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Care of the Hip Fracture Patient

Debra L. Bynum, MD
Division of Geriatric Medicine
University of North Carolina Chapel Hill
November 2007

Background:

Our population is aging with an exponential increase in the numbers of octogenarians, nonagenarians, and centenarians. Those over the age of 85 now comprise 12% of the United States population, and this number is expected to rise [1]. The risk of hip fracture increases with age, and over a third of all patients are over the age of 85 [2]. Hip fractures are associated with 1525% mortality and 30% risk of nursing home placement within the first year [36]. As hip fractures most often occur in the persons who are elderly or frail, the approach to caring for these complicated patients must be thorough and evidence based.

Care of the Hip Fracture Patient: Preoperative Evaluation

Preoperative evaluation of the older patient involves weighing the risks and benefits of surgery and identifying modifiable factors that can improve patient outcomes. The aim cannot be to “clear” the patient.

Most patients, even those with significant dementia and other comorbidities, will need to undergo surgery. Without surgical intervention, patients are left with immobility and significant pain. Issues related to capacity, informed consent, and goals of care are important. A Do Not Resuscitate (DNR) order and other advance directives do not exclude a patient from surgery. The DNR order is usually suspended during the operative time, and this should be made clear to patients and their families.

There have been multiple studies and articles looking at risk assessment tools for preoperative evaluation. Most of this work has focused on cardiac outcomes, despite the fact that over half of all bad outcomes are noncardiac. Overall risk is based upon the risk inherent to the type of surgery and the risk related to the individual. Hip fracture surgery is generally considered to be of intermediate risk. Emergent procedures are inherently more risky than elective surgeries. An urgent procedure of intermediate risk in patients who are often frail with other significant medical problems adds up to a significant baseline risk for most.

Overall risk factors for bad outcomes include age over 75, creatinine over 2.5, poor exercise capacity, hypertension, and diabetes. Each of these factors doubles the risk of mortality. A patient with all of these risk factors has a sixteen times greater risk of death. A recent myocardial infarction or clinical evidence for congestive heart failure (S3 , rales, or jugular venous distension on exam or pulmonary edema on chest x-ray) further increases the risk of an adverse cardiac event or death.

The question of the value of preoperative cardiac testing often arises. Functional cardiac studies looking for myocardial ischemia in preoperative patients are notoriously poor predictors of any significant outcome. A positive dobutamine echo or nuclear perfusion study carries a positive predictive value of only 20% for any significant perioperative event. A negative test does significantly decrease the risk of a postoperative event, but whether or not this changes clinical management is not clear. In addition, there is little in the way of intervention to modify this risk. Initial studies suggested that patients with prior Coronary Artery Bypass Grafting (CABG) had decreased perioperative cardiovascular risk than other patients. Subsequent analyses have shown that there is no overall difference in outcomes when one considers survival bias and the initial mortality associated with the first revascularization procedure. This lack of benefit was demonstrated in the Coronary Artery Revascularization Prophylaxis (CARP) trial that showed no mortality difference in patients with significant coronary disease randomized to coronary revascularization with CABG or Primary Coronary Intervention (PCI) compared to those patients who were managed medically. There are also significant concerns with recent catheterization and stent placement as discontinuation of clopidogrel is associated with an unacceptable risk of myocardial ischemia.

Given the need to proceed with surgery in an urgent fashion, the poor predictive value of functional studies, and the inability to significantly alter outcomes with revascularization prior to an orthopedic procedure, the general guideline is to assess cardiovascular and overall risk based upon historical and physical data and to avoid further functional testing prior to surgery. Data from echocardiography to assess left ventricular function and to evaluate for aortic stenosis may be helpful in chosen cases. Any results should be used to guide the perioperative management of the patient and not to “clear” the patient nor to preclude the patient from surgery.

Preoperative Beta Blockers?

