Orthogeriatrics: The Management of Older Patients with Fragility Fractures

Description

This new Open Access edition supported by the Fragility Fracture Network aims at giving the widest possible dissemination on fragility fracture (especially hip fracture) management and notably in countries where this expertise is sorely needed. It has been extensively revised and updated by the experts of this network to provide a unique and reliable content in one single volume. Throughout the book, attention is given to the difficult question of how to provide best practice in countries where the discipline of geriatric medicine is not well established and resources for secondary prevention are scarce. The revised and updated chapters on the epidemiology of hip fractures, osteoporosis, sarcopenia, surgery, anaesthesia, medical management of frailty, peri-operative complications, rehabilitation and nursing are supplemented by six new chapters. These include an overview of the multidisciplinary approach to fragility fractures and new contributions on pre-hospital care, treatment in the emergency room, falls prevention, nutrition and systems for audit. The reader will have an exhaustive overview and will gain essential, practical knowledge on how best to manage fractures in elderly patients and how to develop clinical systems that do so reliably. Preface to the Second Edition Contents Part I: Background 1: The Multidisciplinary Approach to Fragility Fractures Around the World: An Overview 1.1 Introduction 1.2 General Developments Since 2016 1.2.1 The Global Call to Action 1.2.2 The Formation of National FFNs 1.2.3 Initiation of New Hip Fracture Registries 1.2.4 Implications of These General Developments for the Design of This Second Edition 1.3 Background: Chaps. 2–4 1.3.1 Epidemiology of Fractures and Social Costs: Chap. 2 1.3.2 Osteoporosis in Older Patients: Chap. 3 1.3.3 Frailty and Sarcopenia: Chap. 4 1.4 Pillar I: Co-Management in the Acute Episode—Chaps. 5–11 1.4.1 Establishing an Orthogeriatric Service: Chap. 5 1.4.2 Pre-hospital Care and the Emergency Department: Chap. 6 1.4.3 Perioperative Orthogeriatric Care: Chaps. 7 and 11 1.4.4 Orthogeriatric Anaesthesia: Chap. 8 1.4.5 Hip Fracture: The Choice of Surgery—Chap. 9 1.4.6 Proximal Humeral Fractures: The Choice of Treatment—Chap. 10 1.5 Pillar II: Rehabilitation—Chaps. 12 and 13 1.5.1 Rehabilitation Following Hip Fracture: Chap. 12 1.5.2 The Psychological Health of Patients and Their Caregivers: Chap. 13 1.6 Pillar III: Secondary Prevention—Chaps. 14–16 1.6.1 Fracture Liaison Services: Chap. 14 1.6.2 Current and Emerging Treatment of Osteoporosis: Chap. 15 1.6.3 How Can We Prevent Falls?—Chap. 16 1.7 Cross-Cutting Issues: Chaps. 17–19 1.7.1 Nursing in the Orthogeriatric Setting: Chap. 17 1.7.2 Nutritional Care of the Older Patient with Fragility Fracture: Chap. 18 1.7.3 Fragility Fracture Audit: Chap. 19 1.8 Concluding Remarks References 2: Epidemiology of Fragility Fractures and Social Impact 2.1 Introduction 2.2 Prevalence of Osteoporosis 2.3 Factors Affecting Bone Mineral Density 2.4 Osteosarcopenia 2.5 Falls 2.6 Incidence of Fragility Fractures 2.7 Hip Fracture 2.8 Other Osteoporotic Fractures 2.9 The Burden of Fragility Fractures 2.10 The Costs and Social Impact of Hip Fracture 2.11 The Costs and Social Impact of Other Osteoporotic Fractures 2.12 Conclusions References 3: Osteoporosis and Fragility in Elderly Patients 3.1 Definition 3.2 Epidemiology 3.3 The Anatomy of Bone 3.4 The Physiology of Bone 3.5 Pathogenesis 3.6 Risk Factors for Fragility Fractures 3.6.1 BMD 3.6.2 Age 3.6.3 Previous Fractures 3.6.4 Family History of Fracture 3.6.5 Comorbidities 3.6.6 Drugs 3.6.7 Assessment of Fracture Risk 3.7 Diagnosis 3.7.1 Instrumental