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Citation: Casafont, C.;
González-Garcia, M.J.;
Marañón-Echeverría, A.;
Cobo-Sánchez, J.L.; Bravo, M.;
Piazuelo, M.; Zabalegui, A. Profile of
Patients with Dementia or Cognitive
Impairment Hospitalized with a
Proximal Femur Fracture Requiring
Surgery. Int. J. Environ. Res. Public
Health 2022,19, 2799. https://
doi.org/10.3390/ijerph19052799
Academic Editor: Giuseppe Lanza
Received: 6 February 2022
Accepted: 17 February 2022
Published: 28 February 2022
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International Journal of
Environmental Research
and Public Health
Article
Profile of Patients with Dementia or Cognitive Impairment
Hospitalized with a Proximal Femur Fracture Requiring Surgery
Claudia Casafont 1, María Josefa González-Garcia 2, Ana Marañón-Echeverría3, JoséLuis Cobo-Sánchez 4,5 ,
María Bravo 6,7, MercèPiazuelo 8and Adelaida Zabalegui 1, *
1Subdivision of Research and Teaching in Nursing, Hospital Clínic Barcelona, 08036 Barcelona, Spain;
casafont@clinic.cat
2Care Quality and Information Systems Unit, Hospital Universitario de Navarra, 31008 Pamplona, Spain;
mj.gonzalez.garcia@navarra.es
3Traumatology Department, Hospital Universitario de Navarra, 31008 Pamplona, Spain;
am.maranon.echeverria@navarra.es
4
Research and Innovation Department, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain;
joseluis.cobo@scsalud.es
5Escuela Universitaria Clínica Mompía, Universidad Católica de Ávila, 39108 Mompía, Spain
6Department of Neurology, Hospital Universitario Marqués de Valdecilla, 39008 Pamplona, Spain;
mariabravo19@hotmail.com
7Institute for Research Marqués de Valdecilla, Universidad de Cantabria, 39011 Santander, Spain
8Traumatology Department, Hospital Clínic Barcelona, 08036 Barcelona, Spain; mpiazuel@clinic.cat
*Correspondence: azabaleg@clinic.cat
Abstract:
This study reports the characteristics of patients with dementia or cognitive impairment
hospitalized with a proximal femur fracture requiring surgery. Methods: Multicentric descriptive
longitudinal study conducted in three traumatology units, representing high-technology public
hospitals across Spain. Data collection took place between August 2018 and December 2019 upon
admission to hospital, discharge, one month and three months after discharge. Results: Study
participants (n= 174) were mainly women (81.6%), and the mean age was 90.7
±
6.3 years old.
Significant statistical differences were noted in the decline of functional capacity at baseline and one
month later, and after three months they had still not recovered. Malnutrition increased from baseline
to the one-month follow-up. The use of physical restraints increased during hospitalization, especially
bilateral bedrails and a belt in the chair/bed. After one month, 15.2% of patients had pressure ulcers.
Although pain decreased, it was still present after three months. Conclusion: Hospitalization after
hip surgery for elderly people with dementia or cognitive impairment negatively impacted their
global health outcomes such as malnutrition and the development of pressure ulcers, falls, functional
impairment and the use of physical restraints and pain management challenges. Hospitals should
implement policy-makers’ strategic dementia care plans to improve their outcomes.
Keywords:
dementia; hip fracture; nursing care; hospitalization; dependency; elderly; cognitive
impairment; pain
1. Introduction
Around 50 million people live with dementia worldwide, and 10 million cases are
diagnosed every year. Dementia has physical, psychological, social and economic impacts
as it is one of the major causes of dependency among older people. Because of the aging
population, this number is expected to increase to 78 million in 2030 and 139 million in
2050 [
1
]. People with dementia (PwD) have an increased risk of hip fractures [
2
,
3
]. In fact,
a study conducted in the Netherlands showed that 30% of patients admitted with a hip
fracture had dementia [
4
]. However, dementia seems to be underdiagnosed. A review
estimated that more than 60% of people with dementia are undetected [5].
