Principles of the Orthogeriatric Model of Care: A Primer
DOI:
https://doi.org/10.20344/amp.20768Keywords:
Geriatric Assessment, Geriatrics, Health Services for the Aged, Femoral Neck Fractures, OrthopedicsAbstract
It is well known that over the last few decades, there has been significant growth of the aging population worldwide and especially in Europe, with an increase of more than two years per decade since the 1960’s. Currently, in Europe, people aged over 65 years old represent 20% of the population, creating many new and complex challenges for national healthcare systems. In many countries, geriatric medicine is an established medical specialty, integrated into the primary and secondary care of the older population. In some countries, such as Portugal, specialist training in geriatric medicine is not available, even though the life-expectancy in Portugal is currently 81 years due to a decrease in fertility and mortality, and people aged over 60 currently represent nearly a third of the population. There is strong evidence in the medical literature that a fracture following a fall, and especially a neck of femur fracture, is one of the most serious events that can happen in an older person’s lifetime. These fractures have been associated with increased morbidity, loss of independence, a high rate of institutionalization, and mortality. Rates of mortality after a year from femoral fractures have been proven to be three to four times higher than the expected in the general population, ranging between 15% to 36%. This emphasizes the importance of developing well-organized care pathways for these patients, which combine specialized geriatric care (also known as orthogeriatric care). This narrative review will focus on the core principles of orthogeriatric care and how medical professionals, including those who are not specialized in geriatric care, can effectively use them.
Downloads
References
United Nations. United Nations world population prospects 2022. [cited 2024 Jan 30]. Available from: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/wpp2022_summary_of_results.pdf.
Instituto Nacional de Estatística. Tábuas de mortalidade em Portugal. [cited 2024 Jan 30]. Available from: https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=594474380&DESTAQUESmodo=2.
The World Bank Data. Population ages 65 and above (% of total population) – Portugal. [cited 2024 Jan 30]. Available from: https://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS?locations=PT.
Mundi S, Pindiprolu B, Simunovic N, Bhandari M. Similar mortality rates in hip fracture patients over the past 31 years: a systematic review of RCTs. Acta Orthop. 2014;85:54-9. DOI: https://doi.org/10.3109/17453674.2013.878831
Katsoulis M, Benetou V, Karapetyan T, Feskanich D, Grodstein F, Pettersson U, et al. Excess mortality after hip fracture in elderly persons from Europe and the USA: the CHANCES project. J Intern Med. 2017;281:300-10. DOI: https://doi.org/10.1111/joim.12586
de Joode SG, Kalmet PH, Fiddelers AA, Poeze M, Blokhuis TJ. Longterm functional outcome after a low-energy hip fracture in elderly patients. J Orthop Traumatol. 2019;20:20. DOI: https://doi.org/10.1186/s10195-019-0529-z
Lamb LC, Montgomery SC, Wong Won B, Harder S, Meter J, Feeney JM. A multidisciplinary approach to improve the quality of care for patients with fragility fractures. J Orthop. 2017;14:247-51. DOI: https://doi.org/10.1016/j.jor.2017.03.004
Tarazona-Santabalbina FJ, Belenguer-Varea Á, Rovira E, Cuesta- Peredó D. Orthogeriatric care: improving patient outcomes. Clin Interv Aging. 2016;11:843-56. DOI: https://doi.org/10.2147/CIA.S72436
Fragility Fracture Network. Fragility Fracture Network FFN. [cited 2023 Sep 09]. Available from: https://fragilityfracturenetwork.org/.
European Union of Medical Specialists. Geriatric Medicine - Section of UEMS. [cited 2024 Jan 30]. Available from: https://uemsgeriatricmedicine. org/www/index.asp.
European Union of Medical Specialists Geriatrics Section. Definition of Geriatrics (English Version, original version). [cited 2024 Jan 30]. Available from: https://uemsgeriatricmedicine.org/www/land/definition/ english.asp.
World Health Organization. Ageing and health. 2022. [cited 2024 Jan 30]. Available from: https://www.who.int/news-room/fact-sheets/detail/ ageing-and-health.
