Physiotherapy for people with dementia who fracture their hip

Abstract

Outcomes for people with hip fracture are poor with approximately only 33% of people returning to their prior level of function and only 24% of people independently mobile by six months after hip fracture. The presence of dementia further worsens outcomes with a significantly increased risk of nursing home admission or death. Physiotherapy is a core treatment for people following surgery for hip fracture, yet there is little evidence to guide physiotherapists how to treat this population. The overall aim of this thesis was to determine the evidence surrounding the physiotherapy treatment for people with dementia following hip fracture and explore the experiences of those involved, thus leading to the development of an intervention which could be tested for feasibility. A series of four related studies were undertaken. The first of which was a scoping review which highlighted a paucity of evidence guiding the physiotherapy interventions for this population. Thirteen different databases were searched, with 26 articles being included in the review. Where there was evidence, there was a failure to describe the physiotherapy intervention. Consequently, two qualitative studies were undertaken. The first qualitative study explored the experiences of physiotherapists treating this population and involved semi-structured interviews with twelve physiotherapists. Physiotherapists cited resource pressures, historical reliance of biomedical practices and lack of knowledge as being the main barriers to adopting a person centred care approach that was described as a gold standard of care. The second study explored the experiences of six people with dementia (and five carers) receiving physiotherapy. Both studies concurred that the approach undertaken by the physiotherapist was often biomedical in nature and this failed to meet the needs of the person with dementia and did not reflect a person centred care approach that is suggested for this population. Patients and their carers reported the desire for treatment to be more person centred, but appreciated that physiotherapists were not able to deliver this. Data from the qualitative studies, in conjunction with existing biomedical evidence, informed the development of a logic model depicting a community based physiotherapy intervention for people with dementia following hip fracture. This formed the basis for the final stage of the thesis whereby a mixed-methods feasibility study was undertaken. The logic model incorporated the qualitative data and pre-existing physiological evidence in conjunction with components of behaviour change. The feasibility of recruiting to this study was poor, qualitative inquiry suggested that people with dementia were not being referred for on-going physiotherapy following discharge to the community setting. Failure to recruit to the study meant that testing of the intervention in a clinical setting was not possible. Further qualitative analysis proposed that people with dementia were being reported to have “no rehabilitation potential” in the acute setting as their assessment relied on biomedical measures of assessment. This label then prevented them from being offered further rehabilitation in community settings. Collectively, these series of studies suggested that the failure to approach people with dementia following hip fracture with a biopsychosocial approach, not only reduced their ability to improve, but actually prevented them from being given an opportunity to receive rehabilitation.National Institute for Health Research (NIHR