Views from health professionals on accessing rehabilitation for people with dementia following a hip fracture

Abstract

The literature reports that rehabilitation for elderly patients with mild-to-moderate dementia who have a hip fracture improves functional outcomes. However, access to rehabilitation may be difficult due to misconceptions about the ability of these patients to engage in and benefit from rehabilitation. Additionally, people who are admitted from residential care may not have the same options for rehabilitation as those admitted from home. This study sought to understand from expert clinicians how and why decisions are made to accept a person with dementia post-fracture for rehabilitation. In this Australian-based qualitative study, 12 health professionals across a state and territory were interviewed. These clinicians were the primary decision makers in accepting or rejecting elderly patients with dementia post-fracture into rehabilitation. Three key themes emerged from the data: criteria for accessing rehabilitation, what works well and challenges to rehabilitation. The participants were unanimous in the view that access to rehabilitation should be based on the ability of the patient to engage in a rehabilitation programme and not assessed solely on cognition. In terms of clinical care, a coherent rehabilitation pathway with integration of geriatric and ortho-geriatric services was reported as ideal. Challenges remain, importantly, the perception of some health care staff that people with dementia have limited capability to benefit from rehabilitation. Rehabilitation for this growing group of patients requires multiple resources, including skilled practitioners, integrated clinical systems and staff education regarding the capabilities of people with dementia. Future research in this area with patients with moderate-to-severe dementia in residential care is warranted.

Keywords

dementia rehabilitation fracture eligibility hospital

Background and significance

Worldwide, dementia remains one of the greatest challenges faced by health and social care systems (World Health Organisation, 2012). In Australia an estimated 298,000 people had dementia in 2011 and this is expected to reach 400,000 by 2020 (AIHW, 2012). Dementia has been consistently shown to increase the risk of falls, with rates that are double that of cognitively intact older people (Baker, Cook, Arrighi, & Bullock, 2011; Shaw, 2002). In 2006–7, 16,500 Australians aged over 65 were admitted to hospital with a hip fracture (Collins & Allbon, 2010) and in the state of New South Wales (NSW), 24–29% of these patients had dementia (Scandol, Toson, & Close, 2013).

The social and economic cost of hip fractures in Australia is significant. It is estimated that the average cost to the health system in NSW following a falls injury in people over 65 is AUD$3906 (Watson, Clapperton, & Mitchell, 2010). For those over 65 years, who were admitted to hospital with a hip fracture, 6% died in hospital and 11% were discharged to a facility that was not previously their home (Collins & Allbon, 2010). The combination of having dementia and a hip fracture impacts on patients and their carers in many ways, with rehabilitation being offered as a way to address these challenges. Yet this is an area of policy and practice that requires attention as to date best practice for rehabilitation post-fracture for people with dementia has not been established (Allen et al., 2012).

Care for elderly patients who have a hip fracture is influenced by the configuration of orthopaedic and geriatric services, with the absence of collaborative working shown to cause variation in care to the potential detriment to the patient (Australian and New Zealand Hip Fracture Registry, 2014). Relatively little is known about the care provided for patients with dementia who are admitted to hospital following a fracture. However, there is a perception that access to rehabilitation may be restricted due to a belief that having dementia directly impacts on the ability to engage and benefit from a structured approach to rehabilitation. Reasons for restricted access to rehabilitation have been attributed to the inability of the patient to engage in a rehabilitation programme and/or poor training of staff in the rehabilitation of people with dementia (Connelly & Biant, 2012). Muir and Yohannes (2009) reported that functional recovery of patients with dementia and hip fractures can be as good as those without dementia. In their systematic review of hip fracture rehabilitation for people with dementia, Allen et al. (2012) noted similar results to the study by Muir and Yohannes (2009) concluding that participants with mild-to-moderate dementia receiving rehabilitation post hip fracture showed improved function and ambulation, decreased falls risk with similar relative gains in function compared to those without dementia. Allen et al. (2012) observed that older adults with dementia living in residential aged care settings are often excluded from research studies and as a result, few studies in their review included either individuals living in residential aged care settings or those with severe dementia. They concluded that more research is required to understand rehabilitation per se given there was inconsistency in access, type and amount of rehabilitation delivered across programmes. Importantly they noted the paucity of research post hip fracture, for people with moderate-to-severe dementia, including those living in residential aged care settings (Allen et al., 2012).

