Rapid decline after broken hip

[SunburstsOrMarbleHalls]

My 91 year old mother broke her hip last week and is currently in hospital. She has no diagnosis of dementia but the last 6 weeks I've notices a cognitive decline. Two weeks ago I took her to A&E to rule out a stroke as she was completely disorientated they scanned her and found nothing wrong. She then got a cold so I couldn't follow this up with the GP straight away and then she fell and broke her hip. I was away from home at the time so was unaware and she was home for 3 days before she went to hospital as she refused to let my dad call an ambulance (he has dementia so his decision making is impaired) .

In hospital she was not deemed capable of consenting to the operation and was also put on a deprivation of liberty safeguards. She seems to have lost all short term memory ability and is now struggling to swallow, she is barely eating and when she does she is storing food in her cheeks. She also pulled out her canula when agitated one evening so was moved to an observation ward.

At this point I'm not even sure she will survive the next few weeks but the hospital have told me that physio therapy will see her on Monday to begin looking at how she can be discharged. I am hoping they say it is not suitable for her to return home but I'm really worried in case they say she is.

My father has vascular dementia and can barely address his own basic care needs yet alone anyone else's, he certainly could not lift her or safely carry a meal upstairs to her. I am an only child who works so she will have nobody at home to care for her full time. I don't think carers that pop in would be a solution either as I think she may try to get up when they are not there and may fall again. Her house is social housing with no downstairs toilet, stairs and a regular bath with overhead shower so is not suitable for her mobility needs. It has also come to light that she has not been taking her medication for months despite telling me she had.

I have no POA as she would not agree to it previously as she said she would never go into a home and would not let anyone take away her independence.

She is being ok with the hospital staff but has been quite nasty to me when I go to visit as she is frustrated and frightened. She is demanding to go home and when I say she cant that is when she becomes angry.

I really do not think she is safe to go back home at all and I am unsure what to do. Does anyone have any advice on things I should be doing to ensure she gets the right care?

Sorry for the long thread

I used to work in a nursing home OP and this is a horribly common situation. Often it's a medical event that brings on an extreme decline in wellbeing that the older person is just too frail to recover from. I would contact your local adult social care helpdesk and explain your concerns that this would be an unsafe discharge. The reality is that your Mum will probably need to go into a nursing home from the ward if she becomes well enough - the hospital just wants the bed and in the kindest way possible, it's not their responsibility to sort out her ongoing medical needs.

Don't be afraid of involving the adult social care - they were brilliant when my Dad entered his last months of life and filled the gap between his GP and the palliative care service.

I think it sounds highly unlikely that they would discharge her home in these circumstances. My mum was not as bad as this and they wouldn't allow it.

I would ask to speak to the discharge coordinator at the hospital, tell him or her everything you have put in this post and ask for a best interests meeting (think that's what it's called) with the doctors and social services. You don't have a PoA so you can't make the final decision. Social services can do that taking into account your views.

What they did in my Mums case is discharge her to a care home (for free - it was treated as NHS care) for 6 weeks while she had a full care needs assessment by social services and a memory assessment. At the end of that the outcome was that they did not think she was safe to live alone and we moved her to a care home permanently. There was no DOL in place but I was able to say to her it was a SS and medical decision which she accepted.

That sounds absolutely awful OP, I really feel for you and your parents. We had similar, but not quite so severe, issues with my late DM as she began to lose her cognitive abilities following a series of strokes. She would tell anyone who asked that she could do far more than she actually could. The strain of caring for her had a terrible effect on DF’s health.

I’d have expected an assessment from both Occupational Therapy and Physiotherapy at the very least before anyone was deemed fit to return home. By the sound of things the Hospital have been aware that your DM has diminished cognitive function because of the steps already taken. I’d try to be present at any assessments, or at the very least make sure that the hospital are aware of the limitations of the facilities at home, your DF’s state of health and the extent of his dementia and the fact that your DM isn’t able to manage her medication. Make sure that the hospital know to what extent they can rely on your DM’s answers to any questions.

