Geriatric Comanagement of Fractures in Frail Elderly Patients SEFS2009 Nashville, TN

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Geriatric Co-management of Fractures in Frail
Elderly Patients SEFS-2009 Nashville, TN

• January 2009
• Laurence M. Solberg, MD
• Chief, Geriatrics Consult Service
• Vanderbilt University Medical Center

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Outline

• Geriatric Demographics
• Who are Geriatricians
• Falls in the Elderly
• Working together
• Geriatric Co-management
• Geriatric Fracture Program (GFP) Model
• Conclusion

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People are Living Longer

• Life expectancy is increasing!
• U.S. life expectancy
• 2050 - 82.6 years
• 2007 - 77.9 years
• 1995 - 75.8 years
• 1955 - 69.6 years

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Who Are Geriatricians?

• Internal Medicine or Family Practice certified
  physicians
• Fellowship Founded in 1988 an added
  qualification to Internal Medicine and Family
  Practice
• Elevated to Sub-Specialty status in 2006
• Approximately 6,800 certified Geriatricians in
  the U.S. (Remember 71.5 million Elders in 2030)

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What do Geriatricians do?

• Problem Solvers Chronic problems become more
  difficult to manage as age and co-morbidity
  increases.
• Experts in caring for older persons, especially
  with dementia, delirium, falls, osteoporosis,
  depression.
• Focus on Coordinating care, maintaining
  functional ability, safety of frail elderly
  people.
• Assist with Transitions of care.

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Epidemiology of Falls

• 20-30 in Community dwelling Older Adults
  (Tinetti et al, 1988)
• 30-60 in Nursing Home Residents (Luukinen et
  al, 1994)
• Frequency of falls increases with age (Lord et
  al, 1993)

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More Numbers

• There are 350,000 hip fractures annually in the
  US
• Greater than 90 occur in people 65 and older
• The risk of fracture doubles each decade after 50
  years old
• Estimated that by 2040 hip fractures will exceed
  500,000 annually

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Consequences of Falls

• Morbidity and Mortality
• Psychological Impact
• Institutionalization

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Morbidity and Mortality

• Death
• 9500 deaths associated with falls per year
• 20 of fatal falls occur in Nursing Homes

• Injuries
• 95 Hip Fxs associated with falls (Nyberg 1996)
• Short and Long term rehabilitation
• 2-3 fxs other than Hip
• 10 Soft tissue injury

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Psychological Impact of Falls

• Fear of Injury
• Loss of Confidence
• Decreased Mobility and Functionality
• Loss of Independence

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Institutionalization

• 50 Older Adults hospitalized for Fall injuries
  are unable to return home (Sattin et al, 1990)
• Multiple Falls associated with decreased function
  abilities
• Reduced ability to live independently

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Working Together
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How can Geriatricians help Surgeons?

• Assist with chronic disease management.
• Knowledgeable in Management of Geriatric
  Syndromes
• Cognitive impairment
• Dementia Delirium
• Falls and fall prevention
• Gait abnormality
• Hip fracture
• Osteoporosis
• Urinary Fecal incontinence
• Polypharmacy
• Weight loss or Malnutrition
• Placement Assistance
• Direct transitions of care.

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Geriatrics Co-management

• Orthopedics and Geriatrics co-management was
  developed in England in the 1950s (Hempsall, et.
  al. 1990)
• Successful at
• Reducing in-hospital complications
• Lowering length of stay
• Decreased mortality
• Lower healthcare expenditures

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Why Geriatrics Co-management?
Geriatric outcomes are improved by a geriatric
trauma consultation service.
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Geriatrics Co-management works!
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Geriatrics Consults make a difference!
reduced delirium by over one-third, and reduced
severe delirium by over one-half.
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The Geriatric Fracture Program(GFP)

• Collaberative Care Model
• Team Members
• Emergency Department Staff
• Orthopedics/Trauma Surgery
• Medicine Consult Service
• Geriatrics Consult Service
• Rehabilitation Therapy Department
• Social Workers/Case Managers

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The Geriatric Fracture Program (GFP)

• Principles of the GFP (Friedman JAGS 2008)
• Benefits of surgical stabilization of fracture
• Minimize time to surgery
• Co-management and frequent communication avoids
  iatrogenesis
• Standardized protocals lessen unwarranted
  variability
• Discharge planning starts at admission

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GFP Patient Flow
Emergency Department

• Standardized GFP Ortho admission protocol
  initiated.
• Medicine/Geriatrics notified

Pre-operative Management
Medicine consult for preoperative risk
assessment. Preoperative protocols followed PT/OT
and Discharge planning initiated Patient goes to
OR
Post-operative Management
Geriatrics Consult for Post-op care Patient
managed daily by Geriatrics and Orthopedics.
PT/OT and Discharge planning continue. Discharge
to Rehab.
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Conclusion

• U.S. Population is aging
• Fastest growing segment is 80 and older
• Geriatricians are Sub-specialists in Elder Care
• 1/3 of people over 65 will fall
• Working together Better patient outcomes
• GFP The future of Elder Fracture Care
• Surgical stabilization of fracture
• Minimize time to surgery
• Co-Management avoids iatrogenic illness
• Standardized Protocols
• Early Discharge planning