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Herman Erichsen despaired as his wife, Rita, fought for breath following hip fracture surgery.
Herman Erichsen despaired as his wife, Rita, fought for breath following hip fracture surgery. (Bill Greene/ Globe Staff)
AFTER THE FALL

Battling the voice that says 'give up'

Second of three parts

Rita Erichsen looked haggard and blotchy in the fluorescent light of her hospital room at Beth Israel Deaconess Medical Center . The rat's nest of her gray hair told the tale of another night filled with pain, nausea, and sleeplessness. Her breath came hard.

Four days after surgery, many hip fracture patients would be on their way to a nursing home for rehabilitation. But Rita was still in a haze. She fidgeted with the button that controlled her IV pain medicine. She shook her head, waved, and talked softly to someone only she could see. She brought the edge of a towel to her open mouth, as if to take a bite.

Suddenly, she jerked alert. "I don't know if I'm going to make it," she said in a whisper, forcing the words out one at a time.

Herman , her husband of 54 years, kept vigil, slumped in a bedside chair. He leaned in to gently kiss her forehead. He had never seen her so low.

"She's winning the argument with herself," he said, dropping his head into his hands. "She wants out."

Rita's slide into darkness began with a fall that shattered not only her hip, but her spirit.

For her, as for many older hip fracture patients, the mind had become a major obstacle to recovery. Powerful thoughts of impending frailty, dependence, and pain were consuming her and sapping her will to live.

Deep depression like Rita's engulfs one in seven older people with hip fractures, according to a new study by Dr. Eric Lenze , associate professor of psychiatry and rehabilitation at the University of Pittsburgh . It is one of the grave complications that make hip fracture so difficult to recover from -- more deadly after one year than a stroke and disabling to most of those who survive.

"Patients often feel there's no future to look forward to" and that sense of hopelessness can speed their decline, said Dr. Pamela Williams Russo , a senior staffer at the Robert Wood Johnson Foundation who has studied depression in hip fracture patients.

Researchers in England found that depressed patients were 57 percent more likely to die within two years of a hip fracture than patients who had a positive outlook. There was no difference in the rate of death at one year, perhaps because it can take time for depression to build to a deadly level.

Even comparatively mild depression can slow recovery. As many as half of seniors who break a hip suffer some symptoms of depression and are more likely to end up in a nursing home unless their caregivers attack the problem with extensive rehabilitation and lots of encouragement.

"It's really important for family members and clinicians to exhort them that they are going to go back to independent living," said John Allegrante , a professor of health education at Columbia University . "Once you suggest this is not possible, then you have someone giving up."

For Rita, depression was complicated by symptoms of delirium -- a condition that affects as many as 60 percent of older patients hospitalized for hip fracture surgery. This sudden, serious mental confusion can be triggered by infections, pain, and immobility, all common problems after hip surgery. Anesthesia and pain medicines can make it worse. Rita's first symptoms were hallucinations, but some patients instead become withdrawn and extremely sleepy, making delirium difficult to diagnose.

The consequences can be severe. One study found that hip patients with delirium were nearly three times more likely to die in the first six months. For patients who survive, symptoms can last for months, making rehabilitation feel like walking through deep fog.

An earlier illness
The crisis for Rita began long before she broke her hip. Nearly two years ago, an errant driver ran a stop sign not far from the Erichsens' home in Holliston, and smashed into Rita's car. Tests showed a life-threatening aneurysm, or bulge, in the major vessel that feeds blood from the heart to the rest of the body.

Eight hours of surgery led to nearly a month in intensive care on a ventilator. For 13 days, she didn't even recognize Herman. Then, when she came around, she found that her vocal cords were paralyzed. She needed a breathing tube to inhale. She had gone, abruptly, from an active 73-year-old to -- as she put it -- "a little old lady."

Finally, in September 2005, she made it home. She still needed a walker and a speaking valve, but she began to reclaim her routines.

"She was bossy," said Herman, 77. "Feeling like herself."

Bossy enough to try to manage on her own a week later, when Herman was slow to bring her the towel she wanted. Rita made a quick, impatient turn toward the closet. Her walker caught on the carpet's edge, and she went down, breaking a hip weakened by 50 years of smoking and months of inactivity.

