Practical Issues in Geriatrics Series Editor Stefania Maggi Aging Branch CNR-Neuroscience Institute Padova, Italy
This practically oriented series presents state of the art knowledge on the principal diseases encountered in elderly patients and addresses all aspects of management, including current multidisciplinary diagnostic and therapeutic approaches. It is intended as an educational tool that will enhance the everyday clinical practice of both young geriatricians and residents and also assist other specialists who deal with aged patients. Each volume is designed to provide comprehensive information on the topic that it covers, and whenever appropriate the text is complemented by additional material of high educational and practical value, including informative video-clips, standardized diagnostic flow charts and descriptive clinical cases. Practical Issues in Geriatrics will be of value to the scientific and professional community worldwide, improving understanding of the many clinical and social issues in Geriatrics and assisting in the delivery of optimal clinical care. More information about this series at http://www.springer.com/series/15090
Paolo Falaschi David R. Marsh Editors Orthogeriatrics
Editors Paolo Falaschi Sant Andrea Hospital Sapienza University of Rome Rome Italy David R. Marsh University College London London UK ISSN 2509-6060 ISSN 2509-6079 (electronic) Practical Issues in Geriatrics ISBN 978-3-319-43248-9 ISBN 978-3-319-43249-6 (ebook) DOI 10.1007/978-3-319-43249-6 Library of Congress Control Number: 2016953294 Springer International Publishing Switzerland 2017 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG Switzerland
Preface Why Orthogeriatrics? Frail, elderly patients with fragility fractures make up a large proportion of the workload of most trauma and orthopaedic (T&O) departments. Their needs are very different from younger patients with musculoskeletal injury or conditions requiring surgery, such as total joint replacements. There is now sufficient evidence from around the world to say with confidence that a multidisciplinary approach to their care is not only better for them, but better also for the efficient and cost-effective running of the T&O unit as a whole. The editors and most of the authors of this book are active members of the Fragility Fracture Network (FFN) of the Bone and Joint Decade a global organisation that aims to facilitate the ability of health services everywhere to cope with the rising tide of fragility fractures, particularly hip fractures, that is a consequence of ageing populations. The FFN believes that, despite the differences between the health services of different countries, the superiority of multidisciplinary care in this group of patients is universal. The term orthogeriatrics is used as shorthand, because historically it was collaboration between the specialities of orthopaedic surgery and geriatric medicine that generated the evidence supporting the multidisciplinary approach. However, there are obviously many parts of the world where the speciality of geriatrics is not sufficiently established for this to be feasible. The purpose of this book is therefore to describe and analyse what are the essential components of the orthogeriatric approach that make a beneficial difference to the care of elderly fracture patients, so that activists in all countries can plan how to develop the necessary competencies within the available resources and deliver the care that patients need. Several characteristic features of geriatric medicine can immediately be identified as being especially beneficial to elderly fracture patients: 1. Understanding of the geriatric syndrome of frailty. This is a physiological syndrome quite distinct from fragility which is a mechanical issue affecting bone (it is unfortunate that the same word is used to denote both entities in some languages). 2. A holistic view of older patients health, with an appreciation of the interactions between body systems and between physical, mental and social dimensions. 3. A pragmatic view of treatment goals, identifying what is achievable given the patient s overall state and what is worth the cost to the patient of treatment. v
vi Preface Why Orthogeriatrics? 4. Familiarity with, and influence in, the network of resources available for elderly patients particularly useful in planning timely discharge from the fracture unit. 5. Resources for, and experience in, coordinated multidisciplinary rehabilitation teams for older patients. However, physicians with geriatric competencies are not enough to meet the needs of older fracture patients. Without the input of orthopaedic surgeons, their efforts would be the equivalent of one hand clapping. The geriatrician needs the surgeon to restore the patient s locomotor abilities and remove the cause of their pain just as much as the surgeon needs the physician to keep the patient alive and safe throughout the perioperative and postoperative phases of the acute fracture episode. Furthermore, surgeons need to tailor their treatment to the needs of the frail elderly, for instance by recognising the importance of one single operation that allows full weight-bearing whenever possible (this may seem obvious now, but was not so before the involvement of geriatricians brought the necessary reality check). Of course, the orthopaedic surgeon and the geriatrician are not the only members of the multidisciplinary team that the patient needs. Anaesthetists are also crucial team members; fracture units that have been fortunate enough to find one who sees the elderly fracture patient as a fascinating challenge - rather than a somewhat scary chore - have seen massive improvements in efficiency and quality. Nurses, particularly specialist nurses with experience of elderly patients and fractures, are an immensely valuable resource, capable of multiplying the contribution of geriatric co-management many fold. In countries with specialists in rehabilitation medicine, the later phases of functional recovery need to be integrated with the earlier pre- and postoperative phases. Psychological support for the patient and their carers has a valuable role to play. As with all fragility fractures, an essential part of the management of the acute fracture episode is a systematic attempt to prevent another fracture, by addressing osteoporosis and falls risk. The system for reliably achieving this may be led by an osteoporosis specialist, but we consider this function as an integral part of the holistic orthogeriatric approach. Again, the role of nurses is usually central in delivering secondary prevention on the required scale. We and our contributors have covered all these aspects to the best of our ability. We hope that this book will be helpful in spreading this modern system of management, to the benefit of patients worldwide. Rome, Italy London, UK Paolo Falaschi David R. Marsh
Contents 1 The Orthogeriatric Approach: Progress Worldwide................ 1 David R. Marsh 2 Epidemiology of Hip Fracture and Social Costs.................. 19 Nicola Veronese and Stefania Maggi 3 Osteoporosis in Elderly Patients............................... 31 Paolo Falaschi and Stefania Giordano 4 Frailty, Sarcopenia, Falls and Fractures......................... 47 Finbarr C. Martin 5 Pre-Operative Management................................... 63 Helen Wilson 6 Hip Fracture: The Choice of Surgery........................... 81 Henrik Palm 7 Orthogeriatric Anaesthesia................................... 97 Stuart M. White 8 Post-operative Management.................................. 111 Giulio Pioli, Chiara Bendini, and Paolo Pignedoli 9 The Nursing Role.......................................... 131 Karen Hertz and Julie Santy-Tomlinson 10 Rehabilitation Following Hip Fracture......................... 145 Suzanne Dyer, Joanna Diong, Maria Crotty, and Catherine Sherrington 11 Multi Professional Team: Coordination and Communication........................................ 165 David R. Marsh 12 How to Implement a Fracture Liaison Service.................. 171 C. Cooper, M.C. Schneider, M.K. Javaid, K. Åkesson, B. Dawson-Hughes, R. Rizzoli, J.A. Kanis, and J.Y. Reginster vii
viii Contents 13 Management of Older People with Hip Fractures in China and India: A Systems Approach to Bridge Evidence-Practice Gaps............................. 185 Santosh Rath and Aparajit B. Dey 14 The Psychological Health of Patients and Their Caregivers....................................... 201 Paolo Falaschi and Stefano Eleuteri