Huang HH, Lin PY, Chen TY, Wang TY, Chang JC, Peng LN, et al. Geriatric syndromes predict mortality of people aged 75+ years in the observation room of emergency department: towards function-centric emergency medicine. Arch Gerontol Geriatr. 2022:100:104662. DOI: https://doi.org/10.1016/j.archger.2022.104662
Magnuson A, Schroder S, Nightingale G, Saracino R, Skonecki E, Trevino K. A practical guide to geriatric syndromes in older adults with cancer: a focus on falls, cognition, polypharmacy, and depression. Am Soc Clin Oncol Educ Book. 2019;39:e96-109. DOI: https://doi.org/10.1200/EDBK_237641
Evans SJ, Sayers M, Mitnitski A, Rockwood K. The risk of adverse outcomes in hospitalized older patients in relation to a frailty index based on a comprehensive geriatric assessment. Age Ageing. 2014;43:127-32. DOI: https://doi.org/10.1093/ageing/aft156
Chang SF, Lin PL. Frail phenotype and mortality prediction: a systematic review and meta-analysis of prospective cohort studies. Int J Nurs Stud. 2015;52:1362-74. DOI: https://doi.org/10.1016/j.ijnurstu.2015.04.005
Kamwa V, Seccombe A, Sapey E. The evidence for assessing frailty and sarcopenia in an acute medical unit: a systematic review. Acute Med. 2021;20:48-67. DOI: https://doi.org/10.52964/AMJA.0841
Eamer G, Taheri A, Chen SS, Daviduck Q, Chambers T, Shi X, et al. Comprehensive geriatric assessment for older people admitted to a surgical service. Cochrane Database Syst Rev. 2018;1:CD012485. DOI: https://doi.org/10.1002/14651858.CD012485.pub2
British Geriatrics Society. Comprehensive geriatric assessment toolkit for primary care practitioners. [cited 2023 Jun 12]. Available from: https://www.bgs.org.uk/.
Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173:489-95. DOI: https://doi.org/10.1503/cmaj.050051
Fried L, Tangen C, Walston J, Newman A, Hirsch C, Gottdiener J, et al. Frailty in older adults evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146-56. DOI: https://doi.org/10.1093/gerona/56.3.M146
van Ka GA, Rolland YM, Morley JE, Vellas B. Frailty: toward a clinical definition. J Am Med Dir Assoc. 2008;9:71-2. DOI: https://doi.org/10.1016/j.jamda.2007.11.005
Falaschi P, Marsh D, editors. Orthogeriatrics: the management of older patients with fragility fractures. 2nd ed. Cham: Springer; 2021. DOI: https://doi.org/10.1007/978-3-030-48126-1
Pereira Pinto M, Martins S, Mesquita E, Fernandes L. European Portuguese version of the clinical frailty scale: translation, cultural adaptation and validation study. Acta Med Port. 2021;34:749-60. DOI: https://doi.org/10.20344/amp.14543
Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, et al. Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48:16-31. Erratum in: Age Ageing. 201;48:601. DOI: https://doi.org/10.1093/ageing/afy169
Yuan S, Larsson SC. Epidemiology of sarcopenia: prevalence, risk factors, and consequences. Metabolism. 2023;144:155533. DOI: https://doi.org/10.1016/j.metabol.2023.155533
Morley JE, Anker SD, von Haehling S. Prevalence, incidence, and clinical impact of sarcopenia: facts, numbers, and epidemiology-update 2014. J Cachexia Sarcopenia Muscle. 2014;5:253-9. Erratum in: J Cachexia Sarcopenia Muscle. 2015;6:192. DOI: https://doi.org/10.1007/s13539-014-0161-y
Shafiee G, Keshtkar A, Soltani A, Ahadi Z, Larijani B, Heshmat R. Prevalence of sarcopenia in the world: a systematic review and metaanalysis of general population studies. J Diabetes Metab Disord. 2017;16:21. DOI: https://doi.org/10.1186/s40200-017-0302-x
Dent E, Morley JE, Cruz-Jentoft AJ, Arai H, Kritchevsky SB, Guralnik J, et al. International clinical practice guidelines for sarcopenia (ICFSR): screening, diagnosis and management. J Nutr Health Aging. 2018;22:1148-61. DOI: https://doi.org/10.1007/s12603-018-1139-9
Malmstrom TK, Morley JE. SARC-F: a simple questionnaire to rapidly diagnose sarcopenia. J Am Med Dir Assoc. 2013;14:531-2. DOI: https://doi.org/10.1016/j.jamda.2013.05.018
Marks R, Allegrante JP, Ronald MacKenzie C, Lane JM. Hip fractures among the elderly: causes, consequences and control. Ageing Res Rev. 2003;2:57-93. DOI: https://doi.org/10.1016/S1568-1637(02)00045-4
Ganz DA, Latham NK. Prevention of falls in community-dwelling older adults. N Engl J Med. 2020;382:734-43. DOI: https://doi.org/10.1056/NEJMcp1903252
Blain H, Masud T, Dargent-Molina P, Martin FC, Rosendahl E, van der Velde N, et al. EUGMS Falls and Fracture Interest Group; European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO), Osteoporosis Research and Information Group (GRIO), and International Osteoporosis Foundation (IOF). A comprehensive fracture prevention strategy in older adults: The European Union Geriatric Medicine Society (EUGMS) Statement. J Nutr Health Aging. 2016;20:647-52. DOI: https://doi.org/10.1007/s12603-016-0741-y
James SL, Lucchesi LR, Bisignano C, Castle CD, Dingels ZV, Fox JT, et al. The global burden of falls: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017. Inj Prev. 2020;26:Si3-11. DOI: https://doi.org/10.1136/injuryprev-2019-043484corr1
Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence, risk factors, and consequences in Chinese older people: a systematic review. J Am Geriatr Soc. 2011;59:536-43. DOI: https://doi.org/10.1111/j.1532-5415.2010.03286.x
Montero-Odasso M, van der Velde N, Martin FC, Petrovic M, Tan MP, Ryg J, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing. 2022;51:afac205.
