2. Background and Significance
Trend and the number of older adults at
the age of over 60 years.
(Bunlu Siriphanich, B.E. 2553)
2025
14.9
million
2009
7million
2030
17.8
million
3. Evidence of Hip Fractures
Aged 65 years old and over and were mostly
evident in the age group of over 80 years old.
(Yarrow, & Beech, 2012)
5. • In the western countries,
• the incidents of hip fractures were found in over 550,000 people
every year (UCLA Division of Geriatrics, 2010).
• In Asia,
– Japan was 851, 906, and 1,059 patients in 2004, 2005, and 2006
respectively, and the trends in the incidence and lifetime risk of hip
fracture had showed a significant increase over time among both
genders (Hagino et al., 2009).
• In Thailand,
– 185 people out of a hundred thousand populations, and the
tendency was higher in line with increasing ages.
– The ratio of the incidents between women and men was 2 to 1
(Pattarawan Worathanarat, B.E. 2545).
Incidence & Prevalence
6. Impact of Hip Fracture
Disability
Quality of life
Mortality
Socioeconomic
7. Cause and Risk Factors
• Hip degenerative
• Comorbidity
• Falls
• Age
• Gender
• History of falls and
fracture
• Visual impairment
• Smoking
• Low BMI
• Sedative drugs
• Menopause
8. Treatment of Hip Fracture
• Conservative treatment
• Surgical treatment
Open reduction internal fixation
(ORIF)
Proximal Femoral Nail Antirotation
(PFNA)
10. Factors Contributing to
the Process of Recovery after Surgery
• Gender
• Age
• Health Status
• Perceptual Ability
• Pain
• Physical Ability before
Having Fractures
• Types of Fractures
• Muscle Strength
• Initial Level of
Disability
• Fear of Falling
• Restriction of Activities
• Postoperative
Complications
11. Fear of falling
Lack of
self-confidence
Low perceived
self-efficacy
(Evitt & Quigley, 2004;
Tinetti et al., 1990)
ภาพจาก http://www.thaijoints.com/content_images/hip_08_01.jpg?rand=999486918
12. Functional Ability
• The ability or potential of an individual to
perform different activities required of daily
living according to the levels of ability to
perform activities.
• Functional ability can be divided into two
levels: the ability to do fundamental daily
activities and the ability to perform complex
activities in daily life (Sutthichai Jitapankul, B.E. 2542, as
cited in Sirirat Wichittrakultaworn, B.E. 2545).
13. (Hadjistavropoulo et al., 2011)
Conceptual Framework
Balance
Confidence
(Efficacy)
Falls
Reduced
Stability
Muscle
Decline/
Deconditioning
Avoidance of
Activity
FOF
FA
14. 1) Fear of falling is found low level to high
level in older adults after hip fracture.
2) In Thailand, there is not examine fear
of falling and functional ability in older
adults undergoing hip surgery.
Gap of knowledge
15. Research Questions
1. How about fear of falling and functional
ability among older adults undergoing hip
surgery?
2. Is there any correlation between fear of
falling and functional ability in older adults
undergoing hip surgery?
16. Research Objectives
1. To examine fear of falling in older adults
undergoing hip surgery before rehabilitation
and at 6-week follow-up.
2. To explore functional ability in older adults
undergoing hip surgery before rehabilitation
and at 6-week follow-up.
3. To investigate the correlation between
fear of falling and functional ability in older
adults undergoing hip surgery.
17. Definition of Variables
• Fear of falling is defined as perception on a
lack of confidence to perform activity of daily
life. It was measured by the falls-efficacy scale
(Tinetti, Richman, & Powell, 1990),
• Total scores ≥ 80 points = the risk of falls,
• Total scores ≥ 70 points = the fear of falling.
18. Definition of Variables
• Functional ability is defined as the ability or
potential of individuals in performing basic
activities daily living.
• Measured by Modified Barthel Activity of
Daily Index (MBAI) (Jitapunkul, Kamolratanakul,
Chandraprasert, & Bunnag, 1994).
• Total scores range from 0 - 18 points.
• The higher scores indicate the better
functional ability.
19. 1. General knowledge about hip fracture
- Incidence of hip fracture in older adults
- Cause and risk factors of hip fracture
- Impact of hip fracture
- Treatments of hip fracture
- Postoperative complications of hip surgery
- Functional abilities after hip surgery
2. Fear of Falling and Functional Ability after Hip Surgery
3. Summary of the Literature Reviews
LITERATURE REVIEW
20. METHODOLOGY
The target population
• The older patients ≥ 60 years,
• who were diagnosed by the orthopaedist with
hip fracture, undergoing hip surgery, and
• admitted in general surgery-orthopaedic
wards at tertiary hospitals in Bangkok,
Thailand,
• From July to December 2013.