Whilst it is true that dementia will potentially have an impact on rehabilitation goals there is also evidence that for those living at home, a dementia-specific approach to care, in which interventions are based on the individuals’ preserved abilities, coupled with the caregivers being given skills to work effectively with people with dementia, can improve daily function for people with dementia and give a sense of competence to the carers (Gitlin, Corcoran, Winter, Boyce, & Hauck, 2001; Graff et al., 2006). In a literature review, McFarlane, Isbel and Jamieson (2015) found growing evidence that older adults with mild-to-moderate dementia who receive intensive subacute rehabilitation after surgical repair of a hip fracture may gain comparable benefits in physical function as cognitively intact patients. They also found that health service structures and processes and the knowledge, skills and attitudes of health care workers do not always lead to optimal outcomes for older people with dementia who are admitted to hospital with a fracture.

This main aim of this paper is to describe the views of those working in rehabilitation and to explore whether having dementia affects access to rehabilitation. This study sought to ascertain how and why people with dementia and a fracture are admitted to rehabilitation across a range of facilities both in metropolitan and regional hospitals in a large geographical area in Australia. In doing so, we report the opinions of key health professionals in relation to the care of people with dementia and a hip fracture.

Method

Design

This study used a qualitative design, using in-depth interviews with 12 health professionals who were experienced in the care for elderly people who had dementia and a fracture. An in-depth interview is able to elicit participants’ own thoughts, perceptions, experiences and feelings (Taylor, 2005). Liamputtong (2013) describes a semi-structured interview as an option to structure an in-depth interview where the interviewer steers the interview but allows the participant flexibility to respond within a broad interview framework. In this study, an in-depth telephone interview was used (Minichiello, Aroni, & Hays, 2008) with a semi-structured schedule of questions (see Box 1) to elicit participants’ thoughts, opinions, experiences and feelings regarding the care of elderly people with dementia and a fracture. The University of Canberra Human Research Ethics Committee approved this study (No. 14-131). All participants volunteered and gave verbal consent and reconfirmed their consent in the recordings at interview.

Box 1.

Interview guide.

1. Can you describe your current role, where you work, what are the key features of your work and who works with you (who you are and what you do)?

2. How are people transferred to your unit?

3. What types of dementia (and severity) do you see?

4. Do you have formal admission criteria? What are your admission criteria?

5. For example: 86-year-old man with #NOF with mild/mod dementia. Lives alone with support. Would you accept?

(Prompt: Might also include a person with mod dementia who has not been managing at home.)

6. What pressures exist for you in accessing/freeing beds?

7. Do you think health/allied health professionals working in the rehabilitation area require special training when dealing with people with dementia? Why/Why not. What sort of training is needed?]

8. In your opinion what are the main challenges when treating and rehabilitating people with fractures and dementia?

9. What things do you think could improve (if any) the patient experience?

Recruitment

Participants were recruited using snowball sampling (Liamputtong, 2013) whereby three experts in the area of dementia and fracture care were identified by the research team and asked to participate in the study. In the course of the interview, they were asked if they could recommend other health care professionals who had experience in the area of dementia and fractures and who would have interesting insights and opinions. In this way, a list of potential participants was generated.

A total of 12 individuals were recruited to this study, all of whom were health professionals working in the care of elderly people with a fracture and dementia. Six participants worked in metropolitan tertiary teaching facilities, four in non-metropolitan facilities, and two were visiting consultants working across metropolitan and non-metropolitan hospitals across a state and a territory in Australia. Participants comprised of: physiotherapist(1), geriatricians(5); Ortho-geriatricians(2); rehabilitation physician(1) nurse managers(2) and a clinical nurse specialist. Participants worked in the following areas: orthopaedics, aged care, rehabilitation, and most with cross speciality relationships for example, in aged care and rehabilitation.

