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Orthogeriatrics in the management of frail older patients with a fragility fracture

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Abstract

Summary

This review article examines the role of orthogeriatric management for frail older patients with a fragility fracture. The history of orthogeriatrics and its application in clinical practice around the world is reported, and an evidence-based evaluation for the effect of orthogeriatric management on patient morbidity and mortality is also provided.

It has been more than 50 years since the role of the geriatrician in the management of patients with a hip fracture was first described. The evidence that supports an orthogeriatric model of care has grown exponentially over the last decade. This evidence base is primarily related to hip fractures and demonstrates reduced morbidity and mortality rates amongst patients managed with a recognised model of orthogeriatric care. The societal and economic burden of hip fracture has led to health economic evaluations within this field, many of which have concluded that orthogeriatric management results in cost-effective clinical practice. Based on existing clinical and economic research, national clinical practice guidelines have been developed in several countries which recommend orthogeriatric participation in the management of older patients with a hip fracture. Compliance with such guidance has already demonstrated improved patient outcomes. Although the pathogenesis and prognosis of other types of fragility fracture may be as poor, there is a dearth of clinical research that evaluates the effect of orthogeriatric management on such injuries. Looking to the future, orthogeriatric management is likely to become more widespread, and the robust collection and reporting of patient outcomes from national registries will provide a greater understanding of the impact of orthogeriatric models in the care of all frail older patients with any type of fragility fracture.

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References

  1. ANZSGM (2010) Orthogeriatric Care Revised 2010. http://www.anzsgm.org/documents/PositionStatementNo5-OrthogeriatricCareRevision2010.pdf. Accessed 25 March 2015

  2. Devas MBIB (1963) The geriatric orthopaedic unit. J Bone Joint Surg Br 49-B:186–187

    Google Scholar 

  3. Clark ANGWD (1966) Management of the fractured neck of femur in the elderly patient. Gerontol Clin 8:321–326

    Article  Google Scholar 

  4. Briggs RS (1993) Orthogeriatric care and its effect on outcome. J R Soc Med 86:560–562

    PubMed Central  CAS  PubMed  Google Scholar 

  5. Hoffenberg R, James OFW, Brocklehurst JC, Green ID, Horrocks P, Kanis JA, Wald NJ, MacLellan GE, Vickers RH (1989) Fractured neck of femur: prevention and management. Summary and recommendations of a report of the Royal College of Physicians. J R Coll Physicians Lond 23(1):8–14

    Google Scholar 

  6. Duthie RB (1981) Orthopaedic services: waiting time for out-patient appointments and in-patient treatment: report of a working party to the Secretary of State for Social Services. HM Stationery Office, 1981. https://nhsreality.files.wordpress.com/2014/05/duthie-1981-orthopaedics-1.pdf. Accessed 25 Mar 2015

  7. Elliot JR, Wilkinson TJ, Hanger HC, Gilchrist NL, Sainsbury R, Shamy S, Rothwell A (1996) The added effectiveness of early geriatrician involvement on acute orthopaedic wards to orthogeriatric rehabilitation. N Z Med J 109:72–73

    CAS  PubMed  Google Scholar 

  8. NCEPOD (1999) Extremes of Age. http://wwwncepodorguk/1999ea.htm. Accessed on 25 March 2015

  9. British Orthopaedic Association (2003) The care of fragility fracture patients. British Orthopaedic Association, London

    Google Scholar 

  10. Patel NK, Sarraf KM, Joseph S, Lee C, Middleton FR (2013) Implementing the National Hip Fracture Database: an audit of care. Injury 44:1934–1939

    Article  PubMed  Google Scholar 

  11. Lisk R YK (2014) Reducing mortality from hip fractures: a systematic quality improvement programme. BMJ Qual Improv Report 2014;3. doi:10.1136/bmjquality.u205006.w2103

  12. Lefroy RB (1980) Treatment of patients with fractured neck of the femur in a combined unit. Med J Aust 2:669–670

    CAS  PubMed  Google Scholar 

  13. Lundstrom M, Edlund A, Lundstrom G, Gustafson Y (1999) Reorganization of nursing and medical care to reduce the incidence of postoperative delirium and improve rehabilitation outcome in elderly patients treated for femoral neck fractures. Scand J Caring Sci 13:193–200

