Progress of systematic psychological interventions in elderly patients with femoral fractures: A comprehensive review

Abstract

This review aims to gain a deeper understanding of the psychological state of elderly patients with femoral fractures and provide more theoretical and practical support for clinical treatment and care. Through a literature analysis, we found that elderly patients with femoral fractures face various psychological issues such as anxiety, depression, sleep disorders, and social isolation. The application of systematic nursing interventions in clinical practice, including cognitive-behavioral therapy, mindfulness therapy, family therapy, art therapy, interpersonal therapy, emotion-focused therapy, and relaxation training, has yielded significant results. Systematic psychological interventions can improve the psychological state and quality of life of elderly patients with femoral fractures. Therefore, promoting the application and practice of systematic psychological interventions in the clinical care of elderly patients with fractures will provide more effective psychological services to a wider group of patients with fractures in the future.

Key Words: Elderly femoral fracture; Psychological issues; Systematic psychological intervention; Anxiety and depression

Core Tip: This review highlights the psychological challenges faced by elderly patients with femoral fractures, including anxiety, depression, and social isolation. Systematic interventions like cognitive-behavioral therapy, mindfulness, and relaxation training have shown significant benefits. Promoting these therapies in clinical care can improve patients' mental health and quality of life, offering more effective psychological services to a broader population.

INTRODUCTION

With the changing population structure, the proportion of elderly individuals is continuously increasing, and femoral fractures have become a leading cause of hospitalization among elderly patients. Elderly patients with femoral fractures not only endure the pain and mobility limitations caused by the fracture but also face significant psychological distress. In recent years, research on the psychological issues of elderly patients with fractures has increased. This review focuses on the classification and manifestation of psychological problems among elderly patients with femoral fractures, the systematic and tailored psychological interventions, and their impact on these patients, with the aim of providing a reference for further research in this field.

Femoral fractures can be categorized into proximal femoral, femoral shaft, and distal femoral fractures based on the location of the injury. In elderly patients, femoral fractures most commonly occur in the femoral neck and intertrochanteric region, with femoral neck fractures having the highest incidence, accounting for approximately 50% of all proximal fractures[1]. The main causes of femoral fractures in the elderly include osteoporosis, falls, and external forces. Osteoporosis is a major risk factor for femoral fractures in the elderly, with approximately 80% of proximal femoral fractures being related to osteoporosis, accounting for 4%-6% of distal femoral fractures. Proximal femoral fractures are among the primary reasons for hospitalization in elderly patients and have become an increasingly serious socioeconomic issue. Careful management of perioperative treatment and care in elderly patients is crucial for reducing complications and mortality rates[2-5]. Systematic psychological intervention refers to a series of planned, organized, and targeted psychological intervention measures guided by psychological theories, aimed at improving the psychological state of elderly patients and enhancing their quality of life. Its importance lies in helping elderly patients cope better with the psychological stress caused by the disease, thereby enhancing their self-management abilities and accelerating the recovery process[6-8].

This study employed a retrieval method for the literature search, accessing databases such as the CNKI, WanFang Data, Web of Science, and PubMed. Keywords such as "elderly femur", "psychology", "care", "systematic", and "mindfulness therapy" were used for identifying relevant articles. References related to this review were selected based on the accuracy and reliability of the information. The snowball method was used to expand the scope of the search and obtain more relevant information. Finally, 60 references were included in the review after reviewing the shortlisted literature.

