Factors Considered by Interprofessional Team for Treatment Decision in Hip Fracture With Dementia

Alice C. Baker, MD, MPH; Catherine G. Ambrose, PhD; Paula L. Knudson; Smita S. Saraykar, MBBS, MPH; Linda B. Piller, MD, MPH; Sheryl A. McCurdy, PhD; Nahid J. Rianon, MD, DrPH

Disclosures

J Am Geriatr Soc. 2019;67(6):1132-1137. 

In This Article

Abstract and Introduction

Abstract

Objectives: Patients with dementia are at high risk for hip fractures and often have poor outcomes when a fracture is sustained. Despite this poor prognosis, little data are available on what factors should be prioritized to guide surgical decision making in these cases. We aimed to understand the decision-making process for older dementia patients hospitalized after hip fractures.

Design: We performed a qualitative analysis of in-depth elite interviews conducted with a clinical care team involved in management of patients with dementia after hospitalization for hip fractures.

Setting: Interviews were conducted with an interprofessional team involved in the care of patients with dementia after being hospitalized for hip fractures.

Participants: Interviewees included nine orthopaedic surgeons, three hospitalists, three geriatricians, five nurses, three occupational therapists, three physical therapists, and two clinical ethicists.

Measurements: Verbatim transcripts of the interviews were analyzed and coded using QSR International's NVivo 10 qualitative database management software.

Results: The three main themes that most interviewees discussed were pain control, functional status, and medical comorbidities. Interviewees brought up many factors related to restoring functional status including baseline functional status, rehabilitation potential, social support, and the importance of mobility. Dementia and its impact on rehabilitation potential were mentioned by all geriatricians.

Conclusion: Although frailty, prognosis, and life expectancy were largely absent from the responses, the emphasis on dementia, advanced directives, and involving family or caregivers by the three geriatricians indicates the importance of including geriatricians in the decision-making team for these patients.

Introduction

Hip fractures in older individuals, even without the presence of dementia, increase the risk of mortality (20%-30% within a year), secondary osteoporotic fractures, and multiple medical complications.[1,2] These fractures decrease the patient's quality of life due to impaired mobility and the need for increased level of care and supervision.[1,2] Among survivors, 25% of previously independent patients end up in nursing homes, and 60% cannot perform at least one activity of daily living a year after a hip fracture.[3]

Patients with dementia are at increased risk for hip fractures,[4] and outcomes after hip fractures are worse. They have a higher incidence of overall postoperative complications including delirium, infection, respiratory complications, and readmission after initial hospitalization.[5–7] Readmissions within 30 days of a hip fracture were associated with an increased length of stay, an 18.6% mortality during the admission, and a 56% 1-year mortality.[8] In light of the increased risks associated with hip fractures in patients with dementia, the benefits and types of interventions should be closely examined, specifically focusing on those preserving the highest quality of life.

The mainstay of treatment for most hip fractures focuses on restoring functional status and involves early anatomical reduction and surgical fixation.[9] Although very few studies compared operative vs nonoperative management in the various types of proximal femur fractures,[10] most surgical interventions were associated with a higher likelihood of anatomical fracture reduction and shorter hospital stays. However, with intertrochanteric fractures there is no difference in mortality, pain, leg swelling, or pressure ulcers between surgery and skeletal traction with early immobilization and a high standard of nursing care.[11] In these cases nonsurgical management with novel approaches to analgesia (eg, continuous peripheral pain catheters for achieving pain control and improved ambulatory status) and decreasing opiate consumption may be a better option.[12] About 5% of femoral neck fractures in Medicare patients were stabilized nonoperatively between 1991 and 2008.[13] However, given the exceedingly poor outcomes associated with hip fractures even when treated operatively, there are discussions about including conservative treatment in appropriate cases.[14] Because of the high mortality and functional dependence, hip fractures should trigger an early palliative care approach with open-ended discussions and consideration of nonoperative management,[15] especially in patients with life-limiting diseases. A decision for surgical intervention should only be made after careful consideration of the patient's goals of care.[15]

The American Academy of Orthopaedic Surgeons (AAOS) recommends care by an interprofessional team and aggressive postsurgical physical and occupational therapy for improving outcomes in patients 65 years or older with mild to moderate dementia.[16] Once a patient is admitted to the hospital, surgeons (in collaboration with anesthetists) would typically make surgical decisions following their standard guidelines.[16] However, it is unclear which factors each nonsurgical member of the interprofessional team considers when making decisions about treatment in these patients. Although postsurgical rehabilitation is often discussed by the interprofessional team during hospital rounds as a challenge for hospital discharge, perspectives from physical and occupational therapists and nurses in long-term care units are missing from the scientific literature.

In this study, we aimed to determine the factors that members of a typical geriatric interprofessional team consider when deciding on surgical intervention for patients with hip fractures and dementia.

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