Int. J. Environ. Res. Public Health 2022,19, 2799. https://doi.org/10.3390/ijerph19052799 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022,19, 2799 2 of 11
Commonly, PwD have a decline in functional capacity and reduced muscle strength.
Thus, falls are associated with impaired cognition, reduced gait speeds, impaired balance
and dependency, among other causes [
6
]. It is well known that PwD have a higher risk of
falls, and therefore more hip fractures, and often have poor clinical outcomes. In particular,
frail PwD are more likely to suffer a further hip fracture within three years [7]. Deficiency
in mobility and basic activities of daily living are common through recovery from hip
fractures in this vulnerable group. In fact, in Western countries, around 10–20% of patients
with hip fractures end up institutionalized within 6–12 months [8].
Background
When PwD are admitted to hospital after a hip fracture, the busy, unfamiliar setting
of a high-tech hospital’s acute unit can be challenging, causing anxiety and distress in
patients. They face the discomfort of being in a strange place and there is often a lack of
a clear vision on how to care for them as priorities are usually focused on the reason for
admission in acute care or physical care needs [
9
]. Thus, providing care for hospitalized
PwD is also challenging for healthcare professionals due to the lack of dementia-friendly
care pathways, environments and education, as well as staffing levels [
10
]. For instance,
pain management can be difficult because PwD have difficulties expressing their level
of pain [
11
]. Although many valid instruments have been developed to assess pain in
dementia, adequate pain management is still not properly implemented [
12
]. Nurses
find it hard to differentiate pain from behavioral disturbances. Barriers include a lack
of multidisciplinary communication or workload pressure [
13
]. According to the OECD,
Spain has 5.9 nurses per 1000 inhabitants [
14
], and the mean staffing ratio of patients to
nurses is 12.7, much higher than other European countries. An increase in nurse workload
is associated with a higher patient death rate [15] and missed care [16].
Dementia is associated with malnutrition [
17
], and other comorbidities are commonly
present as well. Reduced intake is often due to pain, poor mobility, being confined to bed
and anorexia of aging, which causes a loss of muscle mass and increases the probability
of fractures. Malnutrition has a negative impact on functional recovery and mortality in
patients with hip fractures [
18
]. Thus, comorbidities, malnutrition and immobility make
them prone to develop pressure ulcers, not only in the hospital setting but also in the
community and long-term care [
19
]. Furthermore, other post-operative complications,
such as wounds or urinary tract or respiratory infections, are likely to develop in PwD.
These complications also result in prolonged lengths of stay, readmissions, higher costs and
reduced physical and social capacities [
20
]. In fact, after having surgery, one-third of these
patients die within a year, and this rate increases with time [21].
There is a lack of specific protocols for dementia care in the acute hospitalization
setting, as well as dementia-friendly units. They are admitted to wards due to an acute
condition and general guidelines are followed. New strategies need to be considered
for patient-centered care in dementia, especially in acute hospitalization, where patients
are out of their familiar surroundings. Focusing on patient-centered care could improve
outcomes in both patients and healthcare workers. In order to develop new strategies, it is
key to know these patients’ overall profile, their outcomes and how they progress after the
surgical procedure.
The aim of this study was to analyze the characteristics of patients with dementia and
cognitive impairment hospitalized with a proximal femur fracture requiring surgery.
2. Materials and Methods
This is a multicentric descriptive longitudinal study.
2.1. Setting
The study was conducted in three traumatology units representing high-technology
public hospitals across Spain: Hospital Clinic, Barcelona (Catalonia), Hospital Universitario
Marqués de Valdecilla (Cantabria) and Hospital Universitario de Navarra (Navarra).
