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Phase 3a geriatrics > Orthogeriatrics > Flashcards

Orthogeriatrics Flashcards

1
Q

What is the commonest cause of major trauma?

A

Older patients falling at home

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2
Q

Define a fragility fracture

A

Fall from standing height or less that results in a broken bone

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3
Q

What may a frail patient with a fragility fracture be subject to in our healthcare system?

A
  1. under-triage
  2. delayed diagnosis
  3. subobtimal care eg osteoporosis is underdiagnosed and undertreated
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4
Q

What is the 30 day mortality from a hip fracture and why?

A

7% - due to comorbidities of these patients and the seriousness of a hip fractuce

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5
Q

What are the main points of the blue book - The care of patients with fragility fracture

A
  • No. of hip fractures likely to double by 2050
  • Most hip fracture patients have complex comorbidities
  • Care is subobtimal
  • Osteoporosis is under-diagnosed and undertreated
    prompt effective MDT management should improve quality of care
  • Need for specialist care with an orthogeriatrician fully integrated into the team
  • Need early rehabilitation
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6
Q

What did the National Confidential enquiry into patient outcome and death find?

A

Poor quality care was being given to elderly operative patients in the UK - care was good in only 38% of pts
Pain was poorly assessed pre and post operatively
Recommends routine input from geriatricians
Delays to surgery result in poor outcomes

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7
Q

What targets have been put in place as a result of these reports? (listed in the National Hip Fracture Database)

A
  • Prompt surgery (within 36 hours of hip fracture)
  • Prompt orthogeriatric assessment (within 72 hours)
  • Pre-operative cognitive testing (using the AMT)
  • Post-operative assessemnt for delirium (using the 4AT)
  • Prompt mobilisation by a physio on the day of surgery or day after surgery
  • Individual rehabilitation goals with the aim of going to their pre-fracture place of residence by 120 days
  • Continued orthogeriatric and MDT review
  • Fraction prevention assessment - look at falls risk assessment and bone health
  • Nutritional assessment
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8
Q

What are the 2 models of orthogeriatric care?

A
  1. Fracture liaison service

2. Dedicated hip fracture unit (dedicated orthogeriatric ward)

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9
Q

What is a fracture liaison service?

A

Patients are admitted under the care of the orthopaedics surgeons, who remain primarily responsible for the patient’s care throughout their admission
Orthogeriatrician input for every patient within 72 hours

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10
Q

What is a dedicated orthogeriatic ward?

A

The patient is initially admitted to an orthopaedic ward but is transferred post-operatively to an orthogeriatrics ward on day 1-3
Both orthogeriatrics and orthopaedics provide input in the admission

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11
Q

Name a particularly important member of the orthogeriatrics MDT and what they do?

A

The hip fracture specialist nurse who coordinates care across the MDT

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12
Q

Who are the members of the MDT that might be involved in an orthogeriatric patient’s care?

A 
Nurses 
junior doctors 
geriatricians 
orthopaedic surgeons 
Radiology
theatre staff 
anaesthetist
occupational therapists 
physiotherapists 
social services 
ambulance 
GP
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13
Q

Is frailty inevitable?

A

NO - it is preventable

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14
Q

Do you have to have cormorbidities to become frail?

A

NO - can happen without comorbidities

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15
Q

How can we prevent frailty?

A

Good nutrition
Physical activity
Reduction of alcohol consumption
Avoid social isolation

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16
Q

Define frailty

A

consists of mutisystem dysregulation, leading to loss of physiological reserve, resulting in a state of increased vulnerability to stressors

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17
Q

List 3 ways we can assess frailty

A
  1. Clinical frailty scale
  2. Timed up and go test (<12 seconds - rise from a chair, walk three meters, turn around, walk back to the chair, and sit down)
  3. Grip strength
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18
Q

What does frailty result in?

A

Increase hospitalisation
Reduced mobility
Loss of independence
Death

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19
Q

Why is it important to recognise frailty?

A

Avoids inappropriate life saving interventions eg critical care excalation, CPR
Allows choice of place of care and death
More patient centred decisions towards the end of life

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20
Q

What is the comprehensive geriatric assessment?

