Hip fractures are sentinel events often associated with reduced function, quality of life and increased mortality. Management decisions in patients with advanced dementia are often complicated due to the need for time-sensitive decisions by surrogates, involving multiple operative and non-operative options, often in the context of uncertain prognosis. This Geriatric Fast Fact reviews important considerations and offers practical recommendations surrounding hip fracture management in patients with advanced dementia.  

Treatment options: Possible treatment options depend on the type and location of fracture, prior level of patient functional status, and patient goals.  Medical management of pain should always be central. There are various orthopedic surgical approaches based on fracture type (e.g., total or partial hip arthroplasty, fixation with a nail or screw). The goals of surgery may range from maximizing comfort to restoration of normal ambulation (1,2). In addition to medical pain management, major non-operative management options include modified weight-bearing status (typically strict bed rest is not required) or traction.

Decision-making approach:     
1. Participants in decision-making begin with patients and family or surrogate decision makers. Care team members with helpful insights may include physicians (e.g., primary care providers, hospitalists, geriatricians, orthopedic surgeons, anesthesiologists, palliative specialists, physiatrists), nurses, therapists, social workers and chaplains. For frail elderly patients residing in nursing facilities, geriatrician involvement can improve 1-year mortality in those undergoing surgery for a hip fracture (3,4,5).
2. Clarify overall goals by evaluating a patient’s anticipated prognosis and baseline quality of life (6). Even for patients with clear goals, decision-making may remain complex, involving uncertainty in risks, benefits, and outcomes. For example:

• A non-ambulatory patient with an anticipated longer survival time may have care goals solely focused on comfort, yet surgery may reduce pain.
• An ambulatory patient who undergoes surgery with goals for life-prolongation may experience complications (e.g., delirium, pressure injuries, infections, or death). 

3. Clearly communicate benefits and burdens of both orthopedic surgical and non-operative management.  This discussion should include information on prognosis, likelihood for functional recovery, patient values and preferences, and pain management strategies in each scenario (6).  Regardless of treatment decisions or goals, providing palliative/hospice care information is indicated for patients with advanced dementia and hip fracture as their survival rates are poor.

Factors to consider:
1. Studies have found that nursing home residents with advanced dementia and hip fracture who undergo surgery (ideally in the first 24 hours) have lower mortality rates compared to patients that do not undergo surgery. (7)
2. Is pain adequately managed with turning and transfers? Are analgesics being tolerated? If not, surgery becomes more indicated. 
3. How high is the surgical risk due to other underlying comorbidities?  
4. What is the surrogate decision-maker’s view about the patient’s quality of life pre-operatively and what the patient would likely consider acceptable quality of life post-operatively.
5. In patients: 

• At end-of-life (e.g., days to weeks), non-operative management is indicated, with comfort-focused end-of-life care. A trial of traction is an option for patients experiencing pain with minimal movement in bed. 
• With a life expectancy of months to years, surgical repair is typically appropriate, especially if the goal is to ambulate again. Few hip fracture survivors remain ambulatory without surgery.