Hip fractures in the elderly : social, economic, and psychological aspects of rehabilitation

Sammanfattning: Hip Fractures in the Elderly - Social, Economic, and PsychologicalAspects of Rehabilitation Lars Strömberg, Department of Surgery, Anaesthesiology, Radiology,and Orthopaedics. Karolinska institutet, Huddinge University Hospital, S-141 86 Huddinge,Sweden. Hip fracture is one of the most common somatic inpatient diagnoses, and its incidencewill increase even further in the years to come. Since most subjects sustaining thiskind of injury are old and living alone, the incapacitation due to the fracture conveysserious social implications. These patients also often suffer from concurrent medicaland psychiatric disorders. Therefore, rehabilitation after hip fracture is a challengingtask and should have a broad scope. We studied 256 consecutive patients admitted to a special hip fracture unit (HFU),focusing on continuity and daily assessment of the patients' function. The goal wasthat most patients with an independent living situation were to retum directly homefrom the emergency hospital. Also, the patients were expected to manage their ownactivities of daily life (ADL) already from the beginning. The caregivers' primaryrole was to encourage the patients to use their own resources. To achieve this, theHFU was densely staffed. Furthemmore, the nurses also made home visits during andafter the patients' stay at the hospital. The continuos monitoring of progress withKatz' ADL index and the Short Portable Mental Status Questionnaire was not only helpfulin the daily work, it also allowed an accurate prediction of the patients' socialprognosis. 92% of the patients who before the injury were relatively independent(Katz 2 B) and who had no evidence of cognitive impaimment (SPMSQ > 8) at admission,and no concurrent disease/injury, were residing in their homes one year after thefracture. Fracture type and patient's age added no further predictive power. Thiseasy-to-use predictor instrument thus allows early social prognosis which is veryhelpful when setting individualized rehabilitation goals. Roughly half of the patients were cognitively impaired at admission, but only13% of those lucid at admission detenorated mentally in the postoperative phase,and most of them had completely regained their mental status at discharge. Even 51%of those mentally impaired upon admission achieved lucidity during their stay atthe HFU. Mental status had a strong impact on somatic complication rate. In the presentstudy, the incidence of postoperative cognitive impaimment was fairly low comparedwith that reported in previous studies, probably because of the enhanced personalcommitment of the caregivers. In this respect we believe that the feed-back fromhome visits and from the continuous assessment was pivotal. Due to the program thenurses were able to follow the patient's progress, in sharp contrast to the usualhip fracture after care policy, where the nurses only see the patients for a fewdays, and the surgeon's only encounter is often in the opcration theater. 85% of the HFU patients were able to return directly home after a mean inpatientstay of 16 days. Halfway through the project, January 1992, a prospective paymentsystem was implemented in Stockholm. For economic reasons hip fracture rehabilitationcould no more be conducted in the emergency hospital and the HFU was closed down.The number of bed-days in the orthopaedic department decreased dramatically, buta further analysis showed that the total number of bed-days after hip fracture remainedunchangcd the patients had simply been transferred to other departments. The averagefour-months health care consumption, including the initial stay, which had decreasedfrom 39 to 28 days, retumed to its former level immediately after the economic reform. The entire health and elderly care cost for a hip fracture patient during thefirst postoperative year was approximately SEK 170,000. The cost was strongly correlatedto prefracture health status and need for care, and to whethcr a second operationof the hip was required or not. We believe that an early and active rehabilitation is a cost-efficient enterprise,from an economic as well as a humanitarian viewpoint. Apart from personal dedicationand commitment in the nursing staff, continuity and feed-back appear to be decisive.And a continuous assessment and follow-up are corner stones. Key words: Hip fracture, rehabilitation, age, cognitive impairment, health economicsStockholm 1998 ISBN 91-628-2838-X