Dementia and Joint Replacement

Andy Easton

Hi there, 

My mom is in the middle (probably more late-middle stage) of dementia.  

She has a hip replacement on 10/1.  She's in agony from it (it's arthritic) and it has severely limited her movement.  I'm also pretty sure it's contributed to some of her confusion and agitation (her sundowning episodes can be pretty bad at times). 

While I am looking forward to her being pain-free, I am also very aware of the potential risks of this type of surgery for someone in her condition.  With that said, there's no hesitation of going through with the surgery because her pain level is fairly unbearable most of the time. 

Anyway, I was wondering if others on here have gone through the same things and what to be aware of on the other side. 

For instance, standard procedure is to keep a patient overnight and then discharge based on observation.  I've told the ortho surgeon multiple times that a next-day discharge will not be possible given her cognitive deficiencies and that neither my father (her primary caregiver) nor myself will be able to rehab her appropriately.  

Any advice on ANY aspect of something like this would be greatly appreciated.  

Thanks much in advance!

Andy

DrinaJGB

All I can contribute is in 2017 my DH with dementia fell and broke his femur high up near the hip joint which required emergency surgery with a nail repair. He spent a few days in inpatient hospital and was transferred to rehab facility.

He was vastly confused and disoriented; could not get up to use bathroom or use call button,etc. I found him each morning sitting in his own urine/waste. I tried to explain to staff that not only did he have a hip/femur repair, but he was cognitvely impaired. He stayed there for a few days before I finally discharge him home because I feared another wound on his backside was beginning to form.

I brought him home and had PT/OT come to the house several times a week. He advanced quickly and on the first follow-up surgical appointment was walking with a cane. The surgeon said at that point in time most of his post-surgical patients come in a wheelchair, and he was very pleased.

  The cognition took a very long time to recover, however.

His neurologist told me that any surgery/anesthesia will set a dementia patient back months or years---which is exactly what we experienced.

M1

Andy, I would ask the surgeon whether s/he is going to do an anterior or posterior approach:  posterior is more standard, but it also carries risk of displacing the prosthesis, and your mother would have to follow "hip precautions" for six to eight weeks, regarding not getting up too quickly, not bending over too far.  These can be hard to remember for someone with dementia.  You might also ask about transfer to a rehab/skilled nursing facility rather than going straight home--would carry some covid risk, obviously, but might provide more help than your or your dad can provide.  I would also ask about the potential for the surgery to be cancelled--no one is doing "elective" surgeries in our area right now.  

Good luck.  Hopefully it will relieve her pain.

harshedbuzz

Andy Easton wrote:

Anyway, I was wondering if others on here have gone through the same things and what to be aware of on the other side. 

We went through joint replacement with 2 of my aunts.

Aunt N broke a hip and wrist in a fall while living in AL. I would put her solidly in earlyish mid-stages. The outcome was not a good one. The anesthesia seemed to have worsened her cognition and ability to participate in her ADLs; it was as if she went from stage 4 to stage 6+ in the days around her surgery. She could not remember she'd had surgery or her aftercare rules and required 24/7 sitters to prompt her to use her walker, not bend and move slowly. She was discharged early from PT because she could/would not comply with instructions and ended up being transferred to SN and died within 2 months.

Auntie C had knee replacement surgery in the midstages. While not the same thing, many of the risks are similar. Auntie's surgery was done under spinal anesthesia and she did really well until she had a stroke in recovery. She never walked again and of course could not really participate in the rehab of the new knee, but it did dramatically lessen the pain and swelling she had. She didn't seem to regress with the surgery or the hospitalization and lived another 8 years. I will say that her guardian has never gotten over the guilt of insisting on TKR and having her sister spend her final years using a wheelchair.

For instance, standard procedure is to keep a patient overnight and then discharge based on observation.  I've told the ortho surgeon multiple times that a next-day discharge will not be possible given her cognitive deficiencies and that neither my father (her primary caregiver) nor myself will be able to rehab her appropriately.  

You need a plan. It doesn't matter what you tell the surgeon about your ability to look after mom, the insurance company makes the call about how long she'll be hospitalized. I had my knee done 2 years ago outpatient- I totally get your concerns. My surgeon does self-directed rehab which was fine for me as I did a lot trying to avoid surgery and was familiar with the exercises and very motivated. 

I also wonder what you mean about your dad rehabbing her. Perhaps she could go to a rehab for a period of time if that is safe where you live. IME, exercises for joint replacement are done multiple times a day and unless she's in a rehab, it's unlikely she'd get supervision from a professional in your home. My mom had a PT post-op for a couple on weeks. He came 3 times a week and she was expected to work on her own several times a day even if he wasn't scheduled. We had a PT visit dad (PWD) for general decline in conditioning and there was no motivating him if the PT wasn't there. He was discharged from care quickly as a result. 

Any advice on ANY aspect of something like this would be greatly appreciated. 

Is there another option for pain control? Have you consulted with a pain specialist or tried injections if they would be appropriate? 

Thanks much in advance!

Andy

fav-dil

My MIL had shoulder replacement surgery a year ago while in mid stage of dementia. Even though the Ortho knew she had dementia, my husband and I were completely blindsided and unprepared for what we had ahead of us from the immediate days after the surgery and the months of 'rehab' that were next to impossible for someone with dementia to follow or cooperate with.  

Things to plan for:

• Discuss anesthesia options with her surgeon ahead of time. We did not even know that there were options or the degree that anesthesia affects dementia.
• Someone will likely need to be with her at the hospital at all times. After surgery, my MIL's delusions were so severe the hospital called us to get someone in to stay with her at all times. We had not planned for this.
• The dementia will likely worsen after surgery. It was months before my MIL settled down again. 
• Do not plan on your mom being responsible for her own rehab. If you can get her discharged to a rehab facility, even for a few days, plan ahead for it. This was an option we did not know she had with medicare.  If possible, get someone to come into the home for physical therapy. My MIL was discharged to us the day after surgery. She was not ready and she was not cooperative in doing her exercises  at home, she constantly took off the sling that was supposed to be on 24/7 and refused to go to physical therapy appointments. It was a constant battle. Needless to say, her shoulder is not in great shape but the pain did subside and she can use her arm, so we are calling it a win!

I'm hoping for the best possible outcome for your mom, you, and your dad.