Inclusion criteria

The main criterion for inclusion was current practice in orthopaedics, rehabilitation or aged care where a significant portion of the case load was elderly people with fractures. Participants were from different geographical areas with varying resources and differing health care structures.

Interview guide

Two researchers conducted the in-depth telephone interviews using the following semi-structured question schedule (see Box 1).

Data analysis

All 12 interviews were conducted over a period of four weeks. Interviews were recorded and lasted from 30 to 45 min. The research team transcribed the interviews within five days of each interview and data analysis commenced post the sixth interview using thematic analysis to identify themes and patterns in the qualitative data (Braun & Clarke, 2006). The following steps reported by Braun and Clarke (2006) were used in the thematic analysis:

The research team members familiarised themselves with the data by transcribing the data and re-reading the data independently in the first instance.

The researchers also did initial coding of the data independently. Codes were generated for similar responses across participants.

The codes were collated into tentative themes independently within the research team.

The research team met and all data were gathered into the potential themes, where coding and potential themes were discussed and debated.

The themes were revised over the entire data set.

The themes were defined.

Interviews were conducted until there was data saturation. Data saturation occurs when similarities in responses from participants reveal no new understanding (Liamputtong, 2013). In this case responses from the 10th to 12th participant did not result in new themes, so data collection ceased.

Findings

The main themes identified from the interviews were as follows:

Accessing rehabilitation;

What works well;

Challenges.

Accessing rehabilitation

Participants in this study all described the process of referral into rehabilitation and some of the decision-making processes accompanying this process. In most cases participants reported that patients post-fracture were admitted to rehabilitation from orthopaedic wards. In some locations this required referral to another site within the same health district or from a metropolitan hospital in their home area. It is worth noting that in this study we did not explicitly seek information on those patients post-surgery who were transferred to the private system.

Access to rehabilitation is undertaken in a variety of ways dependent on location and human resources. For example, as described by a rehabilitation physician:

It can take the form of a referral based admission from multiple sources, including discussion with an ortho-geriatrician, and others or it can be an integrated rehabilitation and aged care service, so there’s no distinction between rehabilitation medicine or geriatric medicine. (P#12)

Participants reported a variety of models for referral. For example, in some metropolitan areas ortho-geriatricians make the assessment in discussion with medical colleagues and advise whether the patient is suitable for rehabilitation. In other locations, care is shared between the orthopaedic team and the geriatric team, or care is led by the orthopaedic team with consultative input from the geriatrician. The arrangement with an ortho-geriatrician is becoming more common as described by one ortho-geriatrician:

Probably about 20 per cent of hospitals in Australia have a true shared care arrangement. About 60 per cent [of hospitals] who operate on hip fracture patients will have some form of ortho-geriatric service, but most are not a true shared care model yet, but that’s the way things are going. (P#5)

There was commentary from a Clinical Nurse Specialist in aged care that patients are transferred to rehabilitation or to another hospital (either private or public) due to pressure on acute orthopaedic beds: ‘Demand exceeds our bed numbers, even with 40 plus beds. Sometimes it feels like a transit lounge’ (P#8). However, it was clear from all interviews that some patients sought private care post-trauma or wanted to: ‘Go back to a local hospital to recover close to home’ (P#8), a choice made by patients and their families in consultation with the medical team.

For patients with dementia and a fracture, there was unanimous agreement from all respondents that this was a growing population, with one geriatrician estimating; ‘At least a third of all patients’ (P#3) with a fracture having dementia. Respondents noted that patients were often around 84 years of age, had issues with polypharmacy and multiple co-morbidities, such as type 2 diabetes and were: ‘Often poorly controlled’ as described by a Clinical Nurse Specialist in aged care (P#9).

