Comprehensive geriatric assessment for older orthopedic patients and analysis of risk factors for postoperative complications

Retrospective Analysis of Risk Factors in Geriatric Hip Fracture Patients Predictive of Surgical Intensive Care Unit Admission

INTRODUCTION

Although numerous risk factors and prediction models affecting morbidity and mortality in geriatric hip fracture patients have been previously identified, there are scant published data on predictors for perioperative Surgical Intensive Care Unit (SICU) admission in this patient population. Determining if a patient will need an SICU admission would not only allow for the appropriate allocation of resources and personnel but also permit targeted clinical management of these patients with the goal of improving morbidity and mortality outcomes. The purpose of this study was to identify specific risk factors predictive of SICU admission in a population of geriatric hip fracture patients. Unlike previous studies which have investigated predominantly demographic, comorbidity, and laboratory data, the present study also considered a frailty index and length of time from injury to presentation in the Emergency Department (ED).

METHODS

A total of 501 geriatric hip fracture patients admitted to a Level 1 trauma center were included in this retrospective, single-center, quantitative study from January 1, 2019, to December 31, 2022. Using a logistical regression analysis, more than 25 different variables were included in the regression model to identify values predictive of SICU admission. Predictive models of planned versus unplanned SICU admissions were also estimated. The discriminative ability of variables in the final models to predict SICU admission was assessed with receiver operating characteristic curves' area under the curve estimates.

RESULTS

 Frailty, serum lactate > 2, and presentation to the ED > 12 hours after injury were significant predictors of SICU admission overall (P = 0.03, 0.038, and 0.05 respectively). Additionally, the predictive model for planned SICU admission had no common significant predictors with unplanned SICU admission. Planned SICU admission significant predictors included an Injury Severity Score (ISS) of 15 and greater, a higher total serum protein, serum sodium <135, systolic blood pressure (BP) under 100, increased heart rate on admission to ED, thrombocytopenia (<120), and higher Anesthesia Society Association physical status classification (ASA) score (P = 0.007, 0.04, 0.05, 0.002, 0.041, 0.05, and 0.005 respectively). Each SICU prediction model (overall, planned, and unplanned) demonstrated sufficient discriminative ability with the area under the curve (AUC) values of 0.869, 0.601, and 0.866 respectively. Finally, mean hospital Length of Stay (LOS) and mortality were increased in SICU admissions when compared to non-SICU admissions.

CONCLUSION

Of the three risk factors predictive of SICU admission identified in this study, two have not been extensively studied previously in this patient population. Frailty has been associated with increased mortality and postoperative complications in hip fracture patients, but this is the first study to date to use a novel frailty index specifically designed and validated for use in hip fracture patients. The other risk factor, time from injury to presentation to the ED serves as an indicator for time a hip fracture patient spent without receiving medical attention. This risk factor has not been investigated heavily in the past as a predictor of SICU admissions in this patient population.

Risk Factors for Postoperative Cognitive Decline After Orthopedic Surgery in Elderly Chinese Patients: A Retrospective Cohort Study

Purpose

We aimed to identify the risk factors for postoperative cognitive decline (POCD) by evaluating the outcomes from preoperative comprehensive geriatric assessment (CGA) and intraoperative anesthetic interventions.

Patients and Methods

Data used in the study were obtained from the Aged Patient Perioperative Longitudinal Evaluation-Multidisciplinary Trial (APPLE-MDT) cohort recruited from the Department of Orthopedics in Xuanwu Hospital, Capital Medical University between March, 2019 and June, 2022. All patients accepted preoperative CGA by the multidisciplinary team using 13 common scales across 15 domains reflecting the multi-organ functions. The variables included demographic data, scales in CGA, comorbidities, laboratory tests and intraoperative anesthetic data. Cognitive function was assessed by Montreal Cognitive Assessment scale within 48 hours after admission and after surgery. Dropping of ≥1 point between the preoperative and postoperative scale was defined as POCD.

