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18/07/24

18 July 2024

Hip fracture: a guide for family carers

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If you're a carer and the person you care for fractures their hip, this guide will ensure that you are equipped with the information you need to support their recovery. 

A carer is anyone who looks after a partner, relative, friend or neighbour who, due to illness, disability, frailty, a mental health problem or an addiction, cannot get by without their support.

There is no single term that best describes the person with a hip fracture as it will differ in every circumstance. We have used 'loved one', 'patient' and 'person you care for' interchangeably throughout this guide.

As members of the Falls and Fragility Fractures Audit Programme Patient and Carer Panel, we’ve each had personal experience of hip fracture, whether as a patient, a carer or as a carer first and a patient a few years later. So we know just how big an impact a hip fracture can have, not only on the person who breaks their hip but also on people like you as their partner, relative or friend.

As well as feeling shocked and worried, you probably have a lot of questions running through your mind at the moment. Why did their hip break so easily? Will they need to have an operation? When will it take place? How long are they likely to be in hospital for? And can anything be done to stop them from having more fractures once they’re back at home?

Unfortunately, finding answers to such questions isn’t always easy, especially when staff are very busy or you’re unsure who you should speak to. That’s why we’re delighted to have worked in partnership with the Royal College of Physicians and experts in older people’s health, orthopaedics, surgery, rehabilitation and nutrition, to produce this guide. 

While we can’t provide you with answers to all your questions, we hope you find it useful, especially while your loved one is in hospital. And if you have any suggestions on how we can improve it, we’d very much like to hear from you. 

‘This is a fantastic resource. I am a carer for my mother-in-law who has advanced dementia and I wish I had access to something like this last year when she was in hospital.'

Tina Strack

Associate director for clinical outcome review programmes, Health Quality Improvement Partnership (HQIP)

‘I would like to congratulate the Patient and Carer Panel on this extraordinary piece of work which shows great insight into both the patient’s and the carer’s perspective of hip fracture.’

Antony Johansen

Consultant geriatrician and clinical lead for the National Hip Fracture Database (NHFD)

Falls and Fragility Fracture Audit Programme

FFFAP@rcp.ac.uk
+44 (0)20 3075 1738
@RCP_FFFAP

Hip fracture: a guide for family carers

The immediate aftermath of hip fracture can be a time of shock and confusion for all those involved. The following steps aim to set out some clear actions that carers can take to support the initial stages of recovery.

Watch for signs of delirium

If your loved one is talking or acting strangely or seems unusually quiet, let staff know without delay as they may have delirium. This is a temporary but serious and distressing condition that can affect their recovery.

NB. If your loved one has been diagnosed with dementia; staff may think that this is the reason for their unusual behaviour. So be sure to point out that what you’re seeing isn’t ‘normal’ for them.

Share what you know about ‘the patient’

If you’re already caring for your loved one or spend a lot of time in their company, you’ll almost certainly know more about them than anyone at the hospital. Not only could your knowledge help staff provide better, safer care, it will also help them to appreciate your loved one as a person as well as a patient.

Here is a checklist for ideas on the kind of information you could share with the hospital team (also available as a separate PDF at page bottom): 

✓ What your loved one likes to be called

✓ Their personal preferences, including strong likes and dislikes

✓ If they have any medical conditions e.g. dementia, diabetes, asthma or heart disease

✓ Any recent changes to their health and well-being or behaviour

✓ Medication they take including inhalers, over-the-counter medicines and supplements

✓ Allergies and dietary requirements

✓ Disabilities and mobility problems

✓ If they use a walking stick, frame or other aid

✓ If they are prone to falling or wandering

✓ Vision and hearing problems and if they use spectacles or a hearing aid

✓ If they need help in going to the toilet

✓ If they have any bladder or bowel problems

✓ Their speech and communication needs

✓ If they have made an advance decision (‘living will’) about their future treatment

✓ If a doctor has signed an order indicating that they should not be resuscitated in the event of a cardiac arrest

✓ If you have a Health and Welfare Lasting Power of Attorney (LPA) that allows you to make decisions about their care if they are no longer able to do so for themselves.

Ask...

