Keywords

13.1 Introduction

The psychological status and wellbeing of those who suffer a hip fracture has an important impact on physical health status, recovery, motivation, and rehabilitation. An appreciation of how psychological wellbeing affects care and progress is important in providing high-quality care that optimises outcomes. The aim of this chapter is to provide an overview of the causes of negative psychological status, provide advice on strategies for identifying those at risk, and give examples of assessments and interventions to aid diagnosis and treatment.

Following a significant fragility fracture, many patients are unable to regain the same functional abilities they had previously. This can lead to a loss of independence in performing daily activities, as well as a significant increase in the risk of suffering further fractures. Most significant fragility fractures are hip fractures, consequently most research relating to fragility fractures has examined outcomes and interventions relating to hip fractures. For this reason, this chapter will focus on hip fracture, but the reader should bear in mind that the same principles apply to other significant fractures.

13.1.1 Why Is Psychological Status Important in the Management of Hip Fracture?

Hip fractures are associated with reduced health-related quality of life (QoL). Buckling and colleagues [1] found that pre-existing need of care, limited function, and depression are independent factors associated with lower QoL during the postoperative period. To appreciate the impact of osteoporosis and osteoporotic fracture treatment, it is important to understand the full impact that osteoporotic fractures have on QoL as this can predict mortality, as well as physical and psychological functioning [2].

13.1.2 Why Is Psychological Status Important in the Outcome of Hip Fracture?

Depression at the time of hip fracture has been estimated at between 9% and 47% (mean 29%) [3]. Following hip fracture, the psychological fallout can be considerable for the patient in terms of negative emotional experiences, reduced level of self-esteem, and tendency to depression.

The presence of negative emotional experiences in older adults who have suffered hip fractures is linked to low psychological tolerance, anxiety, perioperative pain, limited lower limb movements, and high prognostic expectation.

Mental health status at the time of surgery has been reported as being an important determinant of outcome and is associated with poorer functional recovery and higher mortality rates [4]. Conversely, it has been suggested that participants with high psychological resilience were able to achieve a greater gain in recovery compared with participants with low psychological resilience [5]. It has also been suggested that pre-fracture dependence in ADL is a stronger predictor of further functional decline—resulting in institutionalisation or death—than pre-fracture dementia [6]. That the increased occurrence of negative psychological emotions and states, such as anxiety and depression, are likely to be due to several factors such as insufficient knowledge about fractures, psychological preparation for surgery, sequelae of surgery, and concern about the cost of medical services [7]. Negative psychological experiences and states are further aggravated by long recovery times after surgery, reduced mobility, and postoperative pain [8, 9].

13.1.3 Why Is Psychological Status Important in the Rehabilitation from Hip Fracture?

Anxiety associated with fear of falling can have a negative influence on psychological wellbeing as well as on balance. Fear of falling affects walking speed so can negatively impact recovery [10].

Approximately one in five people who are not depressed at the time of their fracture become so after 8 weeks [11]. Depression has been reported to affect long-term functional recovery following hip fracture [12]. The negative effect of depression on daily living activities can even emerge 6 months from the time of injury.

A patient’s active participation in the rehabilitation process can have a positive effect on recovery, but the presence of depression disrupts this process because of reluctance, negative thoughts, slowed speech, decreased movement, and impaired cognitive function common with major depressive disorder. Depression in older adults with hip fracture negatively affects daily function. Psychological status influences recovery [13]. The emotional responses to a hip fracture predict both psychological and physical functioning over time offering an opportunity to enhance recovery through appropriate support [14].

Rehabilitation after hip fracture is negatively affected if function is restricted due to fear of falling (FOF) (Chap. 4) [15]. Anxiety about the possibility that a fall may occur again is associated with a low level of self-efficacy and results in the onset of an anxiety state [16]. In turn, anxiety can cause insecurity and lack of confidence in the individual’s own abilities, so they choose not to risk falling and therefore not to move [17,18,19]. The psychological consequences of falling might be even more disabling than the fall itself [20]. The negative impact of falling on quality of life has been reported to be higher than the impact of stroke or cancer [21]. FOF is both a risk factor for falls and a consequence of a fall. It has been associated with subsequent poorer quality of life, functional decline, depression, and frailty [22, 23]. This may initiate a vicious cycle that reduces participation in activities, impairs rehabilitation outcomes, increases social isolation, provokes new trauma, exacerbates developing deficits, and impairs overall recovery [23,24,25,26].

