Giulio Pioli (Reggio Emilia)

Gruppo Italiano di
Ortogeriatria (SIGG-AIP)
Problematiche
cliniche in ortogeriatria
La comorbilità in
ortogeriatria con
particolare attenzione
agli aspetti
psicogeriatrici
Giulio Pioli
ASMN-IRCCS
Reggio Emilia
Comorbidità prefrattura
Emilia Romagna Survey
Pooled analysis 974 subjects
Età > 75 anni
11-14 % no comorbidity
IADL = 8
4-5 % bedridden
80-85 % 1 or more comorbidities
Able to walk (with or without
help). Some functional
impairments in ADL or IADL
Pioli et al. • Time to surgery and rehabilitation resources affect outcomes in orthogeriatric units.
Arch Gerontol Ger, 2012
Prevalence of depression, cognitive impairment, and delirium in hip fracture
60% had one or more
of the three disorders
40% had none of
the three disorders
Cognitive
impairment
Givens et al. • Functional Recovery After Hip Fracture: The Combined Effects of Depressive Symptoms,
Cognitive Impairment, and Delirium. JAGS, 2008
Demenza come fattore di rischio di frattura
AD case (N = 56,186, mean age 79.9 (SD 6.8) years, range 42–101 years)
Hazard ratios for hip fractures according to age at AD diagnosis
Tolppanen et al. • Incident Hip Fractures among Community Dwelling Persons with Alzheimer’sDisease
in a Finnish Nationwide Register-Based Cohort. PLoS ONE 2013
Pathogenic framework for dementia and hip fractures
Friedman et al. • Dementia and Hip Fractures: Development of a Pathogenic Framework for
Understanding and Studying RiskGeriatric Orthopaedic Surgery & Rehabilitation 2010
Demenza come fattore di rischio dopo la frattura
Pain management
Sieber et al. • Postoperative Opioid Consumption and Its Relationship to Cognitive Function in Elderly
Hip Fracture Patients. J Am Geriatr Soc. 2011
Demenza come fattore di rischio dopo la frattura
Population-based, retrospective cohort study. Ontario, Canada.
45,602 older adults had hip fractures
Mortality
community
long term care
Seitz et al. • Effects of Dementia on Postoperative Outcomes of Older Adults With Hip Fractures: A
Population-Based Study. JAMDA 2014
Demenza come fattore di rischio dopo la frattura
Risk factors known at admission for failing to return to their own home
Vochteloo et al. • Risk factors for failure to return to the pre-fracture place of residence after hip
fracture. Arch Orthop Trauma Surg 2014
Demenza come fattore di rischio dopo la frattura
Mobility recovery
Vochteloo et al. • More than half of hip fracture patients do not regain mobility in the first
postoperative year. Geriatr Gerontol Int 2013
Orthogeriatric multidisciplinary intervention program
Umea˚ University Hospital, Sweden
RCT on patients aged 70 years or older
Subgroup analyses on patients with dementia (64%)
Postoperative complications
Stenvall et al. A multidisciplinary intervention program improved the outcome after hip fracture for
people with dementia—Subgroup analyses of a randomized controlled trial. Arch Gerontol Ger 2014
Recupero funzionale nella demenza
RCT. 243 independently living patients
Intervention: dedicated geriatric ward, multiprofessional team, physiotherapy
sessions twice a day, and daily activities were practised throughout the day with the
nurses , occupational therapy
Control
100
Independent living at 3 month
100
80
80
60
60
40
40
20
20
0
0
0-11
12-17
18-23
24-30
Independent living at 1 year
0-11
12-17
18-23
24-30
Huusko et al. Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with
hip fracture: subgroup analysis of patients with dementia. BMJ 2000
Recupero funzionale nella demenza
Galliera hospital.
Community-dwelling older adults (N199) aged 70 years or older
Variations of the Barthel Index From Prefracture Levels
P= .01
Home-Based Rehabilitation (n.99)
Subgroup with SPMSQ <8
Institutional-Based Rehabilitation ( n.100)
Subgroup with SPMSQ <8
Barone et al. An Analysis of the Feasibility of Home Rehabilitation. Arch Phys Med Rehabil 2006
Giusti et al. Rehabilitation After Hip Fracture In Patients With Dementia. JAGS 2007
Recupero funzionale nella demenza
CONCLUSION:
There is some evidence that older adults with cognitive impairment who receive
intensive inpatient rehabilitation after surgical repair of a hip fracture may be able to
gain comparable benefit in physical function as cognitively intact patients. There is
not enough information to guide recommendations of specific physical therapy
interventions to optimize outcomes in this patient population. Further work is
needed.
Muir et al. The impact of cognitive impairment on rehabilitation outcomes in elderly patients admitted
with a femoral neck fracture: a systematic review. J Geriatr Phys Ther. 2009
Recupero funzionale nella demenza
Multicenter study of the Stockholm Hip Fracture Group
with cognitive impairment (known dementia or low [0–2 points] score) in Short
Portable Mental Status Questionnaire [0–10 points]) and able to walk before the
fracture.
