Aging Clin Exp Res DOI 10.1007/s40520-014-0198-y
POINT OF VIEW
The management of hip fracture in the older population. Joint position statement by Gruppo Italiano Ortogeriatria (GIOG) Giulio Pioli • A. Barone • C. Mussi • L. Tafaro • G. Bellelli • P. Falaschi • M. Trabucchi • G. Paolisso • On behalf of GIOG
Received: 22 October 2013 / Accepted: 16 January 2014 Springer International Publishing Switzerland 2014
Abstract This document is a Joint Position Statement by Gruppo Italiano di OrtoGeriatria (GIOG) supported by Societa` Italiana di Gerontologia e Geriatria (SIGG), and Associazione Italiana Psicogeriatria (AIP) on management of hip fracture older patients. Orthogeriatric care is at present the best model of care to improve results in older patients after hip fracture. The implementation of orthogeriatric model of care, based on the collaboration between orthopaedic surgeons and geriatricians, must take into account the local availability of resources and facilities and should be integrated into the local context. At the same time the programme must be based on the best available evidences and planned following accepted quality standards that ensure the efficacy of the intervention. The position paper focused on eight quality standards for the
management of hip fracture older patients in orthogeriatric model of care. The GIOG promotes the development of a clinic database with the aim of obtaining a qualitative improvement in the management of hip fracture.
G. Pioli (&) Geriatric Unit, Department of Neuromotor Physiology, ASMN-IRCCS Hospital, Via Risorgimento 80, 42100 Reggio Emilia, Italy e-mail: [email protected]
G. Bellelli Geriatric Clinic, San Gerardo University Hospital, Monza, Italy
A. Barone Orthogeriatric Unit, Department of Geriatrics and Musculoskeletal Sciences, Galliera Hospital, Genoa, Italy C. Mussi Division of Gerontology and Geriatrics, University of Modena, Reggio Emilia, Italy L. Tafaro Geriatric Unit, Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy
Keywords fracture
Elderly Orthopaedics Geriatricians Hip
Background Hip fracture is still a devastating event. Epidemiological data show a per-year mortality of over 25 % and an incomplete recovery of pre-fracture conditions in more than 50 % of survivals [1]. In Italy, 90,000 new fracture
P. Falaschi Geriatric Unit, Department of Surgical and Medical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy M. Trabucchi Department of Neuropharmachology, University Tor Vergata, Rome, Italy G. Paolisso Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, II University of Naples, Naples, Italy
G. Bellelli Department of Health Science, University of Milano-Bicocca, Monza, Italy
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events occur per year, with a growing trend coincident to the ageing of the population [2]. Direct costs (including acute in-hospital treatment, post-operative complications, rehabilitation programmes and the use of the health services) and indirect costs (including burden to families related to the patient’s increased, new disability) have been only partially evaluated [2], but they are enormous, and they weigh heavily on the Italian Health Care System. Scientific research puts considerable effort into the development of treatment and interventions that should be able both to reduce the incidence of new fractures and to improve outcomes when fracture has occurred. However, this goal is challenging because of the complexity of dealing with older patients who have incurred fragility fractures, particularly those of the hip. Poor bone health and falls are the main causes of fractures but negative outcomes are generally related to underlying frailty. More than 80 % of patients with hip fracture present two or more comorbidities and/or some impairments to the performance of basic or instrumental activities of daily living [1, 3]. Medical postoperative complications and negative longterm outcomes occur mainly in those patients, who have limited physiologic reserves that are overtaxed by the fracture experience [4, 5]. Therefore, hip fracture is not a single-organ disease, but a complex problem that involves the whole organism, and it needs not only appropriate surgical technique, but also a comprehensive and multidisciplinary approach capable of treating the patient as a whole. Orthogeriatric care generally requires a multidisciplinary approach to older patients with fragility fracture based on the collaboration between orthopaedic surgeons and geriatricians. At present, it is the best model of care to improve results in older patients after hip fracture [6]. The orthopaedic surgeon and geriatrician co-manage the fractured patients and share the responsibility from admission to discharge. Essential members of the multidisciplinary team are also anaesthesiologists, involved mainly in the preoperative phase, and physiatrists and physical therapists during the postoperative phase. Nurses, skilled in the care of elderly patients, are also an important component of the team. Other specialists such as cardiologists, pharmacists, psychologists, social workers, nutritionists and even hospital managers should be involved, when necessary, to guarantee full implementation of a multidisciplinary model of care. Orthogeriatric care is well established as far as hip fracture patients are concerned, but all older patients with fragility fractures might benefit from a collaborative model of care. In particular it should be available to all elderly subjects admitted with fractures such as those of the pelvis, distal femur, legs and humerus, which greatly affect independent deambulation, functional ability and quality of life.
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Table 1 Quality standards of an orthogeriatric model for the care of hip fracture patients Key issues
Standard for the intervention
Responsibility
Combined care of geriatricians and orthopaedic surgeons Multidisciplinary team at each step of the care pathway
Role and skills of the Orthogeriatrician
Senior experience in comprehensive geriatric assessment, in the management of the acute older patient and geriatric syndromes Expertise in the management of medical perioperative complications and delirium Knowledge of factors that identify patients at risk of low recovery and need targeted intervention to prevent complications Knowledge of metabolic bone diseases
Standardization of communication
Written procedure for promoting effective communication between different specialists and the knowledge of their own orders Planning of combined rounds, briefings and meetings
Protocol-driven care
Development of shared protocols based on available evidences regarding the main features of the perioperative phase
Early surgery
Choosing surgery for the majority of patient. Conservative treatment only after a multidisciplinary evaluation and as a result of a shared interdisciplinary choice (quality standard below 4 % of patients) Protocols shared by anaesthesiologist, orthopaedic surgeons and geriatrician for optimizing patients before surgery and ensuring a rapid access to operating theatre. Hip fracture should be ranked as ‘‘delayed urgency’’ (surgery needed within 24–48 h) Availability of designated block time in operating theatres to avoid delays due to system factors
Early mobilization
Surgery performed with goals of stable fixation that allow for immediate weight bearing for all hip fractures Early rehabilitation protocols shared by the orthopaedic surgeon, geriatrician and physiatrist/ rehabilitation therapist Development of protocols for pain relief, management of anaemia, perioperative fluid balance and prevention/treatment of delirium
Aging Clin Exp Res Table 1 continued Key issues
Standard for the intervention
Continuity of care
Multidisciplinary discharge planning to be started early after admission Access to in-hospital and out-patient rehabilitation facilities according to a multidisciplinary rehabilitation plan based on comorbid conditions and pre-fracture functional status. Type and intensity of exercises should be planned to maximize functional recovery regardless of the cognitive level, place of residence (community, nursing homes), and age of the patient
Secondary prevention
and facilities and should be integrated into the local context. At the same time the programme must be based on the best available evidences and planned following accepted quality standards that ensure the efficacy of the intervention (Table 1). Good quality independent guidelines are now available [10–14]. Quality standards of an orthogeriatric model of care for hip fracture patients are the following: •
•
Bone health assessment and pharmacological treatment, as needed, before discharge for all patients Arrangement to ensure a multifactorial fall risk assessment and an individualized intervention if appropriate within the end of postacute/rehabilitant phase
A number of studies have been published in various countries with different trials interventions, populations and outcomes [7]. Given the great heterogeneity of the programmes implemented worldwide, it is not possible to define which model, setting and care organization is the best, in terms of short- and long-term outcomes and cost-effectiveness. However, the simple geriatric-consultant model, characterized by regular reports from a consultant geriatric team to the orthopaedic surgical staff, responsible for overall care, has failed to demonstrate a real beneficial effect on mortality and functional recovery [7]. On the contrary, more complex models, characterised by a multidisciplinary approach involving co-management of patients showed, in randomised-controlled and before-after observational studies, a reduction of acute medical complications, mortality, costs (mainly by shortening hospital stays) and readmissions in the first months after discharge compared to the traditional or simpler models. The orthogeriatric service developed by the Mayo Clinic in Rochester (known as Hip Fracture Program [8, 9]) is the reference model for collaboration based on the co-management of patients by the orthopaedic surgeon and geriatrician and has been adopted in many hospitals of the Unites States and Europe, including Italy.
