Hip Fracture Management in Advanced Dementia Patients - #89Take Quiz
Determination of appropriate post-fracture management of patients with advanced dementia and hip fracture.
Hip fractures are sentinel events often associated with reduced function, quality of life and increased mortality. Management decisions in patients with advanced dementia are often complicated due to the need for time-sensitive decisions by surrogates, involving multiple operative and non-operative options, often in the context of uncertain prognosis. This Geriatric Fast Fact reviews important considerations and offers practical recommendations surrounding hip fracture management in patients with advanced dementia.
Treatment options: Possible treatment options depend on the type and location of fracture, prior level of patient functional status, and patient goals. Medical management of pain should always be central. There are various orthopedic surgical approaches based on fracture type (e.g., total or partial hip arthroplasty, fixation with a nail or screw). The goals of surgery may range from maximizing comfort to restoration of normal ambulation (1,2). In addition to medical pain management, major non-operative management options include modified weight-bearing status (typically strict bed rest is not required) or traction.
1. Participants in decision-making begin with patients and family or surrogate decision makers. Care team members with helpful insights may include physicians (e.g., primary care providers, hospitalists, geriatricians, orthopedic surgeons, anesthesiologists, palliative specialists, physiatrists), nurses, therapists, social workers and chaplains. For frail elderly patients residing in nursing facilities, geriatrician involvement can improve 1-year mortality in those undergoing surgery for a hip fracture (3,4,5).
2. Clarify overall goals by evaluating a patient’s anticipated prognosis and baseline quality of life (6). Even for patients with clear goals, decision-making may remain complex, involving uncertainty in risks, benefits, and outcomes. For example:
- A non-ambulatory patient with an anticipated longer survival time may have care goals solely focused on comfort, yet surgery may reduce pain.
- An ambulatory patient who undergoes surgery with goals for life-prolongation may experience complications (e.g., delirium, pressure injuries, infections, or death).
3. Clearly communicate benefits and burdens of both orthopedic surgical and non-operative management. This discussion should include information on prognosis, likelihood for functional recovery, patient values and preferences, and pain management strategies in each scenario (6). Regardless of treatment decisions or goals, providing palliative/hospice care information is indicated for patients with advanced dementia and hip fracture as their survival rates are poor.
Factors to consider:
1. Studies have found that nursing home residents with advanced dementia and hip fracture who undergo surgery (ideally in the first 24 hours) have lower mortality rates compared to patients that do not undergo surgery. (7)
2. Is pain adequately managed with turning and transfers? Are analgesics being tolerated? If not, surgery becomes more indicated.
3. How high is the surgical risk due to other underlying comorbidities?
4. What is the surrogate decision-maker’s view about the patient’s quality of life pre-operatively and what the patient would likely consider acceptable quality of life post-operatively.
5. In patients:
- At end-of-life (e.g., days to weeks), non-operative management is indicated, with comfort-focused end-of-life care. A trial of traction is an option for patients experiencing pain with minimal movement in bed.
- With a life expectancy of months to years, surgical repair is typically appropriate, especially if the goal is to ambulate again. Few hip fracture survivors remain ambulatory without surgery.
Older adults presenting with hip fracture in the setting of underlying advanced dementia.
Thoughtfully consider and present surgical and non-surgical care options for hip fracture in advanced dementia patients, weighing risk and benefit in light of determined patient and surrogate goals of care.
The incidence of hip fractures for nursing home residents with advanced dementia is about 2.1/100 person years. By 2050, annual hip fracture rates are expected to increase to one million in the USA and 4.5 million globally. Hip fractures are associated with increase in all-cause mortality with an overall mortality of 13% at three months and 23% at 12 months (8). Among nursing home residents with advanced dementia and hip fracture, 35% died within 6 months and 62% died within 2 years of the fracture (9). Risk factors for increased mortality after a hip fracture include age, illness burden, baseline functional impairments, and level of cognitive impairment (4,10,11).
- Identify advanced dementia as a risk factor for high morbidity and mortality after hip fracture.
- List three considerations to assist in determination of appropriate post-fracture management of patients with advanced dementia and hip fracture.
- Explain the options towards pain reduction in hip fracture management of patients with advanced dementia.
Review of Systems (ROS)
1. Handoll, H. H., & Parker, M. J. (2008). Conservative versus operative treatment for hip fractures in adults. Cochrane database of systematic reviews, (3).
2. Mears, S. C. (2014). Classification and surgical approaches to hip fractures for nonsurgeons. Clinics in geriatric medicine, 30(2), 229-241.
3. Folbert, E. C., et al. "Improved 1-year mortality in elderly patients with a hip fracture following integrated orthogeriatric treatment." Osteoporosis International 28.1 (2017): 269-277.
4. Schnell, Scott, et al. "The 1-year mortality of patients treated in a hip fracture program for elders." Geriatric orthopaedic surgery & rehabilitation 1.1 (2010): 6-14.
5. Friedman, Susan M., et al. "Geriatric co‐management of proximal femur fractures: Total quality management and protocol‐driven care result in better outcomes for a frail patient population." Journal of the American Geriatrics Society 56.7 (2008): 1349-1356.
6. Johnston, C. Bree et al. “Hip Fracture in the Setting of Limited Life Expectancy: The Importance of Considering Goals of Care and Prognosis.” Journal of Palliative Medicine. Volume 21, Number 8 (2018): 1069-1073.
7. Alvi, Hasham M., et al. "Time-to-Surgery for Definitive Fixation of Hip Fractures: A Look at Outcomes Based Upon Delay." American journal of orthopedics (Belle Mead, NJ) 47.9 (2018).
8. Schnell, Scott, et al. "The 1-year mortality of patients treated in a hip fracture program for elders." Geriatric orthopaedic surgery & rehabilitation 1.1 (2010): 6-14.
9. Berry, Sarah D et al. “Association of Clinical Outcomes with Surgical Repair of Hip Fracture vs Nonsurgical Management in Nursing Home Residents with Advanced Dementia.” JAMA Internal Medicine. 2018: 178 (6): 774-780.
10. Moerman, Sophie, et al. "Less than one‐third of hip fracture patients return to their prefracture level of instrumental activities of daily living in a prospective cohort study of 480 patients." Geriatrics & gerontology international 18.8 (2018): 1244-1248.
11. Neuman, Mark D., et al. "Survival and functional outcomes after hip fracture among nursing home residents." JAMA internal medicine 174.8 (2014): 1273-1280.