Results

We enrolled 119 patients. The median age was 80.00 years [IQR, 77.00, 82.00] and 68 patients (57.1%) were female. Forty-two patients (35.3%) developed POCD. Three cognitive domains including calculation (P = 0.046), recall (P = 0.047) and attention (P = 0.007) were significantly worsened after surgery. Univariate analysis showed that disability of instrumental activity of daily living, incidence rate of postoperative respiratory failure (PRF) ≥4.2%, STOP-Bang scale score, Caprini risk scale score and Sufentanil for maintenance of anesthesia were different between the POCD and non-POCD patients. In the multivariable logistic regression analysis, PRF ≥ 4.2% (odds ratio [OR] = 2.343; 95% confidence interval [CI]: 1.028-5.551; P = 0.046) and Sufentanil for maintenance of anesthesia (OR = 0.260; 95% CI: 0.057-0.859; P = 0.044) was independently associated with POCD as risk and protective factors, respectively.

Conclusion

Our study suggests that POCD is frequent among older patients undergoing elective orthopedic surgery, in which decline of calculation, recall and attention was predominant. Preoperative comprehensive geriatric assessments are important to identify the high-risk individuals of POCD.

Preoperative comprehensive geriatric assessment and multidisciplinary team input in older people undergoing elective orthopaedic surgery: A feasibility trial

OBJECTIVE

To determine the feasibility of preoperative comprehensive geriatric assessment (CGA) and multidisciplinary team (MDT) input for older people undergoing elective orthopaedic surgery in a tertiary New Zealand setting.

METHODS

This single-centre retrospective study included elective orthopaedic patients older than 65 years (and Māori/Pasifika aged greater than 55 years) with hyperpolypharmacy, frailty, neurocognitive disorders and poor functional status. Patients attended a preoperative clinic where they had a geriatrician-led CGA along with MDT input. The feasibility of this preoperative model was assessed using outcomes of acceptability, accessibility and adherence. A qualitative description of patient demographics along with clinic assessment and interventions further describes this pilot experience.

RESULTS

Sixty patients met inclusion criteria. This group were vulnerable older people (median age 77 years), with a high incidence of hyperpolypharmacy (85%), frailty (80%) and neurocognitive disorders (30%). Acceptability was high (97%), along with CGA accessibility (100%); however, MDT accessibility varied (53-90%). Adherence to MDT intervention was low; with only 26% of patients completing physiotherapy sessions and only 29% adhering to dietary advice. Accurate recall was a significant factor contributing to poor adherence. Comprehensive geriatric assessment was demonstrated to be a broad and flexible intervention.

CONCLUSIONS

CGA with MDT input is an acceptable and accessible intervention to be utilised as part of improved preoperative care for the older person undergoing elective orthopaedic surgery. Further consideration around methods to increase adherence in this patient group should be explored. Future research should focus on refining the intervention, and quantifying impact on patient outcomes.

Comprehensive Geriatric Assessment in the era of telemedicine

The aging global population poses significant medical and social challenges, necessitating efforts to promote healthy aging. Comprehensive Geriatric Assessment (CGA) is a multidimensional diagnostic approach for older adults that aims to improve overall health. Remote CGA, facilitated by technological advancements, offers convenience and other potential advantages. It enables early disease detection, monitors chronic disease progression, delivers personalized care, and optimizes healthcare resources for better health outcomes in older individuals. However, remote CGA also has limitations, including technological requirements, data security, and the need for comprehensive evaluation and simplicity. Collaborative efforts are essential to developing a digital home-based CGA platform that addresses accessibility issues and tailors the assessment process to meet the needs of older adults. Continuous optimization of remote CGA can become a pivotal tool for advancing geriatric care and ensuring the well-being of the aging population. Geriatr Gerontol Int 2024; 24: 67-73.

The role of comprehensive geriatric assessment in the identification of different nutritional status in geriatric patients: a real-world, cross-sectional study

Background

Malnutrition is an often unrecognized problem, but it is common in older patients and leads to adverse outcomes.

