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The influence of informal caregivers on the rehabilitation of the elderly in the postoperative period of proximal femoral fracture

ABSTRACT

Objective

To analyze the influence of informal caregivers on the functional independence of older adults in the postoperative period of proximal femoral fracture due to falls.

Method

It is an integrative review of a corpus for analysis that gathered 23 articles, between 2002 and 2012, from databases “Literatura Latino-Americana e do Caribe em Ciências da Saúde” (Latin-American and Caribbean Health Sciences Literature in Health Sciences), Cumulative Index to Nursing and Allied Health Literature, US National Library of Medicine and Scopus.

Results

There was a predominance of studies by Chinese authors and nurses. The analysis of the studies evidenced that falls followed by fractures lead to dependence of older adults and, consequently, an overload to caregivers. Moreover, older adults and caregivers showed a need for support in the rehabilitation process.

Conclusions

Informal caregivers still need to be included in care planning and to be qualified for such care by health professionals, since they positively influence functional independence in the postoperative period.

Aged; Accidental falls; Femoral fractures; Caregivers; Postoperative period

RESUMO

Objetivo

Verificar a influência do cuidador informal na independência funcional de idosos no pós-operatório de fratura de fêmur proximal por quedas.

Método

Revisão integrativa, cujo corpus de análise reuniu 23 artigos, entre 2002 e 2012, das bases de dados Literatura Latino-Americana e do Caribe em Ciências da Saúde, Scientific Electronic Library Online, Cumulative Index to Nursing and Allied Health Literature, US National Library of Medicine e Scopus.

Resultados

Predominaram estudos com autoria de chineses e enfermeiros. A análise dos estudos evidenciou que as quedas seguidas por fraturas promovem a dependência de idosos e, consequentemente, a sobrecarga aos cuidadores, demonstrando o binômio idoso dependente-cuidador necessitar de apoio no processo de reabilitação.

Conclusões

Os cuidadores informais ainda precisam ser inseridos no planejamento e capacitados para o cuidado pelos profissionais da saúde, uma vez que influenciam positivamente a independência funcional no pós-operatório.

Idoso; Acidentes por quedas; Fraturas do fêmur; Cuidadores; Período pós-operatório

RESUMEN

Objetivo

Verificar la influencia del cuidador informal en la independencia funcional de ancianos en postoperatorio de fractura proximal de fémur por caídas.

Método

Revisión integradora, cuyo análisis se reunieron 23 artículos, entre 2002 y 2012, en las bases de datos Literatura Latinoamericana y del Caribe en Ciencias de la Salud, Cumulative Index to Nursing and Allied Health Literature, US National Library of Medicine e Scopus.

Resultados

Predominaron estudios con autores chinos y enfermeros. El análisis de los estudios evidenció que las caídas que producen fracturas promueven la dependencia de ancianos y, consecuentemente, sobrecarga en los cuidadores, demostrando la dupla anciano dependiente-cuidador necesidad de apoyo en el proceso de rehabilitación.

Conclusiones

Los cuidadores informales necesitan inserción en la planificación, además de capacitación para cuidados por parte de profesionales de salud, toda vez que influyen positivamente en la independencia funcional durante el postoperatorio.

Anciano; Accidentes por caídas; Fracturas del fémur; Cuidadores; Periodo posoperatorio

INTRODUCTION

Proximal femoral fractures (PFF) are common in the elderly population(11. Schilling P, Goulet JA, Dougherty PJ. Do higher hospital-wide nurse staffing levels reduce in-hospital mortality in elderly patients with hip fractures. Clin Orthop Relat Res. 2011;469(10):2932-40.-22. Rohde G, Haugeberg G, Mengshoel AM, Moum T, Wahl AK. Two-year changes in quality of life in elderly patients with low-energy hip fractures: a case-control study. BMC Musculoskelet Dis. 2010;11:226.) and the incidence of falls increases with aging(33. Pinho TAM, Silva AO, Tura LFR, Moreira MASP, Gurgel SN, Smith AAF, et al. Assessing the risk of falls for the elderly in Basic Health Units. Rev Esc Enferm USP. 2012;46(2):320-7.). The risk factors indicated by North American Nursing Diagnosis Association International (NANDA-I) are classified into: environmental (room with furniture and objects/rugs scattered on the floor, poor lighting and slippery floor); cognitive (altered mental status); elderly over 65 years old; physiological (impaired balance, visual impairment, incontinence, difficulty walking, neoplasia and use of some medications(4).

It is estimated that around 5% of hospitalized elderly patients with proximal femoral fractures die during initial hospital stay and one third die in the first year after injury(11. Schilling P, Goulet JA, Dougherty PJ. Do higher hospital-wide nurse staffing levels reduce in-hospital mortality in elderly patients with hip fractures. Clin Orthop Relat Res. 2011;469(10):2932-40.). Thus, in addition to being undesirable to patients, falls followed by PFF are also expensive for their families and the society(11. Schilling P, Goulet JA, Dougherty PJ. Do higher hospital-wide nurse staffing levels reduce in-hospital mortality in elderly patients with hip fractures. Clin Orthop Relat Res. 2011;469(10):2932-40.-22. Rohde G, Haugeberg G, Mengshoel AM, Moum T, Wahl AK. Two-year changes in quality of life in elderly patients with low-energy hip fractures: a case-control study. BMC Musculoskelet Dis. 2010;11:226.), as they may compromise functional independence, that is, the individual’s ability to do something with their own means, requiring a caregiver, either formal or informal. The informal caregiver, usually a family member is not paid for the care delivered and may not have the necessary training to perform the task, unlike the formal caregiver(55. Vieira CPB, Fialho AVM, Freitas CHA, Jorge MSB. Practices of the elderly’s informal caregiver at home. Rev Bras Enferm. 2011;64(3):570-9).