Int. J. Environ. Res. Public Health 2022,19, 2799 3 of 11
2.2. Participants
Participants were people with dementia or cognitive impairment (n= 174) hospitalized
with a proximal femur fracture requiring surgery. Consecutive recruitment was conducted
as they were admitted.
Inclusion criteria were the following:
- Patients aged 65 or older hospitalized for surgery.
-
A score of 5 or less in the Short Portable Mental Status Questionnaire (SPMSQ) test [
22
,
23
].
Moreover, records on dementia diagnosis or physician assessment from the Emergency
Department were consulted. Information was validated by the proxy.
-
Living with an informal caregiver or receiving a caregiver visit at least 3 times per week.
-
Signed informed consent form provided by the patient or by the patient’s legal repre-
sentative.
Exclusion criteria were as follows:
- Patients younger than 65.
- Psychiatric symptoms or Korsakoff’s syndrome.
- No informed consent form.
- No IC.
2.3. Data Collection
Data collection took place between August 2018 and December 2019 at the following
time points following PwD admission to hospital: Within 24 hours of ward admission,
on discharge, one month after discharge in the outpatient traumatology visit and at a
three-month follow-up (phone call). Data were collected by trained nurses with extensive
experience in geriatric orthopedics, and all received training on the study protocol and
data-collection procedures for patients and their caregivers. Data were collected after study
approval was received from all the participating Hospitals’ Ethics Committees and signed
informed consent was provided by study subjects.
2.4. Measures
Measurements collected in PwD included sociodemographic and clinical data (the use
of physical restraints, the number of falls and pressure ulcers).
Functional status was measured with the Barthel Index [
24
,
25
]; comorbidities were
measured with the Charlson Comorbidity Index [
26
,
27
]; pain was measured with the Pain
Assessment in Advanced Dementia Scale (PAINAD) [
28
,
29
]; neuropsychiatric symptoma-
tology was evaluated with the Neuropsychiatric Inventory Questionnaire (NPI-Q) [
30
,
31
];
and nutritional status was checked using the Mini Nutritional Assessment (MNA) [
32
]. All
questionnaires used were the Spanish versions and are valid and reliable. See Figure 1for
data collection and measurements.
Int. J. Environ. Res. Public Health 2022,19, 2799 4 of 11
Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 4 of 11
Figure 1. Data collection and measurements.
2.5. Data Analysis
Descriptive data are presented as means and standard deviations (SD) for continuous
variables and numbers and percentages (%) for categorical variables. Estimated changes
in PwD outcomes were studied with a paired t-test for continuous variables and
McNemar’s test for categorical variables. Outcomes assessed longitudinal changes from
all the collection phases: Baseline (admission), discharge, one-month and three-month fol-
low-up. Confidence intervals of 95% were calculated. All significance tests were two-
tailed, and values of p < 0.05 were considered significant. All analyses were conducted
using the R version 4.1.0. for Windows statistical software package.
2.6. Validity and Reliability/Rigor
This study was conducted following the STROBE reporting standard for cohort stud-
ies [33]. Three hospitals were selected to amplify the sample size and increase its repre-
sentativeness of Spain.
3. Results
3.1. Sample Characteristics at Baseline
Participants in this study (n = 174) were mainly women (81.6%), and the mean age
was 90.7 ± 6.3 years old. Of these, most had a diagnosis of dementia (n = 120), and the
average time since diagnosis was 5.8 ± 4.3 years. The type of dementia was mostly un-
known (39.7%) and 30.5% had a diagnosis of Alzheimer’s disease. According to the Span-
ish Law of dependency, 42% of participants were independent, 21.8% had recognized se-
vere dependency and 27.6% were greatly dependent.
Participants had a comorbidity Index of 2.3 ± 1.5, measured with the Charlson Index.
One-third had at least one comorbidity, one-third had two and another third had more
than two comorbidities, mostly circulatory (73%), endocrine-metabolic (36.2%) and neph-
rological (26.4%).