Al-Ani et al. Does Rehabilitation Matter in Patients With Femoral Neck fracture and Cognitive
Impairment? Arch Phys Med Rehabil 2010
Recupero funzionale nella demenza
Longitudinal study (n 231). Data were collected within 72 hours of admission to and before discharge from
the postacute rehabilitation facilities and at 2, 6, and 12 months following postacute rehabilitation
discharge
Young et al. Longitudinal Functional Recovery After Postacute Rehabilitation in Older Hip Fracture
Patients. J Am Med Dir Assoc 2011
Pattern del recupero funzionale dopo la frattura di femore
Consecutive 1-year survivors aged ≥65 years (n = 362)
Age (y) 81 ± 7, Women 85%
Longitudinal changes in ambulation
Ortiz-Alonso et al. The Pattern of Recovery of Ambulation After Hip Fracture Differs With Age in
Elderly Patients J Gerontol Med Sci 2012
Extended Multidisciplinary Rehabilitation
124 soggetti operati per frattura di femore dopo la riabilitazione standard
RCT
- Intervento: terapia fisica ad incremento progressivo (2 volte la settimana in strutture riabilitative) per
12 mesi. Controllo telefonico mensile più visita geriatrica mensile
- Controllo. Terapia standard compreso l’intervento ortogeriatrico in fase acuta, la riabilitazione
standard e interventi successivi se richiesti.
%
ADL. Variazione media a 12 mesi
rispetto al valore prefrattura
P <0.01
0
intervento
P <0.04
controllo
-0,5
-1
P = 0.02
-1,5
Singh et al. Effects of High-Intensity Progressive Resistance Training and Targeted Multidisciplinary
Treatment of Frailty on Mortality and Nursing Home Admissions after Hip Fracture. JAMDA 2012
Prevalence of depression, cognitive impairment, and delirium in hip fracture
60% had one or more
of the three disorders
40% had none of
the three disorders
Delirium
Givens et al. • Functional Recovery After Hip Fracture: The Combined Effects of Depressive Symptoms,
Cognitive Impairment, and Delirium. JAGS, 2008
Complications during orthopedic stay - Delirium
Prospective inception multicenter cohort study: 806 patients, mean age 86 yrs, 24% male
Relative percent of
total incidence
35%
30%
Total incidence of
delirium: 38% of patients
Prima
intervento
15%
25%
Prevalence of
delirium
PO#3= 22%
20%
15%
10%
5%
Dimissione
2%
Ingresso
9%
0%
Pre-S
0
1
2
3
4
PO days
5
6
7
8
9
10
Delirium e outcome nel paziente con frattura di femore
Prospective 6-month followup of 106 elderly hip fracture patients free from
prefracture dementia.
Logistic regression analysis of factors associated with
development of dementia
Krogseth et al. Delirium Is an Important Predictor of Incident Dementia among Elderly Hip Fracture
Patients. Dement Geriatr Cogn Disord 2011
Delirium e outcome nel paziente con frattura di femore
Prospective observational study,
including 331 hip fracture patients.
OR 0.93 (0.34–2.54) p= 0.894
OR 1.05 (0.58–1.90) p= 0.882
Juliebø et al. Delirium Is Not Associated with
Mortality in Elderly Hip Fracture Patients.
Dement Geriatr Cogn Disord 2010
Lee et al. Frequency, Risk Factors, and Prognosis
of Prolonged Delirium in Elderly Patients After
Hip Fracture Surgery. Clin Orthop Relat Res 2011
Delirium e outcome nel paziente con frattura di femore
Prospective observational study,
including 61 hip fracture patients.
Olofsson et al. Delirium is associated with poor
rehabilitation outcome in elderly patients
treated for femoral neck fractures. Scand J
Caring Sci 2005
Prospective cohort study. 2642
patients aged 65 years
Morandi et al. Delirium Superimposed on
Dementia Strongly Predicts Worse Outcomes in
Older Rehabilitation Inpatients. JAMDA 2014
Fattori di rischio di delirium nel paziente con frattura di femore
Evidence for association
Precognitive impairment
+++
Reduced ADL
+
Injury in an indoor environment
+/-
Fever, infection
++
Operative delay
++
Low BMI
+
Advanced age
++
Fluid and electrolyte abnormalities
+
Drugs
+
Anesthesia
+
Male sex
+/-
Pain
+
Bitsch 2004, Brauer 2000, Furlaneto 2008, Sieber 2010, Juliebo 2009, Lee 2011
Interventi per ridurre il delirium nei pazienti con frattura di femore
RCT 263 pts
cognitively intact at admission
50
45
40
35
30
25
20
15
10
5
0
%
34
33
22
The multi-factorial program for patients in the intervention
group starting pre-hospitally.