Quality standards of an orthogeriatric model of care for hip fracture patients The implementation of an orthogeriatric model of care must take into account the local availability of resources
•
•
The geriatrician should be available throughout the whole of the patient’s care pathway, from admission to hospital to the end of the post-acute rehabilitation phase. The geriatrician should be an expert (or senior supervision should be ensured) in comprehensive geriatric assessment and in the management of acute older patients and, in particular, in the management of geriatric syndromes such as delirium, malnourishment or cognitive impairment. Moreover, he/she should be an expert in peri-operative medical complications and management of elderly patients who have undergone surgery, targeting individualized interventions for patients with high risk of complications. All of these skills define a new specialist generally known as ‘‘orthogeriatrician’’. Well-coordinated multidisciplinary teamwork is best achieved if both the orthogeriatrician and the orthopaedic surgeon are senior and at the same hierarchical level [15]. The role of the orthogeriatrician is primarily the perioperative medical management to identify and treat acute medical illness. In the preoperative phase he/she plays a major role in optimizing the patient for surgical intervention when necessary, to avoid delay in surgical repair, while during the postoperative phase he/she acts to avoid and treat medical post-surgical complications. Standardization of the management of the most common features of the perioperative phase is an established way to improve the quality of the intervention and the outcome. Guidelines identify a number of issues whose management should be driven by protocols [12, 13] (Table 2). Only a few protocols are widely implemented in Italian orthopaedic wards. Most of the issues are still managed without standardizing procedures and care. The geriatrician should promote the development of the most important protocols and play an active role to ensure that appropriate care be provided to patients even if it may be relatively time-intensive. Among the protocols still poorly implemented are the role of pain relief, prevention and treatment of delirium and adequate nutritional intake which should be emphasized out since they greatly affect short- and long-term outcomes [16, 17]. Moreover, several features of perioperative
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Aging Clin Exp Res Table 2 Protocols for the standardization of interventions in orthogertiatrics Protocol
Development/feasibility (1)
Resources (2)
Evidence (3)
Dissemination (4)
Delirium
Complex
High
Established
Limited
Pain
Complex
Low
Established
Partial
Incontinence
Simple
Low/medium
Few data
Partial
Nutrition
Complex
High
Established
Limited
Anaemia—blood transfusion
Simple
Low
Controversial
Partial
Oxygen
Simple
Low
Few data
Partial
Thromboprophylaxis
Simple
Low
Established
Widespread
Antimicrobial prophylaxis
Simple
Low
Established
Widespread
Fluid balance
Complex
Low
Few data
Partial
Skin care
Simple
High
Established
Widespread
Constipation Early rehabilitation
Simple Complex
Low Medium
Few data Few data
Partial Partial
(1) Development/feasibility defined by the number of professionals involved (2) Ranked on the basis of resources (mainly working hours) required for implementing the protocol (3) Based on the quality of published studies and on the coherence of available data (4) Dissemination of protocols in Italy derived from a sample survey (restricted present in few centres; partial often present, but in an incomplete form; widely present in almost all centers)
•
•
management are closely interrelated. For example, poor pain control, dehydration and electrolyte disorders are known risk factors for delirium; therefore, a full strategy of delirium prevention includes effective pain relief and an optimal fluid balance. Similarly, early rehabilitation may be affected by non-optimal management of pain, anaemia, fluid volume and orthostatic hypotension [18]. The goal of the orthogeriatric approach is to maximize the proportion of older hip fracture patients that undergo surgical repair within 24–48 h, avoiding unwarranted delays so that they may re-acquire independent deambulatory ability soon after surgery (starting with active mobilization with full weight-bearing on the first postoperative day). In the Italian context hip fracture should be classified as ‘‘delayed urgency’’ (surgery needed within 24–48 h). Hospital managers should organize operating room time to avoid delays due to system factors. Some studies [19, 20] suggested the benefits of a dedicated operating room. However, guidelines recommend prioritization of hip fracture on operating lists and availability of resources for performing surgical repair during normal working hours every day (including weekend or at least Saturdays) [10, 12]. Recent data [21, 22] showed that harmful effects of prolonged immobilization related to delaying surgery occur mainly in the case of frail older people. Subjects with hip fracture and pre-existing disabilities need more aggressive intervention than those without disabilities and may benefit, to a great extent, from shortening
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•
surgery and bed rest time. To achieve this goal in comorbid and complex patients it is necessary to organize effective teamwork for all the clinicians and professionals involved in the patient care pathway (mainly the orthopaedic surgeon, geriatrician, anaesthetist, physiatrist, nurse and physical therapist). Decisions should be taken by all the clinicians not only on the basis of their own experience and responsibilities but also bearing in mind that each competence should be integrated with a view to achieving the best functional outcome for the patient. A comprehensive intervention should be tailored to suit each patient, taking account his/her comorbidities, risk factors and also life quality and functional recovery. Frequent communication is an essential element of good coordinated care and fosters the development of collegial relationships between team members. Key elements of teamwork are daily briefings, regular meetings and collegial discussion of complex cases, along with the appropriate tools (paper charts or electronic medical records) aimed at fostering information sharing. Discharge from the acute care setting is a critical step in the care pathway of elderly hip fracture patients. Lack of coordination in the handover from the hospital to intermediate and community care may lead to fragmentation of care or unsuitable rehabilitation programmes with negative consequences in terms of life quality and functional recovery. A proper rehabilitation programme should be ensured to all patients irrespective of cognitive level and pre-fracture place of residence. Recent studies [23, 24] indicate that post-hip
Aging Clin Exp Res
•
•
fracture rehabilitation might be beneficial also for patients with moderate to severe dementia, indirectly suggesting that dementia could not be viewed as a barrier to pre-fracture walking abilities. Following Cochrane’s statement [25], patients with hip fracture should be offered a coordinated, multidisciplinary rehabilitation programme with the specific aim of regaining sufficient functionality so as to return to their pre-fracture living arrangements. Criteria for effective geriatric physical therapy in terms of intensity and frequency have not been determined [26, 27], but older patients should not be excluded from high-intensity rehabilitation programmes. Meta-analysis [28] showed that inpatient rehabilitation, specifically designed for geriatric patients, seems to have the potential to improve function, admissions to nursing homes and mortality outcomes compared with usual care. Moreover, recent studies [29, 30] revealed the beneficial effect of booster exercising programmes offered beyond the regular rehabilitation period for patients with hip fracture returning into the community. Following fracture, patients are at high risk of entering a vicious cycle in which fear of falling and muscular weakness contribute to relative immobility and lead to a deterioration of the functional status achieved after regular rehabilitation programmes. Extended exercise rehabilitation seems to be effective in maintaining and further improving muscle strength and balance. Discharge planning is the best way to avoid fragmentation and ensure continuity of care [25]. Along with additional post-discharge support, it may also help reduce length of stay and unplanned readmissions to hospital. Discharge planning should be started early after admission and revised regularly during the stay in hospital. The key issues of the discharge plan after hip fracture include timing of discharge, adequate rehabilitation setting, support arrangements for patients who will probably need a higher level of care after rehabilitation and also re-educational interventions. Discharge planning includes ensuring that the patient has access to available services and resources. The complexity of the plan requires that responsibility be shared by a multidisciplinary team including physicians, nurses, physiotherapists and social workers. Patients and their families should also be involved in defining the plan taking their needs and preferences into account. Secondary prevention of fractures including bone health evaluation and fall risk assessment is an essential part of orthogeriatric care. Each patient should be assessed, during the acute or post acute phases, depending on the model implemented, to determine whether she/he needs vitamin D supplementation and
anti-osteoporotic drugs and should be offered multidisciplinary assessment and interventions to prevent future falls. Geriatrician should have a good knowledge of the complex of these assessments; however, in the absence of these skills, patients should be referred to specialized centres.
