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S. Eleuteri and M. E. B. de Lima
Dedicated psychological care for patients who have suffered hip fractures should
be structured to focus on patients’ wellbeing and quality of life following surgery.
Attention should also be paid to the physical pain that each patient may experience
differently, physical, and psychological rehabilitation, and emotional support.
Psychological adjustment to one’s physical condition, emotional awareness, and
maintaining a state of calm and wellbeing are factors that contribute to improving
postoperative quality of life.
The different negative and positive dimensions that are important to evaluate and
the instruments most likely to be appropriate at each stage discussed should be
addressed by the orthogeriatric team following a bio-psycho-social approach. The
inclusion of a psychologist in the team can help in the assessment of the patients’
psychological wellbeing, using the tools we have detailed above, but can also enable
psychological counselling. During counselling, the psychologist can obtain more
qualitative data to help tailor interventions based on emerging needs and the
resources available as well as give feedback to patients and their caregivers on the
problems and the strengths that emerged in the assessment. It has been demonstrated that twice-weekly counselling for about 45min had a positive inuence on
hip fracture patients’ depressive and anxiety symptoms [55].
Similar results were shown for ‘psychological support therapy’ (PST). This had
a signicant impact on patients who had sustained a femur fracture, contributing to
pain reduction and improvement in psychological status, as well as patients’ quality
of life and nurses’ job satisfaction [56]. The outcomes of PST, which was applied in
addition to routine care for 41 adults following femur fracture, were compared with
the outcomes of routine psychological care alone for a control group.
The PST intervention involved:
1. A psychological support group, consisting of nurses with solid nursing skills and
physicians with extensive clinical experience. Psychologists created the group
by choosing members with psychological intervention skills, especially the ability to recognise and understand patients’ emotions, reduce negative emotions,
and promote positive ones, while being able to communicate effectively with
patients.
2. Older adults who with fractures often do not fully understand the details of surgi-
cal procedures leading to misunderstandings and facing the surgery with a negative state of mind. Team members informed patients and answered all their
questions clearly and patiently. Practitioners were also required to understand
the needs of patients and deliver individualised interventions. The team assessed
the psychological status of patients, interviewed them, observed changes in their
behaviours, understood the emotions felt by patients after sustaining a fracture,
and offered targeted psychological support according to their needs.
3. The team provided fracture-related information through communication modes
adapted to the patient’s level of education and the ability to understand. The
impact of functional exercise on rehabilitation was explained, including both
patients and their family so that worries and doubts were relieved, resulting in
reduction in anxiety. These patients risk much longer and more frequent hospital
stays than other adults. Comprehensive discharge-planning programmes (Chap.
13 Psychological Wellbeing
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219
16) can improve these outcomes. On admission to care facilities, early multidi-
mensional assessment (Chap. 6) can provide indications of how to address
patient needs more effectively. Greater psycho-educational support can be provided during the rehabilitation phase during which there is more time to focus
on this.
4. The importance of nurses strengthening communication with patients and the
need to provide psychological care for them according to their individual
needs was stressed. Nurses also explained to patients the relationship between
their emotional state and maintaining a positive attitude and condence in
their care.
5. Patients were encouraged to maintain communication with the world outside the
hospital and to access support from family members. At the same time, family
members were encouraged to spend more time with them, talking to them and
listening to them to help them adapt to their condition and reduce any negative
emotional states.
6. Patients’ favourite genres of music, such as light or relaxing music, and TV
series were played to divert patients’ attention from their condition, entertain
them, reduce their pain, and reduce their anxiety and negative thoughts.
7. Patients who had successfully recovered after a fracture were invited to share
their experiences to encourage other patients to have a positive approach toward
rehabilitation.
The PST programme made it possible to assess patients’ psychological state,
analyse the factors that contributed to the development of negative thoughts and
emotions, conduct psychological counselling, and help nurses and patients communicate effectively. This strengthened patients’ trust in healthcare personnel, who
played an active role in accelerating the rehabilitation process following a fracture.
In this type of therapy, healthcare practitioners can [57]:
– encourage patients to create a healthy psychological state
– explain to patients the impact that a negative state of mind can have on the reha-
bilitation process
– encourage patients to take the initiative in expressing themselves
– respond to their questions and concerns
– help patients take a positive view toward their health problems and reduce their
negative thoughts and attitudes
– alleviate worries and anxieties
– encourage patients to develop the habit of self-regulating their emotions
Psychological support therapy can also contribute to:
– improving patients’ ability to cope with pain
– reducing psychological pressure
– increasing condence in the process of recovery and rehabilitation
– strengthening psychological and physiological adaptation by increasing toler-
ance to stimuli
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S. Eleuteri and M. E. B. de Lima
Nurses can also encourage patients to maintain active communication with family members so that they have a social support network [58].
