What is the appropriate care plan for an elderly patient with multiple postoperative fractures, severe vitamin D deficiency, and other related health issues?

Comprehensive Care Plan for 82-Year-Old Female with Multiple Post-Operative Fractures

This patient requires immediate initiation of high-dose vitamin D supplementation (50,000 IU weekly for 8 weeks) to correct severe deficiency (<6 ng/mL), followed by maintenance dosing of 800-1000 IU daily, combined with calcium 1000-1200 mg daily, alongside continued orthogeriatric co-management, aggressive physical rehabilitation with fall prevention, and evaluation for osteoporosis pharmacotherapy once fractures stabilize. 1

Immediate Priorities: Vitamin D Deficiency Management

Severe vitamin D deficiency (serum level <6 ng/mL) dramatically increases risk of excess mortality, infections, fractures, and impaired bone healing and must be corrected urgently. 2

• Initiate repletion therapy immediately: High-dose ergocalciferol 50,000 IU weekly for 8 weeks is the standard approach for severe deficiency 3, 4
• Target serum 25(OH)D level: Aim for >30 ng/mL (75 nmol/L) to maximize bone health and fracture healing 4, 5
• Maintenance therapy: After repletion, continue 800-1000 IU daily indefinitely 1, 4
• Concurrent calcium supplementation: Ensure total calcium intake of 1000-1200 mg/day (diet plus supplements) 1
• Monitor response: Recheck 25(OH)D level after 8-12 weeks of repletion 3

Clinical caveat: Vitamin D deficiency is endemic in patients with recent fractures and directly impairs fracture healing and increases fall risk. 1, 4 The patient's severe deficiency likely contributed to her fragility fractures and will impede recovery if not corrected. 2

Anemia Management (Hemoglobin 8.3 g/dL)

Postoperative anemia with Hgb 8.3 g/dL requires close monitoring but not immediate transfusion given the patient is asymptomatic. 1, 6

• Weekly CBC monitoring: Track hemoglobin trends to ensure stability 6
• Transfusion threshold: Consider transfusion if Hgb drops below 9 g/dL, or below 10 g/dL if cardiac symptoms develop 6
• Expected perioperative drop: Hemoglobin typically decreases ~2.5 g/dL after orthopedic surgery 6
• Nutritional support: Optimize protein intake to support erythropoiesis and wound healing 1, 6
• Monitor for bleeding: Assess surgical sites and GI/GU systems for occult blood loss 1

Nutritional Optimization

Low prealbumin (15 mg/dL) and hypoalbuminemia (3.2 g/dL) independently predict nonunion, surgical site infection, and poor functional recovery. 6

• Formal dietary consultation: Implement high-protein, high-calorie diet immediately 1, 6
• Protein target: Aim for 1.2-1.5 g/kg/day to support fracture healing 6
• Monitor markers: Weekly prealbumin and albumin levels to assess response 6
• Nutritional supplementation: Consider oral nutritional supplements if dietary intake inadequate 1, 6
• Daily weights: Track for trends indicating muscle loss or fluid shifts 1

Critical point: Hypoalbuminemia increases surgical site infection risk (P = 0.009) and is independently predictive of nonunion (OR 0.028, P = 0.015). 6 This patient's nutritional status requires aggressive intervention.

Orthogeriatric Co-Management

Orthogeriatric co-management is mandatory for this frail elderly patient with multiple fractures and comorbidities, as it improves functional outcomes, reduces hospital stay, and decreases mortality. 1

• Multidisciplinary team: Coordinate care between orthopedics, geriatrics, physical therapy, occupational therapy, nursing, and nutrition 1
• Daily rounds: Systematic assessment of pain, cognition, skin integrity, bowel/bladder function, and mobility 1
• Medication reconciliation: Review all medications for inappropriate dosing and drug-drug interactions, as polypharmacy increases adverse events (80% potentially avoidable) 6
• Cognitive monitoring: Regular assessment for delirium, which is common post-operatively in elderly patients 1
• Pressure ulcer prevention: Use pressure-relieving surfaces and frequent repositioning 1