Conclusive remarks The orthogeriatric model is a methodological approach that can be implemented in different settings and care organization. There is no evidence that the results are significantly affected by the specific implementation setting, such as general orthopaedic wards, dedicated orthogeriatric divisions or even a more complex system based on intensity of care levels [7]. Nevertheless, it must be stressed that older hip fractured patients have a high incidence of medical complications even during the post-acute phase, and their multidisciplinary management must be carried out beyond the immediate post-operative phase [31]. Promising results have been obtained with organizational models based on post-acute rehabilitation wards dedicated to older hip-fractured patients (Geriatric-orthopaedicrehabilitation units, GORU), allowing for early discharge after surgical repair and a significant shortening of inhospital acute stays [32, 33]. The recovery process of the fractured patients is not linear in time. Some good quality studies [29, 30] demonstrated that prolonged interventions, up to 1 year, offer the highest probability of full functional recovery and of longer permanence at home Therefore, all extended rehabilitation programmes, both hospital and community based, mainly in collaboration with general practitioner, are highly desirable. The extended intervention programme should adopt a comprehensive approach to the supervision of the patient’s motor ability, physical activity, nutrition intake, mood states and compliance with medical recommendations and drug therapy and should be able to address any emerging problem early on. Given the importance of hip fracture to the Italian Health System and the quality of life of elderly people, building a monitoring system dedicated to this disease, in the wake of other Countries, is a mandatory objective, which aims at reaching beyond the standards currently established by Programma Nazionale Valutazione Esiti [34]. The GIOG (Gruppo Italiano OrtoGeriatria), on behalf of SIGG (Societa` Italiana di Gerontologia e Geriatria) and AIP (Associazione Italiana Psicogeriatria), promotes and supports the development of a clinic database with the aim of obtaining a qualitative improvement in the management of hip fracture. This strategy, already implemented in the
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United Kingdom [35, 36], permits the optimization of outcomes and qualitative standard related to the management of hip fracture in older patients.
2.
Conflict of interest The authors have no proprietary interest in any aspect of this statement.
Appendix: The members of Gruppo Italiano Ortogeriatria (GIOG) are: Alimenti Mario, Roma; Annoni Giorgio, Monza; Antonelli Incalzi Raffaele, Roma; Anzivino Fernando, Bologna; Balotta Antonio, Cesena; Barbagallo Mario, Palermo; Barone Antonella, Genova; Bellamoli Claudio, Verona; Bellelli Giuseppe, Monza (Coordinator); Benvenuti Enrico, Firenze; Bernardini Bruno, Rozzano MI; Bianchetti Angelo, Brescia; Bianchi Claudio, Novi Ligure; Bolognesi Anna Giuliana, Piacenza; Bonino Paolo, Aosta; Boscaro Stefania, Vicenza; Boschi Federica, Forlı`; Brugiolo Roberto, Mestre; Calabro` Massimo, Treviso; Camin Marco, Trento; Cappa Giorgietta, Cuneo; Catte Olga, Cagliari; Cavagnaro Paolo, Chiavari; Cecchi Francesca, Firenze; Cirillo Giulio, Forlı`; Cotroneo Antonino, Torino; Coveri Maura, Bologna; Cursi Flavio, Roma; D’Amico Ferdinando, Patti (ME); Davoli Maria Luisa, Reggio Emilia; De Alfieri Walter, Grosseto; De Filippi Francesco, Sondrio; Desideri Giovambattista, L’Aquila; Di Bella Giovanna Palermo; Di Monaco Marco, Torino; Dominguez Ligia Juliana, Palermo; Falaschi Paolo, Roma (Coordinator); Ferrari Alberto Reggio, Emilia; Girardello Renzo, Rovereto (TN); Giusti Andrea, Genova; Greco Antonio, S. Giovanni R (FG); Isaia Giancarlo, Torino; Lunardelli Maria Lia, Bologna; Magnolfi Stefano, Prato; March Albert, Bolzano; Marchionni Niccolo`, Firenze; Marengoni Alessandra, Brescia; Mari Daniela, Milano; Martini Emilio, Bologna; Marzetti Emanuele, Roma; Mitidieri Costanza, Prato; Mussi Chiara, Modena; Nardelli Anna, Parma; Noro Gabriele, Trento; Odetti Patrizio, Genova; Pagani Marco, Rozzano MI; Palummeri Ernesto, Genova; Pellicciotti Francesca, Reggio Emilia; Pioli Giulio, Reggio Emilia; Pula Beatrice, Rimini; Raffaele Angelo, Avezzano; Recchi Domenico, Trento; Romanelli Giuseppe, Brescia; Ruggiero Carmelinda, Perugia; Solinas Antonella, Cagliari; Sterzi Paolo, Cles (TN); Tafaro Laura, Roma; Toigo Gabriele, Trieste; Ungar Andrea, Firenze; Valentini Maurizio, Roma; Zagatti AnnaMaria, Ferrara; Zurlo Amedeo, Ferrara.