Diagnosis 3.7.1.1 Dual X-Ray Absorptiometry (DXA) 3.7.1.2 Quantitative Computerised Tomography (QCT) 3.7.1.3 Quantitative Ultra-Sound (QUS) 3.7.2 X-Ray of the Dorsal and Lumbar Spine 3.7.3 Laboratory Tests 3.8 Management of Osteoporosis 3.8.1 Lifestyle Modification 3.8.1.1 Prevention of Falls 3.9 The Importance of Vitamin D, Calcium and Protein Intake 3.9.1 Vitamin D 3.9.2 Calcium 3.9.3 Protein 3.10 Therapeutic Adherence in Osteoporosis and the Role of Health Professionals References 4: Frailty and Sarcopenia 4.1 Frailty 4.1.1 The Nature of Frailty 4.1.2 Epidemiology of Frailty 4.1.3 How Does Frailty Develop? 4.1.4 Assessment of Frailty in Clinical Practice 4.1.5 Incorporating Frailty into Treatment Plans and Service Design 4.2 Sarcopenia 4.2.1 The Nature of Sarcopenia 4.2.2 Epidemiology 4.2.3 How Does Sarcopenia Develop? 4.2.4 Assessing Sarcopenia in Clinical Practice 4.2.5 Incorporating Sarcopenia into Treatment Plans and Service Design 4.3 The Implications of Frailty and Sarcopenia on Falls, Fractures and the Recovery After Fractures 4.4 Concluding Statement References Part II: Pillar I: Co-management in the Acute Episode 5: Establishing an Orthogeriatric Service 5.1 Introduction 5.2 Designing the Orthogeriatric Service 5.2.1 Step 1: Process Mapping the Hip Fracture Pathway 5.2.2 Step 2: Identify a Core Multidisciplinary Team and Form a Steering Group 5.2.3 Step 3: Analyse and Review the Patient Pathway 5.2.4 Step 4: Evaluate the Resources Required to Drive Change Within the Organisation 5.2.5 Step 5: Develop the Business Case for the Orthogeriatric Service 5.2.6 Step 6: Implementing and Sustaining the Service 5.2.7 Step 7: Collect Evidence of Service Improvement: Audit 5.2.8 Step 8: Embrace the Support of Regional, National and International Organisations 5.3 Conclusion References 6: Pre-hospital Care and the Emergency Department 6.1 Pre-hospital Care 6.1.1 Clinical Assessment: Primary Survey 6.1.2 Clinical Assessment: Secondary Survey 6.1.3 Patient History 6.1.4 Physical Assessment and Vital Signs 6.1.5 Management of Pain 6.1.6 Fluid Replacement 6.1.7 Extrication 6.1.8 Transportation 6.2 The Emergency Department 6.2.1 Nutrition and Hydration 6.2.2 Management of Pain 6.2.3 Ongoing Analgesia 6.2.4 Local Nerve Blocks 6.2.5 Skin Care 6.2.6 Referral for Early Surgery 6.3 Summary References 7: Pre-operative Medical Assessment and Optimisation 7.1 Pre-operative Medical Assessment 7.2 Information Gathering 7.3 Cardiovascular Disease 7.3.1 Valvular Heart Disease 7.3.2 Heart Failure 7.3.3 Conduction Defects, Pacemakers and Implantable Cardiac Defibrillators (ICD) 7.3.4 Atrial Fibrillation (AF) 7.4 Management of Anticoagulants and Anti-platelets 7.5 Anaemia 7.6 Diabetes 7.7 Chronic Kidney Disease (CKD) 7.8 Respiratory Disease 7.9 Medication Review 7.10 Preventing Complications: Thromboembolic Events 7.11 Antibiotic Prophylaxis 7.12 Appropriate Ceilings of Care 7.13 Conclusion References 8: Orthogeriatric Anaesthesia 8.1 Introduction 8.2 The Relationship Between Anaesthetist and Orthogeriatrician 8.3 Preoperative Care 8.3.1 Preoperative Analgesia 8.3.2 Preoperative Preparation 8.3.3 Ethical and Legal Considerations 8.4 Intraoperative Care 8.4.1 General or Spinal Anaesthesia? 