Depression can have a negative effect on recovery following hip fracture.
VOL: 103, ISSUE: 28, PAGE NO: 32-33
Debbie Duignan, RMN, BA; Woodward, BSc, MRes; ; Emily Daniel, BSc; Professor Alistair Burns, MBChB, FRCP, FRCPsych, MD, MPhil, DHMSA
Debbie Duignan is research sister, University of Manchester; Yvonne Woodward is trainee clinical psychologist, University of Liverpool; Emily Daniel is research assistant, University of Manchester; Professor Alistair Burns, is professor of old age psychiatry, University of Manchester.
As part of a large trial, a psychiatric nursing intervention was demonstrated to be effective in reducing mental health difficulties and promoting recovery. This article outlines how the intervention can be applied in practice and includes a comprehensive case study. It also looks at barriers that may be encountered in such work and possible solutions to these, as well as reflecting on the experiences of patients and staff involved.
Hip fracture is one of the most common problems in older adults, affecting 750,000 people per year in the UK (Audit Commission, 1995). It is costly for society, both in terms of the huge financial impact it has on overstretched resources (£400 million per year) and in the severe physical and psychological impact on individuals and their families (Holmes and House, 2000).
It has been recognised that low mood and anxiety can have a detrimental effect on recovery following hip fracture (Billig et al, 1986; Holmes and House, 2000). However, to date there has been little published evidence to demonstrate if intervention can be successful in orthopaedic patients. Our study attempted to discover whether treating depression in post-operative patients can improve functional and psychiatric outcomes (Burns et al, 2007). The results suggest that intervention can be beneficial to this cohort.
Therefore, in this article, we hope to encourage other professionals to recognise the need for intervention and how it can be beneficial to recovery. We will discuss how nurses can achieve improved results easily by recognising need and incorporating this into a care plan.
Mental health problems after hip fracture
Hip fracture can have a significant impact on patients’ lives. As we know, surgery can be distressing for many older people and may interfere with functional recovery by different mechanisms (Feinstein, 1999). Hip surgery is often carried out under local anaesthetic. There can be restrictions on mobility and movement, and intensive rehabilitation programmes following the operation. In a busy ward environment, nurses could overlook the mental health needs of such patients (Barker, 2001).
Research has shown that mental health problems can significantly affect the recovery of hip fracture patients (Holmes and House, 2000). This can be through factors such as reduced motivation, fear of falling and cognitive impairment (Oude Voshaar et al, 2006). This can lead to a lack of mobility that, in turn, has a severe impact on daily activities, such as preparing a meal, shopping or driving a car. The resulting effect on independence can lead to further decline in social activities and mood (Salked et al, 2000). We feel therefore that the role of nurses in recognising and treating mental health needs in this group of patients is of paramount importance.
Who received the intervention?
As part of a large published study carried out over four hospital sites in Greater Manchester (Burns et al, 2007), we identified 121 hip fracture patients aged over 60 years who met the criteria for depression using a screening measure (Geriatric Depression Scale, Yesavage et al, 1983). Of these, 61 were randomised to the nursing intervention. All patients scored above 15 on the Mini Mental State Examination (MMSE) (Folstein et al, 1975), which is a tool for measuring cognitive functioning. The MMSE uses a scale going up to 30, with scores of 25-30 considered normal and a score of 1 indicating severely impaired cognition. The cut-off score of 15 was chosen to screen out participants with severe cognitive impairment, while allowing for the fact that performance on this measure can be affected negatively by depressive symptoms. We felt that it was important that participants were able to engage with the psychiatric intervention, and wanted to ensure they were able to give fully informed consent.
While we had limited inclusion criteria, we do feel, as nurses, that recognising and treating the mental health needs of those with more severe cognitive impairment is also important, and this has been reflected in the more recent literature (Holmes and House, 2000).
Brief summary of results
At six-week follow-up, 28 (52%) of the control group remained depressed, compared with 17 (34%) of the intervention group. Scores on the Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983) and the Geriatric Depression Scale were significantly lower in the group that received the nursing intervention, although a logistic regression used to estimate the treatment effect of the intervention was not statistically significant. However, Burns et al (2007) acknowledged that measuring differences in outcome in hospital patients can be difficult, and trials often return negative results that may be at odds with clinical opinion (Evans et al, 1997). From a nursing viewpoint, we observed that individuals did benefit from the specific intervention and one-to-one contact that was not part of the usual care package for these individuals post-fracture (for a more detailed description of the study results, please refer to Burns et al, 2007).
Below, we present a detailed example of the nursing intervention to demonstrate how it can be applied in clinical practice.
Case Example: Mrs Smith
Following referral, we assessed the patient’s needs in more depth, including a formal measure of depression, the Hamilton Rating Scale (Hamilton, 1960). This allowed us to focus the intervention on an individual basis (as detailed).
The study was designed to incorporate six weekly intervention sessions, followed by six weekly phone calls. The intervention, although structured, was applied in a highly individualised manner. The following case example of one particular patient, Mrs Smith, explains how we implemented the intervention to meet her needs. Details have been changed to ensure confidentiality.