In the early stages of the assessment process, the clinicians noted the clinical challenges of managing delirium and the need for development of patient pathways for those with delirium. There was tacit acknowledgement that for this patient group, there was a need to: ‘give them a go for two weeks to assess their capability to engage with rehab’ (P#5). This was particularly important to rule out delirium, though adoption of a clear management plan to tackle issues such as dehydration, polypharmacy and malnutrition was also reported as important.

In this study, the criteria for access to rehabilitation are best summarised by the following statement from an ortho-geriatrician: ‘Can they follow a simple 2 step command?’ (P#5). In support of this view, but in more detail, another geriatrician stated:

They need to be able to understand and follow instructions. There are some people whose memory function is poor but they can go along with the process. The occupational therapist will look at this and see if someone can retain information the next day. Obviously if someone is significantly cognitively impaired, if you tell them something and they can’t recall it three seconds later then we don’t feel it is appropriate to take them as we don’t feel it is fair to ask them to so something they are not capable of doing. It is really about being able to follow instruction and to have some retention of that. (P#4)

There was general agreement that admission into rehabilitation should be goal based and not be based upon cognitive status or age alone as noted by an ortho-geriatrician;

Rehab units shouldn’t discriminate against older people on the basis of age or cognitive status score, per se. Criteria for admission should be based on the ability to have a reasonable chance of achieving defined goals that are of benefit of the person. (P#6)

Participants reported that entry to rehabilitation included the following key tasks:

Assessing patient ability to participate in rehabilitation with a goal to increase their level of function, usually mobility:

We would need to be convinced that the person could participate in the rehab program, at least to some extent and then they had a goal to increase their level of functioning. The key area of functioning would be mobility. (P#12)

Undertaking a general health review, focussing on hydration, nutrition and functionality to ascertain capability to weight bear for mobility.

Conducting a cognitive assessment with particular focus on the presence of delirium and/or dementia and to ascertain the level of cognition.

What works well

Access to rehabilitation, as a means to improve patient outcomes, for elderly people was perceived by participants to have had increased system support in recent times. The emergence of ortho-geriatricians and models of care that enable systematic collaboration between orthopaedic and geriatric/rehabilitation services was viewed positively by participants. An ortho-geriatrician described how an integrated model of care works:

[The] integrated service is integrated across geriatric medicine and rehab medicine, but it also has multiple components. It has the ortho-geriatric service, it has in-patient care, it does have home-based rehabilitation as well, it has follow up in terms of secondary fracture prevention. It does have links with other services if needed so that the person can receive multiple components of that, if needed, according to their individual requirement. (P#12)

System support and the focus on pathways of care were evidenced by the discussion of the benefits of a state rehabilitation network, as described by a nurse manager as being: ‘a good source of support, giving opportunities to learn from colleagues, and tackle common issues such as admission criteria and discharge, plus generating new ideas and giving us the ability to benchmark ourselves and improve our care’ (P#8).

Emerging work includes new ways of delivering care for confused older patients:

There has been significant work looking at people with a fractured neck of femur who have delirium. The recognition amongst nursing staff and registrars in a variety of surgical settings, means that there are more coherent management plans being put in place. The understanding that people are getting older and frailer, with staff now becoming used to this client group, with the majority having some degree of cognitive impairment is the new normal. Increasingly patients who are cognitively intact can do their rehab from home and that is what it should be like. (P#4)

New ways of approaching dementia care were also mentioned as a positive move in one workplace:

We are specifically looking at a dementia specific approach to falls prevention where we use [occupational therapy] to define people’s preserved cognitive ability. So instead of focusing on people’s cognitive deficits actually identifying where their preserved cognitive abilities are and then using that information. So we use the Allen’s Cognitive Levels. (P#5) (Allen, 1991)

Challenges

Whilst participants were positive about changes that have happened to progress care for people with a fracture and dementia, challenges remain. In non-metropolitan areas, participants described issues with bed availability in the rehabilitation units, recruitment and retention of trained staff, especially allied health staff, ageing staff and the occasions when patients are transferred into the unit without due process as illustrated by this quote: ‘At another level the acute beds are always under pressure so we get people moved sometimes incorrectly for rehab’ (P#8).

