Workforce competencies required to provide community rehabilitation for aged clients after orthopaedic surgery - a literature review.
Prepared by
Emmah Doig
Delena Amsters
For the Community Rehabilitation Workforce Project
16/12/05
Executive Summary
This literature review explored the nature of rehabilitation and support needs of aged clients after orthopaedic surgery. This was undertaken in order to establish the types of workforce competencies required to meet these needs in community rehabilitation (CR) settings. For the purpose of this review CR was defined as delivery of rehabilitation in home and community settings.
Characteristics of the various client groups, as well as short and long term outcomes documented in the literature, were examined in order to inform the community rehabilitation and support needs. In turn, workforce competencies have been extrapolated from the rehabilitation and support needs.
The nature of CR will differ for joint replacements as compared with hip fracture given the unplanned nature of hip fracture. There is an opportunity for provision of pre-admission assessment and education for elective surgery participants so competencies must reflect the ability to provide consistent and meaningful informational support throughout the continuum. The review highlighted the need for high quality CR services to support early discharge programmes as these are commonly utilised in cases of elective orthopaedic surgery.
There was a strong bias in the literature towards the need for expertise in physical and functional management and environmental compensation. However, the literature clearly highlights the need for skills to assist clients to manage changing social and emotional needs and provide a focus on societal participation, both in the short and long term. Pain management skills were seen as an imperative for effective CR due to the high frequency of persistent pain amongst this client population.
Competence in assessing care support needs and carer burden, and knowledge of available community support services are a critical part of CR. Skills to assist clients and caregivers to manage cognitive deficit was emphasised for hip fracture clients. The ability to implement risk management strategies to prevent future falls and allay client fears of future falls is also an essential competency.
Despite the presence of a prescriptive element to provision of CR to this client group, the need for workers to be competent at individualising assessment, planning and intervention was strongly emphasised.
Table of Contents
Executive Summary 2
Table of Contents 3
List of Tables 4
1. Context of the Literature Review 5
1. Context of the Literature Review 5
2. What are the rehabilitation and support needs of people aged 65 and over following discharge from hospital after hip fracture? 5
Characteristics of the hip fracture population 5
Functional status post hip fracture rehabilitation 6
Rehabilitation outcomes after hip fracture for patients with cognitive deficits, dementia and delirium 7
The particular needs of patients with dementia who experience hip fracture 7
3. What are the rehabilitation and support needs of people aged 65 and over following discharge from hospital after THR? 9
Characteristics of the hip replacement population 9
Outcomes post THR 9
Long term outcomes following THR 10
Carer Burden 10
Information needs 11
4. What are the rehabilitation and support needs of people aged 65 and over following discharge from hospital after TKR? 12
Characteristics of the TKR population 12
TKR outcomes 13
Long term outcomes post TKR 13
5. What competencies do CR workers require in order to meet these rehabilitation and support needs? 15
6. Conclusion 16
7. References 18
Appendix 1: Search Strategy 22
List of Tables
Table 1: Rehabilitation and support needs after hip fracture 8
Table 2: Rehabilitation and support needs following THR 11
Table 3: Rehabilitation and support needs following TKR 14
Table 4: CR competencies for workers providing services post hip fracture 15
Table 5: CR competencies for workers providing services post THR and TKR 16
1. Context of the Literature Review
This review has been undertaken as part of the Community Rehabilitation Workforce (CRW) Project, funded through the Commonwealth Pathways Home Programme. The aim of the CRW Project is to optimise the capability of the current and future workforce to develop, implement and evaluate community rehabilitation (CR) programmes to meet the current and emerging health needs of the Queensland community.
This review will assist the CRW Project to determine the CR workforce competencies required to meet the health needs of aged clients after orthopaedic surgery.
The specific questions that will be addressed by this review, in relation to these aims are:
1. What are the rehabilitation and support needs of people aged 65 and over following discharge from hospital after-
a) hip fracture
b) total hip replacement (THR)
c) knee joint replacement (TKR)?