Aims

The purpose of this study is to analyze the prevalence of the risk of undernutrition in elderly patients and the correlation between CGA and nutritional status, and to determine the nutritional status of elderly patients.

Methods

This is a real-world cross-sectional study of continuously enrolled elderly patients aged 65 years or older with a complete CGA database. CGA inventory was prepared by compiling and screening general information, body composition and blood biochemical results. MNA was also conducted for each elderly patient to screen for malnutrition. A multivariable logistic regression analysis was used to determine the association between the CGA and nutritional assessment.

Result

The average age of the 211 selected elderly patients (160 men and 51 women) was 79.60 ± 9.24 years, and their ages ranged from 65 to 96 years. After controlling for confounders, patients with a history of PUD (OR = 2.353, p = 0.044), increased ADLs & IADLs scores (OR = 1.051, p = 0.042) or GDS scores (OR = 6.078, p < 0.001) may increase the incidence of the risk of undernutrition respectively, while an increase in BMI (OR = 0.858, p = 0.032) may lower the incidence of malnutrition risk. In addition, increased ADLs & IADLs scores (OR = 1.096, p = 0.002) or GDS scores (OR = 11.228, p < 0.001) may increase the incidence of undernutrition. However, increased MMSE (OR = 0.705, p < 0.001), BMI (OR = 0.762, p = 0.034), UAC (OR = 0.765, p = 0.048) and CC (OR = 0.721, p = 0.003) may decrease the incidence of undernutrition, respectively.

Conclusion

The study found that the prevalence of risk of undernutrition in elderly patients was the highest. Risk of undernutrition was independently associated with peptic ulcer disease, ADLs & IADLs, GDS and BMI. However, we found that when the nutritional status reached the level of undernutrition, it was related to more factors, including ADLs & IADLs, MMSE, GDS, BMI, UAC and CC. Determining the level of malnutrition through CGA may help to prevent and intervene malnutrition as early as possible.

Comprehensive geriatric assessment to predict adverse events in elderly patients undergoing posterior lumbar fusion surgery

PURPOSE

Although comprehensive geriatric assessment (CGA) has been used widely, its impact on adverse events in elderly patients has not been fully examined. The present study aimed to investigate the relationships between subcomponents of CGA and adverse events (AEs) in elderly patients undergoing posterior lumbar fusion surgery.

METHODS

A total of 242 eligible elderly patients enrolled. Our CGA included activities of daily living, instrumental activities of daily living, nutritional status, cardiac function, pulmonary function, renal function, frailty, cognition, anxiety, depression, delirium, chronic pain score, comorbidity and polypharmacy. Comprehensive complication index was used to summarize postoperative complications and its severity. Logistic regression was performed to determine the relationships between subcomponents of a CGA and postoperative AEs.

RESULTS

Present study found that female were more vulnerable to have AEs. Postoperative major AEs were associated with delirium (odds ratio (OR): 4.302, 95% confidence interval (CI) 1.720-10.761, p = 0.002), nutritional status (OR: 3.030, 95%CI 1.218-7.541, p = 0.017), cognitive impairment (OR: 4.122, 95%CI 1.179-14.407, p = 0.027), Charlson comorbidity index (CCI) (OR: 4.800, 95%CI 1.852-12.440, p = 0.001) and severe dependent (OR: 3.772, 95%CI 1.116-9.841, p = 0.007). Further analysis showed that delirium (OR: 2.824, 95%CI 1.068-7.467, p = 0.036) and CCI (OR: 3.221, 95%CI 1.184-8.766, p = 0.022) were independently related to major AEs.

CONCLUSIONS

These results indicate that preoperative screening preoperative delirium, cognitive, nutrition and CCI are essential to prevent postoperative major AEs of the surgical elderly.

