Orthogeriatric Unit Research Articles

Perioperative Depression in Older Patients after Hip Fracture

Aim: Depression in patients after hip fracture has adverse effects on patient outcomes. This study aimed to identify the prevalence of perioperative depression and the risk factors which predispose patients undergoing emergency hip surgery to perioperative depression. Methods: A cross-sectional study was conducted in hip fracture survivors in an orthogeriatric unit in Western Australia, from 2005 to 2008. Patients were categorized as depressed if Geriatric Depression Scale (GDS) score was five or above. Linear regression was used to analyze the association between age and GDS. Modifying effect of dementia was examined using likelihood ratio test. Results: Depression was present in 18.3% of 1127 patients within two weeks after hip fracture. Mean age was 81.2 years. Prevalence of perioperative depression was highest in the old-old (24.1%) and in patients with pre-existing dementia (64.8%). Advancing age, prefracture institutionalization, use of gait aids, poor physical status, and dementia were associated with higher GDS scores, but not gender or perioperative delirium. The association between increasing depressive symptoms and advancing age was significant in patients without dementia but not in patients with dementia. Conclusions: Depressive symptoms were common during perioperative care for emergency hip surgery. Depression was highly prevalent in patients with dementia after hip fracture regardless of their age. Pre-morbid patient factors may help to identify those patients at risk for depression and should be addressed to optimize rehabilitation participation and outcomes.

Patient profile at Orthogeriatric Unit

Patient profile at Orthogeriatric Unit

Comparative study of patients with recurrent falls and hip fracture in an orthogeriatric unit

Objectives.– To study the factors that increase the risk of recurrent falls. Patients and methods.– In patients older than 69 years hospitalized for hip fracture was assessed the independent association of different variables (clinical, functional and therapeutic) with the risk of recurrent falls by building a logistic regression model using the Odds Ratio (OR) and confidence interval 95% (95%) as a measure of association. We also checked the discriminative ability of the final model by calculating the area under the ROC curve (rock). Results.–Were identified in the finalmodel as independent risk factors for relapse: the level of dependence (OR vs mild dependence. Independence 5.42 95% CI 1.68 to 17.5, OR severe dependence vs. independence to 16.97 95% 3, 74 to 77.0), osteoarthritis (OR 2.56, 95%CI1.03 to6.38), historyofprevious surgery (OR4.57, 95%CI1.63 to 12.8) anxiety-depression (OR 4.01, 95% CI 1.49 10.8), taking neuroleptics (OR 4.01, 95% CI 0.77 to 13.4) and the use of ACE inhibitors (OR 2.82; 95% CI 1.09 7.30). Themodel showed good discriminative ability with rock (0.84, 95% 0.77 to 0.91). Conclusions.– In patients over 69 years, we identified several risk factors for recurrent falls, especially those related to the degree of dependence and mood disorders It would be possible, with these variables, discriminate patients with an increased risk of frequent falls and act accordingly.

Orthogeriatrics unit in a young hospital; coordination's efficacy

Orthogeriatrics unit in a young hospital; coordination's efficacy

Outcome of elderly hip fracture patients admitted to an acute orthogeriatric unit

Outcome of elderly hip fracture patients admitted to an acute orthogeriatric unit

Blood loss and blood transfusion in relation to type of hip fracture

Introduction.–Hip fracture is themost severe complicationof osteoporosis, treatment includesemergencyhospitalizationandsurgery. During postoperative a common complication is anemia. Method.– Retrospective study. Patients admitted with hip fracture to an orthogeriatric unit in a 5 months period. Preoperative and postoperative Hemoglobin (Hb) were studied as well as blood transfusion. Blood transfusion is indicated only if there is severe anemia or when the patient is hemodynamically unstable. Results.– 108 patients were included, with an average age 87,26±7,07 years (range, 76–100). 86,6% were female. Type of hip fracture: Subtrochanteric (6,66%); intertrochanteric (51,1%) and intracapsular (42,2%). The mean Hb on admission was 12,34±1,44 gr/dl. and the mean postoperative Hb (Hb. after 24 hr) was 9,65±1,35 gr/dl. Postoperative drop in hemoglobin in relation to type of hip fracture: pertrochanteric (2,3±1,14); intracapsular (2,6±0,94) and subtrochanteric (3,36±1,53). There were difference between subtrochanteric and the other two types of hip fractures. 66,6% of the patients required blood transfusion. 82 blood unitswere transfused. 34bloodunitswere administered topatients with Hb<8 gr/dl. Percentage of patients transfused in relation to type of hip fracture: Subtrochanteric (100%); intertrochanteric (74%) and intracapsular (52,63%). Number of units transfused per patient in relation to type of hip fracture: Subtrochanteric (2,2); intertrochanteric (1,7) and intracapsular (1,5). Conclusions.– Subtrochanteric fracture reduced hemoglobin more than the other two types of hip fractures. Subtrochanteric fracture was the fracture that required more transfusions during postoperative.