Despite widespread acceptance that beta blockers given prior to surgery reduce the risk of cardiovascular events and mortality, the data behind this may be marginal. Original work from the Poldermans Trial in 1999 demonstrated significant declines in cardiovascular death and infarctions (with a decrease in cardiac death from 17% in the placebo group to 3.4% in the Bisoprolol group and a decrease in non-fatal MI from 17% in the placebo group to 0% in the treatment group). Overall there was a 34% decrease in risk of death or MI in the treatment group compared to the placebo group. There are current concerns however that this data may be skewed—multiple additional studies have demonstrated a positive but much more modest effect of beta blockers. A larger trial (PeriOperative Ischemic Evaluation – POISE) trial is currently underway to further address this issue. Until then, it is reasonable to give patients who are at high risk beta blockers in the perioperative period. It is also reasonable to recognize the risks of therapy in our older, frail patients including hypotension and bradycardia and withhold beta blockers in patients who are at low cardiovascular risk or who are at high risk of complications from their use.

Preoperative Analgesia:

In theory, decreasing the catecholamine response during the preoperative time may help to reduce cardiovascular complications much as beta blockers would. In one randomized trial from Israel, elderly patients with a hip fracture who received epidural analgesia in the Emergency Department had significantly fewer cardiovascular events and mortality compared to the usual treatment group. Limitations of the study include longer wait time to surgery than in the United States in addition to small sample size. Analgesia should begin in the emergency room and aimed at appropriate pain control, even in patients with dementia or who may be at risk for the development of delirium.

Preoperative Optimization of Status:

Management of fluid status is essential as many older patients have systolic or undiagnosed diastolic cardiac dysfunction. Optimization of diabetic control is also important. Most patients will need to have their oral agents held until they are eating again. Insulin doses may need to be reduced if the patient is not eating, but usually should not be totally discontinued unless the patient is hypoglycemic. Metformin should be held if there is any risk of the patient developing renal insufficiency or needing a contrast based radiological study. Many patients may also need baseline insulin in the form of an infusion or glargine. The usual “sliding scale” insulin approach is not very effective. It is crucial not to hold insulin or other therapy as patients may benefit from tighter glycemic control during acute hospitalizations.

It is important to review and discontinue medications that are not needed and potentially harmful. Why did the patient fall? Is polypharmacy a problem? Are there medications that may have contributed to the fall (especially benzodiazepines and medications with anticholinergic activity)? Home medications should be recorded so that medication reconciliation at the time of discharge is complete.

Preoperative traction, previously the standard of care, is now recognized to have no significant improvement in pain control or surgical outcome. Preoperative antibiotics with a first generative cephalosporin or clinidamycin have been demonstrated to significantly decrease deep tissue infections and urinary tract infections in hip fracture patients and should be given 30 minutes prior to skin incision and continued for 24 hours after surgery.

Timing of Surgery:

Several early studies demonstrated that a delay in surgery of more than 48 hours was associated with an increased risk of mortality, pressure ulcers and delirium. The confounder in these studies is the fact that patients with more acute issues and comorbidities were more likely to have delayed surgery, and their higher risk of a bad outcome may not have been caused by the surgical delay. As it is not considered ethical to do a randomized trial of early versus delayed surgery, the consensus is that hip fracture surgery is best done within the first 2448 hours.

Surgical Management:

Intertrochanteric fractures are often managed by placement of a sliding hip screw. Long femoral nails are used for unstable intertrochanteric or subtrochanteric fractures. For a nondisplaced subcapital fracture, open reduction with internal fixation (ORIF) via percutaneous screws are also used. For displaced subcapital fractures the standard is hemiarthroplasty or total hip arthroplasty, which carry longer operating times and increase the risk of surgery (60 minutes operating time for hemiarthroplasty, 150 minutes for Total Hip Replacement (THR).

