Implementation of Orthogeriatrics in Portugal

Abstract

Introduction: Orthogeriatrics is the subspecialty of geriatrics that is dedicated to the care of elderly patients with fragility fractures. The Orthogeriatrics Unit of the Vila Nova de Gaia Hospital Centre was the first unit created in Portugal in October 2015, in a co-management model.

Methods: Patients older than 65 years and with femur fractures were admitted to the unit after surgery. The department was run by internists with differentiation in geriatrics, and multidisciplinary support from orthopaedics, physiatrists, physiotherapists, nutritionists, and social workers, as well as rehabilitation nursing. A comprehensive multidisciplinary assessment was performed upon admission, including comprehensive geriatric assessment as well as postoperative monitoring of complications, investigation of fall mechanisms, functional rehabilitation, and outpatient orientation. Analysed variables included demographics, comorbidities, prior level of functionality, delay of orthopaedic surgery, complications, time of hospitalization, functional prognosis, and destination after discharge. Follow-up was maintained to assess short- and medium-term mortality. Kaplan-Meier curves and Cox regression were used for the statistical analysis of mortality.

Results: In four years of activity with 444 admissions, the typical patients were women (80.7%), with an average age of 84 years, coming from home (92%) after an accidental fall resulting in a proximal femur fracture. About half (54%) were previously autonomous, but with a high index of comorbidities (mean Charlson Index of 4.85), the most relevant of which were arterial hypertension (71%), malnutrition (46%), heart failure (35%), hyperlipidaemia (34%), osteoporosis (32%), and dementia (16%). During hospitalization, most patients had medical complications (86.3%), the most frequent ones being anaemia (45%), infections (35%), namely, urinary, respiratory, and surgical wound infections, acute heart failure (15%), and acute kidney injury (11%). Prevalent geriatric syndromes were also identified and corrected through protocols for delirium, urinary incontinence, pressure ulcers, and constipation. The mean length of stay was 12.49 days. At discharge, 75% presented a modified Rankin Scale score lower than 3 and 73% of patients were able to return home, with a low referral rate to long-term care facilities (5.9%). The in-hospital mortality rate was 2.65%. It was possible to maintain follow-up protocol after discharge in 343 patients, and the mortality at 12 months was 19.23% and at three years, it was 25.52%, with a risk of death almost doubled for patients discharged with a high degree of dependence (modified Rankin Scale score ≥ 3; OR: 2.19; p < 0.001).

Conclusion: We demonstrated reduced in-hospital mortality despite an elderly, frail population, with multiple previous comorbidities and a high number of inpatient intercurrences evidencing the importance of a good in-hospital co-management between internal medicine and orthopaedics, demonstrating the benefit of orthogeriatric units in patients with fragility fractures of the femur.

Keywords: frail elderly; geriatrics; hip fractures; internal medicine; orthogeriatrics; orthopaedics.

Figure 1. Kaplan-Meier survival curve during three years of follow-up