Purpose
Orthogeriatric trauma patients are at risk for functional decline and mortality. It is important to identify high-risk patients in an early stage, to improve outcomes and make better informed ...treatment decisions. The aim of this study was to identify independent risk factors for 30-day mortality in patients aged 85 years or above admitted from the emergency department with a fracture.
Methods
All orthopaedic trauma patients 85 years or above admitted from the emergency department were included. After a 30-day follow-up, mortality was determined by consulting the patient records. Multivariable logistics regression analysis generated odd ratios for mortality risk factors. A subgroup analysis was performed for patients undergoing hip fracture surgery.
Results
The 30-day mortality in geriatric fracture patients admitted to the hospital was 12%. Risk factors for 30-day mortality were: increased age, male sex, decreased hemoglobin levels, living in an institutional care facility and a decreased BMI. For geriatric patients undergoing hip fracture surgery 30-day mortality was 11%. Independent risk factors for this group were: increased age, male sex, and a decreased BMI.
Conclusion
Orthopaedic trauma patients aged 85 years or above who are admitted to the hospital with a fracture are at high risk for mortality. This study identified older age, male sex, and decreased BMI as predictors of 30-day mortality in admitted geriatric fracture patients and in geriatric hip fracture patients undergoing surgery.
ObjectiveThe objective of this study was to explore the experiences from the period after the choice was made for palliative, non-operative management for geriatric patients with a hip fracture, to ...the most important factors in the process, as reported by a proxy.DesignSemistructured interviews were conducted between 1 August 2020 and 1 April 2021 to investigate by-proxy reported patient experiences of non-operative management after hip fracture. Interviews followed a topic guide, recorded and transcribed per word. Thematic analysis was used to identify themes in the data.Setting and participantsPatients were retrospectively identified from the electronic patient record. Relatives (proxies) of the patients who underwent palliative, non-operative management were contacted and were asked to participate in a semistructured interview and were named participants. The participants were proxies of the patients since patients were expected to be deceased during the timing of the interview.ResultsA total of 26 patients were considered eligible for inclusion in this study. The median age of the patients was 88 years (IQR 83–94). The 90-day mortality rate was 92.3%, with a median palliative care period of 11 days (IQR 4–26). A total of 19 participants were subjected to the interview. After thematic analysis, four recurring themes were identified: (1) the decision-making process, (2) pain experience, (3) patient–relative interaction and (4) the active dying.ConclusionsWith the introduction of shared decision-making in an acute setting for geriatric patients with hip fracture, proxies reported palliative, non-operative management as an acceptable and adequate option for patients with high risk of adverse outcomes after surgery. The emerged themes in palliative care for patients with hip fracture show great similarity with severe end-stage disease palliative care, with pain identified as the most important factor influencing comfort of the patient and their environment after hip fracture. Future research should focus on further improving targeted analgesia for these patients focusing on acute pain caused by the fracture.
(1)
Hip fracture patients with very limited life expectancy can opt for non-operative management (NOM) within a palliative care context. The implementation of NOM in the palliative context may affect ...the mortality of the operatively treated population. This retrospective cohort study aimed to determine whether the operatively treated geriatric hip fracture population would have a lower in-hospital mortality rate and fewer postoperative complications after the introduction of NOM within a palliative care context for patients with very limited life expectancy. (2)
Data from 1 February 2019 to 1 February 2022 of patients aged 70 years or older were analyzed to give a comparison between patients before and after implementation of NOM within a palliative care context. (3)
Comparison between 550 patients before and 485 patients after implementation showed no significant difference in in-hospital or 1-year mortality rates (2.9% vs. 1.4%,
= 0.139; 22.4% vs. 20.2%,
= 0.404, respectively). Notably, post-implementation, fewer patients had prior dementia diagnoses (15% vs. 21%,
= 0.010), and intensive care unit admissions decreased (3.5% vs. 1.2%,
= 0.025). (4)
The implementation of NOM within a palliative care context did not significantly reduce mortality or complications. However, NOM within palliative care is deemed a more patient-centered approach for geriatric hip fracture patients with very limited life expectancy.
Introduction:
An aging population in developed countries has increased the number of osteoporotic hip fractures and will continue to grow over the next decades. Previous studies have investigated the ...effect of integrated orthogeriatric trauma units and care model on outcomes of hip fracture patients. Although all of the models perform better than usual care, there is no conclusive evidence which care model is superior. More confirmative studies reporting the efficacy of orthogeriatric trauma units are needed. The objective of this study was to evaluate outcomes of hip fracture patients admitted to the hospital before and after implementation of an orthogeriatric trauma unit.
