82 y.o. Hip Fracture: Regional Logic
Foundational orthopedic scenario balancing Neuraxial vs. General anesthesia in the frail elderly with dementia.
"An 82 y.o. female presents for total hip arthroplasty after a fall at home. History of HTN, stable CAD, and mild dementia. Medications include lisinopril and aspirin. She is currently in pain and slightly confused."
Neuraxial vs. General anesthesia in the elderly, post-operative delirium risks, and management of anticoagulation protocols (ASRA guidelines).
The daughter wants her 'completely asleep.' How do you respond? Defend your block choice while navigating the ethical nuances of consent in a confused patient.
How a Board-Certified Consultant answers this scenario.
For this frail 82-year-old with dementia, my goal is to provide a 'delirium-sparing' anesthetic that maximizes her post-operative mobility. I will strongly recommend a neuraxial technique—specifically a spinal anesthetic—as it can reduce the incidence of post-operative cognitive dysfunction compared to general anesthesia.
I will address the daughter's concerns by explaining that while her mother will be 'awake' in a medical sense, we will provide light, titrated sedation for her comfort during the procedure. I will obtain consent from her legal proxy given her confusion. For her pain, I will perform a fascia iliaca or PENG block pre-operatively to reduce her opioid requirements, which is critical for preventing further cognitive decline in the elderly. I will emphasize that maintaining stable blood pressures via the spinal is paramount to preventing cardiac complications in this age group.