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fractured hip(1)
daves
Posted: Thursday, January 23, 2020 2:23 AM
Joined: 1/18/2020
Posts: 13


my dad who has bad combative behavior just fell and broke his hip - doctors do not think i should have him have surgery because of his really hard to handle behaviors and they think he will not handle the recovery and therapy and likely get infected and will probably kill him - but if he does not get the surgery he will never walk again -i am having a hard time deciding which is best - he recently broke his arm and just getting him back to the hospital to get his cast replaced or even his follow up apointments was beyond difficult-- does anyone have advice on hip surgery ?

thank u


harshedbuzz
Posted: Thursday, January 23, 2020 4:51 AM
Joined: 3/6/2017
Posts: 2079


That must feel like the weight of the world. I am sorry you are in this unhappy place.

I am impressed that the doctors mentioned the option of not doing surgery- so often there is a presumption that it must been done despite the real possibility of a bad outcome. A lot of this would depend on the person's general health and also the stage of dementia in which they are currently.

My family went through 2 similar decisions with my aunts. The younger aunt had moderate dementia and needed knee replacement- her knee was very painful and swollen. In the hours just after the surgery, she suffered a massive stroke and never walked again. Her sister/guardian felt such guilt over the decision, but the surgery relieved the pain and improved her quality of life as a result. As is often the case, TKR is done using spinal anesthesia with sedation so the cognitive impact was not as bad as it might have been with general anesthesia. She lived another 8 years after her surgery. 

My other aunt had what was presumed to be milder dementia when she broke her hip and wrist in a fall in her AL apartment. The surgery was done and things went downhill from there. Aunt had hospital psychosis, pulled out IV lines, undid her surgical dressings, clawed off her cast, lashed out at staff and family. Once in rehab she required a sitter  or family 24/7 which was difficult for our small family to manage. She was unable to follow her PT and OT so she was discharged to a SNF fairly quickly. Between the natural progression of the disease, general anesthesia and the hospitalization she deteriorated rapidly after the fracture. I would say she was around stage 3/4 when she fell and left the hospital a solid stage 6. She passed about 6 weeks after the surgery. 

Thinking of you as you face this difficult choice.

HB

A lot of people like this book as a reference when making these sort of decisions.

http://www.qolpublishing.com/wp-content/uploads/2016/09/HCLP-6th-Edition-3-7-16-Sample.pdf


Teresa701
Posted: Thursday, January 23, 2020 7:09 AM
Joined: 7/19/2018
Posts: 41


My mom broke her hip in September.  The way it broke, 2 bones were going to slide across each other if we didn't do something.  The doctor explained that without at least putting a pin in there, she would be in pain every time she had to be moved.  I was adamant initially that she would not have surgery until this doctor explained that it was the humane thing to do, purely to try not to cause any more pain.  It was not a question of if she would walk again, she would not.

Mom is a early stage 7.  The pin was placed, she was returned to the nursing home.  I insisted on Hospice.  There is no PT, OT, or any other T happening.  She is still able to be given a shower, she sits in a geri chair with lap belt to eat and they put her near the nurses station through the day so she can people watch (this was one of her favorite things to do prior to Alz).  She has a vest restraint when she is in bed, because about a month after the hip break, she fell again and gashed her head open.

Hospice has a bath aide 2 times a week, the nurse, the social worker, and the chaplain(he sings to her, and she tries to join in).  This is in addition to the regular nursing home staff.  

While it was tragic that she lost her mobility, she now has more care than I could ever have done solo.  If you do opt for surgery, keep realistic about the outcome.  Some people may gain back ground, some do not.  As long as mom is taken care of and she is as comfortable as can be given the circumstances, then I made the right decision for us.  

She does take several medications to help with behaviors and pain.  So far, the cocktail seems to be working.  

Hang in there, and know that you will make the right decision for you and your dad.  Please do feel free to ask any questions here.  Lots of people with lots of different experience, and always willing to help.


Janice.alone
Posted: Thursday, January 23, 2020 8:55 AM
Joined: 10/12/2018
Posts: 89


My situation was very much like Teresa701 explained.    My mom had lost her sense of balance and was falling all the time, but didn't realize it because of stage 3-4 dementia.  Finally the fall with a displaced fracture of the femur.  Doctor said the same thing, no surgery would mean awful pain with each and every move, so they operated and pinned the bone.   The anesthesia sent her directly to end-stage dementia and her behavior in the hospital was much like HarshedBuzz described with her aunt.   Mom was sent to SNF where they tried PT for a couple days but with no sense of balance and the advancement of the dementia, she couldn't learn to walk again.   She did receive very good care for the final four months of her life through the SNF and Hospice.  

