94 y.o. female with severe hip pain and senile dementia

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94 y.o. female with severe hip pain and senile
dementia

• Geriatric Case Series
• Hospital for Special Surgery
• January 31, 2008

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94 y.o. Female presents with severe right hip pain

• History of Present Illness
• Progressive senile dementia for past 5 years.
  Poor short term memory. History of petit mal
  seizures for 5 years.
• Mild R hip pain for years but physically and
  socially active. Lived in assisted living
  apartment. Enjoyed croquet.
• 6 mos ago pain became severe and patient refused
  to ambulate.

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94 y.o. Female presents with severe right hip pain

• History of Present Illness
• Gave up all social activities
• Required 24 hour care
• C/O constant severe R hip pain
• Presented for evaluation for R THR accompanied by
  daughter and home health aid

4
94 y.o. Female presents with severe right hip pain

• Additional Orthopedic History
• No other joint complaints. No complaint of back
  pain
• PMH
• No comorbidities except progressive senile
  dementia
• Petit-Mal seizures for 5 years controlled with
  phenobarb. Last seizure 2005
• Meds Prozac 20 mg daily, Phenobarb 60 mg daily
  and Prilosec 20 mg BID. Tylenol prn pain

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94 y.o. Female presents with severe right hip pain

• Physical Exam
• Well appearing elderly female in wheelchair.
  Partially oriented
• Able to verbalize the reason for her visit. Able
  to express desire to be relieved of hip pain.
  Expressed a sense of humor
• Reluctant to walk and severe pain with R hip ROM
• Labs Hgb 14.6 g/dl creat 0.9, BCP wnl ECG wnl.

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94 y.o. Female presents with severe right hip pain

• Hospital Course
• 7/9/07 R THR CSE anesthesia cemented
  constrained cup/cemented stem
• Total EBL 310cc 1 unit prbcs postop hgb 10.1

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94 y.o. Female presents with severe right hip pain

• Hospital Course
• POD1 confused in AM but at baseline by evening.
  Sat and dangled
• POD2 Alert but disoriented. Walked with
  therapist in AM.
• POD2 _at_ 540 pm witnessed seizure and then
  unresponsive for 20 minutes. Thereafter awake but
  somnolent. Stat phenobarb level 10.3 g/dl ( 15-40
  )
• Neuro consult PACU phenobarb bolus

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94 y.o. Female presents with severe right hip pain

• Hospital Course
• POD 6 Floor care No further seizure activity.
  Ambulating 30 ft.
• POD7 Transferred to SNF?/ assisted living.
  Phenobarb level 15.9
• 6 mos postop In assisted living back to
  independent ambulation 24 hr HHA re-engaged
  socially. Family states the surgery a complete
  success.

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DiscussionHip Pain and Its Impact on Overall
Health in Elderly

• Dawson et al cross sectional survey of the
  residents of Oxfordshire gtr 65 yrs
• Incidence of hip pain 20
• Absence of OA overall health status (SF-36)
  equal to under 65 y.o. population
• Hip or knee OA negatively impacted health status
  dose response relationship
• More than 3 involved joints health status gtr
  85 yrs
• Hip and knee symptoms are largely responsible
  for poor health status of elderly. Eradication of
  hip/knee pain will raise the health status(SF-36)
  to a level equal to those under 65

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DiscussionTHR in Nonagenarians

• In 1995 1.25 million nonagenarians in the USA.
• Incidence of THR in the nonagenarian population
  1995
• - 136 THRs per 10,000
• - 33,851 performed
• - Mortality rate 2.3

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Total Joint ArthroplastyThe Octogenarian

• Reported Outcomes
• Berend et al ( J Arthroplasty 182003)
• LInsalata et al ( J Arthroplasty 71992)
• Shah et al ( CORR 4252004 )
• Improvement in hip and knee scores is comparable
  to younger series
• Revisions only for infection TKR higher
  infection risk than THR
• Higher risk of perioperative complications
  longer hospital stays but low perioperative
  mortality

Delerium, MI, Pneumonia, UTI and Decubitius
Ulcer
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Total Joint ReplacementThe Octogenarian
Birdsall et al JBJS 81B 1999
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Prevention of Delirium in Elderlypatients
following hip surgery

• Cochrane Database 2007
• Delerium occurs in 40-60 of elderly orthopedic
  patients
• Pre-existing dementia is most sig. risk factor
• Few studies on prevention only 3 of note
• Stromberg Randomized trial of a pro-active
  reorientation program.
• Kalisvaart randomized trial of prophylactic
  Haldol (1.5 mg /day)
• Marcantonio Pre-op geriatric consultation to
  address risk factors and health issues.

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Prevention of Delirium in Elderlypatients
following hip surgery

• Summary of Studies
• Best results pre-op geriatric consultation
  addressing health issues in preparation for
  surgery
• Reorientation programs and prophylactic Haldol
  ineffective in prevention but may help reduce
  severity and duration of acute episodes.
• Best evidence suggests
• - benefit of proactive geriatric care
• - use of modalities to orient elderly patients
  such clocks, TV, high nursing ratio, and regular
  clothes
• - preventive medication?? Needs study!!

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Allegaert Case Presentation References

• Berend et al ( J Arthroplasty 182003)
• LInsalata et al ( J Arthroplasty 71992)
• Kalisvaart, KJ, deJohnge, JF, Bogaards, MJ
  Haloperidol prophylaxis for elderly hip-surgery
  patients at risk for delirium a randomized
  placebo controlled study. J Am Geriatric Soc
  2005 53 1658-1666.
• Marcantonio, ER, Flacker, JM, Wright, RJ,
  Resnick, NM Reducing delirium after hip
  fracture a randomized trial. J Am Geriatric Soc
  2001 49 516-522
• Shah et al ( CORR 4252004 )
• Siddiqi, N, Stockdale, R, Britton, AM, Holmes, J
  Intervention for preventing delirium in
  hospitalized patients. Cochrane Database Syst
  Rev. 2007 18 CD005563.
• Stromberg, L, Ohlen, G, Nordin, C, Lindgren, U,
  Svensson, O Postoperative mental impairment in
  hip fracture patients. Acta Orthop Scand 1999
  70 250-255
• Williams-Russo, P, Urquhart, BL, Sharrock, NE,
  Charlson, ME Postoperative delirium predictors
  and prognosis in orthopedic patients. J Am
  Geriatric Soc 1992 40 759-767.

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Allegaert Case PresentationSummary Points

• OA hip can severely impact health quality of
  nonagenarians
• THR has higher risk of morbidity but acceptable
  mortality and effectively eliminates pain and
  restores QOL
• Mechanical failure unlikely constraint
• Delirium common esp in demented pts
• Proactive programs help