Aspects of physical medicine and rehabilitation in geriatrics.

Specialists in physical medicine and rehabilitation are important partners during the ageing process: health promotion and prevention for fit elderly people, training and rehabilitation for prefrail people and support for frail people focusing on usage of what is left and dignity in the latest period of life. The main focus is the relationship between IC diagnoses and functioning in everyday life based on the International Classification of Functioning (ICF). The diseases lead to possible treatments; functioning shows the importance of rehabilitative strategies in a team approach. Physiatrists are experts on this complex issue.The main goal of rehabilitative strategies during life course is to maintain function, improve quality of life and delay dependency and need of care.Three settings are chosen to show the different aspects of physical medicine and rehabilitation: health promotion and prevention, rehabilitation and palliative-rehabilitative procedures in long-term care. The non-pharmaceutical treatment of pain, the geriatric assessment, knowledge in discharge management and team communications are important skills.

[Procedural organisation: surgical and anaesthesiological management in hip fractures]. / Ablauforganisation - unfallchirurgisches und anästhesiologisches Management bei Hüftfrakturen.

In patients with hip fractures, in order to reduce the high number of general complications and those associated with the specific treatment, the functional loss and cognitive impairment, implementation of co-ordinated, multidisciplinary treatment pathways, and rehabilitation, is mandatory. The imminent treatment of proximal femoral fracture consists of major orthopaedic surgery in most cases (total or partial hip arthroplasty, osteosynthesis). After the diagnosis of a hip fracture, an adequate pain medication should be initiated. The decision making for the fracture treatment includes fracture type, patient's age, cognitive function, mobility before the fall and functional demands of the patient in the context of patients life expectancy and goals of care. The anaesthesiological evaluation focuses on risk assessment. Medical abnormalities should be optimized within 24 to 48 h, or an increased perioperative risk due to comorbidities has to be accepted. The timing and the course of further preoperative diagnostic examinations and therapeutic interventions should be co-ordinated between the involved medical disciplines. After the operation a structured screening for delirium should be initiated and further evaluation of patient's nutrition, fall-associated medication, living conditions and osteoporosis treatment has to be performed.

Rehabilitation after hip fracture.

Low-trauma hip fracture in old age leads to impairment, increased need of care and mortality. Rehabilitation should start in the department for traumatology and accompany the patient through different settings until the pretraumatic status is reached. Besides the surgical procedure and the medical management of an aged person with complex disease and polypharmacy, the multidisciplinary rehabilitation process is an important factor for regaining ability for self-care and autonomous decisions. Pain management supports the process. The ideal setting is not clear yet. Besides established rehabilitation facilities for elderly people, including the departments for 'Akutgeriatrie/Remobilisation', the 'Outreach Geriatric Remobilisation' project offers new perspectives. It was designed to remobilise patients with multimorbidity in their own homes.

Treatment and prevention of postoperative complications in hip fracture patients: infections and delirium.

The course of older patients with hip fractures is often complicated by infections and delirium. Accurate care and high suspicion for these complications are essential, since these conditions are associated with an increase in mortality, length of hospital stay and nursing home placement, poorer mobility, and functional decline. Because of immunosenescence and higher infection rates, older patients need specific care, immediate diagnosis, and treatment of infections. Numerous guidelines of various medical societies outline the management of nosocomial infections, but there is a need of an individualized treatment plan because of comorbidities and polypharmacy. Hygiene measures have first priority to reduce the rate of infections. Treatment of geriatric syndromes like malnutrition, exsiccosis, gait disorders, falls, delirium, urine incontinence, and organ insufficiency are as important as immunization against pneumococci and influenza. Advanced age, cognitive impairment, hearing loss, peripheral vascular disease, prior delirium episodes, sight disorders, and polypharmacy are established risk factors for delirium; thus, older people with several chronic diseases are prone to delirium. A multifactorial approach, comprising standardized screening, oxygen support, intravenous fluid administration and augmented nutrition, monitoring of vital signs, pain treatment, optimized medication, and modification in perioperative management, significantly reduces delirium incidence during hospitalization for hip fracture. An interdisciplinary approach between surgeons and geriatricians may warrant optimized satisfaction of patients' needs.

Development and validation of a patient safety culture questionnaire in acute geriatric units.

BACKGROUND: Older patients (≥65 years) are exposed to more harm resulting from adverse events in hospitals than younger patients. Theoretical considerations and empirical findings suggest that safety culture is the key to improving the quality of health care. OBJECTIVE: To describe the development of a German-language instrument for assessing patient safety culture (PSC) and its reliability and validity; to verify criterion validity by means of a cross-sectional analysis of the impact of PSC on clinical quality that compares acute geriatric units with a sample from intensive care, surgery and trauma surgery departments, and to report variations in the PSC profile between these groups. METHODOLOGY: Using a review of existing safety culture surveys, multidimensional scaling procedures and expert interviews, we tested the content and convergent validity of a 158-item questionnaire completed by 508 physicians and nurses from 31 acute geriatric units and 7 comparison departments. Criterion validity was verified by various regression models with a self-reported measure of adverse events. Differences in PSC profiles were analyzed using a one-factorial ANOVA and regression models. RESULTS: We identified 7 constructs of PSC and demonstrated substantial convergent and criterion validity. In the acute geriatric units, higher levels of 'management commitment to patient safety' and lower levels of 'error fatalism' were associated with a reduced incidence of medical errors. In the comparison group, only the variable 'active learning from mistakes' was relevant for safety performance. Our results also indicate that acute geriatric units display higher standards than the comparison group in all the aspects of patient safety examined. CONCLUSION: It is possible to measure salient features of PSC using a valid and reliable survey. Some aspects of PSC are more closely related to safety events than others. In acute geriatric units, patient safety appears to be influenced mainly by management's determination of how things are done whereas improvement of the system itself in a more incremental manner is required in the other high-risk ward types.

[Problems of pain measurement and pain therapy in the elderly]. / Problemfelder in der Schmerzmessung und Schmerztherapie im Alter.

Due to complex physical and psychological changes in aging, pain measurement and therapeutic treatment of older and geriatric patients present a special challenge. Nevertheless, even for this category of patients, good treatment results are achievable if age-related particulars and problems are consistently heeded and accounted for. That includes adverse sensory and cognitive effects as much as multimorbidity and the polypharmacy that is frequently related to it. An essential prerequisite for adequate pain therapeutic care in elderly patients is consistent pain measurement. While numerical and verbal scales have also proven their usefulness for patients in advanced age who are not cognitively impaired, instruments must be applied for older people with communicative and/or cognitive restrictions with which the observed behavior of those involved can be surveyed in a multidimensional way.