The results of the studies discussed here lead to an appreciation of the importance of psychological evaluation and support in care for older adults affected by
fragility fractures. As part of the integrated and multidisciplinary approaches to
care, practitioners who can demonstrate the appropriate psychological skills to
assess the psychological wellbeing of patients and their caregivers are essential.
Summary and Main Points for Learning
• Negative emotional experiences in older adults who have suffered hip fractures are associated with low psychological tolerance, anxiety, perioperative pain, limited lower limb movements, and high prognostic expectation.
• Mental health status at the time of surgery has been reported as an important determinant of outcome, with mental health disorders associated with
poorer functional recovery and higher mortality rates.
• The recovery process that follows surgery varies depending on the patients’
comorbidities, cognitive and functional status, and their psychosocial state.
Wellbeing in this sense means more than health as such. It is important to
evaluate different negative and positive dimensions to assess patients’ psychological status when following a bio-psycho-social approach.
• Nurses encourage patients to maintain active communication with family
members so that they have a social support network.
• Psychological support therapy for older fracture patients has been used to
assess their psychological state, analyse the factors that contribute to the
development of negative thoughts and emotions, provide psychological
counselling for patients, and help nurses and patients communicate effectively to increase patients’ trust in health professionals, who play an active
role in accelerating the post-fracture rehabilitation process.
13.5 Suggested Further Study
Being able to empathise with patients, especially from an emotional perspective, is
vital in providing excellent care that includes psychosocial aspects.
Access the following open access (free to download) article: https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC7925874/.
Tutton E, Saletti-Cuesta L, Langstaff D, Wright J, Grant R, Willett K (2021)
Patient and informal carer experience of hip fracture: a qualitative study using interviews and observation in acute orthopaedic trauma. BMJ Open. 11(2):e042040.
https://doi.org/10.1136/bmjopen- 2020- 042040.
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221
Read the article, but particularly focus on the quotations that highlight patient
and family emotional experiences of hip fracture. Ask yourself the following
questions:
• What can I see in the patient and family words (the quotations) in this chapter
that suggests that having a hip fracture is an exceptionally difcult emotional
experience?
• In what way does my team take this emotional experience into account during
care providing?
• Having read the article and this chapter, what I can I now see is important in the
way we provide care that would better support psychological wellbeing in our
patients and their families?
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S. Eleuteri and M. E. B. de Lima
Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Rehabilitation
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14
LaurenBeaupre, KathleenMangione, andCarmenQueirós
14.1 Introduction
Following a fragility fracture, especially a hip fracture, patients face a long journey
to recovery [1]. Older people with fragility fracture are often medically complex,
presenting with concomitant conditions including frailty that require extended care
from multiple carers/providers in both hospital and community settings. Beyond the
physical challenges to recovery, social and psychological factors, including fear of
falling, can also affect the rehabilitation and recovery process. Although hip fracture
is one of the most common and devastating fragility fracture, the rehabilitation concepts discussed in this chapter are also applicable to patients experiencing other
fragility fractures. Previous chapters discussed frailty, early mobility, remobilization and exercise, and falls prevention. This chapter will focus on rehabilitation
across the care continuum, including interprofessional care, for patients following a
L. Beaupre
Division of Orthopaedic Surgery, Departments of Physical Therapy and Surgery, University
of Alberta, Edmonton, Canada
e-mail: Lauren.Beaupre@albertahealthservices.ca
K. Mangione
Arcadia University, Glenside, PA, USA
e-mail: mangionk@arcadia.edu
C. Queirós (*)
Department of Ortho-physiatry, Centro Hospitalar Universitário de Santo António,
Porto, Portugal
Escola Superior de Enfermagem do Tâmega e Sousa, IPSN - CESPU, Penael, Portugal
Health Sciences Research Unit: Nursing, Nursing School of Coimbra, Coimbra, Portugal
Porto, Portugal
© The Author(s) 2024
K. Hertz, J. Santy-Tomlinson (eds.), Fragility Fracture and Orthogeriatric
Nursing, Perspectives in Nursing Management and Care for Older Adults,
https://doi.org/10.1007/978-3-031-33484-9_14
225
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fragility fracture. The aim of the chapter is to promote the role of nurses and other
practitioners in progressing mobility through the rehabilitation process in patients
with fragility fractures.