It is essential to consider psychological status and support as part of the interdisciplinary care approach and to develop clinical practice in this area.

13.2 Learning Outcomes

At the end of the chapter, and following further study, the practitioner will be able to:

  • Identify patients at risk of low psychological health

  • Apply evidence-based tools to assist in the diagnosis and assessment of psychological health

  • Discuss management strategies and priorities in the patient from the psychological perspective

  • Use positive aspects of psychology to increase the possibilities of recovery in the patients

13.3 How Should the Psychological Status Be Assessed?

Table 13.1 illustrates the variety of aspects that it is important to evaluate to obtain a complete assessment of patients’ wellbeing during the different stages of the illness and recovery.

Table 13.1 Areas to be evaluated in an integrative assessment at different stages (1 = admission; 2 = discharge; 3 = 90 days follow-up; 4 = 1 year follow-up; 5 = 2 years follow-up)
Full size table

13.3.1 Psychological Evaluation

The recovery process that follows surgery can vary depending on the patients’ comorbidities, cognitive and functional status, and their psychosocial state. Wellbeing means much more than physical health so psychological assessment is an essential aspect of comprehensive assessment (CGA) for all orthogeriatric patients (see Chap. 6) in evaluating different negative and positive dimensions to assess patients’ psychological status when following a bio-psycho-social approach.

13.3.1.1 Quality of Life

Health-related Quality of Life (QoL) is recognised as an important measure of health status [27]. It is a broad, multidimensional construct that includes domains such as physical, psychological, and social function [28], which facilitates identification of specific aspects of QoL and targeting of associated interventions. Some people suffer from loss of QoL [29] and wellbeing [30] while others move to nursing home facilities [31]. Wellbeing and self-efficacy are important resources for both health and illness and should be considered when exploring ways of promoting recovery [32]. The importance of patients’ perception of the care they receive has been highlighted [33] and, without QoL data, the burden of osteoporotic fractures is likely to be underestimated [34].

The EQ-5D has been recommended for the assessment of QoL in older adults [35]. Although this instrument shows good psychometric properties in older patients, assessing the QoL of cognitively impaired patients is difficult. In people with mild and moderate dementia, these tests yield good validity and good-to-average test–retest reliability for the descriptive system, but not for the Visual Analogue Scale (VAS) which is part of the questionnaire. Proxy assessment is sometimes the only way to gather information regarding QoL when patients are unable to respond because of cognitive difficulties. Family caregivers, however, tend to overestimate health limitations concerning less visible items (such as pain and anxiety/depression). Healthcare professionals often rate patients at the same level for all five domains (some problems with everything). No consensus has been reached as to the most appropriate proxy to apply, but proxy assessment of EQ-5D seems to be the best option when assessing QoL in patients with advanced dementia. QoL should be assessed using the EQ-5D method on admission to determine pre-fracture QoL and in post-admission 90-day and 1-year follow-up. In patients affected by severe dementia, EQ-5D should be completed by a proxy, if one is available [36].

13.3.1.2 Fear of Falling

Fear of falling is linked to self-efficacy—the belief people have about their capability to perform certain tasks [37]. After hip fracture, older people have reported that their lives have changed physically, personally, and socially [38]. During hip fracture rehabilitation, older people have been shown to struggle to take control of their future lives by trying to balance risk-taking and help-seeking [39]. They are aware that, on the one hand, it might prove risky to move around and that they were afraid of falling but, on the other, they wanted to be active and were trying to do things. They were determined to regain independence. Giving information to patients and including them in discussions regarding their progress is essential.

13.3.1.3 Pain

Assessment of pain is considered in Chaps. 7 and 8. Pain can also initially be assessed using the EQ-5D test; however, as previously discussed, the VAS used in the EQ-5D is not reliable in cognitively impaired patients [35]. The VAS within EQ-5D rates overall body pain, while practitioners are also interested in pain at the site of the fracture. The Verbal Rating Scale (VRS) performs well with patients with dementia, and it provides more information about fracture-site pain [40]. Liem et al. [36] agree that this test should be used on the second day after surgery or, in cases of conservative treatment, the second day after admission, and at 90 days and 1 year after admission.