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References 16. 1. Maggi S, Siviero P, Wetle T, Besdine RW, Saugo M, Crepaldi G, Hip Fracture Study Group (2010) A multicenter survey on profile
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of care for hip fracture: predictors of mortality and disability. Osteoporos Int 21(2):223–231 Piscitelli P, Iolascon G, Argentiero A, Chitano G, Neglia C, Marcucci G, Pulimeno M, Benvenuto M, Mundi S, Marzo V, Donati D, Baggiani A, Migliore A, Granata M, Gimigliano F, Di Blasio R, Gimigliano A, Renzulli L, Brandi ML, Distante A, Gimigliano R (2012) Incidence and costs of hip fractures vs strokes and acute myocardial infarction in Italy: comparative analysis based on national hospitalization records. Clin Interv Aging 7:575–583 Pioli G, Frondini C, Lauretani F, Davoli ML, Pellicciotti F, Martini E, Zagatti A, Giordano A, Pedriali I, Nardelli A, Zurlo A, Ferrari A, Lunardelli ML (2012) Time to surgery and rehabilitation resources affect outcomes in orthogeriatric units. Arch Gerontol Geriatr 55(2):316–322 Roche JJ, Wenn RT, Sahota O, Moran CG (2005) Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 331(7529):1374 Bellelli G, Noale M, Guerini F, Turco R, Maggi S, Crepaldi G, Trabucchi M (2012) A prognostic model predicting recovery of walking independence of elderly patients after hip-fracture surgery. An experiment in a rehabilitation unit in Northern Italy. Osteoporos Int 23(8):2189–2200 Pioli G, Giusti A, Barone A (2008) Orthogeriatric care for the elderly with hip fractures: where are we? Aging Clin Exp Res 20(2):113–122 Giusti A, Barone A, Razzano M, Pizzonia M, Pioli G (2011) Optimal setting and care organization in the management of older adults with hip fracture. Eur J Phys Rehabil Med 47(2):281– 296 Friedman SM, Mendelson DA, Bingham KW, Kates SL (2009) Impact of a comanaged Geriatric Fracture Center on short-term hip fracture outcomes. Arch Intern Med 12:169(18) Kates SL, Mendelson DA, Friedman SM (2010) Co-managed care for fragility hip fractures (Rochester model). Osteoporos Int 21(Suppl 4):S621–S625 Association of Anaesthetists of Great Britain and Ireland, Griffiths R, Alper J, Beckingsale A, Goldhill D, Heyburn G, Holloway J, Leaper E, Parker M, Ridgway S, White S, Wiese M, Wilson I (2012) Management of proximal femoral fractures 2011: association of Anaesthetists of Great Britain and Ireland. Anaesthesia 67(1):85–98 British Orthopaedic Association, British Geriatrics Society (2007) Care of Patients with Fragility Fracture. London: BOA. Available at http://www.bgs.org.uk/index.php?option=com_con tent&view=article&id=338:bluebookfragilityfracture&catid=47: fallsandbones&Itemid=307 NICE Guidelines 2011. Hip Fracture Program. Available at: http://publications.nice.org.uk/quality-standard-for-hip-fractureqs16/quality-statement-1-hip-fracture-programme Scottish Intercollegiate Guidelines Network (2009) Management of hip fracture in older people. Clinical guideline 111. Edinburgh: SIGN. Available at: http://www.sign.ac.uk/pdf/sign111.pdf Agency for clinical innovation. The orthogeriatric model of care 2010. Available at: http://www.aci.health.nsw.gov.au/__data/ assets/pdf_file/0013/153400/aci_orthogeriatrics_clinical_practice_ guide.pdf National Confidential Enquiry into Patient Outcome and Death (NCEPDO) (2010) A review of the care received by elderly patients undergoing surgery. Available at: http://www.ncepod. org.uk/2010report3/downloads/EESE_fullReport.pdf#search= ’elderlypatientsundergoingsurgery’’ Hung WW, Egol KA, Zuckerman JD et al (2012) Hip fracture management. Tailoring care for the older patient. JAMA 307:2185–2194
Aging Clin Exp Res 17. Bateman L, Vuppala S, Porada P, Carter W, Baijnath C, Burman K, Lee R, Hargus J (2012) Medical management in the acute hip fracture patient: a comprehensive review for the internist. Ochsner J 12(2):101–110 18. Barone A, Giusti A, Pizzonia M, Razzano M, Oliveri M, Palummeri E, Pioli G (2009) Factors associated with an immediate weight-bearing and early ambulation program for older adults after hip fracture repair. Arch Phys Med Rehabil 90(9):1495–1498 19. Elder GM, Harvey EJ, Vaidya R, Guy P, Meek RN, Aebi M (2005) The effectiveness of orthopaedic trauma theatres in decreasing morbidity and mortality: a study of 701 displaced sub capital hip fractures in two trauma centres. Injury 36(9):1060–1066 20. Lemos D, Nilssen E, Khatiwada B, Elder GM, Reindl R, Berry GK, Harvey EJ (2009) Dedicated orthopedic trauma theatres: effect on morbidity and mortality in a single trauma centre. Can J Surg 52(2):87–91 21. Pioli G, Lauretani F, Davoli ML et al (2012) Older people with hip fracture and IADL disability require earlier surgery. J Gerontol A Biol Sci Med Sci 67:1272–1277 22. Bellelli G, Mazzola P, Corsi M, Zambon A, Corrao G, Castoldi G, Zatti G, Annoni G (2012) The combined effect of ADL impairment and delay in time from fracture to surgery on 12-month mortality: an observational study in orthogeriatric patients. J Am Med Dir Assoc 13(7):664.e9-664.e14. doi:10. 1016/j.jamda.2012.06.007 23. Morghen S, Gentile S, Ricci E, Guerini F, Bellelli G, Trabucchi M (2011) Rehabilitation of older adults with hip fracture: cognitive function and walking abilities. J Am Geriatr Soc 59(8):1497–1502. doi:10.1111/j.1532-5415.2011.03496 24. Poynter L, Kwan J, Sayer AA, Vassallo M (2011) Does cognitive impairment affect rehabilitation outcome? J Am Geriatr Soc 59(11):2108–2111. doi:10.1111/j.1532-5415.2011.03658 25. Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL (2013) Discharge planning from hospital to home. Cochrane Database Syst Rev 1:CD000313. doi:10.1002/ 14651858.CD000313.pub4 26. Sherrington C, Tiedemann A, Cameron I (2011) Physical exercise after hip fracture: an evidence overview. Eur J Phys Rehabil Med 47(2):297–307
27. Crotty M, Unroe K, Cameron ID, Miller M, Ramirez G, Couzner L (2010) Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people. Cochrane Database Syst Rev 20(1):CD007624. doi:10.1002/ 14651858.CD007624.pub3 28. Bachmann S, Finger C, Huss A, Egger M, Stuck AE, CloughGorr KM (2010) Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomized controlled trials. BMJ 20:340 29. Auais MA, Eilayyan O, Mayo NE (2012) Extended exercise rehabilitation after hip fracture improves patients’ physical function: a systematic review and meta-analysis. Phys Ther 92(11):1437–1451 30. Singh NA, Quine S, Clemson LM, Williams EJ, Williamson DA, Stavrinos TM, Grady JN, Perry TJ, Lloyd BD, Smith EU, Singh MA (2012) Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial. J Am Med Dir Assoc 13(1):24–30 31. Halbert J, Crotty M, Whitehead C, Cameron I, Kurrle S, Graham S, Handoll H, Finnegan T, Jones T, Foley A, Shanahan M, Hip Fracture Rehabilitation Trial Collaborative Group (2007) Multi-disciplinary rehabilitation after hip fracture is associated with improved outcome: a systematic review. J Rehabil Med 39(7):507–512 32. Adunsky A, Arad M, Levi R, Blankstein A, Zeilig G, Mizrachi E (2005) Five-year experience with the ‘Sheba’ model of comprehensive orthogeriatric care for elderly hip fracture patients. Disabil Rehabil 27(18–19):1123–1127 33. Huusko TM, Karppi P, Avikainen V, Kautiainen H, Sulkava R (2002) Intensive geriatric rehabilitation of hip fracture patients: a randomized, controlled trial. Acta Orthop Scand 73(4):425–431 34. Programma Nazionale Valutazione Esiti. Available at: http://151. 1.149.72/pne11_new/ 35. The National Hip Fracture Database: Available at: http://www. nhfd.co.uk/ 36. Scottish Hip Fracture Audit. Available at: http://www.shfa.scot. nhs.uk/
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POINT OF VIEW
The management of hip fracture in the older population. Joint position statement by Gruppo Italiano Ortogeriatria (GIOG) Giulio Pioli • A. Barone • C. Mussi • L. Tafaro • G. Bellelli • P. Falaschi • M. Trabucchi • G. Paolisso • On behalf of GIOG
Received: 22 October 2013 / Accepted: 16 January 2014 Springer International Publishing Switzerland 2014
Abstract This document is a Joint Position Statement by Gruppo Italiano di OrtoGeriatria (GIOG) supported by Societa` Italiana di Gerontologia e Geriatria (SIGG), and Associazione Italiana Psicogeriatria (AIP) on management of hip fracture older patients. Orthogeriatric care is at present the best model of care to improve results in older patients after hip fracture. The implementation of orthogeriatric model of care, based on the collaboration between orthopaedic surgeons and geriatricians, must take into account the local availability of resources and facilities and should be integrated into the local context. At the same time the programme must be based on the best available evidences and planned following accepted quality standards that ensure the efficacy of the intervention. The position paper focused on eight quality standards for the
management of hip fracture older patients in orthogeriatric model of care. The GIOG promotes the development of a clinic database with the aim of obtaining a qualitative improvement in the management of hip fracture.
