1. Orthogeriatric Assessment and Rehabilitation
Dr Kathryn Anderson
Royal Victoria Hospital, Edinburgh

2. Introduction Definition Scale of the problem e.g. hip fracture
Assessment
Rehabilitation challenges
Outcomes (SHFA)
Models of Care - review the evidence
Recommendations
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Dr Kathryn Anderson

3. Definition
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Dr Kathryn Anderson

4. Definition Falls and fractures in the elderly are increasing
Orthogeriatrics generally reflects hip fractures but there are a variety of other conditions to consider
Assessment and rehabilitation for the majority is complex
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Dr Kathryn Anderson

5. Scale of Problem Hip Fracture
Accounts for 40% of admissions and 60% of bed days from trauma in NHS >75
Incidence rising annually
In Scotland over 6000 hip fractures reported in 2005
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Dr Kathryn Anderson

6. Scale of Problem Hip Fracture
Well researched and audited especially in Scotland
Cost to NHS £5,000-£20,000 each (£1.7 billion p.a.)
Morbidity/Mortality: 20% die at 12 months
30% institutional care
50% reduction in independence
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Dr Kathryn Anderson

7. Scale of the Problem Other fractures Colles fracture Humeral Neck
Clavicle
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Dr Kathryn Anderson

8. Scale of the problem Other fractures Pubic rami Malleolar 24/11/2018
Dr Kathryn Anderson

9. Scale of the Problem Other fractures Vertebral: Osteoporosis/trauma
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10. Scale of the Problem
Elective total hip/knee replacements for osteoarthritis or Rheumatoid Arthritis
Hip and shoulder dislocations
Renewal or replacement of infected prostheses
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Dr Kathryn Anderson

11. Assessment
Hip Fracture
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Dr Kathryn Anderson

12. Assessment Hip Fracture Immediate assessment in A/E
Pain relief and X-ray as soon as possible
Pressure sore risk
Hydration and nutrition
Core body temp
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Dr Kathryn Anderson

13. Assessment Hip Fracture Conscious level and AMT Continence
Pre-morbid function and social circumstances
Consider cause of index fall
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Dr Kathryn Anderson

14. Assessment Hip Fracture - Pre-operative Management
Antibiotic prophylaxis
Aspirin 150mgs for 35 days
Heparin for “high risk” patients
Consider repeat x-rays, MRI or bone scan in symptomatic patient with normal X-ray.
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Dr Kathryn Anderson

15. Assessment Hip Fracture - Surgical Management
Experienced surgical and anaesthetic staff
“24 hour rule” between 8am-8pm
Delay only for treatment of severe sepsis, anaemia, shock, cardiac/respiratory failure, arrhythmia
Exclusion of severe aortic stenosis especially for spinal anaesthesia.
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Dr Kathryn Anderson

16. Assessment Hip Fracture - Post operative Complications Delirium Pain
Constipation
Pneumonia/Urinary tact infection
PE/DVT
Wound infection/dehiscence
MRSA/C.Difficile
Iatrogenic
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Dr Kathryn Anderson

17. Rehabilitation
When? As soon as possible- discharge planning should start at admission
Where? Depends on patient frailty and residence
How ? Multidisciplinary team
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Dr Kathryn Anderson

18. Rehabilitation Challenges
Poor nutrition (nutritional supplementation)
Anxiety and fear of falling
Gait problems prior to fall
Depression
Dementia
Medical co morbidity
Social and functional challenges
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Dr Kathryn Anderson

19. Rehabilitation Challenges
Bone health - consider osteoporosis and whether investigation and/treatment is indicated, possible or relevant.
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Dr Kathryn Anderson

20. Rehabilitation Challenges
Falls Risk Assessment
How and when?
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Dr Kathryn Anderson

21. Rehabilitation Challenges
Patient/carer expectations
Unresolved medical problems
Inadequate information about orthopaedic plans
Poor documentation/inadequate use of care pathways
Staff education in rehabilitation units with specialist needs
Delayed discharges
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Dr Kathryn Anderson

