What is the best management plan for an 81-year-old female with a history of right hip fracture, chronic kidney disease, and multiple other comorbidities, who is currently on rehabilitation and multiple medications?

Comprehensive Management Plan for an 81-Year-Old Female After Hip Fracture

The optimal management plan for this 81-year-old female with recent hip fracture, CKD stage 4, and multiple comorbidities should include continued rehabilitation, fall prevention, bone health optimization, medication management, and regular follow-up to reduce morbidity and mortality. 1

Rehabilitation Program

• Continue current PT/OT program with focus on:
  • Progressive physical training and muscle strengthening
  • Balance training to prevent future falls
  • Functional mobility exercises to regain independence 1
• Rehabilitation should be continued for at least 3 months post-fracture, with evidence showing significant improvements in walking distance within 6 weeks of structured therapy 2
• Home-based exercises should be encouraged between formal PT sessions using a structured program 3
• Monitor pain during rehabilitation to ensure it doesn't impede progress

Fall Prevention

• Implement multidimensional fall prevention strategies:
  • Home safety assessment to identify and remove hazards
  • Appropriate use of assistive devices (walker currently, transitioning to cane when appropriate)
  • Proper footwear with non-slip soles
  • Adequate lighting, especially at night 1
• Consider referral to a fall prevention program if available

Bone Health Management

• Add calcium and vitamin D supplementation to current medication regimen:
  • Calcium 1000-1200 mg/day (diet plus supplements)
  • Vitamin D 800 IU/day 1
• Consider bone mineral density testing if not recently done
• Initiate anti-osteoporosis medication:
  • Zoledronic acid (IV) would be most appropriate given patient's multiple medications, age, and demonstrated efficacy after hip fracture 1
  • Denosumab is an alternative if zoledronic acid is contraindicated due to CKD stage 4 1, 4

Medication Management

• Continue current medications with careful monitoring:
  • Eliquis 5mg twice daily - appropriate for stroke prevention
  • Irbesartan 300mg daily - monitor renal function closely due to CKD stage 4
  • Jardiance 10mg daily - monitor for efficacy and safety in CKD
• Pain management:
  • Continue gabapentin 400mg BID for neuropathic pain
  • Add lidocaine patch 5% for localized pain (already prescribed)
  • Avoid NSAIDs due to CKD stage 4 4
  • Limit opioid use to breakthrough pain only 5
• Address bradycardia:
  • Monitor heart rate regularly
  • Consider cardiology consultation for evaluation of verapamil's role in bradycardia
  • Potential dose adjustment of verapamil may be needed

Monitoring and Follow-up

• Regular monitoring of:
  • Renal function (CKD stage 4)
  • Electrolytes, particularly potassium with irbesartan
  • Blood pressure and heart rate (bradycardia)
  • Blood glucose (diabetes management)
  • Medication adherence
• Follow-up appointments:
  • Primary care: every 2-3 months initially
  • Nephrology: within 1 month given CKD stage 4
  • Cardiology: within 1 month for bradycardia evaluation
  • Orthopedics: as recommended by surgeon

Patient Education

• Educate patient about:
  • Importance of medication adherence
  • Signs and symptoms requiring immediate medical attention
  • Fall prevention strategies
  • Proper use of assistive devices
  • Home exercise program between PT sessions 1

Special Considerations for CKD Stage 4

• Higher fracture risk in CKD patients (3-year hip fracture incidence of 7.8% in women >65 years with eGFR 15-29) 6, 7
• Increased post-fracture mortality in CKD stage 4 patients 7
• Medication dosing adjustments may be needed for:
  • Gabapentin (already at appropriate dose of 400mg BID)
  • Allopurinol (appropriate at 100mg daily)
  • Bone health medications (prefer IV zoledronic acid with dose adjustment or denosumab) 4

This comprehensive approach addresses the patient's multiple comorbidities while focusing on functional recovery, prevention of future fractures, and appropriate medication management to optimize outcomes and reduce mortality risk.