Rehabilitation After Hip Fracture in a Frail Elderly Patient
An 82-year-old woman is admitted after surgical fixation of a displaced femoral neck fracture following a fall at home. She lives alone, uses a walker, and has mild cognitive impairment (Mini-Mental State Examination 22/30). Comorbidities: hypertension, osteoporosis, and osteoarthritis of both knees. On postoperative day 2 she is alert, afebrile, BP 138/78 mmHg, HR 84/min, SpO2 96% on room air. She has not yet stood. She is on enoxaparin 40 mg daily, paracetamol, and amlodipine. She is reluctant to mobilize because of pain and fear of falling. Her daughter asks whether she will be able to return home.
1. What are the priorities for early rehabilitation and prevention of complications in the first postoperative week?
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Priorities:
- Early mobilization (ideally within 24–48 h post-surgery) with physiotherapy - sit out of bed, stand, and progress to walking with appropriate aid; this reduces delirium, pneumonia, pressure ulcers, and venous thromboembolism.
- Adequate analgesia to enable mobilization (multimodal: regular paracetamol; consider short-term opioids cautiously given cognitive impairment, monitoring for delirium).
- Delirium prevention and monitoring - orientation, sleep hygiene, hydration, early removal of urinary catheters, and review of medications with anticholinergic burden.
- VTE prophylaxis - continue enoxaparin per protocol, with attention to renal function and bleeding risk.
- Osteoporosis treatment - ensure calcium and vitamin D, and initiate or continue bone-protective therapy (e.g., bisphosphonate or denosumab) after fracture, with dental and renal assessment.
- Fall prevention - assess vision, footwear, home hazards, and orthostatic blood pressure.
- Nutrition and pressure-area care.
2. How should the rehabilitation setting and discharge plan be decided, and what factors argue against an immediate return home?
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Decision factors:
- Functional status: she has not yet stood and needs to achieve safe transfers, walking with an aid, and independence in basic activities of daily living before discharge.
- Cognitive impairment (MMSE 22) increases risk of medication errors, falls, and difficulty following a home exercise program.
- Living alone without an identified caregiver means safety at home is uncertain.
- Home environment must be assessed (stairs, bathroom, lighting).
Recommended pathway:
- Inpatient rehabilitation or a transitional care unit for intensive physiotherapy and occupational therapy, rather than immediate discharge home.
- Multidisciplinary assessment (physiotherapy, occupational therapy, social work, geriatrics).
- Home safety assessment and equipment (raised toilet seat, grab bars, walker).
- Care coordination with the daughter and community services; discuss a personal alarm or increased support.
- Set measurable goals (e.g., walk 10 m with a walker, transfer independently) before discharge planning.
- Reassure the daughter that the plan is to maximize independence, not to institutionalize.
3. What medication safety issues should you address before discharge?
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- Anticoagulation: clarify duration of enoxaparin and whether transition to an oral agent is appropriate; check renal function and bleeding risk; educate on signs of bleeding.
- Analgesia: step down opioids promptly; avoid combining multiple sedating agents; review for constipation prophylaxis.
- Antihypertensives: check for orthostatic hypotension contributing to falls; review amlodipine dose and timing.
- Bone health: confirm calcium/vitamin D and anti-resorptive therapy; avoid duplicate supplementation.
- Deprescribing: review any anticholinergic or sedative medications that worsen cognition and fall risk.
- Adherence support: simplify the regimen, use a pill organizer, and involve the daughter; provide a written medication list.