Behavioral disturbance severity results (n = 174), measured with the NPI-Q, were 5.2
± 5.3 and distress results were 4.5 ± 6.8. These represent low severity and distress in be-
havioral disturbances. Results are shown in Table 1.
Figure 1. Data collection and measurements.
2.5. Data Analysis
Descriptive data are presented as means and standard deviations (SD) for continuous
variables and numbers and percentages (%) for categorical variables. Estimated changes
in PwD outcomes were studied with a paired t-test for continuous variables and McNe-
mar’s test for categorical variables. Outcomes assessed longitudinal changes from all the
collection phases: Baseline (admission), discharge, one-month and three-month follow-up.
Confidence intervals of 95% were calculated. All significance tests were two-tailed, and
values of p< 0.05 were considered significant. All analyses were conducted using the R
version 4.1.0. for Windows statistical software package.
2.6. Validity and Reliability/Rigor
This study was conducted following the STROBE reporting standard for cohort stud-
ies [
33
]. Three hospitals were selected to amplify the sample size and increase its represen-
tativeness of Spain.
3. Results
3.1. Sample Characteristics at Baseline
Participants in this study (n= 174) were mainly women (81.6%), and the mean age was
90.7
±
6.3 years old. Of these, most had a diagnosis of dementia (n= 120), and the average
time since diagnosis was 5.8
±
4.3 years. The type of dementia was mostly unknown
(39.7%) and 30.5% had a diagnosis of Alzheimer’s disease. According to the Spanish
Law of dependency, 42% of participants were independent, 21.8% had recognized severe
dependency and 27.6% were greatly dependent.
Participants had a comorbidity Index of 2.3
±
1.5, measured with the Charlson In-
dex. One-third had at least one comorbidity, one-third had two and another third had
more than two comorbidities, mostly circulatory (73%), endocrine-metabolic (36.2%) and
nephrological (26.4%).
Behavioral disturbance severity results (n= 174), measured with the NPI-Q, were
5.2
±
5.3 and distress results were 4.5
±
6.8. These represent low severity and distress in
behavioral disturbances. Results are shown in Table 1.
Int. J. Environ. Res. Public Health 2022,19, 2799 5 of 11
Table 1. Characteristics of patients at admission.
Patient Characteristics Total (n= 174)
Mean ±SD
Age, years 90.7 ±6.3
Gender, female n(%)
Patients with dementia 142 (81.6)
Type of dementia n(%)
Alzheimer’s 53 (30.5)
Unknown 69 (39.7)
Vascular dementia 26 (14.9)
Other 26 (14.9)
Time since diagnosis, years (n= 120) 5.8 ±4.3
Degree of care dependency n(%)
0 73 (42.0)
1 15 (8.6)
2 38 (21.8)
3 48 (27.6)
PwD diseases n(%)
Neurological 137 (78.7)
Circulatory 127 (73.0)
Endocrine-metabolic 63 (36.2)
Respiratory 21 (12.1)
Nephrological 46 (26.4)
Oncological 20 (11.5)
Data are presented as number (percentage) or means ±standard deviation.
3.2. Longitudinal Results
A comparison from baseline to the three-month follow-up was conducted on 125 pa-
tients. From patients at baseline (n= 174), 31 died during the study (17.8%). Eighteen
patients did not complete the last follow-up after three months as they were not willing to
continue to participate. Almost half of the patients (44%) were discharged home and the
other half went to a nursing home (30.4%) or long-term care facility (25.4%).
Functional state decreased significantly (p< 0.001) following Barthel Index measure-
ments (n= 122). On admission, 9% of patients were totally dependent, which increased
to 38.5% on discharge, and 30.3% remained dependent after 3 months. Despite a slight
recovery in the third month, they did not return to the same functional state seen at baseline.
In addition, fully independent patients at baseline (4.1%) were no longer independent after
three months (0.8%). The percentage of participants with mild dependence decreased
significantly (from 43.4% at baseline to 21.3% three months after discharge), shifting to a
higher level of dependency.