1. Supplemental oxygen 3–4 l/min
2. Intravenous (i.v.) fluid supplementation and extra nutrition
3. Increased monitoring of vital physiological parameters
4. Adequate pain relief
5. Avoid delay in transfer logistics:
6. Screen for delirium through daily testing
7. Avoid polypharmacia:
8. Perioperative/Anesthetic period
21
Control
Intervention
Delirium during
hospitalization
Post-operative
delirium
Bjorkelund et al. Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention
study. Acta Anaesthesiol Scand 2010
Interventi per ridurre il delirium nei pazienti con frattura di femore
Delirium prevention protocol
1. Assessing the risk for a delirium at admission,
2. prophylaxis for high-risk patients (2 times a day 1 mg of
haloperidol)
Before after study
200 pts
50
45
40
35
30
25
20
15
10
5
0
Delirium incidence (%)
Delirium
prevention
protocol
2005
2006
2007
2008
Vochteloo et al. Delirium risk screening and haloperidol prophylaxis program in hip fracture patients.
BMC Geriatrics 2011
Interventi per ridurre il delirium nei pazienti con frattura di femore
Pilot study RCT.
30 subjects acelerated care
(surgery within 6 h)
30 subjects standard care
(surgery within 24 h)
Meang age 82 y
HIP ATTACK iInvestigatprs • Accelerated care versus standard care. CMAJ 2013
Prevalence of depression, cognitive impairment, and delirium in hip fracture
60% had one or more
of the three disorders
Depressive
Symptoms
40% had none of
the three disorders
Givens et al. • Functional Recovery After Hip Fracture: The Combined Effects of Depressive Symptoms,
Cognitive Impairment, and Delirium. JAGS, 2008
Osteoporosi e depressione
prospective cohort study of 2,464 community-dwelling men, aged 68 and older,
Osteoporosis in Men Sleep Ancillary Study
Mean annualized rate of bone loss
Men
Diem et al. Depressive symptoms and rates of
bone loss at the hip in older men. Acta
Osteoporos Int. 2013
Women
Diem et al Depressive symptoms and rates of
bone loss at the hip in older men.
J Am Geriatr Soc 2007
Depressione e outcome nel paziente con frattura di femore
423 pts admitted for post-HF surgery
rehabilitation
211 pts admitted for post-HF surgery
rehabilitation
1 year - death or institutionalization
Morghen et al. Moderate to severe depressive
symptoms and rehabilitation outcome in older
adults with hip fracture Int J Geriatr Psychiatry 2011
Bellelli et al. Depressive symptoms combined with
dementia affect 12-months survival in elderly
patients after rehabilitationpost-hip fracture
surgery Int J Geriatr Psychiatry 2008
Depressione e outcome nel paziente con frattura di femore
ambulatory status
Modified Barthel Index
Feng et al. Comorbid cognitive impairment and depression is a significant predictor of poor outcomes in
hip fracture rehabilitation.Int J Geriatr Psychiatry 2010
Depressione dopo la frattura di femore
126 pts underwent surgical repair after HF
Excluded history of major depressive episode and severely cognitively impaired
Lenze et al. Onset of Depression in Elderly Persons After Hip Fracture: Implications for Prevention and
Early Intervention of Late-Life Depression. J Am Geriatr Soc 2007
Depressione dopo la frattura di femore
• Slight reduction in depressive
symptoms in the active arm of
the treatment study.
• In the prevention study, there
was no significant difference in
incident depression
• There were no differences in
the functional and pain
outcomes.
Burns et al. Treatment and Prevention of Depression After Surgery for Hip Fracture in Older People:
Randomized, Controlled Trials. J Am Geriatr Soc 2007
Key points in a complex system
Hip
fracture
Obiettivi primari
Riduzione delle complicanze
Riduzione della mortalità
Aumento del recupero funzionale
Permanenza in comunità al proprio domicilio
Long term
outcomes
Evidence based interventions to improve outcomes after hip fracture
Surgical
timing
Early
Rehab
Delirium
Prevention
Multidisciplinary
rehab
Acute
Protein
Supllement
Orthogeriatric
comangement
Extended
Multiprofessinal
Intervention
Fall
prevention
Long-term
Post-acute
Bone
Health
Take home message
Hip
fracture
Long term
outcomes
Al momento non è noto se in questo sistema complesso un singolo intervento rivolto
a prevenire/trattare il delirum o la depressione migliori gli outcome maggiori nei
pazienti con frattura di femore
L’approccio multidimensionale di tipo ortogeriatrico che include il trattamento della
depressione e la prevenzione del delirium ma che comprende anche la rapida
dell’intervento chirurgico e della mobilizzazione, il supporto nutrizionale, la
prevenzione delle complicanze, l’ottimizzare dei livelli di emoglobina e dei fluidi, è in
grado di incidere sia sulla mortalità che sul recupero funzionale dei soggetti con
frattura di femore sia cognitivamente integri che affetti da demenza.

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