PSYCHOLOGICAL ISSUES IN ELDERLY PATIENTS WITH FEMORAL FRACTURES

Anxiety

Psychological issues in elderly patients with femoral fractures are triggered by various physiological, psychological, and social factors[9,10]. The sudden occurrence of a fracture, along with associated pain, limited mobility, and traumatic procedures, can lead to a series of psychological problems in these patients. Elderly patients with femoral fractures often experience fear and anxiety. In modern society, due to factors such as the rapid pace of life and complex social relationships, the incidence of anxiety is on the rise. Anxiety is closely related to social, physiological, and psychological factors, as well as traumatic experiences. Anxiety in elderly patients with fractures can significantly affect their recovery by hindering physical function restoration, reducing patient compliance, and increasing the likelihood of complications. Some researchers have found that patients fear the severity of their condition and the pain associated with the disease, and worry about a complete recovery[11,12]. During this period, patients may experience intense anxiety characterized by emotional instability; prolonged recovery time and high costs can lead to irritability and reduced psychological resilience. Wu et al[13] in their exploration of the impact of anxiety on postoperative outcomes in elderly patients with femoral fractures discovered that the incidence of postoperative anxiety in elderly patients with intertrochanteric fractures was high, reaching 43.18%. Additionally, postoperative anxiety prolongs hospital stays, delays mobilization, and exacerbates postoperative pain, highlighting the importance of addressing anxiety in elderly patients. In an observational study oversees, 188 elderly patients diagnosed with intertrochanteric femoral fractures were selected for evaluation[14]. The study aimed to analyze the relationship between psychological factors and postoperative prognosis in elderly patients. By accessing data such as the geriatric depression scale and state-trait anxiety inventory scores on the day of surgery, the study sought to predict the outcomes of elderly patients 90 days post-surgery. The researchers found that higher levels of anxiety on the day of surgery were associated with poor outcomes 90 days after surgery. These findings suggest that patients experienced anxiety after sustaining a fracture. Furthermore, Wu et al[13] found that anxiety can exacerbate a patient’s condition and prolong recovery.

Depression

Elderly patients with femoral fractures are also more prone to depression. Long-term bed rest, restricted activity, and multiple cooccurring chronic diseases can contribute to depressive tendencies. Depression not only affects patients’ mental health but also negatively affects treatment outcomes and recovery progress[15-17].

The development of depressive symptoms is closely related to patients’ social environment and physiological and psychological states. Patients with depression are prone to endocrine imbalances and weakened immune function, which—in severe cases-can lead to wound infections that affect fracture recovery post-surgery. Patients with depression often struggle to follow regular treatment regimens and exhibit poor compliance, further complicating the recovery process and prolonging both hospitalization and rehabilitation time after surgery. In Davison’s study[18], follow-up was conducted on patients after ankle fractures and Achilles tendon rupture surgeries. Using the patient health questionnaire (PHQ-9) at 1, 2, 4, 8, 16, 24, 32, 40, and 52 weeks postoperatively, he found that depressive symptoms peaked at one week post-surgery and reached their lowest levels at 52 weeks. The cumulative incidence of mild, moderate, and severe depression was 51.7%, 22.4%, and 6.9 %, respectively. Through detailed follow-up, the study highlighted the specific time periods when depressive symptoms occurred in patients with fractures post-surgery. This finding fills a gap in understanding postoperative depressive states in patients with fractures and has significant implications for their clinical treatment and care. Yi et al[19] and Charles-Lozoya et al[20] suggested that post-fracture patients may feel pessimistic and depressed because of pain, limited activity, and uncertainty regarding the future. They may hold negative attitudes toward their condition, believing that recovery is hopeless or difficult to achieve. This pessimism can lead to a loss of confidence in the treatment and desire to abandon it. Heidari et al[21] noted that elderly patients may require long-term treatment and rehabilitation, which can cause physical pain and mental stress, further exacerbating depressive emotions.

Sleep disturbances

Sleep disturbances are common in elderly patients with femoral fractures. Sleep disorders refer to difficulties in falling asleep, and according to relevant data, over 300 million people in China experienced sleep disorders in 2021, with the incidence of insomnia among adults reaching 38.2%. The factors influencing sleep disorders are complex and varied, comprising lifestyle habits, negative emotions, environmental factors, health conditions, and medications. Patients with fractures often experience severe pain and discomfort, which can render it difficult for them to fall asleep or lead to a decline in sleep quality[22,23]. This, in turn, severely affects the patient’s recovery process. Beetz et al[24] found that long-term sleep disturbances affect not only patients’ mental state and emotional stability but also their physiological functions and recovery progress. Additionally, sleep disturbances can worsen anxiety and depression, creating a vicious cycle. Ali et al[25]. revealed that among 216 patients with fractures, approximately 24.8% reported insomnia, and 23.1% reported sleep movement disorders. The report indicated no significant correlation between fracture type and sleep disorders. Additionally, 6.6% of the patients experienced clinically significant depressive symptoms, while 45.2% reported mild emotional disturbances. The findings of this research confirm that sleep disorders can occur in patients with fractures, while also demonstrating that the type of fracture had no correlation with the prevalence of sleep disorders. Cha et al[26] in a study on elderly patients with hip fracture, found a decline in overall sleep quality three months post-fracture. This study emphasized the need to improve patients’ quality of life through clinical management.