G. Pioli (&) Geriatric Unit, Department of Neuromotor Physiology, ASMN-IRCCS Hospital, Via Risorgimento 80, 42100 Reggio Emilia, Italy e-mail: [email protected]
G. Bellelli Geriatric Clinic, San Gerardo University Hospital, Monza, Italy
A. Barone Orthogeriatric Unit, Department of Geriatrics and Musculoskeletal Sciences, Galliera Hospital, Genoa, Italy C. Mussi Division of Gerontology and Geriatrics, University of Modena, Reggio Emilia, Italy L. Tafaro Geriatric Unit, Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy
Keywords fracture
Elderly Orthopaedics Geriatricians Hip
Background Hip fracture is still a devastating event. Epidemiological data show a per-year mortality of over 25 % and an incomplete recovery of pre-fracture conditions in more than 50 % of survivals [1]. In Italy, 90,000 new fracture
P. Falaschi Geriatric Unit, Department of Surgical and Medical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy M. Trabucchi Department of Neuropharmachology, University Tor Vergata, Rome, Italy G. Paolisso Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, II University of Naples, Naples, Italy
G. Bellelli Department of Health Science, University of Milano-Bicocca, Monza, Italy
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events occur per year, with a growing trend coincident to the ageing of the population [2]. Direct costs (including acute in-hospital treatment, post-operative complications, rehabilitation programmes and the use of the health services) and indirect costs (including burden to families related to the patient’s increased, new disability) have been only partially evaluated [2], but they are enormous, and they weigh heavily on the Italian Health Care System. Scientific research puts considerable effort into the development of treatment and interventions that should be able both to reduce the incidence of new fractures and to improve outcomes when fracture has occurred. However, this goal is challenging because of the complexity of dealing with older patients who have incurred fragility fractures, particularly those of the hip. Poor bone health and falls are the main causes of fractures but negative outcomes are generally related to underlying frailty. More than 80 % of patients with hip fracture present two or more comorbidities and/or some impairments to the performance of basic or instrumental activities of daily living [1, 3]. Medical postoperative complications and negative longterm outcomes occur mainly in those patients, who have limited physiologic reserves that are overtaxed by the fracture experience [4, 5]. Therefore, hip fracture is not a single-organ disease, but a complex problem that involves the whole organism, and it needs not only appropriate surgical technique, but also a comprehensive and multidisciplinary approach capable of treating the patient as a whole. Orthogeriatric care generally requires a multidisciplinary approach to older patients with fragility fracture based on the collaboration between orthopaedic surgeons and geriatricians. At present, it is the best model of care to improve results in older patients after hip fracture [6]. The orthopaedic surgeon and geriatrician co-manage the fractured patients and share the responsibility from admission to discharge. Essential members of the multidisciplinary team are also anaesthesiologists, involved mainly in the preoperative phase, and physiatrists and physical therapists during the postoperative phase. Nurses, skilled in the care of elderly patients, are also an important component of the team. Other specialists such as cardiologists, pharmacists, psychologists, social workers, nutritionists and even hospital managers should be involved, when necessary, to guarantee full implementation of a multidisciplinary model of care. Orthogeriatric care is well established as far as hip fracture patients are concerned, but all older patients with fragility fractures might benefit from a collaborative model of care. In particular it should be available to all elderly subjects admitted with fractures such as those of the pelvis, distal femur, legs and humerus, which greatly affect independent deambulation, functional ability and quality of life.
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Table 1 Quality standards of an orthogeriatric model for the care of hip fracture patients Key issues
Standard for the intervention
Responsibility
Combined care of geriatricians and orthopaedic surgeons Multidisciplinary team at each step of the care pathway
Role and skills of the Orthogeriatrician
Senior experience in comprehensive geriatric assessment, in the management of the acute older patient and geriatric syndromes Expertise in the management of medical perioperative complications and delirium Knowledge of factors that identify patients at risk of low recovery and need targeted intervention to prevent complications Knowledge of metabolic bone diseases
Standardization of communication
Written procedure for promoting effective communication between different specialists and the knowledge of their own orders Planning of combined rounds, briefings and meetings
Protocol-driven care
Development of shared protocols based on available evidences regarding the main features of the perioperative phase
Early surgery
Choosing surgery for the majority of patient. Conservative treatment only after a multidisciplinary evaluation and as a result of a shared interdisciplinary choice (quality standard below 4 % of patients) Protocols shared by anaesthesiologist, orthopaedic surgeons and geriatrician for optimizing patients before surgery and ensuring a rapid access to operating theatre. Hip fracture should be ranked as ‘‘delayed urgency’’ (surgery needed within 24–48 h) Availability of designated block time in operating theatres to avoid delays due to system factors
Early mobilization
Surgery performed with goals of stable fixation that allow for immediate weight bearing for all hip fractures Early rehabilitation protocols shared by the orthopaedic surgeon, geriatrician and physiatrist/ rehabilitation therapist Development of protocols for pain relief, management of anaemia, perioperative fluid balance and prevention/treatment of delirium
Aging Clin Exp Res Table 1 continued Key issues
Standard for the intervention
Continuity of care
Multidisciplinary discharge planning to be started early after admission Access to in-hospital and out-patient rehabilitation facilities according to a multidisciplinary rehabilitation plan based on comorbid conditions and pre-fracture functional status. Type and intensity of exercises should be planned to maximize functional recovery regardless of the cognitive level, place of residence (community, nursing homes), and age of the patient
Secondary prevention
and facilities and should be integrated into the local context. At the same time the programme must be based on the best available evidences and planned following accepted quality standards that ensure the efficacy of the intervention (Table 1). Good quality independent guidelines are now available [10–14]. Quality standards of an orthogeriatric model of care for hip fracture patients are the following: •
•
Bone health assessment and pharmacological treatment, as needed, before discharge for all patients Arrangement to ensure a multifactorial fall risk assessment and an individualized intervention if appropriate within the end of postacute/rehabilitant phase
A number of studies have been published in various countries with different trials interventions, populations and outcomes [7]. Given the great heterogeneity of the programmes implemented worldwide, it is not possible to define which model, setting and care organization is the best, in terms of short- and long-term outcomes and cost-effectiveness. However, the simple geriatric-consultant model, characterized by regular reports from a consultant geriatric team to the orthopaedic surgical staff, responsible for overall care, has failed to demonstrate a real beneficial effect on mortality and functional recovery [7]. On the contrary, more complex models, characterised by a multidisciplinary approach involving co-management of patients showed, in randomised-controlled and before-after observational studies, a reduction of acute medical complications, mortality, costs (mainly by shortening hospital stays) and readmissions in the first months after discharge compared to the traditional or simpler models. The orthogeriatric service developed by the Mayo Clinic in Rochester (known as Hip Fracture Program [8, 9]) is the reference model for collaboration based on the co-management of patients by the orthopaedic surgeon and geriatrician and has been adopted in many hospitals of the Unites States and Europe, including Italy.
