Orthogeriatrics: The Management of Older Patients with Fragility Fractures

Preface to the Second Edition
Contents
Part I: Background
	1: The Multidisciplinary Approach to Fragility Fractures Around the World: An Overview
		1.1	 Introduction
		1.2	 General Developments Since 2016
			1.2.1	 The Global Call to Action
			1.2.2	 The Formation of National FFNs
			1.2.3	 Initiation of New Hip Fracture Registries
			1.2.4	 Implications of These General Developments for the Design of This Second Edition
		1.3	 Background: Chaps. 2–4
			1.3.1	 Epidemiology of Fractures and Social Costs: Chap. 2
			1.3.2	 Osteoporosis in Older Patients: Chap. 3
			1.3.3	 Frailty and Sarcopenia: Chap. 4
		1.4	 Pillar I: Co-Management in the Acute Episode—Chaps. 5–11
			1.4.1	 Establishing an Orthogeriatric Service: Chap. 5
			1.4.2	 Pre-hospital Care and the Emergency Department: Chap. 6
			1.4.3	 Perioperative Orthogeriatric Care: Chaps. 7 and 11
			1.4.4	 Orthogeriatric Anaesthesia: Chap. 8
			1.4.5	 Hip Fracture: The Choice of Surgery—Chap. 9
			1.4.6	 Proximal Humeral Fractures: The Choice of Treatment—Chap. 10
		1.5	 Pillar II: Rehabilitation—Chaps. 12 and 13
			1.5.1	 Rehabilitation Following Hip Fracture: Chap. 12
			1.5.2	 The Psychological Health of Patients and Their Caregivers: Chap. 13
		1.6	 Pillar III: Secondary Prevention—Chaps. 14–16
			1.6.1	 Fracture Liaison Services: Chap. 14
			1.6.2	 Current and Emerging Treatment of Osteoporosis: Chap. 15
			1.6.3	 How Can We Prevent Falls?—Chap. 16
		1.7	 Cross-Cutting Issues: Chaps. 17–19
			1.7.1	 Nursing in the Orthogeriatric Setting: Chap. 17
			1.7.2	 Nutritional Care of the Older Patient with Fragility Fracture: Chap. 18
			1.7.3	 Fragility Fracture Audit: Chap. 19
		1.8	 Concluding Remarks
		References
	2: Epidemiology of Fragility Fractures and Social Impact
		2.1	 Introduction
		2.2	 Prevalence of Osteoporosis
		2.3	 Factors Affecting Bone Mineral Density
		2.4	 Osteosarcopenia
		2.5	 Falls
		2.6	 Incidence of Fragility Fractures
		2.7	 Hip Fracture
		2.8	 Other Osteoporotic Fractures
		2.9	 The Burden of Fragility Fractures
		2.10	 The Costs and Social Impact of Hip Fracture
		2.11	 The Costs and Social Impact of Other Osteoporotic Fractures
		2.12	 Conclusions
		References
	3: Osteoporosis and Fragility in Elderly Patients
		3.1	 Definition
		3.2	 Epidemiology
		3.3	 The Anatomy of Bone
		3.4	 The Physiology of Bone
		3.5	 Pathogenesis
		3.6	 Risk Factors for Fragility Fractures
			3.6.1	 BMD
			3.6.2	 Age
			3.6.3	 Previous Fractures
			3.6.4	 Family History of Fracture
			3.6.5	 Comorbidities
			3.6.6	 Drugs
			3.6.7	 Assessment of Fracture Risk
		3.7	 Diagnosis
			3.7.1	 Instrumental Diagnosis
				3.7.1.1	 Dual X-Ray Absorptiometry (DXA)
				3.7.1.2	 Quantitative Computerised Tomography (QCT)
				3.7.1.3	 Quantitative Ultra-Sound (QUS)
			3.7.2	 X-Ray of the Dorsal and Lumbar Spine
			3.7.3	 Laboratory Tests
		3.8	 Management of Osteoporosis
			3.8.1	 Lifestyle Modification
				3.8.1.1	 Prevention of Falls
		3.9	 The Importance of Vitamin D, Calcium and Protein Intake
			3.9.1	 Vitamin D
			3.9.2	 Calcium
			3.9.3	 Protein
		3.10	 Therapeutic Adherence in Osteoporosis and the Role of Health Professionals
		References
	4: Frailty and Sarcopenia
		4.1	 Frailty
			4.1.1	 The Nature of Frailty
			4.1.2	 Epidemiology of Frailty
			4.1.3	 How Does Frailty Develop?
			4.1.4	 Assessment of Frailty in Clinical Practice
			4.1.5	 Incorporating Frailty into Treatment Plans and Service Design
		4.2	 Sarcopenia
			4.2.1	 The Nature of Sarcopenia
			4.2.2	 Epidemiology
			4.2.3	 How Does Sarcopenia Develop?
			4.2.4	 Assessing Sarcopenia in Clinical Practice
			4.2.5	 Incorporating Sarcopenia into Treatment Plans and Service Design