8.4.2 Peripheral Nerve Block 8.4.3 Spinal Anaesthesia 8.4.4 Sedation 8.4.5 General Anaesthesia 8.4.6 Avoiding Ischaemia 8.4.7 Bone Cement Implantation Syndrome (BCIS) 8.4.8 Standardisation of Anaesthesia 8.5 Postoperative Care References 9: Hip Fracture: The Choice of Surgery 9.1 Aim of Surgery 9.2 Fracture Types 9.2.1 Intra-capsular Fracture Types 9.2.2 Extra-capsular Fracture Types 9.3 Implants 9.4 Surgical Management 9.4.1 Intra-capsular Operations 9.4.2 Extra-capsular Operations 9.5 Surgical Algorithms and National Guidelines References 10: Proximal Humeral Fractures: The Choice of Treatment 10.1 Aim of Treatment 10.2 Evidence and Literature 10.3 Epidemiology 10.4 Fracture Classification 10.4.1 Minimally Displaced Fractures 10.4.2 Displaced Fractures 10.5 Treatment 10.5.1 Non-surgical Treatment 10.5.2 Surgical Management 10.6 Complications 10.7 Outcome Assessment 10.8 Conclusions References 11: Post-operative Management 11.1 Multidisciplinary Management 11.2 Predicting the Risk of Post-operative Complications 11.3 Early Mobilisation 11.4 Pain Management 11.5 Post-operative Hypotension and Fluid Management 11.6 Management of Postsurgical Anaemia 11.7 Nutritional Supplementation 11.8 Post-operative Medical Complications 11.9 Prevention and Management of Specific Complications 11.9.1 Delirium 11.9.1.1 Prevention of Post-operative Delirium 11.9.1.2 Management of Post-operative Delirium 11.9.1.3 Post-operative Cognitive Dysfunction 11.9.2 Cardiovascular Complications 11.9.2.1 Myocardial Infarction 11.9.2.2 Heart Failure 11.9.2.3 Supraventricular Arrhythmias 11.9.3 Infections 11.9.3.1 Post-operative Fever 11.9.3.2 Pneumonia 11.9.3.3 Urinary Tract Infection 11.9.3.4 Surgical Site Infection 11.9.4 Other Complications 11.9.4.1 Acute Kidney Injury (AKI) 11.9.4.2 Gastrointestinal Complications 11.9.4.3 Pressure Ulcers 11.10 Final Remarks References Part III: Pillar II: Rehabilitation 12: Rehabilitation Following Hip Fracture 12.1 The Need for Increased Provision of Rehabilitation Worldwide 12.2 The Principles of Rehabilitation Programmes after Hip Fracture 12.3 What Is Known about the Pattern of Recovery Following Hip Fracture? 12.4 Factors Associated with Poor Outcomes After Hip Fracture 12.5 Key Elements of a Rehabilitation Pathway 12.6 What Programmes Should We Recommend to Help with Recovery? 12.6.1 In-hospital Rehabilitation 12.6.2 Rehabilitation in the Community 12.6.3 Rehabilitation in Low Resource Settings 12.7 Rehabilitation and Cognitive Impairment 12.7.1 Enhanced Interdisciplinary Inpatient Rehabilitation and Care 12.7.2 Enhanced Interdisciplinary Inpatient and Home-Based Rehabilitation 12.8 Psychosocial Factors and Rehabilitation 12.9 Delivery of Rehabilitation Following Hip Fracture in LMICs 12.9.1 Key Evidence-Based Recommendations and Their Implementation in LMICs 12.10 Conclusion References 13: The Psychological Health of Patients and their Caregivers 13.1 Why Is Psychological Status Important in the Management of Hip Fracture? 13.1.1 Why Is Psychological Status Important in the Outcome of Hip Fracture? 13.1.2 Why Is Psychological Status Important in Rehabilitation from Hip Fracture? 13.1.3 Why Is Caregivers’ Psychological Status also Important? 13.1.4 Consequences of Caregiving 13.1.5 The Relationship Between Caregivers’ and Patients’ Psychological Status 13.2 How Should the Psychological Status of Patients and Caregivers Be Assessed? 13.2.1 The Psychological Evaluation of the Patient 13.2.1.1 Quality of Life 13.2.1.2 Fear of Falling 13.2.1.3 Pain 13.2.1.4 Activities of Daily Living 13.2.1.5 Delirium 13.2.1.6 Depression 13.2.1.7 Cognitive Impairment 13.2.1.8 Stress 13.2.1.9 Anxiety 13.2.2 The Psychological Evaluation of Caregivers 13.2.2.1 Psychological Well-Being 13.2.2.2 The Caregiver Burden 13.3 How Can Psychological Status Be Influenced Positively by the Orthogeriatric Team? 13.4 Cultural Influence and the Anthropology of Care References Part IV: Pillar III: Secondary Prevention 14: Fracture Risk Assessment and How to Implement a Fracture Liaison Service 14.1 Introduction 14.2 Fracture Risk Prediction 14.3 Fracture Liaison Service 14.3.1 The FLS Model 14.3.2 Evidence for Effectiveness of FLS 14.4 How to Implement an FLS (a Step-by-Step Guide) 14.4.1 Benchmarking Your Service 