The role of the caregiver has led to changes in the family dynamics, with increased participation of male individuals and older spouses, including relatives such as nieces/nephews, granddaughters/sons and sisters/brothers(66. Gonçalves LHT, Costa MAM, Martins MM, Nassar SM, Zunino R. The family dynamics of elder elderly in the context of Porto, Portugal. Rev Latino-Am Enfermagem. 2011;19(3):458-66.). This excessive workload imposed to the caregiver may cause functional(77. Cardoso L, Vieira MV, Ricci MAM, Mazza RS. The current perspectives regarding the burden on mental health caregivers. Rev Esc Enferm USP. 2012;46(2):513-7.-88. Fuhrmann AC, Bierhals CCBK, Santos NO, Paskulin LMG. Association between the functional capacity of dependent elderly people and the burden of family caregivers. Rev Gaúcha Enferm. 2015;36(1):14-20.) and psychological impairment resulting from the daily activities, changes in social life, financial burden, coping with depressive symptoms and cognitive changes(99. Santos AA, Pavarini SCI. Family functionality regarding the elderly with cognitive impairments: the caretaker’s perception. Rev Esc Enferm USP. 2012;46(5):1141-7.), dysfunction of roles or interruption of family routine(77. Cardoso L, Vieira MV, Ricci MAM, Mazza RS. The current perspectives regarding the burden on mental health caregivers. Rev Esc Enferm USP. 2012;46(2):513-7.).

Given the further population aging, the high incidence of falls among elderly, favoring the occurrence of PFF with the consequent impairment of their functional independence, the number of informal caregivers is expected to increase. So, the following question is posed: − How do informal caregivers influence the process of recovery of the functional independence of these elderly? The justification for this study is that it will allow the recognition of aspects related to informal care that need professional and social investments, to ensure a satisfactory quality of life for elderly and caregivers.

This research is aimed to find scientific articles published in national and international journals, on the influence of informal caregivers on the recovery of functional independence by elderly individuals in the postoperative of proximal femoral fracture (PFF) caused by falls.

METHOD

Integrative review defined as the instrument for access, identification, analysis and synthesis of the literature on a specific theme that allows the construction of a wide analysis of the topic, including discussions on methods and outcomes of publications(1010. Ganong LH. Integrative reviews of nursing research. Res Nurs Health. 1987;10(1):1-11.). This method allows synthesizing previous studies and showing the conclusions of the collected corpus for analysis on a particular phenomenon, and comprises all the studies related to the guiding question used in the search of this literature(1111. Whittemore R. Combining evidence in nursing research: methods and implications. Nurs Res. 2005;54(1):56-62.).

The integrative review comprises the following stages: definition of the problem i.e. the object of the review presented as a question or a primary hypothesis; selection of the sample after definition of inclusion criteria; characterization of the studies (the features or information to be collected from the studies are defined by means of clear criteria, guided by an instrument); analysis of outcomes (identifying similarities and conflicts) and presentation and discussion of the findings(1010. Ganong LH. Integrative reviews of nursing research. Res Nurs Health. 1987;10(1):1-11.).

The guiding question of the review was based on the strategy Patient, Intervention, Comparison and Outcomes, recognized by the abbreviation PICO(1212. Santos CMC, Pimenta CAM, Nobre MRC. The PICO strategy for the research question construction and evidence search. Rev Latino-Am Enfermagem. 2007;15(3):508-11.): P – elderly in the postoperative of proximal femoral fracture (PFF) caused by fall; I – actions of the informal caregiver in the provision of care to the elderly; C – elderly with informal caregiver and elderly without caregiver; O – recovery of functional independence of the elderly. So, the guiding question of the review was: How do informal caregivers influence the recovery of functional independence of elderly in the postoperative of PFF caused by falls?

The selection of the sample was performed in March 2013, through access to the main online databases of healthcare available at the Portal Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Capes (www.capes.gov.br): Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), considered the most important and comprehensive index of scientific and technical literature of Latin America and The Caribbean; Cumulative Index to Nursing and Allied Health Literature (CINAHL), database with more than 3.2 million records since 1937, which provides the full text of more than 700 journals of nursing and health indexed in this database; US National Library of Medicine (PubMed), which includes more than 24 million citations for biomedical literature from MEDLINE, periodicals of life sciences and online books. The citations include links for access to full text of publications of PubMed Central and publisher web sites;Scopus, which contains 55 million records of 21,915 titles of 5,000 editors, considered the largest database of periodicals, books and annals of scientific events, communicating knowledge produced worldwide in the fields of science, technology, medicine, social sciences, arts and humanities.

