perioperative medical care of the elderly hip fracture patient

1. Perioperative Medical Care of the Elderly Hip Fracture Patient Hugo Quinny Cheng, MD Assistant Clinical Professor of Medicine Director, Medicine Consultation Service University of California, San Francisco

2. Hip Fracture: A Geriatric Epidemic 350,000 cases per year Incidence doubled between 1960 and 1980 Incidence expected to triple by 2050 Recent series of 571 cases: 81% of patients > 75 years old 43% of patients > 85 years old Economic cost in excess of $ 6 billion

3. Educational Goals of Module Users of this module should learn: How advanced age should affect perioperative decision-making Optimal postoperative care in hip fracture repair How to evaluate and manage postoperative delirium The long term prognosis after hip fracture

4. Case part 1: �Too old for surgery� Ms. HF is a 91 year old woman who slipped in her shower and sustained a left femoral neck fracture. She has mild dementia, a remote CVA, HTN, and hypothyroidism. At baseline, she lives with her children, walks with a cane, and enjoys attending a daycare program for demented patients. Because of her advanced age, the orthopedic surgeon and her children are reluctant to pursue surgical repair of her hip fracture.

5. Case 1: �Too old for surgery� Because of her advanced age, the orthopedic surgeon and her children are reluctant to pursue surgical repair of her hip fracture.

6. Effect of Age on Surgical Mortality Historical surgical mortality rates in the elderly have been high, but the data are unreliable: Elderly were more likely to have emergency surgery, which has a higher mortality Mortality rates have declined since earlier studies Controlling for comorbidity diminishes the impact of advanced age

7. Decline in Surgical Mortality in Patients over Age 75 Hip Arthroplasty 4.8 - 36 Prostatectomy 1.8 - 10 Endarterectomy 8.0 - 63 All surgery 5.5 -12.5 Valvona J, Sloan F. Rising rates of surgery among the elderly. Health Affairs, 1985; 4:108-19. Found int Perioperative Medicine pg 387-8.Valvona J, Sloan F. Rising rates of surgery among the elderly. Health Affairs, 1985; 4:108-19. Found int Perioperative Medicine pg 387-8.

8. Comorbidity is Stronger Predictor than Age Series of 500 surgical patients over age 80 Effect of age on mortality: Age 80 - 90 5% Age > 90 9% Effect of comorbidity* on mortality : ASA Class II 1% ASA Class III 4% ASA Class IV 25% *American Society of Anesthesiologists� Classification: Class II: mild systemic disease, no functional limitations Class III: severe systemic disease, functional limitations Class IV: incapacitating disease, constant threat to life

9. Current Morbidity & Mortality Statistics 4315 patients over age 50 having elective, noncardiac surgery between 1989-1994: 50-59 60-69 70-79 >80 Mortality (%) 0.3 0.5 0.9 2.6 Death or Major 4.3 5.7 9.6 12.5 Complication (%)

10. Effect of Age on Hip Fracture Mortality 571 patient over age 50 admitted with hip fracture at 4 U.S. hospitals: Age was not a predictor of 6 month mortality in either univariate or logistic regression analyses Predictors of increased mortality were lower prefracture mobility, modified APACHE score, and the presence of a paid helper at home prior to fracture

11. Age and Surgical Risk: Conclusions While advanced age may predict greater operative morbidity and mortality, absolute risks are usually not prohibitive. Patient comorbidity is a greater predictor of adverse outcome than patient age

12. Case part 2: Special Preoperative Evaluation in the Elderly? All parties now agree to surgical repair of the patient�s hip fracture. The surgeon requests a Medicine consultation. The surgeon asks about appropriate preoperative cardiac and pulmonary evaluation, given the patient�s age.

13. Age as Predictor of Perioperative Cardiac Complications Advanced age correlates with increase cardiac risk, but is only a minor predictor: Original Cardiac risk index Assigns 5 points (out of 53 possible) to age > 70 In absence of other predictors, age > 70 predicts only a 7% risk of cardiac complication or mortality after major surgery

14. ACC / AHA Guidelines for Selecting Patients for Preoperative Stress Testing Patients with at least 2 of the following: 1) Stable cardiac disease or Diabetes 2) Undergoing �high risk� surgery major vascular surgery prolonged surgery with major fluid shifts or blood loss 3) Poor functional status (e.g. unable to walk 2 blocks at normal pace or climb a flight of stairs)

15. Age as Predictor of Perioperative Pulmonary Complications Age correlates with increase pulmonary risk, but studies fail to control for comorbidity: Patients > 70 years old have an unadjusted relative risk of 0.9 to 2.4 for pulmonary complications Studies controlling for comorbidity (especially COPD) find age is not an independent predictor

16. Spirometry has Poor Predictive Value

17. Preoperative Cardiac & Pulmonary Tests: Conclusions Preoperative evaluation with noninvasive cardiac stress tests or PFTs is not indicated for most patients with hip fracture Advanced age should not generally alter preoperative cardiac or pulmonary evaluation strategy

18. Case part 3: Perioperative Interventions The patient is deemed to be medically stable without evidence of acute medical problems. No further preoperative studies are planned. Hemiarthroplasty is planned for the next morning The Medicine consultant is now asked to take steps to minimize the risk of postoperative complications.

