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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What is Orthogeriatric?
Why to implement a collaborativemodel of care?
Examples of medical complications inelderly patients with Fragile fractures
The benefits of applying collaborative
model of care for older orthopedicpatients
Models of orthogeriatric care
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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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What is Orthogeriatric?
Why to implement a collaborativemodel of care?
Examples of medical complicationsin elderly patients with Fragilefractures
The benefits of applying collaborative
model of care for older orthopedicpatients
Models of orthogeriatric care
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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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What is Orthogeriatric?
Why to implement a collaborativemodel of care?
Examples of medical complications inelderly patients with Fragile fractures
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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What is Orthogeriatric?
Why to implement a collaborativemodel of care?
Examples of medical complications inelderly patients with Fragile fractures
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