Dear Dr Tanchev

I think THR in patients with elderely patients with cognitive disorders has  high rate of dislocation, so it`s better to do hemiarthroplasty (bipolar) and in case of dependent elderely unipolar hemiarthroplasty

Panayot,

 I do not think pseudarthrosis is the way to go. I think you need to get this person back on his or her feet with as little pain as soon as possible.I would recommend THA over and above internal fixation in anyone over the age of 50 regardless of Alzheimer or not. I believe THA has better outcomes in both the short and long-term. The only question is cementless or cemented. Depending on the overall life expectancy and assuming the patient with Alzheimer is over 65 I would suggest cement.

Regards,

Tim

Thank you, Tim and Ali. I agree with your concerns. Unfortunately, there are some unhappy patients (i.e. over 85) with advanced Alzheimer, heart failure, other severe comorbidities, not ambulatory, etc., where one should have to accept the less evil - "doing no surgery" and counting on palliative care.   

Ali,

I like your comment on Bipolar however with Dual Mobility cups now available I would lean towards this over a bipolar. I would however suggest a bipolar over a pseudarthrosis.

Panayot,

You do bring up significant concerns with comorbidities. I do think a Bipolar can be done by most hip surgeons in under 30 minutes. If the patient is stable enough to risk 30 minutes then this would be my choice. My concern with doing no surgery on a patient with poor compliance "Alzheimer" is just that no compliance. It takes a level of commitment to be non-ambulatory and I think the risk of further injury and pain are likely. 

Patients with Alzeheimer's Disease have a higher incidence of hip fractures in comparison with other elderly people. If their functional outcome remains insufficient, this can lead to loss of mobility so it is necessary interdisciplinary care approach and early op treatment: THR, bipolar and dual mobility model are the solutions. 

Good question once more. There is no academic answer in these cases depending on general patients statement. There no real contraindication for it and I've already done some but most of them deserve a simple functional answer

Dear Dr. LEVI-FAICT,

I think this question is a difficult one. One should have to consider many issues. Frankly speaking, I do not think surgery is always the best way to go. Especially, in cases of repeated dislocations and failure to make such a patient ambulatory, surgery would turn to be "surgery for surgery's sake".  

Panayot,

I agree with your comment that this is a difficult question. In fact I cannot find fault with any of the answers. I tend to look at these questions as what would I want done if I were the patient. I have had family members that had suffered from Alzheimer and I have found it very difficult to see any real ability for sever Alzheimer patients to have enough cognitive ability to function on their own. So I do agree that often surgery should not be done because we can always make things worse but I also believe the potential risk reward from a potential ongoing pain and suffering point of view that the appropriate surgery can reduce future pain and suffering by giving the patient the best opportunity to ambulate as safely as possible. Of course this is assuming my interpretations of the facts which in reality might be totally off base.

Tim, 

I think of the satisfactory results with the so-called Girdlestone hip. This is a historic procedure but also a salvage one in some patients with failed THR (last line of defence). Why not consider accepting a similar state (pseudarthrosis) in very severe Alzheimer patients with severe comorbidities and little functional capacity, relying upon nursing care, physical therapy and analgetics. This consideration of mine does not mean that I do not do THR in similar patients as first choice of treatment.

Panayot,

I would agree last line of defense. Your comment on  relying upon nursing care, physical therapy and analgesics. This in my opinion was a very viable treatment plan 25-30 years ago. Nursing care has suffered over the years with very little nursing going on by Registered Nurses. The average Nursing facility in the States uses Nurses for documentation with aids doing the patient care. These staffers are often not trained and are minimum wage workers. My wife who is now retired was a Death and Dying Nurse that also specialized in Alzheimer patients. There are very dedicated professionals in this field however the average care for the Medicare patient is not adequate in my opinion.

We don't see Girdlestones very often however I am old enough to have seen my share over the years. It seems to me the best Girdlestones were in patients that were healthy and ambulatory.

If the individual patient has resources to ensure proper care I would be more open to this treatment plan. Without proper nursing care the non ambulatory patient is at increased risk for all kinds of ongoing health issue like bed sores , etc.

I don't think we are to far off on choice of treatment.

The volume of increased elderly with sever comorbidities is reaching scary levels with 80% of our Medicare dollar going towards the last 20% of life. The real solution its find viable treatments to reduce and cure Alzheimer.

Dear Panyot I woul rather  a hemiarthroplasty.

Thank you, Chanon, for your participation in this delicate discussion. I accept the opinion of Dr. LEVI-FAICT that in fact "there is no academic answer in these cases". 

The surgeon and the patient's family should have to take a difficult shared decision in the individual case. Not only from medical point of view, but also in the ethical aspect.   

agree to  the above there  no  uniform recepe for this  problem/

 There are not enaugh clinuical details provided but the decision should 

take in account the fpllowing : what comorbidities this patient has and if they

are in a relative balanced condition :  what is the anesthetic risk (APACHE )  and what exactly  is meant by  "Advanced Alzheimer's."  Operation could sometimes be a way to manage  the excessive pain  caused by  the hip fracure that may  turn such a patient to bed-bound condition + heavy analgetics that will result in very short time in bed sores and underfeeding creating  a very poor quality of life and more other complications ...