  • About visiting. Much has changed since the coronavirus pandemic and hospitals will have detailed rules over which patients can have visitors and which people are allowed to visit them.
  • For a key contact. A large team of people will be looking after your loved one while they’re in hospital. It will make life easier if one person on the team is asked to liaise with you when you ask for an update. Ideally this should be the person who’s also responsible for planning your loved one’s discharge.
  • About pain relief. Staff will give your loved one pain relief to make them as comfortable as possible but if you have reason to believe that they’re still in pain, be sure to let staff know. For instance, if the person you care for has dementia, you may have learned that they show that they’re in pain by becoming agitated or aggressive rather than by asking for pain relief.
  • For a copy of the hospital’s guide for visitors. This should provide useful information on visiting times, public transport, car parking, food and drink outlets, a map of the hospital and much more besides.

Offer...

  • A listening ear. Breaking a hip is a traumatic experience that affects people psychologically as well as physically. A 75-year-old woman with a love of rambling may feel that she’s been catapulted into old age and will never wear her walking boots again. An 80-year-old widower who’s been struggling to live on his own may now fear that his only option is to move into residential care. So, give your loved one the opportunity to talk about their feelings. Even though you won’t have all the answers, taking the time to listen can be very helpful.
  • Encouragement to exercise. Usually patients are encouraged by hospital staff to get out of bed and start moving the day after surgery. Some people will never be as mobile as they were before however and may need to use a walking frame or stick. They may also need help to get dressed, have a wash, or take a shower from now on. Even so, it’s important to encourage your loved one to work hard at building up their strength and getting their mobility back. Encourage them to continue doing the exercises recommended by the physiotherapist and celebrate every small step towards recovery.

Look after yourself...

Caring for someone who has frailty or is ill or disabled can have a significant impact on your own health and well-being. It’s important to look after yyour own needs if you want to be able to look after theirs. For example, you could:

  • Pack your own supplies to make your visits more comfortable
  • Tell family and friends about any worries or concerns you have
  • Check to see what help is available for family carers using this handy online tool
  • Alternatively, get in touch with your local carers’ service for information, advice and support.

Hip fracture care in hospital is provided by a large team of specialists working together.

Ask for a 'key contact' - someone on the team who is given the job of liaising with you when you visit or phone the hospital.

Orthogeriatricians are specialists in the care of older people who have had a hip fracture.

Pain relief

  • A broken hip can be very painful and so patients are offered pain relief to keep them as comfortable as possible and to allow examinations, investigations, nursing care and rehabilitation to take place.
  • For some people, paracetamol can be enough to keep pain under control, but most people experience pain on moving in bed that requires additional pain relief.
  • Most people will need stronger pain killers such as morphine, but these tend to cause constipation and bowel medicines may be needed to avoid this.
  • Although stronger pain killers can make some people muddled, so will untreated pain.
  • A local anaesthetic injection in the groin called a ‘nerve block’ can be very effective in reducing pain, with fewer side effects than strong pain killers. A 'nerve block' (injection in the groin) is a form of pain relief that may be considered by the hospital team of paracetamol and opioids do not suffice.

Surgery

“The best form of pain relief for someone with a broken hip is an operation." 

(Antony Johansen, consultant orthogeriatrician)

Most people who break their hip will need to have an operation to provide pain relief and allow them to get back on their feet again as soon as possible.

The National Institute for Health and Care Excellence (NICE) recommends that surgery should take place on the day of, or the day after, admission with a broken hip.

What type of operation will they have?

This will depend on where their hip is broken and will be one of the following:

  • Surgery to replace all or part of the hip joint
  • Surgery to fix the fracture with a plate and/or screws
  • Surgery to fix the fracture with a rod inside the thigh bone.

Some people aren’t well enough for an operation and so the surgeon, anaesthetist and orthogeriatrician may advise that it is best to delay surgery and concentrate on pain relief until the patient’s overall condition has improved.

Very occasionally, a surgeon may decide surgery is not necessary if the broken pieces of bone are lodged together, allowing a person to walk on the broken hip without pain.

Osteoporosis doesn't affect the healing process of bone, so it can still heal as normal after surgery. A broke hip usually takes 6-12 weeks to heal, but it can take longer.

Is the person you care for talking or behaving strangely? Or are they unusually still and quiet? Then they could be suffering from a condition called ‘delirium’. This can seriously affect how well they recover, so please talk to staff as soon as possible if you’re concerned.

If your loved one has previously been diagnosed with dementia, staff may assume that this is the cause of their unusual behaviour. So be sure to let staff know if they don’t normally behave in this way.

More about delirium

Delirium is a temporary problem that can occur after a broken hip or any operation on an older person, especially if they already have difficulties with their memory.