		4.3	 The Implications of Frailty and Sarcopenia on Falls, Fractures and the Recovery After Fractures
		4.4	 Concluding Statement
		References
Part II: Pillar I: Co-management in the Acute Episode
	5: Establishing an Orthogeriatric Service
		5.1	 Introduction
		5.2	 Designing the Orthogeriatric Service
			5.2.1	 Step 1: Process Mapping the Hip Fracture Pathway
			5.2.2	 Step 2: Identify a Core Multidisciplinary Team and Form a Steering Group
			5.2.3	 Step 3: Analyse and Review the Patient Pathway
			5.2.4	 Step 4: Evaluate the Resources Required to Drive Change Within the Organisation
			5.2.5	 Step 5: Develop the Business Case for the Orthogeriatric Service
			5.2.6	 Step 6: Implementing and Sustaining the Service
			5.2.7	 Step 7: Collect Evidence of Service Improvement: Audit
			5.2.8	 Step 8: Embrace the Support of Regional, National and International Organisations
		5.3	 Conclusion
		References
	6: Pre-hospital Care and the Emergency Department
		6.1	 Pre-hospital Care
			6.1.1	 Clinical Assessment: Primary Survey
			6.1.2	 Clinical Assessment: Secondary Survey
			6.1.3	 Patient History
			6.1.4	 Physical Assessment and Vital Signs
			6.1.5	 Management of Pain
			6.1.6	 Fluid Replacement
			6.1.7	 Extrication
			6.1.8	 Transportation
		6.2	 The Emergency Department
			6.2.1	 Nutrition and Hydration
			6.2.2	 Management of Pain
			6.2.3	 Ongoing Analgesia
			6.2.4	 Local Nerve Blocks
			6.2.5	 Skin Care
			6.2.6	 Referral for Early Surgery
		6.3	 Summary
		References
	7: Pre-operative Medical Assessment and Optimisation
		7.1	 Pre-operative Medical Assessment
		7.2	 Information Gathering
		7.3	 Cardiovascular Disease
			7.3.1	 Valvular Heart Disease
			7.3.2	 Heart Failure
			7.3.3	 Conduction Defects, Pacemakers and Implantable Cardiac Defibrillators (ICD)
			7.3.4	 Atrial Fibrillation (AF)
		7.4	 Management of Anticoagulants and Anti-platelets
		7.5	 Anaemia
		7.6	 Diabetes
		7.7	 Chronic Kidney Disease (CKD)
		7.8	 Respiratory Disease
		7.9	 Medication Review
		7.10	 Preventing Complications: Thromboembolic Events
		7.11	 Antibiotic Prophylaxis
		7.12	 Appropriate Ceilings of Care
		7.13	 Conclusion
		References
	8: Orthogeriatric Anaesthesia
		8.1	 Introduction
		8.2	 The Relationship Between Anaesthetist and Orthogeriatrician
		8.3	 Preoperative Care
			8.3.1	 Preoperative Analgesia
			8.3.2	 Preoperative Preparation
			8.3.3	 Ethical and Legal Considerations
		8.4	 Intraoperative Care
			8.4.1	 General or Spinal Anaesthesia?
			8.4.2	 Peripheral Nerve Block
			8.4.3	 Spinal Anaesthesia
			8.4.4	 Sedation
			8.4.5	 General Anaesthesia
			8.4.6	 Avoiding Ischaemia
			8.4.7	 Bone Cement Implantation Syndrome (BCIS)
			8.4.8	 Standardisation of Anaesthesia
		8.5	 Postoperative Care
		References
	9: Hip Fracture: The Choice of Surgery
		9.1	 Aim of Surgery
		9.2	 Fracture Types
			9.2.1	 Intra-capsular Fracture Types
			9.2.2	 Extra-capsular Fracture Types
		9.3	 Implants
		9.4	 Surgical Management
			9.4.1	 Intra-capsular Operations
			9.4.2	 Extra-capsular Operations
		9.5	 Surgical Algorithms and National Guidelines
		References
	10: Proximal Humeral Fractures: The Choice of Treatment
		10.1	 Aim of Treatment
		10.2	 Evidence and Literature
		10.3	 Epidemiology
		10.4	 Fracture Classification
			10.4.1	 Minimally Displaced Fractures
			10.4.2	 Displaced Fractures
		10.5	 Treatment
			10.5.1	 Non-surgical Treatment
			10.5.2	 Surgical Management
		10.6	 Complications
		10.7	 Outcome Assessment
		10.8	 Conclusions
		References
	11: Post-operative Management
		11.1	 Multidisciplinary Management
		11.2	 Predicting the Risk of Post-operative Complications
		11.3	 Early Mobilisation
		11.4	 Pain Management
		11.5	 Post-operative Hypotension and Fluid Management
