Falls that lead to bone fractures occur frequently in older people. These injuries, especially those that require surgery, often start patients down a path toward mounting health problems that threaten their ability to live independently or maintain a good quality of life.
At Brigham and Women’s Hospital, orthopaedic surgeons and geriatricians work together to care for people at critical junctures in their lives, such as in the aftermath of an orthopaedic trauma. The Geriatric Inpatient Fracture Trauma Service (GIFTS), which was established six years ago, includes a dedicated geriatrician who works with the trauma orthopaedic team, geriatric orthopaedic nurses, physical therapists and case managers. The program’s goal is to make sure these patients get care that is adjusted for whatever needs they may have based on their age.
“We’re trying to find a way to embrace aging in a way that recognizes its limitations,” said program leader Houman Javedan, MD, a geriatrician and clinical director with the Brigham’s Division of Aging. “Having this understanding enables us to better care for aging patients. We know what level of resources and expertise they need at every stage of their care, and we can ensure they receive it.”
At the Brigham, all orthopaedic trauma patients over age 70 automatically receive a comprehensive geriatric assessment within the first 24 hours of admission. “This enables us to do preoperative risk assessments and optimization, which in turn helps us to move these patients into surgery more quickly,” Dr. Javedan said. “We are able to identify any special needs a patient may have. Based on that, we can adjust their care appropriately.”
These assessments help determine a patient’s “physiological age,” which geriatricians say is the best way to predict and prepare for challenges that may arise during treatment and recovery. “Everyone thinks age is a number,” Dr. Javedan said. “But we know it’s so much more than that. You can have a 90-year-old who is robust and a 70-year-old who is severely frail. This isn’t something you can determine after a quick visit or review of someone’s chart. You can’t get to the heart of understanding what the patient requires without a full assessment.”
This assessment includes a review of a patient’s physical conditions, mental health and cognitive abilities. It also incorporates a review of their social, emotional and familial relationships, which are important factors in how patients fare after surgery. Geriatric specialists may also help with the assessment of a patient’s living environment, which can impact whether someone can return home after a traumatic injury.
Patients treated under the GIFTS program are co-managed by orthopaedics and geriatrics specialists for the duration of their hospital stay. “We oversee their pre-op and post-op care,” Dr. Javedan said. “We help manage all their medications and work with the anesthesiologists and surgeons to determine any modifications that may be needed based on the patient’s physiological age and level of frailty.”
Members of the GIFTS team also assist with the transition to rehabilitation facilities and help arrange for the appropriate physical therapy.
The program has produced measurable results. A 2016 study, which was published in the Journal of Bone and Joint Surgery and reviewed results from GIFTS, reported a reduction in the rates of delirium after a serious fracture, from about 30 to only 11.2 percent. “People used to think delirium was normal after a major trauma like a hip fracture, but now we know it’s not,” Dr. Javedan said. The study also found a drop in mortality rates one year after surgery, from 25 to 18.1 percent, in patients who were part of GIFTS.
Thanks to the success of GIFTS in the trauma setting, the program has expanded to include older people undergoing elective orthopaedic procedures like joint replacements. Geriatric specialists conduct assessments of older patients before they undergo these surgical procedures. Based on those evaluations, the level of care that patients receive can be adjusted to help them avoid complications and ensure they get the best results.