What is the prognosis and treatment for an 87-year-old male with dementia, status post partial hip replacement (one week ago), presenting with sepsis?

From the Guidelines

The prognosis for an 87-year-old male with dementia, status post partial hip replacement, presenting with sepsis is poor, with a high mortality rate due to the combination of old age, underlying dementia, recent surgery, and sepsis [ 1 ].

Key Considerations

• The patient's age, dementia, and recent surgery increase the risk of poor outcomes and mortality [ 1 ].
• Sepsis is a life-threatening condition that requires prompt and aggressive treatment [ 1 ].
• The Surviving Sepsis Campaign guidelines recommend early goal-directed therapy, including fluid resuscitation, broad-spectrum antibiotics, and supportive care [ 1 ].
• The choice of empiric antimicrobial regimen should be broad enough to cover most pathogens isolated in healthcare-associated infections, and should be modified based on the anatomic site of infection and local microbiologic flora [ 1 ].

Treatment Approach

• Early goal-directed therapy should be initiated promptly, including fluid resuscitation and broad-spectrum antibiotics [ 1 ].
• Broad-spectrum antibiotics should be chosen based on the suspected source of infection and local resistance patterns, and should be modified based on culture results [ 1 ].
• Supportive care should include monitoring of vital signs, organ function, and laboratory results, as well as provision of oxygen, ventilation, and hemodynamic support as needed [ 1 ].
• Palliative care should be considered early in the treatment process, with a focus on symptom management, communication, and family support [ 1 ].

Important Medications

• Broad-spectrum antibiotics, such as meropenem, imipenem/cilastatin, or piperacillin/tazobactam, should be considered for empiric therapy [ 1 ].
• Vasopressors, such as norepinephrine or epinephrine, may be needed to support blood pressure and perfusion [ 1 ].
• Corticosteroids may be considered in patients with septic shock who are refractory to fluid and vasopressor therapy [ 1 ].

From the Research

Prognosis

• The prognosis for an 87-year-old male with dementia, status post partial hip replacement, presenting with sepsis is poor, as sepsis survivors are at increased risk of developing dementia or cognitive impairment 2.
• The risk of dementia or cognitive impairment in sepsis survivors is higher in those with severe sepsis 2.
• Postoperative delirium after hip surgery is also a potential risk factor for incident dementia 3.

Treatment

• Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery may reduce rates of postoperative delirium and some other complications, but the certainty of these results is low 4.
• Geriatrician-led management may lead to shorter hospital stays compared to orthopaedic-led management, but the certainty of this result is also low 4.
• Early identification of cognitive function and appropriate prevention and treatment for dementia are necessary after surgery, especially in cases with postoperative delirium 3.
• Appropriate management and prevention are essential to preserve the cognitive function of sepsis survivors and reduce the risk of dementia 2.

Considerations

• The overall infection rate after hip replacement surgery remains at over 1%, and late sepsis is now the most common type of infection involving hip replacements 5.
• Patient education to prevent sepsis and identify potentially dangerous infections early is crucial for the continued well-being of hip replacement patients 5.
• Predicting mortality in patients with advanced dementia is challenging, but models such as the PROgnostic Model for Advanced Dementia (PRO-MADE) can help identify patients at high risk of one-year all-cause mortality 6.