Other causes of delirium include:

  • being in pain
  • the side-effects of painkillers or other medications
  • changes to someone’s usual medication
  • being in an unfamiliar place or changes to normal, daily routine
  • missing out on meals
  • fear and injury because of a fall
  • worry about getting to the toilet
  • constipation and incontinence
  • suddenly stopping alcohol or smoking
  • dehydration and kidney problems
  • being short of breath or oxygen
  • oxygen masks, catheters and drips
  • infections including chest and urine infections.

How to spot delirium

You know your loved one better than any member of staff and may be able to spot changes in their behaviour that other people may not notice. Watch out for the following:

  • confusion that varies during the day and/or has started suddenly
  • inability to follow a conversation
  • slurred speech
  • agitation or restlessness
  • drowsiness and slow reactions
  • mood swings
  • nightmares
  • paranoia
  • hallucinations.

How you can help

  • Offer reassurance and familiarity
  • Stay calm and explain what’s happening using short, simple sentences, repeating what you say if necessary
  • Remind them of the time and date and make sure that they can see a clock and/or a calendar
  • Bring in some familiar objects from home
  • Help them with familiar activities such as eating and drinking
  • Make sure their glasses are clean and their hearing aids are in working order.
  • Check when the patient's last eye/hearing test was and thus whether they need another one.

If you would like more information about delirium then visit the Alzheimer's Society website which also offers advice and support.

Even though the person you care for is in hospital, you can still be involved in helping them eat nutritious food and drink plenty of fluids. It’s also an opportunity to talk to staff about any problems you’re aware of that may be stopping your loved one from eating a healthy, balanced diet.

When someone is recovering from a hip fracture, eating nourishing food and drinking lots of fluids are essential to making a successful recovery. This means taking in extra calories for energy, protein to build up their muscles, and frequent drinks to keep them hydrated and prevent them from developing pressure sores.

During the hours immediately before your loved one has surgery, they may be told not to eat or drink (otherwise known as ‘nil by mouth’). This makes it safer when they receive an anaesthetic, but there’s no need for them to go without food or drink before this time. Most hospitals are moving to permit water or clear fluids until two hours before surgery, and others allow patients to drink water right up until they leave the ward for their operation.

 

How you can help

As a carer, the close relationship you have with your loved one, and the knowledge you’ve gained from looking after them, make you an invaluable member of their wider care team. So don’t hesitate to ask questions, share your worries or offer to help in practical ways.

  • Share what you know. Have you noticed that your loved one’s appetite is getting weaker? Are you worried that they aren’t getting enough to eat? Are they finding it difficult to chew their food or swallow it? Then be sure to speak to staff as soon as possible so they can deal with any problems at the earliest opportunity.
  • Practical help. Many hospitals actively encourage carers to assist with eating and drinking, so ask if you can be of help at mealtimes. If this isn’t an option, ask if the hospital has a ‘red tray’ system for patients who’ve been identified as malnourished or needing assistance. Such patients will have their food served on a red tray, which prompts staff to give them extra attention when eating, including mashing their food or making it into a puree.
  • Encourage - but don’t pressurise. When you know how important good nutrition is to your loved one’s recovery, it’s easy to feel anxious when offering them food, snacks, and drinks. But however much you want them to eat and drink, keeping calm and offering gentle encouragement is always better than putting them under pressure.
  • Make eating a sociable occasion. Encourage your loved one to get out of bed at mealtimes and join their fellow-patients at the table if possible. Chatting to other people can make mealtimes more enjoyable and lessen any anxieties they might have around eating. One note of caution, however: if they eat very slowly, and everyone else at the table finishes before them, they may say they’re full when they could have eaten more, so it may not always be the best option.
  • Be creative! Instead of bringing in food and snacks in a carrier bag, put them in an eye-catching biscuit tin or a brightly coloured, airtight container. You could call it your ‘secret tuck box’ and get into the habit of ‘raiding’ it together on a regular basis. Putting a snack on a plate they use at home (with a patterned serviette) can also make eating more novel and appealing.

Understanding malnutrition

Today, around one in ten people over the age of 65 are found to be malnourished (or at risk of malnutrition), despite the best efforts of family and friends to provide them with nourishing meals and snacks. Even people who are overweight can be malnourished if the food they’ve been eating hasn’t provided them with enough nutrients. So what are the main causes for not getting enough to eat and drink?

  • Having little or no appetite for food or interest in cooking.
  • Losing one’s sense of taste and smell, which can take the pleasure out of eating
  • Wearing false teeth that no longer fit properly and make eating difficult.
  • Having problems with chewing and swallowing.
  • Feeling lonely or depressed.
  • Being in hospital, especially for a long period of time.
  • A sudden injury or needing an operation, such as for a hip fracture.