National Institute for Health and Care Excellence. Falls in older people: assessing risk and prevention. 2013. [cited 2023 Aug 19]. Available from: https://www.nice.org.uk/guidance/cg161.
Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13:57-65. DOI: https://doi.org/10.1517/14740338.2013.827660
Jyrkkä J, Enlund H, Korhonen MJ, Sulkava R, Hartikainen S. Polypharmacy status as an indicator of mortality in an elderly population. Drugs Aging. 2009;26:1039-48. DOI: https://doi.org/10.2165/11319530-000000000-00000
Kojima G, Bell C, Tamura B, Inaba M, Lubimir K, Blanchette PL, et al. Reducing cost by reducing polypharmacy: the polypharmacy outcomes project. J Am Med Dir Assoc. 2012;13:818.e11-5. DOI: https://doi.org/10.1016/j.jamda.2012.07.019
Morgan SG, Hunt J, Rioux J, Proulx J, Weymann D, Tannenbaum C. Frequency and cost of potentially inappropriate prescribing for older adults: a cross-sectional study. CMAJ Open. 2016;4:E346-51. DOI: https://doi.org/10.9778/cmajo.20150131
Seppala LJ, Petrovic M, Ryg J, Bahat G, Topinkova E, Szczerbińska K, et al. STOPPFall (screening tool of older persons prescriptions in older adults with high fall risk): a delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Age Ageing. 2021;50:1189-99. DOI: https://doi.org/10.1093/ageing/afaa249
Drenth-van Maanen AC, Leendertse AJ, Jansen PA, Knol W, Keijsers CJ, Meulendijk MC, et al. The systematic tool to reduce inappropriate prescribing (STRIP): combining implicit and explicit prescribing tools to improve appropriate prescribing. Thematic. J Eval Clin Pract. 2018;24:317-22. DOI: https://doi.org/10.1111/jep.12787
Royal College of Psychiatrists. RCPsych: delirium. 2019. [cited 2023 Aug 19]. Available from: https://www.rcpsych.ac.uk/mental-health/ mental-illnesses-and-mental-health-problems/delirium.
Bruce AJ, Ritchie CW, Blizard R, Lai R, Raven P. The incidence of delirium associated with orthopedic surgery: a meta-analytic review. Int Psychogeriatr. 2007;19:197-214. DOI: https://doi.org/10.1017/S104161020600425X
Juliebø V, Bjøro K, Krogseth M, Skovlund E, Ranhoff AH, Wyller TB. Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture. J Am Geriatr Soc. 2009;57:1354-61. DOI: https://doi.org/10.1111/j.1532-5415.2009.02377.x
Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. Oneyear health care costs associated with delirium in the elderly population. Arch Intern Med. 2008;168:27-32. DOI: https://doi.org/10.1001/archinternmed.2007.4
Saczynski JS, Marcantonio ER, Quach L, Fong TG, Gross A, Inouye SK, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367:30-9. DOI: https://doi.org/10.1056/NEJMoa1112923
MacLullich AM, Beaglehole A, Hall RJ, Meagher DJ. Delirium and long-term cognitive impairment. Int Rev Psychiatry. 2009;21:30-42. DOI: https://doi.org/10.1080/09540260802675031
Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010;304:443-51. DOI: https://doi.org/10.1001/jama.2010.1013
Inouye SK. Delirium in older persons. N Engl J Med. 2006;354:1157-65. Erratum in: N Engl J Med. 2006;354:1655. DOI: https://doi.org/10.1056/NEJMra052321
Chen Y, Liang S, Wu H, Deng S, Wang F, Lunzhu C, et al. Postoperative delirium in geriatric patients with hip fractures. Front Aging Neurosci. 2022;14:1068278. DOI: https://doi.org/10.3389/fnagi.2022.1068278
MacLullich A. The 4AT. 2010. [cited 2023 Aug 19]. Available from: https:// www.the4at.com/.
