This year has seen a multidisciplinary group of healthcare staff succeed in their aim of raising the care standards and outcomes for hip fracture patients in Ireland. Managing older patients with hip fractures requires a multidisciplinary team of care providers, in which nurses play a key role in providing and co-ordinating care. 

The term ‘hip fracture’ refers to a fracture of the proximal femur (upper quarter) and predominantly is the result of a low trauma fall (ie from standing height or less). Currently there are approximately 3,200 hip fractures every year in Ireland. The gender ratio is 70% female to 30% male. Some 58% of all hip fracture patients are over the age of 80, with 71% residing at home prior to fracture. Their pre-fracture mobility is usually good with 78% mobilising unaided or with one stick.¹

In 2008 a national report into falls and fractures in Ireland’s ageing population identified hip fractures as one of the most serious injuries due to a fall, resulting in lengthy hospital admissions, ongoing care in step-down facilities and ultimately a high cost to the health service.² The rate of hip fracture in the total population aged 50 and over was 407 for females and 140 for males per 100,000.³ Furthermore, hip fractures account for half of all fractures in patients over the age of 65.² 

Without a conscious effort to try to improve both the existing care of hip fracture patients and a strategy to prevent them through falls prevention and bone health assessment we will see at least a doubling in numbers of fractures in the next 20 years and a tripling of the cost to the health service. Currently hip fracture patients have an average length of stay of 18 days and require considerable support after discharge from hospital.¹

Outcomes

The mortality associated with hip fractures at one month is as high as 10% with as many as 33% of patients having died within 12 months post fracture.⁴ There is also a significant reduction in independence, with up to 50% of patients unable to walk independently again, 60% reporting difficulties carrying out one essential activity of daily living and 25% residing in long-term care.⁵ Re-admission rates for this group range between 5-12% within the first six weeks post discharge.⁶ 

Evidence-based nursing care is key for providing optimum care and improving the outcomes for this group of patients. There are specific areas of nursing care to consider when dealing with a hip fracture patient: pain management, delirium prevention and management, pressure ulcer prevention, fluid balance and nutrition, constipation prevention, mobility and falls prevention, bone health and discharge planning. 

Pain management

The pain experienced following a hip fracture is very distressing for patients and prolonged or under-managed pain can impede mobility, functional ability and result in extended hospital admissions. There is a significant link between pain, delirium, depression and sleep disturbances. As nurses, we must be cognisant of the fact that older patients may also suffer from pain unrelated to the fracture. Osteoarthritis, osteoporosis and vascular neuralgias are common conditions in older people that can cause pain.⁷

Pain is often under reported by older patients. As nurses, we must differentiate between the types of pain our patients are suffering, based on the presentation, ie. duration (acute or chronic) and type (nociceptive and neuropathic). We should also consider that the patient can be experiencing different types of pain simultaneously. 

A comprehensive understanding of the patient’s pain, physical, emotional and/or psychological, should be considered to optimise their care.⁸ Using evidence-based pain assessment tools to establish the location, intensity and assessing previous pain management strategies is essential. It is important to understand signs of pain in patients who cannot report their pain as a result of cognitive impairment and dementia. Facial expressions, verbalisations or vocalisations, body movement, changes in interpersonal interactions and mental state changes can all indicate pain in a patient who cannot report it.⁹

Managing pain should be patient specific and combine pharmacological and non pharmacological treatment considerations. Multimodal analgesia may be appropriate. Caution should be shown when using opioids as the requirements for such analgesia decreases with age. Generally regular paracetamol combined with a low dose opioid is quite effective, post-surgery. Pre-operatively, the need for stronger opioids can be greater and consideration should be given to alternative pain relief such as nerve blocks. The key is to assess pain regularly, evaluate the effectiveness of the analgesia administered and review the patient’s pain regime daily. 

Delirium prevention and management

Delirium can be present in as many as 62% of hip fracture patients.¹⁰ It is characterised by an acute alteration in baseline mental function associated with fluctuations of attention, perception and consciousness. It can contribute to functional decline, pressure ulcers, institutionalisation, increased length of hospital stay and even death. It can often be overlooked or misdiagnosed especially when there is a baseline cognitive impairment or dementia present.

The risks of developing delirium include: predisposing factors such as previous episodes of delirium, dementia, or depression, being aged 75 and older, hearing/visual impairments, metabolic/electrolyte disturbances, infection, substance abuse, ADL dependency and incontinence.⁸ Precipitating factors for hip fracture patients are: orthopaedic surgery, prolonged periods fasting, waiting for surgery, medications being added or withdrawn, hypoxia, fluid overload, dehydration, pain, sleep disturbances, noisy environment, immobility caused by drips, catheters and medical devices and constipation. 

