The world's population is aging1; by 2056, approximately 10.5 million Canadians will be 65 years and older, more than doubling the seniors' population from 2006.2 Increasing age can lead to loss of independence requiring admission to a long-term care (LTC) residential facility—those providing permanent residential care. Approximately 250 000 Canadians reside in LTC facilities, representing 4% to 8% of the senior population.3 The most common reason for LTC admission is dementia,4 with more than 50% of individuals living with dementia reported to live in LTC facilities.1,4,5 The need for LTC facilities will certainly increase as at least a 3-fold increase in the number of patients with Alzheimer Disease is anticipated by 2050.6,7
Residents of LTC facilities with dementia fall more often than residents without dementia, increasing the risk of sustaining injurious falls, including those leading to hip fractures.8,9 Between 2003 and 2004, 23 631 Canadians older than 59 years were discharged from hospital after treatment for hip fractures,10 with up to 25% of hip fractures occurring in LTC facilities.11,12 Current evidence suggests that individuals with dementia or those admitted from LTC facilities are usually excluded from postfracture rehabilitation programs and discharged directly to their LTC facilities after hip fractures.11,13,14 These individuals have shorter hospital stays and receive less rehabilitation.11,13–15
We previously performed a systematic review to determine the current state of evidence on recovery after hip fractures in subjects with dementia. Our review16 and others17,18 suggest that those with mild to moderate dementia are able to respond to rehabilitation and experience better functional recovery than those who do not receive postfracture rehabilitation. The subpopulation with dementia was evaluated because a substantial proportion of patients with hip fractures from LTC facilities have cognitive impairment and there was a paucity of literature related to hip fracture recovery in residents of LTC facilities. Given the aging population and the resultant increasing requirements for LTC facilities, understanding effective rehabilitation practices for residents of LTC facilities with dementia following hip fractures may improve outcomes for this frailest group of seniors.
PURPOSE AND METHODS
The purpose of this study was to augment our systematic review findings by determining the current status of (1) reported rehabilitation practices following hip fractures for residents of LTC facilities with dementia and (2) perceived barriers to rehabilitation as reported by rehabilitation professionals working in LTC facilities.
A descriptive Web-based survey was administered during 2010 to rehabilitation professionals working in LTC facilities within a Canadian province. A modified Delphi approach was used to collect information and synthesize our findings; this approach has been found to be an effective way to gain and measure group consensus in health care.19 A Delphi Survey is a series of questionnaires that allow experts or people with specific knowledge to gain group consensus around an issue or develop ideas about potential future developments.20 The modified Delphi process was chosen because it (1) provides a formal process for synthesizing clinical expert opinion when little information is available, (2) provides anonymity to incorporate each participant's private opinion, (3) provides an explicit method for aggregating results, and (4) does not require in-person meetings as the survey can be performed online.21
Survey procedures were approved by Health Research Ethics Board after the systematic review and construction of the first-round survey questions. Anonymity was maintained throughout the process as per ethics requirements, so waiver of consent was granted.
Survey development started with a systematic review16 to determine current evidence regarding hip fracture management in patients with underlying dementia.22Dementia was defined as a global loss of cognitive and intellectual functioning that interfered with social interaction and potentially physical performance.23
In addition, we used an expert panel (physical therapists [PT] working in LTC facilities and a researcher who has experience in hip fracture studies) to ensure that survey content was relevant to LTC. We also included an occupational therapist (OT) who worked in LTC facilities in the review of the draft survey, to ensure clarity and appropriateness of the questions for OT as well.
Survey questions from round 1 (R1) focused on (1) re-habilitation professionals' reported current practices and treatment goals and (2) perceptions of barriers to rehabilitation in LTC facilities for patients with dementia following hip fractures. For responses regarding treatment protocols, respondents indicated how often they used these practices (never/rarely [<10% of time], sometimes [10%-50% of time], often [51%-90% of time], always [>90% of time]). Respondents indicated their treatment protocols for acute (<6 weeks postfracture), subacute (6 weeks to 12 weeks postfracture), and maintenance (>12 weeks postfracture) periods of healing. To measure treatment barriers, respondents indicated how much of an issue chosen factors were, in providing adequate patient care at their facility (not an issue, somewhat an issue, major issue) and how important a list of strategies for managing cognitive and behavioral issues in patients with dementia were (not important, somewhat important, very important).
The following respondent data were also collected: age (5-year categories), gender, training (eg, PT, OT, therapy assistants), years of working experience (5-year categories), and number of (a) beds and (b) rehabilitation staff in the facility. Most questions were close-ended (multiple-choice, ranking, or “indicate all that apply” options) to standardize responses and improve survey completion.24 However, open-ended style questions were also included to explore respondents' opinions on each topic.