Social isolation

With the rapid development of modern society and an increasingly aging population, the issue of social isolation has become increasingly prominent, emerging as an important factor affecting people’s physical and mental health. This issue is particularly prevalent among the elderly population, influenced by various factors, including gender, age, health status, marital status, social support, living arrangements, economic conditions, educational level, and sociocultural factors. It can exacerbate feelings of loneliness and helplessness in patients, leading to additional psychological problems. Furthermore, the lack of social support can cause patients to resist rehabilitation exercises and treatments, resulting in a lack of motivation for self-recovery. During treatment, elderly patients with femoral fractures often require prolonged bed rest or restricted activity, preventing them from participating in social and daily activities typical of healthy individuals. Long periods of isolation and a lack of social support can lead to feelings of loneliness and helplessness, contributing to negative emotions. The impact of fractures on patients’ work and daily lives can cause economic stress and strain on family relationships, further exacerbating feelings of loneliness and helplessness[27-30]. Additionally, Kim et al[31] found that elderly patients may face various problems and challenges during treatment and rehabilitation, such as pain management, infection prevention, and rehabilitation training. These issues can cause doubts and concerns regarding treatment effectiveness and recovery progress. Patients may also question their trust in doctors and treatment plans, which affects their enthusiasm for treatment and cooperation.

SYSTEMATIC PSYCHOLOGICAL INTERVENTIONS AND THEIR APPLICATION

Various psychological interventions have been adopted in clinical practice to address the psychological issues in elderly patients with femoral fractures. Systematic psychological intervention methods aim to help patients develop a positive mindset, improve treatment adherence, and thereby accelerate recovery[32]. Systematic psychological interventions begin with a psychological assessment, evaluating the psychological state and emotional changes of elderly patients to provide a basis for developing detailed intervention plans[33]. Commonly used psychological assessment tools include rating scales such as the self-rating anxiety scale (SAS) and self-rating depression scale (SDS), intelligence tests, behavioral observations, clinical interviews, and psychological questionnaires. After psychological assessment, appropriate psychological intervention measures are applied. Common psychological therapy methods used in clinical practice include cognitive behavioral therapy (CBT), mindfulness therapy, family therapy, art therapy, interpersonal therapy, emotion-focused therapy, and relaxation training[34,35].

CBT is a psychological treatment method that combines cognitive and behavioral therapies. This emphasizes the fact that individuals' emotional and behavioral issues stem primarily from their cognitive processes and belief systems regarding events. The goal is to help patients identify and change maladaptive thought patterns, thereby establishing more positive and healthier modes of thinking and behavior[36]. This therapy posits that a person’s emotions and behaviors are not directly determined by external events but are influenced by the individual’s interpretation and evaluation of those events (i.e., cognition). Therefore, by identifying and correcting irrational cognition, effective adjustments to emotions and behaviors can be achieved. CBT is currently the first-line psychological therapy for patients with pain, focusing on the interplay between their cognition, emotions, physical sensations, and behaviors to understand and address their existing difficulties. It helps patients learn new skills and strategies to cope with chronic pain and alter maladaptive cognitive and behavioral responses to chronic pain[37]. CBT primarily targets psychological issues such as depression and anxiety, as well as problems arising from irrational cognition. Nowakowski et al[38] found that CBT effectively reduced postoperative pain complications in patients with limb fractures. The report also indicated that anxiety, depression, coping ability, and pessimistic emotions such as complaints, are risk factors for postoperative pain development. Scheffers-Barnhoorn et al[39] conducted a prospective study involving CBT intervention for 36 elderly patients after hip fracture surgery. The results showed that the patients had excellent compliance and provided positive evaluations of the psychotherapy. However, according to current research, there are limited data on the application of systematic psychological interventions specifically for femoral fractures, resulting in existing gaps in the application of this method.