Falls increased from admission to discharge (88% to 96%) and then plummeted to
7.2% after three months (p< 0.001). Falls were registered within the last 30 days. Physical
restraints applied on admission were mainly bilateral bedrails (18.8%) and “chair with
table” (8.7%). During hospitalization, the use of physical restraints increased. On discharge,
60.7% had bilateral bedrails on and 26.5% were using a belt in the chair/bed. After
discharge, bilateral bedrail use remained constant. Mostly all patients remained with the
room door open.
Int. J. Environ. Res. Public Health 2022,19, 2799 6 of 11
Pain on admission was measured with the PAINAD tool, reaching a total score of
2.2
±
2.39, where 69.2% of participants had mild pain, 25.2% moderate pain and 5.6%
intense pain on admission. Upon discharge, 22.4% of PwD still had moderate pain and 4.7%
had intense pain. After the three-month follow-up, 3.7% of PwD continued to experience
intense pain and 12.1% experienced moderate pain (Table 2).
Table 2.
Estimated change in outcomes during all study phases (hospital admission, discharge,
1-month follow-up and 3-month follow-up) (n= 125).
Variable Admission Discharge One Month
Follow-Up
Three Months
Follow-Up p-Value †p-Value ‡p-Value §
Functional state
(Barthel) (n = 122) 56.05 ±26.86 27.98 ±20.46 32.55 ±24.27 35.16 ±25.45 <0.001 <0.001 <0.001
Total dependence
(<20) 11 (9.0) 47 (38.5) 43 (35.2) 37 (30.3)
Severe (20–35) 23 (18.9) 38 (31.1) 32 (26.2) 35 (28.7)
Moderate (40–55) 30 (24.6) 26 (21.3) 28 (23.0) 23 (18.9)
Mild dependence
(60–95) 53 (43.4) 11 (9.0) 18 (14.8) 26 (21.3)
Independence (100) 5 (4.1) 0 (0) 1 (0.8) 1 (0.8)
Physical restraints
(n= 117)
Belt in chair/Belt in
bed 7 (6.0) 31 (26.5) 21 (17.9) 15 (12.8) <0.001 0.001 0.061
Chair with table 10 (8.7) 14 (12.2) 20 (17.4) 26 (22.6) 0.480 0.066 0.008
Bilateral bedrails 22 (18.8) 71 (60.7) 49 (41.9) 42 (35.9) <0.001 <0.001 0.004
Pain (PAINAD)
(n= 110) 2.2 ±2.39 1.69 ±2.27 1.22 ±2.13 1.23 ±2.14 0.021 <0.001 0.002
Mild (0–3) 74 (69.2) 78 (72.9) 88 (82.2) 90 (84.1)
Moderate (4–6) 27 (25.2) 24 (22.4) 15 (14.0) 13 (12.1)
Intense (7–10) 6 (5.6) 5 (4.7) 4 (3.7) 4 (3.7)
Pressure ulcers
Presence 3 (2.4) 12 (9.6) 19 (15.2) 16 (12.8) 0.008 <0.001 0.004
Stage 2 2 (1.6) 10 (8.0) 10 (8.0) 9 (7.2)
Stage 3 1 (0.8) 2 (1.6) 7 (5.6) 6 (4.8)
Stage 4 0 (0) 0 (0) 2 (1.6) 1 (0.8)
Location of pressure
ulcer
Sacrum/Back 2 (1.6) 5 (4.0) 4 (3.2) 3 (2.4)
Heel 1 (0.8) 7 (5.6) 12 (9.6) 12 (9.6)
Falls (presence) 110 (88) 120 (96) 24 (19.2) 9 (7.2) 0.004 <0.001 <0.001
Falls (frequency) 1.14 ±1.01 1.22 ±1.16 0.26 ±0.65 0.13 ±0.52 0.086 <0.001 <0.001
0 15 (12.0) 5 (4.0) 101 (80.8) 116 (92.8)
1 94 (75.2) 108 (86.4) 19 (15.2) 5 (4.0)
2 9 (7.2) 5 (4.0) 4 (3.2) 1 (0.8)
Data are presented as number (percentage) or means
±
standard deviation.
