An 88-year-old care home resident with dementia sustains a fractured neck of femur. What are the priorities in the first 24 hours?

Question

An 88-year-old woman with moderate dementia, CFS 6, on apixaban for atrial fibrillation, has a displaced intracapsular femoral neck fracture. She is in pain and agitated in the emergency department.

Accepted Answer

My first action is analgesia, because pain in this patient is both a humanitarian issue and the single largest driver of delirium. I would give regular paracetamol with a carefully titrated opioid and, most importantly, arrange a fascia iliaca compartment block early, which is opioid-sparing and is the standard of care. The second priority is getting her to theatre within 36 hours, because delay beyond that increases mortality, delirium, pressure damage and loss of function, and I would say that explicitly rather than treating the timing as an orthopaedic matter. That means optimising her for surgery rather than investigating her indefinitely: bloods, ECG, group and save, a chest film only if it will change management, and correcting what is genuinely correctable such as dehydration or a treatable arrhythmia. Her apixaban needs early discussion with anaesthetics and orthopaedics, because the timing of the last dose determines whether a spinal is possible and therefore when she can go to theatre. I would ask for orthogeriatric review from admission rather than after the operation. On consent, I would assess her capacity for this specific decision and not assume she lacks it because she has dementia; if she does lack capacity, I would make a documented best-interests decision, consulting her family and checking for any advance decision or health and welfare LPA. Alongside this I would start a delirium prevention bundle from arrival — hydration, orientation, her glasses and hearing aids, avoiding an unnecessary catheter — and attend to pressure areas and nutrition, since care home residents are at high risk of both. Before discharge I would complete a bone health assessment and start treatment, arrange a falls assessment, and plan rehabilitation with the MDT and the care home.

Hip Fracture in a Frail Older Patient

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