From the Guidelines
Management of elderly patients with hip fractures requires a comprehensive, multidisciplinary approach focused on early surgery, pain control, and rehabilitation, with surgery ideally performed within 24-48 hours of admission to reduce mortality and complications, unless medical optimization is needed, as recommended by the most recent guidelines 1. The optimal management strategy for elderly patients with hip fractures involves a multifaceted approach that prioritizes early surgical intervention, effective pain management, and rehabilitation. Key components of this approach include:
- Early surgery: Performing surgery within 24-48 hours of admission, unless medical optimization is necessary, to reduce mortality and complications 1.
- Pain management: Utilizing scheduled acetaminophen and careful use of opioids, as well as regional nerve blocks, to minimize side effects and provide effective analgesia 1.
- Thromboprophylaxis: Initiating low molecular weight heparin or direct oral anticoagulants promptly and continuing for 28-35 days post-surgery to prevent venous thromboembolism 1.
- Nutritional support: Providing protein supplementation and vitamin D plus calcium to support bone health and overall recovery 1.
- Early mobilization: Encouraging early mobilization within 24 hours post-surgery and daily physical therapy to promote functional recovery and prevent complications 1.
- Delirium prevention: Implementing strategies to prevent delirium, such as maintaining normal sleep-wake cycles, ensuring adequate hydration, and minimizing unnecessary medications 1.
- Osteoporosis treatment: Initiating osteoporosis treatment before discharge, typically with bisphosphonates, to prevent future fractures 1. This comprehensive approach, as outlined in the most recent guidelines 1, addresses the complex needs of elderly hip fracture patients and helps reduce mortality, improve functional outcomes, and prevent future fractures.
From the FDA Drug Label
In the Three-Year Study of FIT, fractures of the hip occurred in 22 (2. 2%) of 1005 patients on placebo and 11 (1.1%) of 1022 patients on alendronate sodium, p=0. 047. Figure 1 displays the cumulative incidence of hip fractures in this study In the Three-Year Study of FIT, alendronate sodium significantly reduced the incidence of hospitalizations (25.0% vs. 30.7%). Hip fracture 1.1 2.2 1.1 51¶
The optimal management strategy for elderly patients with hip fractures is not directly stated in the provided text. However, alendronate sodium has been shown to reduce the incidence of hip fractures by 51% in patients with at least one baseline vertebral fracture.
- Key points:
- Alendronate sodium reduced hip fractures from 2.2% to 1.1% in the Three-Year Study of FIT.
- The relative risk reduction for hip fractures was 51%.
- The study population consisted of postmenopausal women with at least one baseline vertebral fracture.
- The results suggest that alendronate sodium may be beneficial in reducing the incidence of hip fractures in this population 2.
From the Research
Optimal Management Strategy for Elderly Patients with Hip Fractures
The optimal management strategy for elderly patients with hip fractures involves a multidisciplinary approach that includes medical specialists, rehabilitation, and orthopedic repair 3, 4, 5, 6, 7.
- Preoperative care:
- Correct medical abnormalities
- Consider the appropriateness, timing, and type of surgical repair in the context of the patient's life expectancy and goals of care 3
- Perioperative care:
- Prophylaxis with antibiotics
- Chemoprophylaxis for venous thromboembolism
- Correction of major clinical abnormalities prior to surgery 3
- Inpatient care:
- Pain control
- Delirium prevention
- Pressure ulcer prevention 3
- Rehabilitation strategies:
- Care transitions:
- Attention to care transitions is necessary
- Treatment for osteoporosis should be considered 3
Multidisciplinary Rehabilitation
Multidisciplinary rehabilitation, supervised by a geriatrician, rehabilitation physician, or other appropriate physician, can result in fewer cases of 'poor outcome' (death or deterioration in residential status) at 6 to 12 months' follow-up 4.
- Inpatient rehabilitation:
- Multidisciplinary rehabilitation probably results in fewer cases of 'poor outcome' (death or deterioration in residential status) at 6 to 12 months' follow-up 4
- Ambulatory setting:
- Supported discharge and multidisciplinary home rehabilitation may result in little to no between-group difference in poor outcome (death or move to a higher level of care or inability to walk) at one year 4
Implementation of a Multidisciplinary Care Pathway
Implementation of a multidisciplinary care pathway for elderly hip fractures can improve patient outcomes, including a lower incidence of in-hospital complications, shorter emergency room length of stay, and shorter overall hospital length of stay 6.