13.3.1.4 Activities of Daily Living

Activities of daily living (ADLs) are an important health outcome for orthogeriatric patients. Recovery of pre-fracture health and functional levels is one of the main goals of care. It is important to assess deterioration in functional level over time. A vast selection of ADL measurement tools is available, but the Katz Activities of Daily Living Scale [41], is the most widely used. In many cases, it can prove difficult to assess pre-injury ADLs accurately at the time of admission. In such cases, consulting a proxy can be useful, who will typically be a family member, friend, or caregiver. ADLs should be assessed on admission to evaluate pre-fracture status. During patient follow-up, ADLs should then be assessed after 90 days and 1 year following admission.

13.3.1.5 Depression

Depression is the most common psychological disorder following hip fracture although it is difficult to assess [42]. An independent relationship exists between low functional capacity and depression symptoms in older people [43]. Social isolation often occurs in older adults who cannot walk well enough to perform daily living activities, and social isolation is an independent risk factor for depression [44]. A vicious cycle of low ADL function is, therefore, created between pre-existing depression and an increase in depression from feelings of inadequacy when performing daily activities. The Geriatric Depression Scale (GDS) may be a valuable instrument with which to assess depression [45]. Depression has been observed more often in women and those whose spouses have died [11]. Depression should be assessed on admission to evaluate its pre-fracture status. During patient follow-up, it should be assessed after 90 days, 1 and 2 years from the date of admission.

13.3.1.6 Stress

The is a link between osteoporosis, fragility fractures, and psychological stress [46]. Relaxation strategies can be used to decrease stress and are described in the last section of this chapter. The Perceived Stress Scale [47] can be useful when assessing stress which should be appraised at discharge and 90 days after admission.

13.3.1.7 Anxiety

Anxiety has emerged as one of the most important aspects of patient assessment on admission [26]. The Short Anxiety Screening Test [48] has been shown to be an easy and valuable tool for the assessment of anxiety in this group of patients. Anxiety should also be assessed upon discharge and 90 days after admission.

13.3.1.8 Psychological Wellbeing

The concept of subjective well-being (SWB) has multiple components. It is affected by positive (e.g. happiness), negative (e.g. depressive symptoms), and cognitive components (e.g. life satisfaction). These multiple components are affected by different social determinants and develop differently at various life stages [49]. The Psychological General Well-Being Index (PGWBI) [50] is a useful test for the investigation of patients’ and caregivers’ psychological wellbeing which should be assessed after admission and at 90 days and 1 year after admission. Reinforcing and increasing positive psychological components, such as resilience, motivation, and internal locus of control, can facilitate recovery.

13.4 How Can Psychological Status Be Influenced Positively by the Orthogeriatric Team?

It is clear that social and psychological elements (both negative and positive) can influence the outcomes of recovery and rehabilitation [51, 52]. The psychological state of the patient plays a key role in rehabilitation [53] so it is crucial that they receive adequate psychological care.

Shi et al. [54] highlighted the importance of systematic and standardised psychological care following hip fracture. Specifically, they compared the outcomes of psychological care devoted to older adults who had suffered a hip fracture with the outcomes of routine psychological care alone provided for a control group. Systematic and standardised psychological care, carried out during the perioperative period, positively benefited the psychological state of patients, relieving symptoms of anxiety and depression significantly.

The main aspects of the psychological care were:

  1. 1.

    A good practitioner–patient relationship: nurses and other practitioners talked with patients while maintaining a caring, kind, and sincere attitude. Through encouragement and suggestions, practitioners kept both patients and their families informed about the importance of the perioperative period and guided them in precautions to be taken. Nurses also explained the anaesthetic program, surgical procedures, and potential risks of surgery and the importance of subjective factors was emphasised.

  2. 2.

    In-depth interview between patients and nurses: through dialogue, patients expressed their psychological difficulties and negative emotions. This enabled nurses and other practitioners to have greater awareness of their state of mind. It was also explained to patients that negative thoughts and emotions can have a negative influence on treatment and prognosis and nurses tried to clarify patients’ doubts and uncertainties.

