ORTOGERIATRIK. Yngve Gustafson Professor, Överläkare. Geriatriskt centrum Umeå Sverige

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1 Yngve Gustafson Professor, Överläkare Geriatriskt centrum Umeå Sverige

2 GERIATRISKT CENTRUM UMEÅ, SVERIGE

3 ANTALET HÖFTFRAKTURER HOS MYCKET GAMLA MÄNNISKOR ÖKAR SNABBT. (150% ökning hos 90+ i Umeå på 10 år). 90+ ökar från till år 2050 i Sverige. Mycket gamla människor drabbas av många komplikationer efter höftfraktur. Fallrelaterade skador orsakar 3 ggr fler dödsfall än trafiken i Sverige. Höftfrakturpatienter har 3 ggr ökad risk att drabbas av en höftfraktur till.

4 Anestesi hos mycket gamla människor: Ett skickligt genomförande snarare än typen av anestesi är viktigast! (Berggren D et al. Anest Analg 1987)

5 Enbart medicinska interventioner har måttlig effekt för resultatet efter höftfraktur Gustafson Y, JAGS 1991 Enbart sjuksköterskeinterventioner har ingen eller obetydlig effekt. En kombination av medicinsk och omvårdnadsintervention visade lovande resultat. Lundström M, Scand J Caring Sci 1999.

6 Förebygg stress (hypercortisolism)genom god trygg omvårdnad i kombination med att förebygga, upptäcka och behandla komplikationer. Förebygg CNS-hypoxi (Hktr>30, syremättnad >90%, undvik hypotoni, behandla feber). Hypercortisolism ökar hjärnans känslighet för hypoxi.

7 GERIATRIK The effect of comprehensive geriatric assessment on one-year mortality and living at home expressed as Odds Ratios (a metaanalysis by Stuck et al. Lancet 1993). Mortality GEMU-units Living at home GEMU= Geriatric evaluation and management units

8 GERIATRIK GERIATRIC-BASED VERSUS GENERAL WARDS FOR ELDERLY ACUTE MEDICAL PATIENTS A RANDOMIZED COMPARISON OF OUTCOMES AND USE OF RESOURCES Kjell Asplund, MD 1, Yngve Gustafson, MD 2, Catrine Jacobsson, RN 3, Gösta Bucht, MD 2, Anders Wahlin, MD 1, Jan-Olof Blom, MSci 4 and Karl-Axel Ängquist, MD 5 Departments of Medicine 1, Geriatrics 2, Advanced Nursing 3, Administration 4, and Surgery 5, University Hospital, Umeå, Sweden J Am Geriatr Soc 48:

9 GERIATRIK Vårdtiden var kortare på geriatrikavdelningen (mean 5.9 vs. 7.3 days; p=0.002). En mindre andel behövde institutionsvård både på kort och lång sikt (22/160 vs 43/187, p=0.028).

10 GERIATRIK Reduced mortality in treating acutely sick, frail older patients in a geriatric evaluation and management unit. A prospective randomized trial. Saltvedt I, Mo ES, Fayers P, Kaasa S, Sletvold O. Section of Geriatrics, Department of Internal Medicine, University Hospital of Trondheim, Trondheim, Norway. J Am Geriatr Soc May;50(5):792-8.

11 Den gamla kvinnan med en höftfraktur betraktas ofta som en vanlig och okomplicerad patient ur medicinsk synvinkel. Den inställningen bidrar sannolikt till det dåliga behandlingsresultatet. Delirium hos en gammal människa särskilt om hon har demens betraktas ofta som naturligt och ounvikligt.

12 DEN GAMLA HÖFTFRAKTUR- PATIENTEN: Kvinnor 70-80% Medelålder 83 Osteoporos 90% 95% har fallit Infektioner Läkemedel Stroke Hjärtsjukdom Epilepsi Delirium

13 DEN GAMLA HÖFTFRAKTUR- PATENTEN: 40% från särskilt boende 30% har haft stroke 30% har demens 25% har delirium 25% är deprimerade 70% ensamboende 70% malnutrierade 100% har ökat näringsbehov efter höftfrakturen

14 DEN GAMLA HÖFTFRAKTUR- PATIENTEN 30% har urinvägsinfektion 50% har dålig munhälsa 25% diabetes 50% nedsatt syn 30% nedsatt hörsel 25% är hypoxiska vid ankomst till sjukhus 40% har sömnapnésyndrom 90% har ramlat många ggr tidigare 80% har varit fysiskt inaktiva

15 DEN GAMLA HÖFTFRAKTUR- PATIENTEN: Tar 7 läkemedel före frakturen och skrivs ut med 10: Antidepressiva (SSRI) Neuroleptika Bensodiazepiner Analgetika Laxermedel Blodtrycksmedel Diuretika Thyreoideahormon

16 Delirium karakteriseras av störd uppmärksamhet, desorientering och fluktuerande förlopp. Delirium är sannolikt det vanligaste sjukdomssymtomet hos äldre människor. En patient med delirium skall alltid utredas för bakomliggande orsaker. Ett multidiciplinärt team behövs för att förebygga, upptäcka och behandla patienter med delirium.

