For two patients, new challenges at home

Last of three parts

From her customary seat at the kitchen table, Angeline Scardino gazed longingly out the window on a gorgeous October afternoon. She was home alone in her daughter's Franklin colonial for the first time since she broke her hip two months earlier.

It was liberating. And terrifying.

Since the day Angie came home from rehab, her daughter, Joanne Hogan, had been her shadow -- accompanying her everywhere, helping her dress, getting up at night if Angie did. The sense of dependency brought Angie to tears.

"I just want to be on my own," she'd told Joanne.

Now she was. Joanne had returned to work, and the sunshine was beckoning.

Angie looked at the deck, then turned away. "It seems as if I can't make that," she said of the slight step down she would have to maneuver. Without help, the four steps down to the garage also seemed out of the question. "I still feel a little skittish. A lot of things I used to enjoy. . . ."

Because of Angie's early progress and her spunk, the surgeon who had fixed her hip, Douglas Ayres, believed she could be one of a small group of older patients who recover completely from hip fracture. She might even end up stronger and more mobile than before. But in the journey home, Angie had lost some of the drive and toughness that propelled her through other hard times.

Some older hip fracture patients never make it home -- about 8 percent die in the first 30 days, according to research commissioned by the Globe. They may suffer serious complications in the hospital or succumb to illness during rehabilitation at a nursing home. An additional 14 percent, particularly those without family or Angie's mental sharpness, spend the remainder of their often-shortened lives in a nursing home, other studies show.

But most go home, where they face huge challenges. By the end of the first year, 29 percent of all hip fracture patients are dead. Understanding why means understanding how easily things can go wrong in this last, longest, and, in many ways, hardest stage of recovery.

At first, patients may get help from visiting nurses and physical therapists. But soon their recovery lies in their own hands and those of friends and family. And the burden on patient and family can be crushing, as Angie and Rita Erichsen would learn.

Three weeks after Rita finally made it home to Holliston, after surgery to repair her hip, she and her husband Herman were preparing a simple supper. This used to be Rita's solo chore, but Herman had become both round-the-clock caretaker and reluctant cook.

He made coffee at the counter, as Rita, in her wheelchair, stirred a pot of soup. Abruptly, Herman stopped, his face contorted in agony.

There was a pulling in his back followed by numbness that trickled down his legs. Herman stumbled to the kitchen table and sat as several more spasms made him light-headed. Rita struggled to stand and go to him. Her walker was parked across the room.

"No, no, no, stay in your chair," Herman remembered hollering. He was thinking to himself: "I can't drop here. If something happens, I can't help you."

Rita's thoughts flew to Herman's silent heart attack two years earlier. Maybe this time, she feared, it wouldn't be so silent.

Rita pushed her Lifeline button. The Holliston ambulance squad was soon carrying Herman out on a stretcher and Rita in a wheelchair. Two months after Rita's fall, they were back at the emergency room.

Herman stayed two days, but test after test turned up no explanation. He guessed the spasms were related to herniated discs and his rheumatoid arthritis. But the nurse and social worker who visited Rita weekly were convinced he was wearing himself out.

The burden of caregiving puts older men like Herman, whose wives have broken their hips, at a 15 percent greater risk of death than other men, a recent study showed. And Rita knew that without Herman, her own chances of getting better were grim. Hip patients without spouses are less likely to recover, and Rita and Herman have a special bond, forged over more than 50 years together.

The visiting healthcare workers pressed Herman, then 76, to accept visits from a homemaker who could help Rita a few hours a week. He firmly declined, saying, "I know I'm tired. So what. My daughter is coming up and I can get a break."

But Robin was also feeling worn, and torn between the needs of her parents and her two children. Herman eventually gave in and hired a housekeeper to clean the house and "baby-sit" Rita twice a week while he ran errands or saw his doctors.

Still, he refused to give up primary responsibility for Rita's well-being.

