What are the best approaches to manage an elderly patient with a history of hip fracture treated with intramedullary (internal fixation) nailing who is refusing to move or participate in physical therapy (physical therapy) and occupational therapy (OT)?

Managing Refusal of Mobilization After Hip Fracture Fixation

When an elderly patient refuses to move or participate in therapy after intramedullary nailing of a hip fracture, immediately implement interdisciplinary care involving orthogeriatrics, physical therapy, occupational therapy, and nursing to systematically address the underlying barriers—this approach has strong evidence for decreasing complications and improving outcomes. 1

Immediate Assessment Framework

Identify and Address Pain as the Primary Barrier

Inadequate analgesia is the most common modifiable cause of refusal to mobilize. 1

• Optimize multimodal analgesia immediately: Regular paracetamol (acetaminophen) 1000 mg every 6 hours forms the foundation, as this decreases supplementary analgesic requirements 2
• Add peripheral nerve blockade if not already in place: Femoral nerve blocks or fascia iliaca compartment blocks provide superior pain control and promote earlier mobilization compared to systemic opioids alone 2
• Include pain evaluation as part of routine nursing observations: Pain during mobilization differs substantially from resting pain and requires careful titration 2
• Reserve opioids strictly for breakthrough pain: Use cautiously due to increased risk of respiratory depression and postoperative confusion in elderly patients 1, 2

Screen for Postoperative Cognitive Dysfunction

Acute confusional state occurs in 25% of hip fracture patients and directly interrupts rehabilitation. 1

• Perform systematic evaluation for delirium: Use standardized screening tools during each nursing shift 1
• Identify and treat underlying medical complications: Check for silent myocardial ischemia, chest infection, urinary tract infection, and electrolyte abnormalities 1
• Optimize multimodal factors: Ensure adequate analgesia, nutrition, hydration, and electrolyte balance 1
• Avoid medications that worsen confusion: Do not use cyclizine due to antimuscarinic effects; use haloperidol or lorazepam only for short-term symptom control if absolutely necessary 1

Assess for Medical Complications Preventing Mobilization

• Check for hypovolemia: This is common postoperatively and impairs mobilization; encourage early oral fluid intake rather than routine IV fluids 1, 3
• Evaluate oxygenation status: Administer supplemental oxygen for at least 24 hours postoperatively, as older patients are at high risk of hypoxia 3
• Screen for symptomatic anemia: Transfuse packed red blood cells if symptomatic 3
• Remove urinary catheters as soon as possible: These increase infection risk and impair mobilization 3

Documentation Requirements for Refusal Discussion

Document the Clinical Context

• Record current pain scores: Both at rest and with attempted movement 2
• Document cognitive status: Note presence or absence of delirium using standardized assessment 1
• List current analgesic regimen: Include doses, timing, and effectiveness 2
• Note vital signs and oxygen saturation: Particularly relevant if patient appears dyspneic or tachycardic 3

Document the Informed Discussion

Frame the conversation around mortality and morbidity risks, not patient preference:

• Explain that prolonged bed rest increases complications and mortality: This is evidence-based and non-negotiable 3
• Specify that immediate weight-bearing as tolerated is the standard of care: Cephalomedullary nails provide sufficient stability for full weight-bearing regardless of fracture pattern 3
• Clarify that rehabilitation constitutes the majority of recovery: The goal is returning to pre-fracture functional status 1
• Document patient's stated reasons for refusal: Pain, fear of falling, dizziness, weakness, or other specific concerns 1

Document the Interdisciplinary Plan

• Record involvement of orthogeriatrics team: This is a strong recommendation for decreasing complications 1
• Note physical therapy and occupational therapy consultations: Document their assessment and recommendations 1, 3
• Include nursing care plan: Maintain nurse-to-patient ratio of 1:4 with regular physician input from geriatric medicine specialists 3
• Document nutritional assessment: Up to 60% of hip fracture patients are malnourished on admission; nutritional supplementation reduces mortality 1, 3

Specific Interventions to Facilitate Mobilization

Optimize Pain Control Before Each Therapy Session

• Administer scheduled analgesia 30-60 minutes before therapy: Do not wait for pain to occur 2
• Consider additional peripheral nerve block: Continuous catheter techniques provide extended analgesia duration 2
• Avoid NSAIDs if renal dysfunction present: Use extreme caution in all elderly patients 2, 4

Implement Graduated Mobilization Protocol

• Start with sitting at edge of bed: This addresses orthostatic hypotension and builds confidence 3
• Progress to standing with walker: Full weight-bearing as tolerated is safe and recommended 3
• Advance to ambulation with physical therapy: Early mobilization improves oxygenation and reduces complications 3

Address Psychological Barriers

• Provide reassurance about implant stability: Explain that the nail is designed for immediate full weight-bearing 3
• Involve family members in education: They can reinforce the importance of mobilization 1
• Set small, achievable goals: Document progress to build patient confidence 1

Critical Pitfalls to Avoid

• Do not accept "patient refuses" as final documentation: This fails to address underlying modifiable factors 1
• Do not delay mobilization based on patient preference: Prolonged bed rest increases complications and mortality 3
• Do not use opioids as the sole analgesic approach: This increases respiratory depression and confusion risk 1, 2
• Do not restrict weight-bearing based on fracture pattern: Cephalomedullary nails provide sufficient stability for immediate full weight-bearing 3
• Do not overlook nutritional status: Malnutrition impairs healing and functional recovery 1, 3

When Conservative Measures Fail

If patient continues to refuse mobilization despite optimized analgesia, treatment of delirium, and interdisciplinary intervention:

• Convene family meeting with orthogeriatrics team: Discuss realistic prognosis with continued immobility 1
• Consider psychiatric consultation: Rule out underlying depression or anxiety disorder 1
• Document capacity assessment: Determine if patient has decision-making capacity regarding their care 1
• Implement fall prevention strategies: Even limited mobilization is superior to complete bed rest 3
• Continue aggressive medical optimization: Prevent complications of immobility including DVT, pneumonia, and pressure ulcers 3