    Article  CAS  PubMed  Google Scholar 

  14. Zuckerman JD, Sakales SR, Fabian DR, Frankel VH (1992) Hip fractures in geriatric patients. Results of an interdisciplinary hospital care program. Clin Orthop Relat Res 274:213–225

    PubMed  Google Scholar 

  15. Huusko TM, Karppi P, Avikainen V, Kautiainen H, Sulkava R (2000) Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia. BMJ 321:1107–1111

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  16. Adunsky A, Arad M, Levi R, Blankstein A, Zeilig G, Mizrachi E (2005) Five-year experience with the ‘Sheba’ model of comprehensive orthogeriatric care for elderly hip fracture patients. Disabil Rehabil 27:1123–1127

    Article  PubMed  Google Scholar 

  17. AAOS (2014) Management of Hip Fractures in the Elderly. http://www.aaos.org/research/guidelines/GuidelineHipFracture.asp. Accessed 25 March 2015

  18. NICE (2011) Hip fracture guidelines. https://www.nice.org.uk/guidance/cg124. Accessed 25 March 2015

  19. Grigoryan KV, Javedan H, Rudolph JL (2014) Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis. J Orthop Trauma 28:e49–e55

    Article  PubMed Central  PubMed  Google Scholar 

  20. Vidan M, Serra JA, Moreno C, Riquelme G, Ortiz J (2005) Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc 53:1476–1482

    Article  PubMed  Google Scholar 

  21. Gonzalez-Montalvo JI, Alarcon T, Mauleon JL, Gil-Garay E, Gotor P, Martin-Vega A (2010) The orthogeriatric unit for acute patients: a new model of care that improves efficiency in the management of patients with hip fracture. Hip Int : J Clin Exp Res Pathol Ther 20:229–235

    Google Scholar 

  22. Sieber CC (2007) [The elderly patient--who is that?]. Internist 48(1190):1192–1194

    Google Scholar 

  23. United Nations (2012) Definitions of an old person. http://www.who.int/healthinfo/survey/ageingdefnolder/en/. Accessed 25 March 2015

  24. Sanderson W, Scherbov S (2008) Rethinking Age and Aging. Popul Bull 63:3–16

    Google Scholar 

  25. Crews DE, Zavotka S (2006) Aging, disability, and frailty: implications for universal design. J Physiol Anthropol 25:113–118

    Article  PubMed  Google Scholar 

  26. Chen X, Mao G, Leng SX (2014) Frailty syndrome: an overview. Clin Interv Aging 9:433–441

    PubMed Central  PubMed  Google Scholar 

  27. Martinez-Selles M, Vidan MT, Lopez-Palop R et al (2009) End-stage heart disease in the elderly. Rev Esp Cardiol 62:409–421

    Article  PubMed  Google Scholar 

  28. Richmond J, Aharonoff GB, Zuckerman JD, Koval KJ (2003) Mortality risk after hip fracture. J Orthop Trauma 17:53–56

    Article  PubMed  Google Scholar 

  29. Svensson O, Stromberg L, Ohlen G, Lindgren U (1996) Prediction of the outcome after hip fracture in elderly patients. J Bone Joint Surg Br Vol 78:115–118

    CAS  Google Scholar 

  30. Smith P, Ariti C, Bardsley M (2013) Focus on hip fracture: trends in emergency admission for fractured neck of femur, 2001 to 2011. Nuffield Trust/Health Foundation, London. http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/131010_focus-on-hip-fracture.pdf. Accessed 25 Mar 2015

  31. Ensrud KE, Ewing SK, Taylor BC et al (2007) Frailty and risk of falls, fracture, and mortality in older women: the study of osteoporotic fractures. J Gerontol A: Biol Med Sci 62:744–751

    Article  Google Scholar 

  32. Wiles MD, Moran CG, Sahota O, Moppett IK (2011) Nottingham Hip Fracture Score as a predictor of one year mortality in patients undergoing surgical repair of fractured neck of femur. Br J Anaesth 106:501–504

    Article  CAS  PubMed  Google Scholar 

  33. Patel KV, Brennan KL, Brennan ML, Jupiter DC, Shar A, Davis ML (2014) Association of a modified frailty index with mortality after femoral neck fracture in patients aged 60 years and older. Clin Orthop Relat Res 472:1010–1017

    Article  PubMed Central  PubMed  Google Scholar 

  34. Krishnan M, Beck S, Havelock W, Eeles E, Hubbard RE, Johansen A (2014) Predicting outcome after hip fracture: using a frailty index to integrate comprehensive geriatric assessment results. Age Ageing 43:122–126

