factors affect recovery

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~- ~ ~, syc~osocia~ factors affect recovery ~~~ dip fracture in the elclerl~? A ~~~~~.~~ ~~ the li~~~~ture M. Jelicic~, G.LJ.M. Ke~~zpen', Arid L.M. vara Eijlc

Department of Health Sciences, School of Medicine, University of Groningen Northern Centre for Health C1re Research, School of Medicine, University of Groningen Groningen, The Netherlands

Correspondence to: M. Jelicic, Ph.D., Northern Centre for Health Care Research/NESTOR, University of Groningen, A. Deusinglaan 1, 9713 AV Groningen, The Netherlands Phone: +31(50)3633052 Fax: +31(50)3632406 Tntrc~cVa~ction Hip fracture is a common health-related problem for older individuals. Approximately 220,000 Femoral Fractures occur among persons aged 65 years and over in the USA each year.' In England the estimated incidence is 54,000 cases per year.'` Fracturing a hip often lias dramatic consequences for the patient. Despite advances in surgical and anesthetic techniques, a substantial proportion of patients die in the 12 months following hospitalization.3'Also, less than half of the older patients with broken hips regain their pre-fracture ambulatory status and/ or functional independence.'"' Research consistently has shown that low pre-fracture physical functioning, pre-existing disease, cognitive dysfunction, and advanced age are associated with poor prognosis:~~5 In 1983, Nickens' suggested chat psychosocial factors, such as depression, social support, and personality features, might play a role in the functional recovery from hip fracture in the elderly. This notion could have important clinical implications. Whereas most biomedical variaUles ]mown to affect recovery from hip fracture cannot be heated, psychological and social risk Factors for poor recovery may be amenable to change.''10 This paper aims to give an overview of research into the effects of psychosocial variables on functional recovery in older patients with femoral fractures. We will review studies which investigated the role of depression, social support, and other psychosocill factors on recovery from hip fracture. Methodological caveats are mentioned and suggestions Por future research in this area are given. Clinical implications of psychbsocial variables affecting

journal of rehlbilitafion sciences 9, nr. 3 - 1996

Abstract This article aims to give an overview of research vn psychosocial factors affecting functional recovery from hip fracture in the elderly. Studies which investigaCed the role of depression, social support, and other psychosocial variables are described. Tt appears that psychosocial factors do influence recove►-y of functional aUilities in patients with a broken hip. However, most research in this area has methodoloa ical drawbacl.s. In a number of studies information on pre-fracture health status, functional abilities and psychosocial variables was measured retrospectively, introducing apossible recall bias. Moreover, many stu~lies have used self-report activities of daily living (ADL)2s an outcome variable. Given that elderly persons with depressive symptomatology tend to underrate their ADL performance, the association between depression and functional recovery may be somewhat inflated. Suggestions for future research are given. It is also argued that, whereas most biomedical risk factors cannot be treated, psychosocial risk factors for poor functionll recovery from hip facture may be amenable to change. This notion could have clinical implications. For instance, it would be possible to treat patients with depressive symptoms with antidepressants and/or psychotherapy. In addition, co enhance the social support received by the patient, family members could be provided with information percaining to the patient's rehabilitation. Keywords: Hip Fracture; Psychosocial Factors; Recovery; Functional Status.

functional outcome after hip fracture will also be discussed. Depression Depression is not uncommon after hip fracture. Biltig and co-workers~~ screened 50 older patients —who sustained afemoral fracture —1'or depression, and noted that 14 of them (28°/0) were clinically depressed. One of the