Comprehensive care of elderly patients with hip fracture: the orthogeriatric model

Introduction: Hip fractures in the elderly are a major source of morbidity and mortality. Interdisciplinary hospital care models proposed for the treatment of these patients include consultant teams, integrated orthopedic-geriatric care, and comprehensive geriatric-led care settings. A prospective interventional cohort study was conducted in 4 public hospitals in the Emilia-Romagna Region of Italy to compare the outcomes of these different care models. This report presents the preliminary results obtained with an orthogeriatric model in one of these centers, a large teaching hospital in Bologna. Materials and methods: Beginning in February 2008, all patients older than 75 years admitted to the University of Bologna’s Sant’Orsola-Malpighi Hospital for hip fractures were cared for in an orthogeriatric unit. The unit consisted of 10 beds in the orthopedic ward that were managed by a geriatric specialist and a multidisciplinary team, which met daily and included an orthopedic surgeon, a physiatrist, a nurse case-manager, staff nurses, a physical therapist, and a social worker. The management protocol included a thorough geriatric work-up to identify comorbidities and risk factors, systematic assessment and prevention of pain and acute disorientation, early verticalization and moblization, postacute rehabilitation therapy, family support, and regular follow-up after discharge. Preliminary results were compared with those achieved in the same orthopedic ward prior to the creation of the Orthogeriatric Unit. Results: During 2008, 226 elderly patients (mean age 86.2 + 5.5 years), 73.4% of whom were women, were admitted to the Orthogeriatric Unit for hip fractures. The mean Charlson comorbidity index of this cohort was 3.0 + 1.8). Half the patients had Activity of Daily Living scores &lt; 4, and cognitive impairment was common (mean score on Short Portable Mental Status Questionnaire: 5.9 + 3.2). Compared with figures obtained in the hospital’s orthopedic ward prior to 2008, in-hospital mortality dropped from 5.98% to 3.98%. The mean overall length of hospitalization was not significantly reduced, but the mean stay in the Orthogeriatric unit decreased by almost 2 days (to 10.46 days from 12.44 days in the traditional orthopedic unit). Discussion: Compared with traditional care models, the orthogeriatric model may allow better integration of the health-care resources available for the management of hip fractures in the elderly, and this improvement may have positive effects on the outcome of these cases.

Oropharyngeal dysphagia in an elderly post-operative hip fracture population: a prospective cohort study

normal ageing processes impact on oropharyngeal swallowing function placing older adults at risk of developing oropharyngeal dysphagia (OD). Anecdotal clinical experience has observed that older patients recovering from hip fracture surgery commonly develop OD post-operatively. to document the presence of OD following hip fracture surgery, and the factors associated with OD. one hundred and eighty-one patients with a mean age of 83 years (range: 65-103) admitted to a specialised orthogeriatric unit were assessed for OD post-surgery for hip fracture. Pre-admission, intra-operative and post-operative factors were examined to determine their relationship with the presence of OD. OD was found to be present post-operatively in 34% (n = 61) of the current population. Multivariate logistic regression analyses revealed the presence of pre-existing neurological and respiratory medical co-morbidities, presence of post-operative delirium, age and living in a residential aged care facility prior to hospital admission to be associated with the post-operative OD. these results highlight that OD is present in a large number of the older hip fracture population. Early identification of OD has important implications for the provision of timely dysphagia management that may prevent secondary complications and potentially reduce the hospital length of stay.