All acknowledge that the state network had improved understanding of rehabilitation of people with fracture and dementia, but beyond the boundaries of the network, there remained a need for education and experience in other disciplines and clinical areas in dealing with people with dementia. The person being labelled as having dementia was still viewed negatively by some colleagues so there remains a need to continue to educate about dementia both within rehabilitation units and external to them, as illustrated by: ‘I think the biggest challenge is around effectively engaging with people who have failing brains and I think that our workforce is inadequately trained to work with people with dementia’ (P#6). ‘I think just a total lack of understanding about what dementia is and the fact that people with dementia can learn, and often they’re very physically fit’ (P#5).

In the rehabilitation process, the concept of destination post-rehabilitation and/or surgery remains a vexed issue. This is especially the case for people who are already in residential care and receiving a high level of care pre-rehabilitation: ‘Sometimes, in fact quite often, they are sent back to the facility, four to five days after hip surgery or one day after perhaps, with a fractured neck of femur’ (P#2).

In all areas but particularly the non-metropolitan areas, there are times when access to nursing home or residential care can be limited, as is gaining timely access to care packages in the community if the person is to return home. Managing and enabling access to these services can cause increased length of stay; however, there was acknowledgment that if the period of rehabilitation had completed, patients may as an interim measure go to their local hospital if there was an available bed.

Engagement of family members in the rehabilitation process was commented upon: ‘Part of the other agenda is how you blend in the family into the rehabilitation. I think that’s another area that could be worked on’ (P#4). Interestingly, some commented on the difficulty of managing family expectations of the rehabilitation process:

There are increased community expectations, of what a hospital can do, sadly we cannot solve everything but hopefully we can get the patient able to live a good life or not have deteriorated on leaving here. Families often expect the hospital to solve their family issues and it ties in with how we as a society now treat elderly people. In many of our communities it used to be that granny lived at home with the extended family, but those days have well and truly gone. (P#7)

Engagement and management of expectations are aspects of the process that requires attention. It is worth noting that participants described many patients as living alone, often without family or in residential care yet still relatively independent until being hospitalised as result of a fall.

Discussion

The primary aim of this research was to report the views of experienced clinicians and managers in aged care regarding how elderly patients with dementia and a fracture gain access to rehabilitation. In meeting this aim, we interviewed 12 professionals working in relevant clinical areas to report their views on how elderly people with a fracture gained access to rehabilitation. The findings of this project have identified three broad themes: what works well, challenges and accessing rehabilitation. In this section, we highlight four areas of interest within the three identified themes that most of the participants expressed as important when looking at elderly people with a fracture accessing rehabilitation.

Integrated models of care

Integrated models of care are supported in the literature (Marcantonio, Flacker, Wright, & Resnick, 2001; Pioli, Davoli, Pellicciotti, Pignedoli, & Ferrari, 2011; Shyu et al., 2013) and by the participants in this study. In NSW, Australia, there are Minimum Standards for the Management of Hip Fracture in the Older Person (NSW Agency for Clinical Innovation, 2014). These standards help to enable consistency of practice regardless of setting. All sites met Standard 1.1 of the aforementioned standards, meaning that the services did show ortho-geriatric and orthopaedic collaboration. In this study, the participants agreed this integrated model of care works well in the setting where the orthopaedic and ortho-geriatric teams are embedded together where the care of the elderly patient takes place. This enables workplace activities such as case conferencing and communication between junior and senior medical staff and other members of the care team to be seamless. Two of the tertiary metropolitan sites met the requirements of Model 1 within the standard, which is considered best practice (Kammerlander et al., 2010). These sites have long-standing and successful working arrangements between the orthopaedic and ortho-geriatric services. For example, in one site, there was an ortho-geriatrician who primarily worked on the orthopaedic ward with an automatic consultation triggered for all elderly persons with a fracture.

