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?

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.

Improving perioperative care – we want your views!

Oliver Boney is a research fellow at the National Institute of Academic Anaesthesia. Here he describes a nationwide research priorities exercise, asking all clinicians who look after surgical patients (as well as patients themselves) what research efforts would make a real difference to improving patient care.

In tandem with its Perioperative Medicine programme, the National Institute of Academic Anaesthesia (NIAA) is running a research consultation exercise, asking ‘What anaesthetic or perioperative research would improve patient outcomes?’

Older people who need surgery are recognised to be at higher risk of a worse postoperative outcome than younger counterparts.However, death after major surgery such as hip fracture repair remains stubbornly high: 8% at 30 days and nearly 30% at 1 year; 30-day mortality after emergency laparotomy for people over 75 years old approaches 25%. How might we improve? Where should efforts be focused?

There is evidence that collaborative working, including input from geriatricians in the perioperative pathway, can improve outcomes in older patients after surgery, but a recent survey highlighted patchy provision of geriatric services in surgery across the UK.

Anaesthetists and surgeons are realising that the benefits of integrated multidisciplinary perioperative care, as demonstrated by the Royal College of Anaesthetists’ recent launch of its vision for the future of Perioperative Medicine (read the recent BGS blog article on this). Although there are many stakeholders in perioperative care, the national priorities for directing research studies and budgets are not yet defined.

Please fill in the survey to define the agenda for all people undergoing surgery. Your views will ensure issues related to older people are noted. To fill in the survey, go to: https://niaa.org.uk/PSPSurvey#pt.

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? 

Who is at greatest risk of dying after a broken hip?

Toby Smith is a Lecturer in Physiotherapy at the Faculty of Medicine and Health Sciences, University of East Anglia. His recent paper published in Age and Ageing has identified those people who are at greatest risk of dying following a broken hip. He tweets at @tobyosmith.

Hip fracture is a major challenge for health services worldwide, and can be catastrophic for the individual who experiences it, in addition to their friends, family and carers. The consequences of a broken hip can range from physical disability through reduced mobility and loss of independence, to death. It has been estimated that approximately 25% to 40% of people following a hip fracture die within the first 12 months after their injury. This has been, in part, attributed to the fact that many of these people are older and have numerous medical conditions which place them at greater risk of death irrespective of their hip fracture.

Given this high risk and the large number of people who experience a hip fracture annually, our team aimed to identify characteristics which could predict who would be at greatest risk of dying following a hip fracture.

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.

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. 

Are the oldest old treated more actively in hospital than previously and do they benefit from it?

Dr. Oksuzyan is Post-doctoral research fellow at the Institute of Public Health, University of Southern Denmark.

Dr. Jeune is Associate Professor of Epidemiology, University of Southern Denmark and Director of the Graduate School of Public Health.

Prof. Christensen is the Director of the Danish Twin Registry and the Danish Aging Research Center University of Southern Denmark and Senior Research Scientist at the Terry Sanford Institute, Duke University, USA.

Are older people admitted to hospitals and receiving surgical treatments more often than people of the same age did a decade ago? To answer this question, our research group compared the percentage of hospitalized people and individuals treated surgically from ages 85 to 99 years who were born in Denmark in 1895 and 1905. Those born in 1895 were followed from 1980 to 1994, whilst individuals born in 1905 were followed from 1990 to 2004. The study was based on Danish register data which is a unique data source for scientific research as it covers the entire Danish population.

New recruits needed to help build services for frail older people undergoing operations

Dr Jugdeep Dhesi is Chair of the BGS Peri-operative 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.

The number of frail older people undergoing elective surgical procedures is rapidly increasing. In fact the number of older people undergoing operations, as a proportion of all those having surgery, is increasing more rapidly than is the proportion of frail older people across the population as a whole.

There are a number of reasons for this. Advances in surgical technique and improvements in anaesthetic management have made it possible to operate safely on patients who would have been considered too frail for surgery in the past. At the same time patients and doctors now expect that they will be able to receive operations much later in life.  

National Hip Fracture Database Reports on Developments in Acute and Post-Acute Care

Dr Helen Wilson, is co chair of the National Hip Fracture Database (NHFD), a joint endeavour of the BGS and the British Orthopaedic Association to improve the care of patients with fragility fractures.

Hip fracture, which usually results from the combination of a fall and pre existing osteoporosis, is the most common serious injury of older people, with around 76,000 cases occurring per year across the UK. Many patients are already frail. Mortality is high, residual disability common, and care costly. Although there is good evidence on best practice in surgical, medical and rehabilitation care following hip fracture, such care and its outcomes – in terms of return home and also of mortality – continue to vary.

The NHFD has published a supplement to its 2012 National Report which demonstrates continuing improvements in acute care but  highlights variations in post-acute care and overall length of NHS stay.