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113:941-8. DOI: https://doi.org/10.7326/0003-4819-113-12-941
Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet. 1993;342:1032-6. DOI: https://doi.org/10.1016/0140-6736(93)92884-V
Ellis G, Whitehead MA, O’Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2011;7:CD006211. DOI: https://doi.org/10.1002/14651858.CD006211.pub2
Pilotto A, Cella A, Pilotto A, Daragjati J, Veronese N, Musacchio C, et al. Three decades of comprehensive geriatric assessment: evidence coming from different healthcare settings and specific clinical conditions. J Am Med Dir Assoc. 2017;18:192.e1-e11. DOI: https://doi.org/10.1016/j.jamda.2016.11.004
Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49:M85-94. DOI: https://doi.org/10.1093/geronj/49.2.M85
Rubenstein LZ, Stuck AE, Siu AL, Wieland D. Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence. J Am Geriatr Soc. 1991;39:S8-16. DOI: https://doi.org/10.1111/j.1532-5415.1991.tb05927.x
Aw D, Sahota O. Orthogeriatrics moving forward. Age Ageing. 2014;43:301-5. DOI: https://doi.org/10.1093/ageing/afu011
Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study BMJ. 2005;331:1374. DOI: https://doi.org/10.1136/bmj.38643.663843.55
Kjørholt KE, Kristensen NR, Prieto-Alhambra D, Johnsen SP, Pedersen AB. Increased risk of mortality after postoperative infection in hip fracture patients. Bone. 2019;127:563-70. DOI: https://doi.org/10.1016/j.bone.2019.07.023
Pincus D, Ravi B, Wasserstein D, Huang A, Paterson JM, Nathens AB, et al. Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. JAMA. 2017;318:1994-2003. DOI: https://doi.org/10.1001/jama.2017.17606
Van Heghe A, Mordant G, Dupont J, Dejaeger M, Laurent MR, Gielen E. Effects of orthogeriatric care models on outcomes of hip fracture patients: a systematic review and meta-analysis. Calcif Tissue Int. 2022;110:162-84. DOI: https://doi.org/10.1007/s00223-021-00913-5
Borsheski R, Johnson QL. Pain management in the geriatric population. Mo Med. 2014;111:508-11.
Dixon J, Ashton F, Baker P, Charlton K, Bates C, Eardley W. Assessment and early management of pain in hip fractures: the impact of paracetamol. Geriatr Orthop Surg Rehabil. 2018;9:2151459318806443. DOI: https://doi.org/10.1177/2151459318806443
Wheatley BM, Nappo KE, Christensen DL, Holman AM, Brooks DI, Potter BK. Effect of NSAIDs on bone healing rates: a meta-analysis. J Am Acad Orthop Surg. 2019;27:e330-6. DOI: https://doi.org/10.5435/JAAOS-D-17-00727
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States. JAMA. 2016;315:1624-45. DOI: https://doi.org/10.1001/jama.2016.1464
Kim CH, Yang JY, Min CH, Shon HC, Kim JW, Lim EJ. The effect of regional nerve block on perioperative delirium in hip fracture surgery for the elderly: a systematic review and meta-analysis of randomized controlled trials. Orthop Traumatol Surg Res. 2022;108:103151. DOI: https://doi.org/10.1016/j.otsr.2021.103151
Ilfeld BM. Continuous peripheral nerve blocks: an update of the published evidence and comparison with novel, alternative analgesic modalities. Anesth Analg. 2017;124:308-35. DOI: https://doi.org/10.1213/ANE.0000000000001581
National Institute for Health and Care Excellence. Hip fracture: management. Clinical guideline [CG124]. 2023. [cited 2024 Jan 30]. Available from: https://www.nice.org.uk/guidance/cg124/resources/ cg124-hip-fracture-full-guideline.
