Assessing frailty in elderly patients with hip fractures: A retrospective review comparing geriatrician and orthopedic trainee assessments.

To assess the correlation of orthopedic surgery residents compared with expert geriatricians in the assessment of frailty stage using the Clinical Frailty Scale (CFS) in patients with hip fractures. A retrospective chart review was performed from January 1, 2015 to December 31, 2019. Patients admitted with a diagnosis of hip fracture were identified. Those patients with a CFS score completed by orthopedic residents with subsequent CFS score completed by a geriatrician during their admission were extracted. Six hundred and forty-eight patients over age 60 (mean 80.5 years, 73.5% female) were admitted during the study period. Orthopaedic residents completed 286 assessments in 44% of admissions. Geriatric medicine consultation was available for 215 patients such that 93 patients were assessed by both teams. Paired CFS data were extracted from the charts and tested for agreement between the 2 groups of raters. CFS assessments by orthopedic residents and geriatrician experts were significantly different at P < .05; orthopedic residents typically assessed patients to be one CFS grade less frail than geriatricians. Despite this, the CFS assessments showed good agreement between residents and geriatricians. Orthopaedic surgery residents are reliable assessors of frailty but tend to underestimate frailty level compared with specialist geriatricians. Given the evidence to support models such as orthogeriatrics to improve outcomes for frail patients, our findings suggest that orthopedic residents may be well positioned to identify patients who could benefit from such early interventions. Our findings also support recent evidence that frailty assessments by orthopedic surgeons may have predictive validity. Low rates of initial frailty assessment by orthopedic residents suggests that further work is required to integrate more global comprehensive care.

Comprehensive geriatric assessment: outcomes of an advanced nurse practitioner-led service for older people requiring emergency surgery.

A comprehensive geriatric assessment (CGA) is a holistic multidimensional review of older people living with frailty or at risk of frailty. In emergency surgical settings, CGAs can be used to identify medical issues and geriatric syndromes among older patients and consequently try to improve their post-operative outcomes. However, there is a lack of geriatrician input in hospitals beyond medical wards, which means that older people who need emergency surgery do not always undergo a CGA, with potential negative repercussions for their post-operative outcomes. One solution to this issue is to employ advanced nurse practitioners (ANPs) to deliver equivalent services. This article presents and discusses the results of an audit of an ANP-led CGA service for older people admitted to hospital for emergency surgery. The ANP reviewed 147 patients during the audit period and identified frailty in 37% and new medical issues in 89% of patients. Interventions initiated by the ANP based on the CGA included requests for additional investigations, referral to allied health professionals and discharge planning. The audit results suggest that ANPs can conduct CGAs in emergency surgical settings effectively.

A cross-sectional study of knowledge and practices in the management of patients with Parkinson's disease amongst public practice-based general practitioners and geriatricians.

BACKGROUND: As most patients are likely to first interface with their community general practitioner (GP) or geriatrician for chronic healthcare conditions, these non-neurologists practitioners are well-placed to diagnose, initiate treatment in symptomatic Parkinson's disease (PD) patients, and provide regular and timely management of their PD. However, current studies suggest that the role of the GP and geriatrician in providing holistic care for PD patients may be limited by factors such as patient perceptions, and a lack of knowledge base in the quality measures of care. This paper aims to better understand the different management styles between GPs and geriatricians practicing in public institutions in Singapore, qualify the difficulties they face in providing patient-centric care for PD patients, and identify any gaps in quality measures of care. METHODS: A questionnaire was completed anonymously by GPs (n = 43) and geriatricians (n = 33) based at public institutions, on a voluntary basis before a compulsory didactic teaching on PD. Questions were modelled after quality measures set out by the American Academy of Neurology, specifically eliciting information on falls, non-motor symptoms, exercise regime and medication-related symptoms. "PD management practices and styles" questions were answered by the respondents on a 4-point Likert scale. RESULTS: Geriatricians spent more time in consult with PD patients compared with GPs (median [Q1-Q3] = 20 [15-30] vs 10 [10-15] minutes, p <  0.001). Geriatricians were more comfortable initiating PD medications than GPs (OR = 11.8 [95% CI: 3.54-39.3], p <  0.001), independent of gender, years of practice and duration of consult. Comfort in initiating dopamine replacement therapy (OR 1.06 [1.00-1.36], p = 0.07; aOR = 1.14 [1.02-1.26], p = 0.02) also increased with physician's years of practice. Unfamiliarity with the types and/or doses of the medications was the most cited barrier faced by GPs (76.7%). Geriatricians were more likely than GPs to ask about falls (100% vs 86.0%, p = 0.025), non-motor symptoms (75.8% vs 53.5%, p = 0.049) and the patient's regular physical activities (72.7% vs 41.9%, p = 0.01). CONCLUSIONS: This study identified key patterns in the management practices and styles of non-neurologists physicians, and identified gaps in current practice. Our data suggests that interventions directed at education on PD medication prescriptions and provision of patient PD education, creation of best clinical practice guidelines, and accreditation by national bodies may instil greater confidence in practitioners to initiate and continue patient-centric PD care. A longer consultation duration with PD patients should be considered to allow physicians to get a greater scope of the patient's needs and better manage them.

