Enhanced Rehabilitation for Elderly People With a Hip Fracture and Depression

Hip fractures can be a disabling medical event for elderly people, causing immobilization,
requiring extensive rehabilitation, and generating fears of loss of function and need for
institutionalization. The onset of disability, as in the case of a hip fracture, is one of
the most important risk factors for late-life depression (LLD). The likelihood of developing
major depressive disorder is highest immediately after sustaining the fracture. Existing
acute medical rehabilitation settings—skilled nursing facilities (SNFs) and inpatient
rehabilitation facilities (IRFs)—often do not adequately meet the needs of depressed elders,
resulting in a missed opportunity for effective and functional recovery. This study will
test a new program that will enhance acute rehabilitation in SNFs to target depression and
functional recovery in the 2 to 4 weeks after surgery. This program, which will be developed
by the research team, will increase the intensity of physical therapy (PT) and occupational
therapy (OT), include evaluations of depressive symptoms and functional recovery, and add
recommendations by mental health experts for further clinical management of depression as
needed.

Participation in this study will last until discharge from the SNF, with follow-up
assessments lasting until 3 months after entry. Participants will be randomly assigned to
receive either the enhanced acute medical rehabilitation or treatment as usual. Participants
receiving the enhanced care will complete 3 hours of enhanced PT and OT per day from study
entry until discharge, excluding weekends. They will also be monitored in terms of treatment
and progress and may receive recommendations for additional care, such as starting an
antidepressant medication or altering dosage of pain medication. Participants receiving
treatment as usual will receive standard PT and OT. Study assessments will take place at
baseline, after 8 and 15 days, and after discharge. Follow-up assessments will occur after
30, 60, and 90 days. Assessments will include questionnaires and interviews measuring
depressive symptoms, functional impairment and disability, physical functioning, cognitive
functioning, and social support.

Inclusion Criteria:

- Admitted to Barnes Extended Care nursing home

- Primary impairment diagnosis of proximal femur (hip) fracture

- Clinically depressive symptoms, including a score of 15 or greater on the Hamilton
Depression Rating Scale (HAM-D) and depressed mood or anhedonia present more days
than not since the fracture

Exclusion Criteria:

- Unable to provide informed consent due to dementia and severe persistent delirium

- Inability to cooperate with the protocol

- Cardiac or other medical instability that would preclude carrying out high intensity
exercises

- Language, visual, or hearing barriers to participation

- Presence of pelvic fractures that do not involve the proximal femur

- Presence of metastatic cancer, including cancer that causes a pathological fracture

- Bilateral acute hip fractures

- Lifetime psychosis or mania

- Alcohol or substance dependence within 6 months, or current (prior to hip fracture)
alcohol or substance abuse