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Eric Widera, MD Assistant Clinical Professor, Division of Geriatrics Director, Hospice & Palliative Care, SFVAMC. September 16, 2008. Don’t Compound the Fracture. Anticipating and Preventing Complications in Elderly Hospitalized Patients. The Elderly Will Inherit the OR.

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Don’t Compound the Fracture

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Don t compound the fracture

Eric Widera, MD

Assistant Clinical Professor, Division of Geriatrics

Director, Hospice & Palliative Care, SFVAMC

September 16, 2008

Don’t Compound the Fracture

Anticipating and Preventing Complications in Elderly Hospitalized Patients

The elderly will inherit the or

The Elderly Will Inherit the OR

Ann Surg. 2003 August; 238(2): 170–177.

The case of a patient and her dog

The Case of a Patient and Her Dog

Mrs. Brittle


Mrs brittle s case

Mrs Brittle’s Case

  • Exam:

    • Shortened and externally rotated left leg.

    • B/L symmetric upper and lower mild rigidity. Mild resting tremor b/l hands

  • EKG: NSR. Prolonged QTc

  • Dx: left non-displaced femoral neck fracture of the hip

Hip fracture s and old age

Hip Fracture’s and Old Age

  • Each Year 1/3 of older adults fall

  • At One Year

    • Mortality: 10-30%

      • Greatest risk at within 6 months

    • 60% recover pre-fracture walking ability

    • 50% recover ADLs

  • Little improvements beyond 6 months in functional recovery

Stevens et al. JAMA 2008

French et al. JAGS 2008

Anticipatory differential diagnosis addx

Anticipatory Differential Diagnosis (aDDx)

  • CV: MIs

  • DVTs

  • Infection – UTI’s, Cellulitis

  • Delirium

  • Pain

  • Falls

  • Repeat Fracture

  • Functional decline

  • Death

Addx cardiovascular events

aDDx: Cardiovascular Events

From Auerbach, A, Goldman, L. Circulation 2006; 113:1361.

Minimize time in the hospital

Minimize Time in the Hospital!

  • Surgical Hip Fracture Repair within 24-48hrs

    • Decreased pain

    • Decreased major post-operative complications

    • Decreased LOS

    • Trend in combined outcomes of death or needing total assistance for locomotion at 6 months

  • Except in pt’s with active co-morbid illnesses

    • Active angina, CHF, severe metabolic disturbences

Addx dvts

aDDx: DVTs

  • DVT Prophylaxis in Hip Fracture Surgery

    • Recommended Drugs:

      • Fondaparinux

      • Low Molecular weight heparin

      • Low Dose Unfractionated Heparin

      • Warfarin (target INR 2-3)

    • Aspirin is not recommended

    • If surgery is delayed – use prophylaxis

7th ACCP conference Guidelines

Addx infections

aDDx: Infections

  • Indwelling urinary catheters

    • remove within 24 hours of surgery

  • Prophylactic Antibiotics for Fx’s

    • Risk of deep wound infections decreased by 60 percent

    • All patients should receive prophylactic antibiotics within 2 hours of surgery

    • 1st generation cephalosporin (vancomycin if allergic)

      • Gillespie et all. Cochrane Database Syst Rev 2001

Addx malnutrition

aDDx: Malnutrition

  • Oral supplements can improve nutritional status and seems to reduce mortality and complications for:

    • undernourished elderly patients in the hospital.

  • Current evidence does not support routine supplementation for:

    • older people at home

    • well-nourished older patients in any setting.

Milne. Ann Intern Med. 2006

Addx delirium

aDDx: Delirium

  • Common

    • 10-50% of hospitalized elderly

  • Serious

    • 1 year mortality: 30-40%

    • Longer LOS

    • Increased NH placement

  • Preventable

Diagnosing delirium the confusion assessment method cam

Diagnosing Delirium: The Confusion Assessment Method (CAM)

Delirium requires both

  • Acute onset and fluctuating course

  • Inattention

    And one of the following

  • Disorganized thinking

  • Altered level of consciousness

    Wei et al. J Am Geriatr Soc. 2008

    Inouye SK. NEJM 2006;354:1157-65

Addx delirium and it s buddy dementia

aDDx: Delirium and it’s buddy Dementia

% of people age >65 with moderate or severe memory impairment

Don t compound the fracture





Clock Draw Abnormal

Clock Draw Normal




Addx delirium prevention

aDDx: Delirium Prevention

  • Yale Delirium Prevention Program

    • Designed to counteract many of the things we do wrong in the hospital

    • Targeted at 6 risk factors

    • Decreased the incidence of delirium, the total number of delirious episodes, and the number of delirium days

Inouye SK. N Engl J Med 1999

Don t compound the fracture

Inouye SK. N Engl J Med 1999

Yale delirium prevention trial results

Yale Delirium Prevention Trial Results

Inouye SK. N Engl J Med 1999

Delirium it s medications 40 of the time

Delirium: It’s Medications 40% of the time!