In the first database, the controlled descriptors (search terms) were combined with Boolean operators in this research: “idoso” orenvelhecimento and “cuidadores” and “fraturas do fêmur” or “fraturas do quadril” and in the last three databases: “aged” or “aging” or “older” or “elderly” and “caregivers” and “femoral fractures” or “hip fractures”.

For data systematization, the authors developed a collection instrument containing data related to authorship and publications. The inclusion criteria adopted were articles entirely available related to the object of research, without language restriction, originated from national and international journals, indexed in the referred databases from January 2002 to December 2012. The exclusion criteria adopted were articles on the following topics: elderly with mental and/or cognitive impairment; elderly with formal caregivers; elderly residing in Long-Stay Institutions; surgical strategies; instrument validation; pharmacology and arthrosis. Thus, 23 articles were established as the corpus for analysis (Figure 1).

Figure 1
– Flowchart of the composition of the sample

RESULTS

Most of the sample of publications was indexed in Scopus (17), followed by CINAHL (10) and in 2010 (6). The corpus for analysis is mostly international (91.30%), published in English (86.96%), Portuguese (8.70%) and Spanish (4.35%), and China was the country with the greatest contribution (34.78%), according to Table 1.

Table 1
– Distribution of selected studies according to the country of the publication of the studies. Botucatu/São Paulo/Brazil, 2012

Chart 1 contains the name and type of study, the thematic axis of the journal where the article was published and the object of study, as well as the influence of informal caregivers on the functional independence of elderly individuals.

Chart 1
– Data related to authorship, type of study, thematic axis and object of the study of articles selected from 2002 to 2012, from databases LILACS, PubMed andScopus, on the influence of informal caregivers on the recovery of functional independence of elderly in the postoperative of PFF caused by falls. Botucatu - São Paulo - Brazil, 2012

DISCUSSION

The studies analyzed in this review demonstrated that a fall followed by PFF is a traumatic event because for leading to dependence on a caregiver and the need for a family rearrangement, aimed to the surgical recovery and functional independence of the elderly.

The clinical status of elderly prior PFF may influence the recovery of functional independence(1616. Lin P-C, Lu C-M. Hip fracture: family caregivers’ burden and related factors for older people in Taiwan. J Clin Nurs. 2005;14(6):719-26.,2424. Hershkovitz A, Kalandariov Z, Hermush V, Weiss R, Brill S. Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture. Arch Phys Med Rehabil. 2007;88(7):916-21.), despite the efforts of families in home care. The factors known to affect post PFF recovery are health status before the fracture, basal functional capacity, emotional status after surgery, cognitive deficits and availability of social support(1616. Lin P-C, Lu C-M. Hip fracture: family caregivers’ burden and related factors for older people in Taiwan. J Clin Nurs. 2005;14(6):719-26.). An investigation conducted in Israel showed that functional improvement is influenced by cognitive changes, followed by the nutritional status at admission (assessed by serum albumin measurement), pre-injury functional level and early surgical intervention(2424. Hershkovitz A, Kalandariov Z, Hermush V, Weiss R, Brill S. Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture. Arch Phys Med Rehabil. 2007;88(7):916-21.).

