What is the best management approach for an elderly patient with a history of fracture, considering their comorbidities such as dementia, diabetes, or cardiovascular disease, and potential osteoporosis?

Orthopedic Geriatric Fracture Liaison Service

Elderly patients with fragility fractures require immediate implementation of orthogeriatric comanagement with a dedicated geriatrician-orthopedic surgeon team on a specialized ward, which reduces 1-year mortality, shortens hospital stay, and accelerates time to surgery compared to standard orthopedic care alone. 1

Acute Fracture Management: The First 48 Hours

Establish a multidisciplinary clinical system immediately upon admission that guarantees the following components 1:

• Adequate pain relief using multimodal analgesia (nerve blocks reduce acute pain more effectively than systemic analgesia alone) before diagnostic investigations 1
• Appropriate fluid management to correct volume and electrolyte disturbances 1
• Surgery within 24-48 hours of admission, as delays beyond 48 hours significantly increase short-term and mid-term mortality rates and medical complications (decubitus ulcers, pneumonia, prolonged hospital stay) 1

Preoperative Assessment Must Include:

• Chest X-ray, ECG, complete blood count, clotting studies, blood type, renal function 1
• Baseline cognitive function assessment (25% of fracture patients develop postoperative cognitive dysfunction) 1
• Identification of malnutrition, anemia, cardiac/pulmonary disease, dementia, and delirium 1
• Do not delay surgery to optimize every medical problem—the harm from prolonged immobility and pain outweighs most medical optimization benefits 1

Orthogeriatric Comanagement Model

The joint care model between geriatrician and orthopedic surgeon on a dedicated orthogeriatric ward demonstrates Level IA evidence (strongest recommendation grade A) for improving outcomes 1:

• Shortest time to surgery 1
• Shortest length of inpatient stay 1, 2
• Lowest inpatient mortality 1, 2
• Lowest 1-year mortality rate (reduces mortality by approximately 30-40% compared to standard care) 1, 2
• Improved functional outcomes 1

The Multidisciplinary Team Should Include:

• Orthopedic surgeon and geriatrician as co-managers 1
• Fracture liaison service coordinator (typically a specialized nurse) 1
• Physical therapist for early mobilization 1
• Occupational therapist for functional assessment 1
• Pharmacist for medication reconciliation 1

Comprehensive Geriatric Assessment

Every patient aged 50+ with a fragility fracture requires systematic evaluation for subsequent fracture risk (Level IA evidence, Grade A recommendation) 1:

Risk Assessment Components:

• DXA scanning of spine and hip to measure bone mineral density 1
• Spine imaging (X-ray or MRI) to identify prevalent vertebral fractures 1
• Clinical risk factor review: family history, prior fractures, smoking, alcohol, medications (glucocorticoids, aromatase inhibitors) 1
• Falls risk evaluation: balance testing, gait assessment, home safety evaluation, vision screening 1
• Secondary osteoporosis screening: thyroid function, vitamin D levels, calcium, parathyroid hormone, celiac disease screening if indicated 1

Managing Comorbidities:

For patients with dementia 1:

• Daily cognitive function monitoring to detect delirium early 1
• Adequate analgesia (untreated pain worsens confusion) 1
• Early mobilization to prevent deconditioning 1
• Avoid anticholinergic medications and minimize opioids 1

For patients with diabetes 1:

• Perioperative glucose control (target 140-180 mg/dL) 1
• Monitor for hypoglycemia during NPO periods 1
• Resume home diabetes medications as soon as oral intake resumes 1

For patients with cardiovascular disease 1:

• Continue beta-blockers and statins perioperatively 1
• Hold anticoagulation only as long as necessary for surgery 1
• Supplemental oxygen for at least 24 hours postoperatively 1

Pharmacological Fracture Prevention

Initiate bisphosphonates (alendronate or risedronate) within 6 months post-fracture—do not wait for "perfect consolidation" 3:

• Alendronate 70 mg weekly or risedronate 35 mg weekly are first-line agents (Level IA evidence) 3
• Reduces subsequent fracture risk by approximately 50% over 3 years 3
• Reduces hip fractures specifically by 40% 3
• Combine with calcium 1000-1200 mg/day and vitamin D 800 IU/day (reduces non-vertebral fractures by 15-20% and falls by 20%) 1, 3

Alternative Agents:

For patients with advanced chronic kidney disease (eGFR <30 mL/min/1.73 m²) 4:

• Bisphosphonates are contraindicated 4
• Denosumab 60 mg subcutaneously every 6 months can be used but requires extreme caution 4
• Mandatory pre-treatment evaluation: intact PTH, serum calcium, 25(OH) vitamin D, 1,25(OH)₂ vitamin D to assess for CKD-MBD 4
• Severe hypocalcemia risk: life-threatening and fatal cases reported; requires supervision by CKD-MBD specialist 4

For patients on chronic glucocorticoids (≥7.5 mg prednisone equivalent daily for ≥6 months) 4:

• Same bisphosphonate regimen as above 4
• Denosumab 60 mg every 6 months is alternative 4
• All require calcium 1000-1200 mg/day and vitamin D 800 IU/day 4

Monitoring:

• Assess adherence regularly—long-term compliance is often poor (only 50-60% at 1 year without FLS support) 1, 3
• Treatment duration: typically 3-5 years initially, then reassess fracture risk 3
• Do not use high-pulse vitamin D dosing (monthly or quarterly)—increases fall risk rather than preventing it 3

Rehabilitation Protocol

Early postfracture physical training and muscle strengthening must begin within days of surgery (Level IIA evidence, Grade B recommendation) 1, 5:

Acute Phase (Days 1-7):

• Mobilize out of bed within 24 hours of surgery 1
• Weight-bearing as tolerated unless contraindicated by fracture pattern 1
• Active and passive range-of-motion exercises 1
• Adequate analgesia to enable participation 1

Subacute Phase (Weeks 2-12):

• Progressive resistance exercises for muscle strengthening 1, 5
• Gait training with assistive devices as needed 1
• Balance training exercises 1, 5

Long-Term Phase (Months 3-24+):

• Continue balance training and multidimensional fall prevention indefinitely—fracture risk remains elevated for 24 months 1, 3, 5
• Home safety modifications (remove throw rugs, improve lighting, install grab bars) 1
• Vision correction if needed 1
• Medication review to minimize fall-risk medications (sedatives, anticholinergics, antihypertensives causing orthostasis) 1

Fracture Liaison Service Implementation

Designate a local responsible coordinator (typically a specialized nurse) who liaises between surgeons, rheumatologists/endocrinologists, geriatricians, and primary care physicians (Level IV evidence, Grade D recommendation) 1, 6:

FLS Coordinator Responsibilities:

• Identify all patients aged 50+ with fragility fractures at hospital presentation 1, 6
• Arrange DXA scanning and vertebral imaging 1, 6
• Initiate or recommend osteoporosis treatment 1, 6
• Provide patient education about disease burden, risk factors, follow-up requirements, and treatment duration 1, 7
• Ensure communication with primary care physician for long-term management 1, 6
• Monitor adherence—FLS programs achieve 75-90% adherence versus 15-20% with standard care 6, 8

FLS Models:

The most effective model is Type C (intensive inpatient FLS) where the coordinator 6, 8:

• Visits inpatients on the orthogeriatric ward 8
• Gathers metabolic history 8
• Provides education on diet, exercise, and fall prevention 8
• Completes discharge report with osteoporosis treatment recommendations 8
• Achieves 75% treatment adherence at 6 months versus 15% with standard care 8

Patient Education Requirements

Educate patients about the following (Level IV evidence, Grade D recommendation) 1, 7:

• Fracture risk remains acutely elevated for 24 months before gradually declining 3
• Importance of medication adherence—stopping bisphosphonates prematurely increases fracture risk 1
• Calcium and vitamin D must continue throughout treatment 1, 4
• Fall prevention strategies are as important as medication 1
• Smoking cessation and alcohol limitation (no more than 2 drinks daily) 1, 4
• Expected treatment duration (typically 3-5 years minimum) 1, 7

Critical Pitfalls to Avoid

Do not delay surgery beyond 48 hours to optimize every medical condition—the mortality and morbidity from prolonged immobility exceed the risks of operating with controlled comorbidities 1

Do not discharge patients without osteoporosis treatment initiated or arranged—only 9-20% receive treatment without FLS intervention 6

Do not start osteoporosis treatment without adequate calcium and vitamin D supplementation—bisphosphonates and denosumab can cause severe hypocalcemia if vitamin D deficient 1, 3, 4

Do not use denosumab in advanced CKD without specialist supervision and pre-treatment CKD-MBD evaluation—fatal hypocalcemia cases reported 4

Do not neglect cognitive assessment—25% develop postoperative delirium, which increases mortality and delays rehabilitation 1

Do not assume patients living in nursing homes will receive adequate follow-up—they have higher 3-month mortality and often do not respond to outpatient FLS invitations; initiate treatment before discharge 1, 9

Do not forget that frail elderly patients with hip fractures have the highest mortality risk—approximately one-third die within the first year without orthogeriatric comanagement 10, 2, 9