The survey was created using the Survey Monkey tool.25 A draft survey was pilot tested in one LTC facility to ensure that the questions were clear in intent and interpretation for the survey respondents.26 Following revisions, the R1 survey was considered complete. The respondents who completed the draft survey were invited to participate in the R1 and round 2 (R2) surveys.
Survey questions for R2 were developed according to areas of disagreement in R1. Areas of focus to achieve better consensus in R2 were (1) perceived treatment barriers, (2) staff knowledge of dementia, (3) communication among health care professionals, and (4) reported treatment protocols in the previously defined healing periods (acute, subacute, maintenance). In addition, we re-collected the respondents' personal and facility information as survey data were anonymous and we could not link R1 and R2 respondents.
Survey respondents were a convenience sample of rehabilitation professionals who (1) worked in LTC facilities in a Canadian province and (2) cared for patients with hip fractures. We attempted to reduce selection bias26 by including all members of the LTC interest groups' provincial e-mail distribution lists. Recipients were encouraged to forward the survey links to other potentially eligible respondents in their facility; thus, the total number of potential recipients is unknown. The primary e-mail lists had 124 rehabilitation professionals. The same individuals were asked to participate in R1 and R2 surveys, so R2 respondents could include those who had previously completed R1 as well as those who only chose to participate in R2. The responses to each of the surveys were independent of each other; we did not identify whether respondents had participated in R1 or not.
A survey link was e-mailed to distribution lists of rehabilitation professionals working in LTC facilities by our clinical expert along with a study information letter. Two reminder e-mails were sent at 1-week intervals as a method to increase response rates. Two survey rounds were used to complete data collection. Further consensus was achieved through the R2 survey by showing initial survey responses and refining survey questions. As consensus was achieved in most areas after the second survey round, a third survey round was deemed unnecessary.
Responses in each category and agreement or disagreement among respondents in the selected topic areas were tabulated. If more than 75% agreement was achieved in the category or combined categories (eg, somewhat an issue and a major issue), the practice/barrier was considered to have attained a consensus of “strong agreement.” If 66% to 75% agreement was achieved, the consensus was considered to be “agreement.” Responses between 50% and 65% were considered to show “neither agreement nor disagreement,” while those less than 50% were considered to be “disagreement.” We also compared the responses, using chi-square tests between different subgroups of rehabilitation professionals, age groups, years of experience, and according to the facility data collected when no consensus was achieved to determine whether these variables had a significant impact on reported findings.
Survey respondents' characteristics (R1 and R2) are presented in Table 1. Respondents were primarily female, with the most common educational level being a PT or OT baccalaureate degree, and who had at least 0.3 of their full-time equivalent devoted to LTC. Physical therapists were older with more working experience, while OTs were younger and less experienced (p < .05). Most respondents (R1: n = 39 [93%]) had training in care of residents with dementia, and many (R1: n = 33 [79%]) worked with these patients daily. Many respondents saw 5 or more hip-fractured patients with dementia annually (R2: n = 17 [63%]).
The majority worked at facilities that employed at least 1 PT and 1 OT, although there were more facilities without a PT (R1: n = 4 [11%]; R2: n = 2 [7%]) than there were without an OT (R1: n = 2 [6%]; R2: n = 0 [0%]). Therapy assistants and recreation therapists also made up an integral part of facility staffing in the respondents' facilities with 31 of 37 respondents (84%) in R1, indicating that their facility employed more than 1.0 full-time equivalent of assistants/recreation therapists.
Facilities were categorized by size, with 4 (10%) responses from small (≤50 beds) facilities, 21 (54%) coming from respondents working in medium-sized (51–150 beds) facilities and 14 (36%) from large (>150 beds) facilities in R1. Most respondents reported that they had allocated treatment space with access to rehabilitation equipment (eg, parallel bars, weights/resistance bands, pulleys) and modalities (eg, heat, cold, ultrasound) (R1: n = 36 [(92%]). The majority of R2 respondents worked in small-sized (n = 13 [48%]) facilities or medium-sized (n = 11 [41%]) facilities. Most respondents worked in major urban centers (R2: n = 18 [86%]).
Treatment Strategies for Patients With Hip Fractures
Therapeutic interventions most frequently used and believed to be important varied by the healing phase of the hip fracture (Tables 2 and 3). In the acute phase (<6 weeks postfracture), therapists focused on ambulation, transfers, bed mobility, and staff's and residents' family education. In the subacute (6–12 weeks postfracture) and maintenance (>12 weeks postfracture) phases, treatment focused on ambulation and balance (Table 2).
