Several studies found an association between surgical delay and the risk of complications [17, 18], and one meta-analysis reported a significantly reduced incidence of pneumonia and pressure ulcers in patients undergoing surgery within 24–48 h from admission [20]. Therefore, time to surgery appears to be one of the most influential and potentially modifiable risk factor for post-operative complications. In this context, implementing the practice of early surgery in frail older people with pre-fracture functional impairment represents one of the best strategies to improve overall outcomes [21].

In the post-operative phase, a number of issues should be regularly checked, and all patients should undergo standardised procedures. The best way to face the complex needs of older adults presenting with hip fracture, to improve the quality of the interventions, to minimise errors and omissions, and to reduce post-operative complications is to:

Tailored and individualised interventions based on patients’ characteristics, specific needs or clinical instability should be an integral part of daily healthcare, but the overall post-operative management should be as highly standardised as possible. In this context, protocols, based on the best available evidence, must be developed, shared and implemented by the multidisciplinary team, taking into account local resources. A minimum set of standardised protocols that should be implemented in the orthogeriatric setting include the following

In addition, depending on the clinical status, intravenous therapies should be replaced by oral formulations as soon as possible.

Routine nutritional assessment should be a standard procedure in the management of older hip fracture patients, as some of them may be already malnourished on admission. In addition, many patients may undergo a deterioration of their nutritional status during hospital stay, due to increased energy expenditure related to metabolic stress, and to reduced food intake related to lack of appetite, nausea and psychological factors. It has been estimated that, in the post-operative period, a quarter of patients consume less than 25 % of meals offered by hospital, and about half of patients consume between 25 % and 50 % of meals [22]. Several studies have linked protein and energy malnourishment with adverse clinical outcomes in the acute setting. The negative effects of undernourishment include muscle wasting and weakness, impaired mobility, pulmonary complications, pressure ulcers, and impaired immune response, further predisposing to increased post-operative infections and mortality [23]. Irrespective of pre-fracture functional status, patients with a post-operative dietary intake less than 25 % have a higher number of complications [22]. Oral nutritional supplementation may be a suitable approach to enhance energy and protein intake. A recent meta-analysis concluded that oral nutritional supplementation in elderly patients after hip fracture surgery promotes early rehabilitation, reduces complications and decreases infection rate [24]. Given the difficulty many patients experience in meeting energy requirements in the early post-operative phase, even patients who were normally nourished pre-fracture may well benefit from oral nutritional supplements [25]. Finally, more aggressive nutritional interventions, such as tube feeding or parenteral supplies, should be reserved only for patients with a low level of consciousness or to malnourished patients unable to eat.

Post-operative anaemia is extremely frequent, related to blood loss during surgical procedure and haemodilution, and is associated with reduced ambulation and functional independence. Recent guidelines based on randomised-controlled trials [26] recommend a restrictive threshold for transfusion, not greater than 8 g/dl of haemoglobin, in post-operative patients. It has been suggested that blood transfusions may be harmful to patients, by reducing the recipient’s immune response and thereby increasing the susceptibility to infections [27]. However, transfusion protocols should be based also on other clinical features of patients. Particularly, the presence of cardiac or renal diseases, a low pre-injury haemoglobin level, or specific abnormalities of vital signs may influence the decision to transfuse despite a haemoglobin value greater than 8 g/dl. For instance, a more liberal transfusion strategy has been shown to increase overall survival patients from residential nursing homes [28].

A high proportion of hip fracture patients present with vitamin D deficiency [29] at the time of fracture. Hypovitaminosis D has been related to increased risk of post-operative medical complications [30] and poor functional recovery [31]. Thus, optimisation of the vitamin D level should start early after admission.

Delirium is a common complication that affects about one third of elderly hip fracture patients in the peri-operative period. It has a detrimental effect on functional and clinical outcomes, producing longer length of hospitalisation and slow and incomplete recovery. It is still not clear if delirium may affect long-term survival or recovery [32]. Hyperactive delirium may be easily diagnosed, being characterised by psychomotor agitation, interfering with patients’ care and safety. On the other hand, the hypoactive variant, characterised by a decreased level of consciousness and apathy, may be grossly under-diagnosed. It should be acknowledged that some patients may present with a mixed variant of delirium, fluctuating between hyperactive and hypoactive states. Therefore, all patients must be daily screened and assessed, starting in the first post-operative day, using standardised tools. Both the geriatric nurses and the physicians should be involved in the early detection of delirium.