    Article  PubMed  Google Scholar 

  35. Brown JP, Josse RG, Scientific Advisory Council of the Osteoporosis Society of C (2002) 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. Can Med Assoc J 167:S1–S34

  36. Seeman E (2002) Pathogenesis of bone fragility in women and men. Lancet 359:1841–1850

    Article  PubMed  Google Scholar 

  37. Ebeling PR (1998) Osteoporosis in men. New insights into aetiology, pathogenesis, prevention and management. Drugs Aging 13:421–434

    Article  CAS  PubMed  Google Scholar 

  38. Lips P (1997) Epidemiology and predictors of fractures associated with osteoporosis. Am J Med 103:3S–8S, discussion 8S-11S

    Article  CAS  PubMed  Google Scholar 

  39. Chrischilles EA, Butler CD, Davis CS, Wallace RB (1991) A model of lifetime osteoporosis impact. Arch Intern Med 151:2026–2032

    Article  CAS  PubMed  Google Scholar 

  40. Center JR, Bliuc D, Nguyen TV, Eisman JA (2007) Risk of subsequent fracture after low-trauma fracture in men and women. JAMA 297:387–394

    Article  CAS  PubMed  Google Scholar 

  41. Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA (1999) Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet 353:878–882

    Article  CAS  PubMed  Google Scholar 

  42. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res : Off J Am Soc Bone Miner Res 22:465–475

    Article  Google Scholar 

  43. Johnell O, Kanis JA, Oden A, Sernbo I, Redlund-Johnell I, Petterson C, De Laet C, Jonsson B (2004) Fracture risk following an osteoporotic fracture. Osteoporos Int 15:175–179

    Article  CAS  PubMed  Google Scholar 

  44. Ganda K, Puech M, Chen JS, Speerin R, Bleasel J, Center JR, Eisman JA, March L, Seibel MJ (2013) Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int 24:393–406

    Article  CAS  PubMed  Google Scholar 

  45. British Geriatric Society (2007) Orthogeriatric models of care. http://www.bgs.org.uk/index.php/topresources/publicationfind/goodpractice/371-orthogeriatricmodels. Accessed 25 March 2015

  46. Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN, Budge MM (2006) Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma 20:172–178, discussion 179-180

    Article  CAS  PubMed  Google Scholar 

  47. Friedman SM, Mendelson DA, Bingham KW, Kates SL (2009) Impact of a comanaged Geriatric Fracture Center on short-term hip fracture outcomes. Arch Intern Med 169:1712–1717

    Article  PubMed  Google Scholar 

  48. Leung AH, Lam TP, Cheung WH, Chan T, Sze PC, Lau T, Leung KS (2011) An orthogeriatric collaborative intervention program for fragility fractures: a retrospective cohort study. J Trauma 71:1390–1394

    Article  PubMed  Google Scholar 

  49. Deschodt M, Braes T, Flamaing J, Detroyer E, Broos P, Haentjens P, Boonen S, Milisen K (2012) Preventing delirium in older adults with recent hip fracture through multidisciplinary geriatric consultation. J Am Geriatr Soc 60:733–739

    Article  PubMed  Google Scholar 

  50. Shyu YI, Liang J, Wu CC, Su JY, Cheng HS, Chou SW, Chen MC, Yang CT (2008) Interdisciplinary intervention for hip fracture in older Taiwanese: benefits last for 1 year. J Gerontol A: Biol Med Sci 63:92–97

    Article  Google Scholar 

  51. Stenvall M, Olofsson B, Nyberg L, Lundstrom M, Gustafson Y (2007) Improved performance in activities of daily living and mobility after a multidisciplinary postoperative rehabilitation in older people with femoral neck fracture: a randomized controlled trial with 1-year follow-up. J Rehabil Med 39:232–238

    Article  PubMed  Google Scholar 

  52. Van Rompaey B, Elseviers MM, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L (2009) Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care 13:R77

    Article  PubMed Central  PubMed  Google Scholar 

  53. Bjorkelund KB, Hommel A, Thorngren KG, Lundberg D, Larsson S (2011) The influence of perioperative care and treatment on the 4-month outcome in elderly patients with hip fracture. AANA J 79:51–61