Mrs Smith, a 68-year-old woman, lived with her husband in their own home. Her husband had physical health difficulties and relied on her to care for him and drive him to appointments. She led an active life and was a former ballroom-dancing champion. She fell while out shopping and broke her left hip. She was operated on two days later and given a hemiarthroplasty (half hip replacement). The physiotherapist told her she would have to follow strict guidelines to ensure she recovered fully. When she was assessed, she reported worries about how she would cope in the future.
We assessed Mrs Smith in hospital two weeks after her operation. Her mood was low but, on further assessment, it was decided that she did not need medication. However, it was obvious that she did require psychiatric intervention and guidance. At this point, Mrs Smith expressed concern about being the main carer for her spouse.
- Engagement and building rapport;
- Assessment of depression/need for medication;
- Discussion of problems and agreement on needs to be met.
The following week we visited Mrs Smith at home, and met her husband. He was also voicing concerns about how they would manage to get their shopping as they did not have any other family members. He also had a hospital appointment at the end of the month, and was concerned about transport and support. Mrs Smith’s mood remained low, although we felt that she was encouraged by our support and recognition of her difficulties.
- Assessment of activities of daily living in home environment;
- Assessment of systemic network;
- Practical help, such as booking ambulance transport with carer to offer support;
- Discussion and solution to weekly shopping (neighbours offered to do this);
- Positive reinforcement and counselling.
When we visited this week there were less practical concerns following the arrangements for shopping etc. At this particular time, Mrs Smith was expressing concerns as she wished to sleep upstairs but was unable to manage the stairs as they did not have a handrail. In addition, she was experiencing discomfort in her hip. It became clear that this was because she had not been fully informed of the precautions necessary following the operation. She was trying to sleep on the injured hip which, along with other precautions she was not aware of, can lead to further injury or even dislocation. Also, her mood remained low because of the restrictions on her activity levels due to immobility. She expressed frustration and boredom, and felt hopeless about the future.
- Contacted occupational therapy department to arrange for a fitting of the handrail;
- Contacted the community physiotherapy team and arranged a home visit for reassessment and further educational guidance about precautions and exercises;
- Supportive counselling around mood and feelings of frustration. Problem-solving involved substituting physically demanding activities and identifying previous interests (such as sewing) that were more achievable and equally enjoyable.
By week four, Mrs Smith reported that she had followed our suggestions and had begun to take up activities that were achievable. She stated that she felt more motivated and not as low, and wanted to start driving the car against medical advice (12 weeks is recommended before getting in a car after this operation). This was a difficult situation, as her enthusiasm was encouraging but she was not thinking about potential consequences. She did confide in us that she had driven the car a few hundred metres to see how she felt. It was helpful to put myself in her position, and I could empathise fully with her situation and feelings. Due to our strong therapeutic relationship we were able to work collaboratively to resolve this challenging situation.
- Empathic listening to allow Mrs Smith to vent her frustration and express her needs;
- Discussion of the need for strict precautions, and weighing pros and cons to prevent impulsive decisions;
- Practical intervention - for example, we looked at the insurance regulations;
- Continuing assessment of mood, especially in light of frustrations, and further positive reinforcement.
At week five, Mrs Smith had decided to refrain from driving for the recommended time. We reinforced alternative options during this time, and discussed how problem-solving skills could be useful for other difficult decisions. As her mood remained lifted, we discussed planning for the future and setting achievable goals. Mrs Smith then decided to book a holiday for her and her husband, and to aim to be fully recovered to travel in five months’ time. She felt that this would help her to remain positive and give her a goal to work towards. This was a very positive step forward and we felt that Mrs Smith was benefiting from our visits.
- Counselling and forward planning;
- Encouragement, for example, holiday brochures;
- Discussion with spouse (with permission), looking at his thoughts and feelings on his wife’s progression and how he was coping;
- Discussion about coming to the end of the six weekly visits and preparing for this.
At the final session, Mrs Smith expressed concern about her ability to cope without our visits. We discussed her coping mechanisms in detail and reinforced our previous work. We reminded her that weekly phone calls would follow for six weeks, and any potential difficulties could be discussed then. This time, Mrs Smith had invited her spouse to be present at the session and we were able to reinforce our intervention within the wider systemic network.
- Discussion of coping mechanisms and reinforcement of previous work;
- Assessment of mood to see if onward referral to psychiatry was required;
- Feedback to other health professionals, including GP, to ensure consistency of care.
Follow-up - six weeks of supportive phone calls
These phone calls were arranged between Mrs Smith and myself, and took place at a mutually convenient time each week. Themes that emerged during these discussions included:
- The benefit of continuing positive reinforcement and supportive counselling;
- The importance of open and honest discussion about her feelings and how she was coping;
- The opportunity to identify any remaining practical difficulties that occurred since week six, and work together to implement strategies to help her cope. This also allowed us to build Mrs Smith’s confidence in her ability to problem-solve.
