My father was in a skilled nursing area to do his rehab. He refused physical therapy often and would tell me a "story" that they didn't come or were busy. I would talk to him and let him know that they would discontinue if he kept refusing and he would never get back on his feet. Then I would talk to the therapists and they would agree to continue, then he would refuse. You can't make them do it and you have to accept that they are making a choice that doesn't match up with what you want for them. It's heartbreaking.
Mad - you have been given some wonderful real experience stories. For me the central issue would be establishing what your MIL's cognitive ability is & what her overall health status is (and her likelihood of successful surgery &anesthesia).
If she is the fully capable & healthy but manipulative little old lady who wants everybody to do for her, well she is able to do the rehab required. Won't be easy but she can do what is needed and Medicare will pay for the costs of rehab. BUT if she has dementia to the point that she just cannot understand having to do the exercises and within the sequences required, well that is a whole different issue & will be a problem for Medicare to pay for her rehab as she is not "progressing" so Medicare will decline payment after the initial 21 days post hospitalization / post surgery. MIL could actually find herself in a worse situation post surgery than before with just having a bad hip.
So what is MIL's capability?
For us, my mom had rotor cuff surgery about 8 years ago when she was in her 80's. Surgery went just fine and rehab was out-patient in a sports rehab facility (this was good as mom went in the morning and they were pretty empty and she got lots of direct attention) along with twice daily home exercises. Mom did it for almost 5 months & home health was hired to do things around the house for the first 3 months or so post surgery. She was goal focused to be able to raise her arms to be able to roll her hair. Now flash forward and mom is now in a NH as she is in her 90's. She fell and shattered her hip @ NH from pulling her wheelchair. Now physically she could go through surgery and do well in surgery & recovery BUT the reality now is that her dementia (Lewy) is pretty end stage so there is no way she could do or understand the repetition needed to go through rehab. The medical director of the NH & I spoke on all this and we were in agreement that really mom should not have surgery due to her late dementia stage. She is now bedfast and on hospice.
Please think carefully IF your MIL truly has the cognitive ability to be able to do what is required after surgery for rehab.
The hospital will insist that she have rehab while still a patient. This will all be discussed prior to the surgery and if she continues to insist on not having rehab they simply won't do the procedure.
If your mom has dementia I hate to say it but there is only one way. Don't say a thing. After hospital load her in the car and take her to the rehab facility. Stay with her for about an hour. In that hour expect a horrible scene and to feel guilty but remember she needs to be there for rehab. Pick a good facility. Make sure you are a strong presence there. Go at different times every day. Go often. Bring goody's for the staff. Make friends with the staff. This will get her better care. I have worked in many of these places and I am giving you the recipe for good care. You want to make them think you can walk in at any second. She will be ok. Really. You may even be surprised at how well she does!
Tekka - well for my mom bedsores not much of an issue. Now mom is tiny, petite and under 90 lbs at the time of the fall. Hospice (this was her first hospice provider, more on that below) had a specialized bed with a breathing mattress on a timer brought in within a day. This is the type of low bed with a pump under it so the mattress ebbs & flows. It enables them to NOT have any body part resting hard in 1 area for very long so minimal or no bedsores. For mom it works well as she is light enough for the system. If they are a big person, I just don't see how this works as well though.
If they are bedfast, good hospice group is the key imho if they could live past the initial 90 day period. My mom's first hospice was less than stellar and I basically fired them within the first 6 weeks and got another hospice group in for mom. Hospice #1 average patient was 5 weeks of care. Mom is now on month 18 hospice #2 and this hospice average patient care is 8 months. Hospice, since it is Medicare, is "self directive" - aka you can select the provider. Just like you can select an MD on Medicare. What seems to happen is that often the NH has a short list of hospice they refer out to and family just accepts that hospice group. But you do NOT have to; you as your person's DPOA & MPOA can change hospice providers. The one mom got as # 1, well we never were going to be kum-ba-ya in what I expected. Medicare pays hospice about 5K a month in basic visit costs too. CMS sends out a statement detailing all this, & really you want to look at your elders CMS statements to see just how expensive all this just is. Pretty staggering. But I digress, the 2nd hospice group has approached care quite a bit differently and lots more proactive: in addition to a newer moving mattress bed with a double pump at the head & footboards (lots quieter and stronger air circulations); they also brought in a geri-chair for sitting (this is on wheels and she can be placed onto it and moved/walked about) & this was used 3 X a week till about mid-summer when she had a TIA in August; a gerichari for bathing (wide plastic with holes in it and on wheels so she gets actual showers done by hospice aide with a NH aide as it's a 2 person bathing team system at this NH, she actually is much cleaner now since on hospice); 2 floor mattresses (these are the dense blue long rectangular ones that preschools have for nap time) as mom does not understand she has a hip break and still tries to get out of bed (and has partially). She is not restrained at all. Mom has Lewy Body Dementia and still on good days knows who everybody is and can be quite sharp and can still have interest in food & can still pretty much bite, chew, swallow and sometimes hold a sandwich half and self-feed. She is one tough old bird. Personally I expect a call any day that she has had another TIA and it's over. Will power is amazing.