Another factor that certainly impacts the recovery of functional independence of elderly is the establishment of a harmonious interdependence relationship. The recovery stage involves different settings and health care actions, and caregivers are involved in the entire process(3030. Nahm E-S, Resnick B, Orwig D, Magaziner J, DeGrezia M. Exploration of informal caregiving following hip fracture. Geriatr Nurs. 2010;31(4):254-62.,3333. Louie S W-S, Poon M-Y, Yu S-Y, Chan W-L, Au K-M, Wong K-M. Effectiveness of a patient/carer in an empowerment programme for people with hip fractures. IJTR. 2012;19(12):673-81.). In other words, elderly with PFF require long-term care due to disabling complications that generate dependence on the family(2121. Shawler C. The empowerment of older mothers and daughters: rehabilitation strategies following a hip fracture. Geriatr Nurs. 2006; 27(6):371-7.-2222. Li H-J, Shyu Y-IL. Coping processes of Taiwanese families during the post-discharge period for an elderly family member with hip fracture. Nurs Sci Q. 2007;20(3):273-9.), according to the functional needs(1919. Lin P-C, Hung SH, Liao MH, Sheen SY, Jong SY. Care needs and level of care difficulty related to hip fractures in geriatric populations during the post-discharge transition period. JNR. 2006;14(4):251-60.). Typically, care is provided by female family members (1919. Lin P-C, Hung SH, Liao MH, Sheen SY, Jong SY. Care needs and level of care difficulty related to hip fractures in geriatric populations during the post-discharge transition period. JNR. 2006;14(4):251-60.,2121. Shawler C. The empowerment of older mothers and daughters: rehabilitation strategies following a hip fracture. Geriatr Nurs. 2006; 27(6):371-7.,2626. Martins JJ, Nascimento ERP, Erdmann AL, Candemil MC, Belaver GM. O cuidado no contexto domiciliar no discurso de idosos/familiares e profissionais. Rev Enferm UERJ. 2009;17(4):556-62.), and spouses are primary caregivers in most cases(1919. Lin P-C, Hung SH, Liao MH, Sheen SY, Jong SY. Care needs and level of care difficulty related to hip fractures in geriatric populations during the post-discharge transition period. JNR. 2006;14(4):251-60.,2828. Rocha L, Budó MLD, Beuter M, Silva RM, Tavares JP. Vulnerabilidade de idosos às quedas seguidas de fratura de quadril. Esc Anna Nery. 2010;14(4):690-6.-2929. Taylor NF, Barelli C, Harding KE. Community ambulation before and after hip fracture: a qualitative analysis. Disabil Rehabil. 2010;32(15):1211-90.). Daughters(1616. Lin P-C, Lu C-M. Hip fracture: family caregivers’ burden and related factors for older people in Taiwan. J Clin Nurs. 2005;14(6):719-26.,2121. Shawler C. The empowerment of older mothers and daughters: rehabilitation strategies following a hip fracture. Geriatr Nurs. 2006; 27(6):371-7.,2323 Lin P-C, Lu C-M. Psychosocial factors affecting hip fracture elder’s burden of care in Taiwan. Orthop Nurs. 2007;26(3):155-61.,2929. Taylor NF, Barelli C, Harding KE. Community ambulation before and after hip fracture: a qualitative analysis. Disabil Rehabil. 2010;32(15):1211-90.), daughters-in-law(2222. Li H-J, Shyu Y-IL. Coping processes of Taiwanese families during the post-discharge period for an elderly family member with hip fracture. Nurs Sci Q. 2007;20(3):273-9.-2323 Lin P-C, Lu C-M. Psychosocial factors affecting hip fracture elder’s burden of care in Taiwan. Orthop Nurs. 2007;26(3):155-61.), siblings(2929. Taylor NF, Barelli C, Harding KE. Community ambulation before and after hip fracture: a qualitative analysis. Disabil Rehabil. 2010;32(15):1211-90.) and children(2323 Lin P-C, Lu C-M. Psychosocial factors affecting hip fracture elder’s burden of care in Taiwan. Orthop Nurs. 2007;26(3):155-61.) are usually cited. However, not all families can properly care for an elderly with PFF(2222. Li H-J, Shyu Y-IL. Coping processes of Taiwanese families during the post-discharge period for an elderly family member with hip fracture. Nurs Sci Q. 2007;20(3):273-9.) and cultural factors influence the option for formal caregivers(2727. Min WJ, Barrio C. Cultural values and caregiver preference for Mexican-American and non-latino white elders. J Cross Cult Gerontol. 2009;24(3):225-39.).

Since PFF is an acute event, the transition of care from hospital to home conducted by health professional deserves attention, as it has a positive impact on the recovery of the functional Independence of elderly. An Australian study compared the effect of early discharge with traditional hospital rehabilitation on elderly who had PFF and their caregivers and found significant reduction in the suffering of caregivers of patients who received their experts in rehabilitation at home, though with no effect on patients’ outcomes in a 12-month period(1515. Crotty M, Whitehead C, Miller M, Gray S. Patient and caregiver outcomes 12 months after home-based therapy for hip fracture: a randomized controlled trial. Arch Phys Med Rehabil. 2003;84(8):1237-9.).

Moreover, some researchers suggested strategies deemed appropriate to minimize problems and suffering in the coping with a new life condition after the traumatic event of PFF, such as providing guidance on the access to online information made available by research centers(3030. Nahm E-S, Resnick B, Orwig D, Magaziner J, DeGrezia M. Exploration of informal caregiving following hip fracture. Geriatr Nurs. 2010;31(4):254-62.); suggesting names of institutions with specialized multidisciplinary teams to meet the needs of the binomial family caregiver - dependent elderly(1717. Macleod M, Chesson RA, Blackledge P, Hutchison JD, Ruta N. To what extent are carers involved in the care and rehabilitation of patients with hip fracture? Disabil Rehabil. 2005;27(18-19):1117-22.,3131. Shyu Y-IL, Chen M-C, Liang J, Tseng M-Y. Trends in health outcomes for family caregivers of hip-fractured elders during the first 12 months after discharge. J Adv Nurs. 2012;68(3):658-66.); assessing and stimulating the social perception of caregivers(1616. Lin P-C, Lu C-M. Hip fracture: family caregivers’ burden and related factors for older people in Taiwan. J Clin Nurs. 2005;14(6):719-26.,3131. Shyu Y-IL, Chen M-C, Liang J, Tseng M-Y. Trends in health outcomes for family caregivers of hip-fractured elders during the first 12 months after discharge. J Adv Nurs. 2012;68(3):658-66.) and assigning the process of care transition to a case manager(1414. Megret Caballero A, Naranjo Arroyo M, Fong González Y. Educación a familiares sobre el manejo del adulto mayor dependiente. Rev Cubana Enferm. 2002;18(1):43-9.), as well as addressing the psychological factors of the caregiver(2929. Taylor NF, Barelli C, Harding KE. Community ambulation before and after hip fracture: a qualitative analysis. Disabil Rehabil. 2010;32(15):1211-90.).