Anesthesia:

Although there is some conflicting data in multiple small studies, most agree that regional (spinal) anesthesia is preferable to general anesthesia in older patients. Although the original studies are small and often lacking in rigor and power, there is some suggestion in large systematic reviews that regional anesthesia may reduce the risk of deep venous thrombosis, pulmonary embolism, pneumonia and mortality. Patients who undergo regional anesthesia still have the same risk of developing delirium. One potential downside is the small but clinically important risk of an epidural hematoma in postoperative patients who receive anticoagulation.

Prevention of Venothrombotic Events:

There are very clear guidelines established from the 7th conference on Antithrombotic and Thrombolytic Therapy in 2004. Hip fracture patients are considered to be at extremely high risk for venothrombotic events (VTE) with a 50% risk of Deep Venous Thrombosis (DVT), 27% risk for proximal DVT, and 1.47.5% risk of fatal Pulmonary Embolism (PE) in those who do not receive prophylaxis. Factors that increase the risk of a VTE include advanced age, delayed surgery, and a limited functional status. Those whom we view as the most frail (and therefore hesitate to anticoagulate) are actually those who are at the highest risk for DVT and PE!

Mechanical devices are not adequate. Aspirin may be slightly better than placebo but is also not adequate. Aspirin plus other forms of anticoagulation may be slightly better at decreasing the risk of VTE, but increases the risk of major bleeding and therefore is not recommended.

Multiple studies have demonstrated a significant decrease in the risk of DVT/PE with Low Molecular Weight Heparin (LMWH). Fondaparinux is likely better than LMWH with a comparable risk of bleeding (2% risk of major bleeding with each). Low dose unfractionated heparin (LDUH) at 5000 units SQ TID is another alternative in elderly patients.

Although Fondaparinux is often not used because of expense, it has been shown to be more effective than LMWH. In one randomized controlled trial of 1000 patients with hip fractures, 40 mg enoxaparin was compared with 2.5 mg of fondaparinux. At day 11, 8.3% in the fondaparinux group compared to 19.1% in the enoxaparin group had evidence for a VTE. The risks for proximal DVT was 0.9% and 4.3%. There was no difference in the risk for major bleeding.

Some argue that the need for anticoagulation has been overstated because the risk of proximal DVT and PE is much less than the risk of all VTE, which include distal DVT. Prior strategies have focused on aspirin and screening Doppler ultrasounds of the lower extremities, which is not effective. Although previously thought to be insignificant, we now recognize the real risk of propagation of distal deep venous thrombosis and the need to prevent and treat these.

Current recommendations also extend the time for patients to be anticoagulated. In one study of 600 hip fracture patients, patients were assigned to either fondaparinux or placebo starting 68 days postoperatively (all patients received fondaparinux for the first 68 days). After 3 weeks, 35% of patients in the placebo group had evidence of a VTE compared to only 1.4% in the fondaparinux group. Only 0.3% in the treatment group had a symptomatic VTE compared to 2.7% in the placebo group. There was no significant increased bleeding rate and no difference in overall mortality between the groups.

In summary, the guidelines from the 7th conference, based upon strong evidence from multiple randomized controlled trials in addition to years of observational studies, are clear.

1. Recommendations are for the routine use of fondaparinux, LMWH or LDUH.

2. Vitamin K antagonists such as warfarin, with a goal INR of 23, are also effective but more challenging to titrate and maintain.

3. There is no evidence for the routine use of aspirin at any dose.

4. Aspirin plus other anticoagulants should not be used because of an increased risk of bleeding.

5. Mechanical devices should only be used in patients with an absolute contraindication to anticoagulation.

6. If surgery is to be delayed, begin LMWH or LDUH preoperatively (European studies in which preoperative administration of anticoagulation is standard do not demonstrate any significant increase in bleeding or wound healing).

7. Continue anticoagulation at least 2835 days after surgery, possibly longer in high risk patients.

8. Patients with hip fractures, older age, and other comorbidities are actually at the highest risk for DVT and PE and anticoagulation should not be withheld as the risk for thrombosis and mortality is greater than the risk of prophylaxis. In patients with a high baseline risk, there is actually a higher potential Absolute Risk Reduction in events with treatment.