    PubMed  Google Scholar 

  54. Gupta A (2014) The effectiveness of geriatrician-led comprehensive hip fracture collaborative care in a new acute hip unit based in a general hospital setting in the UK. J R Coll Physicians Edinb 44:20–26

  55. Kammerlander C, Roth T, Friedman SM, Suhm N, Luger TJ, Kammerlander-Knauer U, Krappinger D, Blauth M (2010) Ortho-geriatric service–a literature review comparing different models. Osteoporos Int 21:S637–S646

    Article  CAS  PubMed  Google Scholar 

  56. Martinez-Reig M, Ahmad L, Duque G (2012) The orthogeriatrics model of care: systematic review of predictors of institutionalization and mortality in post-hip fracture patients and evidence for interventions. J Am Med Dir Assoc 13:770–777

    Article  PubMed  Google Scholar 

  57. Griffiths R, Alper J, Beckingsale A et al (2012) Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 67:85–98

    Article  CAS  PubMed  Google Scholar 

  58. Braithwaite RS, Col NF, Wong JB (2003) Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc 51:364–370

    Article  PubMed  Google Scholar 

  59. Hasserius R, Karlsson MK, Jonsson B, Redlund-Johnell I, Johnell O (2005) Long-term morbidity and mortality after a clinically diagnosed vertebral fracture in the elderly–a 12- and 22-year follow-up of 257 patients. Calcif Tissue Int 76:235–242

    Article  CAS  PubMed  Google Scholar 

  60. Bonne S, Schuerer DJ (2013) Trauma in the older adult: epidemiology and evolving geriatric trauma principles. Clin Geriatr Med 29:137–150

    Article  PubMed  Google Scholar 

  61. Hasserius R, Karlsson MK, Nilsson BE, Redlund-Johnell I, Johnell O, European Vertebral Osteoporosis S (2003) Prevalent vertebral deformities predict increased mortality and increased fracture rate in both men and women: a 10-year population-based study of 598 individuals from the Swedish cohort in the European Vertebral Osteoporosis Study. Osteoporos Int 14:61–68

    Article  CAS  PubMed  Google Scholar 

  62. Aw D, Sahota O (2014) Orthogeriatrics moving forward. Age Ageing 43:301–305

    Article  PubMed  Google Scholar 

  63. Ho WW, Kwan Dai DL, Liu KW, Chow KM, Lau E, Woo J, Leung KS (2009) To investigate the effect and cost-effectiveness of implementing an orthogeriatric intervention for elderly patients with acute hip fracture: the experience in Hong Kong. J Am Geriatr Soc 57:2153–2154

    Article  PubMed  Google Scholar 

  64. Edwards BJ, Song J, Dunlop DD, Fink HA, Cauley JA (2010) Functional decline after incident wrist fractures–Study of Osteoporotic Fractures: prospective cohort study. BMJ 341:c3324

    Article  PubMed Central  PubMed  Google Scholar 

  65. Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P (2011) Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 343:d6553

    Article  PubMed Central  PubMed  Google Scholar 

  66. Liu-Ambrose T, Donaldson MG, Ahamed Y, Graf P, Cook WL, Close J, Lord SR, Khan KM (2008) Otago home-based strength and balance retraining improves executive functioning in older fallers: a randomized controlled trial. J Am Geriatr Soc 56:1821–1830

    Article  PubMed  Google Scholar 

  67. Palvanen M, Kannus P, Piirtola M, Niemi S, Parkkari J, Jarvinen M (2014) Effectiveness of the Chaos Falls Clinic in preventing falls and injuries of home-dwelling older adults: a randomised controlled trial. Injury 45:265–271

    Article  PubMed  Google Scholar 

  68. Antonelli Incalzi R, Gemma A, Capparella O, Bernabei R, Sanguinetti C, Carbonin PU (1993) Continuous geriatric care in orthopedic wards: a valuable alternative to orthogeriatric units. Aging 5:207–216

    CAS  PubMed  Google Scholar 

  69. Khasraghi FA, Christmas C, Lee EJ, Mears SC, Wenz JF Sr (2005) Effectiveness of a multidisciplinary team approach to hip fracture management. J Surg Orthop Adv 14:27–31

    PubMed  Google Scholar 

  70. Adunsky A, Lerner-Geva L, Blumstein T, Boyko V, Mizrahi E, Arad M (2011) Improved survival of hip fracture patients treated within a comprehensive geriatric hip fracture unit, compared with standard of care treatment. J Am Med Dir Assoc 12:439–444