		11.6	 Management of Postsurgical Anaemia
		11.7	 Nutritional Supplementation
		11.8	 Post-operative Medical Complications
		11.9	 Prevention and Management of Specific Complications
			11.9.1	 Delirium
				11.9.1.1	 Prevention of Post-operative Delirium
				11.9.1.2	 Management of Post-operative Delirium
				11.9.1.3	 Post-operative Cognitive Dysfunction
			11.9.2	 Cardiovascular Complications
				11.9.2.1	 Myocardial Infarction
				11.9.2.2	 Heart Failure
				11.9.2.3	 Supraventricular Arrhythmias
			11.9.3	 Infections
				11.9.3.1	 Post-operative Fever
				11.9.3.2	 Pneumonia
				11.9.3.3	 Urinary Tract Infection
				11.9.3.4	 Surgical Site Infection
			11.9.4	 Other Complications
				11.9.4.1	 Acute Kidney Injury (AKI)
				11.9.4.2	 Gastrointestinal Complications
				11.9.4.3	 Pressure Ulcers
		11.10	 Final Remarks
		References
Part III: Pillar II: Rehabilitation
	12: Rehabilitation Following Hip Fracture
		12.1	 The Need for Increased Provision of Rehabilitation Worldwide
		12.2	 The Principles of Rehabilitation Programmes after Hip Fracture
		12.3	 What Is Known about the Pattern of Recovery Following Hip Fracture?
		12.4	 Factors Associated with Poor Outcomes After Hip Fracture
		12.5	 Key Elements of a Rehabilitation Pathway
		12.6	 What Programmes Should We Recommend to Help with Recovery?
			12.6.1	 In-hospital Rehabilitation
			12.6.2	 Rehabilitation in the Community
			12.6.3	 Rehabilitation in Low Resource Settings
		12.7	 Rehabilitation and Cognitive Impairment
			12.7.1	 Enhanced Interdisciplinary Inpatient Rehabilitation and Care
			12.7.2	 Enhanced Interdisciplinary Inpatient and Home-Based Rehabilitation
		12.8	 Psychosocial Factors and Rehabilitation
		12.9	 Delivery of Rehabilitation Following Hip Fracture in LMICs
			12.9.1	 Key Evidence-Based Recommendations and Their Implementation in LMICs
		12.10	 Conclusion
		References
	13: The Psychological Health of Patients and their Caregivers
		13.1	 Why Is Psychological Status Important in the Management of Hip Fracture?
			13.1.1	 Why Is Psychological Status Important in the Outcome of Hip Fracture?
			13.1.2	 Why Is Psychological Status Important in Rehabilitation from Hip Fracture?
			13.1.3	 Why Is Caregivers’ Psychological Status also Important?
			13.1.4	 Consequences of Caregiving
			13.1.5	 The Relationship Between Caregivers’ and Patients’ Psychological Status
		13.2	 How Should the Psychological Status of Patients and Caregivers Be Assessed?
			13.2.1	 The Psychological Evaluation of the Patient
				13.2.1.1	 Quality of Life
				13.2.1.2	 Fear of Falling
				13.2.1.3	 Pain
				13.2.1.4	 Activities of Daily Living
				13.2.1.5	 Delirium
				13.2.1.6	 Depression
				13.2.1.7	 Cognitive Impairment
				13.2.1.8	 Stress
				13.2.1.9	 Anxiety
			13.2.2	 The Psychological Evaluation of Caregivers
				13.2.2.1	 Psychological Well-Being
				13.2.2.2	 The Caregiver Burden
		13.3	 How Can Psychological Status Be Influenced Positively by the Orthogeriatric Team?
		13.4	 Cultural Influence and the Anthropology of Care
		References
Part IV: Pillar III: Secondary Prevention
	14: Fracture Risk Assessment and How to Implement a Fracture Liaison Service
		14.1	 Introduction
		14.2	 Fracture Risk Prediction
		14.3	 Fracture Liaison Service
			14.3.1	 The FLS Model
			14.3.2	 Evidence for Effectiveness of FLS
		14.4	 How to Implement an FLS (a Step-by-Step Guide)
			14.4.1	 Benchmarking Your Service
			14.4.2	 Potential Barriers and How to Overcome them
			14.4.3	 Implementation in a Low-Resource Setting
		14.5	 Conclusions
		References
	15: Current and Emerging Treatment of Osteoporosis
		15.1	 Introduction
		15.2	 Pharmacological Treatment for All Patients with Fragility Fractures