Postoperative Pain Control:

Uncontrolled pain has been associated with higher rates of cardiovascular events and delirium. Options for pain control include epidural, PCA, or nurse administered analgesics. There is some data that the epidural route may provide better pain relief, but there is no clear difference in time to recovery of physical independence in older patients. Epidural analgesia still has a risk of respiratory depression, may be difficult to use in patients with delirium, and may make early mobilization challenging.

Although assessment of pain in patients with dementia and/or delirium may be difficult, it can be done with standardized scales and clinical observations. Morphine is the most predictable and may be less likely to increase confusion when compared to other agents. Medications to be avoided include benzodiazepines (unless there is evidence for withdrawal syndromes), propoxyphene, meperidine, and diphenhydramine (benadryl).

Although many fear the risk of delirium with narcotics in older patients, there is some evidence that delirium is associated with poor pain control. In one study of elderly hip fracture patients, patients who received lower doses of morphine actually had higher rates of delirium. There is the potential confounder that patients who were viewed by their physicians to be at higher risk for the development of delirium were less likely to receive higher doses of morphine. Regardless, current recommendations based this type of data in addition to the ethical responsibility of the physician to provide comfort necessitate adequate analgesia for these patients.

Postoperative Monitoring:

There is evidence that an elevated troponin level in the postoperative period is associated with an increased risk of mortality and morbidity. The higher the troponin, the higher the first year mortality. There are some that recommend following troponin levels and EKGs routinely in the postoperative period as many ischemic events in the elderly may be silent. It is not clear that this is clinically useful as a standard.

Foley Catheters:

Patients will have a catheter placed preoperatively. There is good evidence to support removal of the catheter after 24 hours. Patients with a foley have a 25% risk of urinary infection. In addition, the foley catheter may serve as a “restraint” in frail patients who need to rapidly mobilize. Urinary retention can be assessed with postvoid residuals (bladder ultrasounds if possible) and managed by In and Out catheterizations until bladder function is restored.

Delirium:

Delirium is the most common complication following surgery in the older patient. Delirium is a marker for bad outcomes and has been associated with an increased mortality, increased risk of needing a higher level of care after discharge, and an increased length of hospital stay. Multiple studies have demonstrated that targeted interdisciplinary interventions can significantly decrease the risk of delirium.

There are multiple risk factors for delirium – most of these are the same risk factors for hip fracture and “frailty.” Risk factors include advanced age, underlying cognitive impairment, prior history of delirium, alcohol abuse, malnutrition, depression, polypharmacy, and the type of surgery. Hip fracture surgery is associated with a 30% risk of delirium. We further increase the risk for confusing patients with restraints which practically include foley catheters, intravenous lines, oxygen tubing, telemetry boxes, Sequential Compression Devices (SCDs), and machines that monitor vital signs. We then add to this environmental noise, sleep disturbances, and missing visual or hearing aides.

There are specific medications that deserve special note as being highly associated with delirium. These agents include those with anticholinergic properties, especially diphenhydramine (benadryl). Antipsychotic agents, antibiotics such as quinolones, histamine blockers such as cimetidine, benzodiazepines, and certain narcotics such as propoxyphene and meperidine have been implicated.

Patients should be assessed by the Confusion Assessment Method or other simple screens initially and then daily. An attempt should be made to decrease sleep interruptions with unnecessary lab draws or other assessments. Family and friend involvement is crucial, and a sitter or personal assistant may be needed. Restraints, physical and chemical, should be avoided. The medication list should be monitored continuously and medications kept to a minimum. Assessments for complications such as infection, hypoxemia, pneumonia, and ischemia should be done. Patients should be up as soon as possible, many can be weight bearing as tolerated the next day. Patients should not be restrained discontinue unnecessary lines, oxygen tubing, boxes, and catheters. If a patient becomes “agitated,” make sure it is not due to pain, urinary retention, hypoxemia, ischemia, or other causes before attributing it to delirium.

