Unequal opportunities for patients with and without cognitive impairment : relatives’ and significant others’ views on care and rehabilitation after hip fracture

Abstract

The overall aim of the studies that form the basis of this doctoral thesis was to explore how cognitive impairment affects the care and rehabilitation of hip fracture patients, as revealed by their relatives and significant others. A further aim was to investigate to what extent dementia, delirium and other comorbid conditions in hip fracture patients was put on record in Stockholm County Council’s In-patient Care Register (ICR) database.

Study I focused on frequencies of dementia and delirium diagnoses in a hip fracture population (I). Study II focused on the relatives and significant others views on the conditions of rehabilitation for older patients with dementia. Study III focused on how relatives to cognitively impaired and cognitively intact hip fracture patients experienced the first six months post fracture, in order to determine whether the patients’ cognitive impairment affected the relatives’ experiences. Study IV focused on cognitively impaired and cognitively intact hip fracture patients’ outcomes and their proxies’ perceptions of a sixmonth rehabilitation period.

The results are based on data from 14 993 hip fracture patients (from 1994 to 1999) registered in the ICR, aged 65 years or older (I). Moreover, interview data from the 20 relatives (aged 37 to 88 years) to the patients with cognitive impairment (II), diaries from 11 relatives to patients with and without cognitive impairment (III), and questionnaires from 32 relatives to patients with and without cognitive impairment (IV). The Mini Mental State Examination (MMSE) and Katz´ Activities of Daily Living Index (ADL) were used to assess the patients. The patients were recruited consecutively, together with their relatives (spouses, children, and other relatives) and other significant persons (friends and staff). The data were analysed with descriptive statistics and correlations (I), content analysis (II), latent content analysis (III) and comparative statistics and manifest content analysis (IV).

Based on the result of the four studies in this thesis, it can be concluded that patients with cognitive impairment, i.e. dementia and confusion, are not given the care and attention they need after a hip fracture. This is based on the relatives’ views and assertions, which point out that rehabilitation outcomes for cognitively impaired patients are less successful and that their rehabilitation care is less carefully prepared and/or supported by physiotherapists, when compared to cognitively intact patients. This leads to greater dissatisfaction among relatives to hip fracture patients with cognitive impairment.

The results indicate that health personnel lack knowledge and strategies that can control and prevent the cognitively impaired patients’ behaviour and support them during rehabilitation. Moreover, although the in-patient care register seems to be suitable for planning hip fracture care, it may not be appropriate for patients with comorbid diagnoses, since the register was found to be unreliable in relation to the secondary diagnoses of dementia and delirium. This indicates unequal opportunities for hip fracture patients with and without cognitive impairment. The way forward implicates an improvement in education, guidelines, and support, so that cognitively impaired patients’ are given the opportunity to complete their rehabilitation programmes. Furthermore, a more friendly approach is required when dealing with cognitively impaired patients in various care settings.