Implantación de una Unidad de Ortogeriatría de Agudos en un hospital de segundo nivel

BackgroundPatients with hip fracture (HF), due to their characteristics, require a specific support. The Acute Orthogeriatric Unit (OGU) has been shown to be one of the most beneficial. ObjectiveTo evaluate the main variables of HF patients treated at an OGU and compare them with the previous referral model (RC). Material and methodsA prospective observational study with retrospective control was conducted on 169 patients, split into two groups. In the RC group, patients were admitted to conventional trauma ward. In the OGU group, an early geriatric assessment was performed, and patients were simultaneously attended daily by the orthopaedic surgeon, nurse and geriatrician, and the surgery times, work load, discharge and destination, were planned in a weekly meeting with the rest of professionals. ResultsA total of 71 patients were included in the RC group and 96 in the OGU group. The preoperative characteristics were similar, except for a slightly higher comorbidity in the OGU group. The OGU patients were operated on earlier (3.82±2.08 vs 4.61±2.5 days; P<.32), and overall hospital stay was reduced by 28% (11.84±4.04 vs 16.46±8.4 days; P<.001). The functional efficiency (Barthel Index at discharge-Barthel Index at admission/overall stay - stay before surgery) was higher in the OGU group (1.56±0.7 vs 2.61±1.1; P<.05). There were no differences in functional status, mortality or discharge location. ConclusionsThe OGU is a level of care that provides effective medical care in HF patients in general hospitals.

Inappropriate prescribing in older hip fracture inpatients admitted to an orthogeriatric unit: The role of STOPP/START criteria

Inappropriate prescribing in older hip fracture inpatients admitted to an orthogeriatric unit: The role of STOPP/START criteria

The effect of a pre- and post-operative orthogeriatric service on cognitive function in patients with hip fracture. The protocol of the Oslo Orthogeriatrics Trial

BackgroundHip fractures mainly affect older people. It is associated with high morbidity and mortality, and in particular a high frequency of delirium. Incident delirium following hip fracture is associated with an increased risk of dementia in the following months, but it is still not firmly established whether this is an association or a causal relationship. Orthogeriatric units vary with respect to content and timing of the intervention. One main effect of orthogeriatric care may be the prevention of delirium, especially if preoperative and postoperative care are provided. Thus, the aim of Oslo Orthogeriatric Trial, is to assess whether combined preoperative and postoperative orthogeriatric care can reduce the incidence of delirium and improve cognition following hip fracture.Methods/designInclusion and randomisation will take place in the Emergency Department, as soon as possible after admission. All patients with proximal femur fractures are eligible, irrespective of age, pre-fracture function and accommodation, except if the fracture is caused by a high energy trauma or the patient is terminally ill. The intervention is pre-and post-operative orthogeriatric care delivered on a dedicated acute geriatric ward. The primary outcome measure is a composite endpoint combining the Clinical Dementia Rating Scale (CDR) and the 10 word memory task at four months after surgery. Secondary outcomes comprise incident delirium, length of stay, cognition, mobility, place of residence, activities of daily living and mortality, measured at 4 and 12 months after surgery. We have included 332 patients in the period 17th September 2009 to 5th January 2012.DiscussionOur choice of outcome measures and our emphasis of orthogeriatric care in the preoperative as well as the postoperative phase will enable us to provide new knowledge on the impact of orthogeriatric care on cognition.Trials registrationClinicalTrials.gov NCT01009268

The Combined Effect of ADL Impairment and Delay in Time from Fracture to Surgery on 12-Month Mortality: An Observational Study in Orthogeriatric Patients