Although antipsychotic medications have become popular in the management of hospitalized patients with delirium, these agents should be avoided. There is no consistent data that these agents improve any outcome. In a randomized, placebo controlled trial of low dose haloperidol (1.5 mg/day), there was no difference in the primary endpoint of incidence of delirium. They are not approved for this indication and have a FDA issued black box warning for their use in elderly patients because of an observed increased risk of stroke and sudden death in this population. There is a small subset of patients with extremely aggressive behavior or delirium with psychotic features associated with hallucinations or delusions that are disturbing that may have improved behavioral scores with these agents. If used, they should be used in very small doses (such as 0.5 mg of haloperidol, .5 mg of risperidone, 2.5 mg of olanzepine, or 25 mg of quetiapine) and should be discontinued after 13 days.

Side effects of antipsychotic medications include sedation, orthostasis, increased falls risk, confusion, increased risk of delirium, edema, weight gain, and cardiovascular complications including QT prolongation. Use for more than three days is associated with tardive dyskinesia and other movement disorders and can occur even with the newer atypical agents.

Nutritional Status:

Malnutrition before and after hip fracture surgery is independently associated with an increased morbidity and mortality risk in the elderly. There is no data to support aggressive nasogastric or PEG tube feeding in this population, and postoperative parenteral nutrition is associated with a high complication rate. It is recommended to optimize nutrition with a liberal diet and nutritional supplements, recognizing that poor nutritional status (based upon clinical exam, low BMI, low albumin, and low transthyretin) is a marker for poor outcomes.

Pressure Ulcers:

Decubitus ulcers occur in 1040 % of patients after a hip fracture and are also a marker for poor outcomes. Pressure ulcers can be prevented with attentive care including frequent turning (every two hours) and early mobilization.

Pneumonia:

Pneumonia results in 2550% of all deaths after hip fracture surgery. Aggressive aims to ambulate the patient, getting him/her out of bed to a chair, providing incentive spirometry,and encouraging overall good pulmonary toilet can decrease the risk for developing pneumonia in the early postoperative period. Pneumonias that develop after several months are a leading cause of later deaths in patients.

Anemia and Transfusions:

Although traditionally patients have had frequent transfusions in the hospital with a goal to keep the hematocrit above 30, there is evidence to suggest that this strategy does not offer any significant benefit to patients in this setting. Anemia and worsening anemia in the postoperative period are common in the older patient. There is evidence from the medical ICU setting that patients with a more aggressive transfusion strategy actually did not do as well as those in whom a lower hematocrit was tolerated. This is a little more challenging in older patients. There are some small studies that suggest that older patients in the postoperative period or those who have cardiac ischemia may need a slightly higher hematocrit. Current recommendations are for a moderately restrictive transfusion approach in these patients, aiming to keep a hemoglobin at 78 (higher if there is active bleeding or ischemia), but not to try to aggressively keep a hemoglobin of over 10.

Prevention of Future Fractures:

Patients with a hip fracture are at the highest future risk of having another fracture. Other risk factors for fractures include age over 65, benzodiazepine use, tachycardia, the inability to perform a chair rise, low BMI, poor exercise tolerance, and poor depth perception or vision in addition to the traditional causes of osteoporosis including corticosteroid use, smoking, sex, and genetics.

Treatment of Osteoporosis: 70% of people over the age of 80, and all of our older patients admitted with hip fractures due to minimal trauma, have osteoporosis. Despite this, only 5% of patients admitted with a hip fracture are adequately treated at the time of discharge. Older patients, who are at the highest risk for future fractures, are less likely to receive treatment for their osteoporosis.

