Background: Proximal femoral fracture (commonly referred to as hip fracture) is a major health problem in the frail elderly , and 42% have cognitive impairment . People with cognitive impairment who break their hip are more likely to die or be admitted to institutional care than people without . The cost of health and social care is higher in this group . Systematic reviews found that there was insufficient evidence to conclude whether models of enhanced rehabilitation were more effective than usual care , and that more research is required.
An enhanced rehabilitation programme following surgical repair of hip fracture in the elderly was developed  using the methods outlined in the MRC framework for complex interventions . The first phase developed a rehabilitation intervention designed to enhance usual care comprising both physical and psychological components . The second phase assessed the feasibility and acceptability of the new rehabilitation programme in a randomised feasibility study [9-11]. A definitive phase III randomised controlled trial is in progress and testing the effectiveness and cost-effectiveness of the enhanced rehabilitation programme (FEMuR III, HTA 16/167/09). However, this programme excludes people with cognitive impairment who lack the capacity to give informed consent.
Aims of the research: The aims of the project are to improve the health of people with cognitive impairment (including dementia) following a hip fracture. You will aim to adapt an enhanced community-based rehabilitation programme for use by people with cognitive impairment, who lack the mental capacity to give informed consent, with the assistance of their carers. You will aim to assess whether the methods for a future randomised controlled trial in this patient group are feasible.
Design: Phase I - to work with carers to adapt the rehabilitation workbook and diary and develop approaches and materials suitable for use by hip fracture patients with cognitive impairment. Also, to refine the adapted workbook, diary, approaches and materials in co-production workshops with carers and therapists.
Phase II - to conduct a randomised feasibility study with concurrent exploratory economic analysis and process evaluation. This feasibility study will use expertise learnt during the FEMuR III RCT, and will recruit participants from NHS sites in Merseyside and North Wales.
Setting: Patient participants and their carers will be recruited on orthopaedic and rehabilitation wards; the intervention will be delivered in the community following hospital discharge.
Target population: Patients recovering from surgical repair of proximal femoral fracture with cognitive impairment (including dementia), who lack the mental capacity to give informed consent, together with their informal and primary (familial) carers.
Inclusion criteria: Age 60 years or older; recent proximal hip fracture; surgical repair by replacement arthroplasty or internal fixation; lacking mental capacity to give informed consent due to cognitive impairment; a relative or other carer who can act as consultee, and who is willing and able to participate in the joint intervention; living and receiving rehabilitation from the NHS in the area covered by trial sites.
Exclusion criteria: Any serious problem which could undermine participation such as major physical or sensory disabilities, learning disability, or severe agitation, carer not able to understand English.
Intervention: An enhanced community-based rehabilitation intervention, adapted for use by people with cognitive impairment, with the assistance of their carer, consisting of: a workbook, goal-setting diary, and other materials (e.g. cue cards) designed to increase the amount and quality of patients’ practice of physical exercise and activities of daily living, and six additional therapy sessions.
Outcomes: The main outcomes will be to test the feasibility of methods for a future definitive RCT for people with cognitive impairment who lack mental capacity. We will use methods described by the Quintet Recruitment Intervention (QRI)  to understand how the feasibility study protocol has been integrated into the clinical service in the recruitment centres, identify the patient pathway where eligibility for recruitment is assessed and identify where potential participants might be lost. We will assess the process of obtaining consent using patients’ carers as consultees and identify barriers to recruitment such as a perception that participation is burdensome. Outcome measurement for the main RCT will also be assessed, which will be outcome measures completed on behalf of patients by their carers at baseline and 4 months’ follow-up.
Please contact Professor Nefyn Williams on [email protected]
, if you are interested in applying, providing a personal statement of why the project is of particular interest to you and how the project meets your skills and future aspirations.
This opportunity will remain open until a suitable candidate has been found: