What is the best treatment approach for a patient with a hip fracture, anxiety, and increased alcohol use due to feelings of overwhelm?

Treatment Approach for Hip Fracture with Anxiety and Alcohol Use

This patient requires immediate surgical fixation within 24-48 hours combined with multidisciplinary orthogeriatric care that addresses pain control, alcohol dependence screening, and psychological distress through coordinated rehabilitation. 1

Immediate Perioperative Management

Pain Control Priority

• Administer regular paracetamol immediately as first-line analgesia, which forms the foundation of acute care before definitive stabilization 2, 3
• Add opioid analgesia cautiously, with dose reduction particularly important given the high prevalence (40%) of renal dysfunction in hip fracture patients 1, 3
• Consider femoral nerve block or fascia iliaca block for superior pain control, though these may not reliably block all three nerves (femoral, obturator, lateral cutaneous) 2, 3
• Avoid NSAIDs until renal function is confirmed, as they are relatively contraindicated in this population 1, 3

Surgical Timing and Approach

• Proceed with surgery within 24-48 hours of admission, as this significantly reduces short-term and mid-term mortality rates and reduces complications from immobility 1
• Immobilize the limb immediately to minimize pain and prevent further soft tissue injury 2, 3
• Ensure comprehensive preoperative assessment including chest X-ray, ECG, full blood count, renal function, and cognitive baseline function 1

Alcohol Dependence Management

Recognition and Screening

• Recognize that alcohol dependence is common, under-diagnosed, and a significant risk factor for perioperative morbidity in hip fracture patients 1, 4
• The clinical evaluation alone has poor sensitivity—it correctly identifies only 35 of 56 individuals (62%) with hazardous alcohol use compared to validated screening tools 5
• Use validated screening tools like AUDIT (Alcohol Use Disorders Identification Test) rather than relying solely on clinical judgment 5

Perioperative Considerations

• Anticipate and manage alcohol withdrawal appropriately to prevent complications that could increase thrombosis risk and overall morbidity 4
• Monitor for abnormally low initial Bispectral Index (BIS) levels in alcoholic patients, which can affect anesthetic management 4
• Maintain optimal fluid management throughout the perioperative period, as this is particularly important in patients with alcohol dependence 4

Thromboprophylaxis in Alcohol-Using Patients

• Prescribe fondaparinux or low molecular weight heparins for thromboprophylaxis, as hip fracture patients have a 37% prevalence of DVT and 6% prevalence of PE 4
• Administer low molecular weight heparin between 18:00 and 20:00 to minimize bleeding risk related to neuraxial anesthesia 4
• Employ thromboembolism stockings or intermittent compression devices intra-operatively 4

Psychological Distress and Anxiety Management

Recognition of Psychological Burden

• Understand that psychological distress affects 31-36% of hip fracture patients throughout the first year, with anxiety being a prominent component 6
• Frailty at onset of hip fracture is the most important prognostic factor for symptoms of depression (OR 2.74) and anxiety (OR 2.60) 6
• The combination of overwhelming life circumstances (moving, staffing changes) with hip fracture creates compounded psychological vulnerability 6

Acute Confusional State Management

• Postoperative cognitive dysfunction occurs in 25% of hip fracture patients and requires multimodal optimization including adequate analgesia, nutrition, hydration, electrolyte balance, and mobilization 1
• Use haloperidol or lorazepam only for short-term symptom control, not as routine management 1
• Avoid cyclizine due to antimuscarinic side effects in older persons 1

Comprehensive Orthogeriatric Care Model

Multidisciplinary Team Structure

• Implement orthogeriatric comanagement with joint care between geriatrician and orthopedic surgeon on a dedicated orthogeriatric ward, which has been shown to have the shortest time to surgery and length of stay 1
• Ensure ward care with a nurse:patient ratio of 1:4, with regular input from physicians specialized in medicine for the elderly 1
• Coordinate care involving physiotherapists, occupational therapists, social workers, nursing staff, and relatives 1

Postoperative Care Essentials

• Administer supplemental oxygen for at least 24 hours postoperatively, as older patients are at risk of postoperative hypoxia 1
• Encourage early oral fluid intake rather than routine intravenous fluids, and remove urinary catheters as soon as possible 1
• Provide nutritional supplementation, as up to 60% of hip fracture patients are clinically malnourished on admission 1

Rehabilitation and Recovery

Structured Rehabilitation Program

• Begin rehabilitation ideally coordinated by orthogeriatricians, aimed at returning the patient to pre-fracture levels of activity and residence 1
• Continue regular paracetamol administration, augmented by carefully prescribed opioid analgesia during remobilization 1
• Include pain evaluation as part of routine postoperative nursing observations 1

Secondary Prevention

• Actively consider secondary prevention of falls and osteoporosis in the early postoperative period, as subsequent fragility fracture is associated with particularly poor prognosis 1
• Provide printed information describing typical care pathways for hip fracture patients to patients, carers, and relatives 1

Critical Pitfalls to Avoid

• Do not delay pain assessment and management while focusing on other interventions—document pain scores before and after analgesia to guide ongoing management 2, 3
• Do not use standard opioid dosing without considering renal function, and do not prescribe NSAIDs without checking renal function first 1, 3
• Do not rely solely on clinical judgment to identify alcohol use—use validated screening tools as clinical evaluation has poor sensitivity 5
• Do not overlook the high prevalence of psychological distress—early identification of frail patients at high risk is essential 6
• Do not delay surgery beyond 48 hours unless absolutely necessary for medical optimization, as prolonged immobility increases complications 1

Alcohol and Recovery Considerations

• Note that alcohol consumption per se does not clearly indicate worse hip fracture recovery outcomes—47% of patients remain alcohol consumers throughout recovery without negative effects on disability or physical function 7
• However, alcohol dependence (distinct from moderate consumption) remains a significant perioperative risk factor requiring specific management 1, 4