Hip fractures and dementia: clinical decisions for the future

A 92-year-old woman with dementia presented to the emergency department in pain with a right comminuted pertrochanteric femoral fracture after a fall. She had lived in a nursing home with severe cognitive impairment (mini-mental state examination score of 7/30), double incontinence and deteriorating mobility (increasingly wheelchair-dependent). Her other significant past medical history included insulin-dependent type 2 diabetes mellitus, chronic renal failure (baseline creatinine 100 µmol/l) and poorly controlled hypertension. Her next of kin was her son, who lived in Hong Kong. There were no documented advance care directives or medical powers of attorney recognized by her nursing home. She had sustained a non-ST-segment elevation myocardial infarction (NSTEMI) in association with the fall (Fig. 1). As a result and given other significant comorbidities, initial anaesthetic review deemed that she had an unstable cardiac risk, with high possibility of intraoperative mortality. The anaesthetic recommendation was for a delay of 24–72 h in operative fixation, in order to allow monitoring and optimization of cardiac status. A palliative care review controlled her pain, via a continuous subcutaneous infusion of fentanyl. Over the next 2 days, she had a transthoracic echocardiogram (which revealed normal left ventricular size and function), an orthogeriatric and further anaesthetic review. She was subsequently deemed fit for surgery, but remained a ‘very high risk for anaesthesia’. The option of continuing non-operative management was not discussed and her son consented for the insertion of a dynamic hip screw. The patient's postoperative recovery was complicated by anaemia and aspiration pneumonia, both of which were successfully treated. Her perioperative symptoms of delirium and pain received ongoing palliative management, facilitating a good recovery by Day 5 of her admission. Figure 1: ECG at the time of admission. Note ST depression most prominent in leads V4–6 and II. Initial troponin T 25 ng/l, rising to 214 ng/l on Day 5 (reference range <13 ng/l). The operative intervention was successful from an analgesic viewpoint. However, she was now bedbound and inappropriate for rehabilitation. She was therefore discharged back to her nursing home, a week after admission. In discussion with her son, he reflected on his decision—aware of his mother's poor premorbid quality of life and her life-prolonging treatment. It was clear that he was struggling with this outcome, but the complexity of his decision was recognized and supported by the palliative care team. The nurse manager at the facility reported progressive disability, with prominent confusion and agitation subsequent to her return. She remained in the nursing home for 4 months, until her death from complications of her dementia.