14.4.2 Potential Barriers and How to Overcome them 14.4.3 Implementation in a Low-Resource Setting 14.5 Conclusions References 15: Current and Emerging Treatment of Osteoporosis 15.1 Introduction 15.2 Pharmacological Treatment for All Patients with Fragility Fractures 15.2.1 Bedridden Fractured Patients 15.2.2 Make a Diagnosis Before Treatment 15.2.3 Set Up an Appropriate and Personalised Treatment 15.3 Non-pharmacological Treatment 15.3.1 Lifestyle and Exercise 15.4 Pharmacological Interventions 15.4.1 Ca and Vitamin D to All Patients in Association with Anti-osteoporotic Therapy 15.4.2 Choose the Safe and Effective Drug for the Orthogeriatric Patient 15.5 Antiresorptive Therapies 15.5.1 Bisphosphonates 15.5.1.1 Adverse Events 15.5.1.2 Technical Remark 15.5.2 Rank Ligand Inhibitor 15.5.2.1 Adverse Events 15.5.2.2 Technical Remark 15.6 Anabolic Drugs 15.6.1 Parathyroid Hormone Receptor (PTHr) Agonists: Teriparatide and Abaloparatide 15.6.1.1 Adverse Events 15.6.2 Anti-Sclerostin Antibody: Romosozumab 15.6.2.1 Adverse Events 15.6.2.2 Technical Remark for Anabolic Agents 15.7 Influence of Osteoporosis Medication on Fracture Healing 15.8 Conclusion References 16: How Can We Prevent Falls? 16.1 Epidemiology of Falls 16.2 How to Assess Older Patients’ Risk of Falling 16.2.1 Definition of Older People at Low, Moderate or High Risk of Falling 16.3 Fall Prevention Intervention in Patients with Low Risk of Falling 16.4 Multifactorial Interventions in Patients with Moderate Risk of Falling 16.5 Multifactorial Falls Risk Assessment and Interventions in Patients with High Risk of Falling 16.6 Fall Assessment and Prevention in Care Settings 16.7 Fall Assessment and Prevention in Patients with Cognitive Impairments 16.8 Falls Clinics and Fracture Liaison Services 16.9 Conclusion References Part V: Cross-Cutting Issues 17: Nursing in the Orthogeriatric Setting 17.1 Introduction 17.2 Nursing Care Quality 17.3 Acute Care 17.3.1 Complexity and Frailty 17.3.2 Nursing Assessment and Management of Pain 17.3.3 Nursing Assessment and Management of Delirium 17.3.4 Pressure Ulcer Prevention 17.3.5 Nutrition, Hydration, Acute Kidney Injury and Constipation 17.3.6 Healthcare Associated Infection 17.3.6.1 Pneumonia: Nursing Assessment, Prevention and Management 17.3.6.2 Urinary Tract Infection: Nursing Assessment, Prevention and Management 17.3.7 Venous Thromboembolism: Nursing Interventions for Prevention 17.4 Rehabilitation, Discharge and Continuing Care 17.5 Palliative and End of Life Care 17.6 Secondary Prevention, Health Improvement and Health Promotion 17.7 Nursing Resources, Education and Leadership References 18: Nutritional Care of the Older Patient with Fragility Fracture: Opportunities for Systematised, Interdisciplinary Approaches Across Acute Care, Rehabilitation and Secondary Prevention Settings 18.1 Background 18.2 SIMPLE or Specialised Nutrition Care? 18.3 Screening for Nutrition Risk (SIMPLE) 18.4 Interdisciplinary Assessment (SIMPLE) 18.5 Make the Diagnosis/(es) (SIMPLE) 18.6 Plan with the Patient (SIMPLE) 18.7 ImpLement Interventions (SIMPLE) 18.7.1 Interventions to Improve Nutrition Knowledge 18.7.2 Interventions to Influence Nutrient Intake 18.7.3 Interventions Leading to Coordinated Nutrition Care Across Disciplines and Settings 18.8 Evaluating Ongoing Care Requirements (SIMPLE) 18.9 Recommended Further Reading References 19: Fragility Fracture Audit 19.1 Introduction 19.2 Hip Fracture Audit 19.3 Obstacles to Hip Fracture Audit and International Comparison 19.4 Hip Fracture Audit and the Improvement of Care 19.5 Audit of Other Fragility Fractures and Fracture Liaison Services (FLS) 19.6 Expansion of Hip Fracture Registries in Other Regions 19.7 New Developments in Fracture Audit References