What is the best management approach for an elderly patient with a history of osteoarthritis (OA), hypothyroidism, hypertension (HTN), chronic kidney disease (CKD), and cognitive impairment, who presents with a mildly displaced left intertrochanteric hip fracture and scalp hematoma after a fall?

Neurology-Specific Evaluation and Management Recommendations

Primary Neurological Assessment

This patient requires urgent orthopedic surgical consultation for her mildly displaced left intertrochanteric hip fracture, with surgery ideally performed within 24-48 hours of admission to reduce mortality and complications. 1 From a neurological standpoint, the key concerns are: (1) determining if the fall was mechanical versus syncope/seizure-related, (2) assessing cognitive status and delirium risk, and (3) evaluating the scalp hematoma for any intracranial complications.

Fall Mechanism Evaluation

• The reported dizziness preceding the fall warrants cardiac evaluation including ECG and orthostatic vital signs, as syncope significantly impacts perioperative risk and recurrent fall prevention 1
• The unwitnessed nature of the fall and mild confusion raise concern for possible loss of consciousness, though the patient denies this 1
• Discrepancy between patient's report (kitchen) and family's observation (washing room) suggests either confusion or possible post-ictal state that should prompt consideration of seizure, though this is less likely given lack of other seizure stigmata 2
• Recent emotional distress and anxiety from the theft incident may have contributed to inattention or orthostatic hypotension if the patient was not eating/drinking adequately 2

Cognitive Assessment and Delirium Risk

• The patient's baseline "moderate cognitive impairment" combined with current disorientation to place (oriented x2-3) places her at extremely high risk for postoperative delirium, which significantly increases mortality and functional decline 1
• Current mild confusion may represent early delirium, baseline cognitive impairment, or pain-related distraction—serial assessments are needed 1
• Hypothyroidism can worsen cognitive function and must be optimized perioperatively, as undertreated hypothyroidism is associated with increased complications in hip fracture patients 3

Scalp Hematoma Management

• The small left parietal subgaleal hematoma without intracranial injury on CT requires only observation with serial neurological checks 4, 2
• Monitor for signs of expansion (increasing size, new neurological deficits, altered mental status) though this is unlikely given initial CT was negative 4
• The left suboccipital soft tissue swelling suggests the head struck posteriorly, consistent with a backward fall mechanism 2

Perioperative Neurological Optimization

Immediate Pre-Surgical Management

• Interdisciplinary orthogeriatric care is mandatory and reduces complications and mortality 1
• Surgery should occur within 24-48 hours unless medical optimization is needed, as delays beyond 48 hours increase mortality 1
• Multimodal analgesia with fascia iliaca or femoral nerve block should be administered immediately to reduce opioid requirements and delirium risk 1
• Avoid excessive opioids given her CKD and cognitive impairment—use scheduled acetaminophen as baseline with judicious opioid supplementation 1, 2

Anesthesia Considerations

• Either spinal or general anesthesia is appropriate per AAOS guidelines, though spinal may reduce delirium risk in cognitively impaired patients 1
• Ensure adequate hydration and avoid hypotension during anesthesia, as elderly patients with cognitive impairment are particularly vulnerable to perioperative cerebral hypoperfusion 1, 2

Surgical Approach for Intertrochanteric Fracture

• Cephalomedullary nail fixation is the recommended treatment for this mildly displaced intertrochanteric fracture 1
• Tranexamic acid should be administered intraoperatively to reduce blood loss and transfusion requirements 1
• Blood transfusion is indicated only for symptomatic anemia or hemoglobin <8 g/dL in asymptomatic patients 1

Postoperative Neurological Management

Delirium Prevention and Management

• Implement a structured delirium prevention protocol including reorientation, sleep hygiene, early mobilization, adequate pain control, and minimizing unnecessary medications 1, 2
• Avoid benzodiazepines and anticholinergics which significantly worsen delirium in elderly patients 1
• Ensure thyroid hormone replacement is continued perioperatively as hypothyroidism exacerbates cognitive dysfunction 3
• Serial cognitive assessments using validated tools to detect delirium early 1

Mobilization and Rehabilitation

• Weight-bearing as tolerated should begin immediately postoperatively to prevent deconditioning and complications from immobility 1, 4, 2
• Early physical therapy within 24 hours of surgery reduces complications and improves functional outcomes 2
• Avoid bed rest, as immobility dramatically increases risk of pneumonia, pressure ulcers, DVT, and further cognitive decline 4, 2

VTE Prophylaxis

• Venous thromboembolism prophylaxis is mandatory for 4 weeks postoperatively using low-molecular-weight heparin (e.g., enoxaparin) or sequential compression devices 1
• Adjust dosing for CKD to prevent bleeding complications 1

Secondary Prevention and Long-Term Management

Fall Prevention

• Comprehensive fall risk assessment is essential given the unwitnessed fall, reported dizziness, and cognitive impairment 2, 5
• Evaluate and treat orthostatic hypotension, review medications that increase fall risk (sedatives, antihypertensives), and assess vision and home safety 2, 5
• Physical therapy focusing on balance and gait training reduces recurrent falls 2

Osteoporosis Management

• Bisphosphonate therapy should be initiated to reduce risk of subsequent fractures unless contraindicated 1, 2, 5
• DEXA scan, vitamin D, calcium, and parathyroid hormone levels should be obtained 1
• Referral to Fracture Liaison Service for comprehensive osteoporosis management 2

Cognitive and Thyroid Optimization

• Ensure adequate thyroid hormone replacement as hypothyroidism is associated with worse outcomes after hip fracture 3
• Cognitive rehabilitation and support services given baseline moderate cognitive impairment 2
• Address the recent psychological trauma from the theft incident, as anxiety and depression worsen recovery 2

Critical Pitfalls to Avoid

• Do not delay surgery beyond 48 hours unless absolutely necessary for medical optimization, as mortality increases significantly 1
• Do not rely on the patient's self-report of fall mechanism given cognitive impairment—obtain collateral history and investigate cardiac/neurological causes 1, 2
• Do not prescribe excessive opioids in this patient with CKD and cognitive impairment—use multimodal analgesia with nerve blocks 1, 2, 6
• Do not assume the scalp hematoma is benign without serial neurological assessments, though intracranial injury is unlikely given negative CT 4, 2
• Do not overlook hypothyroidism optimization, as it significantly impacts surgical outcomes and cognitive function 3