When your loved one is malnourished

Although it can be upsetting to hear that your loved one hasn’t been getting enough to eat and drink, it can be a relief to know that healthcare professionals are aware of the problem, especially if you’ve been worried about their diet for some time. Together with the hospital team, you can then focus on getting their eating and drinking back on track, including making sure they’re getting enough calcium and vitamin D.

After surgery, the human body requires extra calories (energy) to help with the healing process, so don’t be surprised if your loved one is encouraged to have sugar in their tea and coffee made with lots of milk!

Nutrition for bones

Most people who fracture their hip will have a condition called osteoporosis, where bones become weak and are more likely to break.

For more information about osteoporosis including eating the right foods and taking supplements to keep bones as healthy as possible, visit: Royal Osteoporosis Society – Nutrition for bones

The NHS website also has information on choosing food for healthy bones: Food for healthy bones

Preparing for discharge

When someone leaves hospital after a hip fracture, they will usually need more support than they did before they broke their hip, including help with eating, drinking and food preparation. It’s certainly worth talking to the occupational therapist about aids and equipment that could help with independent eating, drinking and preparing meals. These items are provided free of charge and include:

  • A step stool or perching stool for use in the kitchen.
  • A grab stick for reaching or lifting light items in hard-to-reach places.
  • A kitchen trolley to move meals and other items from one place to another.

You could also make sure that their fridge, freezer, and cupboard are stocked with quick and easy meals and snack options.

If someone has problems swallowing

Occasionally, physical problems with swallowing can prevent someone from eating or drinking. This is known as dysphagia, and sometimes means that feeding through a tube needs to be considered.

Usually this would be through a ‘nasogastric tube’, passed through the nose and down into the stomach. This can allow a patient to receive all the food and fluid they need, but the patient needs to be willing to have a tube passed through their nose and be prepared to keep it in place for many days.

For more information about swallowing problems and tube feeding, visit: Dysphagia (swallowing problems)

The aim of surgery is to allow a patient to get up and put weight onto their hip straight away. After their operation, your loved one will have some pain and discomfort to start with and will feel weaker than usual. This is perfectly normal and should improve as they continue to recover.

People tend not to have much pain when they are resting, but their pain killers need to be adjusted so that it is possible for them to get up and start moving around.

Rehabilitation usually begins on the day after surgery, when a physiotherapist will carry out an assessment and provide an exercise programme that sets out a series of goals to achieve. Something as simple as getting out of bed for lunch can be an important first step on the road to recovery.

As the patient's carer, what you know about them and how they express pain can help staff to gauge the strength of painkiller required.

“I think what upset my dad was that he expected to wake up with a plaster cast. I wish someone had explained this to him before his operation because he was really scared to move after his op.”

 (Patient and Carer Panel member) 

How you can help

Words of encouragement can go a long way in helping people follow their rehabilitation plan. Each sign of progress, even if it just getting out of bed for a meal, deserves praise as this helps to keep their morale up.

Some patients will need extra support with walking, getting to the toilet and performing the exercises recommended by the therapist. This is especially true for those with dementia or delirium, where it is important to get back to familiar routines as quickly as possible.

Everyone will experience some initial pain and discomfort and feel weaker than usual. Reassure them that this is perfectly normal and should improve as they continue to recover.

Getting out of bed and on their feet as soon as possible will also reduce the patient's risk of getting pneumonia, blood clots and pressure sores.

 

Planning for rehabilitation at home

The person you care for will need a rehabilitation plan, information about their expected recovery and advice about returning to activities such as work, hobbies and driving.

As their carer, it’s a good idea to speak to the therapy team before your loved one is discharged. For example, you may want to ask how you can help the person you care for perform their exercises and make sure they do them correctly at home.

You may also want to alert the team to things in the home such as steps and stairs that may cause difficulties. It may be useful for therapists visit the home before discharge and advise on a suitable living space.

Ask what forms of rehabilitation will be available after they leave hospital and for the contact details of the hospital therapy team so you can get in touch if you need to after discharge.

Carers are very welcome to attend rehabilitation treatment sessions with the person they care for. Just ask a member of the therapy team.

Every person who fractures their hip is different, so it’s not easy to predict when they’ll be well enough for discharge. A lot depends on how quickly they recover from surgery, their rehabilitation progress and their overall health.

“My mother would never admit how much she relied on me. She told the nurse that she could manage fine on her own if they sent her home. I was standing there thinking ‘oh no you can’t’ but I couldn’t bring myself to say it in front of her.”