There were also recommendations for the training of caregivers in the development of health education programs(2323 Lin P-C, Lu C-M. Psychosocial factors affecting hip fracture elder’s burden of care in Taiwan. Orthop Nurs. 2007;26(3):155-61.,3232. Siddiqui MQA, Sim L, Koh J, Fook-Chong S, Tan C, Howe TS. Stress levels amongst caregivers of patients with osteoporotic hip fractures: a prospective cohort study. Ann Acad of Med Singapore. 2010;39(1):38-42.-3333. Louie S W-S, Poon M-Y, Yu S-Y, Chan W-L, Au K-M, Wong K-M. Effectiveness of a patient/carer in an empowerment programme for people with hip fractures. IJTR. 2012;19(12):673-81.); care models that encourage the participation of elderly and self-care; hospital discharge plan that includes support groups, social service and health care information(1616. Lin P-C, Lu C-M. Hip fracture: family caregivers’ burden and related factors for older people in Taiwan. J Clin Nurs. 2005;14(6):719-26.-1717. Macleod M, Chesson RA, Blackledge P, Hutchison JD, Ruta N. To what extent are carers involved in the care and rehabilitation of patients with hip fracture? Disabil Rehabil. 2005;27(18-19):1117-22.,1919. Lin P-C, Hung SH, Liao MH, Sheen SY, Jong SY. Care needs and level of care difficulty related to hip fractures in geriatric populations during the post-discharge transition period. JNR. 2006;14(4):251-60.); and a project of rehabilitation that includes information to caregivers(1717. Macleod M, Chesson RA, Blackledge P, Hutchison JD, Ruta N. To what extent are carers involved in the care and rehabilitation of patients with hip fracture? Disabil Rehabil. 2005;27(18-19):1117-22.,1919. Lin P-C, Hung SH, Liao MH, Sheen SY, Jong SY. Care needs and level of care difficulty related to hip fractures in geriatric populations during the post-discharge transition period. JNR. 2006;14(4):251-60.).

The sample shows different strategies adopted in different countries to train caregivers and in the transition of hospital care to home care. These actions impact the quality of care and hence the functional independence of patients. However, no consensus was reached on a protocol, and it is recommended that each health service choose the most appropriate models to the needs of the families.

In the USA, an 8-week interactive online program for caregivers of elderly who had PFF was assessed and was found to improve the knowledge of care(3535. Nahm ES, Resnick B, Orwig D, Magaziner J, Bellantoni M, Sterling R, et al. A theory-based online hip fracture resource center for caregivers. Nurs Res. 2012;61(6):413-22.). Information technology favors this type of strategy, but not all caregivers have access to such resources.

In a general hospital in Cuba, members of a health team performed an educational intervention for family members of dependent elderly and found that all of them had poor knowledge on patient care before the intervention; after the intervention, 85.48% showed adequate knowledge on the issue(1414. Megret Caballero A, Naranjo Arroyo M, Fong González Y. Educación a familiares sobre el manejo del adulto mayor dependiente. Rev Cubana Enferm. 2002;18(1):43-9.). However, a study with caregivers of elderly who suffered fractures indicated that, despite the training provided to the medical and/or nursing team before hospital discharge, difficulties associated to home care persisted(1919. Lin P-C, Hung SH, Liao MH, Sheen SY, Jong SY. Care needs and level of care difficulty related to hip fractures in geriatric populations during the post-discharge transition period. JNR. 2006;14(4):251-60.,3030. Nahm E-S, Resnick B, Orwig D, Magaziner J, DeGrezia M. Exploration of informal caregiving following hip fracture. Geriatr Nurs. 2010;31(4):254-62.). The explanation for the divergence between these studies is perhaps the fact that, in the acute stage of the disease, most information is provided at discharge, and caregivers do not have the opportunity to clarify any doubts. It is known that many caregivers are informal and not prepared to perform these duties(2626. Martins JJ, Nascimento ERP, Erdmann AL, Candemil MC, Belaver GM. O cuidado no contexto domiciliar no discurso de idosos/familiares e profissionais. Rev Enferm UERJ. 2009;17(4):556-62.,2828. Rocha L, Budó MLD, Beuter M, Silva RM, Tavares JP. Vulnerabilidade de idosos às quedas seguidas de fratura de quadril. Esc Anna Nery. 2010;14(4):690-6.,3030. Nahm E-S, Resnick B, Orwig D, Magaziner J, DeGrezia M. Exploration of informal caregiving following hip fracture. Geriatr Nurs. 2010;31(4):254-62.).