 In retrospect, I think I still would have done the surgery to alleviate the pain, but then my mom was a tiny little woman who was rarely physically combative.   Any behavior like that could be controlled with a firm hand holding her in place.  And in a purely selfish (and maybe horrible) way of looking at my mom's situation, the fall and surgery greatly shortened the amount of time she had to suffer the ravages of dementia.  And it ended my duty of caring for her at home. (I know, that's really selfish.)

With your dad's behavior issues, perhaps being non-mobile would make his care easier.  But, the mental aspects of being non-mobile for him could make it much worse.  If he became bed-bound, would it be in a care facility?   You've got a difficult decision ahead.   I wish you luck with whatever you do.


Abuela
Posted: Thursday, January 23, 2020 9:26 AM
Joined: 6/24/2012
Posts: 492


Teresa... talk to me about "demanding" hospice.  My mom just qualified for services and mostly because she has been 'falling'.  I feel fortunate that we are not facing a fracture but it could happen any day.  She 'fell' on Monday and was 'unattended' so they had to send her too ER.   I had to chat with the doctor at the ER and say we are not operating on mom so stop the tests.  She got up and walked around unaided and they sent her home, but it was sort of ridiculous.   And mom could not remember why she was in the hospital.  And when they asked about her knee she did not know what they were talking about.  I feel as if we 'dodged' a bullet.
zauberflote
Posted: Thursday, January 23, 2020 10:30 AM
Joined: 10/24/2018
Posts: 767


Dave, you have probably decided by now, but here is my experience with my mom. Last summer her hip sheared, and she fell. It was the same displaced fracture spoken of by others. She was already on hospice, and they tended to her peace of mind while we waited for the mobile x-ray, which showed nothing. Mom still had pain in the hip, so we decided to go to the ER. Those x-rays gave a Very clear picture of what was going on. Both the surgeon and the hospitalist offered us three options: do nothing, and mom would be in pain for the rest of her now-to-be-non-ambulatory life, as the femoral neck might not heal. Pinning was a very poor option, simply because of the type of displacement. So if pinned she might still have a lot of pain, and would probably not walk again. Last option, a partial replacement, which would allow her to live the rest of her life with a much larger possibility of walking, and a very much smaller possibility of pain. She is 92 years old, and was already in stage six. Hospice helped us family to make the decision to go ahead with the partial replacement. Walking was so important to her, and lack of pain was so important to all of us.

She survived the surgery with flying colors apparently, spent six more nights in the hospital with a surprisingly small amount of delirium, and was discharged straight back to her MC with hospice coming back on board. We engaged 24/7 CNA's , and found a mobile self-pay physical therapist, who was exactly what we needed. Mom did indeed walk again. However she fell twice again in quick succession, and hit her head one of those times. Since we had not gone out for any follow-ups on the hip, the hitting the head trip to the emergency room provided us a good picture that the stem was solid and healing was moving apace. So after those falls, for a long time she was not allowed to walk, except with family. She is now mostly wheelchair-bound, but her hip does not hurt. Staff walks her probably once every two weeks, but I have chickened out in a very cowardly way. She does keep making movements as to get out of her wheelchair, but doesn't seem to mind when I tell her that we can just wheel there in this chair, wherever we're going.

There is a huge difference between my mother and your father-- Mom is not more than 1% "combative", and she has mostly given up on that, because she has set her spirit to endure this awful place. 

I know you will decide the right thing for your father, yourself, and the rest of the family, but it is a very hard place to be in. 


King Boo
Posted: Thursday, January 23, 2020 1:06 PM
Joined: 1/9/2012
Posts: 3200


Sometimes doctors don't have the 'big eye' view; sometimes they do.

What would I ask?

How is the comfort/pain factor different between the scenarios?

Is there temporary medication that we can use to reduce behaviors through the healing period?

Is my Dad's behavior optimized through medication prescribed by a Geriatric Psychiatrist, not a generalist MD?

And, very important, - "How will I feel about me if I make this decision?"

There are some conditions that one has no choice but to treat, and others where you  have a choice.

Pain would be my main parameter; function my second; life expectancy third.


KawKaw
Posted: Thursday, January 23, 2020 3:11 PM
Joined: 11/22/2019
Posts: 185


King Boo wrote: "Pain would be my main parameter; function my second; life expectancy third."

I think this order of operations is an excellent way to help me judge future treatment for my mother. 

Thank you.