After a hip fracture: the days in hospital and the return home

A fall at home or in the care home, a trip to A&E, surgery the next day or the day after. For the family, the hip fracture seems resolved once the operation goes well. For the team caring for the person afterwards, that is where the work begins.

This article is about those days: the ones spent in hospital and the first ones after returning, to the care home or to their own home.

Why a hip fracture leaves such a mark

A hip fracture is one of the most serious consequences of a fall in an older person, and not only because of the pain or the surgery. A review published in 2016 in BMC Geriatrics, which brought together 38 cohort studies on long-term disability after fracture, found that only 40 to 60% of people regained their pre-fracture level of mobility. Among those who were independent in personal care before the fracture, 20 to 60% needed help with various tasks one and two years later. Most of the recovery happened in the first six months, and people living in care homes recovered less than those living in the community.

Mortality in the first year is also high, for reasons that go beyond the fracture: age, frailty and the conditions the person already had. That is why international guidance treats hip fracture as a problem of geriatric medicine, not just orthopaedics — the orthogeriatric model of care, in which orthopaedics and geriatrics look after the patient together, is what NICE recommends in the UK.

The first days: why getting up matters

NICE's hip fracture guideline (CG124) is clear on one point: physiotherapy assessment and mobilisation on the day after surgery, unless medically or surgically contraindicated, and mobilisation at least once a day from then on. The UK's National Hip Fracture Database uses “out of bed by the day after the operation” as one of its quality indicators.

The reason is the one we described in immobility in hospital: in an older person, every day in bed costs strength, balance and confidence that then take much longer to recover. The obstacles to early mobilisation are well known — low blood pressure, poorly controlled pain, nausea and delirium are among the most cited — and almost all can be treated or prevented.

Even with early mobilisation, there are hours and days when the person is idle: between physiotherapy sessions, waiting for tests, waiting for a place in continuing care or for transport. Those are the days that pass most slowly.

Delirium: often mistaken for “just old age”

Delirium — a state of acute confusion that comes on over hours or days and fluctuates through the day — is a common complication after hip fracture and surgery. It can show as agitation, but also as drowsiness and apathy, which means it is easily missed. It delays mobilisation, prolongs the hospital stay and is associated with worse outcomes.

NICE recommends assessing cognitive status on admission and watching for delirium throughout the stay. The preventive measures are low-tech and highly effective when they are followed: glasses and hearing aids in place, good hydration, pain control, sleep at night, orientation (a clock, a calendar, daylight), early mobilisation and familiar faces. We wrote about the subject in another setting in delirium in intensive care.

For families, the most useful message is this: new confusion is not “normal for their age” and should be reported to the team as soon as it is noticed.

The fear of falling again

After a fall that ended in surgery, a fear of falling again is almost to be expected. The problem is when that fear starts to decide: the person refuses to stand, clings to whoever is helping, asks to stay in the chair. It is a cycle we know well — less movement, less strength, more reasons to be afraid — and one we covered in fear of falling.

A few things help the team and the family:

• Ask directly whether the person is afraid. Many will not say so unless asked, and the refusal gets read as a lack of willingness.
• Explain what is going to happen before each time they get up: who is helping, how far they will go, what happens if they get tired.
• Small, visible goals. Sitting on the edge of the bed, then the chair, then the bedroom door. Each one counts.
• Don't reinforce the fear by accident. Phrases like “careful, don't get up on your own” are necessary, but it is worth balancing them with what the person can already do.

Motivation for physiotherapy

Recovery after a hip fracture depends a great deal on what the person does between sessions, and on how willingly they do it. Tiredness, pain, low mood, confusion and missing home are common reasons for saying “not today”. Adherence is one of the factors that weigh most on the outcome, as we discussed in adherence to physiotherapy.

What tends to help is not complicated: a goal that makes sense to the person (“getting back to the garden”, “going to the toilet on my own”), praise for concrete progress, sessions at the time of day when the person is at their best, pain controlled before exercise, and a family that knows what is being attempted and what they can reinforce.

On the return — to the care home or home — continuity is the weak point. It is worth making sure the care home knows what the person was already doing in hospital, what restrictions apply and what the physiotherapy plan is, so that nobody starts from scratch.

Where RVer can fit in, and where it can't

Precision matters here. RVer is not rehabilitation: it does not replace physiotherapy and does not speed up recovery from the fracture. The guided movement module, RVer Motion, is in development and is not covered by the base product's registration.

What the base product can do is more modest: on the idle days, an accompanied activity, seated or lying down — there is a lying-down mode for those who cannot yet get out of bed — in a place the person knows, for a few minutes. For some people it is a calm moment, a break from the tedium of the room and a starting point for a conversation about what they want to get back to doing. The session is always run by a professional, stops whenever the person wants, and only happens when the clinical team considers it appropriate — not, for example, in someone with active delirium who is very agitated.

In summary

• A hip fracture changes the lives of many older people: in a 2016 review, only 40 to 60% regained their previous mobility.
• NICE recommends physiotherapy assessment and mobilisation on the day after surgery, unless contraindicated.
• Delirium is a common and often silent complication; new confusion should be reported straight away.
• The fear of falling again can hold recovery back: ask, explain and use small goals.
• On returning to the care home or home, continuity of the physiotherapy plan is the weakest point.
• RVer is not rehabilitation; it can be a calm, accompanied activity on the idle days.

This article is for information only and does not replace clinical assessment or the plan set by the orthopaedic, geriatric and physiotherapy team. If in doubt after discharge, contact the person's doctor or SNS 24 (808 24 24 24); in an emergency, call 112.

RVer is a virtual reality system for clinical use designed for healthcare settings, whose base product is registered as a Class I Medical Device in EUDAMED (Basic UDI-DI 56006195127RVERTZ) and with INFARMED (Portugal, CDM 94571546) and bears the CE mark under MDR 2017/745. The RVer Motion, RVer Neuro and RVer Exposure modules are in development and are not covered by that registration.