Implications for clinical practice
It is important to acknowledge that this intervention was carried out by a research team which was not part of the usual clinical care for patients following hip fracture. It is fair to say that ‘treatment as usual’, which the intervention was compared against in the Burns et al (2007) study, did vary between hospital sites. For example, some individuals had access to outreach physiotherapy while others did not. Our intervention, therefore, was an additional resource that may not be available in all trusts. However, we feel that the intervention could be adopted by nurses working in this field, to enhance outcomes for individuals identified as depressed.
It is recognised that it may not be possible for patients to receive the intervention from a named nurse on a one-to-one basis in all settings. However, increased liaison between ward and community-based nurses could be encouraged to identify patients who may benefit from the intervention, and to ease the transition to discharge and beyond. We do feel that our intervention goes beyond what is currently available for hip fracture patients in routine care, and highlights specific areas where care could be improved to alleviate symptoms of depression.
Barriers to research
During this study, we experienced initial resistance from some nursing staff who did not appreciate why we were carrying out the research. Many focused solely on the physical care needs of the patients and saw our involvement as an unnecessary intrusion and taking of their time. However, it was important to build up a mutually supportive relationship with the care team and, as the study progressed and positive results began to emerge, the research became an integral part of the patient care. Staff even began to encourage our involvement, and requested regular feedback reports on the study progress.
Below we have summarised some of the initial barriers that we experienced, both with the staff and other challenges, and we have tried to suggest some potential solutions from our experience that helped to facilitate the research process in both an acute and community setting.
Barrier to intervention
Initial staff resistance to research
Resistance from medical team
- access to surgeons
- encouragement of prescribing
Accessing community networks
- wide catchment areas and variable support networks across sites
Working with the family
- resistance to relatives’ involvement after serious traumatic event
Practical research difficulties
- confidentiality on the wards/privacy
Subjective perceptions of intervention
Both the patients and us found this a rewarding and worthwhile experience. We were intervening with patients who had experienced an unpleasant and traumatic event in their lives, one which had potential long-term consequences for their quality of life. However, as nurses we feel that we made a positive difference to the recovery of those involved and also that we recognised the need for psychiatric interventions on an orthopaedic ward. We were pleased at how, despite initial barriers, the care teams supported us and, ultimately, this intervention was integrated easily into the care plans.
Below are some reflections and quotes from those involved, which help to illustrate the feelings of staff and participants.
‘From the initial visits with the majority of patients, just having the opportunity to talk about their experiences with an independent person led to immediate improvement and set the course for change.’ (Research nurse delivering the intervention)
‘Initially I was sceptical about the need for her on the ward - we are really busy and the medical care is the priority with these patients. We are short-staffed enough without having to get involved with extra work. However, we found that her presence on the ward was really beneficial and patients were more motivated towards rehabilitation and physiotherapy than those that she did not see.’ (Ward manager commenting on nurse intervention)
‘I didn’t understand why I needed to talk to someone at first - I mean, everyone would be sad after that type of operation, wouldn’t they? But I soon began to look forward to her coming and would be able to ask her questions each week rather than bothering my doctor. I knew I had someone coming each week to support me because my husband didn’t always understand.’ (Patient who received the intervention)
In this paper we have discussed the benefits of a psychiatric nursing intervention to treat depression in people following a hip fracture operation. We have outlined how this can be achieved over six weekly sessions, followed by six weekly phone calls. We believe it would be beneficial to those patients who are identified as having low mood to have access to this service, and it is clear that identifying mental health issues and implementing treatment can have a positive effect on recovery. We felt the intervention also supported nursing staff when planning rehabilitation and discharge back home.
We would like to thank the staff and patients who participated in the study for all their help.
Audit Commission (1995) United they stand: coordinating care for elderly patients with hip fracture. London: HMSO.
Barker, P. (2001) The Tidal Model: developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric Mental Health Nursing; 9: 2, 229-232.
Billig, N. et al (1986) Assessment of depression and cognitive impairment after hip fracture. Journal of the American Geriatric Society; 34: 7, 499-503.
Burns, A. et al (2007) Treatment and prevention of depression after surgery for hip fracture in older people: randomized, controlled trials. Journal of the American Geriatric Society; 55: 1, 75-80.
Evans, M. et al (1997) Placebo-controlled treatment trial of depression in elderly physically ill patients. International Journal of Geriatric Psychiatry; 12: 8, 817-824.
Feinstein, A. (1999) Mood and motivation in rehabilitation. In Cognitive Neurorehabilitation. Stuss, D.T., Winocur, D. (eds). New York: CambridgeUniversity Press.
Folstein, M.F. et al (1975) Mini-MentalState. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric research; 12 (3): 189-198.
Hamilton, M. (1960) A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry; 23: 56-62.
Holmes, J., House, A. (2000) Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study. Psychological Medicine; 30: 921-929.
Oude Voshaar, R.C. et al (2006) Fear of falling more important than pain and depression for functional recovery after surgery for hip fracture in older people. Psychological Medicine; 36: 1635-1645.
Salkeld, G. et al (2000) Quality of life related to fear of falling and hip fracture in older women: a time trade off study. British Medical Journal; 320: 341-346.
Yesavage, J.A. et al (1983) Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research; 17: 37-49.
Zigmond, A.S., Snaith, R.P. (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica; 67: 361-370.