Integrating assessment of cognitive status in elderly cardiovascular care.

Cardiovascular clinicians tend to pay little attention to issues related to cognition, and yet those caring for older adults will encounter a variety of conditions that may lead to cognitive impairment. Most commonly, these include cardiovascular disease-specific conditions such as cerebrovascular disease or heart failure, but may also include neurodegenerative conditions, mood disorders, medication side effects and polypharmacy, and nutritional deficiencies and metabolic derangements among others. This review presents evidence supporting the importance of assessing cognitive status in older adults with cardiovascular disease, and suggests a practical approach to assessment and management of cognitive impairment in this population when it is found. Special attention is paid to the importance of collaboration between cardiovascular and geriatric specialists, and the value it may bring to patients.

Are we on the same page? Exploring the role of the geriatrician in the care of the older surgical patient from the perspective of surgeons and geriatricians.

There is increasing recognition that the ageing population represents a challenge to existing surgical services. National reports recommend that geriatricians proactively review older surgical patients to improve care and outcomes. However, this approach has not been widely translated into practice. A qualitative study was conducted using 12 semi-structured interviews of surgeons and geriatricians to explore the role of the geriatrician in the care of older surgical patients. Participants agreed that the current system did not meet the needs of older surgical patients. Geriatricians valued their holistic way of working but these generalist skills can overlap with other specialties, seen by some as wasting resources. Three models of care were proposed, with the ownership and location of the patient as well as the role of education being the key variables. The main obstacle preventing integrated working was the concern of de-skilling the surgeons, narrowing their role to that of a 'technician'. Other barriers included loss of autonomy; lack of evidence; and a lack of recognition of the need for a geriatrician. There is acceptance that closer working practices are necessary to meet the needs of this complex patient group but a lack of evidence, together with significant human factors, are challenges that must be addressed to realise this aim.

Safe working in a 7-day service. Experience of hip fracture care as documented by the UK National Hip Fracture Database.

Objective: to describe differences in care and 30-day mortality of patients admitted with hip fracture on weekends (Saturday-Sunday) compared to weekdays (Monday-Friday), and their relationship to the organisation of care. Methods: data came from the National Hip Fracture Database (NHFD) linked to ONS mortality data on 52,599 patients presenting to 162 units in England between 1 January and 31 December 2014. This was combined with information on geriatrician staffing and major trauma centre (MTC) status. 30-day mortality and care were compared for patients admitted at weekends and weekdays; separately for patients treated in units grouped by the mean level of input by geriatricians, weekend geriatrician clinical cover and MTC status. Differences were adjusted for variation in patients' characteristics. Results: there was no evidence of differences in 30-day mortality between patients admitted at weekends compared to weekdays (7.2 vs 7.5%, P = 0.3) before or after adjusting for patient characteristics in either MTCs or general hospitals. The proportion receiving a preoperative geriatrician assessment was lower at weekends (42.8 vs 60.7%, P < 0.001). 30-day mortality was lower in units with higher levels of geriatrician input, but there was no weekend mortality effect associated with lower levels of input or absence of weekend cover. Conclusion: there was no evidence of a weekend mortality effect among patients treated for hip fracture in the English NHS. It appears that clinical teams provide comparably safe and effective care throughout the week. However, greater geriatrician involvement in teams was associated with overall lower mortality.

