Frail elderly people with bone trauma

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Frail elderly people with bone trauma

• A model for post-acute rehabilitation

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The main headings

• The scale of the job
• Timely acute management
• The need for high skills
• Multi-disciplinary care from the start
• Models for rehabilitation
• Fine tuning
• Follow up

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TRAUMA
POOLE H
Assess and stabilise
Operate as soon as poss
Joint care in immediate post-op phase
Transfer to orthogeriatric service
Systematic diagnostic and rehab approach
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The scale of the problem

• Ageing population in Dorset
• 23 age 65 (UK 17)
• 9 age 80 (UK 5 )
• Generally affluent but 3 deprived urban
  districts and rural deprivation
• catchment population of c 600,000

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Reason for the plateau?

• Osteoporosis prophylaxis (drugs, diet, etc)?
• Osteoporosis Dorset?
• A cohort effect?
• Falls risk reduction?
• Injury reduction (hip protectors)?

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Audits/recommendations
1. Audit Commission. United they stand
co-ordinating care for elderly patients with hip
fracture. London HMSO, 1995 (www.jr2.ox.ac.uk/ban
dolier/band25) 2. Royal College of Physicians.
Fractured neck of femur, prevention and
management. JRCP(1989)238-12 3. Todd CJ et al.
Differences in mortality after fracture of the
hip the East Anglian audit. BMJ(1995)310904-8.
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Signals of good care
lt 1 hour in the Emergency Department Timely
use of antibiotics Thromboembolic prophylaxis
(drugs or - mechanical) Surgery within 24
hours (as soon as medically stable) Senior
surgeon and anaesthetist At least 50
attempting mobility by post-op day 3 Lower
rates of pressure sores, UTI and pneumonia Full
medical assessment, MDT review and discharge
planning Systematic liaison between
Geriatricians and Surgeons
.
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Acute setting
haemodynamic state, Hb, volume, rhythm etc
hydration, electrolytes pressure care
peri-operative thromboprophylaxis pain
management infection screen thermoregulation
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Metabolic impact
hypovolaemia / anaemia gtgt hypoxia, acidosis
cortisol surge gtgt catabolic, diabetogenic
catecholamine surge gtgt catabolic, anxiety,
arrhythmogenic acute phase proteins gtgt
thrombogenic cytokines / interleukins gtgt role
uncertain oxidant surge gtgt effect uncertain
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Diagnostic sweep

• The cause of the FALL
• Repeat history and examination
• screening bloods, RSU, CXR, ECG, O2sat
• cognitive screen (MMSE, FAB, HAD)
• careful basic observations
• gtgt then others as required

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Cause of the fall- common

• Drug effects
• Postural instability (neurological)
• Orthostatic hypotension
• Painful/unstable lower limb joints
• Lower limb weakness
• Dyspraxia (global or focal)
• Executive dysfunction

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Cause of the fall- less common but important

• Cardiogenic syncope (needing PPM)
• Epilepsy
• Vasodepressor syncope
• Hypoglycaemia
• Metabolic cause of weakness (low K, low Ca,
  catabolic states etc)
• Behavioural disorders

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Nutritional assessment

• weight/skinfold
• biochem. and haem. indicators
• history
• home visit information
• dietetic advice

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Main nutritional issues

• Cachectic states (usually malignant, dementia,
  depression or CCF
• Iron deficiency
• Obesity
• B12/folate deficiency
• Vit D subnutrition

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Vit D subnutrition

• About 5 have low Ca with raised PTH
• About 1 have overt osteomalacia
• Overall rate uncertain, but might be 20
• Needs to be looked for
• Responds to replacement
• Improved tensile bone strength

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OM treatment outcome
42 patients with FNF (collected over 11
years) bone biopsy positive for
osteomalacia all had low Ca, high ALP, most
had low phosphate all those tested for PTH
were high (13) treated with standard oral
replacement with vit D and Ca entered an
intention to treat nutritional support service
followed up for 2 years NOTE only survivors
reported, patients with renal failure excluded
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Clinical pathways

• Helpful as a framework
• Can hinder a bespoke service
• Many exceptions in these patients
• More useful in the acute phase
• Critical steps approach more useful

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Critical Steps

• Cause of the fall
• Osteoporosis secondary prophylaxis
• Mental state assessment
• Full drug review
• Thrombo-prophylaxis in AF
• MDT discussion
• Full discharge planning

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Models for O-G rehab.

• Fully embedded in orthopaedic ward
• Fully separated
• Triage to MFE
• Early supported discharge with major investment
  in DH and community services
• Various hybrids

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Other benefits of specialist O-G services

• Concentration of expertise
• Consistent (and equitable) standard
• Opportunities for audit and quality assurance
• Research
• Focus for service development