What is an appropriate multimodal analgesic regimen for an elderly patient with a hip fracture that balances adequate pain control while minimizing opioid‑related delirium, respiratory depression, and gastrointestinal side effects?

Pain Management for Elderly Hip Fracture Patients

Immediate First-Line Treatment

Administer intravenous acetaminophen 1000 mg every 6 hours as the cornerstone of your pain regimen, starting immediately upon presentation and continuing throughout the perioperative period. 1, 2

• This scheduled dosing reduces postoperative delirium by 53% (15.4% vs 32.8%, p=0.024) compared to no acetaminophen, primarily by reducing opioid requirements 3
• IV acetaminophen decreases hospital length of stay by 2 days (6.37 vs 8.47 days, p=0.037) and reduces need for one-to-one supervision by 62% 3
• Maximum daily dose must not exceed 4 grams in 24 hours 4

Regional Anesthesia: Critical Component

Place a peripheral nerve block (fascia iliaca compartment block) immediately at presentation, before surgery. 1, 2

Technical Approach:

• Single-shot technique: Administer 30-40 mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine 1, 5
• Continuous infusion option: Initial bolus of 10-20 mL of 0.2% bupivacaine, followed by continuous infusion at 6 mL/h until postoperative day 1 morning 1, 5

Evidence for Nerve Blocks:

• Reduces preoperative opioid consumption by 39% (18.0 vs 29.5 MME, p=0.007) without increasing pain scores 5
• Particularly effective for femoral neck fractures, reducing opioid use by 59% (12.0 vs 29.0 MME, p<0.001) 5
• Decreases acute confusional state, chest infections, and time to first mobilization 1
• Safe even in patients with moderate cognitive impairment without worsening cognitive status 1

Multimodal Adjunctive Medications

Add NSAIDs cautiously for severe pain only after evaluating contraindications. 1, 2

Critical NSAIDs Contraindications:

• Absolute contraindication: GFR <45 mL/min with concurrent aspirin use 6
• Increased risks include bleeding, gastrointestinal complications, acute kidney injury, and cardiovascular events 6
• Consider COX-2 selective inhibitors as safer alternative when NSAIDs are needed 2

Incorporate these additional agents into your protocol: 1, 2

• Gabapentinoids: For neuropathic pain components 2, 6
• Lidocaine patches: Apply topically to localized pain areas 1, 2
• Intravenous dexamethasone: Single intraoperative dose of 8-10 mg provides analgesic and anti-emetic effects 2

Opioid Management: Reserve for Breakthrough Only

Use opioids exclusively for breakthrough pain at the lowest effective dose for the shortest duration possible. 1, 2, 6

Opioid Dosing Principles:

• Implement progressive dose reduction due to morphine accumulation risk leading to over-sedation, respiratory depression, and delirium 1, 6
• Elderly patients have increased fat-to-lean body weight ratio prolonging half-life and decreased glomerular filtration reducing drug excretion 4
• Tramadol may be considered as it causes less respiratory and gastrointestinal depression, but avoid in patients with seizure history 6
• Never combine with benzodiazepines or skeletal muscle relaxants outside highly monitored settings 6

Opioid-Related Outcomes:

• Multimodal analgesia reduces 48-hour opioid consumption by 59% (5.5 vs 13.3 mg, p=0.014) 7
• Both inadequate analgesia AND excessive opioid use increase postoperative delirium risk 2, 4

Epidural/Neuraxial Analgesia for Selected Patients

Consider epidural analgesia (bupivacaine/fentanyl or bupivacaine/morphine infusion) for patients with severe pain or contraindications to peripheral nerve blocks. 1, 2

Important Caveats:

• Requires close monitoring due to risks of hypoventilation, atelectasis, and pneumonia from effects on respiratory muscles 1
• Carefully evaluate anticoagulation status before placement to avoid bleeding complications 2, 6
• Hypotension may occur requiring vasopressor support 1
• Motor block can limit mobilization 1

Non-Pharmacological Interventions

Implement these measures immediately alongside pharmacological therapy: 1, 2, 6

• Proper limb immobilization 1, 2
• Ice pack application to affected areas 1, 2
• Early mobilization as tolerated to prevent complications 6

Implementation Algorithm

At Presentation (Emergency Department):

1. Start IV acetaminophen 1000 mg immediately, then every 6 hours 1, 2
2. Place fascia iliaca compartment block within first hour 1, 2
3. Apply ice packs and immobilize limb 1, 2
4. Assess renal function and contraindications before adding NSAIDs 6

Intraoperatively:

1. Administer dexamethasone 8-10 mg IV 2
2. Consider continuous nerve block catheter if not already placed 1, 5
3. Continue scheduled acetaminophen 2

Postoperatively:

1. Continue acetaminophen 1000 mg IV every 6 hours for first 24-48 hours 2, 3
2. Add NSAIDs/COX-2 inhibitors if severe pain and no contraindications 1, 2
3. Apply lidocaine patches to surgical site 1, 2
4. Reserve opioids for breakthrough pain only, using lowest effective doses 1, 2
5. Reassess pain systematically every 4-6 hours 6, 4

Critical Pitfalls to Avoid

Systematic pain assessment is mandatory—42% of patients over 70 receive inadequate analgesia despite reporting moderate to high pain levels. 2, 4

• Use behavioral pain assessment tools (CPOT, BPS) for non-verbal or cognitively impaired patients 6
• Elderly patients with cognitive impairment receive inadequate pain management leading to poorer mobility, quality of life, and higher mortality 2, 4
• Do not delay pain medication administration—drugs should be given early in trauma patients 6
• Avoid tricyclic antidepressants due to anticholinergic effects causing confusion, constipation, and movement disorders 4
• Monitor for acetaminophen in combination products to prevent inadvertent overdose exceeding 4 g/24 hours 4

Expected Outcomes with Multimodal Approach

This protocol achieves superior pain control with reduced complications: 7

• Lower pain scores at all time points (6 hours: 1.9 vs 2.9, p<0.001; 48 hours: 1.7 vs 2.2, p<0.001) 7
• 59% reduction in opioid consumption 7
• 53% reduction in delirium rates 3
• Shorter hospital stays and reduced need for skilled nursing facilities 8, 3