A

A multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person’s medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long-term follow-up

(starts on admission and extends throughout admission, holistic MDT care)

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21
Q

What are the domains of the comprehensive geriatric assessment?

A 
Medical conditions and comorbidities 
Geriatric giants 
Medications 
Nutritional status 
Affective status - mood etc 
Cognitive status 
Functional status - ADLs and mobility 
Social issues - social support, finances and accomodation
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22
Q

What parts of the comprehensive geriatric assessment may be done pre-operatively?

A
  • Assess severity of comorbidities
  • Medication review - particularly looking at anti-hypertensives, nephrotoxic drugs, stopping any unecessary or harmful medications
  • Prevent delays to theatre eg anticoagulation issues
  • Discussion esclation and resuscitation plans with the patient and their loved ones
  • Correct any significant anaemia, address anticoagulation issues, volume depletion, electrolyte imabalnces treat infection, manage cormorbidities eg heart failure, arrythmias
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23
Q

What parts of the comprehensive geriatric assessment may be done post-operatively?

A
  • Manage any complications - eg VTE, cardiovascular events, infection, pressure sores, poor nutrition, constipation and wound breakdown
  • Recognise post-op delirium
  • Assess bone health and start treatment
  • Understand the cause of the fall and make a falls assessment
  • Facilitate early mobilisation and rehabilitation
  • Communication with family and carers to set relaisitc expectations and answer concerns and do advance care planning
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24
Q

What aspects are there to a nutritional assessment?

A

Preoperative carbohydrate loading (using carbohydrate loaded drinks)
Red trays to highlight those at risk of malnutrition
Complete MUST score - Malnutrition Universal Screening Tool

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25
Q

What scoring system is used to assess cognitive function as part of the CGA?

A

AMT - Abbreviated Mental Test

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26
Q

What scoring system is used to assess for post-operative delirium?

A

4AT

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27
Q

What are the components of the 4AT?

A

Alertness
AMT -4: age, DOB, place, current year
Attention - months of the year backwards
Acute change or fluctuating course

28
Q

How can we reduce the risk of post-op delirium?

A
  • Ensure adequate oxygenation
  • Correct hypoperfusion and anaemia
  • Maintain normal fluid and electrolyte balance, treat dehydration
  • Provide analgesia
  • Deprescribing harmful or unnecessary medications
  • Ensure regular bladder and bowel function and removing an catheters post-op, use laxatives, enemas and suppositories if needed
  • Bladder scans if suspicion of urinary retention
  • Adequate nutritional intake with nutritional supplements, assistance with meals
  • glasses and hearing aids work
  • radio, calendar, clock
  • reassurance
  • early mobilisation and rehabilitation
29
Q

How is pain relief provided to surgical orthogeriatric patients?

A

Fascia iliaca nerve block
Regular IV or oral paracetamol
Opiates at the lowest effective dose with laxative (dihycrocodine or oxycodone or buprenorphine patch - latter good as low side effects)
AVOID NSAIDs and nefopam

30
Q

How often is pain assessed and when?

A

Assess regularly to allow movement required for investigations, nursing care and rehab

  • Immediately
  • Within 30 mins of initial analgesia
  • Hourly once on the ward
  • At routine nursing obs
31
Q

What does FRAX assess?

A

10 year risk of major fracture incl. hip fracture

32
Q

What are the secondary prevention methods for osteoporosis?

A

Non-pharmacological

  • weight bearing exercises and muscle strengthening
  • Falls prevention
  • Smoking cessation and alcohol avoidance
  • advice to look at royal osteoporosis society

Pharmacological

  • calcium and Vit D replacement
  • bisphosphonates (ie antiresoptive drugs)
33
Q

What do you have to ensure before starting bisphosphonates

A

No serious dental issues - osteonecrosis of the jaw

Renal impairment

34
Q

Discuss administration of bisphosphonates

A

first line if probability is >1% is oral with alendronic acid (unless history of GORD or peptic ulcer)
IV if probability is >10% or PO not tolerated or contraindicated

35
Q

How do you take alendronic acid?

A

Take first thing in the morning
Stand or sit upright for 30 mins
But difficult to do if there is cognitive impairment

36
Q

What are the complications of long term bisphosphonate therapy?