(Patient and Carer Panel member) 

 

Planning for discharge 

The hospital team will produce a discharge plan based on an assessment of the person you care for and how much support you are able or willing to provide as their carer. The plan will say when it’s safe to discharge them, who will be involved in the next stages of their care and rehabilitation, and what measures need to be put in place to ensure effective recovery at home.

The discharge plan may include arrangements to provide equipment or home adaptations such as grab rails in the bathroom or a raised toilet seat. As their carer, it’s important that you’re involved in the discharge plan and understand what it means.

You should be involved in discussions about future arrangements for their care or rehabilitation at home. They will also arrange for any aids and equipment, such as equipment to help mobility and safety at home.

In understanding your loved one’s circumstances, ward staff will take into account any care you are able or willing to provide. For example, some people are happy to help with cooking, cleaning and shopping but feel uncomfortable providing personal care such as washing, bathing and taking someone to the toilet. You may find it easier to discuss this without your loved one being present.

The hospital should make sure your loved one has enough medication for the first week so that it does not run out before their GP practice can prescribe more. If you are responsible for giving them their medications, and they normally take several different items, the pharmacist might be able to put them into a pre-packed container called a ‘dosette’ box. Many pharmacies will also deliver medications to the house on request.

Be sure to keep a written copy of the discharge plan for reference, along with the contact details of a key member of the hospital care team. If anything is unclear, speak to a member of staff or an adviser from the hospital’s Patient Advice and Liaison Service (PALS). 

Bladder problems

Getting to the toilet can be very difficult after a broken hip. Even after surgery and rehabilitation, some people will still have problems with bladder control. Some patients will have had problems before they were admitted to hospital such as needing the toilet suddenly or more frequently, difficulty passing urine or leaking urine.

People are often embarrassed to talk about such things, but it is important to do so before the person you care for goes home. Bladder problems will affect the care they need once they’re back at home, so it’s important to discuss continence aids while they’re still in hospital if possible.

If their bladder problems are likely to continue after discharge, ask staff about a follow-up appointment or a continence assessment by district nurses at home.

How you can help 

As a carer, you play a key role in ensuring that the transition from hospital to home runs smoothly and safely. For example, you could:

  • Arrange appropriate transport for the journey home.
  • Make sure the fridge and food cupboards are well stocked.
  • Consider setting up a regular online supermarket delivery slot so that you be there on delivery days.
  • Make sure the central heating is working and at the right temperature for the time of year.
  • Make neighbours aware that the person you care for is returning home. You may want to give them your contact details in case any problems arise when you are not there.
  • If the person you care for has a dog, arrange for someone to take them for a walk while they build up their strength.
  • Make sure the person you care for has enough medication and that they or you know how and when to take it.
  • Make sure the person you care for knows how to use any adaptations and equipment that have been provided for them.
  • If you believe they need additional adaptations or equipment, speak to the rehabilitation team.
  • Arrange to be with the person you care for when they receive their first visit from the rehabilitation team.

A carer’s assessment

When you provide unpaid care to a partner, relative or friend who can’t get by without support, you’re entitled to a carer’s assessment. This will give you the opportunity to discuss what you are able and willing to do as a carer and what would make life easier for you such as:

  • Someone to take over your caring role so you can have a break
  • Gym membership, exercise classes and pamper sessions
  • Help with taxi fares if you don't drive
  • Help with gardening and housework
  • Training on how to lift safely
  • Attending local carers’ support groups
  • Advice about benefits

A carer’s assessment is free and anyone over 18 can ask for one. To arrange for a carer’s assessment, contact adult social services at your local council. NB. If the person you care for lives in a different local authority area from you, your carer’s assessment may be carried their local authority rather than your own.

The follow-up phone call or letter 

Today, surgery for hip fracture is so successful that, for most patients, a follow-up appointment at an outpatient clinic is no longer necessary.

However, the hospital may contact the person you care for (or contact you, if you have Health and Welfare Power of Attorney) by phone or letter to check on their progress 3 – 4 months after they return home. They will be particularly keen to make sure they’ve been continuing to take any bone-strengthening treatment they’ve been prescribed.

Even if you don’t have a Health and Welfare Power of Attorney, it’s a good idea to make sure you’re with the person you care for when they take the call or reply to the letter (with their permission, of course).

Further information

The information on this website has been written primarily for carers whose loved ones are in hospital following a hip fracture. A wider range of information can be found on the Royal Osteoporosis Society website.

Other useful links

Carers UK

Carers Trust

Age UK

Versus Arthritis

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