Perioperative Management of Elderly Patients with Hip Fracture

1336 December 2014 W ORLDWIDE 1.6 million patients suffer from hip fracture every year, and this number has increased by 25% every decade as the population continues to grow.1 Nevertheless, a decrease in hip fracture rate has been recently observed, particularly in women (up to −24% in women older than 85 yr), owing to several factors including awareness about osteoporosis and the danger of falls.2 Hip fracture has devastating consequences in the elderly patients and thus is associated with a poor outcome. This contrasts markedly with the relatively simple surgical procedures needed for treatment. One third of elderly patients with hip fracture are dead 1 yr later and, in surviving patients, hip fractures have a negative effect on daily life activities and quality of life.1–3 The elderly patients with hip fracture remain a medical challenge for the anesthesiologist, mainly because of the frequent and numerous comorbidities encountered; moreover, the incidence of these comorbidities has increased during the past years.2 Many improvements have been introduced in the care of these patients, including improved surgical devices, earlier mobilization, prophylactic administration of antibiotics and anticoagulant, as well as increased rate of admission into rehabilitation unit. Nevertheless, the mortality rate has plateaued since 1998.2 Given the magnitude of the problem, some effective strategies have been recently proposed to prevent mortality after hip fracture.3,4 This Clinical Concept and Commentary summarizes these strategies and explain the future directions for research, but focuses on specific issues related to hip fracture and not to more general aspect related to anesthesia in elderly patients.5 Morbidity and Mortality After hip fracture, in-hospital mortality ranges from 2.3 to 13.9%, but the risk persists beyond the immediate surgical period with 6-month mortality rates ranging from 12 to 23%. 3 The mortality risk increases within 6 months and thereafter decreases, and is higher in men. When compared to elective hip replacements, patients presenting with hip fracture have a 6to 15-fold mortality risk.6 This difference is explained by the high prevalence of preexisting medical conditions in this population: 75% of patients are older than 70 yr,1 and 95% of patients present with at least one major preoperative comorbidity (fig. 1). 7 Three in four hip fracture-associated deaths may be causally related to preexisting medical conditions rather than the fracture itself.8 This indicates that the hip fracture destabilizes a frail elderly population with a high burden of preexisting morbidities, thereby resulting in excess mortality. Some new acute conditions (stroke and cardiac events) may have also provoked falling and thus hip fracture. Frailty should be understood as a vulnerability and a decline of physiologic age-related functional capacities to confront an acute stress such as hip fracture. To summarize, it can be considered in the presence of at least one of the following conditions: (1) advanced age, the “oldest old” (i.e., >90 yr); (2) presence of several comorbidities; and (3) new acute medical conditions. Any of these conditions can weaken elderly patients with hip fracture.