hip fracture. They encouraged these individuals to be positive, to do what they were told to do in the rehabilitation setting, to keep on working with the therapists, and to avoid worry. While this small sample is likely not to be representative of all individuals post hip fracture, their optimism following this type of acute event should be carefully considered. All too often for older adults and their professional and nonprofessional caregivers, hip fractures are perceived as the beginning of a functional and emotional decline. As noted by the participants in this study, recovery can occur with optimal medical management, the support of professional therapists and other healthcare providers, determination on the part of the individual, and that the support and encouragement of others in the social network are equally important.

Limitations

Participants in this study were recruited from the Baltimore metropolitan area; therefore sociodemographic and geographical variations may limit the generalizability of the findings to other populations or cities. The Rehab&Hipfx study had stringent eligibility criteria because it was designed to evaluate the effectiveness of rehabilitation. Due to these inherent data source limitations, the findings of this study may be applicable only to hip fracture patients with similar characteristics. While the study findings were found to be credible with rehabilitation clinicians and researchers, they were not verified with post hip fracture patients. Finally, because the themes were determined by the interview guide, additional exploratory research exploring functional recovery experiences from the perspective of post hip fracture patients is warranted.

Supplementary Material

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