Materials and methods:
This retrospective cohort study was conducted at a level 2 trauma center between 2016 and 2018. Patients aged 70 years or older with a hip fracture undergoing surgery were included to evaluate the implementation of an orthogeriatric trauma unit. The main outcomes were postoperative complications, patient mortality, time spent at the emergency department, time to surgery, and hospital length of stay.
Results:
A total of 806 patients were included. After implementation of the orthogeriatric trauma unit, there was a significant decrease in postoperative complications (42% vs. 49% in the historical cohort, p = 0.034), and turnaround time at the emergency department was reduced by 38 minutes. Additionally, there was significantly less missing data after implementation of the orthogeriatric trauma unit. After correcting for covariates, patients in the orthogeriatric trauma unit cohort had a lower chance of complications (OR 0.654, 95% CI 0.471-0.908, p = 0.011) and a lower chance of 1-year mortality (OR 0.656, 95% CI 0.450-0.957, p = 0.029).
Conclusions:
This study showed that implementation of an orthogeriatric trauma unit leads to a decrease in postoperative complications, 1-year mortality, and time spent at the emergency department, while also improving the quality of data registration for clinical studies.
Level of Evidence:
Level III.
Objectives: Little is known about the post-operative functional outcomes of severely frail femur fracture patients, with previous studies focusing on complications and mortality. This study ...investigated patient- or proxy-reported outcomes after femur fracture surgery in older adult patients with severe frailty. Methods: This was a retrospective cross-sectional study of older adult (>70 years) patients with severe frailty (defined by a Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) ≥ 0.40), who underwent femur fracture surgery at a Level 1 Trauma Center. Patients or their proxy (i.e., close relative) reported mobility, psychosocial, and functional outcomes at least 1-year after surgery. Results: Thirty-seven predominantly female (76%) patients with a median age of 85 years (IQR 79–92), and a median FI-CGA of 0.48 (IQR 0.43–0.54) were included. Eleven patients (30%) regained pre-fracture levels of ambulation, with twenty-six patients (70%) able to walk with or without assistance. The majority of patients (76%) were able to have meaningful conversations. Of the patients, 54% of them experienced no to minimal pain, while 8% still experienced a lot of pain. Functional independence varied, as follows: five patients (14%) could bathe themselves; nine patients (25%) could dress themselves; fourteen patients (39%) could toilet independently; and seventeen patients (47%) transferred out of a (wheel)chair independently. Conclusions: Despite the high risk of mortality and perioperative complications, many of the most severely frail patients with surgically treated femur fractures regain the ability to ambulate and live with a moderate degree of independence. This information can help healthcare providers to better inform these patients and their families of the role of surgical treatment during goals of care discussions.
The number of geriatric hip fracture patients is high and expected to rise in the coming years, and many are frail and at risk for adverse outcomes. Early identification of high-risk patients is ...crucial to balance treatment and optimize outcome, but remains challenging. Previous research in patients with multitrauma suggested that neutrophil phenotype analysis could aid in early identification of high-risk patients. This pilot study investigated the feasibility and clinical value of neutrophil phenotype analysis in geriatric patients with a hip fracture.
A prospective study was conducted in a regional teaching hospital in the Netherlands. At the emergency department, blood samples were collected from geriatric patients with a hip fracture and analyzed using automated flow cytometry. Flow cytometry data were processed using an automated clustering algorithm. Neutrophil activation data were compared with a healthy control cohort. Neutrophil phenotype categories were assessed based on two-dimensional visual assessment of CD16/CD62L expression.
Blood samples from 45 geriatric patients with a hip fracture were included. Neutrophils showed an increased activation profile and decreased responsiveness to formyl peptides when compared to healthy controls. The neutrophil phenotype of all patients was categorized. The incidence of severe adverse outcome was significantly different between the different categories (
= 0.0331). Moreover, patients with neutrophil phenotype category 0 developed no severe adverse outcomes.
Using point-of-care fully automated flow cytometry to analyze the neutrophil compartment in geriatric hip fracture patients is feasible and holds clinical value in determining patients at risk for adverse outcome. This study is a first step toward immuno-based precision medicine for identifying geriatric hip fracture patients that are deemed fit for surgery.
