European Geriatric Medicine - Supplement 1 - Volume 6

Symposia / European Geriatric Medicine 6S1 (2015) S157

–

S176

S159

accumulation of degenerative diseases and particularly cancer.

During the second part of last century, many theories of aging have

been proposed, to explain biologically this epidemiological link.

According to the Mutation accumulation theory, aging and cancer

have a common driver, the mutation burden. According to the

Antagonist pleiotropy theory, genes may confer advantages in early

life but become harmful in the elderly, inducing aging phenotypes,

while the Disposable soma theory describes the ability, in superior

eukaryotes, to distinct germ lines from somatic cells, conferring a

higher protection against aging in germ cells.

Strikingly, all these theories have found support during modern

biology era with experimental evidence on telomere biology,

senescence and stem cells regulation pathways. However,

increasing lines of evidence support on the top of these pathways

the existence of evolutionary-conserved programs, which regulate

the balance of energy. According to a Hyperfunction theory, aging

is a quasi-program favoring both age-related diseases and cancer

that could be tuned down by longevity pathways regulation.

This presentation will summarize these hypotheses and the

experimental data accumulated in the last sixty years, linking aging

and cancer.

Invited symposium: Pre- and postoperative care

S-04

Quality improvement in hip fracture care

I. Saltvedt

, O. Sletvold

, D. Marsh

, A. Johansen

, G. Pioli

St Olavs hospital, Trondheim, Norway;

Norwegian University of

Science and Technology (NTNU), Trondheim, Norway;

University

College London, London, England;

University hospital of Wales,

Cardiff, England;

ASMN Hospital, Reggio Emilia, Italy

Hip fractures are common among frail elderly patients and

may have serious consequences as impaired mobility, function,

quality of life, increased mortality and considerable costs for the

society.Because of the ageing population, the burden of disease

from fragility fractures is going to increase to a frightening extent

and current clinical systems will have to evolve to cope. In this

symposium research based upon audits, surgical methods and

orthogeriatric care that has been shown to improve outcomes for

hip fracture patients will be presented.

Rising to the global challenge

(David Marsh): Whilst Europe and

North America will see a doubling of hip fracture numbers in the

next few decades, in the emerging economies, six-fold increases

are expected. Disaster can only be prevented if two strategies are

vigorously followed: (i) prevent as many hip fractures as possible

by secondary prevention – reliably delivered to every fragility

fracture patient (including vertebral fractures) and (ii) manage the

fractures that do occur in the most cost-effective way, which means

multidisciplinary care, particularly orthogeriatric co-management.

The mission of the Fragility Fracture Network is to promote these

strategies globally, by focusing on the patients who present with

fractures and the (most often) orthopaedic surgeons who look after

them. While the two strategies above are the key message, good

outcomes also depend crucially on high quality surgery and the

FFN pays careful attention to this, not least because that gets the

attention of the surgeons.

Ageing bone heals, but it does so slowly and therefore the surgical

fixation has to remain strong for a long time; this is a challenge

when the bone is porotic, with greater risk of pull-out of implants.

Furthermore, protection from weight-bearing is not realistic in frail

patients so the limb has to be structurally stable immediately post-

surgery. Strategies to meet these surgical challenges include use of

intramedullary fixation, fixed angle devices and joint replacement

when a metaphyseal fracture is too difficult to fix. It is important to

realise that anti-resorptive drugs do not interfere with the fracture

healing process, except when a diaphyseal fracture is very rigidly

fixed. The latter surgical technique should therefore not be used

in fragility fractures and anti-osteoporotic treatment should always

be given as soon as possible, to prevent the next fracture.

The National Hip Fracture Database (NHFD)

–

Audit in Action

(Antony Johansen): All 180 trauma units in England, Wales and

Northern Ireland are now routinely uploading data to the National

Hip Fracture Database (NHFD) that is the largest national hip-

fracture audit in the world with 65,000 records each year and

over a third of a million patients since 2007. Over 95% of all new

cases are included. These data are used to audit each patients’ care

against standards defined by the British Orthopaedic Association,

the British Geriatrics Society, and the National Institute for Health

and Care Excellence (NICE).

Data are fed back to individual hospitals, and in its annual report

the NHFD also provides comparison of data, allowing units to

benchmark their performance against other hospitals which allow

the identification of ’outlier’ hospitals to whom advice and specialist

support can be offered.

This continuous process of quality improvement has supported

major changes in the care offered to patients. In particular it has

allowed NHS England to incentivise orthogeriatrician support to

Hip Fracture Programmes that were central to NICE Guideline

CG124, and this has supported trends for progressive reductions

in mortality and length of stay after the injury.

Our results are set alongside data from national data sources to

allow a more comprehensive picture of final length of stay and

mortality. Casemix adjusted reporting on two key measures (30

day mortality, and successful return to own home by 30 days) is

used to compare different hospitals’ outcomes.

Clinicians and managers have used NHFD participation to prompt,

monitor and evaluate clinical and service developments to improve

the quality and cost effectiveness of hip fracture care. The report

includes brief summaries of successful innovations that might

encourage similar developments elsewhere.

Overview of orthogeriatric treatment

(Giulio Pioli): In the

preoperative phase the goal of medical management is to maximize

the proportion of older hip fracture patients that undergo a

quick surgical repair. Usually about one third of elderly hip

fracture patients has abnormalities or active diseases at admission

but only less than 5% have medical problems that need a

surgical delay greater than 24 h. Fluid management and pain

control should be started very early possibly in the emergency

department as part of the initial orders given for emergency

care. A complete geriatric assessment is the best way to identify

and quantify medical and psychosocial comorbidities and pre-

fracture functional abilities in order to elaborate a comprehensive

therapeutic plan for preventing postoperative complications and

scheduling rehabilitation and discharge planning. However, almost

half of the patients experiences some minor medical complication

in the early postoperative phase, 15% develop major cardiovascular

events such as heart failure, myocardial infarction or stroke and

4–8% experiences a chest infection or sepsis. Standardization of the

management of the most common features of the perioperative

phase is an established way to improve the quality of the

intervention and the outcome in the postoperative phase. Subjects

with hip fracture and pre-existing disabilities may benefit, to a

great extent, from shortening bed rest time. However, the overall

goal of treatment for all patients is early mobilization, in an

effort to prevent the complications associated with prolonged

immobilization and to return the patient to functional activity.

Orthogeriatric co-management of hip-fracture patients; results

from two Norwegian RCTs

(Olav Sletvold): Recently results from

two Norwegian randomized controlled trials on orthogeriatric

care of hip-fracture patients has been published; the Oslo