Once a delirium is identified or suspected, early intervention is key. This can often be a terrifying experience for the patient so providing reassurance and some familiarity to the patient will help. Ask family members to come and sit with the patient and consider moving the patient to a quieter room. Use the PRISM-E guide to identify the causes of the delirium: 

P: Pain, poor nutrition 

R: Retention, restraints

I: Infection, immobility 

S: Sleep disturbances, sensory deficits

M: Metabolic imbalances, mental status, medications 

E: Environmental.¹¹

Time, understanding and consistency of care are key to managing delirium, which can resolve quickly but may be prolonged and in some cases unresolved. It is not advocated to prescribe sedative medications in patients with delirium as this increases their risk of falls and may mask the reason for the delirium. In some instances where conservative management has failed and patients are distressed, actively hallucinating or a risk to themselves or others, the administration of the lowest clinically appropriate dose medication could be considered, but a geriatric or medical consult should precede this.

Pressure ulcer prevention

Hip fracture patients are at a high risk of developing a pressure ulcer.¹² This is considered localised injury to skin or tissue as a result of pressure or pressure with shear. Pressure ulcers can result in considerable pain, increased length of stay and hospital costs.

The incidence of pressure ulcers in hip fracture patients in Ireland is 4% but may be as high as 10%.¹ Older patients have a predisposition to pressure ulcers especially following a fracture and in combination with, diabetes, respiratory disease, low haemoglobin, low blood pressure, immobility and altered mental state. 

A thorough skin assessment should be completed on admission and any pre-existing issues identified. This should include colour/discolouration, temperature, moisture level, turgor and skin integrity. A pressure risk assessment should also be conducted and relevant preventative care implemented based on the risk. It is important to reassess the risk score regularly as hip fracture patients conditions can improve, or deteriorate, quickly. 

Understanding the classification of ulcers is important to ensure optimum treatment of the damaged skin. The EPUAP description includes four stages: 

1. Non-blanching erythema 

2. Partial-thickness, ie. loss of dermis

3. Full-thickness skin loss 

4. Full-thickness tissue loss.¹³

Appropriate prevention strategies should be applied to prevent or limit the progression of an ulcer. Consider: emollients for hydration of dry skin; skin protection barriers in cases where excessive moisture is present; reducing the amount of pressure and duration of time this pressure is exerted by a combination of encouraging the patient to regularly mobilise if possible, change position, or be repositioned; and use pressure relieving devices such as pressure relieving mattresses, cushions or heel-suspension boots. Encourage the patient to participate in relieving their pressure areas and report any soreness immediately. 

The patient’s nutritional status should be considered as this can contribute to the risk of developing a pressure ulcer significantly. Patients who are malnourished are twice as likely to develop pressure ulcers. 

Remember pressure ulcers can develop any time during admission to hospital so be vigilant with continued daily skin inspections and regular pressure area checks. Proper manual handling techniques will reduce the risk of shear when repositioning patients. Hip fracture patient’s heels and sacra are especially at risk of pressure ulcers.

References

1. Irish Hip Fracture Database Preliminary Report 2013 www.noca.ie
2. Health Service Executive, National Council of Ageing and Older People,Department of Health and Children, 2008. Strategy to prevent Falls and Fractures in Ireland’s Ageing Population. Summary, Conclusions and Recommendations
3. Dodds MK, Codd MB, Looney A, Mulhall KJ. Incidence of hip fracture in the Republic of Ireland and future projections: a population-based study. Osteoporosis Int. 2009 Dec;20(12):2105-10
4. Alzahrani, K, Gandhi, R, Davis, A & Mahomed, N. (2010) In-hospital mortality following hip fracture care in southern Ontario. Canadian Journal of Medicine. 54 (5) 294-298
5. Wehren, LE & Magaziner,J. (2003) Hip fracture: risk factors and outcomes. Curr Osteoporos Rep. Sep;1(2): 78-85
6. Boockvar, KS et al (2003) Hospital readmissions after hospital discharge for hip fracture: surgical and nonsurgical causes and effect on outcomes. Journal of American Geriatrics Society 51:399-40
7. American Geriatrics Society (2009) Panel on persistent pain in older persons. Pharmacological management of persistent pain in older persons. Journal of American Geriatrics Society 57, 1331-1346
8. Maher. A, Mewehan. J et al (2012) Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 1). International Journal of Orthopaedic and Trauma Nursing, 16, 177-194
9. American Geriatrics Society (2002) Panel on persistent pain in older persons. The management of persistent pain in older persons. Journal of American Geriatrics Society 50, S205-S224
10. White, J E, Khan, WS, Smitham, PJ. (2011) Perioperative implications of surgery in elderly patients with hip fractures: an evidence based review. The Journal of Perioperative Practice 21(6), 192-197
11. http://geropsychiatriceducation.vch.ca/docs/edudownloads/delirium/delirium_screening_PRISME.pdf
12. Baath, C, Wilde-Larsson, B, Idvall, E, Hall-Lord, Ml (2010) Registered nurses’ and enrolled nurse assessments of postoperative pain and risk for malnutrition and pressure ulcers in patients with hip fracture. International Journal of orthopaedic and trauma nursing. 14, 30-39.
13. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009) Prevention and treatment of pressure ulcers. Quick reference guide. National Pressure Ulcer Advisory Panel, Washington DC