  3. 3.

    Relaxation and concentration: patients were asked to relax, assuming a comfortable position, while maintaining focused attention. When they experienced negative emotions, anxieties, or fears, nurses helped them by identifying their causes, so that they could intervene with strategies aimed at limiting their onset as much as possible.

  4. 4.

    Listening to music: the benefits, goals, and directions related to listening to music were explained. Playing music occurred only if patients were willing to listen. Three main genres of music were used: classical, soft, and stimulating. The volume of music was adjusted according to the patients’ perceived level of wellbeing and relaxation. Music was played twice a day, in the morning and evening.

  5. 5.

    Limiting the influence of negative emotions of family members: negative emotions expressed by family members can have an influence on patients, especially on the process of rehabilitation and functional recovery. It is, therefore, important for family members to provide psychological and emotional support as well as material support throughout the treatment period to help strengthen patients’ self-confidence in themselves and their ability to recover.

Although the study discussed was a short-term follow-up conducted with a limited sample of patients, the results indicated the benefits of offering individualised psychological care. Healthcare practitioners should listen to patients’ thoughts and opinions and learn about their feelings and emotions. Emotional and psychological support, health education and the use of music can be effective tools in caring for older adults with hip fractures. Through increased communication between practitioners and patients, support from family members and the promotion of positive emotions and confidence in treatment, patients can increase their ability to cope with problems.

Dedicated psychological care for patients who have suffered hip fractures should be structured to focus on patients’ wellbeing and quality of life following surgery. Attention should also be paid to the physical pain that each patient may experience differently, physical, and psychological rehabilitation, and emotional support. Psychological adjustment to one’s physical condition, emotional awareness, and maintaining a state of calm and wellbeing are factors that contribute to improving postoperative quality of life.

The different negative and positive dimensions that are important to evaluate and the instruments most likely to be appropriate at each stage discussed should be addressed by the orthogeriatric team following a bio-psycho-social approach. The inclusion of a psychologist in the team can help in the assessment of the patients’ psychological wellbeing, using the tools we have detailed above, but can also enable psychological counselling. During counselling, the psychologist can obtain more qualitative data to help tailor interventions based on emerging needs and the resources available as well as give feedback to patients and their caregivers on the problems and the strengths that emerged in the assessment. It has been demonstrated that twice-weekly counselling for about 45 min had a positive influence on hip fracture patients’ depressive and anxiety symptoms [55].

Similar results were shown for ‘psychological support therapy’ (PST). This had a significant impact on patients who had sustained a femur fracture, contributing to pain reduction and improvement in psychological status, as well as patients’ quality of life and nurses’ job satisfaction [56]. The outcomes of PST, which was applied in addition to routine care for 41 adults following femur fracture, were compared with the outcomes of routine psychological care alone for a control group.

The PST intervention involved:

  1. 1.

    A psychological support group, consisting of nurses with solid nursing skills and physicians with extensive clinical experience. Psychologists created the group by choosing members with psychological intervention skills, especially the ability to recognise and understand patients’ emotions, reduce negative emotions, and promote positive ones, while being able to communicate effectively with patients.

  2. 2.

    Older adults who with fractures often do not fully understand the details of surgical procedures leading to misunderstandings and facing the surgery with a negative state of mind. Team members informed patients and answered all their questions clearly and patiently. Practitioners were also required to understand the needs of patients and deliver individualised interventions. The team assessed the psychological status of patients, interviewed them, observed changes in their behaviours, understood the emotions felt by patients after sustaining a fracture, and offered targeted psychological support according to their needs.

  3. 3.

    The team provided fracture-related information through communication modes adapted to the patient’s level of education and the ability to understand. The impact of functional exercise on rehabilitation was explained, including both patients and their family so that worries and doubts were relieved, resulting in reduction in anxiety. These patients risk much longer and more frequent hospital stays than other adults. Comprehensive discharge-planning programmes (Chap. 16) can improve these outcomes. On admission to care facilities, early multidimensional assessment (Chap. 6) can provide indications of how to address patient needs more effectively. Greater psycho-educational support can be provided during the rehabilitation phase during which there is more time to focus on this.

