1.1 Principles of orthogeriatric medical care
To access the References, please follow the URL link
1 Introduction
Despite the large amount of surgical care delivered to older adults [1], perioperative practice remains inappropriately anchored to the surgical experience of more robust and less comorbid patients. At best, many common and accepted approaches to specific illnesses are ineffective in older adults, and at worst, these practices contribute to serious morbidity and mortality [2, 3]. The negative impact of usual medical and surgical care is most pronounced in frail and medically complicated patients [4, 5].
The typical fragility fracture patient (FFP) is emblematic of patients for whom usual medical care is often the wrong care. To those who treat and research this population, it is not surprising that superior postoperative outcomes have been found through unique clinical and systems approaches to the geriatric patient [6, 7], strategies that often diverge from the types of medical investigations and treatments used in most care settings.
Fortunately, there is growing evidence that improved clinical outcomes can be obtained in frail older adults with osteoporotic fractures through the incorporation of a relatively small number of standard approaches and clinical pathways [8]. The major barriers to implementing these approaches are not technological or financial but involve an understanding and commitment to creating systems and expertise that focus on standardizing care, avoiding adverse events, and adapting treatments to the unique physiology and prognosis of the older adult.
While the details of such care will change as the evidence base expands, we expect the basic strategies outlined in this book to remain relevant for years to come. In the chapters that follow, readers will be introduced to the principles and specifics of caring for the typical FFP, based on the improved outcomes produced by orthogeriatric comanagement in organized fracture center programs. To set the stage, there are a number of principles that are important to recognize.
2 Key principles
2.1 Older adults are not simply adults with more illnesses
Compared with younger adults, older adults have unique physiologies, regardless of the presence or absence of specific comorbidities [9, 10]. Aging results in biological changes that render the older adult more susceptible to the harms of immobility, diagnostic tests, and medication effects. For this reason, many common medical practices can be ineffective or harmful in older adults. Examples include exaggerated hypotension in the presence of anesthetics and blood loss, low thresholds for delirium, complications due to polypharmacy, and rapid functional decline with immobility. This general decreased ability to respond to physiological stress is best described as frailty [11].
2.2 Hip fracture surgery can be performed safely and effectively even on frail patients
High-performing hip fracture centers produce low short-term mortality rates (ie, less than 2%), even in populations with high degrees of frailty and comorbidity [6, 12]. Advances in anesthesia, implant technology allowing for early weight bearing as tolerated, orthopedic procedural improvements, and orthogeriatric comanagement all contribute to rapid, safe, and effective repair of the overwhelming majority of hip fracture patients. Urgent surgery in the optimized patient is now standard care to avoid the short-term harms of ongoing pain, blood loss, and immobility.
2.3 Age is not the most important indicator of risk or prognosis in hip fracture patients
While age is a general predictor for outcomes and complications, it is more helpful to base risk assessments and treatment decisions on functional status, cognitive status, and comorbidity [13]. Asking patients about their day-to-day life can help estimate operative risk, recovery potential, and life expectancy better than disease-based assessments.
2.4 Surgical delay and immobility leads to irreversible muscle loss in the older adult
Early surgery is superior [14] and essential for frail and comorbid patients. The medical and surgical team must constantly weigh the impact of functional decline and operative delay against operative risk. Even the frailest patients can usually be optimized quickly, repaired, and begin immediate full weight bearing and rehabilitation [15].
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
