The right to physiotherapy rehabilitation for people living with dementia following a hip fracture.

Introduction  

As a physiotherapist working in Medicine of the Elderly rehabilitation, I am also currently a part time student undertaking the MSc in Advancing Physiotherapy Practice at Queen Margaret University (QMU), Edinburgh.  As part of my MSc degree, I opted to study the module, *‘Developing rights-based practice for Allied Health Professionals (AHP) working with people living with dementia, their families and carers’.  This module is delivered by the Division of Occupational Therapy & Arts Therapies at QMU, in partnership with Alzheimer Scotland, and is available to all AHP’s.  One advantage therefore of undertaking my MSc at QMU has been the flexibility of choosing modules across disciplines which has allowed me to study subject topics most relevant to my existing practice.

A key policy informing the module content of the rights-based AHP MSc module is ‘Connecting People, Connecting Support Transforming the allied health professionals’ contribution to supporting people living with dementia in Scotland, 2017-2020’.  The development and publication of this first policy in Scotland guiding the work of AHPs with people living with dementia, was funded by the Scottish Government, led by the National Alzheimer Scotland AHP Consultant.  The work undertaken to support the publication of Connecting People, Connecting Support, reflects a new synergy between the practice of AHPs and the lives of people living with dementia.  Consequently, in part, one aspiration of this policy is about AHP’s in Scotland maximising their contribution to supporting people living with dementia, their families, partners and carers to live positive, fulfilling and independent lives, for longer.

Central to this is the AHP approach which focuses on 5 key elements (diagram 1).  In relation to physiotherapy, one important element of this approach is ‘maximising [the] physical wellbeing’ of people living with dementia.  In turn, this supports our professional ambition to enhance access to services to allow people with dementia to continue to live a good quality of life, at home, for as long as possible.  Consequently, this perspective underpinned the development of my assessed presentation related to the MSc module, entitled,

‘A person living with dementia has the right to physiotherapy rehabilitation following a hip fracture’.

Diagram 1: The Allied Health Professional (AHP) Approach (Connecting People, Connecting Support, 2017).

AHP blog pic 1

A person living with dementia has the right to physiotherapy rehabilitation following a hip fracture.

As a physiotherapist one aim is to restore the function and independence that people had prior to injury, to discharge back to their own homes if possible.   Many obstacles can stand in the way of this happening especially to a person living with dementia, for example, acute confusion, pain, noise and an unfamiliar environment and people.  We as healthcare professionals are therefore making judgements and decisions about people’s future in the unfamiliar environment of a hospital ward, often using terms such as “no rehab potential”.  It prompts a question; how do we determine if a person does or does not have the potential to rehabilitate and what evidence do we have to support this?

 A rights-based approach

A rights-based approach ensures that a person’s human rights are put at the very centre of policies and practice (Scottish Commission for Human Rights Act, 2006).  It is widely recognised that people living with dementia are frequently denied their rights (WHO, 2015).  As such, the PANEL approach (Alzheimer Scotland, 2017) provides a framework from which we can help protect people’s rights.  People living with dementia have the right to be as independent as possible, be part of their community and access rehabilitation.

Over 40% of people with a hip fracture have dementia or a cognitive impairment (Resnick et al. 2016) and it has been suggested this population of patients have poorer functional outcomes and a more uncertain rehabilitation journey (Huusko et al. 2000).  Only 40-60% of people regain their pre-admission level of mobility following a hip fracture leading to an increased likelihood of admission to 24-hour care (Hall et al. 2017).  Consequently, there is an indication that people living with dementia receive less rehabilitation as it is assumed to be more challenging to manage this group of patients.

Reasons have been suggested as to why rehabilitation with people living with dementia can be poorer, for example:

  • Cognitive, emotional and motor issues related to dementia.
  • Lack of staff understanding, knowledge and experience in how to encourage engagement and participation, resulting in patients deemed to have no rehabilitation potential. Hall et al (2017) in a qualitative study reported that less experienced physiotherapists feel fear and panic treating this population of patients and this may lead to under treatment.
  • Barriers exist in accessing rehabilitation services due to a perceived lack of potential to improve.
  • Lack of treatment time and resources, including staff.