Delayed surgery (ie, >48 hours from arrival in hospital) and pre-fracture disability are thought to be long-term risk factors for mortality in patients with hip fracture (HF). However, the combined effect on mortality of these two conditions has not been satisfactorily assessed in previous studies. To assess the combined effect of pre-fracture disability and delayed surgery on 12-month mortality in a population of elderly patients after HF surgical treatment. Retrospective cohort study with 12-month follow-up. An orthogeriatric unit (OGU) in a university hospital in Italy. All patients (n= 390) admitted to an OGU from March 2007 to December 2010 who underwent proximal HF surgery and who were not transferred to other hospitals were considered for the analyses. Pre-fracture disability was defined as having an impairment in more than one activity of daily living (ADL). The 12-month mortality was assessed by a Kaplan-Meyer analysis and by a Cox proportional hazards regression models adjusting for relevant potential confounders. After adjusting for potential confounders, patients with both delayed surgery and pre-fracture disability had a significantly higher 12-month mortality (hazard ratio [HR]= 5.80; 95% confidence interval [CI]= 2.11-15.92) than patients with neither delayed surgery nor disability (reference group). Patients with disability but not delayed surgery had a nearly 4-fold increased mortality risk (HR, 3.98; 95% CI 1.41-11.27) than patients in the reference group. Patients with both pre-fracture disability and delayed HF surgical treatment had a nearly six-fold increased 12-month mortality risk than did patients with neither disability nor delayed surgery.

Vitamin D supplementation is required to normalize serum level of 25OH-vitamin D in older adults: an observational study of 974 hip fracture inpatients.

Vitamin D deficiency is highly prevalent in older adults in all continents. In this study we assessed the vitamin D status of hip fracture subjects across different hospitals in a real word situation using the data from a multicenter cohort study on outcomes in orthogeriatric units. We performed a prospective cohort study on 974 consecutive patients 75 yr or older admitted with fragility hip fracture over a 12 months period at 4 general hospitals of different districts in Emilia Romagna Region, Italy. Data collected included comorbidity, cognitive impairment, prefracture functional status, walking ability, living arrangement along with the use of antiosteoporotic drugs, serum intact PTH and serum 25-hydroxyvitamin D [25(OH)D]. Mean 25(OH)D serum levels were 12.2±9.4 ng/ml and 84.2% of patients had levels below recommended values. Male had a higher probability to have values within the reference range [odds ratio (OR): 1.74 (1.13-2.67); p=0.012] while living in nursing resulted negatively related even if only close to statistical significance [OR: 0.24 (0.06-1.02); p=0.051]. Vitamin D supplementation appeared to be the strongest factor associated with adequate level of vitamin D levels [OR: 4.50 (2.57-7.88); p<0.001). This study confirmed the very high rate of severe vitamin D deficiency in Italian subjects admitted with hip fracture. Our study also showed that supplementation of vitamin D is the strongest determinant influencing serum 25(OH)D level of older persons with hip fracture and these results should be taken into account when planning treatment in older persons.

Early interdisciplinary hospital intervention for elderly patients with hip fractures – functional outcome and mortality

OBJECTIVES:Hip fractures are associated with high levels of co-morbidity and mortality. Orthogeriatric units have been shown to be effective with respect to functional recovery and mortality reduction. The aim of this study is to document the natural history of early multidisciplinary intervention in elderly patients with hip fractures and to establish the prognostic factors of mortality and walking ability after discharge.METHODS:This observational, retrospective study was performed in an orthogeriatric care unit on patients aged ≥70 years with a diagnosis of hip fracture between 2004 and 2008. This study included 1363 patients with a mean age of 82.7±6.4 years.RESULTS:On admission to the unit, the average Barthel score of these patients was 77.2±27.8 points, and the average Charlson index score was 2.14±2.05. The mean length of stay was 8.9±4.26 days, and the readmission rate was 2.3%. The in-hospital mortality rate was 4.7%, and the mortality rates at one, six, and 12 months after discharge were 8.7%, 16.9%, and 25.9%, respectively. The Cox proportional hazards model estimated that male sex, Barthel scale, heart failure, and cognitive impairment were associated with an increased risk of death. With regard to functionality, 63.7% of the patients were able to walk at the time of discharge, whereas 77.4% and 80.1% were able to walk at one month and six months post-discharge, respectively. The factors associated with a worse functional recovery included cognitive impairment, performance status, age, stroke, Charlson score, and delirium during the hospital stay.CONCLUSIONS:Early multidisciplinary intervention appears to be effective for the management of hip fracture. Age, male sex, baseline function, cognitive impairment and previous comorbidities are associated with a higher mortality rate and worse functional recovery.

