As life expectancy continues to increase in the United States, the number of elderly people and those with chronic health conditions like osteo­porosis is also rising. The number of people older than 65 is expected to increase from 37.1 million to 77.2 million by the year 2040. With this aging trend, the incidence of hip fractures is also expected to increase. “The care of patients with hip fracture is improving, but it’s still a significant healthcare challenge that dramatically affects patients and their caregivers,” says W. Timothy Brox, MD. “These individuals are at greater risk of death after their hip fracture. They also experience other problems, including being unable to return to prior living circumstances, the need for increased super­vision, and decreased quality of life and mobility. Furthermore, hip fracture patients are at increased risk for secondary fractures.”

Welcome Guidelines

In 2014, the American Academy of Orthopaedic Surgeons (AAOS) released a clinical practice guideline (CPG) on managing hip fractures in the elderly. The guideline included many evidence-based recommen­dations throughout the continuum of care, ranging from preoperative treatments to post-discharge management. Some of the recommendations in the guidelines are aimed at reducing delirium in hip fracture patients, according to Dr. Brox, who chaired the AAOS CPG writing group. “Delirium is common among hip fracture patients,” he says. “Patients with postoperative delirium are less likely to return to their pre-injury levels of function. They’re also at higher risk for postoperative complications and are more frequently placed in nursing homes. The lower the incidence of post-fracture delirium, the more completely and effectively patients will recover.”

Hip-Fractuce-Adults-Callout

Beyond delirium, the AAOS writing group gave a “strong” recommendation for preoperative regional analgesia to reduce pain in hip fracture patients, a practice that is not currently a standard of care in all hospital settings. The CPG also recommends that hip fracture surgery take place within 48 hours of a hospital admission for a hip fracture. “After hip fracture surgery, intensive physical therapy is paramount to improving functional outcomes,” adds Dr. Brox. Following a hip fracture, the AAOS recommends that patients participate in rehabilitation, be evaluated and treated for osteoporosis, and consider using vitamin D and calcium supplements.

A Helpful Tool

“These recommendations are part of the process of informing clinicians on how to improve care now,” says Dr. Brox. “They’re meant to be used in real time as an educational tool to augment the clinical judgment of healthcare providers and patient preferences. They can be especially helpful when making decisions on how to proceed with treatments for hip fracture patients. The themes of reducing delirium, controlling pain throughout care, and encouraging participation in rehabilitation are important to enhancing outcomes for these patients.”

References

American Academy of Orthopaedic Surgeons. Management of hip fractures in the elderly: evidence-based clinical practice guideline. September 5, 2014. Available at: http://www.aaos.org/research/guidelines/HipFxGuideline.pdf.

Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302:1573-1579.

Hannan EL, Magaziner J, Wang JJ, et al. Mortality and locomotion 6 months after hospitalization for hip fracture: risk factors and risk-adjusted hospital outcomes. JAMA. 2001;285:2736-2742.

Randell AG, Nguyen TV, Bhalerao N, Silverman SL, Sambrook PN, Eisman JA. Deterioration in quality of life following hip fracture: a prospective study. Osteoporos Int. 2000;11:460-466.