Mindfulness therapy-which encompasses mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy has been a trending research topic in psychological treatment over the past decade[40,41]. This therapy emphasizes cultivating a nonjudgmental and nonreactive attitude by consciously and neutrally observing everything in the present moment, including physical sensations, emotions, thoughts, and the surrounding environment. This approach aims to alleviate suffering, improve mental health, and enhance the quality of life. The core concept of mindfulness therapy is awareness, which involves maintaining a focused and open state regarding current feelings, emotions, and thoughts without making judgments, reacting to, or avoiding them. The goal is to enhance individuals’ awareness, allowing them to recognize their feelings, emotions, and thoughts more clearly, thereby managing them more effectively[40,41]. Mindfulness therapy has been shown to effectively reduce anxiety and depression levels[42]. Additionally, it is widely used in the treatment and alleviation of various emotional and psychological issues, such as anxiety and depression, and has demonstrated significant effects in treating personality, addiction, and eating disorders[43]. Wang[44] applied mindfulness therapy to treat elderly patients after hip fracture fixation surgery, and the results showed that this method effectively reduced postoperative pain, shortened the time of catheter removal, and decreased the use of analgesics 24 hours postoperatively. Tan and Gao[45] used mindfulness therapy to treat patients with spinal fractures and found that MBSR reduced psychological stress responses. The study group showed improvements in depression, anxiety, fear, paranoia, and obsessive-compulsive symptoms, thus enhancing their psychological health.

Family therapy is a psychological treatment method aimed at an entire family. Unlike individual psychotherapy, it focuses on the interactions and relationships among family members rather than the individual’s internal psychological structure. Family therapy aims to assist families in eliminating abnormal or pathological situations by improving communication, emotional expression, role allocation, and other familial aspects, thereby facilitating healthy family functioning. This method is particularly suitable for patients experiencing psychological issues owing to conflict or disharmony within their families. The application of family therapy begins with an assessment of the overall family situation, including the family structure, organization, communication, emotional expression, role-playing, alliance relationships, and family identity. Based on the assessment results, a personalized treatment plan is formulated, outlining the treatment goals and specific methods. Methods implemented in family therapy include family meetings, role-playing, and behavioral training, which help family members improve their relationships, enhance understanding, and resolve conflicts. Finally, the effectiveness of the treatment is regularly evaluated, and the treatment plan is adjusted based on progress and feedback from family members[46]. In a study by Cai et al[47], 103 patients with depression were selected for a controlled trial. The observation group received mentalization-based family therapy, whereas the control group received the conventional intervention. After three months of treatment, the observation group showed improvements in self-efficacy scores, depression scores, and suicidal ideation, significantly outperforming the control group. This study indicates that mentalization-based family therapy can enhance the self-efficacy of patients with depression, reduce the severity of depression, lower suicidal ideation, and improve their coping strategies, thereby enhancing family functioning (See Table 1 for detailed descriptions and applications of family therapy, art therapy, interpersonal therapy, emotion-focused therapy, and relaxation training)[48-53].

Table 1 Common psychological treatment methods for femoral fractures.

Treatment methods	Definitions and applications
Family therapy	A type of psychotherapy that focuses on the entire family rather than individual members. Unlike individual psychotherapy, it emphasizes the interactions and relationships among family members rather than the internal psychological structure of an individual. The aim of family therapy is to assist the family in eliminating abnormal or pathological conditions by improving internal communication, emotional expression, and role distribution, thereby achieving healthy family functioning[46,47]
Art therapy	A psychotherapy method that involves expressing oneself through art forms such as painting, music, dance, and drama, allowing individuals to freely associate during creation and experience, thus reaching deep-seated, inexpressible experiences. This non-verbal approach helps patients open internal channels, reduce psychological defenses, release emotions, and promote self-awareness and growth[48]. This method is suitable for patients with cognitive impairments, anxiety, depression, autism, or schizophrenia
Interpersonal therapy (IPT)	A psychotherapy method that focuses on interpersonal relationship problems. It helps patients develop new relational patterns and promote social functioning. IPT has been proven effective for various psychological disorders such as depression and is widely applied globally[49,50]. This method is primarily used for individuals with mild to moderate depression, as well as those with anxiety, personality disorders, and patients recovering from schizophrenia
Emotion-focused therapy (EFT)	A psychotherapy method that emphasizes enhancing emotional focus during treatment. It helps individuals become aware of, accept, and understand their emotional experiences. Based on the idea that emotions are fundamental to self-construction and key to self-organization, EFT aims to improve emotional awareness, regulation, and transformation to achieve effective treatment outcomes[51,52]. This method is mainly applicable to patients experiencing emotional issues such as anxiety, depression, and anger management
Relaxation training therapy	An effective psychotherapy technique that trains individuals to consciously control psychological and physiological activities to reduce arousal levels and improve disordered functions. This therapy includes methods such as breathing relaxation, muscle relaxation, and imagery relaxation, aiming to help individuals achieve a state of physical and mental relaxation[53]. This method is primarily used for patients with anxiety disorders, individuals with autism, and elderly patients under significant psychological stress

