We talk a lot about delirium after hip fracture, but what can we do about it?

Dr. Susan Freter is an Associate Professor of Medicine at Dalhousie University, and a staff geriatrician at the Nova Scotia Health Authority in Halifax, Canada.  She has a special interest in delirium prevention and management in orthopaedic patients.  

Geriatricians talk a lot about post-operative delirium.  It is common after surgeries, especially in people with a lot of risk factors (or we could say, especially in the presence of frailty), and even with recovery it makes for a bad experience.  The occurrence of hip fracture, which mostly befalls patients who are older and frail, demonstrates this routinely.  We know that taking extra care with at-risk patients can help to prevent delirium.  Taking extra care can manifest in different forms: educating the caregivers, paying attention to hydration (is the patient actually drinking the cup of water that is plonked down in front of them?), paying attention to constipation (preferably before a week has gone by), making sure hearing aids are in the ears, and using medication doses that are geared for frailty, rather than for strapping 20 year olds. But how can what we talk about be translated into what we do? Does the ‘doing’ actually work in practice?

How do geriatricians improve outcomes after hip fracture?

Jenny Neuburger is a Senior Research Analyst at the Nuffield Trust  (@NuffieldTrust) and a Visiting Research Fellow at the London School of Hygiene & Tropical Medicine. She and her co-authors have recently published research in Age and Ageing journal.

We have just published a paper showing that geriatrician involvement in hip fracture care can improve patient outcomes.  Patients treated on wards with higher numbers of geriatrician hours tended to have lower mortality within the 30 days after presentation.

We measured geriatrician hours worked in orthopaedic departments using data collected via the National Hip Fracture Database annual survey each year from 2010 to 2013 for English hospitals.  Over this period, geriatrician hours increased from 1.5 to 4.0 hours per patient, reflecting investments made in response the financial incentives introduced under the Best Practice Tariff scheme.

Can We Choose Wisely?

Dr Ramai Santhirapala is an Honorary Consultant in Anaesthesia and Perioperative Medicine at Royal Surrey County Hospital and a Clinical Advisor at the Academy of Medical Royal Colleges. In the latter role she advises on the international programme ‘Choosing Wisely’, which aims to improve conversations between healthcare providers and patients. Dr Santhirapala’s specialist interests are shared decision making and end of life care, believing patients should lie at the heart of healthcare decisions. She has published in the British Journal of Anaesthesia and Perioperative Medicine and is undertaking research into educational needs for physicians to practice shared decision making. She tweets at @ramai23

Shared decision making (SDM) is increasingly synonymous with healthcare, moving away from paternalism towards a balanced approach to decision making involving both patients and clinicians. What exactly is SDM? That is the ubiquitous question to which there is currently no universally agreed answer. The King’s Fund intimates a definition pointing out SDM is a process during which patients and physicians use evidence based information to support the deliberation process based on patients’ values, beliefs and preferences. This highlights that a physician is still expected to bring clinical expertise, whilst a patient brings expertise on what matters to them.

Perioperative Assessment at the BGS Autumn Meeting

Dr Jugdeep Dhesi is Chair of the BGS Perioperative Care of Older People Ungergoing Surgery SIG (POPS) and is consultant physician and clinical lead for the POPS service at Guy’s and St Thomas’ Hospitals. She will be Chairing the POPS Session at the BGS Autumn Meeting.

Older surgical patients are presenting us geriatricians with challenges. How should geriatric medicine fit into the national agenda for perioperative medicine? Which models of care work best in improving outcomes for this complex multimorbid group of patients? Do different surgical subspecialties require different approaches? How should these services differ between the district general and teaching hospital? Should elective and emergency older surgical patients be given equivalent geriatric medicine input? How can we balance the frequent calls to involve geriatricians in the care of older surgical patients against the numerous unfilled consultant posts in ‘traditional’ geriatric medicine that already exist? These issues will be explored in the POPS SIG session at the BGS meeting in Glasgow (Friday 25th November).

It’s Time to Reframe How We Care for Older Adults Facing Surgery

Dr. Ko is Director of the American College of Surgeons Division of Research and Optimal Patient Care and ACS NSQIP, and Principal Investigator of the Coalition for Quality in Geriatrics Surgery (CQGS) Project, based in Chicago, Illinois. He is a practicing surgeon, who serves as professor of surgery and health services at the UCLA Schools of Medicine and Public Health and holds the Robert and Kelly Day Chair in Surgical Outcomes.

Dr. Rosenthal is Chair of the Geriatric Surgery Task Force, Co-Principal Investigator, CQGS Project. She is professor of surgery at Yale University, and chief of surgery at the VA Connecticut Healthcare System. Specializing in geriatric surgery, Dr. Rosenthal is dedicated to helping older patients who have a variety of gastrointestinal and biliary diseases.

The United States population is dramatically aging. The baby boom generation has reached 65. In fact, there are at least 10,000 people turning 65 every day. The U.S. Census Bureau projects the percentage of men and women 65 years and older will more than double between 2010 and 2050.

Now, more than ever, we see a demographic imperative to pay attention to the rapidly growing number of older adults.  Despite the fact that patients 65 and older make up only 13 percent of the U.S. population, they account for more than one-third of the operations we perform in the U.S. each year.