Time to surgery and rehabilitation resources affect outcomes in orthogeriatric units

Objective: To compare the pathways of care and clinical results for patients admitted for hip fracture (HF) in 3 orthogeriatric co-managed care centers in order to estimate the effect of system factors on mortality and functional outcome. Design: Prospective inception multicenter cohort study. Setting: Three tertiary Hospitals. Participants: 806 patients consecutively admitted with HF. Measurements: 1-Year mortality, the loss of 1 or more functional abilities in activities of daily living (ADLs), and the recovery/maintenance of independent ambulation at 6 months from the fracture. Results: On the whole sample, 71.1% of patients survived 1 year from the fracture. In one hospital the risk of 1-year mortality was significantly higher even after adjusting for age, sex, comorbidity, prefracture functional status and cognitive impairment (odd ratio (OR) 1.56, 95% confidence interval (CI) 1.15–2.18, p=0.01). This was principally explained by a longer time to surgery (5.2 days±3.2 vs 2.7±2.3 and 2.7±2.2, p<0.001). The three hospitals also differed in the rate of subjects losing the ability in ADLs after 6 months from the fracture (54.2%, 61%, 43.5%, p=0.016), while no statistical differences were found in the recovery of independent ambulation. On the basis of multivariate models, a lower access to post-acute rehabilitation could account for lower outcome in functional status. Conclusions: This study suggests that system factors such as time to surgery and rehabilitation resources can affect functional recovery and 1-year mortality in orthogeriatric units and they could explain different outcomes when comparing care models.

“N-active”: a new comanaged, orthogeriatric ward

The incidence of hip fractures increases with increasing age. Besides the actual trauma, it is mainly the comorbidities and an increased postoperative complication rate in old patients that lead to increased mortality in this patient population. Around 25% of patients who had previously been living independently continue to need long-term care after a hip fracture. Given this situation, the comanaged orthogeriatric unit "N-active" was opened at the Nuremberg Hospital in December 2010. The following article describes implementation of the ward and preliminary data. These show a positive impact of comanagement in terms of patient outcome, staff satisfaction, and also financial aspects.

Fracture du col du fémur et urgences gériatriques : prise en charge, organisation et indicateurs

Hip fracture is a common condition associated with a poor outcome with 20-30% one-year mortality in the elderly. Autonomy and quality of life remains key considerations in this population. Emergency management should consider associated diseases and treatments, as well as fall and fracture. Management should target particular conditions such as pain, anemia and transfusion, time to surgery and occurrence of pressure sores, and should consider these as quality criteria. In this way, a new approach must be evaluated and requires an optimal cooperation between emergency physician, orthopaedic surgeon, anaesthetists and geriatrician. Place and interest of new models of care such as orthogeriatrics unit have to be determined.

Effect of in-hospital comprehensive geriatric assessment (CGA) in older people with hip fracture. The protocol of the Trondheim Hip Fracture Trial

BackgroundHip fractures in older people are associated with high morbidity, mortality, disability and reduction in quality of life. Traditionally people with hip fracture are cared for in orthopaedic departments without additional geriatric assessment. However, studies of postoperative rehabilitation indicate improved efficiency of multidisciplinary geriatric rehabilitation as compared to traditional care. This randomized controlled trial (RCT) aims to investigate whether an additional comprehensive geriatric assessment of hip fracture patients in a special orthogeriatric unit during the acute in-hospital phase may improve outcomes as compared to treatment as usual in an orthopaedic unit.Methods/designThe intervention of interest, a comprehensive geriatric assessment is compared with traditional care in an orthopaedic ward. The study includes 401 home-dwelling older persons >70 years of age, previously able to walk 10 meters and now treated for hip fracture at St. Olav Hospital, Trondheim, Norway. The participants are enrolled and randomised during the stay in the Emergency Department. Primary outcome measure is mobility measured by the Short Physical Performance Battery (SPPB) at 4 months after surgery. Secondary outcomes measured at 1, 4 and 12 months postoperatively are place of residence, activities of daily living, balance and gait, falls and fear of falling, quality of life and depressive symptoms, as well as use of health care resources and survival.DiscussionWe believe that the design of the study, the randomisation procedure and outcome measurements will be of sufficient strength and quality to evaluate the impact of comprehensive geriatric assessment on mobility and other relevant outcomes in hip fracture patients.Trials registrationClinicalTrials.gov, NCT00667914