L. Beaupre et al.
14.2 Learning Outcomes
At the end of the chapter, and following further study, the practitioner will be able to:
• Dene the goals of rehabilitation for patients with fragility fractures transition-
ing back to their community settings
• Describe the role of the nurse and other practitioners in empowering the family
to participate in and enhance rehabilitation processes.
• Outline the evidence and make pragmatic suggestions for including older adults
with dementia and fragility fractures in all rehabilitation processes
• Apply strategies to encourage full return to function and participation in the
community.
14.3 Long-Term Outcomes Following Significant
Fragility Fracture
Many older adults who experience a low trauma fall and fragility fracture will experience a decline in physical mobility, basic and instrumental activities of daily living, and quality of life in the year following fracture. The risk of institutionalization
is increased, but this is not signicantly different after fragility fractures of the hip,
pelvis, and spine—suggesting increasing disability among all those with fragility
fractures [2].
Older adults who sustain a fragility fracture after a fall are likely to fall again. In
an Australian study of 336 older adults who sustained a lower extremity fragility
fracture, 43% of the participants fell again during the following year and approximately 10% sustained a second fracture [3]. In 161,000 older USA residents who
had sustained a hip fracture, the risk of subsequent fracture was approximately 5.5%
and most likely to be another hip fracture. The risk of further fractures increased
with age, being female, and having comorbid conditions [4]. A critical review of
disability outcomes following hip fracture found that older adults in New Zealand
were four times more likely to be unable to mobilize in the community 2years after
fracture [5]. By 6 months post fracture, 42–71% of surviving patients recovered
basic ADLS.In instrumental ADLs, of the 34% who were independent prior to the
fracture, only 14% were independent after a year. Across the globe, decline in quality of life (QoL) measures (EQ. 5D) was in the region of 10–20% at both 4- and
12-months post fracture. The review also reported studies which noted the need for
increased domestic services in the home and reported decline in both cognitive and
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physical health the year post fracture [5]. The studies in the critical review could
only include the survivors under usual care conditions. The review did not address
potential for recovery for a given patient or for those who receive optimal care.
227
14.4 Post-acute Rehabilitation
Most older adults who sustain a signicant fragility fracture (e.g., hip or pelvis) will
receive post-acute rehabilitation. This rehabilitation may occur in multiple settings,
making care complex [6, 7]. In-patient acute rehabilitation centers provide patients
with daily physical and occupational therapy. Nursing homes can also provide daily
rehabilitation services, but usually at less intensity than acute rehabilitation centers.
Rehabilitation can occur in patients’ homes (including assisted living facilities or
group homes) and at out-patient centers, but the frequency of visits is usually two to
three times per week at best [7]. While the ultimate goal of rehabilitation services is
to restore patients to the highest level of function and/or return patients to their level
of function prior to the fracture, the care is often fragmented by the transition in
settings and by the multiple professionals communicating with patients.
14.5 Rehabilitation andExercise
Rehabilitation combines the key features of exercise science with functional training
for basic and instrumental activities of daily living. Although exercise and remobilization are considered in detail in Chap. 8, it is important to consider these as part of the
rehabilitation process. For rehabilitation to be successful, gradually rebuilding strength
and endurance in activity is important. Supporting patients in exercise for rehabilitation is an interdisciplinary team’s responsibility. In particular, the nursing and therapy
teams need to work closely together to support patients in undertaking exercise and
other rehabilitation activities. Rehabilitation needs to be incorporated into care activities so that it is performed several times a day, rather than only when a physiotherapy,
an occupational therapist or a rehabilitation nurse is present.
In terms of exercise science, “progressive overload,” “specicity,” and “reversibility” are key principles that are applied to all types of exercise affecting muscle,
bone, and function which will impact on rehabilitation:
• Progressive overload is that an individual needs to provide a load to the tissue
(muscle or bone) that is “more than the customary load” for there to be an
increase in muscle strength or bone formation. Lifting the leg or extending the
knee may be an appropriate exercise day 1 after hip surgery but, for the muscle
to get stronger as the exercise becomes easier, a greater load (weight) is needed
to continue to increase muscle strength.
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