Patients should receive supplemental calcium at 1500 mg/day and vitamin D. Prior recommendations were for 400800 IU vitamin D per day. It is now known that elders, especially those in skilled nursing facilities, have an extremely high prevalence of Vitamin D deficiency. Vitamin D supplementation is thought to have effects on skeletal muscle and other organs in addition to bone metabolism and supplementation in the elderly not only improves bone mineral density but also decreases the risk of falls. A recent meta-analysis of 29 randomized trials demonstrated a reduction in fractures in patients over the age of 50 who were given calcium and Vitamin D (at least 800 IU/day). The data was not convincing for patients who only received 400 IU Vitamin D per day (the amount in a standard multivitamin). Even moderately low Vitamin D levels are thought to lead to elevations in parathyroid hormone (PTH) which then increase bone breakdown and contribute to osteoporosis. Vitamin D supplementation is safe, even in patients with primary hyperparathyroidism. Vitamin D intoxication and hypercalcemia has been reported in patients who have received more than 50,000 IU /day, but is not seen even in patients who have taken up to 10,000 IU /day for up to 5 months. It is currently recommended that all patients need at least 800 IU of vitamin D3 a day in addition to sensible sun exposure. Patients who are at risk, which includes all those admitted with a hip fracture, should have a 25-hydroxyvitamin D level checked. PTH levels should be considered as even mildly elevated PTH levels seen with Vitamin D levels of less than 40 ng/ml (75100 mm/L) have been associated with an increased risk for falls and fractures. If a patient is deficient, patients should receive 50,000 IU Vitamin D2 (which is the available prescription form in the United States) every week for 8 weeks. A repeat 25-hydroxyvitamin D level is then checked and an additional 8 weeks of supplementation at 50,000 IU per week is given if the vitamin D level is less than 30 ng/ml. Maintenance dose should then be given at 50,000 IU Vitamin D2 every 24 weeks with a goal 25 hydroxyvitamin D level of 30-60 ng/ml and normal PTH. The same recommendations are given for patients with underlying primary hyperparathyroidism.

Calcitonin may have some benefit with a reduction of pain in patients who present with an acute vertebral compression fracture, but is not as effective as other agents for the treatment of osteoporosis. Other options such as Selective Estrogen Receptor Modulators (raloxifene) are approved for use and have the same effects on bone as estrogen replacement without the cardiovascular or cancer risk. These agents do carry the side effects of hot flashes in postmenopausal women, are expensive, and likely not as effective bisphosphonates.

Bisphosphonates should be considered first line for the treatment of osteoporosis, decrease bone resorption, and have been shown to decrease the risk of hip and vertebral fractures. Alendronate and risodronate have been used for years, and more recently once monthly Ibandronate (boniva) has become a popular choice. Intravenous preparations such as pamidronate were in the past primarily used for the treatment of hypercalcemia of malignancy and the associated osteoporosis of multiple myeloma. These agents are not recommended in patients with renal failure and have an associated risk of esophageal irritation if not taken correctly, but overall have proven incredibly safe and well tolerated. Despite well publicized concerns about the risk of Bisphosphonate Associated Osteonecrosis, the true incidence of this in patients who do not have underlying severe dental disease or malignancy is likely grossly overblown. Concern from case reports and animal studies that these agents may delay wound and bone healing has not been supported in clinical studies.

The bisphosphonates have a long half life and effectiveness. There is recent evidence to strongly support the use of once yearly zoledronic acid in patients with hip fracture. The HORIZON (Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly) was a randomized controlled trial of over 2000 patients who presented with a hip fracture and were allocated to receive either IV zoledronic acid or placebo within 90 days of their fracture. Patients were followed for nearly 2 years, and all patients received calcium and vitamin D. Enrolled patients were unable or unwilling to take an oral bisphosphonate, and no patients who had recently been on an oral bisphosphonate were included. Patients in the zoledronic acid group had a significant decrease in new fractures (8.6% compared to 13.9 % of those in the placebo group) and in overall mortality (9.6% vs 13.3%). There was no increased risk of jaw osteonecrosis, poor healing, or atrial fibrillation seen. We do not know if zoledronic acid is superior to oral bisphosphonates as there has been no direct comparison study. Given the impressive results, current recommendations from our institution include the administration of zoledronic acid intravenously prior to discharge in all patients without renal failure who are admitted with a hip fracture.