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first studies examining the relationship between psychosocial factors, including depression, and recovery of functional status after hip fracture was conducted Uy Mossey and colleagues.~~ They interviewed 219 elderly patients one to three weeks after hip fracture surgery and retrospectively obtained information on prefracture health status and functional abilities such as walking ability, activities of daily living (ADL) and instrumental activities of daily living (IADE), cognitive function, psychosocial factors, and treatment-related variables. Psychosocial variables included presence of depressive symptoms, personality dimensions of neuroticism and extraversion, and social support (i.e., the availability and frequency of contact with lriends and family). There were follow up assessments 2, 6 and 12 months postsurgery. Recovery at 12 months was characterized in terms of degree of return to prefracture functional status, extent of depressive symptomatology and physical fiinction. Note that overall physical function and return to prefracture levels of function differ in that the former is based on sample distribution, while the latter reflects the degree the individual returns to his or her self-reported prefracture levels. Consistent with the existing literature, cognitive dysfunction, and prefracture physical fiinction were predictive of recovery 12 months after hip fracture. Depressive symptoms in the immediate postoperative period were also associated with recovery. The remaining psychosocial variables had a minimal relationship with recovery parameters. Additional analyses on the same patient sample were published by Mossey and co-workers.13 Patients with a broken hip who survived the first 12 postsurgical months were classified according to the persistence of depressive symptoms. Four groups were created: 1) persistently low, 2) persistently high, 3) initially high followed by low, and 4) initially low followed by high levels of depression. Recovery indices included ambulation, physical function(ADL and IADE)and return to prefracture physical functioning. Persistent depressive symptoms had a strong association with poor functional recovery. Mosey et al. reported that —statistical controlling for the biomedical variables affecting recovery from femoral fracture —patients who indicated persistently low levels oí' depressive symptoms were three times more likely than those with persistently elevated depression scores to achieve independence in walking, nine times more likely to regain prefracture levels of physical functioning, and nine times more likely to be in the highest quartile of overall physical function. Pre-fracture levels of depression were found to be unrelated to recovery from hip fracture. Marottoli and coworkers14 — using a prospective design —followed 120 members of the New Haven Established Populations for Epidemiologie Studies of the Aging (EPESE) cohort, who suffered a hip fracture. In the New Haven EPES~ cohort 2,806 elderly adults are interviewed periodically about their physical, psychological, and social functioning. Functional status (i.e., self-reported performance of dressing, transferring, and walking ability) was assessed 6 weeks and 6 months after hip fracture surgery. Whereas pre-morbid physical and cognitive function were associ-

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ated with recovery, depression and other psychosocial factors measured prior to hip fracture were not. However, in line with the investigations of Mossey et al., presence of depressive symptoms 1t 6 weeks post-fracture did predict poor physical function at 6 months. Post-fracture depression combined with cognitive impairments may be especially detrimental to patients recovering from broken hips. Thirty-five older patients were studied by Billig and co-workers'S immediately after surgery for hip fracture, and at 3 and 6 months post-fracture. Based on initial cognitive status and presence of depressive symptoms, patients were classified as (1)"healthy", (2) depressed only,(3) cognitively impaired only, and (4) depressed and cognitively impaired. At 6 months postfracture, patients who were depressed and cognitively impaired had lower ADL scores than "healthy" patients. The findings reported by Billig et al. were replicated by Shamash and colleagues.1ó Does depression influence functional abilities after.hip fracture, or does poor fimctional status lead to depressive symptoms? This issue was addressed by Mutran lnci coworkers." Atotal of 210 older females with~bxoken hips were interviewed as soon after surgery as possible (to obtain pre-fracture information), and at 2 and 6 months post-surgery. Psychosocia] vlriables included different aspects of social support (frequency, source, and adequacy of support) and depression. Walling ability was used as a measure of recovery. Path analysis revealed that biomedical variables were the most powerful predictors of wallting ability 6 months post-fracture, but were less important at 2 months. Adequacy of social supporc and depression affected functional recovery 2 months after surgery. However, by 6 months the causal influence was in the reverse direction with low improvement in walking ability leading to more depressive symptoms. Social support It is well documented that people who have supportive social relationships enjoy better physical and mental health —although the underlying mechanism is not entirely clear.!° A number oP studies have looked al the relationship between social support and recovery from hip fracture. Cummings and colle~gues19 interviewed 111 elderly patients with hip fractures before discharge fiom hospital (i.e. a few weeks after fracturing of the hip). Each patient was asked to name all tl~e people who could provide companionship, instrumental support (e.g., assistance with household tasks or transportation), Ind emotional support (e.g., confiding about personal problems). Then, the patient rated how close he or she felt to each person. Based on the number of people who were rated as "very or somewhat close" a patient's "core" network of support was determined. In ~►ddition to this eslimate of social support, the patients were interviewed 1'or other potential predictors of outcome such as depression, cognitive status, premorbid functional abilities, and preexisting disease. At 6 months after the fracture, functional status was assessed using aself-report ADL questionnaire. Cummings and colleagues found that functional