  • Sleeping Meds

    • Benadryl

    • Ambien

  • Anxiety Meds

    • Ativan, Valium

  • Pain Meds

    • Meperidine (Demerol)

  • Antiparkinsons Meds

  • Anti-cholinergic Meds

    • Ditropan

    • Atropine

    • Benadryl

  • Anti-nausea Meds

    • Phenergan

    • Reglan

  • Antidepressents

  • Muscle Relaxants

    • Flexeril

Delirium treatment iv haloperidol

Delirium: Treatment IV haloperidol

  • Prophylaxis with haloperidol vs placebo for hip fracture:

    • No decrease the incidence of postoperative delirium (15 vs 16.5%)

    • Reduce its duration, LOS, and severity Side effects

  • Side Effects

    • EPS symptoms

    • Nov 2007: FDA warning on Torsades de pointes & QT prolongation w/ IV

Addx pain

aDDx: Pain

  • Delirium risk increased in hip fracture patients who:

    • Received less than 10mg IV morphine equivalents per day

    • Received meperidine (Demerol)

    • Had severe pain

      Morrison. J Gerontol A Biol Sci Med Sci 2003

Addx falls

aDDx: Falls

  • Account for at least 40% of all accidents in the hospital

  • 30% to 50% of inpatient falls result in injury

  • 5% to 10% result in serious injuries.

Addx falls in the hospital

aDDx: Falls in the hospital

  • Commonly occur while attempting to perform activities unassisted

    • especially elimination-related activities

  • Only 3% of patients used call lights immediately before the fall

    Hitchio. J Gen Intern Med 19. 732-739.2005

Factors associated with falls in the hospital

Factors Associated with Falls in the Hospital

  • Difficulty with ambulating

  • Difficulty with dizziness and balance

  • Increase in patient-to-nurse ratio

  • Lower limb weakness

  • Poor tandem walking

  • History of falls

  • Medications

  • Dehydration

  • Agitation and confusion

  • Frequent toileting

  • Visual impairment

Restraints and falls

Restraints and Falls

  • No data to support that restraints reduce falls

  • Falls and fall-related serious injuries may increase with restraints

  • Restraint removal does not increase the incidence of falls or fall-related injuries

    • Actually may decrease with restraint removal

Restraints and mobility

Restraints and Mobility

  • 6 independent predictors of recovery after hip fracture of ambulatory ability

    • 4 were related to mobility:

      • lack of a DVT diagnosis

      • absence of a urinary catheter

      • absence of restraints

      • nurse-rated bed mobility at admission

        Brown, CJ 1: J Hosp Med. 2006

Bilateral full siderails

Bilateral Full Siderails

  • No reduction in likelihood for falls, serious injuries, or recurrent falls

  • Adverse effects: increased immobility, infections, negative psychological effects, and urinary incontinence and infections

  • 1985-2006: 691 entrapment reports, 413 deaths

    O’Keeffe St. Lancet 2004; 363-364.

    De Letter. Med Sci Law. 2008

Addx falls1

aDDx: Falls

Tinetti. NEJM 2003

Addx falls2

aDDX: Falls

  • Vitamin D

    • 700-800IU of Vitamin D a day have shown a decrease in falls and fractures.

    • 400IU trials do not show consistent benefit

    • 25-OH vitamin D target levels of 30-40ng/ml

      J Am Geriatr Soc 2007;55:234–9

      JAMA. 2004 Apr 28; 291(16):1999-2006.

Addx repeat fracture

aDDx: Repeat Fracture

  • 1st aim: prevent another fall

    • Falls are a stronger predictor of fracture than osteoporosis

    • Rx: Vit D, Muti-Factorial Strategy, Home Hazard Reduction, P.T.

  • 2nd aim: treat osteoporosis

    • Bisphosphonates

Addx repeat fractures

aDDx: Repeat Fractures

RCT of IV Zolendronic Acid

  • 2127 patients

  • 5mg IV zoledronic acid vs placebo within 90 days after hip fracture and yearly

  • All got Vitamin D and Calcium

  • Significantly Decreased @ 2 years:

    • Repeat Fracture: 8.6 vs 13.9%, NNT 19

    • Non-verterbral Fracture: 7.6 vs 10.7%

    • Hip Fracture: 2.0 vs 3.5% (NS)

    • Death: 9.6 vs 13.3 (P=0.01), NNT 27

      Lyles et al. NEJM, November 1, 2007, 1799-1809

Addx functional decline

aDDx: Functional Decline

* Begin Rehab on the first post-operative day and advance as tolerated

Federal Interagency Forum on Aging-Related Statistics.

Anticipate death

Anticipate Death

  • Advance Directives

  • DPOA

  • Goals of Care

    • If things don’t go the we hope they will, what should we do?

Don t compound the fracture



Eric Widera, MD

Assistant Clinical Professor, Division of Geriatrics

Director, Hospice & Palliative Care, SFVAMC

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