Most information provided in educational interventions concern hospital discharge and surgery(1515. Crotty M, Whitehead C, Miller M, Gray S. Patient and caregiver outcomes 12 months after home-based therapy for hip fracture: a randomized controlled trial. Arch Phys Med Rehabil. 2003;84(8):1237-9.,2121. Shawler C. The empowerment of older mothers and daughters: rehabilitation strategies following a hip fracture. Geriatr Nurs. 2006; 27(6):371-7.,2626. Martins JJ, Nascimento ERP, Erdmann AL, Candemil MC, Belaver GM. O cuidado no contexto domiciliar no discurso de idosos/familiares e profissionais. Rev Enferm UERJ. 2009;17(4):556-62.,3232. Siddiqui MQA, Sim L, Koh J, Fook-Chong S, Tan C, Howe TS. Stress levels amongst caregivers of patients with osteoporotic hip fractures: a prospective cohort study. Ann Acad of Med Singapore. 2010;39(1):38-42.) and this is insufficient, considering the context of falls, surgeries and rehabilitation. Also, despite their wish to have direct access to information, for many caregivers the only source of information is their elderly patients(1717. Macleod M, Chesson RA, Blackledge P, Hutchison JD, Ruta N. To what extent are carers involved in the care and rehabilitation of patients with hip fracture? Disabil Rehabil. 2005;27(18-19):1117-22.-1818. Jones CA, Feeny DH. Agreement between patient and proxy responses of health-related quality of life after hip fracture. J Am Geriatr Soc. 2005;53(7):1227-33.19).

A national study on home care showed that the families were satisfied with the visits of the health teams, since they stimulated the recovery of functional dependence of the elderly. Nevertheless, the periodicity of these meetings was considered insufficient(2626. Martins JJ, Nascimento ERP, Erdmann AL, Candemil MC, Belaver GM. O cuidado no contexto domiciliar no discurso de idosos/familiares e profissionais. Rev Enferm UERJ. 2009;17(4):556-62.). The focus of these home visits, although inserted in a context that presupposes family care, is only the elderly, since most caregivers reported not having any formal instruction in this type of care and had to deliver it in an empirical way(2626. Martins JJ, Nascimento ERP, Erdmann AL, Candemil MC, Belaver GM. O cuidado no contexto domiciliar no discurso de idosos/familiares e profissionais. Rev Enferm UERJ. 2009;17(4):556-62.).

Therefore, some actions aimed to facilitate walking and contribute to the recovery of the functional independence of elderly are performed. After the event, some families make changes and adaptations in their homes to meet the needs of the patients, the elderly use walkers or canes, some slow their pace of walking and other change their walking style(2222. Li H-J, Shyu Y-IL. Coping processes of Taiwanese families during the post-discharge period for an elderly family member with hip fracture. Nurs Sci Q. 2007;20(3):273-9.). The use of hip protectors was evaluated in a study conducted in Taiwan(2020. Huang H-C, Lee C-H, Wu S-L. Hip protectors: a pilot study of older people in Taiwan. J Clin Nurs. 2006;15(4):436-43.), which identified benefits in the prevention of fractures, but poor adherence due to discomfort and difficulty in wearing them.

Despite the different protocols aimed to the recovery of functional independence in elderly and the inclusion of caregivers, analysis of the studies indicated the challenges associated to the caregiver role. It should be stressed that overburdened caregivers cannot provide ideal care and, thus, fail to stimulate the functional independence of elderly. The corpus of analysis showed that caregivers are overburdened by care activities, work and family responsibilities, which lead many of them to exhaustion(2020. Huang H-C, Lee C-H, Wu S-L. Hip protectors: a pilot study of older people in Taiwan. J Clin Nurs. 2006;15(4):436-43.,3030. Nahm E-S, Resnick B, Orwig D, Magaziner J, DeGrezia M. Exploration of informal caregiving following hip fracture. Geriatr Nurs. 2010;31(4):254-62.). Besides, financial overload was identified as the main cause of stress, resulting from expenses that exceed the family budget related to medical appointments, private rehabilitation sessions and expenses with transportation(3232. Siddiqui MQA, Sim L, Koh J, Fook-Chong S, Tan C, Howe TS. Stress levels amongst caregivers of patients with osteoporotic hip fractures: a prospective cohort study. Ann Acad of Med Singapore. 2010;39(1):38-42.).

A study that monitored caregivers of elderly with PFF over a 12-month period found that the family members improved in the scores related to performance, including bodily pain, social functioning, limitations to perform the activity due to emotional and physical problems. However, the score for general and mental health status was significantly lower after 12 months than in the first month after hospital discharge of the patients(3434. Shyu Y-IL, Chen M, Wu C, Cheng H. Family caregivers’ needs predict functional recovery of older care recipients after hip fracture. J Adv Nurs. 2010;66(11):2450-9.). Regarding mental health, caregivers with high levels of depressive symptoms reported more sleep disorders than individuals who do not perform caregiving activities. It is known that sleep problems increase the risk of various adverse effects, including falls, memory decline, physical and mental stress(2525. Kochar J, Fredman L, Stone KL, Cauley JA. Sleep problems in elderly women caregivers depend on the level of depressive symptoms: results of the caregiver-study of osteoporotic fractures. J Am Geriatr Soc. 2007;55(12):2003-9.), which may have a negative impact on the care provided by caregivers.