2. What competencies do CR workers require in order to provide these rehabilitation and support needs to people aged 65 and over following discharge from hospital after-
a) hip fracture
b) hip joint replacement
c) knee joint replacement?
The scope of the review has been limited to hip fracture, knee replacement and hip replacement as these are the major orthopaedic diagnostic groups for patients over 65 who are hospitalised in Queensland. The full literature search strategy is outlined in Appendix 1.
2. What are the rehabilitation and support needs of people aged 65 and over following discharge from hospital after hip fracture?
The characteristics of the hip fracture population as well as short and long term outcomes after hip fracture, indicate probable rehabilitation and support needs for this client group. A summary of these probable key needs and a description of the supporting literature have been provided in Table 1.
Characteristics of the hip fracture population
Arinzon (1) reports the incidence of osteoporotic fractures as increasing and refers to this as an epidemic. Consequently, there is an expected need for increased resources to treat people with fractured neck of femur due to an ageing population (2, 3) which suggests that measures to facilitate early discharge will be imperative. A comprehensive ortho-geriatric approach to rehabilitation following hip fracture, rather than an orthopaedic approach alone is advocated given the diversity and constellation of potential problems in older people due to the complications arising from age related concomitant medical conditions (4).
Increasing age has been associated with poorer functional recovery from hip fracture and older patients (85 years and over) have been found to be more functionally dependent pre-fracture, have higher co-morbidities and are likely to live alone (1, 5). Co-morbidities including osteoarthritis, pulmonary disease, diabetes, stroke, previous fracture, depression and cognitive deficit have been found to be more prevalent in old-old patients (85 years and over) compared to young elderly (65-74 years) (1). Hip fracture is more than twice as frequent in patients with dementia compared to the general population (6). Lieberman et al (7) reported the incidence of hearing or visual impairment in a large group of 896 patients hospitalised for rehabilitation with hip fracture to be approximately 25%. Visual impairment was found to have a significant and negative impact on efficacy of rehabilitation and the authors concluded that attention needs to be paid to optimising a patient’s visual acuity in rehabilitation (7).
Functional status post hip fracture rehabilitation
The majority of patients fail to regain their pre-fracture ambulatory and functional status (5, 8, 9) which provides the impetus for studies investigating rehabilitation programs that extend beyond the initial post operative period (ie. six and 12 months post fracture). Several factors have been associated with functional recovery following hip fracture. Older age, poorer pre-fracture physical function and cognitive deficit have been associated with poorer prognosis and functional recovery after hip fracture (1, 5, 8). Co-morbid status, gender, type of fracture and operative delay have also been associated with functional outcome (1). Increasing age and the presence of co-morbidities has been associated with increased use of home health care after rehabilitation (10).
There is a high prevalence of persistent hip pain at three months after surgical repair of a hip fracture. Those with moderate to severe hip pain report greater difficulty with activities of daily living (ADL) performance and worse self perceptions of quality of life which in turn is associated with more symptoms of depression (11). The implications of these results are that patient education about the prevalence of pain and strategies for management, as well as monitoring and treatment of depression are essential for optimising outcomes. Hip fracture is one of the most serious consequences of a fall. Mckee et al (12) found that perceived risk of further falls was associated with high functional limitations post fall and worry over further falls was associated with falling again after discharge. Further investigation was recommended into the worry over further falls in the recovery from hip fracture and the potential for intervention (12). An Australian study by Whitehead et al (13) showed that in a group of patients who had returned to live in the community post hip fracture, 20% had fallen at four months post hip fracture and this group had less confidence in their ability to carry out activities without falling (falls efficacy) than the non-fallers, and higher levels of handicap. Those assessed as having a low gait speed also demonstrated lower falls efficacy and higher levels of handicap than those with a normal gait speed. However ADL as measured by the Modified Bartel Index (MBI), which is a common rehabilitation outcome measure, was not significantly different between these groups. This suggests a range of outcome measures needs to be taken to ensure a comprehensive assessment.