Quality standards of an orthogeriatric model of care for hip fracture patients The implementation of an orthogeriatric model of care must take into account the local availability of resources
•
•
The geriatrician should be available throughout the whole of the patient’s care pathway, from admission to hospital to the end of the post-acute rehabilitation phase. The geriatrician should be an expert (or senior supervision should be ensured) in comprehensive geriatric assessment and in the management of acute older patients and, in particular, in the management of geriatric syndromes such as delirium, malnourishment or cognitive impairment. Moreover, he/she should be an expert in peri-operative medical complications and management of elderly patients who have undergone surgery, targeting individualized interventions for patients with high risk of complications. All of these skills define a new specialist generally known as ‘‘orthogeriatrician’’. Well-coordinated multidisciplinary teamwork is best achieved if both the orthogeriatrician and the orthopaedic surgeon are senior and at the same hierarchical level [15]. The role of the orthogeriatrician is primarily the perioperative medical management to identify and treat acute medical illness. In the preoperative phase he/she plays a major role in optimizing the patient for surgical intervention when necessary, to avoid delay in surgical repair, while during the postoperative phase he/she acts to avoid and treat medical post-surgical complications. Standardization of the management of the most common features of the perioperative phase is an established way to improve the quality of the intervention and the outcome. Guidelines identify a number of issues whose management should be driven by protocols [12, 13] (Table 2). Only a few protocols are widely implemented in Italian orthopaedic wards. Most of the issues are still managed without standardizing procedures and care. The geriatrician should promote the development of the most important protocols and play an active role to ensure that appropriate care be provided to patients even if it may be relatively time-intensive. Among the protocols still poorly implemented are the role of pain relief, prevention and treatment of delirium and adequate nutritional intake which should be emphasized out since they greatly affect short- and long-term outcomes [16, 17]. Moreover, several features of perioperative
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Aging Clin Exp Res Table 2 Protocols for the standardization of interventions in orthogertiatrics Protocol
Development/feasibility (1)
Resources (2)
Evidence (3)
Dissemination (4)
Delirium
Complex
High
Established
Limited
Pain
Complex
Low
Established
Partial
Incontinence
Simple
Low/medium
Few data
Partial
Nutrition
Complex
High
Established
Limited
Anaemia—blood transfusion
Simple
Low
Controversial
Partial
Oxygen
Simple
Low
Few data
Partial
Thromboprophylaxis
Simple
Low
Established
Widespread
Antimicrobial prophylaxis
Simple
Low
Established
Widespread
Fluid balance
Complex
Low
Few data
Partial
Skin care
Simple
High
Established
Widespread
Constipation Early rehabilitation
Simple Complex
Low Medium
Few data Few data
Partial Partial
(1) Development/feasibility defined by the number of professionals involved (2) Ranked on the basis of resources (mainly working hours) required for implementing the protocol (3) Based on the quality of published studies and on the coherence of available data (4) Dissemination of protocols in Italy derived from a sample survey (restricted present in few centres; partial often present, but in an incomplete form; widely present in almost all centers)
•
•
management are closely interrelated. For example, poor pain control, dehydration and electrolyte disorders are known risk factors for delirium; therefore, a full strategy of delirium prevention includes effective pain relief and an optimal fluid balance. Similarly, early rehabilitation may be affected by non-optimal management of pain, anaemia, fluid volume and orthostatic hypotension [18]. The goal of the orthogeriatric approach is to maximize the proportion of older hip fracture patients that undergo surgical repair within 24–48 h, avoiding unwarranted delays so that they may re-acquire independent deambulatory ability soon after surgery (starting with active mobilization with full weight-bearing on the first postoperative day). In the Italian context hip fracture should be classified as ‘‘delayed urgency’’ (surgery needed within 24–48 h). Hospital managers should organize operating room time to avoid delays due to system factors. Some studies [19, 20] suggested the benefits of a dedicated operating room. However, guidelines recommend prioritization of hip fracture on operating lists and availability of resources for performing surgical repair during normal working hours every day (including weekend or at least Saturdays) [10, 12]. Recent data [21, 22] showed that harmful effects of prolonged immobilization related to delaying surgery occur mainly in the case of frail older people. Subjects with hip fracture and pre-existing disabilities need more aggressive intervention than those without disabilities and may benefit, to a great extent, from shortening
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•
surgery and bed rest time. To achieve this goal in comorbid and complex patients it is necessary to organize effective teamwork for all the clinicians and professionals involved in the patient care pathway (mainly the orthopaedic surgeon, geriatrician, anaesthetist, physiatrist, nurse and physical therapist). Decisions should be taken by all the clinicians not only on the basis of their own experience and responsibilities but also bearing in mind that each competence should be integrated with a view to achieving the best functional outcome for the patient. A comprehensive intervention should be tailored to suit each patient, taking account his/her comorbidities, risk factors and also life quality and functional recovery. Frequent communication is an essential element of good coordinated care and fosters the development of collegial relationships between team members. Key elements of teamwork are daily briefings, regular meetings and collegial discussion of complex cases, along with the appropriate tools (paper charts or electronic medical records) aimed at fostering information sharing. Discharge from the acute care setting is a critical step in the care pathway of elderly hip fracture patients. Lack of coordination in the handover from the hospital to intermediate and community care may lead to fragmentation of care or unsuitable rehabilitation programmes with negative consequences in terms of life quality and functional recovery. A proper rehabilitation programme should be ensured to all patients irrespective of cognitive level and pre-fracture place of residence. Recent studies [23, 24] indicate that post-hip
Aging Clin Exp Res
•
•
fracture rehabilitation might be beneficial also for patients with moderate to severe dementia, indirectly suggesting that dementia could not be viewed as a barrier to pre-fracture walking abilities. Following Cochrane’s statement [25], patients with hip fracture should be offered a coordinated, multidisciplinary rehabilitation programme with the specific aim of regaining sufficient functionality so as to return to their pre-fracture living arrangements. Criteria for effective geriatric physical therapy in terms of intensity and frequency have not been determined [26, 27], but older patients should not be excluded from high-intensity rehabilitation programmes. Meta-analysis [28] showed that inpatient rehabilitation, specifically designed for geriatric patients, seems to have the potential to improve function, admissions to nursing homes and mortality outcomes compared with usual care. Moreover, recent studies [29, 30] revealed the beneficial effect of booster exercising programmes offered beyond the regular rehabilitation period for patients with hip fracture returning into the community. Following fracture, patients are at high risk of entering a vicious cycle in which fear of falling and muscular weakness contribute to relative immobility and lead to a deterioration of the functional status achieved after regular rehabilitation programmes. Extended exercise rehabilitation seems to be effective in maintaining and further improving muscle strength and balance. Discharge planning is the best way to avoid fragmentation and ensure continuity of care [25]. Along with additional post-discharge support, it may also help reduce length of stay and unplanned readmissions to hospital. Discharge planning should be started early after admission and revised regularly during the stay in hospital. The key issues of the discharge plan after hip fracture include timing of discharge, adequate rehabilitation setting, support arrangements for patients who will probably need a higher level of care after rehabilitation and also re-educational interventions. Discharge planning includes ensuring that the patient has access to available services and resources. The complexity of the plan requires that responsibility be shared by a multidisciplinary team including physicians, nurses, physiotherapists and social workers. Patients and their families should also be involved in defining the plan taking their needs and preferences into account. Secondary prevention of fractures including bone health evaluation and fall risk assessment is an essential part of orthogeriatric care. Each patient should be assessed, during the acute or post acute phases, depending on the model implemented, to determine whether she/he needs vitamin D supplementation and
anti-osteoporotic drugs and should be offered multidisciplinary assessment and interventions to prevent future falls. Geriatrician should have a good knowledge of the complex of these assessments; however, in the absence of these skills, patients should be referred to specialized centres.