(Buddingh et al. 2013; Killington et al. 2016; Hall et al. 2017)

Dementia and Rehabilitation

There are a small number of studies that have shown with enhanced rehabilitation there is an increased likelihood of gaining pre-admission mobility, decreased length of stay in hospital, reducing the likelihood of long-term placement for people living with dementia (Smith et al. 2015).   However, these studies have been deemed to be of low quality evidence.  There have also been studies looking at the treatment strategies we can employ to engage participation in rehabilitation of people living with dementia (Buddingh et al. 2013; Fjellman-Wiklund et al. 2016; Hall et al. 2017).  These strategies include family involvement, simple instructions, adjusting the environment, short sessions, consistent physiotherapist, a familiar environment, knowing the persons’ life story, interpreting body language.  Again, there is insufficient evidence to guide physiotherapy treatment interventions and strategies for people living with dementia, with little evidence to show how engaged people are with physiotherapy.  There is a need to develop evidence using specific interventions and strategies to investigate innovative ways to rehabilitate people living with dementia to enable us to improve quality of life.

 How did the module influence my practice?

Through studying the AHP rights-based practice module, I developed a focus which helped to highlight strategies that could positively influence a change in my practice, leading to enhancement, for example:

  • Family and carer involvement.
  • Incorporate increased assessments in patients’ own environment.
  • Adapt communication.
  • Using knowledge of a persons’ life to adapt treatment e.g. hobbies, work, music.
  • Focus on strengths with positive feedback, adopting an assets-based approach.
  • Consistent therapist.

In addition, there have been qualitative changes in how I practice since completing the module.  Specifically, my confidence has grown allowing me to embrace conversations with other members of the multi-disciplinary team when discussing a person’s potential for rehabilitation and the importance of home visits.  As a result, the module has provided the opportunity to share and discuss more widely with colleagues across the multi-disciplinary team evidence to influence incremental change to existing practice.

In summary, this has emphasised our insight and understanding of the possibility and importance of valuing the rights of people living with dementia to ensure equal access to physiotherapy-led rehabilitation, in our case, following a hip fracture.

Questions:

How do you determine a persons’ rehabilitation potential?

What strategies do you use to ensure that you have given someone the best possible chance to rehabilitate?

Contributor:

AHP blog pic 2

Vicki Salisbury

Twitter: https://twitter.com/vicki_salisbury

Email: Vicki.Salisbury@nhslothian.scot.nhs.uk

Vicki Salisbury, Team Lead Physiotherapist, Assessment and Rehabilitation Centre, Western General Hospital, NHS Lothian.

I work in Medicine of the Elderly rehabilitation previously working on ortho-geriatric rehab wards as a Band 6 for 4 and a half years before getting a Band 7 post in a day hospital setting.

*To find out more about the MSc module co-delivered by Alzheimer Scotland and Queen Margaret University, Edinburgh, ‘Developing rights-based practice for Allied Health Professionals (AHP) working with people living with dementia, their families and carers’, refer to an earlier blog post, dated 18th April 2019, here: https://letstalkaboutdementia.wordpress.com/ 

The module will start again this year on the 19th September.

2 thoughts on “The right to physiotherapy rehabilitation for people living with dementia following a hip fracture.

  1. hi vicky

    thank you for your blog – i have found it really interesting to read, and it echoes many of the things i see in our mental health complex care dementia wards. One of the things I often see is a “lag period” post-op with people with dementia (which i often see as post-op hypoactive delirium)

    some of my ways of determining rehab potential are:

    * does someone have a drive to move? is that drive automatic or can it be facilitated?
    * risk enablement and positive risk taking – is the persons quality of life improved by being mobile?
    * pain – this must be well controlled before a decision is made. I have seen many people with dementia post op only on paracetamol as they have not asked for pain relief -once pain is well controlled, their drive to move often improves.
    * what are the person and/or family goals? it may be that a goal to sit up comfortably, and transfer with a wzf is achievable but walking independently is not. Vice versa, a person may decide they want to walk immediately and this reduces stress and distress.
    * what was pre-op level of mobility. i see this as a guide only as some people can rehab to better than pre-op function. others will not regain it.

    Strategies.
    Time, repetition, non-verbal cueing (i talk much less and offer more guided instruction than verbal instruction), involvement of whole MDT (inc carers) in rehab, positive risk taking, environmental modification, seating, incorporate rehab into daily routine, positive focus on what people can do. etc.etc.
    would love to know more about this work.

    Thanks

  2. In the community based team I work in, we use an evidence based approach of holistic and functional assessment in patients’ homes, often together with family / carers and in liaison with care providers, GP , D/N etc as needed, to give a full picture and to aid goal setting and planning.
    Therapy is aimed at enabling self-management to as high degree as possible- regularly involving people active in the person’s life, encouraging activities and routines they show / voice an interest in and using other available resourses- exercise groups, walking groups, aids etc. I spend significant time on encouraging and enabling carers in cases where patients’ dementia severely restrict their engagement, as these people have a major part to play in optimising the person’s potential to improve and maintain their mobility and function.
    They also may need support, at times of continued deterioration in the person with dementia.

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