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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
What scoring system is used to assess cognitive function as part of the CGA?
AMT - Abbreviated Mental Test
26
What scoring system is used to assess for post-operative delirium?
4AT
27
What are the components of the 4AT?
Alertness AMT -4: age, DOB, place, current year Attention - months of the year backwards Acute change or fluctuating course
28
How can we reduce the risk of post-op delirium?
- 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
How is pain relief provided to surgical orthogeriatric patients?
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
How often is pain assessed and when?
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
What does FRAX assess?
10 year risk of major fracture incl. hip fracture
32
What are the secondary prevention methods for osteoporosis?
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
What do you have to ensure before starting bisphosphonates
No serious dental issues - osteonecrosis of the jaw | Renal impairment
34
Discuss administration of bisphosphonates
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
How do you take alendronic acid?
Take first thing in the morning Stand or sit upright for 30 mins But difficult to do if there is cognitive impairment
36
What are the complications of long term bisphosphonate therapy?
Atypical femoral fracture
37
How do we reduce the risk of atypical femoral fracture from bisphosphonates?
Monitor bone turnover markers to see when a treatment holiday is required
38
What issues are discussed in advance care planning?
Treatment of infections - would they like a trial of treatment in the community or in hopsital?
39
What clinical indicators may point towards the issue that a pateitn is nearing the end of their life?
- 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
What might a discussion about palliative care entail?
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
Define osteoporosis
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
Describe the pathophysiology of osteoporosis
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
What are the risk factors for osteoporosis?
- 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
Which drugs can lead to osteoporosis?
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
What are the categories of conditions that can cause secondary osteoporosis?
Endocrine | Inflammatory
46
What endocrine conditions can cause secondary osteoporosis?
 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
What conditions other than endocrine can cause osteoporosis?
``` Rheumatoid arthritis IBD Osteogenesis imperfecta type I diabetes Coeliac disease (malabsorption) chronic liver disease ```
48
What endocrine conditions can cause secondary osteoporosis?
 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
What conditions other than endocrine can cause osteoprosis?
Rheumatoid arthritis IBD Osteogenesis imperfecta
50
What are the FRAX questions?
``` Age Sex Height and weight Previous fracture Parent fractured hip Current smoker Glucocoticoids Rheumatoid arthritis Secondary osteoporosis Alcohol ```
51
What investigations would you do for osteoporosis
DEXA scan - Dual energy X-ray absorptiometry
52
What T scores are classed as osteopenia?
T score -1 to -2.5 (ie -1 to -2.5 SD below 0)
53
What T scores are classed as osteoporosis?
T score ≤-2.5 in 2 sites (ie -2.5 SD below 0)
54
What T scores are classed as osteopenia?
T score -1 to -2.5
55
What are the primary prevention strategies for osteoporosis?
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
What medications may be used for osteoporosis?
- 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
What are the primary prevention strategies for osteoporosis?
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
How do you take alendronic acid?
With a large glass of water on an empty stomach while staying upright for 30 mins
59
What are the two drug types for treatment of osteoporosis?
o Antiresorptive drugs – decrease osteoclast activity (bisphosphonates, HRT, Denosumab) o Anabolic drugs – increase osteoblast activity (Teriparatide)
60
How do you take alendronic acid?
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
What is major trauma?
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
How do bisphosphonates work?
stick to the bone and disable osteoclasts that ingest it
63
What is major trauma?
Serious injury that could result in disability or death (eg hip fracture)
64
What is the name of the national database collecting data on trauma in the UK
Trauma Audit and Research Network was developed (TARN)
65
What factors need to be considered when performing ATLS -advanced trauma life support in older pts?
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
What are the problems encountered when managing older trauma pts?
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
What factors need to be considered when performing ATLS -advanced trauma life support in older pts?
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

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