Interprofessional Surgical Decision Making for Hip Fractures in Elderly Demented Patients
Hip fractures represent a major cause of morbidity and mortality among older adults. Patients with dementia are at high risk for hip fractures and often have poor outcomes. Unfortunately, despite the poor prognosis for older patients with dementia who get hip fractures, there is little data to guide surgical decision making in these cases. In order to understand decision-making factors currently being used for older dementia patients with hip fractures we conducted 28 in-depth elite interviews with providers from many different specialties. Interviewees included orthopedic surgeons, internists, geriatricians, nurses, physical therapists, occupational therapists, and clinical ethicists who are involved in in-hospital care of needing surgical intervention for fragility hip fractures. Participants were given two cases of patients over 65 with dementia and hip fracture and asked to elaborate on points for or against surgical interventions in these cases and to discuss scenarios when to and when not to perform surgical intervention in older patients with osteoporosis-related fragility hip fractures. Verbatim transcripts of the interviews were analyzed and coded using QSR International’s NVivo 10 qualitative database software. The three main categories that interviewees discussed were pain control, functional status, and medical comorbidities. Pain control was often cited as a reason to operate, and non-operative analgesia strategies were rarely discussed. In terms of restoring functional status, interviewees brought up many factors to consider including baselines functional status, rehab potential, social support, and the importance of mobility. Participants discussed medical comorbidities predominantly in terms of their impact on surgical risk, though some did consider overall health status and life expectancy. Discussions of frailty and the impact of a hip fracture on overall prognosis were largely absent, and none of the respondents mentioned consulting palliative care of a discussion about goals of care before proceeding with surgery. A stronger, more systematic approach to the care of these patients is needed in order to avoid unnecessary, aggressive interventions in patients with advanced dementia and limited life expectancy.
Baker, Alice, "Interprofessional Surgical Decision Making for Hip Fractures in Elderly Demented Patients" (2017). Texas Medical Center Dissertations (via ProQuest). AAI10786034.