†
Comparison between admission
and discharge.
‡
Comparison between admission and one-month follow-up. § Comparison between admission
and three-month follow-up.
Int. J. Environ. Res. Public Health 2022,19, 2799 7 of 11
The number of pressure ulcers, with the majority of them being stage II and III,
increased significantly (p< 0.001 after one month). Upon admission, 2.4% of PwD had a
pressure ulcer, compared with 9.6% on discharge. After one month, the presence of an ulcer
increased to 15.2% of patients and decreased to 12.8% three months later. The location of
pressure ulcers one month after discharge was mainly on the heels (9.6%) and sacrum/back
(3.2%). These results are shown in Table 2. A Supplementary File has been added for a
detailed ratio of pressure ulcers to hospitals and nursing.
Nutritional status was measured with MNA at baseline and one-month follow-up
(n = 141). The overall MNA score was 17.43
±
4.4. on admission and decreased to 15.36
±
4.9
(p< 0.001). Results are shown in Table 3.
Table 3. Comparison of nutritional status between admission and one-month follow-up (n= 141).
Variable Admission One Month Follow-Up pValue
Nutritional status (MNA) 17.43 ±4.4 15.36 ±4.9 <0.001
Malnutrition (<17) 51 (36.2) 76 (53.9)
Risk of malnutrition (17–23.5) 63 (44.7) 40 (28.4)
Normal (24–30) 27 (19.1) 25 (17.7)
Data are presented as number (percentage) or means ±standard deviation.
4. Discussion
The overall condition of older people with dementia or cognitive impairment deterio-
rated after hospitalization and surgery for a hip fracture, especially due to malnutrition
and the development of PUs, falls, functional impairment and the use of physical restraints
and pain management challenges.
From baseline, participants were already significantly malnourished or at risk of
malnutrition. A systematic review found a relationship between frailty and malnutrition
in the community setting; older malnourished people were likely to be frail, although
only a few frail older people were malnourished. Of those found to be malnourished, 68%
were also physically frail, and 25.8% were prefrail [
34
]. Although we did not measure
frailty in our study, our sample had a similar profile, and the results were comparable. We
should also consider sarcopenia as an added factor to frailty, where muscle mass, strength
and function deteriorate [
35
]. Our results are similar to those of studies in patients with
cognitive impairment, where 30% of patients were malnourished, 56% were at risk and 14%
had a normal nutritional status [
35
]. Chye et al. [
36
] also reported a lower prevalence of
malnutrition in frail older people with cognitive impairment (23% malnourished, 49.2%
at risk of malnutrition and 27.7% with normal nutrition). However, we have to consider
the median age of participants (66.4
±
7.8 years) compared to our cohort (90.7
±
6.3) [
36
].
Moreover, our study results show statistically significant worsening of nutritional status
one month after discharge, a 17.7% rise in malnourished participants from baseline and a
reduction in participants with normal nutrition status from 19.1% to 17.7% (p<0.001).
Due to malnourishment and frailty, participants were prone to developing pressure
ulcers. Another important factor to consider regarding hospitalization after surgery among
elderly patients is the development of pressure ulcers. Galivanche et al. [
37
] reported that
5.15% of patients undergoing hip fracture surgery developed PUs. Our population had
a higher rate, as it was rather frail and malnourished and also showed dependency in
activities of daily living and pre-existing PUs. This could predict a higher risk of PUs. The
three hospitals protected heels with foam dressings as per protocol in all elderly patients
at risk of developing PUs and also maintained regular comfort measures, such as the use
of pillows and frequent repositioning to avoid pressure. However, heels remained the
prime site for PUs. After discharge, the number of PUs kept rising, and those that existed
progressed to a more-severe stage. Half of our patients were discharged into long-term care
facilities or nursing homes where patients are looked after by care assistants with higher
Int. J. Environ. Res. Public Health 2022,19, 2799 8 of 11
patient ratios and heavier workloads. This could explain some worsening aspects in these
patients after discharge.