At our local hospital, as well as a series of questions, patients use a mocked up house to demonstrate making a cup of tea and a sandwich, getting out of a chair, climbing stairs etc. It doesn’t sound as though your DM would be able to do these things? If the hospital have the fullest picture and a proper assessment is carried out I would hope that it would be clear to everyone that your DM couldn’t return home safely.

Sending a hug, it’s very hard looking after elderly parents with health problems. Try and find moments to look after yourself in all this. I hope it works out.

My late OH, who has Parkinsons and was a retired GP, fell and knew he had fractured his femur straight away - he sat on the floor and said "This is the beginning of the end." He had seen it all before. He was of course right. A slowish end - 9 months. This is so common.

Involve Social Services. But do not hope for her to suddenly turn a corner and improve - it is just not how it goes. I am so sorry.

How stressful and upsetting for you OP.

Have the doctors mentioned post operative delirium? It's incredibly common in older patients, particularly after hip surgery. https://pmc.ncbi.nlm.nih.gov/articles/PMC9813601/#:~:text=It%20is%20reported%20that%20compared,et%20al.%2C%202005).

Talk to the staff about a D2A (Discharge to Assess) nursing home placement. I've included a link which explains it simply (it happens to be for a particular council but all areas should provide this). I think the assessment period is usually 6 weeks, they will then reassess whether she is fit to return home, or needs a permanent care home placement.

https://www.havering.gov.uk/adult-social-care/discharge-assess

Who is caring for your father currently? Does he have carers?

Ask to speak to the discharge planning team at the hospital and tell them your concerns. I've see this so many times, where the patient will say anything to get home! It sounds like the house hasn't been suitable for years. I can't imagine someone in their 90's having to climb in and out of a bath with a shower over the top! Have they ever had an occupation therapy review of the house- to add rails/safety features etc?

Unfortunately, its common to get delirium after an injury/fall. A family friend had similar. He did improve slightly, but it was like he'd developed dementia overnight! So shocking to see, a man that had previously walked miles a day, drive, did his own shopping etc to then not remember where he lived.

Even IF your parent had 4 carer visits a day, this would only keep them there so long, and still wouldn't be safe IMO. I'd be asking about nursing home placements for them both together. Its really hard OP. Sending hugs your way x

D2A was only a thing in my Local Authority during Covid. It was in place to get people out of hospital quickly. It doesn't exist where I work now.

Oh really, thank you. I've heard of it being used recently but maybe it's only certain areas.

On the one hand, hospitals are not keen to keep people in when they are no longer treating them and there is somewhere safe for them to go.

BUT the hospital deemed your mum as lacking capacity and put a DOLs in place to safeguard her. Their process will very much be ‘where can she go that’s safe for her’.

Your job is to emphasise

• the need for very careful assessment of her capacity - while she may appear fine at times to them she is unlikely to be able to make realistic decisions
• she needs 24/7 care at this point
• there is nobody at home to care for her - on the contrary, she is your dad’s carer. (You probably need to get an assessment of his needs PDQ too)
• you can provide only limited, occasional oversight of her care
• you do not have POA, although you are her NOK, so cannot take on responsibility for her affairs

I would expect them to be thinking rehab hospital or a rehab placement in a nursing home at this stage; if they suggest anything else then your constant refrain is “is this safe for her? Is this safe for DF?”

(I assume they have ruled out underlying UTIs?)

This kind of crisis can go two ways - it can be the beginning of the end, but it can also result in a flourishing for those who have been neglecting themselves but suddenly start receiving care that ensures they are well fed and watered, their health is closely monitored, physio is undertaken properly, and their social needs are well met.

My mum broke her hip at the same age, OP. Her decline was shocking to witness but she did recover from it and went back home. She definitely suffered from delirium after the operation, thinking people were plotting to kill her, that she was going out to events with the staff (literally unable to move from her bed but thought she went out dancing late at night!) - at times it was funny and other times very distressing. It's common after hip operations, as others have said. She did return more or less to normal again and stayed in hospital for about ten weeks. When she came home we realised she didn't really recognise her house.

There's no way your mum will be able to go home now or at all if she doesn't have someone there virtually all the time. I know she doesn't want to go to a nursing home but I think this is the time for you to start investigating them. Look for recommendations from people and when you suggest them to her, make sure you tell her you know of someone's mum who went there, etc. She will be resistant but a recommendation can take you a long way.

It's such a stressful time and I'm so sorry for you all.

Thanks so much for the advice. I think a lot of masking has occurred as Iv just found lots of unpaid bills.

My dad is considerably younger than my mum and is in his mid 70's.
Despite his dementia diagnosis he is still able to get up and dressed and only needs me to check on him once per day. He still will pop the betting shop and place a bet every Saturday and meet a friend in the pub for a pint afterwards. He still a fair way from needing carers but I think sheltered accommodation may be a good option for him if my mum goes into a care home. He has been having a combination of ready meals and my frozen home cooking and is ok heating them up. As long as do the cleaning and washing and send meals he seems to be ok.

I've been up to visit this afternoon and she is very sleepy. She had a chest infection from her cold before her fall and despite iv antibiotics it has not cleared.
Physio came to see her today and said she isn't alert enough to get her up yet. Her diet has been changed to pureed due to her swallowing difficulties.
She is now not telling them when she needs the loo so the bed changing is particularly painful for her, this is a new development.

The nurses are keeping a close eye on her and possible delirium, they have her on a drip to keep her hydrated and are encouraging her to drink and they are putting her on a nebuliser to help her chest. The worry is that this chest infection will develop into pneumonia.

Its so difficult to see the rapid decline and change in her.

Thank you for all your suggestions so far

There is a very similar recent thread on down this forum OP - 'Where Do We Go From Here'. As you can see these threads have rung a lot of bells with people whose parents have taken falls and declined so rapidly. You need to be very firm with the discharge team that your dad could not possibly cope with your mother in this state. Their priority is safety and preventing further falls so I daresay she will be discharged into nursing care. The incontinence that developed in hospital was also a new development with my mother. If your mum was suffering with a broken hip for three days before receiving any hospital care how was she managing to go to the bathroom? Have they ruled out pelvic injuries as well?

My mum has also developed incontinence after a recent hospital stay and her mobility has also declined significantly (from walking unaided and being able to get from sit to stand well, to needing a zimmerframe, shuffling and needing help to get up and down). The speed at which decline happens is really hard to get your head around.

I will go and have a look at that thread now thanks

Re using the loo after her fall at first she was using a bedpan that she had as she had a few utis last year so still had it in her bedroom. As the pain worsened just before she went in hospital she had a few accidents as she was more immobile. She was only passing urine as she stopped eating. I had no idea this was happening as when I phoned my dad said oh your mum is in bed as her back is hurting as that is what she had told him. He never mentioned the fall until I got home.

When I called in he said the fall was only a little bump so my mum thought she had just jolted her back, She fractured 2 vertebrae 16 years ago and they discovered she had osteoporosis and osteoarthritis so she has a lot of back pain and discomfort most of the time. She hasn't had any other breaks up until now but of course even a small bump can break a bone with osteoporosis.

I’m so sorry to read this. This is exactly what happened to me although my dad had already passed. My mum was diagnosed with delirium and was in and out of hospital 3 times before Vascular dementia was diagnosed. SW were insistent she was ok to go home but she was helpless and I’m an only child too. I had to quote “unsafe discharge and carer burnout” on loop. Docs were great and wouldn’t discharge her. Thankfully I got her a place in a lovely care home and she’s far more settled but please, please look after yourself as if you give SW any indication you can cope they will leave you to it. Sending love and luck x