journal of rehabilitation sciences 9, nr. 3 - 1996

CLINICAL NOTE recovery from hip fracture was associated with the number of social supports. The relationship between social support and recovery remained after controlling for confounding biomedical variables. Depression was also associated with recovery but this relationship did not attain statistical significance. Further evidence for an effect of social support on recovery from femoral fractures was reported by Magaziner and co-workers,10 who studied 340 older patients hospitalized for a fractured hip. Before discharge from hospital, information was obtained on pre-fracture status (i.e., health status, functional abilities, cognitive function), depression, and three aspects of social support: presence of spouse, size of social network, and member of contacts per year. At 2, 6, 12 months post-fracture, ADL and IADL were assessed through a structured interview. Magaziner and co-workers reported that, in addition to several biomedical factors, depression and contact with network were predictive of functional recovery. Wilcox and colleagues'0 followed á4 elderly patients who were admitted to a hospital with fractured hips, as well as 79 stroke patients and 106 patients with myocardial infarction (MI). The subjects were from the New Haven EPESE cohort (see above), and hence baseline measures were available. Different aspects of instrumental, emotional and financial support were assessed before and 6 weeks after the occurrence of the medical event: availability, number of sources, and adequacy of support. With respect to availability of support, respondents were asked whether or not they had anyone they could count on for each type of support. The number of sources was determined by lsking the respondents to name the people who had been most helpful in providing each type of support. In order to assess the adequacy of support, respondents were requested to indicate, for each type of support, if they could have used more support than they received. Functional disability was measured at 6 weeks and 6 months post-event with an ADL scale. Wilcox Ind colleagues found that MI patients were less disabled at the two post-hospitalization interviews than both hip fracture and stroke patients. Biomedical variables and adequacy of emotional support were predictors of functional recovery at 6 weeks, while ADL score and adequacy of task support at 6 weeks were associated with recovery at 6 months. Other psychosocial factors Evidence suggests that recovery from illness may be related to the way individuals cope with health-related problems.'' According to Folkman and Lazarust 'there are two different ways of dealing with negative events: emotion-focused and problem-focused coping. ~motionfocused forms of coping include distancing, escapeavoidance, accepting responsibility, and positive reappraisal; while problem-focused coping comprise confrontation and planfut problem-solving. Roberto'`3-''S investigated the strategies of 101 elderly women to cope with their hip fractures. About 8 months post-fracture the subjects were asked about pre-fracture health problems and ADL, their current cognitive status, locus of control, so-