A

Atypical femoral fracture

37
Q

How do we reduce the risk of atypical femoral fracture from bisphosphonates?

A

Monitor bone turnover markers to see when a treatment holiday is required

38
Q

What issues are discussed in advance care planning?

A

Treatment of infections - would they like a trial of treatment in the community or in hopsital?

39
Q

What clinical indicators may point towards the issue that a pateitn is nearing the end of their life?

A
  • 2 or more unplanned hospital admissions in the last 6 months
  • Persistent and recurrent infections
  • significant weight loss of more than 5% in the last 6 months
  • Frailty and dementia
  • Delirium
  • rapidly rising frailty score over time
  • Escalation or carer distress
  • Frailty + multimorbidity
40
Q

What might a discussion about palliative care entail?

A

Discussion about stopping active treatment and shifting focus to symptom control
Avoiding interventions that cause distress - eg cannulation, blood tests
Preferred place of care and death
Wishes and preferences

41
Q

Define osteoporosis

A

A SYSTEMIC skeletal disease characterised by LOW BONE MASS and MICROARCHITECTURAL DETERIORATION of bone tissue with a consequent increase in BONE FRAGILITY and SUSCEPTIBILITY TO FRACTURE

42
Q

Describe the pathophysiology of osteoporosis

A

Poor:
o Bone mineral density (peak bone mass and rate of bone loss)
o Bone strength
o Bone quality

Results in thin trabeculae that are no longer connected - especially the horizontal trabeculae that are affected

43
Q

What are the risk factors for osteoporosis?

A
  • Increased age
  • low BMI
  • Frailty and immobility
  • FH hip fracture
  • Osteomalacia
  • Malnutrition and vitamin D deficiency
  • Smoking and alcohol
  • Certain medications
  • Conditions causing secondary osteoporosis
44
Q

Which drugs can lead to osteoporosis?

A

o Steroids
o Depo-Provera
o Long term PPI use
o Aromatase inhibitors – breast cancer treatment that reduces oestrogen levels
o GnRH analogues – used for endometriosis
o Androgen deprivation – eg men treated for prostate cancer
o Antiepileptics eg Phenytoin – changes vitamin D metabolism

45
Q

What are the categories of conditions that can cause secondary osteoporosis?

A

Endocrine

Inflammatory

46
Q

What endocrine conditions can cause secondary osteoporosis?

A

 Hyperthyoidism
 Primary Hyperparathyroidism – thyroid and PTH increase bone turnover
 Cushing’s – high cortisol increases bone resorption and induces osteoblast apoptosis
 Early menopause – can be iatrogenic
 Male hypogonadism
 Anorexia

47
Q

What conditions other than endocrine can cause osteoporosis?

A 
Rheumatoid arthritis 
IBD 
Osteogenesis imperfecta 
type I diabetes  
Coeliac disease (malabsorption)
chronic liver disease
48
Q

What endocrine conditions can cause secondary osteoporosis?

A

 Hyperthyoidism
 Primary Hyperparathyroidism – thyroid and PTH increase bone turnover
 Cushing’s – high cortisol increases bone resorption and induces osteoblast apoptosis
 Early menopause – can be iatrogenic
 Male hypogonadism
 Anorexia

49
Q

What conditions other than endocrine can cause osteoprosis?

A

Rheumatoid arthritis
IBD
Osteogenesis imperfecta

50
Q

What are the FRAX questions?

A 
Age 
Sex
Height and weight 
Previous fracture 
Parent fractured hip
Current smoker
Glucocoticoids 
Rheumatoid arthritis 
Secondary osteoporosis 
Alcohol
51
Q

What investigations would you do for osteoporosis

A

DEXA scan - Dual energy X-ray absorptiometry

52
Q

What T scores are classed as osteopenia?

A

T score -1 to -2.5 (ie -1 to -2.5 SD below 0)

53
Q

What T scores are classed as osteoporosis?

A

T score ≤-2.5 in 2 sites (ie -2.5 SD below 0)

54
Q

What T scores are classed as osteopenia?

A

T score -1 to -2.5

55
Q

What are the primary prevention strategies for osteoporosis?

