Three-year National report from the Gruppo Italiano di Ortogeriatria (GIOG) in the management of hip-fractured patients.

BACKGROUND: Hip fractures (HF) are a major issue worldwide. We aimed at evaluating the practices in delivering care to patients with HF among several Italian Orthogeriatric centers. METHODS: The study took place from February 2016 to July 2018. Seven performance indicators (pre-surgical cognitive assessment, surgery performed ≤ 48 h from fracture, removal of urinary catheter/absence of delirium/start of physiotherapy on the first post-operative day, prescription of bone protection at discharge, and discharge toward rehabilitation) were collected. RESULTS: The 14 participating hospitals totally recruited 3.017 patients. Patients were old (median age 86 years; Inter Quartile Range [IQR] 80-90), mostly females (77%). Nearly 55% of them were already impaired in mobility and about 10% were nursing home residents. Median time-to-surgery was 41 h (IQR 23-62). Models of care greatly varied among centers, only 49.3% of patients being co-managed by geriatricians and orthopedics. There was high variability across centers in four indicators ("pre-surgical cognitive assessment", "bone protection prescription", "use of urinary catheter" and "start of physiotherapy"), moderate in two indicators ("surgery performed ≤ 48 h from fracture" and "discharge toward rehabilitation" and low in one ("absence of delirium on day following surgery"). Comparison with international studies suggests very different ways of providing care to HF Italian patients. CONCLUSIONS: The study results suggest high inter-center variability in the key-performance indicators, and different approaches in providing care to our HF patients in comparison to other countries. A National debate on the topic is required in Italy to harmonize practices of orthogeriatric care.

Simultaneous bilateral femoral neck fracture and end-stage renal disease in a 76-year-old woman: a case report.

Hip fracture is a common occurrence in the elderly. Due to the growing demand for the specific care of these patients, we established the Orthogeriatric Unit (OGU) at San Gerardo University Hospital (Italy) in 2007. However, simultaneous bilateral femoral neck fractures among the geriatric population (those aged ≥65 years) are rarely reported in the literature. Reporting the rare case of a frail 76-year-old woman admitted with bilateral hip fracture and end-stage renal disease, we explain the important role played by the OGU and its flexible multidisciplinary approach for providing comprehensive care to patients with multimorbidity and clinical complexity. The team of geriatricians, orthopedic surgeons, anesthesiologists, and, in this case, a nephrologist, helped in the careful planning and timing of the single-step surgical repair, decided the appropriate type of anesthesia, and optimized outcomes. After a prompt evaluation of the patient, the OGU approach can achieve clinical stabilization prior to intervention. Along with a strict follow-up in the postoperative phase, this could result in a significant reduction of complications and mortality rates and an early start to a tailored rehabilitation process. We strongly suggest employing facilities with multidisciplinary teams for cases involving complex patients at short-term high risk for poor clinical outcomes. Indeed, the usual single-specialist model of care is gradually being abandoned worldwide.

Postoperative delirium and pre-fracture disability predict 6-month mortality among the oldest old hip fracture patients.

BACKGROUND: Age is one of the most robust risk factors for hip fracture. Recent projections indicate that almost half of hip fractures are occurring with an increasing trend among the "oldest old" (i.e., in those aged >85 years). AIMS: To compare clinical characteristics, outcomes, and risk factors for 6-month mortality in two groups of "oldest old" patients (group 1 = 85-89, group 2 > 90 years), after hip fracture surgery. METHODS: Observational prospective cohort study with 6-month follow-up, performed in an Orthogeriatric Unit of an academic hospital between March 2007 and November 2012. RESULTS: Two hundred seventy-five patients (group 1: N = 171; group 2: N = 104) underwent a comprehensive geriatric assessment, including demographics, clinical, functional, nutritional, and mental status. The 6-month rehospitalization and mortality rates after surgery were assessed through structured telephone interviews with patient's caregivers. Multivariate logistic regression models were used to evaluate predictors of 6-month mortality, adjusting for relevant covariates. Fifty-eight patients died at follow-up. The in-hospital and 6-month mortality rates were significantly higher for patients of group 2 than for those of group 1. After adjusting for covariates, the multivariate logistic regressions showed that severe disability (OR 2.24, 95 % CI 1.08-4.65) and postoperative delirium (POD) (OR 3.80, 95 % CI 1.72-8.39) were predictors of 6-month mortality. CONCLUSIONS: Patients aged >90 years who underwent hip fracture surgery are more likely to die at 6 months than those aged 85-89 years. Pre-fracture disability and POD are predictors of this excess of mortality.

Functional and clinical outcomes of patients aged younger and older than 85 years after rehabilitation post-hip fracture surgery in a co-managed orthogeriatric unit.