Conclusive remarks The orthogeriatric model is a methodological approach that can be implemented in different settings and care organization. There is no evidence that the results are significantly affected by the specific implementation setting, such as general orthopaedic wards, dedicated orthogeriatric divisions or even a more complex system based on intensity of care levels [7]. Nevertheless, it must be stressed that older hip fractured patients have a high incidence of medical complications even during the post-acute phase, and their multidisciplinary management must be carried out beyond the immediate post-operative phase [31]. Promising results have been obtained with organizational models based on post-acute rehabilitation wards dedicated to older hip-fractured patients (Geriatric-orthopaedicrehabilitation units, GORU), allowing for early discharge after surgical repair and a significant shortening of inhospital acute stays [32, 33]. The recovery process of the fractured patients is not linear in time. Some good quality studies [29, 30] demonstrated that prolonged interventions, up to 1 year, offer the highest probability of full functional recovery and of longer permanence at home Therefore, all extended rehabilitation programmes, both hospital and community based, mainly in collaboration with general practitioner, are highly desirable. The extended intervention programme should adopt a comprehensive approach to the supervision of the patient’s motor ability, physical activity, nutrition intake, mood states and compliance with medical recommendations and drug therapy and should be able to address any emerging problem early on. Given the importance of hip fracture to the Italian Health System and the quality of life of elderly people, building a monitoring system dedicated to this disease, in the wake of other Countries, is a mandatory objective, which aims at reaching beyond the standards currently established by Programma Nazionale Valutazione Esiti [34]. The GIOG (Gruppo Italiano OrtoGeriatria), on behalf of SIGG (Societa` Italiana di Gerontologia e Geriatria) and AIP (Associazione Italiana Psicogeriatria), promotes and supports the development of a clinic database with the aim of obtaining a qualitative improvement in the management of hip fracture. This strategy, already implemented in the
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United Kingdom [35, 36], permits the optimization of outcomes and qualitative standard related to the management of hip fracture in older patients.
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Conflict of interest The authors have no proprietary interest in any aspect of this statement.
Appendix: The members of Gruppo Italiano Ortogeriatria (GIOG) are: Alimenti Mario, Roma; Annoni Giorgio, Monza; Antonelli Incalzi Raffaele, Roma; Anzivino Fernando, Bologna; Balotta Antonio, Cesena; Barbagallo Mario, Palermo; Barone Antonella, Genova; Bellamoli Claudio, Verona; Bellelli Giuseppe, Monza (Coordinator); Benvenuti Enrico, Firenze; Bernardini Bruno, Rozzano MI; Bianchetti Angelo, Brescia; Bianchi Claudio, Novi Ligure; Bolognesi Anna Giuliana, Piacenza; Bonino Paolo, Aosta; Boscaro Stefania, Vicenza; Boschi Federica, Forlı`; Brugiolo Roberto, Mestre; Calabro` Massimo, Treviso; Camin Marco, Trento; Cappa Giorgietta, Cuneo; Catte Olga, Cagliari; Cavagnaro Paolo, Chiavari; Cecchi Francesca, Firenze; Cirillo Giulio, Forlı`; Cotroneo Antonino, Torino; Coveri Maura, Bologna; Cursi Flavio, Roma; D’Amico Ferdinando, Patti (ME); Davoli Maria Luisa, Reggio Emilia; De Alfieri Walter, Grosseto; De Filippi Francesco, Sondrio; Desideri Giovambattista, L’Aquila; Di Bella Giovanna Palermo; Di Monaco Marco, Torino; Dominguez Ligia Juliana, Palermo; Falaschi Paolo, Roma (Coordinator); Ferrari Alberto Reggio, Emilia; Girardello Renzo, Rovereto (TN); Giusti Andrea, Genova; Greco Antonio, S. Giovanni R (FG); Isaia Giancarlo, Torino; Lunardelli Maria Lia, Bologna; Magnolfi Stefano, Prato; March Albert, Bolzano; Marchionni Niccolo`, Firenze; Marengoni Alessandra, Brescia; Mari Daniela, Milano; Martini Emilio, Bologna; Marzetti Emanuele, Roma; Mitidieri Costanza, Prato; Mussi Chiara, Modena; Nardelli Anna, Parma; Noro Gabriele, Trento; Odetti Patrizio, Genova; Pagani Marco, Rozzano MI; Palummeri Ernesto, Genova; Pellicciotti Francesca, Reggio Emilia; Pioli Giulio, Reggio Emilia; Pula Beatrice, Rimini; Raffaele Angelo, Avezzano; Recchi Domenico, Trento; Romanelli Giuseppe, Brescia; Ruggiero Carmelinda, Perugia; Solinas Antonella, Cagliari; Sterzi Paolo, Cles (TN); Tafaro Laura, Roma; Toigo Gabriele, Trieste; Ungar Andrea, Firenze; Valentini Maurizio, Roma; Zagatti AnnaMaria, Ferrara; Zurlo Amedeo, Ferrara.