A

Reduce alcohol intake – toxic to the bone
Stop smoking
Load bearing exercise
Adequate calcium and vitamin d intake
Physiotherapy assessment - muscle strength and endurance, aerobic capability, balance, posture, falls assessment and prevention

56
Q

What medications may be used for osteoporosis?

A
  • Calcium, adcal

Oral bisphosphonates – 1st line – with counselling on how to take it
• Alendronic acid
• Risidronate – lower GI side effects

IV Zeledronate
• IV bisphosphonate
• In the hospital, good for poor compliance, cognitive problems or GI side effects
• Given once a year

HRT
• Advise to take HRT till the age of 60
• Risks include: breast cancer, stroke, CVD, VTE, vaginal bleeding

Subcutaneous Denozumab – second line
• Monoclonal antibody to RANK L
• Given every 6 months, can be given at home
• Doesn’t stay in the body like bisphosphonates, so when you stop it, bone density starts to reduce quite quickly
• Bind to the RANK-L, stops osteoclast activation by acting as a dummy receptor

Subcutaneous Teriparatide
• Parathyroid hormone analogue
• Very expensive – use when pts don’t respond to the other drugs

57
Q

What are the primary prevention strategies for osteoporosis?

A

Reduce alcohol intake – toxic to the bone
Stop smoking
Exercise – needs to be load bearing (so not swimming or cycling), even in older life, exercise can lead to a plateauing in bone loss
Adequate calcium and vitamin d intake
Physiotherapy assessment
Posture and range of movement – serial height measurements (for vertebral fractures) and curvature of spine
Muscle strength and endurance
Aerobic capability, balance, pain and function

58
Q

How do you take alendronic acid?

A

With a large glass of water on an empty stomach while staying upright for 30 mins

59
Q

What are the two drug types for treatment of osteoporosis?

A

o Antiresorptive drugs – decrease osteoclast activity (bisphosphonates, HRT, Denosumab)

o Anabolic drugs – increase osteoblast activity (Teriparatide)

60
Q

How do you take alendronic acid?

A

With a large glass of water on an empty stomach while staying upright for 30 mins

upright for 30 mins before taking, GI side effects, atypical femoral fractures if taking for a long time, has long half-life (if they have been treated for 3 years, still in their system for 7 years)

61
Q

What is major trauma?

A

Serious injury that could result in disability or death (eg hip fracture)
- Injury Severity Score >15 (severe hip fracture on its own is 16)

62
Q

How do bisphosphonates work?

A

stick to the bone and disable osteoclasts that ingest it

63
Q

What is major trauma?

A

Serious injury that could result in disability or death (eg hip fracture)

64
Q

What is the name of the national database collecting data on trauma in the UK

A

Trauma Audit and Research Network was developed (TARN)

65
Q

What factors need to be considered when performing ATLS -advanced trauma life support in older pts?

A

A - airway: arthritis of TMJ, increased risk of C spine injuries due to OA
B - breathing: easily broken ribs, decreased chest wall compliance
C - circulation: decreased maximum HR, may be on beta blockers or diuretics which slow HR, which can lead to normal vital signs when the pt is not normovolaemic
D - disability: osteoprosis, more likely to get a subdural haematoma from tears of bridging veins
E - exposure: more likely to get hypothermia, pressure ulcers and soft tissue infection as skin is thinner and less able to thermoregulate

66
Q

What are the problems encountered when managing older trauma pts?

A

triage systems not good at identifying older major trauma pts :

  • Teaching on trauma focusses on high energy mechanisms
  • initial treatment is more likely to be in a lower level trauma unit or district general hospital where they are seen by a junior doctor, so less likely to be transferred to specialist care and have a trauma call activated
  • Longer times for investigation and intervention – longer time to CT and surgery
67
Q

What factors need to be considered when performing ATLS -advanced trauma life support in older pts?

A

A - airway: arthritis of TMJ, increased risk of C spine injuries due to OA
B - breathing: easily broken ribs, decreased chest wall compliance
C - circulation: decreased maximum HR, may be on beta blockers or diuretics which slow HR, which can lead to normal vital signs when the pt is not normovolaemic
D - disability: osteoprosis, more likely to get a subdural haematoma from tears of bridging veins
E

Phase 3a geriatrics (13 decks)

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