La unidad de ortogeriatría de agudos. Evaluación de su efecto en el curso clínico de los pacientes con fractura de cadera y estimación de su impacto económico

Objective To study the effects of the management of hip fracture patients in an acute orthogeriatric unit shared between the departments of Orthopedic Surgery and Geriatrics compared with the usual hospital care, and to analyse financial differences in both systems of care. Method Prospective quasy-experimental randomized intervention study in 506 patients admited to a terciary hospital with an osteoporotic hip fracture. The usual model of care was the admission to the orthopedic ward with a request to Geriatrics (RC) and the study model consisted of the admission to an orthogeriatric unit (OGU) for the shared co-management between orthopaedic surgeons and geriatricians. This model included the appointment of one spokesperson from each department, the specialist geriatric nurse management, early geriatric assessment, shared daily clinical care, weekly joint ward round and coordinated planning of the surgery schedule, the start of the ambulation and the time and setting of patient discharge. Results Two hundred fifty five consecutive patients admitted to the OGU and 251 patients managed simultaneusly by the RC model were included. Except for a mean age slightly lower in the OGU group, there were no differences neither in the baseline patients characteristics nor in the surgical rates between the two groups. Among the OGU patients group it was more frequent to receive rehabilitation in the acute setting, to be able to walk at discharge and to be referred to a geriatric rehabilitation unit (all with P<.05). The OGU patients received geriatric assessment and were operated on earlier than the RC patients ( P<.001). The length of stay in the acute ward was 34% shorter in the OGU patients (mean 12.48±5 vs 18.9±8.6 days, P<.001) (median 12 [9-14] vs 17 [13-23] days, P<.001). The whole hospital length of stay, including the days spent in the geriatric rehabilitation units, was 11% shorter in the OGU patients (mean 21.16 ±14.7 vs 23.9 ±13.8 days, P<0.05) (median 14 [10-31] vs 20 [14-30] days, P<.001). The OGU saved 1,207 € to 1,633 € per patient when estimated by the costs for process model, and 3,741 € when estimated by the costs for stay model. Conclusions The OGU is a hospital setting that provides an improvement in the patients functional outcome and a reduction in the hospital length of stay. Therefore it saves health care resources. These findings show the OGU as an advisable setting for the acute care of hip fracture patients.

Use of Warfarin is Associated with Delay in Surgery for Hip Fracture in Older Patients

Introduction: Delay in surgery for hip fractures in older patients may affect mortality and the risk of delirium. Delay in surgery may occur as a result of several factors. It has not been established whether certain patient-related factors, such as a high international normalized ratio (INR) caused by warfarin treatment is associated with delay in surgery. The aim of this study was to explore the associations between warfarin treatment, INR, and time from admission to surgery. Methods: This is an observational study based on data from a database of all hip fracture patients aged ≥ 65 years who were admitted to an orthogeriatric unit. The database included data from 1192 consecutive patients admitted from January 2007 to April 2010. Data were collected during routine work. Use of warfarin, patient characteristics, medical complications, length of stay, and time from admission to surgery were registered from the patients' records, and INR at admission in warfarin users. Results: Warfarin was used by 117 (9.8%) patients at admission, which included more men (n = 42; 14.4%) than women (n = 75; 8.3%) (P = 0.003). The mean age was 85 years, with no difference between users and nonusers. Warfarin users had more comorbid diseases (mean, 2.1 vs 1.8; P = 0.003), poorer health status (American Society of Anesthesiologists score of 3–5 in 77.8% vs 51.0%), and longer waiting time for surgery compared with nonusers (mean, 23 vs 12 hours; P < 0.001). There was no difference in need for blood transfusions (28.2% of users compared with 25.3% of nonusers; P = 0.49). Length of stay was longer among warfarin users compared with nonusers (mean, 14.6 vs 11.7 days; P = 0.002). Warfarin users with an INR of ≥ 2 had a longer waiting time than those with an INR of < 2, but they had a longer waiting time than nonusers. Conclusion: Hip fracture patients who are using warfarin experience a longer waiting time for surgery, most likely due to more comorbidities. A more active approach to better management of comorbidities may reduce waiting time for surgery in warfarin users.