17 Prevention and treatment of postoperative delirium - A randomized controlled trial Maria Lundström, RN. Birgitta Olofsson, RN. Michael Stenvall, RP. Stig Karlsson, RN, PhD. Lars Nyberg RPT, PhD. Undis Englund, MD. Bengt Borssén, MD, PhD. Olle Svensson, MD, PhD. Yngve Gustafson, MD, PhD. Lundstrom M, Ageing Clin Exp Res 2007 Stenvall M, J Rehab Med 2007 Stenvall M, Osteoporosis Int 2007

18 Design: A randomized control trial (RCT). Aged 70 years and older. N=102 vs. 97 The postoperative intervention program: Comprehensive geriatric assessment Prevention and treatment of complications associated with delirium Teamwork

19 Delirious patients in the orthopaedic department: No assessment of underlying causes of delirium - treatment with morfine, sedatives and neuroleptics. Resulted in delayed detection and treatment of complications.

20 Delirious patients in the geriatric department: Immediate and systematic assessment of underlying causes of delirium (A Delirium Check List) - treatment of underlying causes. Three times more complications treated in the geriatric department compared to the orthopaedic department.

21 Intervention ward, n=102 Control ward, n=97 p Delirium postoperatively 55% 75% Duration of delirium (days) 5.0± ± Discharged with delirium 0% 27% <0.001 Urinary tract infections 31% 51% Decubital ulcers 9% 22% Falls 12% 27% 0.006

22 Postoperative delirium in patients with dementia: The duration of postoperative delirium was shorter in the intervention ward (3.2±4.1 days vs. 12.8±17.6, days, p=.003). 42% of those with dementia were discharged delirious from the control ward compared to none from the intervention ward (p<.001).

23 The mean length of hospital stay (±SD) All patients/intervention ward 28.0±17.9 days All patients/control ward 38.0±40.6 days All patients p=0.028 Delirious patients p=0.032 Delirious patients/intervention ward 31.4±19.3 days Delirious patients/control ward 43.6±42.7 days

24 Long term outcome: OR to be an independent walker one year after the hip-fracture was 3.0 in favour of those treated in the geriatric department.

25 Conclusion: A geriatric team applying comprehensive geriatric assessment, management and rehabilitation reduces postoperative delirium and associated complications which also results in shorter hospitalization and better long term outcome.

26 All frail old people and especially those with dementia should always be taken care of by a geriatric team (when acutely ill)..but are there are even better solutions? Can we prevent frail old people from beeing admitted to orthopaedic departments?

27 Fall and injury prevention among older people in residential care a randomised study. Jensen J, Lundin-Olsson L, Nyberg L, Gustafson Y. Department of Community Medicine and Rehabilitation, Geriatric Medicine and Physiotherapy Ann Int Med, 136: ; 2002

28 BACKGROUND Falls and fractures is a major threat to the health of old people. Old people in hospitals and in residential care suffers from almost half of all hipfractures in Sweden despite that only 7% of old people stay in such institutions.

29 METHOD Comprehensive geriatric assessment of riskfactors for falls. Assessments after a fall regarding precipitating factors for the fall. Multi-factorial intervention performed by a geriatric team including prescription of hipprotectors.

30 RESULTS Reduction of falls compared to control Adjusted Odds Ratio (95% CI) 0.49 ( ) Reduction of hip-fractures compared to control Adjusted Odds Ratio (95% CI) 0.23 ( )

31 CONCLUSION: An interdisciplinary and multi-factorial prevention program targeting residents, staff, and the environment can reduce falls and femoral fractures.

32 GENERAL CONCLUSION: Geriatric assessment, management and rehabilitation is a prerequisite for successful treatment of frail old people. Geriatric assessment and treatment is complicated but effective when properly performed by a team.

33 GENERAL CONCLUSION: Geriatric assessment and treatment will reduce unnecessary suffering for a large proportion of old and frail people. Great economic savings are possible if resources for geriatric assessment, treatment and rehabilitation are expanded.

34 GERIATRIC MEDICINE THE ONLY POSSIBLE SOLOTION FOR THE FUTURE. Thank you for your attention!