Weight-Bearing Restriction After Hip Fracture in a Patient with Advanced Dementia
An 84-year-old woman with moderate-to-severe dementia (unable to follow two-step commands consistently, oriented to person only) is 5 days post-cemented hemiarthroplasty for a displaced femoral neck fracture. The surgeon orders partial weight bearing (PWB) on the operative leg for 6 weeks. She lives with her daughter in a two-story home with a bathroom on the second floor. She has been attempting to stand alone at night and has fallen twice in the hospital, once resulting in a skin tear. Her premorbid ambulation was household with a rolling walker. She is 5'2", 105 lb, with a Braden score of 15 and a Morse Fall Scale of 65. The daughter asks whether her mother 'just needs to try harder.'
1. How should the therapist reconcile the PWB order with this patient's cognitive inability to comply, and what is the safest mobilization plan?
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PWB is a compliance-dependent order; a patient who cannot reliably modulate load cannot be held to it. The clinician should:
- Contact the surgeon to clarify whether the restriction is truly load-limiting or a default post-op order. Cemented hemiarthroplasty for a fragility fracture often permits weight bearing as tolerated; the order may be modifiable. Document the conversation.
- Until clarified, mobilize with maximal external control: gait belt, two-person assist, and a device that limits loading (e.g., a walker used with a guarded, non-weight-bearing-leaning technique is not equivalent to PWB-do not pretend it is). Consider a pre-gait program at the edge of bed and a high-low bed with a bed alarm.
- Do not document 'patient noncompliant' as a moral failing; document the cognitive barrier and the safety plan.
The judgment point: the therapist does not simply 'try harder' with the patient, nor does the therapist ignore the order-the therapist escalates to the ordering surgeon and designs an environment that makes the error hard to commit.
2. What fall-prevention and disposition decisions follow from her Morse score and home layout?
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Morse 65 = high fall risk; combine with cognitive impairment and night-time standing attempts, which are the highest-yield target.
- Night safety: bed alarm, low bed, call-light teaching to the daughter rather than the patient, and a toileting schedule (scheduled voiding reduces impulsive night standing).
- Environment: the second-floor bathroom is a discharge barrier. Options in order of preference: (a) establish a temporary main-floor sleeping and toileting setup before discharge; (b) short-term skilled nursing facility stay for rehab and caregiver training if home setup cannot be achieved safely; (c) home with 24-hour supervision only if the daughter can genuinely provide it.
- Do not discharge to a two-story home with unsupervised night mobility and a fresh hip prosthesis on the assumption that the patient will 'learn.'
The exam-tested reasoning is that fall risk here is driven by cognition and impulsivity, not strength alone, so strength training is necessary but insufficient; environmental and supervisory controls carry the acute risk.