  4. 4.

    The importance of nurses strengthening communication with patients and the need to provide psychological care for them according to their individual needs was stressed. Nurses also explained to patients the relationship between their emotional state and maintaining a positive attitude and confidence in their care.

  5. 5.

    Patients were encouraged to maintain communication with the world outside the hospital and to access support from family members. At the same time, family members were encouraged to spend more time with them, talking to them and listening to them to help them adapt to their condition and reduce any negative emotional states.

  6. 6.

    Patients’ favourite genres of music, such as light or relaxing music, and TV series were played to divert patients’ attention from their condition, entertain them, reduce their pain, and reduce their anxiety and negative thoughts.

  7. 7.

    Patients who had successfully recovered after a fracture were invited to share their experiences to encourage other patients to have a positive approach toward rehabilitation.

The PST programme made it possible to assess patients’ psychological state, analyse the factors that contributed to the development of negative thoughts and emotions, conduct psychological counselling, and help nurses and patients communicate effectively. This strengthened patients’ trust in healthcare personnel, who played an active role in accelerating the rehabilitation process following a fracture. In this type of therapy, healthcare practitioners can [57]:

  • encourage patients to create a healthy psychological state

  • explain to patients the impact that a negative state of mind can have on the rehabilitation process

  • encourage patients to take the initiative in expressing themselves

  • respond to their questions and concerns

  • help patients take a positive view toward their health problems and reduce their negative thoughts and attitudes

  • alleviate worries and anxieties

  • encourage patients to develop the habit of self-regulating their emotions

Psychological support therapy can also contribute to:

  • improving patients’ ability to cope with pain

  • reducing psychological pressure

  • increasing confidence in the process of recovery and rehabilitation

  • strengthening psychological and physiological adaptation by increasing tolerance to stimuli

Nurses can also encourage patients to maintain active communication with family members so that they have a social support network [58].

The results of the studies discussed here lead to an appreciation of the importance of psychological evaluation and support in care for older adults affected by fragility fractures. As part of the integrated and multidisciplinary approaches to care, practitioners who can demonstrate the appropriate psychological skills to assess the psychological wellbeing of patients and their caregivers are essential.

Summary and Main Points for Learning

  • Negative emotional experiences in older adults who have suffered hip fractures are associated with low psychological tolerance, anxiety, perioperative pain, limited lower limb movements, and high prognostic expectation.

  • Mental health status at the time of surgery has been reported as an important determinant of outcome, with mental health disorders associated with poorer functional recovery and higher mortality rates.

  • The recovery process that follows surgery varies depending on the patients’ comorbidities, cognitive and functional status, and their psychosocial state. Wellbeing in this sense means more than health as such. It is important to evaluate different negative and positive dimensions to assess patients’ psychological status when following a bio-psycho-social approach.

  • Nurses encourage patients to maintain active communication with family members so that they have a social support network.

  • Psychological support therapy for older fracture patients has been used to assess their psychological state, analyse the factors that contribute to the development of negative thoughts and emotions, provide psychological counselling for patients, and help nurses and patients communicate effectively to increase patients’ trust in health professionals, who play an active role in accelerating the post-fracture rehabilitation process.

13.5 Suggested Further Study

Being able to empathise with patients, especially from an emotional perspective, is vital in providing excellent care that includes psychosocial aspects.

Access the following open access (free to download) article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7925874/.

Tutton E, Saletti-Cuesta L, Langstaff D, Wright J, Grant R, Willett K (2021) Patient and informal carer experience of hip fracture: a qualitative study using interviews and observation in acute orthopaedic trauma. BMJ Open. 11(2):e042040. https://doi.org/10.1136/bmjopen-2020-042040.

Read the article, but particularly focus on the quotations that highlight patient and family emotional experiences of hip fracture. Ask yourself the following questions:

  • What can I see in the patient and family words (the quotations) in this chapter that suggests that having a hip fracture is an exceptionally difficult emotional experience?

  • In what way does my team take this emotional experience into account during care providing?

  • Having read the article and this chapter, what I can I now see is important in the way we provide care that would better support psychological wellbeing in our patients and their families?