Now about the pain she is on morphine and a couple of other meds (for agitation & that kinetic movement they do). I think the pain is manageable this past year as the break has finally healed and set. Her knee basically has set so that it crosses over towards her other leg and bent at the knee. She had a weight wrap around 1 of her ankles so that she can't get too out there in movement. Again this is something that hospice orders and provides for. Her leg placement actually is good as she can be cleaned relatively easily at this angle.
You know none of this is pretty but I'm continually amazed at the depth of care that a good hospice group can provide.
The only thing I can advise is for you and your doctor to team up and let her know that rehab is the only option after the surgery. Where does your MIL stay?
I agree with others that the first decision is to compare the risks and benefits of having the surgery. Since it is not always possible to get a person with dementia to cooperate with rehab, ask the doctors about the outcome if she has the surgery and does not do the rehab. Also talk about the risks of anesthesia on her dementia symptoms.
If there are more benefits than risks and you go ahead with the surgery, then the next decision is where is she more likely to cooperate with therapy? Realize that neither home nor a care center guarantees that she will cooperate. All you can do is provide an encouraging setting. If she goes home, in addition to the PT and OT folks coming in and working with her, her caregiver should work with her between their visits. It is useless to expect her to do the exercises on her own.
Jeanne bring up a good point about it being useless to expect the elder to do the exercises on their own. I was fortunate in that my mom was specific goal oriented for her rotor cuff rehab but even then someone had to remind her of the the time to do it and the correct # of reps and equipment to be used at home twice a day at home. Now that I think back it was pretty involved….for her arm extension exercises placed tape with # on the kitchen table as to start @ 1, then 2 etc and had this rolled up and taped towel for her to grab to do this. Also had these rubber bands attached to door handles and a pulley set up in the hallway that was mirrored. All this stayed put for 5 months too. I think I stayed maybe 3 1/2 weeks post surgery with her initially (I live in another state & I'm an only child), then got home health to come in daily for maybe a couple of months but I also came back maybe 3 times for another couple of weeks each time over the 5 month whole rehab cycle. It's a lot of commitment on everybody's part to do rehab even with a compliant fully understanding adult; its just so harder with an elder with dementia.
Medicare rules are pretty no nonsense in what they need to do to be considered progressing in their rehab care too. They are expected to rehab through pain just like how nowadays mom's are supposed to get up and start walking hours after a C-section. Is often really hard for family and the elder to understand. If they whine, complain & just won't do and they could, then the PT has to write a non-compliance eventually & Medicare will not pay.
Good answers all around. Be aware, tho, that she may decide not to be compliant and will wind up wheelchair or bed bound. Anesthesia on very elderly people is super tricky. My DIL is an anesthesiologist and she has refused to be in on several procedures--due to the patient's baseline health. She wouldn't have done my mom's that's for sure. Oddly enough, after the huge drama we had with mother, she was actually asking me who my back dr is (I am having major back surgery in Jan.) I told her and she said "Could you put in a good word for me with him? I want back surgery now my hip is fixed". I think I much have looked pretty stupid with my mouth hanging open. After her last go round, her ortho doc said "No more surgeries. Period." She's still dr shopping. I think she had some dementia post surgery and just doesn't remember how bad she was--oh and she stopped doing PT at home as soon as the "cute" PT stopped coming. This is not unusual, sadly.
my mother fell and broke her hip, had surgery that evening...(really what choice do you have at that point?) we put her in the best rehab we could find. They couldn't guarantee us that she would have 24/7 care, my sister and I stayed all day every day because she couldn't remember or understand that her hip was broken. She was high risk to fall and did, two weeks in. We had to fight the nurses every time for her pain meds. they would come in and ask her "Would you like some pain meds?" and of course she would kneejerk say no..she had DEMENTIA! so they would take the meds back and I would lay there listening to her moan and say 'oh oh!' all night.
she died in less than three weeks. I think she was too far gone in the dementia..