Physical Rehabilitation and Fall Prevention

Early introduction of physical training and muscle strengthening, combined with long-term balance training and multidimensional fall prevention, is essential for functional recovery. 1

• Continue intensive PT/OT: Patient currently requires max assist ×2; progressive mobilization is critical 1
• Weight-bearing precautions: Strictly maintain NWB right lower extremity, WBAT left lower extremity with boot, WBAT left upper extremity with sling 1
• Balance training: Implement once weight-bearing status allows, as this reduces fall risk by 15-20% 1
• Address dizziness: Evaluate for orthostatic hypotension, medication effects, or vestibular dysfunction causing reported dizziness with position changes 1
• Environmental modifications: Low bed, call light within reach, adequate lighting, clear pathways 1
• Assistive devices: Ensure proper walker/wheelchair fit and training 1

Common pitfall: Dizziness with sitting/standing significantly increases fall risk and may indicate dehydration, medication effects, or autonomic dysfunction requiring evaluation. 1

Pain Management

Continue tramadol 50 mg q6h PRN, but monitor closely for side effects including constipation, dizziness, and cognitive impairment in this elderly patient. 1

• Multimodal analgesia: Consider adding acetaminophen scheduled dosing (if no hepatic contraindication) to reduce opioid requirements 1
• Pain assessment: Regular evaluation using validated scales to ensure adequate control 1
• Minimize opioid use: Taper as fracture pain improves to reduce fall risk and constipation 1
• Non-pharmacologic measures: Ice, elevation, positioning for comfort 1

Constipation Prevention

Continue polyethylene glycol 17 g daily, as immobility and opioid use dramatically increase constipation risk. 1

• Bowel regimen: Maintain scheduled laxative, not PRN 1
• Hydration: Encourage fluid intake of at least 1500-2000 mL daily if not contraindicated 1
• Fiber supplementation: Add if tolerated and adequate hydration maintained 1
• Monitor bowel movements: Document frequency; intervene if >3 days without BM 1
• Escalate therapy: Add stimulant laxative (senna) if polyethylene glycol insufficient 1

Thromboembolism Prophylaxis

Continue aspirin 325 mg BID as prescribed for orthopedic postoperative prophylaxis. 1

• Duration: Typically 4-6 weeks post-operatively for lower extremity fractures 1
• Monitor for bleeding: Given multiple surgical sites and aspirin use 1
• Sequential compression devices: Consider if patient remains largely immobile 1
• Early mobilization: Best prophylaxis when safe per weight-bearing restrictions 1

Fracture Healing Monitoring

Systematic neurovascular checks and cast/splint assessment are essential to detect complications early. 1

• Neurovascular checks: Continue each shift assessing pulses, capillary refill, sensation, motor function 1
• Cast integrity: Inspect for loosening, pressure areas, drainage, odor 1
• Compartment syndrome vigilance: Monitor for severe pain, paresthesias, pallor, pulselessness (though less common post-operatively) 1
• Wound assessment: Evaluate surgical incisions for signs of infection (erythema, warmth, drainage, dehiscence) 1
• Follow-up imaging: Coordinate with orthopedics for scheduled radiographs to assess healing 1

Secondary Fracture Prevention: Osteoporosis Evaluation and Treatment

Every patient aged 50+ with a recent fracture should be systematically evaluated for osteoporosis and subsequent fracture risk. 1

Diagnostic Evaluation (Once Acute Phase Stabilizes)

• DXA scan: Order dual-energy X-ray absorptiometry of spine and hip to assess bone mineral density 1
• Vertebral fracture assessment: Obtain lateral spine imaging to detect silent vertebral fractures 1
• FRAX calculation: Calculate 10-year fracture risk using clinical risk factors 1
• Secondary osteoporosis screening: Check TSH (already done: 3.04, normal), consider 24-hour urine calcium, serum protein electrophoresis if indicated 1