Regarding the use of physical restraints, there are discrepancies with respect to ex-
periences and beliefs, especially regarding their use on elderly, cognitively impaired pa-
tients [
38
]. In cases of agitation, belts or restraints are used only with medical prescriptions.
Our results show physical restraints are still used during hospitalization, especially bilat-
eral bedrails and chairs with tables and belts. Although there was a slight reduction after
discharge, their use continued. The RightTimePlaceCare (RTPC) study reported the use of
physical restraints in 17.8% of PwD at home and 83.2% in institutional care in Spain, rates
that are twice as high as the overall figure for eight other European countries [39].
The functional state of these patients also deteriorated from admission to discharge
and the one-month follow-up visit. Total dependency, in most cases, implies the inability to
move and thus falls are avoided. According to our results, mobility after surgery could be
reduced as patients did not fully recover their functional state. These results are supported
by Dyer et al. [
8
], who found that patients with a high-dependence pre-fracture are less
likely to recover their level of independence in activities of daily living. Moreover, Bower
et al. [
40
] indicated that the fear of falling is high among these patients (61% 4 weeks post-
fracture and 47% 12 weeks after) and therefore these PwD often cut back on activities and
exercise routines, thus worsening their functional state. Balance impairment and mobility
limitations are intrinsic factors of falls [
41
]. In fact, participants had a higher rate of falls
one month after their discharge from hospital.
Furthermore, Cunningham et al. [
42
] indicated that, in the elderly, more physical
activity predicts higher functional status as well as a reduction in the risk of fractures. This
suggests that falls could probably be prevented if physical activity was adequate in PwD.
In addition, in order to enhance mobility, proper pain assessment with recommended scales
should be used in PwD or those with cognitive impairment [43].
We used the PAINAD scale for pain assessment, a behavioral observational tool for
PwD who are unable to communicate, which focuses on breathing, vocalization, facial
expression, body language and consolability [
28
]. This tool showed a correlation with pain
biomarkers in saliva, which confirms its usefulness for assessing pain in PwD [
44
]. Based on
the PAINAD scale results, a significant number of participants remained in pain throughout
the study. These results are supported by those of other studies showing that PwD still
remain undertreated for pain [
45
]. Moreover, Nowak et al. [
46
] found low Barthel scores
among institutionalized patients with cognitive impairment inappropriately treated for
pain. Our cohort received scheduled paracetamol and metamizole during hospitalization,
and PRN (as needed) analgesia at home. Implementing standardized protocols to guide
nurses and ICs in decision-making is essential to ensure better control of pain in PwD [
47
].
It should be pointed out that if patients’ pain is under control, they would probably move
more and consequently improve their overall physical condition.
Our results indicate that the overall condition of PwD deteriorated following surgical
hip replacement. PwD did not recover their initial functional capacity, and pressure ulcers
and malnutrition also increased. These complications seem to delay patient recovery and
wellness. Therefore, the healthcare system should implement new patient-centered care
strategies to improve PwD outcomes and wellbeing, especially in the acute setting. This
increasing population group needs close follow-ups to improve these indicators and to view
the process from a holistic perspective. For instance, dementia-friendly wards should be
considered to care for all PwD hospitalized instead of admitting them into diagnosis-related
wards. Specialized staff could have a specific care path for PwD and also consider their
caregivers during their hospitalization.
