A Culture Change in Geriatric Traumatology

Abstract

To design and consolidate a more patient-tailored approach for geriatric fracture patients will require a culture change. The author proposes to regard falls and subsequent fractures in geriatric patients not just as a common pathway of frailty, but rather as an end-stage manifestation of frailty. Although exceptions exist, these fractures should be considered an ill omen and characterize patients who are nearing or who are at the end of life. If care for these patients is to be improved, a shift in thinking is required. Physicians (including surgeons) should learn to better appreciate the complexity of geriatric trauma patients and bring about a culture change in geriatric traumatology. First, surgeons must learn to recognize frail patients and acknowledge that falls and resulting fractures are abnormal. Fractures in the geriatric population are symptoms of a larger set of problems, and merely treating the fracture does not address underlying frailty. Surgeons must also have a rudimentary understanding of geriatrics and palliative care, and be aware of the presence of cognitive impairment and reduced decisional capacity in 20% to 50% of all geriatric fracture patients.22,43,51–53 The most effective way to raise awareness for these aspects of care would be to incorporate them in the curriculum of residency programs. Second, we should aspire to provide more holistic and person-centered care. The first step should be to identify high-risk patients in an early stage and to have goals of care discussions. Ask patients what is important to them and balance benefits and harms of surgery against their goals of care. Palliative care, which may or may not include surgery, should be considered for severely frail patients. Third, we must adopt better preventive medicine strategies. Appropriate screening intervals and criteria are controversial for primary prevention of osteoporotic fractures, but for secondary prevention, all patients over the age of 50 years who suffer a fragility fracture should be screened for osteoporosis.54,55 The secondary prevention of osteoporosis is proven effective, with a low number needed to screen and number needed to treat.56 However, a worldwide care gap remains and only a small minority of patients who suffer an osteoporotic fracture subsequently receive treatment for osteoporosis.55,57 The primary reason for this lack of medical care is often reported to be a lack of understanding on the part of the treating physician regarding the role of osteoporosis as the cause of the fracture.55 Finally, and perhaps most importantly, we must find better ways to work together with our patients. The acute nature of trauma cannot be changed, cognitive impairment cannot be modified easily, and a degree of uncertainty in prognosis will always make medical decision making challenging in the field of geriatric trauma. However, collaboration with our patients may greatly be improved if parts of the decision making process are moved to the non-acute phase. Every older individual (including, but not limited to patients) should be motivated to deliberate on what their goals of care are in case of hospitalization, and to have advance care planning directives in place. To achieve this, awareness campaigns, goals of care discussions in outpatient settings, integration of geriatrics in the residency curriculum, and improved collaboration with primary care and nursing home physicians must all be part of the solution. We must encourage older individuals to think about what their treatment preferences are in case of hospitalization, long before they present to the emergency department. This will be an ambitious undertaking, but it is paramount to the culture change in geriatric traumatology.