Ambulation and Balance
A daily walking program and increasing walking distance were the most frequent strategies reported to return patients to an ambulatory status (Table 2). This transitioned to include decreasing assistance in the subacute and maintenance phases. The 2-wheeled walker was the most frequently used gait aid. The 2 most frequently reported balance training strategies were weight shifting and marching (Table 2). The use of weight shifting was high in the acute treatment phase and gradually tapered off in the maintenance phase.
Strength, power, flexibility, and endurance exercises for the lower extremity were frequently performed and important at all rehabilitation stages (Tables 2 and 3). Family involvement was frequently reported and considered most important in the acute phase but remained present throughout rehabilitation (Tables 2 and 3). Upper extremity exercises were more frequently reported during maintenance (Table 2). Although modalities were available, they were not frequently employed (Table 2). The main method of pain management reported by respondents was timing the therapy of hip fracture with analgesic administration (R1: n = 31 [94%]). Other common methods of pain management included patient positioning, encouraging range of motion and mobility, using assistive equipment, and educating caregivers and family.
Frequency and duration of treatment sessions varied by discipline and rehabilitation phase (Table 4). The PTs typically saw the patients more frequently for longer durations than the OTs, particularly in the acute phase. Both groups reduced their treatment frequency over time; in the maintenance phase, the OTs reported longer treatment sessions than the PTs.
Barriers to Patient Care
Round 1 respondents strongly agreed on several barriers to providing best care for hip-fractured patients with dementia: inadequate treatment time (n = 31 [97%]) and staff (n = 28 [(90%]); patients' cognitive, emotional, and motor issues related to dementia (n = 31 [97%]); family's understanding of hip fracture and dementia (n = 28 [90%]); and communication among facility staff (n = 25 [(78%]). Round 2 respondents strongly agreed that more knowledge about dementia was required for care providers who had not received formal training in management of dementia (n = 24 [81%]). There was also agreement in R2 that LTC communication could be improved by increasing staff knowledge of hip fracture treatment (eg, implications of the surgical procedure, positional contraindications) and staff confidence in dealing with residents with dementia (n = 16 [73%]), as well as having adequate time for rehabilitation staff to train other disciplines (eg, in-service training) (n = 20 [91%]). There was strong agreement that communication with hospital staff (surgeon or rehabilitation) could be improved through provision of clear information on weight-bearing status (n = 16 [73%]) and the rehabilitation protocol (n = 19 [86%]).
Managing Dementia-Related Behavioral and Cognitive Issues
Although patient cognitive, emotional, and motor issues were clearly acknowledged as barriers to patient management in R1, more than half of R2 respondents (n = 11 [59%]) reported that these issues would not prevent treatment. When asked in R2 whether dementia-related issues prevented patients from making a significant recovery when rehabilitation was adapted to their cognitive issues, most respondents felt that both emotional (R2: n = 22 [82%]) and cognitive issues (R2: n = 20 [(71%]) negatively affected recovery. However, there was strong agreement in R1 that providing simple instructions (n = 16 [73%]), adjusting the environment (n = 27 [79%]], and working with the team (n = 26 [76%]) were very important for managing these issues.
Although hip fractures are relatively common in residents of LTC facilities, evidence is sparse as to how to optimize their recovery through rehabilitation.11,13,14 Furthermore, evidence for best rehabilitation practices in patients with dementia, common in LTC population, is limited16–18 but consistently suggests that mild to moderate dementia is not an impediment to rehabilitation after hip fracture. Muir et al17 and Allen et al,16 in their systematic reviews, reported that although patients with dementia made similar gains in functional recovery as those without dementia, the data were limited in their descriptions of the actual rehabilitation intervention. Most studies reported that the intervention was multidisciplinary and the measured outcomes were typically focused on functional independence and ambulation, but very few details were provided.