Despite all the doctors Rita was seeing for various medical problems, Herman knew that only he was getting the whole picture. And it wasn't pretty.

Through all her health troubles, Angie had sustained herself on the slender hope that she would one day return to her own home, the modest ranch in upstate New York where she had raised her three children. But now that dream was fading, displaced by unaccustomed melancholy. Only about one-quarter of hip fracture patients manage to pick up their lives as they left them. Would she be one of them?

The day after Christmas, with Joanne's help, Angie did go back, plodding up the stairs she had rebuilt with double railings and wide treads just before she left abruptly to live with her daughter. As she entered the kitchen, her cane in her right hand, her eyes welled up.

"Will I come back here?" she asked herself. "I don't think so. I was told I can't live alone."

The house was dark, with the drapes drawn to discourage potential burglars. But it had a cozy feeling of a life interrupted in mid-conversation.

She moved slowly through the rooms as memories flooded back. She ran her hand over the inlaid table that she purchased after years of longing for a fine dining set and gazed fondly at the wagon-wheel light fixture overhead that her son Joseph had bought with his paper-route earnings. She nodded at a rocking chair she would like to bring to Franklin, and frowned when Joanne said it would be "a décor challenge" in her modern house.

Angie sat down at her favorite spot in the kitchen. She found drugstore receipts from 2003. Pictures of her dachshunds covered most of the fridge. She recalled the comfort of close neighbors as she fought back tears.

"I'll probably have to end up selling" the house, she said.

Rita was struggling with her own losses. She was tired of being waited on, tired of ceding control, tired of this painfully diminished version of herself.

"It's time for you to throw your wife out," she said to Herman one gloomy afternoon after a lung specialist suggested she might never regain her ability to breathe without the help of a tube in her throat.

"What are we going to do if I don't get better?"

In April, Rita decided to risk day-surgery on her vocal cords, a procedure doctors said would give her a 50-50 chance of eventually getting rid of the breathing tube. Complications sent her back to the intensive care unit at Beth Israel Deaconess Medical Center, then home again, even weaker than before. "I get ahead a couple of steps and then I go back a lot more," she said.

The depression could have sucked Rita downward, into inertia, then death. But Herman and Robin mobilized quickly. Robin, a physical education teacher, pushed Rita to do more -- get out of bed, exercise daily, walk with a cane, try a few steps without support. Herman took his wife out for dinner several times a week, resuming one of their longtime pleasures.

In a month, she returned to outpatient therapy, walking on a treadmill and riding a stationary bicycle in a routine prescribed to improve her breathing. The continuing therapy, far more than most hip patients get, had the added benefit of strengthening her legs and improving her outlook. Some research suggests that six months of outpatient physical therapy and exercise training, beyond the few weeks of home care most patients get, can make a big difference in quality of life.

Rita began to resume more everyday activities, picking up the fragments of her life. She chipped away at the year's worth of mail that covered the dining room table. She headed out to the sunporch, down an eight-inch step to water her plants. And for the first time in nearly 18 months, she prepared to climb to the second floor of her house.

"Today, my leg doesn't bother me at all. I can do anything," she said with newfound bravado, one afternoon in June.

She waited until Herman had gone to run errands, knowing her adventure would frighten him. Then she took her cane and climbed steadily up the 15 stairs. Panting, she stopped to catch her breath, then moved down the hall to her study. Dust and cobwebs covered the computer she used for her genealogy hobby. Rita shut her eyes to block the reminder of a slice of life that seemed lost.

A few minutes later, Rita paused at the top of the stairs, her face suddenly pale. Then, abruptly, she sat on the landing and bumped her way down.

Despite the unceremonious descent, she was proud. "I'm making progress."

Angie had been making progress, too, in physical therapy. She was stronger, and that strength was helping her beat back her fear of falling. But as therapy ended, seven months after she broke her hip, she had still not ventured outside alone. Indeed, she hadn't been getting out much at all. With Joanne working more than full time, Angie left the house only when Joanne escorted her to physical therapy twice a week, to doctor's appointments, or to the mall on weekends.

