Or Tho Geriatrics

7/31/2019 Or Tho Geriatrics

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Orthogeriatrics:Introduction and the roleof the Geriatrician

Prof. Ahmed K. Mortagy

Professor of Geriatric Medicine andGerontology

Ain Shams Faculty of Medicine


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What is Orthogeriatric?

Why to implement a collaborativemodel of care?

Examples of medical complicationsin elderly patients with Fragilefractures

The benefits of applyingcollaborative model of care for olderorthopedic patients

Models of orthogeriatric care


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Definition

Orthogeriatirc care is defined as specialist medical carefor older patients with orthopedic disorders that isprovided collaboratively by Orthopedic and geriatric careservices.

The model has been shown to decrease length of stay,medical complications and mortality.


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Randomised controlled trials has beendemonstrated that orthogeriatric model of carelead to a 45% decreased probability of majorcomplications (delirium, pneumonia, DVT, PE,

pressure ulcers.) or mortality. Vidan et al (2005) and Fisher et al (2006) in two

prospective studies showed that there was areduction of 21% in medical complications, 3% inmortality and 20% in readmission at six months

for medical reasons when applying collaborativeorthogeriatric model.


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Examples of medical complications inelderly patients with Fragile fractures

The benefits of applying collaborative

model of care for older orthopedicpatients



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1- Hip fracture is a commoncause of morbidity and

mortality in older people

The rate of hip fracture increases dramatically overthe age of 50.

With increasing age there is an increased likelihoodof medical comorbidity, functional andpsychological issues, as well as medicalcomplications in patients under the care ofsurgeons whose training does not and should not,encompass specialised medical care.


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2- The incidence of falls and hipfracture increases with age

Many studies showed that the number of patients withhip fracture increases with age.

In one representative hospital, 75% of emergencysurgical admissions for patients over the age of 75 wereto orthopedic surgery, most of these followed falls.

The age of elective joint replacement patients is alsoincreasing, leading to increased risk of medicalcomplications in this group.

Some studies predict a 45% increase in hip fracturebetween 2000-2020 (Pocock et al 1999)


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3- Older patients with hipfractures have longer lengths of

stay

data demonstrated that orthopedicpatients under 50 years of age hadan average hospital stay ofapproximately 2.25 days, while

patients over 70 years of age stayedan average of 8.96 days.


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4- Postoperative medicalcomplications for older

patients are common

Vidan et al 2005 in USA and Merchant 2007 in

Singapore showed that postoperative medicalcomplications are increased by 60-70% in olderpatients.

These complications impact on patients ability toreturn to their previous functional status and

independent living and they increase mortality.


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5- Comprehensive geriatricassessment and management

Can

Identify concomitant medical and psychologicalissues.

Minimise or avoid unnecessary postoperativecomplications.

Assist with early discharge planning.

Serra and Moreno (2006) showed that Geriatriccare that is provided early and daily reduce-in-hospital mortality and medical complications inelderly patients with hip fracture.


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6- Rehabilitation

Halbert et al (2007) Showed in arandomised control trial that acceleratedrehabilitation decreased average length ofhospital stay by 20% in patients with hipfractures.


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7- Osteoporosis and vitamin Ddeficiency

These are associated with most frail older patientswith fracture and elective joint replacements.

Replacement of vitamin D, pereferably in its activeform should begin as soon as deficiency isidentified.

Follow-up appointments to instigate treatment ofosteoporosis are extremely important.


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8- Assessment of risk offurther fall

Ideally the Geriatrician should be closelylinked with a falls and fracture prevention

program

It is important that the majority ofpatients are allowed to weight bear astolerated, as limited weight bearing adds

approximately 14 days to the length ofstay of patients with hip fractures


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Examples of medical complicationsin elderly patients with Fragilefractures

The benefits of applying collaborative

model of care for older orthopedicpatients



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1- Delirium

Studies show that it occurs in 50-60% of olderpatients with hip fractures (Edlund et al 2001,Flecker and Write (2008).

Robertson et al (2006) and Milisen et al (2008) intheir large follow up studies showed that Deliriumis often undetected, misdiagnosed or undertreated,with severe consequences for the patient.

It is associated with longer length of stay, highercost and poor patient outcomes (Saravay et al2004 and Ackermann et al 2006)


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Delirium can be prevented in up to one third of atrisk patients and where prevention is notpossible, severe delirium can be reduced by up to50%.


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2- Polypharmacy and adverseevents requiring hospitalisations

This is very common in the elderly.

Unnecessary medications are costly, complex for the

patients to manage and potentially harmful.

Geriatrcians are specifically trained in the managementof polypharmacy in older patients.

Medication management through Geriatricians comparedwith General physicians has been shown to reduce the

number of drugs prescribed and reduce drug-druginteractions (Saltvedt and Spigset 2005).


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3- Pressure Ulcers

Can result in a significant increase in

length of stay and patient mortality,reducing quality of life and significantlyincreasing the cost of patient care.

Pressure ulcers may be associated with

delirium and urinary incontinence.


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4- Poorly controlledpostoperative pain

This can be due to a number of factorsincluding an impaired ability to

communicate or reluctance to report painor take medications.

Poorly controlled pain has been shown tobe associated with delirium.

Older patients are also more prone toadverse effects of opioids and NSAID.


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5- Urinary incontinence,retention and infection

Very common in frail older patients

postoperatively. Can contribute to pressure sores.

They impact negatively on patient well-being, recovery and length of hospital

stay.


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The benefits of applyingcollaborative model of care for

older orthopedic patientsModels of orthogeriatric care


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1- Fewer medical complications

This will reduce morbidity and mortalityleading to better overall outcomes forpatients.


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2- Significant cost savings

With reductions in length of stay, includingacceleration to rehabilitation withappropriate options.


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3- Medications are managed inpartnership

This is because the team approach forolder patients with dementia andnutritional difficulties addresses the issuesmore easily.


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4- The duration and severity ofdelirium

This has been shown to be decreased withcare by Geriatricians


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5- Reduced readmission rate

This has been demonstrated for medicalcomplications.


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6- Improved communication

Between the specialties, patients and theirfamily and carers.


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The benefits of applying collaborativemodel of care for older orthopedic

patientsModels of orthogeriatric care


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1- Orthogeriatric Liaison/Collaborative care:

The Orthogeriatric patients is admittedunder the orthopedic surgeon with early andongoing active care by a Geriatrician basedon agreed blanket criteria. This involves adedicated Geriatrician who provides dailymanagement of the patient through dailyward rounds.


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2- Shared Orthogeriatic care:

In this model the Orthogeriatric patientsis admitted under the care of both theOrthopedic surgeon and the Geriatrician.Both teams take responsibility for pre- and

postoperative multidisciplinary care.


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3- Consultative Orthogeriatric care:

The Orthogeriatric patients is admitted

under Orthopedic surgeon and theorthopedic team manage their care. Inputfrom Geriatrician is requested when an issuearises, but generally does not involveregular input. This model does not allow forpreemptive assessment and management ofmedical issues to lead to the best outcomes.


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Thank you

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