22. Outcomes Difficult to measure
Subject of audit SHFA (Scottish Hip Fracture Audit)
Compare case mix /process and outcome, includes pre and post op progress, surgical procedures, rehabilitation outcomes up to 4 months and mortality.
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Dr Kathryn Anderson

23. Outcomes Scottish Hip Fracture Audit Began in 1993
Data collection patchy due to variation in funding
Involved 21 hospitals across Scotland
Data collected now informs practice and development of guidelines
Hip fracture is now a tracer condition for research into care for older people
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Dr Kathryn Anderson

24. Outcomes
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25. Outcomes
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26. Outcomes
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27. Outcomes National database: www.networks.nhs.uk/nhfdn
Standardisation of Audit of Hip fracture in Europe (SAHFE PROGRAMME)
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28. Models of Care
Reduced LOS and institutionalisation rates in systems with “formal geriatric liaison”……..
Which model works best and why?
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Dr Kathryn Anderson

29. Models of Care Geriatric Orthopaedic Units (GORU’S)
Geriatric Hip Fracture Programmes (GHFP’S)
Early Supported discharge schemes (ESD)
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30. Models of Care GORU’s Developed in the 1970’s Vary between hospitals
Geriatrician–led multidisciplinary inpatient rehabilitation usually separate from acute hospital
Frailer patients
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31. Models of Care Early Supported Discharge Schemes
Developed in the 1990’s
Vary between hospitals and schemes
Generally therapist led, may have geriatrician input
Patients generally less frail
Rehabilitation in the home environment with increased social support at this time
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Dr Kathryn Anderson

32. Models of Care Geriatric Hip Fracture Programmes ‘Liaison’
Geriatric team input starts in orthopaedic unit
Frail patients go to rehabilitation unit
Less disabled patients remain in the orthopaedic wards for rehabilitation
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Dr Kathryn Anderson

33. Models of Care Comparison of Models
41 studies- 14 Randomised controlled trials
10 Specific therapy/nursing/medical intervention
7 GORU
6 ESD
6 PPS
5 GHF programmes
4 Miscellaneous
3 ICP for hip fracture
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Dr Kathryn Anderson

34. Models of Care Comparison of Models Length of stay Readmission
Morbidity
Mortality
Functional outcome
Quality of life
Cost
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35. Models of Care Comparison of Models
Median LOS for hip fracture is 20 days (15-23)
Length of stay reduced in ESD and GHFP.
Slight trend for readmission in ESD
GORU’S no benefit on overall LOS but 10-56% of all patients end up in GORU
Better rate of return to previous residence in all 3
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Dr Kathryn Anderson

36. Models of Care Comparison of Models Inpatient mortality 7.5%
No evidence of reduced morbidity in any of the programmes but some i.e. GORU and ESD showed reduction in mortality
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Dr Kathryn Anderson

37. Models of Care Comparison of models
No model superior (or inferior) in terms of functional outcomes
Quality of life data disappointing
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Dr Kathryn Anderson

38. Models of Care Comparison of Models
GHFP’s and ESD likely to be cost-saving due to reduced length of stay
GORU less clear but may save up to £2,200 per patient or net cost of nearly £600 each
Care at home for £1600 per year versus care in a nursing home £19,000 per year
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Dr Kathryn Anderson

39. Models of Care Ideal Model ? Shared care from point of admission.
Early Supported Discharge schemes for fitter patients
Early step-down to rehab unit may be general or specialist orthopaedic
Innovative schemes for care at home (social work)
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Dr Kathryn Anderson

40. Recommendations Audit outcomes
More research into individual elements of programmes
Include quality of life and cost, carer burden and societal costs
Invest in robust schemes for falls prevention
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41. References www.shfa.scot.nhs.uk
Cameron I, Crotty M,Currie C, Finnegan T, Gillespie L, Gillespie W, et al. Geriatric rehabilitation following fractures in older people: a systematic review. Health Technol Assess 2000;4(2)
Prevention and Management of Hip Fracture in Older People SIGN Guideline 56 (2002)
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Dr Kathryn Anderson