TREATMENT OF PATIENTS WITH ALZHIMERS & (Back to contents) RELATED DISORDERS WITH HIP FRACTURES
Ambulation is a significant quality of life issue for patients
with dementia
and also for their families . Ambulation decreases the probability
of skin
breakdown . Patients with dementia who cannot ambulate safely
often require
restraints to keep them in wheelchairs increasing agitation ,
contractures
and incontinence . Keeping them bed bound adds pneumonia to these
problems.
While ambulation poses a risk of falling for these patients ,
most
patients, families and staff agree that the increased quality
of life and
happiness is well worth the risk.
We have good results in our facility . Literature indicates
that dementia is
a negative factor for rehabilitation and significantly increases
the risk of
mortality, but we have found with patience and perseverance we
can return
virtually all of those who survive to a level of function equal
to , or only
slightly below their prior functional level.
All patients admitted with the diagnosis of hip fracture in
a two year period
were reviewed . One of our facility is a 120 bed skilled nursing
facility
exclusively dedicated to caring of patients with alzhimers and
related
disorders . We admit only residents who have a significant likelihood
of
needing long term care following their rehabilitation or our own
residents
who have fallen and fractured a hip and need rehabilitation .
We attempt to
keep our residents functioning at a high level as possible . Activities
are
appropriate to the level of cognition and are always functional.
The staff
are well trained,caring and professional . Even though we have
severely
impaired dementia patients , we have only 7-10% that require physical
restraints , rather positioning devices to achieve proper body
alignment
while up in wheelchairs .
Physical therapy treatment in this study consisted of sessions
ranging from
1 week to 16 weeks and treatment sessions were generally 45 -
60 minutes.
Length of rehabilitation was dependent on potential and progress
and was
evaluated weekly. The patients were also screened by occupational
therapy
and treated when appropriate. Physical therapy included upper
extremity and
lower extremity strengthening , bed mobility , balance training
, transfer
training , gait training with or without assistive device and
patient /family
/staff education. We found that we had to be creative and flexible
with our
treatments. We learned with each patient what cueing was necessary
to
maximize with their intact procedural memory skills. We also learned
that
rehabilitation took longer if weight bearing was limited or the
patient was
cognitively impaired which led to weaning off the walker sometimes
because
they would not remember to use it. Studies show progress in hip
fracture
patients upto 6 months and very little after that. Studies also
shows that
lesser amount of rehabilitation time and concluding that the patient
could
not walk is inappropriate with this patient population. It has
been stated
in literature that rehabilitation takes 4 times longer even in
patients who
were lucid prior to surgery if they developed confusion following
the surgery
. There were 15 patients treated for hip fracture all of whom
were
moderately to severely cognitively impaired. All the patients
who survived
were able to ambulate at the time of discharge from physical therapy
atleast
100 ft. Some required assistance for safety due to decreased judgment
and
cognition. We found that some patients had to be weaned off the
walker and
trained with no assistive device as they were unable to remember
it on their
own. Four patients were able to ambulate totally independent and
5 needed
supervision only. All the patients 'graduating' from physical
therapy were
referred to restorative nursing care for maintenance 5 days /week
x 4 weeks
and later to the wing staff. Functional maintenance program was
established individually for each patient and followed through
with
restorative nursing . On follow up several months later most of
these
patients were still ambulating at the same level as that at discharge.
Patients with dementia are happier and more content when they
have
independence of movement and ambulation . It is also easier for
nursing
staff to care for patients who are mobile . We feel that we have
a unique
opportunity for study of results of rehabilitation working in
an all dementia
facility.
We understand that in traditional hospitals and subacute care
facilities,
staff are not familiar with patients with dementia and their special
needs.
Patients who are confused cause severe nursing problems due to
violent
disturbing or perilous behavior. We know a physician who says
she needs to
get patients back from acute hospitals within 3 days or they probably
will
not survive or return to their prior level of function. It has
been our
experience that rehabilitation teams become frustrated quickly
with patients
with dementia and do not give them the time and effort they need
to achieve
the highest level of function possible. The burden of rehabilitation
of
patients with dementia are transferred to skilled nursing facilities
due to
insurance implications. We do find some discrepancies in recovery
depending
on how the hip fracture is managed . Often with patients with
cognitive
deficits , non weight bearing , partial weight bearing are not
an option .
Non weight bearing is an important obstacle . Patients who are
non weight
bearing for 2 -3 months (as it occasionally happens) stands minimum
chance of
return to ambulation . Studies show that even though patients
with ORIF are
not ambulating as quickly as those with THA they catch up later.
In conclusion , we feel patients with alzhimers disease and
related disorders
who sustain hip fracture require more patience , creativity and
a slightly
longer period of rehabilitation , but the results and increased
quality of
life are well worth the effort.
CHENDA DASARATHY P.T.