And so she would arrive at Beth Israel hospital, petrified at the prospect of another operation. Awaiting surgery, she beckoned to her daughter, Robin , and kissed the silver cross around Robin's neck. It had belonged to Rita's youngest child, Elizabeth , who died in a car crash at 17. Rita had worn it nearly every day from Elizabeth's accident until her own. She wondered to herself: Would she be joining Elizabeth soon?

The operation to repair the break was complicated because the knob of Rita's hip bone had been severed from the shaft. Surgeon Douglas Ayres , working gently because the bone was "like gossamer" in some places from osteoporosis, inserted a metal replacement.

Rita's blood pressure plummeted during the surgery, the first sign of the problems to come. Hours later, she was fighting for breath in the recovery room.

"She's had failure to thrive," said Susan Stetson , her nurse. Respiratory failure was the gravest threat, and there were hints of a dangerously irregular heart beat.

Stetson switched Rita's painkiller from morphine to Dilaudid, hoping it would make breathing easier by reducing her drowsiness. Dilaudid, however, like many opioid painkillers, can trigger delirium.

Herman, arriving from Holliston, caressed her shoulder. "What did they do to you?" he asked. His rumpled clothes proclaimed his own ragged state.

Rita had always been the glue of the family. She was the nursing student who became a recovery room nurse, then quit to raise their children, Robin, Mark, and Elizabeth. Herman was a star basketball player who became an engineer.

As Herman's career took the family from coast to coast, Rita took care of just about everything at home. Eventually they settled in Holliston and Herman rose to vice president at Data Instruments, retiring in 1999. Herman and Rita planned to travel, but Herman developed severe rheumatoid arthritis and diverticulitis and suffered a silent heart attack. Rita spent five years nursing him before falling ill herself.

Now, he said, "I only worry about one thing: Is she there when I get there? If she's feeling bad, I feel bad. If she's feeling good, I feel good. I keep it simple."

She was feeling terrible. Some 14 hours after surgery, when many patients would be out of bed, Rita didn't even realize she was in the hospital. Pain pulsed through her haze. An alarm sounded as Rita's blood oxygen level fell.

Stetson instructed Rita again on how to push the pain button, but it was unclear if she had heard or understood.

Robin leaned over the bed and tried to rouse her mother. Blinking back tears, she touched Rita's shoulder and began to talk about her day.

"You're going to be OK," she told her mother.

Rita ever-so-slowly shook her head.

A weakening will
But even as her breathing strengthened in the next few days, her will weakened. She let a physical therapist sit her up, but refused to get out of bed.

"I've got too many things wrong with me," Rita said. "I feel like giving up."

The hallucinations -- images of funerals and long-dead relatives -- were terrifying; the pain, excruciating; her vision, blurry. After the aneurysm surgery, she'd fought her way back, and here she was again. Why? Her own impulsiveness, she told herself. Could she recover? What kind of life would it be? And what would it mean for her family?

"I couldn't see how they could put up with much more or how I could put up with much more," she said later. "I thought once they got over their grief, they could turn their lives around."

Robin was feeling a similar tug. "If a person's not enjoying anything in life, should we make them live?" Robin asked.

But, more, she and Herman were determined to keep Rita in the fight. They talked of the future and brought her treats.

And they badgered the staff, who had been more focused -- out of need -- on stabilizing Rita's vital signs than on her mental state. At Robin's insistence, the doctors put Rita back on the antidepressant she was taking before she fell. At Herman's insistence, they took her off Dilaudid.

To combat the hallucinations, the doctors also prescribed an antipsychotic medicine. They switched Rita to a less sedating antinausea pill. And they brought in a pain specialist, who gave Rita a drug for nerve pain that allowed her to sleep through the night.

The staff was relentlessly cheerful, reminding Rita of every small sign of progress. When a physical therapist found herself rebuffed by Rita, she came back again and again to nudge her out of bed. Her nurses tried to find humor in Rita's room full of hoses and tubes. "I've got your Gucci bag," joked one, holding Rita's urine bag. "The problem is finding shoes to match."