Dealing with dementia, fractures and co-morbidities is poorly managed generally

Delirium is an issue that is attracting increasing attention, yet the participants view was it is not always recognised, or is mis-diagnosed and consequently not treated. This is a view supported by the literature (LaMantia et al., 2015). Recently, participants reported a change in practice, with a management plan commencing early in the post-operative period, to help separate delirium from dementia. These types of developments in relation to delirium management are also reported in the literature (Gustafson, 2012). At the time of writing, nationally, the draft Clinical Care Standards on hip fracture care and delirium were under public consultation (www.safetyandquality.gov.au/ccs).

Eligibility into rehabilitation

It was clear from this study that having dementia per se was not an exclusion criterion for access to rehabilitation. All participants reported that eligibility for access into rehabilitation should primarily be based on the ability to achieve rehabilitation goals and having rehabilitation potential and/or being able to actively participate in the rehabilitation process. Ultimately how these broad requirements were met rested with the leading geriatrician, ortho-geriatrician or rehabilitation physician, with participant agreement that as a minimum patient’s ability to follow a two-step command demonstrated the required cognition to engage in a rehabilitation process.

It was interesting to note that there was common agreement from participants in relation to the need for eligibility criteria, with criteria being sufficiently flexible to give the relevant medical practitioner discretion in the admission process. All participants agreed that cognitive status alone should not be used as a criterion for access to rehabilitation. While overall cognitive status was a consideration, the ability to follow simple instructions and physical functioning was also important. This is an important whole of system message regarding treatment of people with dementia in acute settings, as it is supported in the literature (McGilton et al., 2013) and as such should influence future policy and practice.

Staff awareness and staff retention is a challenge

As in any public health system, issues of resourcing, retaining and recruiting well-trained staff can be challenging especially in rural areas where access to allied health staff was more limited than in the metropolitan areas. Yet as Muir and Yohannes (2009) noted, resource limitation of itself may create an environment whereby those with best chance of active rehabilitation have priority. In this study, it was noted that patient management in relation to bed access, length of stay and post-rehabilitation destination was challenging especially in relation to residential care. Coming from residential care was perceived as a barrier in itself to rehabilitation, with people often returning to residential care post-operatively, thus missing opportunity for active rehabilitation. There was acknowledgement by participants that this area requires further investigation.

Participants in this study reported a general lack of awareness regarding how to treat and engage a person with dementia in rehabilitation. In the main the participants were of the view that many health professionals were ignorant about living with dementia and how to effectively communicate and engage with a person with the condition. This lack of knowledge can often mean that a person with dementia who could benefit from rehabilitation is not given the chance to benefit from rehabilitation and this is also reported in the literature (Nilsson & Rogmark, 2011; Rydholm Hedman, 2007).

The commentary from the participants in this study made it clear that having dementia was not a barrier to rehabilitation post hip fracture. Indeed in one area, clients with moderate cognitive impairment are accepted into rehabilitation, due to the expertise of staff in achieving positive outcomes for this client group. Knowledge of living with dementia, for all health care professionals was described by all participants as vital to enabling rehabilitation and overall care of people with dementia. The ability of staff to understand how dementia affects engagement in the rehabilitation process is supported in the literature as a critical part of dementia care (Mass, Specht, Buckwalter, Gittler, & Bechen, 2008).

Conclusion

We commenced this study with the view that people post hip fracture with dementia were probably being excluded from rehabilitation. It is heartening to learn and observe from this study that having mild-to-moderate dementia is not necessarily an exclusion criterion for rehabilitation. Rather this study describes and reveals broad eligibility criteria supported by clinical pathways at a system level. The perceived benefits of increasing collaborative working between orthopaedic and geriatric services are highlighted in this study, with reporting of greater understanding of patient potential for rehabilitation and improved patient outcomes. This is an area worth exploring with further research. Another area for research is the longer term destinations of people with dementia and the variation in care for people coming from residential care.

Finally, this study highlighted the need for systemic education on dementia across all health professionals as there was significant frustration expressed about the lack of understanding of dementia in the wider health system.