Perioperative Medicine

On a freezing cold Friday in January, the Royal College of Anaesthetists held a stakeholder event launching their vision for the future of Perioperative Medicine: the delivery of integrated care to those undergoing high risk surgery, provided by a perioperative team, to enable better patient outcomes and experience within the context of more effective and efficient use of finite resources.

The morning was attended by the great and the good and whilst dominated by anaesthetists there was a wide representation including the BGS and the Royal College of Physicians.

A simple but effective five minute animated film introduced the concept along with a vision document both available on the website www.rcoa.ac.uk/perioperativemedicine

The speakers used powerful statistics:  16 billion pounds spent on surgery each year in the NHS, 20 million referrals for elective surgery which continues to increase year on year, 27,000 undergoing surgery each day of which 700 are high risk.  The overall on-table mortality lies in the region of 0.06% but with in-patient mortality at 3.6%.  There is also a significant morbidity with up to 15% of those undergoing elective surgery experiencing often predictable and potentially preventable complications with prolonged post-operative morbidity.

Yet it seems that we know the answers, supported by a reasonable evidence base and shown to be cost-neutral, if not cost-saving.  This has been demonstrated by Enhanced Recovery Programmes in a number of conditions, the successes of the hip fracture programmes with widespread implementation of orthogeriatrics and in the Proactive Care of Older People undergoing Surgery (POPS).  Jugdeep Dhesi eloquently presented the work of the POPS team and represented both acute medicine and geriatric medicine on the expert panel emphasizing the importance of recognising frailty and the benefits of comprehensive geriatric assessment.

It was suggested that the majority of the public would assume that joined up personalised care for those undergoing high risk surgery already exists in the NHS but sadly we know this not to be true.  All agreed that it should not be left to the overburdened medical registrar to sort out in the middle of the night.

The future is likely to be Perioperative Medicine.  Work on a curriculum, a training programme and workforce planning have already begun.  The BGS and the RCP both vocalised their support.  Those keen to be involved should register their interest at perioperativemedicine@rcoa.ac.uk

Helen Wilson, Consultant Orthogeriatrician 

Proactive care of Older People undergoing Surgery (POPS)

Jude Partridge is a Clinical Research Fellow and Jugdeep Dhesi is a Consultant Geriatrician and Clinical Lead at Guy’s and St Thomas’ NHS Foundation Trust. They have recently reported on a UK survey of geriatric medicine delivered services in surgery in Age and Ageing journal.

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has published another thorough and methodologically robust report, Lower Limb Amputation: Working Together. On this occasion they examined the care of the non-traumatic amputee across the UK and concluded that “only 229/519 (44.1%) of patients were receiving a standard of care with which the advisors would be happy for themselves or their family and friends. In other words, clinical management could have been better in half of the patients included in the study”.

Unsurprisingly, the majority of cases reviewed in this report were older, multimorbid and due to the lower limb amputation, at a transition point in terms of functional status. This older, multimorbid population were inadequately prepared for surgery (only two fifths of elective patients had preassessment) and commonly required medical input from a physician postoperatively (60%). So, did NCEPOD miss an opportunity to link past reports with this current review? 

For he’s a jolly good fellow…

David Shipway is a final year registrar in geriatric medicine working at London’s Charing Cross and St Mary’s Hospitals, Imperial College NHS Trust. He is currently developing a new comprehensive surgical liaison service for patients undergoing gastrointestinal surgery.

With population ageing, the number of oldest old undergoing surgery is increasing markedly. For anyone who’s recently been the medical registrar on-call, it will come as no surprise to hear that there is considerable unmet need on the surgical wards of the UK. But the experience of pioneers in this field has proved that reactive post-operative care is not enough: a proactive approach immediately following the decision to operate is needed to improve outcomes for older patients undergoing surgery.

Have you heard about POPS? – Pro-active care of Older People undergoing Surgery

Jason Cross is a Clinical Nurse Specialist for the Proactive Care of Older People (POPS) team at Guys and St Thomas Hospitals and is a member of the BGS Proactive care of Older People undergoing Surgery (POPS) special interest group. He Tweets at @jdcross1970

Following the publication of the National Confidential Enquiry into Patient outcome and Death (NCEPOD) report An age old Problem 2011 and the Royal College of Surgeons (RCS) report Access all ages 2012, interest in the specialist area of perioperative medicine for the older surgical patient is gathering momentum. As a result, clinicians, commissioners and patients are recognising there is a need to have geriatrician input in surgical pathways for older people.

Chance favours the prepared: surgery in older patients

David Cohen is a consultant geriatrician at Northwick Park Hospital and a spokesperson of the British Geriatrics Society.

The Duke of Edinburgh’s recent admission to hospital raised the question of surgery in older people.  Surgery and an anaesthetic are a major stress on anybody and older people are particularly susceptible.  This not only applies to people who are frail and have other illnesses but also to people who appear very fit.  Obviously, in an emergency, there may be no choice other than to go ahead with surgery but in non-urgent situations it is important to take particular precautions in later life.  Anyone contemplating surgery should make sure that they have a good general medical history and examination well before the operation.  Problems that may affect recovery should be carefully sought and investigated so that there are no surprises.