Prehabilitation: a new area of integration between geriatricians, anesthesiologists, and exercise therapists.

Surgery in combination with risk factors such as poor physical and nutritional status have detrimental effects on short- and long-term aspects of recovery and quality of life, especially in elderly patients whose functional reserve is limited. Strategies to minimize these effects and accelerate return to baseline levels have focused on the intra- and post-operative period; however, this may not be the most opportune time to intervene. Instead, the preoperative period may be a more emotionally salient and physically enabling time to initiate an intervention aimed at attenuating surgical stress and enhancing recovery after surgery. The process of increasing patients' functional reserve in anticipation for surgery is referred to as prehabilitation. Elements of surgical prehabilitation programs include a structured exercise program consisting of both resistance and aerobic training, supplemented by flexibility exercises and nutritional optimization through counselling and supplementation. In general, individuals who are the least fit and the most sedentary have shown the most improvement when they initiate an exercise program. Since their physiologic reserve is limited, even small amounts of physical training can yield significant improvements. The interaction of physical activity and nutrition promotes anabolism, thereby preparing patients to better withstand the stress of surgery and subsequently mitigating the impact on postoperative outcome.

Tumour boards in geriatric oncology.

Multidisciplinary tumour board is an integral part of cancer treatment planning. Although no definite survival benefits have yet been shown by mostly observational studies, other benefits of multidisciplinary tumour board have been identified. Traditionally the multidisciplinary tumour board involves participation of treating clinicians-medical, radiation and surgical oncologists. They tend to focus on the cancer alone. There is an increasing awareness that the treatment goal for cancer in older adults is not primarily on prolonging survival, with functional preservation and quality of life being particularly important for this population. The use of Comprehensive Geriatric Assessment and the input of the geriatrician in informing the oncologists regarding treatment decision have increasingly been shown to be beneficial. The integration of the geriatrician into the multidisciplinary tumour board should be urgently explored.

A multi-centre randomised trial to compare the effectiveness of geriatrician-led admission avoidance hospital at home versus inpatient admission.

BACKGROUND: There is concern that existing models of acute hospital care will become unworkable as the health service admits an increasing number of frail older people with complex health needs, and that there is inadequate evidence to guide the planning of acute hospital level services. We aim to evaluate whether geriatrician-led admission avoidance to hospital at home is an effective alternative to hospital admission. METHODS/DESIGN: We are conducting a multi-site randomised open trial of geriatrician-led admission avoidance hospital at home, compared with admission to hospital. We are recruiting older people with markers of frailty or prior dependence who have been referred to admission avoidance hospital at home for an acute medical event. This includes patients presenting with delirium, functional decline, dependence, falls, immobility or a background of dementia presenting with physical disease. Participants are randomised using a computerised random number generator to geriatrician-led admission avoidance hospital at home or a control group of inpatient admission in a 2:1 ratio in favour of the intervention. The primary endpoint 'living at home' (the inverse of death or living in a residential care setting) is measured at 6 months follow-up, and we also collect data on this outcome at 12 months. Secondary outcomes include the incidence of delirium, mortality, new long-term residential care, cognitive impairment, activities of daily living, quality of life and quality-adjusted survival, length of stay, readmission or transfer to hospital. We will conduct a parallel economic evaluation, and a process evaluation that includes an interview study to explore the experiences of patients and carers. DISCUSSION: Health systems around the world are examining how to provide acute hospital-level care to older adults in greater numbers with a fixed or shrinking hospital resource. This trial is the first large multi-site randomised trial of geriatrician-led admission avoidance hospital at home, and will provide evidence on alternative models of healthcare for older people who require hospital admission. TRIAL REGISTRATION: ISRCTN60477865 : Registered on 10 March 2014. Trial Sponsor: University of Oxford. Version 3.1, 14/06/2016.