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References 16. 1. Maggi S, Siviero P, Wetle T, Besdine RW, Saugo M, Crepaldi G, Hip Fracture Study Group (2010) A multicenter survey on profile
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of care for hip fracture: predictors of mortality and disability. Osteoporos Int 21(2):223–231 Piscitelli P, Iolascon G, Argentiero A, Chitano G, Neglia C, Marcucci G, Pulimeno M, Benvenuto M, Mundi S, Marzo V, Donati D, Baggiani A, Migliore A, Granata M, Gimigliano F, Di Blasio R, Gimigliano A, Renzulli L, Brandi ML, Distante A, Gimigliano R (2012) Incidence and costs of hip fractures vs strokes and acute myocardial infarction in Italy: comparative analysis based on national hospitalization records. Clin Interv Aging 7:575–583 Pioli G, Frondini C, Lauretani F, Davoli ML, Pellicciotti F, Martini E, Zagatti A, Giordano A, Pedriali I, Nardelli A, Zurlo A, Ferrari A, Lunardelli ML (2012) Time to surgery and rehabilitation resources affect outcomes in orthogeriatric units. Arch Gerontol Geriatr 55(2):316–322 Roche JJ, Wenn RT, Sahota O, Moran CG (2005) Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 331(7529):1374 Bellelli G, Noale M, Guerini F, Turco R, Maggi S, Crepaldi G, Trabucchi M (2012) A prognostic model predicting recovery of walking independence of elderly patients after hip-fracture surgery. An experiment in a rehabilitation unit in Northern Italy. Osteoporos Int 23(8):2189–2200 Pioli G, Giusti A, Barone A (2008) Orthogeriatric care for the elderly with hip fractures: where are we? Aging Clin Exp Res 20(2):113–122 Giusti A, Barone A, Razzano M, Pizzonia M, Pioli G (2011) Optimal setting and care organization in the management of older adults with hip fracture. Eur J Phys Rehabil Med 47(2):281– 296 Friedman SM, Mendelson DA, Bingham KW, Kates SL (2009) Impact of a comanaged Geriatric Fracture Center on short-term hip fracture outcomes. Arch Intern Med 12:169(18) Kates SL, Mendelson DA, Friedman SM (2010) Co-managed care for fragility hip fractures (Rochester model). Osteoporos Int 21(Suppl 4):S621–S625 Association of Anaesthetists of Great Britain and Ireland, Griffiths R, Alper J, Beckingsale A, Goldhill D, Heyburn G, Holloway J, Leaper E, Parker M, Ridgway S, White S, Wiese M, Wilson I (2012) Management of proximal femoral fractures 2011: association of Anaesthetists of Great Britain and Ireland. Anaesthesia 67(1):85–98 British Orthopaedic Association, British Geriatrics Society (2007) Care of Patients with Fragility Fracture. London: BOA. Available at http://www.bgs.org.uk/index.php?option=com_con tent&view=article&id=338:bluebookfragilityfracture&catid=47: fallsandbones&Itemid=307 NICE Guidelines 2011. Hip Fracture Program. Available at: http://publications.nice.org.uk/quality-standard-for-hip-fractureqs16/quality-statement-1-hip-fracture-programme Scottish Intercollegiate Guidelines Network (2009) Management of hip fracture in older people. Clinical guideline 111. Edinburgh: SIGN. Available at: http://www.sign.ac.uk/pdf/sign111.pdf Agency for clinical innovation. The orthogeriatric model of care 2010. Available at: http://www.aci.health.nsw.gov.au/__data/ assets/pdf_file/0013/153400/aci_orthogeriatrics_clinical_practice_ guide.pdf National Confidential Enquiry into Patient Outcome and Death (NCEPDO) (2010) A review of the care received by elderly patients undergoing surgery. Available at: http://www.ncepod. org.uk/2010report3/downloads/EESE_fullReport.pdf#search= ’elderlypatientsundergoingsurgery’’ Hung WW, Egol KA, Zuckerman JD et al (2012) Hip fracture management. Tailoring care for the older patient. JAMA 307:2185–2194
Aging Clin Exp Res 17. Bateman L, Vuppala S, Porada P, Carter W, Baijnath C, Burman K, Lee R, Hargus J (2012) Medical management in the acute hip fracture patient: a comprehensive review for the internist. Ochsner J 12(2):101–110 18. Barone A, Giusti A, Pizzonia M, Razzano M, Oliveri M, Palummeri E, Pioli G (2009) Factors associated with an immediate weight-bearing and early ambulation program for older adults after hip fracture repair. Arch Phys Med Rehabil 90(9):1495–1498 19. Elder GM, Harvey EJ, Vaidya R, Guy P, Meek RN, Aebi M (2005) The effectiveness of orthopaedic trauma theatres in decreasing morbidity and mortality: a study of 701 displaced sub capital hip fractures in two trauma centres. Injury 36(9):1060–1066 20. Lemos D, Nilssen E, Khatiwada B, Elder GM, Reindl R, Berry GK, Harvey EJ (2009) Dedicated orthopedic trauma theatres: effect on morbidity and mortality in a single trauma centre. Can J Surg 52(2):87–91 21. Pioli G, Lauretani F, Davoli ML et al (2012) Older people with hip fracture and IADL disability require earlier surgery. J Gerontol A Biol Sci Med Sci 67:1272–1277 22. Bellelli G, Mazzola P, Corsi M, Zambon A, Corrao G, Castoldi G, Zatti G, Annoni G (2012) The combined effect of ADL impairment and delay in time from fracture to surgery on 12-month mortality: an observational study in orthogeriatric patients. J Am Med Dir Assoc 13(7):664.e9-664.e14. doi:10. 1016/j.jamda.2012.06.007 23. Morghen S, Gentile S, Ricci E, Guerini F, Bellelli G, Trabucchi M (2011) Rehabilitation of older adults with hip fracture: cognitive function and walking abilities. J Am Geriatr Soc 59(8):1497–1502. doi:10.1111/j.1532-5415.2011.03496 24. Poynter L, Kwan J, Sayer AA, Vassallo M (2011) Does cognitive impairment affect rehabilitation outcome? J Am Geriatr Soc 59(11):2108–2111. doi:10.1111/j.1532-5415.2011.03658 25. Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL (2013) Discharge planning from hospital to home. Cochrane Database Syst Rev 1:CD000313. doi:10.1002/ 14651858.CD000313.pub4 26. Sherrington C, Tiedemann A, Cameron I (2011) Physical exercise after hip fracture: an evidence overview. Eur J Phys Rehabil Med 47(2):297–307
27. Crotty M, Unroe K, Cameron ID, Miller M, Ramirez G, Couzner L (2010) Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people. Cochrane Database Syst Rev 20(1):CD007624. doi:10.1002/ 14651858.CD007624.pub3 28. Bachmann S, Finger C, Huss A, Egger M, Stuck AE, CloughGorr KM (2010) Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomized controlled trials. BMJ 20:340 29. Auais MA, Eilayyan O, Mayo NE (2012) Extended exercise rehabilitation after hip fracture improves patients’ physical function: a systematic review and meta-analysis. Phys Ther 92(11):1437–1451 30. Singh NA, Quine S, Clemson LM, Williams EJ, Williamson DA, Stavrinos TM, Grady JN, Perry TJ, Lloyd BD, Smith EU, Singh MA (2012) Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial. J Am Med Dir Assoc 13(1):24–30 31. Halbert J, Crotty M, Whitehead C, Cameron I, Kurrle S, Graham S, Handoll H, Finnegan T, Jones T, Foley A, Shanahan M, Hip Fracture Rehabilitation Trial Collaborative Group (2007) Multi-disciplinary rehabilitation after hip fracture is associated with improved outcome: a systematic review. J Rehabil Med 39(7):507–512 32. Adunsky A, Arad M, Levi R, Blankstein A, Zeilig G, Mizrachi E (2005) Five-year experience with the ‘Sheba’ model of comprehensive orthogeriatric care for elderly hip fracture patients. Disabil Rehabil 27(18–19):1123–1127 33. Huusko TM, Karppi P, Avikainen V, Kautiainen H, Sulkava R (2002) Intensive geriatric rehabilitation of hip fracture patients: a randomized, controlled trial. Acta Orthop Scand 73(4):425–431 34. Programma Nazionale Valutazione Esiti. Available at: http://151. 1.149.72/pne11_new/ 35. The National Hip Fracture Database: Available at: http://www. nhfd.co.uk/ 36. Scottish Hip Fracture Audit. Available at: http://www.shfa.scot. nhs.uk/
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