What is the best treatment approach for an elderly patient with dementia and a non-displaced sacral fracture, considering their cognitive and physical limitations?

Management of Non-Displaced Sacral Fractures in Elderly Patients with Dementia

Direct Answer

For elderly patients with dementia and non-displaced sacral fractures, implement immediate orthogeriatric comanagement with multimodal analgesia (avoiding opioids), early mobilization within 24-48 hours, and systematic secondary fracture prevention—this conservative approach achieves functional improvement even in patients with dementia and bilateral fractures. 1, 2

---

Immediate Pain Management Strategy

Start with regional nerve blocks combined with scheduled acetaminophen as first-line treatment, explicitly avoiding opioids which dramatically increase delirium risk in dementia patients. 1

• Provide multimodal analgesia before diagnostic workup to prevent immobility-related complications 1
• Opioids carry increased risk of falls, delirium, and mortality in elderly patients—particularly dangerous in those with pre-existing dementia 1
• Document pain scores at rest and with movement before and after analgesia administration 3

---

Orthogeriatric Comanagement Structure

Implement immediate multidisciplinary orthogeriatric comanagement on a dedicated ward to reduce mortality, length of stay, and complications—this is critical as sacral fractures carry mortality rates comparable to hip fractures despite being traditionally considered "stable." 1

The comprehensive geriatric assessment must systematically evaluate:

• Nutritional status with oral supplementation implementation 1
• Electrolyte and volume disturbances requiring correction 1
• Anemia screening with appropriate transfusion thresholds 1
• Cardiac and pulmonary comorbidities 1
• Cognitive function baseline and delirium risk—particularly important given pre-existing dementia 1
• Complete medication review 1
• Renal function 1

---

Early Mobilization Protocol

Begin weight-bearing as tolerated within 24-48 hours to prevent thromboembolism, pressure ulcers, pneumonia, and deconditioning. 1, 2

• Implement supervised ambulation initially with fall prevention strategies including room modifications 1
• Physical training and muscle strengthening should begin immediately post-fracture 1, 4
• Conservative therapy achieves improvements in all patients regarding need for care, mobility without aids, and risk of falling—even in patients with bilateral sacral insufficiency fractures 2
• Patients with bilateral fractures show no significant difference in functional improvement compared to unilateral fractures when treated conservatively 2

---

Delirium Prevention in Dementia Patients

Implement multi-component non-pharmacological prevention strategies, as dementia patients have extremely high baseline risk (dementia prevalence reaches 85% in hip fracture patients). 1, 5

Critical interventions include:

• Hydration management 1
• Sleep-wake cycle normalization 1
• Cognitive orientation 1
• Strict avoidance of opioids which dramatically increase delirium risk 1

---

Thromboembolism Prophylaxis

Administer pharmacologic VTE prophylaxis with low molecular weight heparin plus mechanical compression devices. 1

• Use mechanical prophylaxis alone if anticoagulation is contraindicated 1

---

Secondary Fracture Prevention

Systematically evaluate all patients for subsequent fracture risk and initiate anti-osteoporotic treatment even without DXA scan, as sacral fractures in elderly patients are typical fragility fracture patterns. 1, 6

The evaluation includes:

• Review of clinical risk factors 1
• DXA of spine and hip when feasible 1
• Imaging of spine for vertebral fractures 1
• Falls risk assessment 1, 6
• Identification of secondary osteoporosis causes 1

Prescribe drugs demonstrated to reduce vertebral, non-vertebral, and hip fractures (bisphosphonates or denosumab). 1, 6

• For patients with dementia, malabsorption, and non-compliance, zoledronic acid (intravenous) or denosumab (subcutaneous) are preferred alternatives to oral bisphosphonates 6
• Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 6, 3
• Monitor regularly for tolerance and adherence 1

---

Special Considerations for Dementia Patients

Dementia increases hip and pelvic fracture risk up to 3-fold through multiple mechanisms including increased falls, osteoporosis, and medication side effects. 7

• Dementia is under-diagnosed in elderly hospitalized patients—formal cognitive assessment during inpatient stay is essential 5
• An interdisciplinary care program for all fragility fracture patients decreases complications and improves outcomes, with strong evidence supporting this approach 6
• For frail elderly patients with major fractures, an orthogeriatric and multidisciplinary approach is warranted 6

---

Functional Outcome Monitoring

Use validated assessment tools including Barthel Index, Tinetti Mobility Test, and Timed Up & Go Test to objectively track functional recovery. 2

• These tests are well-suited for reproducible, objective assessment of mobility, need for assistance, and fall risk 2
• Conservative therapy achieves improvements in all measured domains even in patients with dementia and bilateral fractures 2

---

Implementation Requirements

Designate a local responsible lead to coordinate secondary fracture prevention with established liaison between orthopaedic surgeons, geriatricians, and general practitioners. 1

• Provide patient and caregiver education about disease burden, risk factors, follow-up, and treatment duration 1
• Systematic follow-up is advocated as part of a five-step plan: identifying patients, inviting for fracture risk evaluation, differential diagnosis, therapy, and follow-up 6