21. Sample
Inclusion criteria:
1. Male or female aged ≥ 60 years;
2. Being able to perform activities daily living by
themselves before the admission;
3. Having good consciousness, with a total score
based on Thai Mental State Examination (TMSE)
≥ 24 points (Mental rehabilitation group, B.E. 2536)
4. Being able to communicate either by listening,
speaking, reading, or writing Thai language; and
5. Being willing to participate in the study.
22. Exclusion criteria:
1. Having complications after surgery, such as
joint dislocation, or re-operation during
admission;
2. Being unable to be discharged according to
the clinical pathway in each hospital.
Sample
23. • the power and sample size tables by Cohen (1992)
• Spearman’s rho (rs) to be equal to -.78
(Jellesmark, Herling, Egerod, & Beyer, 2012)
• α = .05, power of test = .80 (Nunta Khandee, B.E. 2553)
• The effect size was .50
(Cohen, 1992, 157)
Sample
27. Instruments
• Instrument for screening
– Thai Mental State Examination (TMSE)
(Appendix A)
• Instrument for data collection
– Demographic and Health Information
Questionnaire (Appendix B)
– Fall Efficacy Scale (FES) (Appendix C)
– Modified Barthel Activities of Daily Index (MBAI)
(Appendix D)
28. Thai Mental State Examination (TMSE)
• by Nipon Puangwarintr et al.
(Mental Rehabilitation Group, B.E. 2536)
• six aspects
– Orientation - Registration
– Attention - Calculation
– Language - Recall
• Total scores of 30 points
• > 24 points had normal mental state
or had no dementia.
29. Validity and reliability
• Mean 27.38 points (SD. = 2.02)
(Mental Rehabilitation Group, B.E. 2536)
• In this study:
(TMSE) score in the normal cognition
Ranged from 25-30 scores,
mean ± SD = 27.55 ± 1.62.
Thai Mental State Examination (TMSE)
30. Fall Efficacy Scale (FES)
• Developed by Tinetti et al. (1990).
• ranged from 1 point (very confident)
to 10 points (not confident at all).
• Total scores ≥ 80 points = risk of falls
• Total scores ≥ 70 points = fear of falling
• Test-retest reliability revealed that
Pearson’s correlation coefficient = .71
The validity showed a good internal consistency
(α = .91) (Tinetti et al., 1990)
31. • In this study,
FES was validated by 5 expertises.
The content validity index = .93
10 older adults were selected to test for
instrument’s reliability.
The Cronbach’s alpha was .95.
Fall Efficacy Scale (FES)
33. Modified Barthel Activities of Daily Index
(MBAI)
• Modified from Barthel ADL Index (Mahoney & Barthel,
1965)
• Translated into Thai by Jitapunkul et al. (1994).
• Total scores ranged from 0-20 points.
• In this study
The total activities to be measured include 9
activities.
Total scores ranged from 0 to 18 points
High scores indicate good functional ability and
high performance in doing basic activities daily living.
34. • Validity and reliability
• In 703 older patients. The Cronbach’s alpha
reliability was .67, and its inter-rater reliability
was .79 (Jitapunkul et al., 1994).
• In this study,
The MBAI was validated by 5 experts, and
then content validity index was calculated as.78.
The reliability was tested in 10 older adults,
which reported the Cronbach’s alpha of .90.
Modified Barthel Activities of Daily Index
(MBAI)
38. Visited at
least one
time before
and after
surgery for
maintain
the
relationship
Before
rehabilitation
FES
(10 minutes)
&
Appointment
At 6-week
Follow-up
FES
&
MBAI
(15-20
minutes)
C
H
E
C
K
E
D
Data Collection
39. Data Analysis
• Statistical Package of Social Science for
windows (SPSS/FW)
• Descriptive statistics, percentage, mean, and
standard deviation were used to analyze the
demographic data and health information
40. How do about fear of falling and functional
ability among older adults undergoing hip
surgery have fear of falling?
• Wilcoxon Signed Ranks Test
Is there any correlation between fear of falling and
functional ability in older adults undergoing hip surgery?
• Spearman rank correlation coefficient
Analysis for Research Question
41. Spearman rank correlation coefficient
The interpretation of the correlation
coefficient was presented as follows
(Munro, 2005):
.90 - 1.00 = very high correlation
.70 - .89 = high correlation
.59 - .69 = moderate correlation
.29 - .49 = low correlation
.00 - .25 = little if any correlation
42. RESULTS
Part I
The demographic characteristics of participants
Part II
The health information of participants
Part III
The research questions.