One day, when Joanne was at work, Angie finally made her way down the garage steps alone, repeating to herself, "I can't be a sissy. I can do it. I can do it."

She walked around the garage with her cane, then back up the stairs to the house.

"I felt like a big shot," she said. Until she told Joanne, who was none too pleased. She worried about Angie falling when no one was around.

But Angie kept at it. She set herself another modest goal -- getting to the mailbox, about 60 feet from the house, on her own.

Day after day, she ventured a little bit farther down the driveway. Then, on a glorious June morning, two months after she first stepped out alone, she decided to go for it. Grinning at her own ingenuity, she tied open the door with an exercise band, "to keep it from hitting me in the back as I go out."

Leaning on her walker, she stepped cautiously from the house to the landing of the garage stairs. Then, she descended gingerly. At the bottom, she steadied herself with her cane and forged across the garage. But she slowed with tiredness and fear halfway down the driveway, where it slopes gradually to the street. Finally, she summoned the willpower to trudge the few remaining feet. The box was empty.

In five minutes, she was back in the house, smiling wanly at her achievement. Her outing was far less than the quarter-mile she used to walk, but it was a start.

It was almost an end. She felt so lightheaded while walking one day in late August that she called for the rescue squad. At the hospital, doctors diagnosed a small blockage in her heart, treatable with medicine.

It was Angie's second major setback since the hip fracture. Months earlier, she had awakened with excruciating back pain, barely able to get out of bed. Ayres had diagnosed a compression fracture in Angie's upper back. Angie's age -- now 82 -- and her inactivity had caught up with her, causing osteoporosis and muscle weakness.

Ayres had already put Angie on extra calcium, vitamin D, and Fosamax, a bone-preserving drug. Her geriatrician added calcitonin, which helps prevent spinal fractures, making Angie one of the few hip fracture patients to get needed treatment for osteoporosis.

Following the hospitalization for the heart blockage, Angie returned home, exhausted and weak from bed rest, with doctor's orders not to go out without an escort. Stuck with the walker again, she moved slowly and heavily around the house, her back rounded into the very position that Ayres said could cause more fractures. Her hip would stiffen and ache if she didn't walk, but every step aggravated her back. Pain kept her from pushing herself harder, as she refused even Tylenol. Such unrelenting pain often hastens disability in hip patients.

For two weeks, a nurse and physical therapist came to the house, but then Angie was on her own again. Back to long days with only the dogs for company. Back to screwing up her courage to face the steps alone.

The leaves had all fallen off the trees before she made it back to the mailbox, cane in hand. This time, the box was full. But when she dropped some of the mail on the way to the house and had to balance precariously to pick it up, she decided the simple chore was too challenging.

"I really don't want to be taking that chance," she said. "If there's a lot of stuff, I'm going to leave it there."

As Angie struggled, Rita was striding forward. She was physically stronger than she'd been in months because Herman took her to exercise class twice a week. She was mentally stronger because she was able to breathe normally, rather than through the tube, for 12 hours at a time. More and more, in the house, she was doing chores without the walker or the cane.

Her frustrations weren't gone. She still wasn't gardening, she didn't feel comfortable taking her grandchildren to play at the local pond as she used to, and she wasn't ready to walk outdoors without the cane. But she made it to her family reunion in Peabody, celebrating their role as the town's first settlers and inspiring her return to her genealogy hobby.

For her one-year check-up with orthopedic surgeon Douglas Ayres, she toted the walker for the long haul from the garage and the cane for assurance around the clinic at Beth Israel Deaconess Medical Center. Then, she parked both on the far side of the examining room as she took a seat near the door.

Do you still need the devices to walk? Ayres asked.

Wordlessly, Rita rose and headed down the long hallway unassisted. With her body erect, her step steady, and her smile broad, she radiated life.

End of Series

Alice Dembner can be reached at dembner@globe.com.