Dr. Leibovitz, 

It is not the story of a given patient, it is rather a question of principles. Maybe it could be formulated as follows: Would you do THA at all costs in elderly with Alzheimer ?

Panayot,

Would you do THA at all costs in elderly with Alzheimer ? Under that direction my answer would be no.

Tim

Dear Colleagues, the question is delicate.

In next months, I hope to be able to post in ResearchGate a paper reporting the [+] results of our experience about the rehabilitation of persons with dementia having both hip fracture & Behavioural and Psychic Symptoms of Dementia, within the Special Care Unit at Golgi Geriatric Institute. Most of our patient got a surgical hip treatment [majority was hip replacement].

best regards, Mauro Colombo

The older, impaired or institutionalized patient would benefit from hemiarthroplasty via the anterolateral approach. Most of the studies found better function and less pain after primary arthroplasty.

Depends on the state of the the patient. An still ambulatory patient will mobilize himself afterwards, thus avoiding the pains of being bedridden. A bedridden one still has to be mobilized during every nursery act, so the best method is the method which preserves active or passive mobility. I'm not aware of good evidence for a specific approach. In our institution, surgeon use THR with reasonable success.

As the population ages, the prevalence of AD and other dementias, as well as the incidence of proximal femoral fractures are going to rise. Prevention of Hip fractures is very important and consists with efforts at fall prevention and treatment of osteoporosis. Multifactorial approach programs are very important.

As a student I am only providing an opinion based on personal experience working with mid and final stage Alzheimer's patients.  Three patients in my care were subjected to surgical repair of this type of injury.  All three were unable to be cared for safely when they were returned to the dementia facility within days of receiving surgery.  None could be restrained in order to prevent them from attempting to a)get out of bed. b) get out of princess or wheel chairs.  The patients did not understand their condition nor the process of injury that had occurred and did not understand or remember that they were unable to move around.  None of the three patients survived beyond three months.  They experienced numerous mechanical lifts from prone positions after numerous falls and further injury.  None of this occurred due to lack of staff, but because the Alzheimer patients that I cared for did not have the cognitive ability to recognise the condition and function that was affected by the surgery. Without chemical or physical restraint, it is difficult for the patient to recover, and very difficult for the family to endure.

Thank you, Robyn, for your valuable contribution. You tackle the hot point of the problem. Medicine is not just technical and chemical means and protocols, but also has to solve equations of humanity. 

Dr. Yanchev

It is about quality of life and compassion, dementia patients experience pain as everyone else.  Medicating this pain most certainly accelerates this condition.  THR is as important to patients presenting this condition and I am all for it.

Best Regards

Jeff

i prefer to leave him alone  as he start ambulation and avoid serious complicationS of THR

dear all, now I have the paper I mentioned a while ago

I hope this work may further ignite the current debate

best regards, Mauro

It is a difficult question, but based on my opinion I would try avoiding as much as possible. I did work as a clinician and as a researcher with elderly patients and from my clinical experience the outcome can be very poor if the Alzheimer is really advanced. They will have low level of understanding and therefore, they will not follow commands to exercise or their reaction to physiotherapy can be somewhat aggressive. I understand that they must be in pain as any other OA hip patient, but they will put themselves under other risks after surgery and these risks may result in consistent episodes of pain. For example, hip dislocation. They will need constant supervision to avoid bringing their legs too high or crossing their legs - depending on your surgical procedure. I saw many cases of patients with different levels of Alzheimer and after TKR and THR their responses were dictated by the amount of support they had from family member rather than their physical ability to exercise. If they are not cognitively well, they normally lack the willingness to move on. On the other hand, age is a factor that may change this poor outcome, but again I believe that family must play an important role even for younger patients with Alzheimer.

In the case of a Hip Fracture - your choices will be limited. I believe that patients will benefit from a THR if hip fracture is the reason of replacement - because they will have a chance to rehabilitate rather than be limited to a wheelchair or a bed. Most importantly - I think every case should be studied carefully and the family must be part of the final decision.

Best regards,

Kamary

a needed clarification, after the careful words by Kamary: all patients treated in our SCU were referred by hospitals wherein their vast majority got surgery; their levels of behavioural and psychic symptoms of dementia warranted entry in our SCU instead of being discharged to our other geriatric rehabilitation - like the one I work in.

Best regards, Mauro

Good to know that Mauro, thank you for your clarification and I finished reading your paper, very helpful.

Thank you

It is a question that it is not answered yet within the scientific fora. If we analyse that these patients are almost equal mentally to those with atrophic senile dementia, the answer will be easier. Trying to answer this I will put forward the following.

Demented patients have a potential greater danger to have a fall.

Demented patients do uncontrolled movements (potentially a non-permeable flexion)

Demented patients do not fully understand the risks of "touching" or "investigating" their surgical wounds

Risks from these "activities":

Infection, dislocation of the joint and periprosthetic fractures.

Question: Do we perform surgery to these patients for a fracture of neck of femur (NOF)?

The answer is: Yes we do, with the limitation of examining their environment and assessing the risks.

Which common surgery we perform in a case of NOF?

Hemi-arthroplasty

Coming to the present question. Personally I will not perform a THR but a Hemi-arthroplasty following assessment of the patient's living post-op environment and solving the problems within it. In a case of a young patient a bipolar hemi will perform better.