43. Table 4.1 Demographic Characteristics of
Participants. (N=33)
Variables Frequency Percentage
Gender
Female 22 66.7
Male 11 33.3
Age (Years) (Rang = 61-91 years,; Mean = 74.9,; SD.= 8.1 )
60 - 74 14 42.4
75 - 84 16 48.5
≥ 85 3 9.1
Marital status
Widowed 17 51.5
Married 12 36.3
Single 2 6.1
Divorce or Separate 2 6.1
44. Variables Frequency Percentage
Religion
Buddhist 33 100.0
Educations
No formal education 4 12.1
Primary school 13 39.4
Secondary school 5 15.2
Junior or High school diploma 8 24.2
Bachelor degree 3 9.1
Income Per Month
sufficient 28 84.8
insufficient 5 15.2
45. Variables Frequency Percentage
Source of Income
Children/spouse 17 51.5
Pension 7 21.1
Owner business 5 15.2
Personal saving 2 6.1
Other …(welfare of elderly) 2 6.1
Payment Method for Treatment
Government welfare 20 60.6
Universal coverage scheme 8 24.2
Social security scheme 3 9.1
Cash 2 6.1
46. Table 4.2 Health Information of Participants
(N=33)
Variables Frequency Percentage
Body mass index (kgs/m2)
(Rang = 15.57-33.30 kgs/m2,; Mean = 22.45 kgs/m2,; SD.= 5.24 kgs/m2)
< 18.5 5 15.3
18.5-22.9 11 33.3
23-24.9 8 24.2
25-29.9 8 24.2
≥ 30 1 3.0
48. Variables Frequency Percentage
Co-morbidities
Bone & Joint problem 7 21.2
Respiratory problem 3 9.1
Anemia 2 6.1
Endocrine Hormone dysfunctions 2 6.1
Urinary problem 2 6.1
Cerebrovascular accident 1 3.0
Cancer 1 3.0
Cause of Hip Fracture
Falls during ADL 18 54.5
Accident/Trauma 15 45.5
History of falls
None 23 69.7
1 times a year 6 18.2
2 times a year 1 3.0
3 times a year 2 6.1
> 3 times a year 1 3.0
49. Variables Frequency Percentage
Visual impairment
No 10 30.3
Yes 23 69.7
Cataract 10 30.3
Blur and Myopia/Hyperopia 9 27.3
Glaucoma 4 12.1
History of Medication Use
Cardiovascular & Hypertensive drugs 23 69.7
Dyslipidemia drugs 14 42.4
Bone & relief pain for bone and joint drugs 11 33.3
Diabetic drugs 9 27.3
Gastrointestinal drugs 9 27.3
50. Variables(Cont.) Frequency Percentage
History of Medication Use
Vitamin 6 18.2
Anemia 5 15.2
Diuretic drugs 3 9.1
Sedative drugs 3 9.1
Anti-histamine 1 3.0
History of Alcohol Drinking
Never 29 87.8
Used to drink 2 6.1
Current Drinks 2 6.1
History of Smoking
Never 28 84.8
Used to smoke 2 6.1
Current Smokes 3 9.1
51. Variables Frequency Percentage
Functional Ability before Admission
Total self-care independent 33 100.0
Living Status before Admitted
Living with spouse 21 63.7
Living with spouse and children 11 33.3
Living with cousin 1 3.0
Pre-Operative Laboratory Values
Hemoglobin (g/dl) (N=33) (Rang = 8.10-17.40 g/dl,; Mean = 11.50 g/dl,; SD.= 2.03 g/dl)
< 10 g/dl 8 24.2
≥ 10 g/dl 25 75.8
Hematocrit (%) (N=33) (Rang = 24.90-49.30 %,; Mean = 34.86 %,; SD.= 5.54 %)
< 30 % 6 18.2
≥ 30 % 27 81.8
Albumin (g/dl) (N=25) (Rang = 2.62-4.50 g/dl,; Mean = 3.63 g/dl,; SD.= .49 g/dl)
< 3.5 g/dl 9 36.0
≥ 3.5 g/dl 16 64.0
52. Variables Frequency Percentage
Type of Hip Fracture
Neck of femur 20 61.6
Intertrochateric 12 36.4
Subtrochanteric 1 3.0
Type of Operations
Hip arthroplasty 16 48.5
Hemiarthroplasty 14 87.5
Total hip arthroplasty 2 12.5
Internal fixation 17 51.5
Proximal femoral nail
antirotation (PFNA)
11 64.7
Plate and screws 6 35.3
53. Variables Frequency Percentage
Post-Operative Pain Management
None 4 12.1
Yes 29 87.9
Received continuous in 24 hr. in Day 1st 29 87.9
Received prn. for pain after 24 hr. in Day 1st 29 87.9
Received prn. for pain in Day 1st to Day 3rd 19 57.6
Other 2 6.1
Type of Walking Aids when Discharge
Walker 27 81.8
Wheel chair 6 18.2
Rehabilitation after Discharge
Weight as tolerate 15 45.5
Partial weight bearing 11 33.3
Non-weight bearing 7 21.2
54. Variables Frequency Percentage
Living Status after Discharge
Same before admission 33 100.0
Complications in hospital
No 24 72.7
Yes 9 27.3
Anemia 3 9.1
Hyperglycemia 2 6.1
Flatulence 1 3.0
Electrolyte imbalance 1 3.0
Pulmonary embolism 1 3.0
Urinary tract infection 1 3.0
56. Table 4.3 Mean and Standard Deviation of
Study Variables among Participants (N=33)
Variables
Possible
Scores
Actual
Scores
Before
Rehabilitation
(Mean ± SD.)