Patients at risk of developing incident post-operative delirium can already be identified at hospital admission, since a number of risk factors have been described. Pre-fracture cognitive impairment is the strongest risk factor, followed by body mass index/albumin and prevalent multiple comorbidities [33]. Delirium in the frail elderly can represent the first symptom of an underlying/undercurrent complication, such as an infection, coronary syndrome, urinary retention, constipation or dehydration. Therefore, once a patient presents with a new episode of delirium, it is absolutely mandatory to undertake a comprehensive clinical assessment, appropriate laboratory diagnostic work-up and other specific diagnostic tests.

The early detection and prompt correction of clinical/laboratory abnormalities and risk factors is probably the most effective approach to prevent delirium in hip fracture elderly patients. The preventive intervention should be multi-component, and, usually, non-pharmacological, and should include:

This approach requires a multidisciplinary team and is part of the orthogeriatric model of care. This multi-component intervention has been demonstrated to decrease by 40 % the incidence of delirium compared to the traditional care approaches [34], and to be cost-effective in hip fracture patients [35]. Since pain is one of the main triggers for post-operative delirium, effective analgesia is essential in prevention strategies. Acetaminophen and nerve blocks should be preferred to opiates, which may increase the risk of delirium.

The type of anesthesia (particularly neuraxial versus general anesthesia) does not appear to affect the incidence of delirium, but deep sedation has been associated with a higher risk of post-operative delirium [36]. Thus, the use of intra-operative monitoring of depth of anesthesia and the choice of a lighter sedation are likely to be effective in reducing post-operative delirium.

Pharmacological prevention of delirium through administration of low dose of neuroleptic drugs is still a matter of debate. Current evidence does not support the routine use of antipsychotics, albeit, in some trials, they demonstrated reduced incidence of post-operative delirium, particularly in orthopaedic patients at higher risk [37].

Once delirium has occurred, it should be tackled through a multifactorial approach, not dissimilar from preventive strategies. Non-pharmacological procedures should be always implemented and exacerbating factors should be identified and addressed. In case of agitation that can hamper the healthcare or rehabilitation, or even be dangerous for patient and caregiver, pharmacological treatment with antipsychotics is usually employed. Notably, antipsychotics do not treat delirium but simply reduce symptoms. Antipsychotics should never be used in the hypoactive variant. These pharmacological agents should be used at the lowest effective dose, dosing regimens should be individualised for each patient, and, the treatment effects should be monitored daily in order to correct the dose or discontinue the therapy when appropriate. The antipsychotics commonly used are: haloperidol (0.25–2 mg oral or intramuscular), risperidone (0.5–2 mg oral), quetiapine (25–100 mg oral), olanzapine (2.5–10 mg oral). QT prolongation contraindicates all these drugs. Benzodiazepines should be avoided in patients with delirium, except for subjects with severe agitation and violent inclination in which short-acting formulation (e.g., midazolan 1–5 mg intramuscular or intravenous) may produce a rapid tranquillisation. In patients with sleep deprivation, the drug of choice is trazodone (25–100 mg oral).

Some patients experience a more subtle cognitive disorder, affecting a wide range of cognitive domains, particularly memory and executive function. This condition, dissimilar from delirium, is generally designated as post-operative cognitive dysfunction (POCD) and it may not be evident during the first post-operative days. Compared to delirium, POCD shows a less acute onset, is characterised by normal consciousness, and may last weeks to months. For an accurate diagnosis, neuropsychological testing is required but a pre-fracture evaluation is usually lacking in hip fracture patients for comparison. There are many risk factors for POCD: advanced age, pre-existing cardio-vascular disease and mild cognitive impairment. POCD is generally reversible, albeit in some patients with persistent dysfunction, the apolipoprotein E4 genotype has been found, suggesting a link with the development of dementia [38].

Ischaemic heart disease and cardiac failure account for more than one third of early deaths after hip fracture [39]. The incidence of cardiac complications after hip fracture is quite variable in epidemiological studies, depending on the diagnostic criteria considered. Patients with a history of cardiac disease, stroke or peripheral vascular disease are at high risk of developing cardiac complications in the post-operative phase [40]. These subjects should be accurately monitored after surgery. In most of the cases, hip fracture patients with acute coronary syndrome or with ST elevation do not experience typical chest pain; they may present with delirium, congestive heart failure or may even be asymptomatic. The routine measurement of troponin and ECG assessment are thus mandatory for the diagnosis. In some studies [41] troponin changes have been found in a high rate of patients without clinical symptoms or new signs of ischemia in the ECG, however, currently troponin assessment should be reserved for patients with suspicious symptoms or risk factors. In high-risk subjects, antiplatelet drugs should not be stopped preoperatively or should be re-started early after surgery.