Anaesthetic challenges in a nonagenarian with Parkinson's disease undergoing hip fracture surgery: a case report

Hip fractures in nonagenarian patients with multiple comorbidities present substantial anaesthetic challenges. Parkinson's disease (PD) adds further complexity through motor symptoms, autonomic dysfunction, and the imperative for uninterrupted dopaminergic therapy.

We report the perioperative anaesthetic management of a 93-year-old male with hypertension, Parkinson's disease, hypothyroidism, and dyslipidaemia who underwent cemented left hemiarthroplasty for a transcervical neck of femur fracture. The case was additionally complicated by a significant language barrier, as the patient was exclusively fluent in Newari. Spinal anaesthesia was administered at L3-L4 using 3 mL of 0.5% hyperbaric bupivacaine with 5 µg intrathecal dexmedetomidine, selected to prolong anaesthesia based on discussion with the orthopaedic team; the rationale and limitations of this dosing strategy are critically appraised in the Discussion. Intraoperatively, the patient developed three episodes of hypotension, likely related to sympathetic blockade and adjuvant effects, managed with incremental doses of mephentermine. An episode of intraoperative hypoglycaemia (blood glucose 55 mg/dL) was promptly corrected with 50% dextrose. Postoperatively, the patient developed transient hypoactive delirium due to temporary interruption of dopaminergic therapy, which resolved after resumption of enteral medications by postoperative day 2. On postoperative day 3, the patient developed aspiration pneumonia after oral feeding was initiated by family members despite a functioning nasogastric tube. The condition was managed with antibiotics and supportive care. The patient subsequently improved and was discharged on postoperative day 10.

Spinal anaesthesia is feasible in nonagenarians with multiple comorbidities, including Parkinson's disease. This case highlights the need for evidence-based dose optimisation and proactive complication prevention. It further emphasises the importance of low-dose bupivacaine-based spinal anaesthesia in very elderly patients, meticulous perioperative glycaemic monitoring, continuation of dopaminergic therapy, structured delirium prevention strategies, caregiver education, and strict adherence to dysphagia-safe feeding protocols in high-risk geriatric patients.