19. The Effect of Optimal Perioperative Medical Management East Anglian Audit: 580 hip fracture patients at 8 British hospitals 90 day survival ranged from 76% to 95% Length of stay ranged from 13 to 28 days One hospital had best survival, shortest LOS, and fastest time to patient mobilization Wide inter-hospital variation in DVT prophylaxis Concluded that the �total package of care� at the �best� hospital led to good outcomes

20. Preventing Cardiac Complications with Beta-blockers 200 patients with CAD or at least 2 CAD risk factors (age > 65, cholesterol > 240, HTN, current smoker, diabetes) randomized to Atenolol or placebo before major surgery: Patients on atenolol had 11% absolute risk reduction in mortality after 2 years of follow-up Patients on atenolol had 15% absolute risk reduction in non-fatal cardiac events after 2 years of follow-up

21. Venous Thromboembolism Pulmonary embolism accounts for 14% of deaths after hip fracture Multiple randomized trials show that prophylaxis prevents DVT after hip fractures Use of DVT prophylaxis was associated with reduced mortality after hip fracture Current guidelines recommend low molecular weight heparin or low intensity warfarin (INR target 2-3) after hip fracture

22. Utility of DVT Prophylaxis after Hip Fracture

23. Timing of Surgery No trials comparing immediate to delayed surgery Cohort studies have shown that surgery within 48 hours of fracture leads to lower mortality at 4 weeks and 1 year Other cohort studies suggest that surgery before medical stabilization leads to higher mortality Comorbidity confounds conclusions

24. Rehabilitation Early mobilization is safe and generally recommended Results from randomized trials of rehabilitation strategies and intensities are inconsistent Cohort studies suggest that early mobilization and more intensive physical therapy (2 or more sessions per day) lead to earlier ambulation and improved independence

25. Perioperative Care: Conclusions Optimal perioperative care can impact on morbidity and mortality after hip fracture Strongly consider beta-blockers for patients with coronary disease or multiple cardiac risk factors Use DVT prophylaxis (LMWH or warfarin) Impact of timing of surgery and intensity of rehabilitation are unclear, but early surgery and early, intensive rehabilitation may be beneficial

26. Case part 4: Postoperative Delirium On postoperative day #2, Ms. HF becomes confused and agitated. She pulls out her IV catheter and tries to climb out bed. Furthermore, she is unable to work with physical therapists. The Medicine consultant is asked to assess and manage her delirium.

27. Postoperative Delirium: Epidemiology Incidence in Hip Fracture Patients Varies greatly between studies. May be as high as 61% after hip fracture 10 - 33% of hip fracture patients are delirious at time of hospital admission Associated with higher mortality, longer length of stay, and risk of institutionalization

28. Postoperative Delirium: Prediction In unselected surgical patients, predictors included: Age > 70; Alcohol abuse; Baseline cognitive dysfunction; Poor functional status; Markedly abnormal sodium, potassium or glucose levels; Thoracic surgery; Aortic aneurysm repair Studies of hip fracture patients found age, dementia, and prefracture functional status predicted delirium

29. Postoperative Delirium: Etiology 571 hip fracture patients were interviewed daily; 54 (9.5%) developed delirium Only 7% were assigned definite cause: drugs, infection, fluid-electrolyte disorder Majority of cases had no single clear etiology Contributing factors included underlying dementia, sensory deprivation, infection, drugs, and fluid-electrolyte disorder

30. Postoperative Delirium: Treatment Few randomized controlled trials, so recommendations are based largely on expert opinion: Treat specific causes Quiet environment & avoid extraneous stimulation Frequent re-orientation and reassurance Reserve restraints for patients at high risk for self-harm Haldol is preferred agent for managing hallucinations, agitation, paranoia (0.5 -1 mg IM / IV initial dose, adjusted every 1 - 2 hours) if conservative measures fail

31. Postoperative Delirium: Conclusions Delirium is common after hip fracture repair Age and prefracture cognitive and functional status are major predictors Common reversible causes include drugs, infection, fluid-electrolyte disturbances, sensory deprivation If conservative measure (reorientation and reassurance) are ineffective, haldol is the preferred drug to manage severe delirium

32. Case part 5: Long-term Prognosis Unnecessary medications are discontinued, and Ms. HF�s children spend more time at her bedside. Her delirium improves by postoperative day # 4. On postop day # 6, she is discharged to a skilled nursing facility to continue physical therapy. Her children ask about her prognosis for recovery.

33. Long Term Prognosis: Mortality 1-year mortality in various studies: 12 - 37% Study compared observed and expected mortality one year after hip fracture: Average age 79 years Observed 1-year mortality 37 % Expected 1-year mortality at time of fracture 6.3% Major causes of death: pneumonia, PE, stroke, MI, CHF, malignancy

34. Long Term Prognosis: Mortality Many possible predictors of mortality: Older age and male sex are univariate predictors but not in multivariate analysis Other identified predictors: Comorbidity, as measured by APACHE or ASA Class Cognitive state: 11% 6-month mortality in cohort with high MMSE score vs. 50% in patients with low score Functional status: ADL scores, mobility scores Surgery before medical stabilization

35. Long Term Prognosis: Function Ambulation: 50-65% regain prior level of ambulation 20% remain non-ambulatory Ability to return home: 50-60% of patients are able to live in the community Good prognostic indicators for return to home: age < 85; prefracture mobility; prefracture ability to perform some ADLs; living with another person before fracture; ability to walk independently at time of discharge

36. Long Term Prognosis: Function Activities of Daily Living: Only 33% regained prior capacity to perform ADLs Only 21% regained I-ADL Predictors of poor recovery: older age, presence cognitive impairment, prefracture physical disability, and discharge to continuing care facility

37. Long-term Prognosis: Conclusions Long-term mortality is increased after hip fracture Many patients never regain ambulation and ability to live at home and perform ADLs Predictors of poor functional recovery include older age, prefracture functional & cognitive impairment, and functional status on hospital discharge

38. Case Conclusion 2 weeks later Ms. HF was discharged from the skilled nursing facility. One year later, she is able to walk with a walker, but can still live at home with her children. She remains active in her day treatment program.