After a hip fracture
Repairing a hip fracture doesn’t end with surgery; regaining one’s mobility and independence relies on a successful rehabilitation programme.
GROWING older is not always fun, specifically in terms of health and fitness.
You suddenly start to develop aches and pains, you’re no longer as eagle-eyed as you used to be, and forget about easily stretching out when it comes to those yoga poses.
You might discover that you have high blood pressure (hypertension) or diabetes or arthritis, and your waistline may not be as svelte as it used to be either.
More insidious is that your balance becomes poorer, your reflexes become slower and your bone density also decreases – this, unfortunately, is a recipe for falls and fractures.
According to a 2007 study published in the International Journal of Rheumatic Diseases, hip fractures occur in nine out of 10,000 Malaysians above 50 years of age (0.0009%).
This number increased to 50 out of 10,000 for Malaysians aged above 75 years of age (0.005%).
Women were twice as likely to have a hip fracture compared to men, as women are prone to osteoporosis – a condition where your bones start to thin and become weak – due to their decreased oestrogen levels after menopause.
These numbers were similar to those in the most recent Annual Report of the National Orthopaedic Registry Malaysia (Norm) Hip Fracture published in 2009.
The report found that 71.4% of the patients admitted for hip fractures in public hospitals in 2009 were aged 70 and above, with 41.4% being in the 70-79 years age group.
Female patients outnumbered male patients by two to one.
Both publications also found that Chinese patients were the most prone to suffer from hip fractures, as Chinese ethnicity is also a risk factor for osteoporosis.
According to the report, the most common reason by far for the hip fracture was falls, as experienced by 83.1% of the patients.
Treatment for a hip fracture is surgery to stabilise or fix the fracture, so that it can heal by itself. In some cases, part of the hip might need to be replaced.
As almost all hip fracture patients are senior citizens, there are some who are not medically fit for the surgery and some who may not wish to undergo the surgery – 32.2% and 34.5% respectively of all patients who did not undergo surgery in the report.
Some of the methods in managing such cases include traction, bed rest and restricted movement.
In total, the report found that 97.4% of all hip fracture patients were successfully treated and discharged.
A tailored programme
However, this is just the beginning of the recovery process.
It is essential for patients to go for rehabilitation, consisting of physiotherapy and occupational therapy.
According to consultant geriatrician Dr Chen Queen Liung, fracturing a hip is actually a marker of frailty, as people of all ages can fall, but not break their bones.
She explains: “Frailty is actually a syndrome where we are losing muscle mass, we’re losing strength and our hand grip is very weak.
“There are also other issues, for example, maybe some memory issues that affect their judgement of the environment they are walking in, and when they lose balance, they cannot react fast enough to
compensate and either stop themselves from falling or breaking their fall so that they don’t injure themselves so much.”
Physiotherapy helps to strengthen the patient’s muscles and increases their range of movement.
It is also important for patients to be evaluated either by a geriatrician, who specialises in the health and care of older adults, or a rehabilitation physician, who specialises in managing patients with physical disabilities or loss of function.
Says consultant rehabilitation physician Dr Kavitha Ratnalingam: “By the time you hit the geriatric population, their problems can be so varied.
“From a medical perspective, they have multiple medical problems at that stage, which does affect their recovery.
“For example, they could be diabetic. Because they are likely to be
a long-term diabetic, there might be muscle wasting, especially in the leg muscles, which might not be as strong as they could be because the illness makes them weaker.
“And that makes rehabilitation more challenging and is something we need to focus on.”
She gives another common example of a urinary tract infection: “Sometimes, for surgery, they put in a catheter so that they pass urine into a bag, and that can cause a urinary tract infection.
“And that infection alone will cause patients to be confused and delirious.
“So you really need to treat that before you can do rehabilitation.”
She adds that heart problems are also common among the elderly, which means that they cannot be pushed as hard physically as someone without a heart problem and their rehabilitation programme needs to be tailored accordingly.
Another aspect is the social situation.
With families becoming smaller and work taking up so much time, “it’s difficult to then be there as a carer for your family member, so unfortunately, there is a tendency of ‘we can’t do anything about it, so we have to send them to a nursing home’,” says Dr Kavitha.
However, she adds that successful rehabilitation can restore more function to a patient, allowing them to be more independent.
Occupational therapy, in particular, helps the patients to accomplish daily activities of living.
This makes their families more inclined to bring them home, as the patient can manage their daily routine with the aid of a part-time carer.
Dealing with elders
According to physiotherapist and ReGen Rehabilitation Hospital director of therapy Chelvi Muniandy, goal-setting is very important in a rehabilitation programme.
“These patients already have their own mindset and they are much older than us, they (think they) know better than us in many ways, so that is why the goalsetting is very important – we need to know exactly what they want,” she says.
Giving the example of a patient whose goal is to go to the toilet independently, she says that the main aim would be to strengthen their muscles.
“It is not as simple as for a younger patient where we can just instruct them on how to do the proper exercises.
“Because they might have other issues – one of which, of course, is pain – we have to modify the exercise according to their ability.
“And we have to teach them all the techniques one by one.
“Even something as simple as taking toilet paper to clean up while on the toilet is not simple after a fracture, because the patient would be afraid to lean forward to do it.
“So the occupational therapist has to teach them the technique of doing it.
“The physiotherapist has to teach them how to stand up and transfer themselves safely.”
While some families might opt to look online and hire a freelance physiotherapist for their elderly relative, Chelvi emphasises that it is important for the physiotherapist and the doctor in charge to work closely together in order to manage the patient properly.
“If these exercises are not done in the right way, there will be issues,” she says.
She adds: “Whatever we teach the patient has to be transferable to their home environment – all this has to be seen as therapy as a whole, so the physiotherapist and occupational therapist have to discuss and work closely with the rehabilitation physician and geriatrician.”
Even choosing a wheelchair or walking aid for the patient needs to be carefully done so that the devices are suitable and safe for the patient’s home.
Chelvi also notes that our muscles do not work in quite the same way once we have aged.
“Maybe the patient already had some weaknesses before their fall, so we have to look at their condition before and after the fall.
“We have to understand them and get feedback from the family on how they were before the fall, so that we can cater for them.
“If you don’t understand the patient and push them straight away, they will get upset and won’t cooperate.
“Then they get labelled as lazy or stubborn, which is not true.”
Patience is crucial for therapists, she says, giving the example of a patient who refused to open her mouth.
“I don’t know how much of talking we had to do before she finally opened her mouth.
“It turned out that she didn’t like the food – but she didn’t say anything, she just didn’t open her mouth.
“So we had to understand why she didn’t want to open her mouth.”
Dr Chen notes that while goals like wanting to go to the toilet independently might seem trivial to those of us who are healthy, it is very different for an elderly patient who is immobile.
“When a patient comes to that level, they have lost their dignity.
“They have really lost hope and believe that they are going to die soon. Sometimes, a lot of negative things come into their mind and that is what we are working against.
“When they become so ill because of their physical disability, whether permanent or temporary, even getting out of bed to get themselves onto the commode or toilet can seem impossible.
“So we need to give them hope, to motivate them, to believe in them, and to restore their dignity, their self-respect and their selfesteem.”
Adds Chelvi: “Our aim is to make them functional – quality of life is so important.
“They want to live, they want to be with friends, they want to move, so you cannot say, ‘No, you just stay at home.’
“So you have to make them functional.”