Because many hospital stays are too short to distinguish depression from passing blues and antidepressants can take weeks to work, encouragement and support are typically the first-choice treatments. Delirium can sometimes be addressed more directly and swiftly: Beth Israel is training nurses and doctors to do this. But turning around a patient's will is another story.

"It's such a big issue in recovery," said Dr. Kathryn Agarwal , director of Beth Israel's geriatric consultation service. "But I don't think we've figured out how best to change that outlook."

Rita's turnaround began slowly, but a week after surgery, she was able to muster an occasional smile.

Sitting up in bed, her hair neatly combed, she ordered lunch with a trace of her old gusto. Herman happily circled her choices on the hospital menu.

Later, with the help of two rehabilitation therapists, she stood, bent steeply over her walker, and dared some tiny steps. In eight minutes, she traveled 2 feet.

She was exhausted, but as therapist Katelyn Powers began to leave, Rita reached for her hand and gave her a thank-you squeeze.

Rita explained what had changed. Through the haze, she'd heard Herman and Robin's exhortations and recalled the support they'd provided during other hard times. As the hallucinations faded, she began to draw on her own deep reserves. She tried to talk herself out of the pain -- she'd delivered three babies, after all. Was this really so bad in comparison? And then there was this simple fact: She was surviving, day after day.

"Every night that I get through, I'm saying the good Lord let me and He's pulling for me to fight a little harder," said Rita. "Not that I'm that religious . . ."

With Rita finally on an upward track, Herman had hoped to bring her directly home from Beth Israel. But it became increasingly clear that she would need weeks of rehabilitation.

"She will be limited, but her mind is back," Herman said. "I'll take her any way she does come back. . . . You get to a certain age when just being able to get up and say hello to each other is enough."

As they discussed rehabilitation options, lunch arrived. On her plate was a juicy slice of watermelon -- whole, not pureed into blandness as all her food had been. She savored every bite.

Taking steps toward home
But Rita's mental struggle was not over. At Kindred Hospital in Brighton for rehabilitation, pain medication again made her delirious. The hallucinations returned. Even when the worst of the fog lifted, she was increasingly forgetful and confused, unable to hold onto her therapists' names or the precautions required to keep from popping the new hip out of its socket.

And depression lurked. For more than two weeks, Rita declined to get dressed. When she finally acquiesced, it led to a 45-minute struggle that nearly did her in. Stepping into a pants leg is nearly impossible if you're afraid of falling. Pulling on a sock without bending over or crossing your legs requires using a device called a sock aid that takes some dexterity. Working around both an oxygen tube and a urinary catheter is exhausting.

Still, the physical therapists pushed, prodded and praised, and Rita began to respond. "You looked like a champ," said Norbert Murray , assistant director of physical therapy, after Rita walked from one end of the hospital to the other with her walker. "You're better than you think you are."

By the fourth week of rehabilitation, she was beginning to plan for life at home, but she still needed lots of help. And she was growing more worried about the burden on Herman. "If anything happens to Herman," she said, "I'd probably pine away."

A few hours later, Herman sagged against the kitchen sink of their large home, lighting his third cigarette in 40 minutes. His clothes hung loosely on his thin frame, his belt cinched to take up the slack of lost pounds. His wedding ring was taped to keep it from sliding off his finger.

At the other end of the house, the bedroom rug that had caused Rita's fall was rolled in a corner. Her bed was buried under boxes and drawers pulled from dressers in preparation for the workmen who would install wall-to-wall carpeting in a few hours.

For at least two weeks, Herman had been telling everyone that he was overwhelmed at the prospect of caring for Rita. Now, as Kindred's head physical therapist, Sarah Bolus , arrived to assess the safety of the Erichsens' home, Herman's fear exploded in frustration and anger.

"You're telling me all these things I need. But she's going to come home and have everything lying around on the floor," Herman ranted. "I'd like to make the house safer and I don't have time."

Under the hail of protestations, Bolus conceded that the house wasn't yet ready for Rita's arrival. She agreed to recommend that Kindred keep her another two days.

Herman collapsed onto the couch in the family room. Rita's lifeline was fraying.

Tomorrow: Rita and Angie face long months of recovery at home

Alice Dembner can be reached at Dembner@globe.com

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