At 6-Week
Follow-Up
(Mean ± SD.)
FOF 10-100 10-100 39.59 ± 27.14 16.12 ± 12.29
FA 0-18 10-18 18.00 ± 0.00 17.09 ± 1.79
57. Table 4.4 Wilcoxon Signed Ranks Test for
Functional Ability in Older Adults
undergoing Hip Surgery (N=33)
Functional ability (FA)
Mean
Rank
Sum of
Ranks
Z p
At 6-week follow-up
Before admission
Negative Rank
Positive Rank
Ties
10a
0b
23c
5.50
0.00
55.00
0.00
-2.831 .005*
Note: FA = Functional Ability, *p < .01
(a) FA at 6-week follow-up < FA before admission
(b) FA at 6-week follow-up > FA before admission
(c) FA at 6-week follow-up = FA before admission
58. Table 4.5 Wilcoxon Signed Ranks Test for
Fear of Falling in Older Adults
undergoing Hip Surgery (N=33)
Fear of falling (FOF)
Mean
Rank
Sum of
Ranks
Z p
At 6-week follow-up
Before rehabilitation
Negative Rank
Positive Rank
Ties
24a
2b
7c
14.46
2.00
347.00
4.00
-4.356 .000*
Note: FOF = Fear of falling, *p < .01
(a) FOF at 6-week follow-up < FOF before rehabilitation
(b) FOF at 6-week follow-up > FOF before rehabilitation
(c) FOF at 6-week follow-up = FOF before rehabilitation
59. Table 4.6 Correlation Matrix among
Study Variables. (N=33)
Variables 1 2 3
1. FOF before rehabilitation 1.00
2. FOF at 6-week follow-up .41* 1.00
3. FA at 6-week follow-up -.37* -.63** 1.00
Note: FOF = Fear of falling, FA = Functional ability,
*p < .05; **p < .01
60. Study limitations
1. The purposive sampling was used to
select the participants in this study. Therefore,
the results of the study could not represent all
older adults undergoing hip surgery.
61. 2. This study collected the data in 4 tertiary
hospitals in Bangkok. Although these hospitals
had doctors specialized in orthopedics, nursing
practices, surgery, and treatment in a similar
way, the data collection revealed that there had
been some different protocols, such as surgery
consideration, starting rehabilitation by walking
practice, and discharge consideration.
Study limitations
62. The participants in some hospitals had not
been followed up after being discharged from
the hospital due to their inconvenience in seeing
the doctor as per the appointment. Therefore,
the researcher collected the data after
undergoing hip surgery for 6-week follow-up
over the phone, possibly affecting the
assessment on actual ability of the patients.
Study limitations
64. Recommendations
for nursing practices
The multidisciplinary team approach,
relatives and nurses in charge of home visits
should also involve in patient care during the
hospitalization and after the discharge,
especially during 6-week rehabilitation period
when the patients required the walking aid, in
order to promote confidence in walking and
reduce fear of falling.
65. Recommendations
for nursing education
Assess risk factors of falling and mitigate
such risk factors to prevent falling, but also
assess psychological factors, especially fear of
falling, in order to cover all dimensions of
health promotion for older adults.
66. Recommendations
for next studies
Next studies should involve factors relating
to fear of falling and factors contributing to
functional ability after undergoing hip surgery in
order to acquire specific factors to develop a
program for purpose of reducing fear of falling
and increasing functional ability in older adults
after undergoing hip surgery.
67. • correlation between fear of falling and long-term
functional ability, such as 3 months, 6 months, and 1
year after undergoing surgery, in order to follow up
their rehabilitation.
• Compare between fear of falling and rehabilitation,
or activities of older adults with hip fractures in
order to ensure more extensive study, and acquire
fundamental information on specific health
promotion for patients of different treatments.
Recommendations
for next studies