Other agents such as Teriparatide (PTH) given intermittently are currently used in patients with severe osteoporosis. Teriparatide has been demonstrated to decrease the risk of fractures and improve BMD, but is a very expensive subcutaneous preparation. This agent should not be used in combination with a bisphosphonate as there is evidence to suggest that the combination is inferior to either agent alone. The long half life of bisphosphonates necessitates a long “wash out” period prior to the initiation of teriparatide.

In addition, fracture reduction strategies also need to include a home assessment, strengthening and gait assessment, assistive devices if needed, cognitive assessment, urinary incontinence treatment, medication review, exam for peripheral neuropathy and visual impairment, screen for alcohol or other drug abuse, and a history of prior falls which can lead to a fear of falling syndrome which actually increases the risk of future falls.

Although hip protectors would seem to be an effective and simple intervention to prevent fractures, there is no strong data to support their use. In a recent randomized controlled trial (HIP PRO), soft hip protectors were studied in nursing home residents and showed no efficacy, despite good adherence to their use.

Discharge Planning:

Most patients will require either acute or subacute rehabilitation prior to returning home. Physical and Occupational Therapy assessments, Recreation Therapy intervention, Social Work involvement, and staff participation are essential in the development of a plan of care for the patient discharged after undergoing surgery for a hip fracture.

Summary of Recommendations: Care of the Patient with a Hip Fracture

Preoperative Evaluation:

The goal is to weigh risks and benefits of surgery and identify modifiable factors to improve outcomes, NOT to “clear” the patient.

Most patients, even those with significant dementia, will need to proceed with surgery.

Predictors of adverse outcomes include age over 75, creatinine over 2.5, poor functional capacity, hypertension, and diabetes.

Myocardial infarction within the past 6 months, unstable angina, or clinical CHF increase the risk of an adverse cardiac outcome.

Preoperative functional cardiac studies are usually not indicated.

Patient outcomes are not improved by preoperative revascularization.

Echocardiography in selected patients to assess LV function/rule out aortic stenosis.

Patients should proceed to surgery within 48 hours.

Preoperative Beta Blockers:

The original data suggesting a large benefit to preoperative beta blockers is under question; overall benefit is likely modest.

Older patients are at an increased risk for hypotension and bradycardia.

Preoperative Analgesia:

Provide adequate preoperative pain control, even in patients with dementia or delirium.

Other Management Issues:

Judicial fluids as many have systolic and diastolic ventricular dysfunction.

Optimize diabetic control, do not withhold insulin or rely only upon “sliding scale” regimens.

Review medications and decrease polypharmacy.

Patients should receive a first generation cephalosporin or clindamycin preoperatively and for 24 hours after surgery.

Anesthesia:

Regional (spinal) anesthesia is preferable to general anesthesia.

Prevention of Venothrombotic Events:

Patients with a hip fracture are at high risk for the development of VTE.

Recommendations Include the Routine Use of:

Fondaparinux at 2.5 mg/day

Low Molecular Weight Heparin (enoxaparin at 40 mg/day)

Low Dose Unfractionated Heparin (5000 units SQ TID)

There is no evidence to support the use of aspirin alone or in combination with other anticoagulants.

Mechanical devices and aspirin are not effective; mechanical devices alone should only be used in patients with an absolute contraindication to anticoagulation.

If surgery is delayed, begin LMWH or LDUH preoperatively.

Continue anticoagulation for at least 2835 days after surgery.

Age and “frailty” are not contraindications to prophylaxis; these patients are at the highest risk for clots!