    Article  PubMed  Google Scholar 

  71. Deschodt M, Flamaing J, Haentjens P, Boonen S, Milisen K (2013) Impact of geriatric consultation teams on clinical outcome in acute hospitals: a systematic review and meta-analysis. BMC Med 11:48

    Article  PubMed Central  PubMed  Google Scholar 

  72. Buecking B, Timmesfeld N, Riem S, Bliemel C, Hartwig E, Friess T, Liener U, Ruchholtz S, Eschbach D (2013) Early orthogeriatric treatment of trauma in the elderly: a systematic review and metaanalysis. Deut Arztebl Int 110:255–262

    Google Scholar 

  73. Haywood KL, Griffin XL, Achten J, Costa ML (2014) Developing a core outcome set for hip fracture trials. Bone Joint J 96-B:1016–1023

    Article  CAS  PubMed  Google Scholar 

  74. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM (2001) Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 49:516–522

    Article  CAS  PubMed  Google Scholar 

  75. Stenvall M, Olofsson B, Lundstrom M, Englund U, Borssen B, Svensson O, Nyberg L, Gustafson Y (2007) A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture. Osteoporos Int 18:167–175

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  76. Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, Debeer J, Bhandari M (2010) Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ : Can Med Assoc J = J Assoc Med Can 182:1609–1616

    Article  Google Scholar 

  77. Wilkins K (1999) Health reports. Ottawa : Statistics Canada = Statistique Canada, 1989

  78. Clague JE, Craddock E, Andrew G, Horan MA, Pendleton N (2002) Predictors of outcome following hip fracture. Admission time predicts length of stay and in-hospital mortality. Injury 33:1–6

    Article  PubMed  Google Scholar 

  79. Fransen M, Woodward M, Norton R, Robinson E, Butler M, Campbell AJ (2002) Excess mortality or institutionalization after hip fracture: men are at greater risk than women. J Am Geriatr Soc 50:685–690

    Article  PubMed  Google Scholar 

  80. Miura LN, DiPiero AR, Homer LD (2009) Effects of a geriatrician-led hip fracture program: improvements in clinical and economic outcomes. J Am Geriatr Soc 57:159–167

    Article  PubMed  Google Scholar 

  81. Magaziner J, Simonsick EM, Kashner TM, Hebel JR, Kenzora JE (1990) Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol 45:M101–M107

    Article  CAS  PubMed  Google Scholar 

  82. Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM (2014) Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med 174:1273–1280

    Article  PubMed Central  PubMed  Google Scholar 

  83. Randell AG, Nguyen TV, Bhalerao N, Silverman SL, Sambrook PN, Eisman JA (2000) Deterioration in quality of life following hip fracture: a prospective study. Osteoporos Int 11:460–466

    Article  CAS  PubMed  Google Scholar 

  84. Adunsky A, Lusky A, Arad M, Heruti RJ (2003) A comparative study of rehabilitation outcomes of elderly hip fracture patients: the advantage of a comprehensive orthogeriatric approach. J Gerontol A Biol Med Sci 58:542–547

  85. (2014) Global elderly care in crisis. Lancet 383:927

  86. Leddin DJ (1997) Health economics: a clinician’s perspective. Can J Gastroenterol 11(Suppl B):106B–107B

    PubMed  Google Scholar 

  87. Della Rocca GJ, Moylan KC, Crist BD, Volgas DA, Stannard JP, Mehr DR (2013) Comanagement of geriatric patients with hip fractures: a retrospective, controlled, cohort study. Geriatr Orthop Surg Rehabil 4:10–15

    Article  PubMed  Google Scholar 

  88. Ginsberg G, Adunsky A, Rasooly I (2013) A cost-utility analysis of a comprehensive orthogeriatric care for hip fracture patients, compared with standard of care treatment. Hip Int : J Clin Exp Res Pathol Ther 23:570–575

    Article  Google Scholar 

  89. RCP (2014) National Hip Fracture Database. https://www.rcplondon.ac.uk/projects/national-hip-fracture-database-nhfd. Accessed 25 March 2015

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Sabharwal, S., Wilson, H. Orthogeriatrics in the management of frail older patients with a fragility fracture. Osteoporos Int 26, 2387–2399 (2015). https://doi.org/10.1007/s00198-015-3166-2

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