With the acceleration of societal aging, the number of elderly patients is increasing annually and mental health issues are becoming more prominent. Compared with younger individuals, elderly patients with femoral fractures often experience anxiety and depression due to aging, physical decline, and pain, significantly affecting their quality of life and recovery from illness[54]. Therefore, the application of systematic psychological interventions for elderly patients with femoral fractures is receiving increasing attention. Systematic psychological intervention refers to a series of planned, organized, and targeted psychological measures guided by psychological theories to improve the mental state and quality of life of elderly patients, enabling them to cope more effectively with their conditions and thereby accelerate their recovery[55].

Ai and Cheng[56] applied a perioperative systematic psychological intervention combined with medication in elderly patients with hip fractures, and the results showed that the postoperative visual analogue scale (VAS), SAS, and SDS scores of all patients were lower than their preoperative scores. The patients’ psychological state, pain status, and daily living abilities showed significant improvements. Qin et al[57] found that early systematic psychological intervention can improve postoperative anxiety and depression, reduce stress response levels, and accelerate postoperative recovery in elderly patients with lower limb fractures. Li and Wang[58] used systematic psychological intervention methods on patients with peptic ulcers accompanied by anxiety and depression and found that this method not only significantly alleviated negative emotions but also enhanced the clearance rate of Helicobacter pylori and reduced the recurrence rate. In their exploration of the impact of systematic psychological care on patients with fractures, Cai et al[59] concluded that it can shorten surgical time, reduce anxiety and depression, alleviate pain, improve clinical care satisfaction, and lower the incidence of complications. Li et al[60] conducted a randomized controlled study involving 82 elderly patients with femoral neck fractures. After undergoing systematic psychological intervention, the observation group showed improvements in Harris hip and comprehensive quality of life scale-74 scores. Post-intervention, the scores on the SAS, SDS, and VAS decreased, indicating significant effects of psychological care. This study found that systematic psychological intervention methods are widely applied in clinical settings; however, specific quantitative measures are lacking. Many researchers have indicated that this method can help improve patients’ negative emotions and shorten rehabilitation time, but there are limited data from comprehensive and in-depth studies on specific metrics, such as the duration of time shortened.

CONCLUSION

Elderly patients with femoral fractures often experience a range of psychological issues owing to sudden physical pain, limited mobility, and traumatic procedures, which can affect their prognosis. Therefore, careful management of perioperative treatment and care in elderly patients is essential. The sudden occurrence of fractures, prolonged periods of solitude, and a lack of social support may cause patients to feel lonely and helpless, leading to negative emotions. Elderly patients often experience fear and anxiety, and are prone to depression because of prolonged bed rest, restricted mobility, and multiple chronic diseases. Overall sleep quality declines in the first three months following a fracture. The emergence of these issues in elderly patients can severely affect their quality of life and overall well-being. Therefore, implementing systematic nursing intervention methods to address the psychological problems associated with femoral fractures in the elderly holds significant value and importance in clinical practice. Systematic interventions that integrate psychological assessments, psychotherapy, and pharmacotherapy aim to further improve the psychological state and quality of life of elderly patients. Currently, clinical research on the application of systematic nursing for elderly patients with femoral fractures is limited, and the psychological care methods implemented are relatively singular. Additionally, this approach has not been included in standard nursing protocols for elderly patients with femoral fractures. In future, we should continue to strengthen the research and practical exploration of systematic psychological interventions for elderly patients with femoral fractures to provide more comprehensive and effective psychological support and intervention services for this population.