Rehabilitation outcomes after hip fracture for patients with cognitive deficits, dementia and delirium
Patients with cognitive deficit have been shown to demonstrate similar functional gains (compared to baseline functioning) after inpatient rehabilitation post hip fracture to those without cognitive deficit (4, 14, 15) indicating that they should not be excluded as candidates for rehabilitation. Beloosesky et al (16) found pre-fracture mobility status to be predictive of mobility gains after hip fracture rehabilitation rather than cognitive status. Generally, length of stay in inpatient rehabilitation has been found to be significantly longer for those with cognitive impairment (4), with the exception of Beloosesky et al (16) who found there to be no differences in length of stay based on cognitive function.
Patients with dementia tend to have a reduced length of acute hospital stay following hip fracture compared to patients without dementia as they are often able to return to a residential care facility (2). Van Dortmont et al (17) concluded that patients with dementia who undergo hemi arthroplasty for displaced fractured neck of femur have higher mortality rates and significantly worse outcomes in terms of return to pre-fracture mobility status when compared to those without dementia. Those patients with more severe Alzheimer’s disease have been found to be more likely to remain immobile after hip fracture and this factor was found to be a major influence in precluding return to the same residential care facility (18). Post-operative delirium has been associated with the development of dementia.
One study (19) investigated patients admitted with hip fracture with no evidence of pre-fracture dementia and assessed them for postoperative disorientation and confusion with subsequent follow-up five years after discharge. The results indicated that those who experienced post-operative delirium were more likely to develop dementia and had a higher mortality rate (19). The authors indicated that those experiencing pre or post operative delirium should be assessed for aetiology and underlying organic brain disorder (19).
The particular needs of patients with dementia who experience hip fracture
The unique needs of patients with dementia who experience hip fracture are demonstrated in a study by Hedman et al (20). This study explored the perspectives of the next of kin of patients with dementia who underwent rehabilitation following a hip fracture. The study identified that relatives felt that competence is diminished in terms of hearing, vision, health, cognition, memory and communication and the person needs specific rehabilitation support. In light of this they identified the need for support in rehabilitation in terms of: strategies to attract patients into performing rehabilitation activities to prevent the person becoming bedridden; help with practising tasks; reminding the person what to do; supervision and positive encouragement. Relatives also identified the impact of the environment on the person with dementia, including the staff’s knowledge of dementia and the patient’s abilities, and emphasised the benefit of a familiar environment for the patient.
Table 1: Rehabilitation and support needs after hip fracture
Need / Description / ReferenceStrengthening,
Transfers training,
ADL retraining,
Environmental compensation / the descriptive Tinetti study suggests the main CR needs are in the areas of upper and lower extremity conditioning, transfers training, complex ADLs such as dressing and bathing and more environmental compensation for instrumental ADLs such as shopping and laundry. / (21)
Individualised rehabilitation plans and support arrangements / Due to the likelihood of the presence of complicating factors such as co-morbidities and cognitive deficits, the context, content and duration of rehabilitation programs and the amount and duration of support is most appropriately assessed on a case-by-case basis. / (1, 5, 8, 10)
Home health care / Patients that are clinically more complex with co-morbidities and are older are likely to require home health care after rehabilitation. / (10)
Involvement of patient and family in decision making / Patients and their families need to be involved in communication and decision making, especially during hospital to home transition. / (22)
Fatigue management,
Pain management / Interventions are needed to assist in dealing with fatigue and persistent hip pain including energy conservation techniques, planning rest periods, pain management strategies which may in turn reduce depression, improve quality of life and increase independence with ADLs. / (11, 23)
Falls prevention / Interventions such as group sessions are needed to reduce fear of falling and reduce feelings of loss of control may improve function and reduce the number of subsequent falls. / (12, 13, 23)
Adaptive Equipment / Prescription of adaptive equipment to promote function as this has been identified as a factor in successful transition from hospital to home. / (23)
3. What are the rehabilitation and support needs of people aged 65 and over following discharge from hospital after THR?
The characteristics of the population undergoing THR as well as short and long term outcomes after THR indicate probable rehabilitation and support needs for this client group. A summary of these probable key needs and a description of the supporting literature, has been provided in Table 2.