Medical assessment and care

Elderly hip fracture patients need comprehensive preoperative evaluation and management, often involving multiple specialties, because of their frequent comorbidities and complications. However, surgery should not be unnecessarily delayed.

While finding and addressing significant problems is an appropriate goal, a prolonged work-up, or time spent on issues that cannot be promptly improved, may delay surgery without benefit for the patient. Current evidence suggests that most patients with femoral neck fractures have better results if operated within 48 hours after injury. Patients with more than three medical comorbidities may benefit from a longer attempt at medical optimization, but generally should have surgery within 4 days.

Postoperatively, 20% or more of elderly patients with hip fractures will develop at least one medical complication (most commonly cardiac or pulmonary). Frequency of complications is predictably higher in those patients with more severe comorbidities, and they have expectedly higher risks of postoperative death. Involvement of anesthesia and medical consultants in the perioperative care of these patients makes management easier, and may improve results.
Routine perioperative care for the elderly hip fracture patient should include:

• Antibiotics (usually a 1st generation cephalosporin) begun just prior to surgery and stopped soon after (typically within 24 hrs).
• Prophylaxis against venous thromboembolic disease (VTE), according to institutional protocols, with particular attention to those patients who have increased risk factors, especially prior VTE.
• Nutritional supplementation, since many elderly patients have unrecognized malnutrition, even in the presence of apparently sufficient socioeconomic resources.
• Pain management with care to avoid excessive use of narcotics (to reduce risk of postoperative delirium).
• Attention to avoidance of pressure sores, particularly on the heel of the affected leg (which should be kept off the bed by a pillow that supports the entire calf without producing knee flexion). Frequent turning and early mobilization help prevent pressure ulcers in other locations.
• Early mobilization out of bed, with supported ambulation beginning in the first postoperative day. This is facilitated by use of appropriately selected surgical procedures that do not require non weight bearing.
• Early planning for discharge to an appropriate setting - be it home, rehabilitation facility, chronic care facility, or other setting based upon resources available for the individual patient, and the local health care system. Planning for discharge must include postoperative assessment of the patient’s ability safely to transfer and ambulate, as well as to take care of other essential activities of daily living.
• Consideration should be given to assessment and treatment of osteoporosis, since this condition is typically present for any elderly patient who sustains a hip fracture and may help prevent future fractures.

Predicting whether a patient can successfully return home may be difficult, but here are some guidelines that may be helpful.
Studies have shown that as few as 50% of patients were able to return home, and that mortality rates are lower in those that do return home compared with rates in those that are transferred to nursing homes or rehabilitation centers.

Predictors of a patient’s ability to return home include:

• a younger age (less than 85 years)
• ability to walk independently preoperatively
• ability to perform activities of daily living preoperatively
• living with another person
• ability to walk independently at the time of discharge from the hospital.