Orthogeriatrics: Introduction and the role of the Geriatrician

Prof. Ahmed K. Mortagy

Professor of Geriatric Medicine and Gerontology

Ain Shams Faculty of Medicine

What is Orthogeriatric? Why to implement a collaborative model of care? Examples of medical complications in elderly patients with Fragile fractures The benefits of applying collaborative model of care for older orthopedic patients Models of orthogeriatric care

Definition

Orthogeriatirc care is defined as specialist medical care for older patients with orthopedic disorders that is provided collaboratively by Orthopedic and geriatric care services. The model has been shown to decrease length of stay, medical complications and mortality.

 Randomised controlled trials has been demonstrated that orthogeriatric model of care lead to a 45% decreased probability of major complications (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 a reduction of 21% in medical complications, 3% in mortality and 20% in readmission at six months for medical reasons when applying collaborative orthogeriatric model.

 What is Orthogeriatric?

Why to implement a collaborative model of care?

Examples of medical complications in elderly patients with Fragile fractures The benefits of applying collaborative model of care for older orthopedic patients

Models of orthogeriatric care

1- Hip fracture is a common cause of morbidity and mortality in older people

The rate of hip fracture increases dramatically over the age of 50. With increasing age there is an increased likelihood of medical comorbidity, functional and psychological issues, as well as medical complications in patients under the care of surgeons whose training does not and should not, encompass specialised medical care.

2- The incidence of falls and hip fracture increases with age

Many studies showed that the number of patients with hip fracture increases with age. In one representative hospital, 75% of emergency surgical admissions for patients over the age of 75 were to orthopedic surgery, most of these followed falls.

The age of elective joint replacement patients is also increasing, leading to increased risk of medical complications in this group.
Some studies predict a 45% increase in hip fracture between 2000-2020 (Pocock et al 1999)

3- Older patients with hip fractures have longer lengths of stay

data demonstrated that orthopedic patients under 50 years of age had an average hospital stay of approximately 2.25 days, while patients over 70 years of age stayed an average of 8.96 days.

4- Postoperative medical complications for older patients are common

Vidan et al 2005 in USA and Merchant 2007 in Singapore showed that postoperative medical complications are increased by 60-70% in older patients.

These complications impact on patients ability to return to their previous functional status and independent living and they increase mortality.

5- Comprehensive geriatric assessment and management Can

Identify concomitant medical and psychological issues. Minimise or avoid unnecessary postoperative complications. Assist with early discharge planning. Serra and Moreno (2006) showed that Geriatric care that is provided early and daily reduce-inhospital mortality and medical complications in elderly patients with hip fracture.

6- Rehabilitation

Halbert et al (2007) Showed in a randomised control trial that accelerated rehabilitation decreased average length of hospital stay by 20% in patients with hip fractures.

7- Osteoporosis and vitamin D deficiency

These are associated with most frail older patients with fracture and elective joint replacements.
Replacement of vitamin D, pereferably in its active form should begin as soon as deficiency is identified. Follow-up appointments to instigate treatment of osteoporosis are extremely important.

8- Assessment of risk of further fall

Ideally the Geriatrician should be closely linked with a falls and fracture prevention program
It is important that the majority of patients are allowed to weight bear as tolerated, as limited weight bearing adds approximately 14 days to the length of stay of patients with hip fractures

 What is Orthogeriatric? Why to implement a collaborative model of care? Examples of medical complications in elderly patients with Fragile fractures The benefits of applying collaborative model of care for older orthopedic patients Models of orthogeriatric care

1- Delirium
Studies show that it occurs in 50-60% of older patients with hip fractures (Edlund et al 2001, Flecker and Write (2008). Robertson et al (2006) and Milisen et al (2008) in their large follow up studies showed that Delirium is often undetected, misdiagnosed or undertreated, with severe consequences for the patient. It is associated with longer length of stay, higher cost and poor patient outcomes (Saravay et al 2004 and Ackermann et al 2006)

 Delirium can be prevented in up to one third of at risk patients and where prevention is not possible, severe delirium can be reduced by up to 50%.

2- Polypharmacy and adverse events 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 management of polypharmacy in older patients. Medication management through Geriatricians compared with General physicians has been shown to reduce the number of drugs prescribed and reduce drug-drug interactions (Saltvedt and Spigset 2005).

3- Pressure Ulcers

Can result in a significant increase in length of stay and patient mortality, reducing quality of life and significantly increasing the cost of patient care. Pressure ulcers may be associated with delirium and urinary incontinence.

4- Poorly controlled postoperative pain

This can be due to a number of factors including an impaired ability to communicate or reluctance to report pain or take medications.

Poorly controlled pain has been shown to be associated with delirium.

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

5- Urinary incontinence, retention and infection

Very common in frail older patients postoperatively. Can contribute to pressure sores.

They impact negatively on patient wellbeing, recovery and length of hospital stay.

 What is Orthogeriatric?
Why to implement a collaborative model of care?

Examples of medical complications in elderly patients with Fragile fractures

The benefits of applying collaborative model of care for older orthopedic patients Models of orthogeriatric care

1- Fewer medical complications

This will reduce morbidity and mortality leading to better overall outcomes for patients.

2- Significant cost savings

With reductions in length of stay, including acceleration to rehabilitation with appropriate options.

3- Medications are managed in partnership

This is because the team approach for older patients with dementia and nutritional difficulties addresses the issues more easily.

4- The duration and severity of delirium

This has been shown to be decreased with care by Geriatricians

5- Reduced readmission rate

This has been demonstrated for medical complications.

6- Improved communication

Between the specialties, patients and their family and carers.

 What is Orthogeriatric?
Why to implement a collaborative model of care?

Examples of medical complications in elderly patients with Fragile fractures

The benefits of applying collaborative model of care for older orthopedic patients Models of orthogeriatric care

 1- Orthogeriatric Liaison/ Collaborative care: The Orthogeriatric patients is admitted under the orthopedic surgeon with early and ongoing active care by a Geriatrician based on agreed blanket criteria. This involves a dedicated Geriatrician who provides daily management of the patient through daily ward rounds.

 2- Shared Orthogeriatic care: In this model the Orthogeriatric patients is admitted under the care of both the Orthopedic surgeon and the Geriatrician. Both teams take responsibility for pre- and postoperative multidisciplinary care.

 3- Consultative Orthogeriatric care: The Orthogeriatric patients is admitted under Orthopedic surgeon and the orthopedic team manage their care. Input from Geriatrician is requested when an issue arises, but generally does not involve regular input. This model does not allow for preemptive assessment and management of medical issues to lead to the best outcomes.

Thank you