What is the appropriate management for an 87-year-old patient with advanced dementia, history of shoulder and hip fractures with partial hip replacement, and Catheter-Associated Urinary Tract Infection (CAUTI), presenting with severe hypotension?

From the Guidelines

The appropriate management for an 87-year-old patient with advanced dementia, history of shoulder and hip fractures with partial hip replacement, and Catheter-Associated Urinary Tract Infection (CAUTI), presenting with severe hypotension is to replace the urinary catheter prior to initiating antimicrobial therapy.

Rationale

• The patient's CAUTI is likely caused by multidrug-resistant uropathogens, and catheter replacement can help reduce the risk of polymicrobic CA-bacteriuria 1.
• Replacing the catheter can also lead to a shorter time to improved clinical status and a lower rate of CA-UTI within 28 days after therapy 1.
• It is essential to obtain urine culture specimens from the freshly placed catheter, if feasible, prior to initiating antimicrobial therapy to ensure accurate diagnosis and effective treatment 1.
• In addition to managing the CAUTI, it is crucial to address the patient's severe hypotension, which may require fluid resuscitation and other supportive measures to prevent further complications.
• The patient's advanced age, dementia, and history of fractures also require careful consideration to prevent further decline and ensure optimal management of their overall condition.

From the Research

Management of Advanced Dementia with Hip Fracture and CAUTI

• The patient's condition is complex, with advanced dementia, history of shoulder and hip fractures, partial hip replacement, and CAUTI, presenting with severe hypotension 2, 3, 4, 5, 6.
• Patients with dementia are at a higher risk of hip fractures and have higher morbidity and mortality after hip fractures, emphasizing the need for careful management 2, 4, 6.
• Early analgesia and timely surgical fixation of fracture are beneficial for hip fracture patients with dementia, and early and intensive inpatient rehabilitation can improve postoperative outcomes 2.
• A multidisciplinary approach, including orthogeriatric teams and fracture liaison services, can decrease mortality and improve long-term outcomes in hip fracture patients with dementia 2, 3, 5.

Considerations for Physical Rehabilitation

• Physical rehabilitation for people with advanced dementia who fracture their hip requires a holistic and person-centered approach, with highly skilled and trained professionals 3.
• The expert consensus process identified 59 statements that provide an overarching understanding of the multidisciplinary expertise needed to deliver rehabilitation interventions to this population 3.
• Physiotherapy or other interventions cannot be used in isolation, and people with dementia require a comprehensive approach to deliver rehabilitation interventions 3.

Association of Clinical Outcomes with Surgical Repair

• Surgical repair of a hip fracture was associated with lower mortality among nursing home residents with advanced dementia, and should be considered together with the residents' goals of care in management decisions 5.
• Pain and other adverse outcomes were common regardless of surgical management, suggesting the need for broad improvements in the quality of care provided to nursing home residents with advanced dementia and hip fracture 5.

Prevalence of Dementia in Elderly Patients with Hip Fracture

• Dementia is very common in older patients admitted for surgery, and extremely common in those with hip fracture, with a prevalence of 85% in hip fracture patients compared to 61.5% in controls 6.
• Dementia is a major risk factor for hip fracture in the elderly, and its diagnosis and management should be considered in the care of patients with hip fracture 4, 6.