The present review detected a significant contribution from Chinese researchers and the nurses that participated in the study. Filial piety, the sense of obligation of adult children to aging parents is a reflection of the traditional Chinese ethics and performs a crucial role in care and family protection, both in the long term and in the transition of care after hospital discharge(1414. Megret Caballero A, Naranjo Arroyo M, Fong González Y. Educación a familiares sobre el manejo del adulto mayor dependiente. Rev Cubana Enferm. 2002;18(1):43-9.,2222. Li H-J, Shyu Y-IL. Coping processes of Taiwanese families during the post-discharge period for an elderly family member with hip fracture. Nurs Sci Q. 2007;20(3):273-9.), which possibly explains the Chinese contribution to the object of the study.

Finally, one limitation of this review concerns the fact that instruments that allow analysis of the methodological quality of the studies included in the corpus of analysis, such as the Critical Appraisal Skills Program (CASP)(3636. Casp-uk.net [Internet]. Oxford: Critical Appraisal Skills Programme (CASP); c2013. CASP Checklists; [about 3 screens]. Available from: http://www.casp-uk.net/#!checklists/cb36.
http://www.casp-uk.net/#!checklists/cb36...
).

FINAL CONSIDERATIONS

China has published many studies on the object of this study, and there is little contribution of Spanish and Portuguese speaking countries. The nursing scientific community has been conducting in-depth studies with elderly, caregivers and their families.

Caregivers play a key role on the rehabilitation of elderly who had PFF, in what concerns motivation, training for walking, facilitation of access to health services, among other aspects. However, other factors interfere in this process, namely: old age, health status prior to the fracture, basal functional capacity, nutritional status at hospital admission, post-surgical emotional status, depression, cognitive deficits and support system availability.

Caregivers are considerably overburdened by the difficulties of providing adequate care, financial tension, and conflicts on the relationship with the elderly and poor social support. Participation in decision making, improved access to legal and medical information, possibility of sharing care experiences, presence of a secondary caregiver and increased social support improve the self-efficacy of care, though without significant reduction in caregiver overload.

The estrangement between health team and caregivers, whose role is not recognized by health professionals is another complication. The main source of information of many caregivers is provided by their elderly patients, and thus, care is provided empirically. Finally, the review indicated that caregivers may have a positive impact on post-surgical recovery and functional independence of elderly patients. However, further studies are needed to investigate whether different cultural contexts interfere in the acceptance and development of the caregiver’s role and to compare results obtained with elderly with and without cognitive and psychiatric impairment.

