Don’t Compound the Fracture

1. 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

2. The Elderly Will Inherit the OR Ann Surg. 2003 August; 238(2): 170–177.

3. The Case of a Patient and Her Dog Mrs. Brittle Max

4. 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

5. 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

6. Anticipatory Differential Diagnosis (aDDx) • CV: MIs • DVTs • Infection – UTI’s, Cellulitis • Delirium • Pain • Falls • Repeat Fracture • Functional decline • Death

7. aDDx: Cardiovascular Events From Auerbach, A, Goldman, L. Circulation 2006; 113:1361.

8. 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

9. 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

10. 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

11. 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

12. aDDx: Delirium • Common • 10-50% of hospitalized elderly • Serious • 1 year mortality: 30-40% • Longer LOS • Increased NH placement • Preventable

13. 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 http://www.icudelirium.org Wei et al. J Am Geriatr Soc. 2008 Inouye SK. NEJM 2006;354:1157-65

14. aDDx: Delirium and it’s buddy Dementia % of people age >65 with moderate or severe memory impairment

15. Mini-Cog Recall=3 Recall=0 Recall=1-2 Clock Draw Abnormal Clock Draw Normal Dementia No Dementia

16. 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

17. Inouye SK. N Engl J Med 1999

18. Yale Delirium Prevention Trial Results Inouye SK. N Engl J Med 1999

19. 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

20. 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

21. 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

22. 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.

23. 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

24. 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

25. 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

26. 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

27. 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

28. aDDx: Falls Tinetti. NEJM 2003

29. 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.

30. 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

31. 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

32. aDDx: Functional Decline * Begin Rehab on the first post-operative day and advance as tolerated Federal Interagency Forum on Aging-Related Statistics.

33. Anticipate Death • Advance Directives • DPOA • Goals of Care • If things don’t go the we hope they will, what should we do?

34. Anticpatory Differential Eric Widera, MD Assistant Clinical Professor, Division of Geriatrics Director, Hospice & Palliative Care, SFVAMC Eric.widera@ucsf.edu