Geriatricians critical to treatment of elderly patients

Fracture patients may need care by multidisciplinary team.

Issue: Issue 1 2003

TORONTO — According to David Marsh, MD, professor of trauma and orthopaedics at Queen’s University in Belfast, elderly patients who arrive at trauma centers with osteoporotic fractures are often treated like second-class patients.

It does not have to be that way, not if orthopaedic trauma surgeons begin to demand the right resources to treat those most difficult and complicated patients and prevent their eventual return, Marsh said.

“As the population ages, properly treating these patients is going to require more resources than we currently have,” he said. “The multidisciplinary team that you need to look after elderly osteoporotic fracture patients, if you want good quality care, needs to be big.”

Marsh, who spoke about his experience working alongside a geriatrician on a fracture ward said that a firmly entrenched flow chart with skilled physicians overseeing elderly fracture care needs to become a priority in hospital trauma centers.

Those centers that do not initiate such a plan are doomed to fail to fulfill their patients’ needs, Marsh said at the 8th Biannual Meeting of the International Society for Fracture Repair.

“The presentation of a patient to a fracture service is an opportunity for the detection and treatment of significant medical problems including, but not confined to, the fragility of the bone itself,” Marsh said. “We can bring about secondary prevention and we need to have geriatricians helping us do this. They need to be dedicated to the service and they need to integrate a multidisciplinary team.”

Proven benefits

Why the urgent need for an orthogeriatrician? In Marsh’s opinion, it comes down to dealing with the special needs of the elderly patient and the specific skills required of the medical community to treat them properly.

Marsh said studies have demonstrated that care systems regularly visited by geriatric teams have not provided much overall improvement, but a resident geriatric physician on the fracture ward can significantly decrease mortality and patient length of stay and improve staff morale.

“Orthogeriatricians have several roles,” Marsh said. “They have to get the patient’s medical condition optimized for surgery in consultation with the other surgical colleagues. They have to coordinate the actions of junior surgical staff, teach medical students and develop protocols. They are excellent at doing the holistic-issues research in fracture units. They have to be the leader of a multidisciplinary team with a discharge coordinator on the rehab team.”

Short of introducing a geriatrician to the staff, orthopaedic trauma surgeons must familiarize themselves with the needs of the elderly so that they do not just blindly treat the fracture and send patients on their way, Marsh said.

Elderly untruths

They should not be given strong analgesics. In reality, sometimes giving analgesia is vital to the recovery of an elderly patient. What must be addressed coincidentally, however, is the need for a laxative to combat the constipative analgesic.
Delay to surgery results in an increased mortality rate. Marsh did not know of any evidence to support this theory. He said it is sensible to delay surgery if the delay allows for the improvement and stabilization of some of the patient’s comorbidities.
Instant pain relief is unimportant. In fact, Marsh said that pain relief might be the single most important factor. “Pain can transform an elderly person’s life into an absolute hell. Patients who are cognitively impaired may not be able to let the uninitiated nurse know that they’re in pain in the conventional way and thereby not receive the analgesia that they need.”

For your information:

Marsh D. Multidisciplinary aspects of fracture treatment in osteoporotic patients. Presented at the 8th Biannual Meeting of the International Society for Fracture Repair. Oct. 9-11, 2002. Toronto.