REFERÊNCIAS

  • 1
    Schilling P, Goulet JA, Dougherty PJ. Do higher hospital-wide nurse staffing levels reduce in-hospital mortality in elderly patients with hip fractures. Clin Orthop Relat Res. 2011;469(10):2932-40.
  • 2
    Rohde G, Haugeberg G, Mengshoel AM, Moum T, Wahl AK. Two-year changes in quality of life in elderly patients with low-energy hip fractures: a case-control study. BMC Musculoskelet Dis. 2010;11:226.
  • 3
    Pinho TAM, Silva AO, Tura LFR, Moreira MASP, Gurgel SN, Smith AAF, et al. Assessing the risk of falls for the elderly in Basic Health Units. Rev Esc Enferm USP. 2012;46(2):320-7.
  • 4
    Santos SSC, Silva ME, Pinho LB de, Gautério DP, Pelzer MT, Silveira RS. Risk of falls in the elderly: an integrative review based on the North American Nursing Diagnosis Association. Rev Esc Enferm USP. 2012;46(5):1227-36.
  • 5
    Vieira CPB, Fialho AVM, Freitas CHA, Jorge MSB. Practices of the elderly’s informal caregiver at home. Rev Bras Enferm. 2011;64(3):570-9
  • 6
    Gonçalves LHT, Costa MAM, Martins MM, Nassar SM, Zunino R. The family dynamics of elder elderly in the context of Porto, Portugal. Rev Latino-Am Enfermagem. 2011;19(3):458-66.
  • 7
    Cardoso L, Vieira MV, Ricci MAM, Mazza RS. The current perspectives regarding the burden on mental health caregivers. Rev Esc Enferm USP. 2012;46(2):513-7.
  • 8
    Fuhrmann AC, Bierhals CCBK, Santos NO, Paskulin LMG. Association between the functional capacity of dependent elderly people and the burden of family caregivers. Rev Gaúcha Enferm. 2015;36(1):14-20.
  • 9
    Santos AA, Pavarini SCI. Family functionality regarding the elderly with cognitive impairments: the caretaker’s perception. Rev Esc Enferm USP. 2012;46(5):1141-7.
  • 10
    Ganong LH. Integrative reviews of nursing research. Res Nurs Health. 1987;10(1):1-11.
  • 11
    Whittemore R. Combining evidence in nursing research: methods and implications. Nurs Res. 2005;54(1):56-62.
  • 12
    Santos CMC, Pimenta CAM, Nobre MRC. The PICO strategy for the research question construction and evidence search. Rev Latino-Am Enfermagem. 2007;15(3):508-11.
  • 13
    Eastwood EA, Magaziner J, Wang J, Silberzweig SB, Hannan EL, Strauss E, et al. Patients with hip fracture: subgroups and their outcomes. J Am Geriatr Soc. 2002;50(7):1240-9.
  • 14
    Megret Caballero A, Naranjo Arroyo M, Fong González Y. Educación a familiares sobre el manejo del adulto mayor dependiente. Rev Cubana Enferm. 2002;18(1):43-9.
  • 15
    Crotty M, Whitehead C, Miller M, Gray S. Patient and caregiver outcomes 12 months after home-based therapy for hip fracture: a randomized controlled trial. Arch Phys Med Rehabil. 2003;84(8):1237-9.
  • 16
    Lin P-C, Lu C-M. Hip fracture: family caregivers’ burden and related factors for older people in Taiwan. J Clin Nurs. 2005;14(6):719-26.
  • 17
    Macleod M, Chesson RA, Blackledge P, Hutchison JD, Ruta N. To what extent are carers involved in the care and rehabilitation of patients with hip fracture? Disabil Rehabil. 2005;27(18-19):1117-22.
  • 18
    Jones CA, Feeny DH. Agreement between patient and proxy responses of health-related quality of life after hip fracture. J Am Geriatr Soc. 2005;53(7):1227-33.19
  • 19
    Lin P-C, Hung SH, Liao MH, Sheen SY, Jong SY. Care needs and level of care difficulty related to hip fractures in geriatric populations during the post-discharge transition period. JNR. 2006;14(4):251-60.
  • 20
    Huang H-C, Lee C-H, Wu S-L. Hip protectors: a pilot study of older people in Taiwan. J Clin Nurs. 2006;15(4):436-43.
  • 21
    Shawler C. The empowerment of older mothers and daughters: rehabilitation strategies following a hip fracture. Geriatr Nurs. 2006; 27(6):371-7.
  • 22
    Li H-J, Shyu Y-IL. Coping processes of Taiwanese families during the post-discharge period for an elderly family member with hip fracture. Nurs Sci Q. 2007;20(3):273-9.
  • 23
    Lin P-C, Lu C-M. Psychosocial factors affecting hip fracture elder’s burden of care in Taiwan. Orthop Nurs. 2007;26(3):155-61.
  • 24
    Hershkovitz A, Kalandariov Z, Hermush V, Weiss R, Brill S. Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture. Arch Phys Med Rehabil. 2007;88(7):916-21.
  • 25
    Kochar J, Fredman L, Stone KL, Cauley JA. Sleep problems in elderly women caregivers depend on the level of depressive symptoms: results of the caregiver-study of osteoporotic fractures. J Am Geriatr Soc. 2007;55(12):2003-9.
  • 26
    Martins JJ, Nascimento ERP, Erdmann AL, Candemil MC, Belaver GM. O cuidado no contexto domiciliar no discurso de idosos/familiares e profissionais. Rev Enferm UERJ. 2009;17(4):556-62.
  • 27
    Min WJ, Barrio C. Cultural values and caregiver preference for Mexican-American and non-latino white elders. J Cross Cult Gerontol. 2009;24(3):225-39.
  • 28
    Rocha L, Budó MLD, Beuter M, Silva RM, Tavares JP. Vulnerabilidade de idosos às quedas seguidas de fratura de quadril. Esc Anna Nery. 2010;14(4):690-6.
  • 29
    Taylor NF, Barelli C, Harding KE. Community ambulation before and after hip fracture: a qualitative analysis. Disabil Rehabil. 2010;32(15):1211-90.
  • 30
    Nahm E-S, Resnick B, Orwig D, Magaziner J, DeGrezia M. Exploration of informal caregiving following hip fracture. Geriatr Nurs. 2010;31(4):254-62.
  • 31
    Shyu Y-IL, Chen M-C, Liang J, Tseng M-Y. Trends in health outcomes for family caregivers of hip-fractured elders during the first 12 months after discharge. J Adv Nurs. 2012;68(3):658-66.
  • 32
    Siddiqui MQA, Sim L, Koh J, Fook-Chong S, Tan C, Howe TS. Stress levels amongst caregivers of patients with osteoporotic hip fractures: a prospective cohort study. Ann Acad of Med Singapore. 2010;39(1):38-42.
  • 33
    Louie S W-S, Poon M-Y, Yu S-Y, Chan W-L, Au K-M, Wong K-M. Effectiveness of a patient/carer in an empowerment programme for people with hip fractures. IJTR. 2012;19(12):673-81.
  • 34
    Shyu Y-IL, Chen M, Wu C, Cheng H. Family caregivers’ needs predict functional recovery of older care recipients after hip fracture. J Adv Nurs. 2010;66(11):2450-9.
  • 35
    Nahm ES, Resnick B, Orwig D, Magaziner J, Bellantoni M, Sterling R, et al. A theory-based online hip fracture resource center for caregivers. Nurs Res. 2012;61(6):413-22.
  • 36
    Casp-uk.net [Internet]. Oxford: Critical Appraisal Skills Programme (CASP); c2013. CASP Checklists; [about 3 screens]. Available from: http://www.casp-uk.net/#!checklists/cb36
    » http://www.casp-uk.net/#!checklists/cb36
  • Research financed by Training Scholarship (2012/15990-3), budget item Regular Research Project FAPESP (2012/09618-4).

Publication Dates

  • Publication in this collection
    2016

History

  • Received
    20 Oct 2014
  • Accepted
    21 Dec 2015
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