If she is the fully capable & healthy but manipulative little old lady who wants everybody to do for her, well she is able to do the rehab required. Won't be easy but she can do what is needed and Medicare will pay for the costs of rehab. BUT if she has dementia to the point that she just cannot understand having to do the exercises and within the sequences required, well that is a whole different issue & will be a problem for Medicare to pay for her rehab as she is not "progressing" so Medicare will decline payment after the initial 21 days post hospitalization / post surgery. MIL could actually find herself in a worse situation post surgery than before with just having a bad hip.
So what is MIL's capability?
For us, my mom had rotor cuff surgery about 8 years ago when she was in her 80's. Surgery went just fine and rehab was out-patient in a sports rehab facility (this was good as mom went in the morning and they were pretty empty and she got lots of direct attention) along with twice daily home exercises. Mom did it for almost 5 months & home health was hired to do things around the house for the first 3 months or so post surgery. She was goal focused to be able to raise her arms to be able to roll her hair. Now flash forward and mom is now in a NH as she is in her 90's. She fell and shattered her hip @ NH from pulling her wheelchair. Now physically she could go through surgery and do well in surgery & recovery BUT the reality now is that her dementia (Lewy) is pretty end stage so there is no way she could do or understand the repetition needed to go through rehab. The medical director of the NH & I spoke on all this and we were in agreement that really mom should not have surgery due to her late dementia stage. She is now bedfast and on hospice.
Please think carefully IF your MIL truly has the cognitive ability to be able to do what is required after surgery for rehab.
If they are bedfast, good hospice group is the key imho if they could live past the initial 90 day period. My mom's first hospice was less than stellar and I basically fired them within the first 6 weeks and got another hospice group in for mom. Hospice #1 average patient was 5 weeks of care. Mom is now on month 18 hospice #2 and this hospice average patient care is 8 months. Hospice, since it is Medicare, is "self directive" - aka you can select the provider. Just like you can select an MD on Medicare. What seems to happen is that often the NH has a short list of hospice they refer out to and family just accepts that hospice group. But you do NOT have to; you as your person's DPOA & MPOA can change hospice providers. The one mom got as # 1, well we never were going to be kum-ba-ya in what I expected. Medicare pays hospice about 5K a month in basic visit costs too. CMS sends out a statement detailing all this, & really you want to look at your elders CMS statements to see just how expensive all this just is. Pretty staggering. But I digress, the 2nd hospice group has approached care quite a bit differently and lots more proactive: in addition to a newer moving mattress bed with a double pump at the head & footboards (lots quieter and stronger air circulations); they also brought in a geri-chair for sitting (this is on wheels and she can be placed onto it and moved/walked about) & this was used 3 X a week till about mid-summer when she had a TIA in August; a gerichari for bathing (wide plastic with holes in it and on wheels so she gets actual showers done by hospice aide with a NH aide as it's a 2 person bathing team system at this NH, she actually is much cleaner now since on hospice); 2 floor mattresses (these are the dense blue long rectangular ones that preschools have for nap time) as mom does not understand she has a hip break and still tries to get out of bed (and has partially). She is not restrained at all. Mom has Lewy Body Dementia and still on good days knows who everybody is and can be quite sharp and can still have interest in food & can still pretty much bite, chew, swallow and sometimes hold a sandwich half and self-feed. She is one tough old bird. Personally I expect a call any day that she has had another TIA and it's over. Will power is amazing.
Now about the pain she is on morphine and a couple of other meds (for agitation & that kinetic movement they do). I think the pain is manageable this past year as the break has finally healed and set. Her knee basically has set so that it crosses over towards her other leg and bent at the knee. She had a weight wrap around 1 of her ankles so that she can't get too out there in movement. Again this is something that hospice orders and provides for. Her leg placement actually is good as she can be cleaned relatively easily at this angle.
You know none of this is pretty but I'm continually amazed at the depth of care that a good hospice group can provide.
If there are more benefits than risks and you go ahead with the surgery, then the next decision is where is she more likely to cooperate with therapy? Realize that neither home nor a care center guarantees that she will cooperate. All you can do is provide an encouraging setting. If she goes home, in addition to the PT and OT folks coming in and working with her, her caregiver should work with her between their visits. It is useless to expect her to do the exercises on her own.
Medicare rules are pretty no nonsense in what they need to do to be considered progressing in their rehab care too. They are expected to rehab through pain just like how nowadays mom's are supposed to get up and start walking hours after a C-section. Is often really hard for family and the elder to understand. If they whine, complain & just won't do and they could, then the PT has to write a non-compliance eventually & Medicare will not pay.
she died in less than three weeks. I think she was too far gone in the dementia..
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