Reid IR, Billington EO. Drug therapy for osteoporosis in older adults. Lancet. 2022;399:1080-92. Erratum in: Lancet. 2022;400:732. DOI: https://doi.org/10.1016/S0140-6736(21)02646-5
Van Camp L, Dejaeger M, Tournoy J, Gielen E, Laurent MR. Association of orthogeriatric care models with evaluation and treatment of osteoporosis: a systematic review and meta-analysis. Osteoporos Int. 2020;31:2083-92. DOI: https://doi.org/10.1007/s00198-020-05512-y
Office for National Statistics. Profile of the older population living in England and Wales in 2021 and changes since 2011. 2023. [cited 2023 Jul 12]. Available from: https://www.ons.gov.uk/ peoplepopulationandcommunity/birthsdeathsandmarriages/ageing/ articles/profileoftheolderpopulationlivinginenglandandwalesin2021an dchangessince2011/2023-04-03#:~:text=The%20number%20of%20 people%20aged,from%2016.4%25%20to%2018.6%25.
Hawley S, Inman D, Gregson CL, Whitehouse M, Johansen A, Judge A. Predictors of returning home after hip fracture: a prospective cohort study using the UK National Hip Fracture Database (NHFD). Age Ageing. 2022;51:afac131. DOI: https://doi.org/10.1093/ageing/afac131
Middleton M, Wan B, da Assunção R. Improving hip fracture outcomes with integrated orthogeriatric care: a comparison between two accepted orthogeriatric models. Age Ageing. 2017;46:465-70. DOI: https://doi.org/10.1093/ageing/afw232
Kristensen PK, Thillemann TM, Søballe K, Johnsen SP. Can improved quality of care explain the success of orthogeriatric units? A populationbased cohort study. Age Ageing. 2016;45:66-71. DOI: https://doi.org/10.1093/ageing/afv155
Middleton M. Orthogeriatrics and hip fracture care in the UK: factors driving change to more integrated models of care. Geriatrics. 2018;3:55. DOI: https://doi.org/10.3390/geriatrics3030055
Neuburger J, Currie C, Wakeman R, Johansen A, Tsang C, Plant F, et al. Increased orthogeriatrician involvement in hip fracture care and its impact on mortality in England. Age Ageing. 2017;46:187-92. DOI: https://doi.org/10.1093/ageing/afw201
Patel R, Judge A, Johansen A, Marques EM, Chesser T, Griffin XL, et al. Patients’ recovery of mobility and return to original residence after hip fracture are associated with multiple modifiable components of hospital service organisation: the REDUCE record-linkage cohort study in England and Wales. BMC Geriatr. 2023;23:459. DOI: https://doi.org/10.1186/s12877-023-04038-2
Zhang J, Yang M, Zhang X, He J, Wen L, Wang X, et al. The effectiveness of a co-management care model on older hip fracture patients in China - a multicentre non-randomised controlled study. Lancet Reg Health West Pac. 2021;19:100348. DOI: https://doi.org/10.1016/j.lanwpc.2021.100348
Tarazona-Santabalbina FJ, Ojeda-Thies C, Figueroa Rodríguez J, Cassinello-Ogea C, Caeiro JR. Orthogeriatric management: improvements in outcomes during hospital admission due to hip fracture. Int J Environ Res Public Health. 2021;18:3049. DOI: https://doi.org/10.3390/ijerph18063049
Office for Health Improvement & Disparities. Guidance falls: applying all our health. 2022. [cited 2024 Apr 07]. Available from: https://www.gov. uk/government/publications/falls-applying-all-our-health/falls-applyingall- our-health.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Acta Médica Portuguesa
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All the articles published in the AMP are open access and comply with the requirements of funding agencies or academic institutions. The AMP is governed by the terms of the Creative Commons ‘Attribution – Non-Commercial Use - (CC-BY-NC)’ license, regarding the use by third parties.
It is the author’s responsibility to obtain approval for the reproduction of figures, tables, etc. from other publications.
Upon acceptance of an article for publication, the authors will be asked to complete the ICMJE “Copyright Liability and Copyright Sharing Statement “(http://www.actamedicaportuguesa.com/info/AMP-NormasPublicacao.pdf) and the “Declaration of Potential Conflicts of Interest” (http:// www.icmje.org/conflicts-of-interest). An e-mail will be sent to the corresponding author to acknowledge receipt of the manuscript.
After publication, the authors are authorised to make their articles available in repositories of their institutions of origin, as long as they always mention where they were published and according to the Creative Commons license.
