Residents Living with Dementia sometimes Fracture their Shoulder; Here’s How to Treat the Fracture while still Providing Quality Dementia Care

It’s not the ideal scenario, but I’ve certainly seen it. And it’s tough.

As OTs, we certainly learn how to treat shoulder fractures and injuries, but never how to treat them within the context of a neurocognitive diagnosis.

I find it helps to look at fracture healing in phases.

I’m not assigning a specific timeline to these phases because that’s going to look specific to each individual and be largely dependent upon the orders and information you receive from the orthopedic doctor. Instead, look at these as guidelines as a means to help guide how you prioritize and plan treatments.

Phase 1: Manage Pain and Fit for New Equipment

Pain management is crucial for a strong recovery plan. Keep an ice pack schedule. Check in with nursing to ensure the Resident is medicated before care and before each therapy session. Keeping pillows up around the shoulder and under the arm while in bed or resting in a chair will help support the extremity better.

Every routine task will be different post fracture. Emotions are going to be high, so play their favorite music, have a stuffed animal or comfort item close by, and provide reassuring and comforting comments throughout all levels of mobility and care.

Equipment will need to be re-assessed. If the Resident used a wheelchair prior to the fracture, assess the height and length of the arm rest to ensure that the extremity can be appropriately positioned and supported in the chair. If the Resident used a rolling walker or Rollator, that device will need to be discontinued until the orthopedic doctor clears the Resident for range of motion and weight bearing. Because canes require a higher level of balance compared to a walker, this is probably not going to be the best option. Instead, opt for a hemi-walker. If the Resident can’t safely learn to use a hemi walker, then hand-hold assist from a staff member may be the best option during healing.

Phase 2: Trial Weight Bearing and Range of Motion with Assistance in a Gravity Eliminated or Minimized Plane

Once the orthopedic doctor has cleared for weight bearing and/or range of motion (at any level), we need to get that arm moving. The longer we wait, the harder recovery will be and the more difficult it becomes to regain full range of motion, strength, and function (in my experience).

I’ll often advocate to the doctors via an email or written note the Resident’s level of dementia/overall cognitive status in hopes that these will be considered when determining weight-bearing status. And I’ve actually seen quite a few Residents return from initial hospitalization for the fracture with a ‘weight-bearing as tolerated’ order just because it’s evident that the individual’s cognition will make any other level of weight bearing difficult to follow/maintain.

Traditionally, we’d have an individual start range of motion and strength in a gravity eliminated or minimized plane using exercises across a tabletop while seated or along the plinth mat while supine or side lying. Often for Residents living with dementia, these exercises don’t always make sense. So the ability to engage to full tolerance is limited.

What I like to do instead is try to engage the Resident in a preferred gross motor activity or group, and I’ll hold the extremity to assist with range of motion and decrease the amount of effect gravity has. This might happen during an exercise class, a music or dance group, or could even look like basic stretches while the Resident is watching television.

Phase 3: Begin to Reintegrate the Extremity into Tasks, Following the Resident’s Cues

Again, we have to wait for the clearance from the orthopedic doctor. Once we have that, we’re going to try for as much mobility and motion as possible.

Practically, that often looks like providing less assistance during dressing tasks. Placing a toothbrush or utensil in the hand of the affected extremity and cueing the Resident to eat or brush their teeth. Trying different dances, games, ball tosses, or other activities that promote shoulder range of motion. Adding a weighted cuff to the wrist while performing a preferred task. Reintroducing a previously used walker or Rollator with bilateral hand-hold.

I’ve worked with dozens of Residents in the moderate stages who have forgotten that the fracture was ever present 1-2 weeks after the instance of the fracture. So as long as pain is managed and everything is within doctor’s orders, I let the Resident use the extremity as much as they want/can.

Phase 4: Determine New Baseline

The reality is, these Residents will absolutely benefit from ongoing therapy intervention. And I truly believe that if they were allotted the time, they could regain a lot of ground with months and months of therapy. But in these long-term care settings, it’s just not possible to keep a Resident on program for the time that would be needed. Advocate for services as much as possible. But once you see those “ongoing plateaus”, you need to determine the new recommended baseline and communicate that effectively to all necessary staff. This includes the best assistive devices to use, the amount and type of cues needed to complete daily tasks, current safety levels, and the structured routines that best support the Resident.

It’s important to know that if the Resident underwent anesthesia for a surgical repair of the fracture, data shows that anesthesia can progress dementia symptoms. So you may notice a new change in cognition and that change may or may not resolve with time.

In the end, a lot of Residents have really surprised me. They’ve shown great recovery and actually do return to an ambulatory status by the end of care. Often they receive initial services under a skilled Medicare Part A stay for a month or two, then continue with services for one to two more months under their secondary payer source.

Give them the chance. Advocate for the skilled intervention. And be encouraged by the results as much as you can.