#388

Decision Making for Patients with Advanced Dementia and a Hip Fracture

  • Elizabeth A Bukowy DO
  • Elizabeth L Thiel MD

Download PDF

Background   Hip fractures are common in patients with advanced dementia, and many experts advocate that they be considered a sentinel ‘palliative’ event due to their strong association with reductions in quality of life and 1-year survival. Management decisions are often complicated due to the need for quick decisions by surrogates, involving multiple surgical and non-surgical options, often done in the context of uncertain prognosis. This Fast Fact reviews important considerations and practical recommendations about hip fracture management in patients with advanced dementia. 

Epidemiology   Falls cause 95% of hip fractures (1). The chances of a fall resulting in a hip fracture increases as people age, and in those with dementia such that the incidence of hip fractures for nursing home residents with advanced dementia is about 2.1/100 person years (2). Hip fractures in the elderly are associated with an increase in all-cause mortality with an overall mortality of 13% at 3 months and 23% at 12-months (3). For nursing home residents with advanced dementia, the mortality risk of a hip fracture is likely worse; in one study, 35% died within 6 months and 62% died within 2 years of the fracture with a median survival of 1.4 years for those treated surgically and 0.4 years in those treated non-surgically (4). For those who undergo surgical repair, there is usually a significant decline in function as many do not return to their prior level of function (5). Predictors of significant loss of function and increased mortality after a hip fracture include older age, living in a facility, co-morbidities, severe cognitive impairment, baseline dependence, longer hospital stay, and postsurgical complications (2,4-6).

Treatment   Type and location of fracture, prior level of function, and patient goals all factor into management options. Regardless, pain management should always be a central component in clinical management. There are multiple orthopedic surgical approaches based on fracture type: total or partial hip arthroplasty, or fixation with a nail or screw. The goals of surgery can be for comfort or restoration of normal ambulation (7,8). In addition to medical pain management, non-surgical management may also include modified weight-bearing status (typically strict bed rest is not required) or traction.

Clinical Decision-Making Pearls  

  • Clarify overall goals by evaluating a patient’s anticipated prognosis and baseline quality of life. That said, even for patients with clear goals, what to do requires complex decision-making involving uncertain risks and benefits. For instance, a non-ambulatory patient with a longer anticipated survival and comfort-focused goals of care may receive considerable analgesic benefit from operative management of a hip fracture.  Conversely, an ambulatory patient who undergoes surgery with life-prolonging goals of care, is at risk for delirium, pressure injuries, infections, or other complications.
    • In addition to surrogate decision makers, internists, geriatricians, orthopedic surgeons, anesthesiologists, palliative specialists, and physiatrists can clarify treatment options, prognosis, and care preferences.
    • Multiple studies have found that for nursing home residents with advanced dementia and hip fractures, patients who undergo surgery have lower mortality rates compared to those who do not have surgery, especially when the surgery is done within 24 hours. A systemic review and meta-analysis preformed on the timing of surgery in older patients with hip fracture found a statistically significant reduction in 1-year mortality of 18% in those operated on within 24 hours compared to over 24 hours (9). Repair within 24 hours is also associated with fewer postoperative complications (heart attack, pneumonia, or venous thromboembolism) at 30 days:  10% vs. 12% (10). 
    • If a patient has a life expectancy of days to weeks, non-operative, comfort-focused end-of-life management is generally recommended by many experts (see Fast Fact #150).  Traction is an option for patients who tolerate it and have pain with minimal movement in bed. 
    • If a patient has a life expectancy of months to years, surgical repair is typically appropriate especially if the goal is to ambulate again. Few hip fracture survivors remain ambulatory without surgery. For non-ambulatory patients, consider additional factors such as:
      • Is pain adequately managed even with turning and transfers? Are analgesics being tolerated? If not, operating becomes more favorable. 
      • How high is the surgical risk due to other underlying comorbidities?  
      • What is the surrogate decision-maker’s view about the patient’s quality of life pre-operatively and what the patient would likely consider acceptable quality of life post-operatively?

Recommendations   Hip fractures in those with advanced dementia should prompt clinicians to stop and consider the overall 1-year mortality of their patient. Prognosis should be transparently discussed with patients and the family. This discussion should include information on likelihood for functional recovery, patient values and preferences, advance care planning documentation, code status, and intensive care unit/re-hospitalization preferences.  The benefits and burdens of both surgical and non-surgical management should be clearly communicated along with the best case, worst case, and the most likely scenario regarding both options (11). Considering the poor long-term survival, we recommend initial hospice counseling for all patients with advanced dementia after a hip fracture (see Fast Fact #138).  

References

  1. Parkkari J, Kannus P, Palvanen M, et al. Majority of hip fractures occur as a result of a fall and impact on the greater trochanter of the femur: a prospective controlled hip fracture study with 206 consecutive patients. Calcif Tissue Int. 1999; 65:183–7.
  2. Dyer S, et al. A critical review of the long-term disability outcomes following hip fracture. BMC Geriatrics. 2016;16: 158.
  3. Schnell S, et al.  1-year mortality of patients treated in a hip fracture program for elders. Geriatric Orthopaedic Surgery & Rehabilitation. 2010; 1: 6-14.
  4. Berry S, et al. Association of Clinical Outcomes with Surgical Repair of Hip Fracture vs   Nonsurgical Management in Nursing Home Residents with Advanced Dementia. JAMA Internal Medicine. 2018;178(6): 774-780.  
  5. Moerman S, et al. Less than one‐third of hip fracture patients return to their prefracture level of instrumental activities of daily living in a prospective cohort study of 480 patients.” Geriatrics & Gerontology International. 2018; 18:1244-1248. 
  6. Neuman MD, et al. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Internal Medicine.2014; 174: 1273-1280.
  7. Handoll HH, Parker MJ. Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev. 2008;(3):CD000337.
  8. Mears SC. Classification and surgical approaches to hip fractures for nonsurgeons. Clinics Geriatric Medicine. 2014; 30(2):229-241.
  9. Klestil T, et al. Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis. Scientific Reports. 2018; 8: 13933.
  10. Pincus D, Ravi B, Wasserstein D, et al. Association Between Wait Time and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery. JAMA. 2017;318(20):1994-2003.
  11. Kruser J, et al. Best case/worst case: training surgeons to use a novel communication tool for high-risk acute surgical problems.” J Pain Symptom Manage 2017; 4: 711-719.

Conflicts of Interest: The authors have disclosed no relevant conflicts of interest

Institutional Affiliations: The Medical College of Wisconsin, Milwaukee, WI.

Version History:  originally edited by Drew A Rosielle; first electronically published in November 2019