From the literature and supported by this study it would seem that barriers to this patient group accessing subacute inpatient rehabilitation include pressures in hospital systems, particularly access to beds, patient prioritisation based on their level of dementia; sub-optimal management of comorbidities and avoidable medical complications including delirium; staff education and limited resources, both human and physical.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Dementia Collaborative Research Centre – Assessment and Better Care as part of an Australian Government Initiative.

Stephen T Isbel, BAppSc (OccTher), MOT, MHA, HScD, is the course convenor of the Master of Occupational Therapy at the University of Canberra. His research interests include caring for people with dementia, social capital and older drivers and post-stroke rehabilitation.

Maggie I Jamieson, BA, MPH, PhD, is a public health academic at the University of Canberra. She has worked in health services and non-government sectors at an executive level and has been successful in enabling research to be undertaken and applied to clinical practice. She is experienced in mixed methods research, especially with disenfranchised populations, systematic review and meta-analysis, with translation of research findings into policy and practice being a particular strength.

References

Allen

(1991) Cognitive disability and reimbursement for rehabilitation and psychiatry. Journal of Insurance Medicine 23(4): 245–247.

Allen

Koziak

Buddingh

Liang

Buckingham

Beaupre

L. A.

(2012) Rehabilitation in patients with dementia following hip fracture: A systematic review. Physiotherapy Canada 64(2): 190–201. DOI:10.3138/ptc.2011-06BH.

Australian and New Zealand Hip Fracture Registry (ANZHFR) Steering Group. (2014). Australian and New Zealand guideline for hip fracture care: Improving outcomes in hip fracture management of adults. Sydney, Australia: Australian and New Zealand Hip Fracture Registry Steering Group.

Australian Institute of Health and Welfare (2012) Dementia in Australia. Cat. no. AGE 70, Canberra, Australia: AIHW.

Baker

N. L.

Cook

M. N.

Arrighi

H. M.

Bullock

(2011) Hip fracture risk and subsequent mortality among Alzheimer’s disease patients in the United Kingdom, 1988–2007. Age and Ageing 40(1): 49–54. DOI:10.1093/ageing/afq146.

Braun

Clarke

(2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101.

Collins, P., & Allbon, P. (2010). The problem of osteoporotic hip fracture in Australia. Canberra: Australian Institute of Health and Welfare (Bulletin 76).

Connelly

Biant

(2012) Dementia and hip fracture: How can adapting acute management improve outcomes? British Undergraduate Emergency Journal 1(3): . Retrieved from http://www.medsurgemergencies.co.uk/category/british-undergraduate-emergency-journal/buej-2012-1/.

Gitlin

L. N.

Corcoran

Winter

Boyce

Hauck

W. W.

(2001) A randomized controlled trial of a home environmental intervention: Effect on efficacy and upset in caregivers and on daily functioning of persons with dementia. The Gerontologist 41(1): 4–14.

10.

Graff

M. J. L.

Vernooij-Dassen

M. J. M.

Thijssen

Dekker

Hoefnagels

W. H. L.

Rikkert

M. G. M.

(2006) Community based occupational therapy for patients with dementia and their care givers: Randomised controlled trial. British Medical Journal 333(7580): 1196. DOI:10.1136/bmj.39001.688843.BE.

11.

Gustafson

(2012) Outcomes of hip fractures: Rehabilitation programmes: Comprehensive geriatric assessment and rehabilitation – A prerequisite for successful treatment of people who have suffered a hip-fracture. European Geriatric Medicine 3: S19.

12.

Kammerlander

Roth

Friedman

S. M.

Suhm

Luger

T. J.

Kammerlander-Knauer

Blauth

(2010) Orthogeriatric services – A literature review comparing different models. Osteoporosis International 21(Supp 4): S637–S646.

13.

LaMantia

Messina

Jhanji

Nazir

Maina

McGuire

Miller

(2015) Emergency medical service, nursing, and physician providers’ perspectives on delirium identification and management. Dementia (London). 1–15).. DOI:10.1177/1471301215591896.