Postoperative Pain Control:

Patients will need clinical assessments for pain and nurse administered analgesics.

Morphine is likely the most predictable and easily titrated medication.

Avoid benzodiazepines, propoxyphene, meperidine, and diphenhydramine.

Adequate pain control is essential and may decrease the risk for delirium

Postoperative Cardiac Monitoring:

Routine cardiac markers and EKGs are likely of limited clinical value.

Have a low threshold to suspect ischemia in patients with atypical symptoms (tachycardia, delirium, hypoxemia, tachypnea).

Foley Catheter:

Place preoperatively.

Remove 24 hours after surgery.

Evaluate for urinary retention with bladder scan and use I/O catheterizations as needed until restoration of bladder function.

Delirium:

Identify patients at risk.

Involve family, friends or sitters/personal assistants as needed.

Remove “restraints” including foley catheters, intravenous lines, oxygen tubing, SCDs, telemetry boxes as soon as possible.

Minimize environmental interruptions and sleep disturbances.

Get hearing and visual aids.

Avoid notorious medications: NO diphenhydramine, anticholinergic agents, antipsychotic agents, benzodiazepines, meperidine.

Assess and follow patients with the Confusion Assessment Method.

Rule out other medical causes of delirium if it develops.

Avoid antipsychotic medications!

Nutritional Status:

Liberalize diet (do not place on cardiac diet) and provide supplements.

Pressure Ulcers:

Mobilize early (most patients can be weight bearing as tolerated the next day).

Frequent turning (every 2 hours) for bed bound patients.

Pneumonia:

Early mobilization

Incentive spirometry

Anemia:

No evidence to support routine transfusions to keep Hbg over 10/hematocrit over 30.

Prevention of Future Fractures:

All patients should receive 1500 mg calcium/day.

Check 25 hydroxyvitamin D level, consider checking PTH.

Goal 25 hydroxyvitamin D level of 3060 ng/ml and normal PTH.

Vitamin D Replacement for Deficiency :

50,000 IU Vitamin D2 every week for 8 weeks.

Recheck 25 hydroxyvitamin D level.

If still less than 30, give additional 50,000 IU/week for 8 weeks.

Once replaced, maintenance with 50,000 IU Vitamin D2 every 4 weeks.

Recommendations are the same for patients with primary hyperparathyroidism.

Treat Osteoporosis!

Zoledronic Acid, 5 mg intravenous, given prior to discharge and then once yearly.

Documentation in procedures of discharge summary.

Other options such as weekly alendronate (fosamax) or monthly ibandronate (boniva).

Discharge Planning:

PT, OT, and RT need to be involved early.

Social work involvement for home assessments or placement often needed.

PMR consult for acute rehab options.

References:

He, Wan, Manisha Sengupta, Victoria Velkoff, and Kimberly DeBarros, U.S. Census Bureau, Current Population Reports, P 23209, 65 + in the United States: 2005, U.S. Government Printing Office, Washington, DC, 2005.

Foss NB, Kehlet H. Mortality analysis in hip fracture patients: Implications for design in future outcome trials. British J Anesth 2005; 94: 249.

Shah MR, Aharonoff GB, Wolinsky P, Zuckerman JD, Koval KJ. Outcome After Hip Fracture in Individuals Ninety Years of Age and Older. J Orthopedic Trauma 2003; 17(8) Suppl: S6S11.

Wolinsky FD, Fitzgerald JF, Stump TE. The Effect of Hip Fracture on Mortality, Hospitalization, and Functional Status: A Prospective Study. Am J Public Health 1997; 87: 398403.

Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W, Rimm AA. Hip fracture incidence among the old an very old: a population based study. Am J Public Health 1990; 80: 8713.

Bass E, French DD, Bradham DD, Rubenstein LZ. Risk-adjusted mortality rates of elderly veterans with hip fractures. Ann Epidemiol 2007; 17(7): 5149.

 

 

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