AIM: Literature investigating rehabilitation outcomes after hip surgery among individuals aged ≥85 years is sparse. We compared the characteristics and outcomes of patients aged under and over 85 years, and assessed factors potentially associated with rehabilitation success as described by the Barthel Index (BI). METHODS: From 2011 to 2014, we prospectively enrolled 328 patients (n = 152 aged <85 years, n = 176 aged ≥85 years) admitted to an orthogeriatric unit (Sondrio, Italy) with a diagnosis of hip fracture requiring surgical treatment. We excluded patients who were being treated conservatively. Outcomes included absolute functional gain (AFG; BI at discharge - BI on admission), rehabilitation effectiveness index (AFG / length of stay) and postoperative complications. RESULTS: Older patients were more functionally (mean BI on admission: 11.7 ± 9.6 vs 16.4 ± 12.2, P < 0.001) and cognitively impaired than their younger counterparts (34.1% vs 18.4%, P < 0.001). Surgery time (1.9 ± 1.2 vs 2.3 ±1.3 days, P = 0.008) and length of stay were shorter for older patients (5.7 ± 2.1 vs 6.6 ± 2.4 days, P < 0.001). There were no differences in terms of complications. Patients aged <85 years showed better functional outcomes (BI, AFG, REI) at discharge than patients aged ≥85 years (mean AFG: 38.2 ± 24.2 vs 26.1 ± 22.0, P < 0.001). BI on admission (OR 1.05, 95% CI 1.02-1.08) and cognitive impairment (OR 0.58, 95% CI 0.34-0.98) were independently associated with rehabilitation outcomes, regardless of chronological age. CONCLUSIONS: Both groups (aged <85 and ≥85 years) showed a significant functional improvement at discharge. Older patients show a residual ability to recover after surgery. A high rehabilitation efficiency - regardless of age - should be pursued even for the oldest old patients experiencing hip fracture. Geriatr Gerontol Int 2018; 18: 1194-1199.

Italian intersociety consensus on prevention, diagnosis, and treatment of delirium in hospitalized older persons.

Delirium is a severe neuropsychiatric syndrome characterized by inattention and global cognitive dysfunction in the setting of an acute medical illness, medical complication, drug intoxication, or drug withdrawal. The most important risk factors are advanced age and dementia, whereas pain, dehydration, infections, stroke, metabolic disturbances, and surgery are the most common triggering factors. Although delirium is a common clinical syndrome in different settings of care (acute care hospitals, inpatient rehabilitation facilities, nursing homes, and hospices), it often remains under-recognized, poorly understood, and inadequately managed. There exists a clear need for improved understanding to overcome cultural stereotypes, and for the development and dissemination of a comprehensive model of implementation of general good practice points. A network of Italian national scientific societies was thus convened (1) to develop a collaborative multidisciplinary initiative report on delirium in elderly hospitalized patients, (2) to focus the attention of health care personnel on prevention, diagnosis, and therapy of patients suffering from delirium, and (3) to make the health services research community and policy-makers more aware of the potential risks of this condition providing a reference for training activities and data collection.

Study of respiratory function in the elderly with different nutritional and cognitive status and functional ability assessed by plethysmographic and spirometric parameters.

From a sample of 265 elderly subjects (age 80.2 +/- 6.8 years) admitted to a geriatric care unit, free from cardiac and respiratory diseases, with normal chest X-ray and gas analysis, 53 subjects were selected and their respiratory functions (assessed by spirometric parameters and airway resistance 'Raw') were studied to correlate them with nutritional status, cognitive impairment, independence in everyday life activities and mood disorders, assessed, respectively, by the Mini Nutritional Assessment, rapid Mini Mental State test (MMSr), activities of daily living (ADL), instrumental activities of daily living (IADL) evaluation, Barthel Index and Cornell Depression Scale. The enrolled subjects were able to perform normally a forced expiration, although most of them committed errors in this test, according to the American Thoracic Society (ATS) criteria. Thus, about 32% started at lung volume0.12 s); in 62% of the subjects expiration time was too short and in 58% the terminal plateau was <2 s. Nevertheless, the spirometric parameters (and Raw) were considered normal. Forced vital capacity and peak expiratory flow (but not FEV1) were higher in the subjects without disability, while cognitive and nutritional status did not seem to have any influence on spirometric performance; MMSr score was related to compliance with ATS criteria for acceptability of the forced manoeuvre; mental and mood disorders, nutritional conditions and disability did not seem to have any influence on error rates. Our data show that our geriatric enrolled patients were able to perform an imperfect, often unfinished, but acceptable forced expiration; dynamic index values were related to disability, while the errors in starting the test were related to the mental conditions.

A comparison between two co-managed geriatric programmes for hip fractured elderly patients.

BACKGROUND AND AIMS: Hip fracture in older people is an event associated with a high incidence of morbidity and mortality. In this study we compared the clinical outcomes of two groups of orthogeriatric patients in an orthogeriatric care (OC) programme. The OC course, developed into the GeriatricWard, starts from the Emergency Department (OC-1, n=174) or from the Orthopaedic Department after surgery (OC-2, n=87). METHODS: For this purpose, OC patients were prospectively enrolled from March 2007 to June 2009, following OC criteria. Door-to-bed time, time to surgery, mobilisation time, length of stay, and post-operative complications were compared between the OC groups. RESULTS: OC-1 patients differ from OC-2 ones only for residence at admission (14.4% vs 4.6% lived in nursing homes, p=0.02). Concerning outcomes, in the OC-1 group only mobilization time was significantly lower (p=0.01). No differences were observed in post-operative complications. CONCLUSIONS: In frail older people, hip fracture co-management, with the geriatrician as primary attendant, leads to satisfying outcomes. The OC-1 and OC-2 courses exhibit similar clinical results. An improvement in several organisational aspects, including coordination between hospital and rehabilitation services, is warranted.