14.

Liamputtong

(2013) Qualitative research methods, 4th ed. Melbourne, Australia: Oxford University Press.

15.

Marcantonio

E. R.

Flacker

J. M.

Wright

R. J.

Resnick

N. M.

(2001) Reducing delirium after hip fracture: A randomised trial. Journal of the American Geriatrics Society 49(5): 516–522.

16.

Mass

M. L.

Specht

J. P.

Buckwalter

K. C.

Gittler

Bechen

(2008) Nursing home staffing and training recommendations for promoting older adults’ quality of care and life: Part 1. Deficits in the quality of care due to understaffing and undertraining. Research in Gerontological Nursing 1(2): 123–133.

17.

McFarlane

Isbel

Jamieson

(2015) Factors determining eligibility and access to subacute rehabilitation for elderly people with dementia and hip fracture. Dementia: The International Journal of Social Research and Practice. 1–11).. DOI:10.1177/1471301215599704.

18.

McGilton

K. S.

Davis

A. M.

Naglie

Mahomed

Flannery

Jaglal

Stewart

(2013) Evaluation of patient-centered rehabilitation model targeting older persons with a hip fracture, including those with cognitive impairment. BMC Geriatrics 13(136): 1–8. DOI:10.1186/1471-2318-13-136.

19.

Minichiello

Aroni

Hays

T. N.

(2008) In-depth interviewing: Principles, techniques, analysis, Sydney, Australia: Pearson Education Australia.

20.

Muir

Yohannes

(2009) The impact of cognitive impairment on rehabilitation outcomes in elderly patients admitted with a femoral neck fracture: A systematic review. Journal of Geriatric Physical Therapy 32: 24–32.

21.

Nilsson

Rogmark

(2011) Hemiarthroplasty for displaced femoral neck fracture: Good clinical outcome but uneven distribution of occupational therapy. Disability and Rehabilitation 33(23/24): 2329–2332. DOI:10.3109/09638288.2011.570412.

22.

NSW Agency for Clinical Innovation (2014) Minimum standards for the management of hip fracture in the older person, Sydney, Australia: ACI NSW agency for clinical innovation.

23.

Pioli

Davoli

M. L.

Pellicciotti

Pignedoli

Ferrari

(2011) Comprehensive care. European Journal of Physical and Rehabilitation Medicine 47(2): 265–279.

24.

Rydholm Hedman, A. M. (2007). Unequal opportunities for patients with and without cognitive impairment: Relatives’ and significant others’ views on care and rehabilitation after hip fracture (doctoral thesis). Stockholm: Institutionen för neurobiologi, vårdvetenskap och samhälle/Department of Neurobiology, Care Sciences and Society. Retrieved from https://openarchive.ki.se/xmlui/handle/10616/40023.

25.

Scandol

J. P.

Toson

J. C. T.

(2013) Fall-related hip fracture hospitalisations and the prevalence of dementia within older people in New South Wales, Australia: an analysis of linked data. Injury 44(6): 776–783.

26.

Shaw

F. E.

(2002) Falls in cognitive impairment and dementia. Clinics in Geriatric Medicine 18: 159–173.

27.

Shyu

Y. I. L.

Liang

Tseng

M. Y.

H. J.

C. C.

Cheng

H. S.

Chen

C. Y.

(2013) Comprehensive and subacute care interventions improve health-related quality of life for older patients after surgery for hip fracture: A randomised controlled trial. International Journal of Nursing Studies 50(8): 1013–1024.

28.

Taylor

M. C.

(2005) Interviewing. In: Holloway

(ed.) Qualitative research in health care, Maidenhead, UK: Open University Press, pp. 39–55.

29.

Watson

Clapperton

Mitchell

(2010) The incidence and cost of falls injury among older people in New South Wales 2006/07, Sydney, Australia: NSW Department of Health.

30.

World Health Organisation. (2012). Dementia: A public health priority. Geneva, Switzerland: WHO.