Survival and Results after Resection and Reconstruction with Megaprosthesis at the Hip in Octogenarians

Few data are available about results after procedures of resection and megaprosthesis at the hip in very elderly patients. The aim of our study was to ascertain survival and complications in patients aged 80 or older undergoing these major orthopedic procedures. A consecutive series of 27 procedures in 26 patients aged 80-93 years was evaluated. In total, 15 procedures were performed due to oncological diseases, 6 were performed following joint arthroplasty failures or periprosthetic fractures, and 6 were performed after trauma or trauma sequelae. Survival of the patients ranged from 0 to 122 months. Overall survival was 56% at 3 years, 24% at 5 years, and 16% at 8 years. An early postoperative death during the first 3 months occurred in five patients (18.5%). The only preoperative parameter negatively affecting survival was preoperative hemoglobin lower than 11 g/dL. Local complications were similar to reported rates in all-age patients' series. In our experience, resection and megaprosthetic reconstruction can also be a valid choice in very elderly patients, with 56% of patients living more than two years from surgery and 24% more than five. Nevertheless, early postoperative deaths are frequent. A multidisciplinary evaluation of frailty of the patient must be accomplished, and patients and relatives must be informed about the risks of the procedure.

Gluteal Muscle Fatty Atrophy: An Independent Risk Factor for Surgical Treatment in Elderly Patients Diagnosed with Type-III Fragility Fractures of the Pelvis

BACKGROUND

Gluteal muscle fatty atrophy (gMFA) might impair pelvic stability and negatively influence remobilization in patients with fragility fractures of the pelvis (FFP). This study aimed to investigate the association between gMFA and surgical indication in patients with FFP.

METHODS AND MATERIALS

A retrospective analysis of 429 patients (age ≥80) diagnosed with FFP was performed. gMFA of the gluteus maximus, medius, and minimus was evaluated using a standard scoring system based on computer tomography images.

RESULTS

No significant difference was found in gMFA between genders or among FFP types. The severity of gMFA did not correlate with age. The severity of gMFA in the gluteus medius was significantly greater than in the gluteus maximus, whereas the most profound gMFA was found in the gluteus minimus. gMFA was significantly more severe in patients who underwent an operation than in conservatively treated patients with type-III FFP, and an independent correlation to surgical indication was found using logistic regression.

CONCLUSION

Our findings imply that gMFA is an independent factor for surgical treatment in patients with type-III FFP. Besides focusing on the fracture pattern, the further evaluation of gMFA could be a feasible parameter for decision making toward either conservative or surgical treatment of type-III FFP.

Assessment of Risk Factors for Postoperative Delirium in Older Adults Who Underwent Spinal Surgery and Identifying Associated Biomarkers Using Exosomal Protein

PURPOSE

With an increase in the aging population, the number of patients with degenerative spinal diseases undergoing surgery has risen, as has the incidence of postoperative delirium. This study aimed to investigate the risk factors affecting postoperative delirium in older adults who had undergone spine surgery and to identify the associated biomarkers.

METHODS

This study is a prospective study. Data of 100 patients aged ≥ 70 years who underwent spinal surgery were analyzed. Demographic data, medical history, clinical characteristics, cognitive function, depression symptoms, functional status, frailty, and nutritional status were investigated to identify the risk factors for delirium. The Confusion Assessment Method, Delirium Rating Scale-R-98, and Nursing Delirium Scale were also used for diagnosing delirium. To discover the biomarkers, urine extracellular vesicles (EVs) were analyzed for tau, ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), neurofilament light, and glial fibrillary acidic protein using digital immunoassay technology.

RESULTS

Nine patients were excluded, and data obtained from the remaining 91 were analyzed. Among them, 18 (19.8%) developed delirium. Differences were observed between participants with and without delirium in the contexts of a history of mental disorder and use of benzodiazepines (p = .005 and p = .026, respectively). Tau and UCH-L1-concentrations of urine EVs-were comparatively higher in participants with severe delirium than that in participants without delirium (p = .002 and p = .001, respectively).

CONCLUSION

These findings can assist clinicians in accurately identifying the risk factors before surgery, classifying high-risk patients, and predicting and detecting delirium in older patients. Moreover, urine EV analysis revealed that postoperative delirium following spinal surgery is most likely associated with brain damage.