This study has some limitations. While data from patients during hospitalization and
outpatient visits at one-month post-discharge were collected through interviews by nurse
researchers, the three-month follow-up was conducted by phone. Telephone interviews
had lower response rates; some informal caregivers declined to complete them, probably
Int. J. Environ. Res. Public Health 2022,19, 2799 9 of 11
because the questionnaires were too long, and they already had a large burden. Although
data were collected by different interviewers, they all followed the same protocol.
A strength of this study is providing an overall profile of this vulnerable group
hospitalized in three high-technology hospitals representing different areas in Spain. Many
studies have been conducted in the community and long-term or residential setting, but
not in acute hospitalization where units are not dementia-friendly. Further research would
be useful to gain a deep understanding of each item evaluated in this study.
5. Conclusions
Hospitalization for elderly PwD undergoing surgical procedures due to hip fractures
negatively impacted their overall status. During the study timeframe, our cohort became
more dependent and malnourished; the number of pressure ulcers increased; physical
restraints were used more often; and pain was not properly controlled. Conversely, the
number of falls and related injuries decreased significantly after three months. It is nec-
essary to implement effective strategies to improve overall outcomes of PwD requiring
hospitalization.
Supplementary Materials:
The following are available online at https://www.mdpi.com/article/10
.3390/ijerph19052799/s1, Supplementary File: Detailed Ratio of Pressure Ulcers to Hospitals and
Nursing.
Author Contributions:
Conceptualization, A.Z., J.L.C.-S. and C.C.; methodology, A.Z., J.L.C.-S. and
C.C.; software, C.C.,A.Z.; validation, A.Z., C.C., J.L.C.-S., M.P., A.M.-E., M.J.G.-G. and M.B.; formal
analysis, A.Z. and C.C.; investigation, A.Z., C.C., J.L.C.-S., M.P., A.M.-E., M.J.G.-G. and M.B.; resources,
A.Z. and C.C.; data curation, A.Z. and C.C.; writing—original draft preparation, C.C.; writing—review
and editing, A.Z., C.C., J.L.C.-S., M.P., A.M.-E., M.J.G.-G. and M.B.; visualization, A.Z., C.C., J.L.C.-S.,
M.P., A.M.-E., M.J.G.-G. and M.B.; supervision, A.Z. and C.C.; project administration, A.Z.; funding
acquisition, A.Z. All authors have read and agreed to the published version of the manuscript.
Funding:
This study received a research grant from the Carlos III Institute of Health, Ministry
of Economy and Competitiveness (Spain) with reference “PI17/01049”, Co-funded by European
Regional Development Fund. Carlos III Institute is a national reference center for funding research
projects and research networks on health sciences.
Institutional Review Board Statement:
This study was approved by the Clinical Research Ethics
Committee at each hospital; Comité Ético Hospital Clinic, Barcelona (HCB/2017/0499), Comité Ético
de Investigación Clínica de Cantabria IDIVAL (2017.241) and Comitéde Ética Navarra (Pyto2017/39).
Bearing in mind participants presented dementia or cognitive impairment, they expressed their
willingness to participate accompanied by a family member, caregiver or legal guardian. This study
follows Declaration of Helsinki guidelines (World Medical Association, 2013). Participants were
able to withdraw from the study at any time. All data have been treated following EU Regulation
2016/679 of the European Parliament and Council of April 27th 2016 in relation to the handling of
personal data and Organic Law 3/2018 of 5th December on Personal Data protection and digital
rights warranty.
Informed Consent Statement:
An information sheet was provided to inform participants of the
purpose of the study, and a consent form was signed by each participant prior to data collection.
Data Availability Statement:
Data presented in this study are available on request from the corre-
sponding author; data are not publicly available.
Acknowledgments:
The authors would like to thank all the staff at traumatology units in the included
hospitals for their cooperation and willingness to participate in the study.
Conflicts of Interest:
The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or
in the decision to publish the results.
Int. J. Environ. Res. Public Health 2022,19, 2799 10 of 11
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