			15.2.1	 Bedridden Fractured Patients
			15.2.2	 Make a Diagnosis Before Treatment
			15.2.3	 Set Up an Appropriate and Personalised Treatment
		15.3	 Non-pharmacological Treatment
			15.3.1	 Lifestyle and Exercise
		15.4	 Pharmacological Interventions
			15.4.1	 Ca and Vitamin D to All Patients in Association with Anti-osteoporotic Therapy
			15.4.2	 Choose the Safe and Effective Drug for the Orthogeriatric Patient
		15.5	 Antiresorptive Therapies
			15.5.1	 Bisphosphonates
				15.5.1.1	 Adverse Events
				15.5.1.2	 Technical Remark
			15.5.2	 Rank Ligand Inhibitor
				15.5.2.1	 Adverse Events
				15.5.2.2	 Technical Remark
		15.6	 Anabolic Drugs
			15.6.1	 Parathyroid Hormone Receptor (PTHr) Agonists: Teriparatide and Abaloparatide
				15.6.1.1	 Adverse Events
			15.6.2	 Anti-Sclerostin Antibody: Romosozumab
				15.6.2.1	 Adverse Events
				15.6.2.2	 Technical Remark for Anabolic Agents
		15.7	 Influence of Osteoporosis Medication on Fracture Healing
		15.8	 Conclusion
		References
	16: How Can We Prevent Falls?
		16.1	 Epidemiology of Falls
		16.2	 How to Assess Older Patients’ Risk of Falling
			16.2.1	 Definition of Older People at Low, Moderate or High Risk of Falling
		16.3	 Fall Prevention Intervention in Patients with Low Risk of Falling
		16.4	 Multifactorial Interventions in Patients with Moderate Risk of Falling
		16.5	 Multifactorial Falls Risk Assessment and Interventions in Patients with High Risk of Falling
		16.6	 Fall Assessment and Prevention in Care Settings
		16.7	 Fall Assessment and Prevention in Patients with Cognitive Impairments
		16.8	 Falls Clinics and Fracture Liaison Services
		16.9	 Conclusion
		References
Part V: Cross-Cutting Issues
	17: Nursing in the Orthogeriatric Setting
		17.1	 Introduction
		17.2	 Nursing Care Quality
		17.3	 Acute Care
			17.3.1	 Complexity and Frailty
			17.3.2	 Nursing Assessment and Management of Pain
			17.3.3	 Nursing Assessment and Management of Delirium
			17.3.4	 Pressure Ulcer Prevention
			17.3.5	 Nutrition, Hydration, Acute Kidney Injury and Constipation
			17.3.6	 Healthcare Associated Infection
				17.3.6.1	 Pneumonia: Nursing Assessment, Prevention and Management
				17.3.6.2	 Urinary Tract Infection: Nursing Assessment, Prevention and Management
			17.3.7	 Venous Thromboembolism: Nursing Interventions for Prevention
		17.4	 Rehabilitation, Discharge and Continuing Care
		17.5	 Palliative and End of Life Care
		17.6	 Secondary Prevention, Health Improvement and Health Promotion
		17.7	 Nursing Resources, Education and Leadership
		References
	18: Nutritional Care of the Older Patient with Fragility Fracture: Opportunities for Systematised, Interdisciplinary Approaches Across Acute Care, Rehabilitation and Secondary Prevention Settings
		18.1	 Background
		18.2	 SIMPLE or Specialised Nutrition Care?
		18.3	 Screening for Nutrition Risk (SIMPLE)
		18.4	 Interdisciplinary Assessment (SIMPLE)
		18.5	 Make the Diagnosis/(es) (SIMPLE)
		18.6	 Plan with the Patient (SIMPLE)
		18.7	 ImpLement Interventions (SIMPLE)
			18.7.1	 Interventions to Improve Nutrition Knowledge
			18.7.2	 Interventions to Influence Nutrient Intake
			18.7.3	 Interventions Leading to Coordinated Nutrition Care Across Disciplines and Settings
		18.8	 Evaluating Ongoing Care Requirements (SIMPLE)
		18.9	 Recommended Further Reading
		References
	19: Fragility Fracture Audit
		19.1	 Introduction
		19.2	 Hip Fracture Audit
		19.3	 Obstacles to Hip Fracture Audit and International Comparison
		19.4	 Hip Fracture Audit and the Improvement of Care
		19.5	 Audit of Other Fragility Fractures and Fracture Liaison Services (FLS)
		19.6	 Expansion of Hip Fracture Registries in Other Regions
		19.7	 New Developments in Fracture Audit
		References