cial network, depressive symptoms, coping strategies, and their perceived recovery. Locus of control refers to the way people think they are in control of the events in their lives. Perceived recovery was measured by asking subjects to rate their physical fimctioning as compared to the day before their hip fractures. Controlling for prefracture health status, Roberto observed that an external locus of control (i.e., expressing a belief in chance and powerful others), presence of depressive sympeoms, and emotion-focused coping strategies were associated with poor perceived recovery. The relationship between patient expectations and recovery from hip fracture was studied by Borkan and Quirk.' -6 Eighty older patients who suffered from femoral fractures, were interviewed one to two days after surgery. Interviews consisted of both open-ended and multiple choice questions pertaining to perceptions and expectations about hip fracture. Patients were also asked to fill out a questionnaire measuring pre-fracture ADL, psychological well-being, and sickness behavior. At 3 months post-surgery a similar questionnaire was administered to assess functional recovery. Borkan arrd'Quirk reported that, controlling for biomedical confounders, p1[ients who expected full recovery (i.e., optimists) exhibited Uetter walking ability than those who expected partial recovery (i.e., pessimists). Discussion Psychosocial factors affect functional recovery from hip fracture in the elderly. Virtually all studies which looked at post-fracture depression and recovery from femoral fiactures yielded evidence for an association between poor prognosis and presence of depressive sy~nptomatology. Two conditions seem especially harmful to patients recovering from hip Fracture: persistence oi' depressive symptoms" and depression coupled with cognitive dysfimction."•16 Having supportive relationships also appears to influence recovery from hip fracture, although some forms of support, e.g., receiving adequate support, seem to have a larger impact nn recovery than other forms.l''0 There is reason to believe treat factors such as expectations, locus of control, and coping strategies may affect the recovery process of hip fracture patients. A caveat of most of the studies reviewed in this paper is that pre-fracture information on health status, ftinctional abilities and psychosocial variables was measured retrospectively. In one study patients were asleed about premorbid health some 8 months after fracture of tl~e femur!'''`` Memory of the personal past may —especially after experiencing serious medical events such as hip fractures — be sensitive to distortions.'`' In order to avoid a recall Uias, it would be better to use a truly prospective design, i.e., to obtain baseline information before hip fracture. Another problem of most of the research projects in this area concerns the use of self-reported ADL as an index of functional recovery. Kempen and coworkers'$ observed that, on self-report measures of ADL, elderly persons with depressive symptomatolo~y tend tv systematically underrate their performance. Thus, in studies which used self-reported AllL as an outcome

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measure, the association between depression and functional recovery may be somewhat inflated. We recommend the use of objective measures of ADL in fiiture research on recovery of functional abilities after femoral fractures. Why do psychosocial factors influence functional recovery from hip fracture? It is possible that patients with either depressive symptoms, pessimistic ideas about their recovery, emotion-focused coping strategies, and external locus of control, may be less motivated to engage in rehabilitation activities. On the other hand, patients with either supportive relationships, optimistic ideas about their recovery, problem-focused coping strategies, and internal locus of control, may be extra motivated to take part in rehabilitation programs. A few psychosocial variables which are likely to affect recovery from femoral fractures, have not yet been investigated. One of these variables is fear of falling. Tinetti and Powell' pointed out that fall incidents in older persons may lead to fear of falling or low self-confidence at avoiding falls during relatively nonhazardous activities. It could be the case that patients with broken hips wl~o are afraid of falling demonstrate poor recovery because they avoid activities necessary for rehaUilitation. Low self-perceived competence and personal efficacy in hip fracture patients can also be induced by overprotective family members. Constant reminders such as `be careful', `let me do it for you', `don't do that, you might fall', although well intended, could have harmful effects. In order to get a complete picture of all the psychosocial factors influencing functional recovery from hip fracture in the elderly, we suggest that these variables should be studied in addition to variables as depression, social support, and coping strategies. What are the clinical implications of psychosocial factors affecting prognosis after hip fracture? As mentioned in the introduction, most biomedical factors predicting outcome in patients with broken hips, e.g., premorbid cognitive dysfunction and pre-existing disease, cannot be changed easily. However, it would be possible to treat patients with depressive symptoms with either antidepressants and/or psychotherapy. It may be wise to screen hip fracture patients for depressive symptoms at fixed times with a questionnaire, e.g. with the Hospital Anxiety and Depression Scale (the HADS). Patients with elevated levels of depression could then be referred to a clinical psychologist or a hospital psychiatrist. In addition, patient expectations could be changed by providing patients with realistic information about the rehabilitation process. Given the importance of social support in the recovery from hip fracture, it is also advisable to provide family members with adequate information pertaining to the patient's rehabilitation. Although it is not yet clear whether fear of falling plays a role in functional recovery from hip facture, this type of fear might be treated with psychotherapy. Note that not all psychosocial factors can be altered easily. Locus of control can be regarded as a stable personality feature in most people30 and is, therefore, difficult to change.

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Aclaiowledgement Preparation of this paper was supported by a grant from the Netherlands Organisation for Scientific Research NWO (grant 904-54-562)

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