Geriatric Hip Fracture Co-Management Pannida Wattanapanom, M.D., FACP.
An 80 year old man with a hip fracture The General Medicine approach: Medical clearance for surgery
Role of Geriatrician Assess caused of fracture Assess operative risk Maximize opportunity for surgery Provide longitudinal care Manage Medical complications
Assess cause of the fracture Fall Cardiac symptom prior to fall Neurologic symptom prior to fall Loss of consciousness
Assess operative risk Assess - Patient specific risk - Surgery specific risk
Surgery specific risk Intermediate procedure risk Urgent procedure Surgical delay is associated with increased Mortality Major complications PU Pre-operative pain
Surgery specific risk Early surgery is associated with early ambulation, reduced LOS Surgery should be performed after patient s medically stable Our goal : To OR within 48 hours J Orthop trauma 2009 Jul;23(6):386-94
Patient specific risk Cardiac risk assessment and reduction Revised Cardiac Risk Index 1. History of ischemic heart disease 2. History of congestive heart failure 3. History of cerebrovascular disease (stroke or transient ischemic attack) 4. History of diabetes requiring preoperative insulin use 5. Chronic kidney disease (creatinine > 2 mg/dl) 6. Undergoing suprainguinal vascular, intraperitoneal, or intrathoracic surgery Risk for cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest:0 predictors = 0.4%, 1 predictor = 0.9%, 2 predictors = 6.6%, 3 predictors = >11%
Evaluating comorbidities Comorbidity is a major factor in determining the outcomes (complication, mortality, functional outcome, cost) Prevalence of comorbidities increases with advancing age BMJ 2005;331:1374 Multivariate Cox regression analysis of effect of all preoperative variables on 30 day mortality. Figures are hazard ratios (95% confidence intervals)
Evaluating comorbidities instruments The Charlson Index The functional comorbidity index (FCI) The ASA score ACS NSQIP
The Charlson Index
ACS NSQIP Surgical Risk
Patient specific risk Medication management - Consider risk VS. benefit - Continue home medications - Stop loop diuretic/metformin - Specific consideration of beta-blocker, continue if on it
Patient specific risk Assess the patient s cognitive ability and capacity to understand the anticipated surgery Preexisting cognitive impairment strongly predicts postoperative delirium, which is associated with worse surgical outcome
Other considerations Pre-operative traction demonstrate no benefit Pressure ulcer prevention by using pressure reducing mattress
Post operative consideration Discharge planning Pain management Early Mobilization Delirium prevention Osteoporosis Evaluation and Treatment Falls prevention
Early Mobilization Improved functional outcome Decreased complication (delirium, DVT ) Reduced deconditioning
Pain Management PAC with transition to oral med ASAP * Avoid NSAIDS Team effort Scheduled + Break -through and Pre-rehab Pressure-relieving mattress
Delirium Prevention Delirium prevention is very important for the patient and family. It is much easier to prevent that treat once it has occurred. Medications do not help prevent of treat delirium-rather, most cause delirium.
Delirium Prevention A Multi-component interactions to prevent delirium - Routine, frequent orientation - Non-pharmacologic sleep protocol - Early aggressive mobilization - Sensory aids- glasses and hearing aids - Volume repletion
Other considerations DVT prophylaxis Early remove foley s catheter Nutritional assessment protein supplement should be considered for malnourished patients Falls prevention
Orthogeriatric care models and outcomes in hip fracture patient A significant reduction of in-hospital mortality and long-term mortality LOS was significantly reduced, particularly in the shared care model J Orhtop trauma 2014 Mar;28(3)