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

Hip fracture is one of the most common somatic inpatient diagnoses, and its incidence will increase even further in the years to come. Since most subjects sustaining this kind of injury are old and living alone, the incapacitation due to the fracture conveys serious social implications. These patients also often suffer from concurrent medical and psychiatric disorders. Therefore, rehabilitation after hip fracture is a challenging task 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 was that most patients with an independent living situation were to return directly home from the emergency hospital. Also, the patients were expected to manage their own activities of daily life (ADL) already from the beginning. The caregivers' primary role was to encourage the patients to use their own resources. To achieve this, the HFU was densely staffed. Furthermore, the nurses also made home visits during and after the patients' stay at the hospital. The continuous monitoring of progress with Katz' ADL index and the Short Portable Mental Status Questionnaire was not only helpful in the daily work, it also allowed an accurate prediction of the patients' social prognosis. 92% of the patients who before the injury were relatively independent (Katz 2 B) and who had no evidence of cognitive impairment (SPMSQ > 8) at admission, and no concurrent disease/injury, were residing in their homes one year after the fracture. Fracture type and patient's age added no further predictive power. This easy-to-use predictor instrument thus allows early social prognosis which is very helpful when setting individualized rehabilitation goals.

Roughly half of the patients were cognitively impaired at admission, but only 13% of those lucid at admission deteriorated 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 at the HFU. Mental status had a strong impact on somatic complication rate. In the present study, the incidence of postoperative cognitive impairment was fairly low compared with that reported in previous studies, probably because of the enhanced personal commitment of the caregivers. In this respect we believe that the feed-back from home visits and from the continuous assessment was pivotal. Due to the program the nurses were able to follow the patient's progress, in sharp contrast to the usual hip fracture after care policy, where the nurses only see the patients for a few days, and the surgeon's only encounter is often in the operation theater.

85% of the HFU patients were able to return directly home after a mean in patient stay of 16 days. Halfway through the project, January 1992, a prospective payment system was implemented in Stockholm. For economic reasons hip fracture rehabilitation could 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, but a further analysis showed that the total number of bed-days after hip fracture remained unchanged the patients had simply been transferred to other departments. The average four-months health care consumption, including the initial stay, which had decreased from 39 to 28 days, returned to its former level immediately after the economic reform.

The entire health and elderly care cost for a hip fracture patient during the first postoperative year was approximately SEK 170,000. The cost was strongly correlated to pre-fracture health status and need for care, and to whether a second operation of 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 dedication and commitment in the nursing staff, continuity and feed-back appear to be decisive. And a continuous assessment and follow-up are corner stones.