Medical decision-making for frail geriatric trauma patients is complex, especially toward the end of life. The goal of this paper is to review aspects of end-of-life decision-making, such as frailty, ...cognitive impairment, quality of life, goals of care, and palliative care. Additionally, we make recommendations for composing a patient-tailored treatment plan. In doing so, we seek to initiate the much-needed discussion regarding end-of-life care for frail geriatric patients.
•The frailty index offers insight into multiple systems and is a quantitative measure of frailty, meaning that it can capture the dynamic change of frailty in patients.•The frailty index can be used ...to predict discharge destination from both the hospital and rehabilitation facility, 90-day mortality, and return to home after rehabilitation.•The frailty index can be used to help guide medical decision making and to determine which patients benefit from intensive rehabilitation.
Many geriatric hip fracture patients utilize significant healthcare resources and require an extensive recovery period after surgery. There is an increasing awareness that measuring frailty in geriatric patients may be useful in predicting mortality and perioperative complications and may be useful in helping guide treatment decisions. The primary purpose of the study is to investigate whether the frailty index predicts discharge disposition from the hospital and discharge facility and length of stay.
In this retrospective cohort study, patients aged 65 years and older presenting to a level 1 trauma center with a hip fracture and a calculated frailty index were eligible for inclusion. The primary outcome was discharge disposition. Secondary outcomes were hospital and discharge facility length of stay, 90-day hospital mortality and readmissions, and return to home.
A total of 313 patients were included. The frailty index was a robust predictor of discharge to a skilled nursing facility (OR 1.440 per 0.1 point increase). Patients with a higher frailty index were at higher risk of 90-day mortality and less likely to return to home at the end of follow-up. There was a very weak correlation between the frailty index and hospital length of stay (ρ=0.30) and rehab length of stay (ρ=0.26).
The frailty index can be used to predict discharge destination from both the hospital and rehabilitation facility, 90-day mortality, and return to home after rehabilitation. In this study, the frailty index had a very weak correlation with length of stay in the hospital and in discharge destination. The frailty index can be used to help guide medical decision making, goals of care discussions, and to determine which patients benefit from intensive rehabilitation.
To evaluate the quality of evidence published in geriatric traumatology, to investigate how many studies include patients with cognitive impairment, and to investigate which methods are used to ...determine cognitive impairment.
A search was conducted in PubMed for all publications in English in 154 selected journals between 01/01/2017 and 01/01/2020.
Clinical studies investigating patients 65 years of age and older with fractures in the appendicular skeleton or pelvis were included.
Two independent reviewers performed full-text screening and data extraction for all articles.
A comparative analysis was performed for prospective cohort studies and RCTs. The results are discussed in a narrative review.
A total of 2711 publications were screened for eligibility, and after exclusion, a total of 723 articles were included. There is a focus on retrospective studies investigating mortality and complications. Studies are often small in sample size, and there are relatively few prospective studies, RCT studies, patient-reported outcomes, and quality of life. Patients with cognitive impairment are selectively excluded from clinical studies, and no consensus exists on how cognitive impairment is diagnosed. This review identified pitfalls and provides recommendations to navigate these issues for future studies. Many studies exclude cognitively impaired patients, which may result in selection bias and inability to extrapolate results. The lack of use of objective measures to define cognitive impairment and lack appropriate outcome measures for the cognitively impaired is an important issue that needs to be addressed in future research.
The preoperative phase is a potential window of opportunity. Although frail elderly patients are known to be more prone to postoperative complications, they are often not considered capable of ...accomplishing a full prehabilitation program. The aim of this study was to assess the feasibility of Fit4SurgeryTV, an at-home prehabilitation program specifically designed for frail older patients with colorectal cancer.
The Fit4SurgeryTV program consisted of a daily elderly adapted computer-supported strength training workout and two protein-rich meals. Frail patients 70 yrs or older with colorectal cancer were included. The program was considered feasible if 80% of the patients would be able to complete 70% of the program.
Fourteen patients (median age, 79 yrs; 5 males) participated. At baseline, 86% patients were physically impaired and 64% were at risk for malnourishment. The median duration of the program was 26 days. The program was feasible as patients followed the exercises for 6 (86%) of 7 days and prepared the recipes 5 (71%) of 7 d/wk. Patients specifically appreciated at-home exercises.
This study showed that at-home prehabilitation in frail older patients with colorectal cancer is feasible. As a result, patients might be fitter for surgery and might recover faster. The perioperative period could serve as a pivotal time point in reverting complications of immobility.
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