Older adults with dementia living in LTC facilities are often excluded from research, and accordingly, few studies in systematic reviews that examined hip fracture recovery in those with dementia included residents of LTC facilities or those with severe dementia.16,17 We undertook a survey of LTC rehabilitation professionals to augment current evidence and found that, although cognition and emotional issues related to dementia were reported as barriers to rehabilitation after hip fracture, LTC rehabilitation staff consistently reported employing strategies to manage these issues. Residents were provided with rehabilitation upon their return to LTC facilities following hip fractures, regardless of cognitive status. The LTC rehabilitation staff's reported approach is supported by limited evidence that suggests that several strategies can be employed by health care professionals to manage dementia-related cognitive and behavioral symptoms, thereby improving these patients' prognoses.27,28
Return to prefracture ambulation and mobility appeared to be the most important goals of rehabilitation in LTC facilities; thus, LTC rehabilitation staff report similar rehabilitation goals to those reported in the systematic reviews of post–hip fracture rehabilitation.16,17,29 However, LTC facilities staff also identified that barriers to providing adequate post–hip fracture rehabilitation care included having inadequate time and numbers of staff to provide treatment. Although 50% of PT respondents indicated that they were seeing patients 5 times per week in the acute recovery phase, many PT respondents and most OT respondents saw patients only 3 times per week, even during the acute recovery phase. After the first 6 weeks, treatment frequency and duration decreased with therapists seeing patients for a minimum of 15 minutes, 1 to 3 times per week. It is not clear why OTs saw the patients less frequently than the PTs and for shorter treatment sessions during the acute healing phase; further work is needed to measure the actual interventions performed by each of these disciplines. The reported treatment durations are substantially lower than those reported in the rehabilitation intervention studies,16,17,29 suggesting that residents of LTC facilities with dementia who have hip fractures are not receiving optimal postfracture rehabilitation because of inadequate resources, both personnel and time.
Chudyk et al29 undertook a systematic review of studies that examined rehabilitation after hip fracture for all subjects and reported that the most common interventions focused around ambulation, followed by a focus on functional activities and then by strengthening exercises and balance activities. These activities are very similar to that reported by the rehabilitation staff in LTC facilities. It is interesting to note that in R1, therapists were asked about treatment practices while in R2, the importance of various treatment practices was explored. Ambulation was highly rated in both rounds, whereas balance was rated as being important but was less frequently performed. This difference may be due to the challenges in undertaking balance activities with subjects who have dementia, but further work is needed to clarify this finding.
Many cognitively impaired people reside in LTC facilities and rehabilitation efforts do occur in these settings.1,4 Limiting studies to community and/or independent living individuals as well as individuals with mild to moderate dementia overlooks a substantial proportion of patients with hip fractures and quite possibly the patients needing more frequent and prolonged rehabilitation to optimize recovery. Long-term care therapists report that treatment is possible in these settings, so further research should examine the intensity and duration of rehabilitation required to promote maximal recovery in residents of LTC facilities.
Our study has a number of strengths. We started our evaluation with a systematic review, which highlighted the paucity of information and lack of sound methodological studies in this area.16 Little information could be gleaned in regard to LTC rehabilitation practices, as much of the published research excluded residents of LTC facilities. In the absence of evidence, we undertook a survey of reported practices and perceived barriers to the rehabilitation of hip-fractured patients with dementia residing in LTC facilities to understand current management of these subjects. In addition, our survey used accepted survey development strategies22,24,26 and employed a modified Delphi approach, which is considered an acceptable method to gain consensus in health care.19,20 Using this approach allowed us to develop more focused questions and informed us about practice adaptations for treatment of subjects with dementia. Thus, our survey generated some preliminary evidence about current practices and rehabilitation goals of LTC rehabilitation professionals managing these patients.
Convenience sampling was used to contact survey respondents, potentially limiting the generalizability of our results although our sample consisted of rehabilitation professionals currently working in the setting of interest. Thus, there is no obvious reason why they would respond differently than a random sample from the same population. We also did not ask rehabilitation staff whether treatment practices varied by severity of dementia. Furthermore, our survey examined only reported practices and could not associate patterns of recovery with reported care. Finally, unlike LTC facilities in the United States, Canadian LTC facilities are reserved for permanent residential care and do not typically provide episodic skilled nursing or rehabilitation after injury or illness. Thus, our results may not generalize to the United States. Further work is required to determine whether the level of rehabilitation provided in LTC facilities affects recovery following hip fracture in residents of LTC facilities with dementia.
Rehabilitation goals in LTC facilities for patients with dementia following hip fractures appear similar to those reported in other settings. There were consistent reports from survey respondents, which concurred with published evidence that cognitive impairment requires the implementation of management strategies but does not prevent rehabilitation. There was strong consensus among survey respondents that, with acceptable resources within LTC facilities, adequate rehabilitation may be provided to these individuals. Thus, more research is required to identify “best” rehabilitation practices in the LTC population for patients with dementia who have had hip fractures.
Dr Beaupre receives salary support from Alberta Innovates–Health Solutions (formerly Alberta Heritage Foundation for Medical Research) as a Population Health Investigator.
This study was completed as part of the degree requirements in the MScPT program at the University of Alberta.
We thank Heather Marta for her guidance and support in developing and interpreting the survey.
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