Orthogeriatric Assessment and Rehabilitation

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 Dr Kathryn Anderson

3. Definition 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 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 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 Dr Kathryn Anderson

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

8. Scale of the problem Other fractures • Pubic rami • Malleolar Dr Kathryn Anderson

9. Scale of the Problem Other fractures • Vertebral: Osteoporosis/trauma Dr Kathryn Anderson

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 Dr Kathryn Anderson

11. Assessment • Hip Fracture 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 Dr Kathryn Anderson

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

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

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

24. Outcomes Dr Kathryn Anderson

25. Outcomes Dr Kathryn Anderson

26. Outcomes Dr Kathryn Anderson

27. Outcomes National database: • www.networks.nhs.uk/nhfdn • Standardisation of Audit of Hip fracture inEurope (SAHFE PROGRAMME) Dr Kathryn Anderson

28. Models of Care • Reduced LOS and institutionalisation rates in systems with “formal geriatric liaison”…….. • Which model works best and why? Dr Kathryn Anderson

29. Models of Care • Geriatric Orthopaedic Units (GORU’S) • Geriatric Hip Fracture Programmes (GHFP’S) • Early Supported discharge schemes (ESD) Dr Kathryn Anderson

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 Dr Kathryn Anderson

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 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 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 Dr Kathryn Anderson

34. Models of Care Comparison of Models • Length of stay • Readmission • Morbidity • Mortality • Functional outcome • Quality of life • Cost Dr Kathryn Anderson

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 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 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 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 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) 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 Dr Kathryn Anderson

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 Assess2000;4(2) • Prevention and Management of Hip Fracture in Older People SIGN Guideline 56 (2002) Dr Kathryn Anderson