Pharmacologic Treatment Considerations

Pharmacologic treatment should use drugs demonstrated to reduce vertebral, non-vertebral, and hip fractures, with first-line agents being oral bisphosphonates (alendronate or risedronate). 1

• Timing: Initiate after fractures have healed sufficiently (typically 3-6 months post-operatively) and vitamin D deficiency corrected 1
• First-line options: Alendronate or risedronate are preferred due to efficacy, tolerability, low cost, and extensive clinical experience 1
• Alternative agents: For patients with oral intolerance, dementia, malabsorption, or non-compliance, consider zoledronic acid (IV annually) or denosumab (subcutaneous every 6 months) 1
• Efficacy data: Bisphosphonates reduce spine and hip fractures by 50% over 3 years 1
• Monitoring: Assess tolerance, adherence, and consider repeat DXA in 2 years 1

Important consideration: This patient's history of "irregular adherence and inability to keep appointments" (from guideline case example) suggests oral bisphosphonates may be problematic. 1 Once appropriate, strongly consider zoledronic acid 5 mg IV annually or denosumab 60 mg subcutaneous every 6 months for better adherence. 1

Non-Pharmacologic Interventions

Non-pharmacological treatment is essential and includes adequate calcium/vitamin D, smoking cessation, and alcohol limitation. 1

• Calcium and vitamin D: Already addressed above (1000-1200 mg calcium, 800-1000 IU vitamin D daily maintenance) 1
• Smoking cessation: Critical, as smoking is a well-known risk factor for nonunion and future fractures 6
• Alcohol limitation: Advise moderation if applicable 1
• Weight-bearing exercise: Implement once fractures healed and weight-bearing allowed 1

Patient and Family Education

Patients should be educated about disease burden, fracture risk factors, follow-up requirements, and treatment duration. 1

• Fracture risk: Explain that one fracture significantly increases risk of subsequent fractures 1
• Medication adherence: Emphasize importance of consistent vitamin D, calcium, and future osteoporosis medications 1
• Fall prevention: Review home safety modifications needed before discharge 1
• Weight-bearing precautions: Ensure patient and family understand restrictions and progression timeline 1
• Warning signs: Teach recognition of infection, cast problems, neurovascular compromise requiring immediate attention 1
• Therapy participation: Emphasize critical importance of PT/OT for functional recovery 1

Disposition Planning

Continue skilled nursing facility care until patient achieves sufficient mobility and ADL independence for safe discharge home with home health services. 1

• Discharge criteria: Ability to transfer safely with appropriate assist level, adequate pain control, stable medical status 1
• Home modifications: Assess need for ramps, grab bars, shower chair, raised toilet seat 1
• Home health services: Arrange PT/OT continuation, nursing for wound checks and medication management 1
• Durable medical equipment: Ensure walker, wheelchair, commode as needed 1
• Follow-up appointments: Schedule with orthopedics, primary care, and other specialists as indicated 1

Medication Interactions and Polypharmacy Review

Review all medications for inappropriate dosing and potential interactions, as polypharmacy increases adverse drug reactions. 6

• Current regimen review: Tramadol, aspirin 325 mg BID, polyethylene glycol appear appropriate 6
• Drug-drug interactions: Monitor for bleeding risk with aspirin; tramadol may increase fall risk via dizziness 1, 6
• Vitamin D dosing: High-dose vitamin D (50,000 IU weekly) requires monitoring for hypercalcemia, though rare at therapeutic doses 3
• Avoid high-pulse vitamin D: Do not use very high intermittent doses (e.g., 300,000 IU), as these increase fall risk 1

Critical warning: Proton pump inhibitors (if added) decrease calcium absorption and increase fracture risk; selective serotonin reuptake inhibitors (if needed for depression) may double fracture risk. 1 Avoid these medication classes if possible in this high-risk patient.