Keywords

6.1 Introduction

In 2023, the population of the world exceeded eight billion for the first time, and as it continues to grow, so does the proportion of older adults. This can be seen as a positive result of the advancement of modern medicine and the evolution of specialties and interventions specific to the care of older people. However, as people age, they develop more chronic conditions, requiring more medications and needing more healthcare resources to support them. Globally, there is a need to focus on how to support the health and well-being of older people without risking overburdening stretched and/or resource-limited health services. It is widely accepted that, in many countries, fragility fractures will continue to rise in accordance with an increasing older population.

Healthcare professionals will encounter patients with fractures in a variety of clinical settings such as general practice, emergency departments, fall clinics, intermediate care services, acute medical wards, rehabilitation, convalescence services, their own homes, and long-term residential care homes. Older people with fragility fractures are a diverse group, and their care needs are complex. Although some have comparatively few underlying health problems, many have a series of interconnected illnesses and psychological and social problems requiring a range of health and social care interventions. Following a fragility fracture, it is often social and functional decline relating to frailty and vulnerability that has the biggest impact on an older person’s ability to maintain independence (Chap. 3).

Throughout this book, there is reference to orthopaedic and geriatric co-management of patients with or at risk of a fragility fracture, known as orthogeriatric care. Although the orthogeriatric speciality is well established in some countries, it is not common in many others. The primary focus of orthogeriatric care is to ensure that those older adults admitted with a fragility fracture receive as high a standard of care in an orthopaedic unit as they would in a setting specialising in the care of the older adult. The care should provide excellent orthopaedic surgical management as well as excellent geriatric care, in a way that is collaborative, interdisciplinary and person-centred.

Evidence about how best to care for fragility fracture patients has been garnered from the ever-growing number of national clinical audits around the globe [1]. The objectives of these are usually to collect data about the care, standards and outcomes of those with a hip fracture. In some countries, this has recently evolved to capture evidence about other non-hip fragility fractures. This data has become a powerful driver for the development of orthogeriatric services in many countries including England, Ireland, Scotland, Wales, Northern Ireland, Australia, Denmark, Sweden, Norway, Spain and Canada. The audits gather and analyse information about all aspects of care including, as a core data set, geriatric review, bone health and specialist fall assessment. Some audits have been evolving to capture nutritional screening and delirium assessment, alongside functional and quality-of-life measures.

The term ‘geriatric syndrome’ encompasses older adults’ common health problems that do not fit into distinct organ-specific disease categories and that have multifactorial causes including frailty (Chap. 3), cognitive impairment (Chap. 12), delirium, incontinence, malnutrition (Chap. 11), falls (Chap. 4), gait disorders, pressure ulcers/injuries (Chap. 9), sleep disorders, sensory deficits, fatigue and dizziness. These can all lead to lowered quality of life (QoL) and increased disability [2].

To diagnose these geriatric syndromes, a comprehensive, interdisciplinary geriatric assessment should be performed, undertaken as part of the orthogeriatric assessment as an essential aspect of orthogeriatric care. There is compelling evidence that improves outcomes for older adults. Early orthogeriatrician review helps avoid delay to surgery, improves perioperative care and expedites rehabilitation and discharge planning [3]. Problems that relate to ageing such as functional impairment and dementia are common and often unrecognised or adequately addressed by other healthcare professionals. Identifying problems specific to ageing so that interventions can be tailored to meet the individual’s needs when they also have a fragility fracture requires a detailed and comprehensive assessment. This helps clinicians manage these conditions and prevent or delay their progression, deterioration and complications. This must be conducted collaboratively by the whole interdisciplinary team so that the skills of each team member can contribute to building a picture of the patient’s needs through the entire care continuum (Fig. 6.1). Nursing and other practitioners’ assessment are a significant part of this process.

Fig. 6.1
A photo of three labeled cylindrical pillars representing co-managing acute episodes, rehabilitation, and secondary prevention.

The three pillars of the fragility fracture care continuum (Adapted from Fragility Fracture Network https://fragilityfracturenetwork.org/)

Full size image

The aim of this chapter is to outline the nursing role in supporting the care of older adults who have sustained a fragility fracture. This will focus on how the nurse’s role is integrated into the interdisciplinary team, who have a combined goal to ensure that the patient receives a comprehensive (ortho)geriatric assessment (CGA).

6.2 Learning Outcomes

At the end of this chapter, and following further study, the practitioner will be able to

  • Explain the principles of comprehensive (ortho)geriatric assessment (CGA) from a nursing perspective.

  • Identify how the CGA process applies to the whole interdisciplinary team.

  • Discuss the nursing contribution to comprehensive assessment of the older person with fragility fracture.

6.3 The Purpose of CGA

A 2017 Cochrane systematic review found that those patients who were cared for based on CGA while they are inpatients were more likely to be discharged home as well as more likely to survive admission to hospital, have good outcomes and return home [4]. The better an older person’s health and well-being are understood, the more effective interventions are likely to be. This enables the orthogeriatric team to manage other health issues and threats at the same time as the fracture. The British Geriatric Society (2021) defined CGA as ‘a multidimensional, interdisciplinary diagnostic process to determine medical, physiological and functional capabilities of a frail older person in order to develop a coordinated and integrated care plan for treatment and long term follow-up’. The process of CGA is coordinated, communicated and person-centred and involves five central assessment themes [5]:

  • Environmental

  • Functional

  • Social networks

  • Medical

  • Psychological/cognitive

Assessment involves collecting information about a person’s circumstances and needs and making sense of that information to help in decision-making about what support, treatment and care are needed; it should be timely and comprehensive.The assessment of older adults differs from standard medical/health review in three ways

  1. 1.

    It focuses on older adults with complex problems.

  2. 2.

    It emphasises functional status and quality of life.

  3. 3.

    It takes advantage of an interdisciplinary team.

The gathering of information as part of CGA is not the responsibility of the geriatrician/physician in isolation. Their skill is in interpreting the data and recommending a course of action to resolve the challenges identified. An ongoing and interdisciplinary approach to assessment is essential to obtain the broadest understanding of the person’s well-being prior to their admission or fall. A multidimensional assessment considers medical comorbidities, physical and baseline functional ability, and environmental and social factors affecting the person with a fracture. From this assessment, an integrated personalised plan of care can be developed, applying not only to the peri-operative period but also in the rehabilitation and transitional care to home and community services.

Nurses and other allied health professionals take an active part in the CGA process, with getting to know the person, their strengths and needs being an important first step in effective care [6]. This reflects the APIE (assessment, planning, implementation and evaluation) approach familiar to nurses. Comprehensive assessment can also facilitate the identification of individual needs and identification of risks that might impact care outcomes and inform effective discharge planning [7].

The first step in CGA is to identify those individuals who are likely to benefit from this process alongside the orthogeriatric team approach. According to NICE (2016) [8], older people who present because of a fall, immobility, dementia or delirium; have polypharmacy or incontinence; or are approaching the end of life should receive CGA.

Following a fragility fracture, the most common vehicle for CGA is that of orthogeriatric assessment. The Scottish, UK, Irish and Australian guidelines on hip fracture care all recommend that CGA-orthogeriatric assessment should take place within 3 days of admission. Both the Scottish and Irish standards state that this assessment could be undertaken by either a geriatrician/physician or a specialist nurse with experience in the management of older people; the geriatrician or specialist nurse is not responsible for obtaining all of the information required, but synthesise the information, identify interventions and formulate a plan of care. The Scottish guidelines [9] recommend that the following should be considered part of CGA for orthogeriatric patients:

  • Assessment of comorbidities

  • Assessment of functional abilities

  • Medication review

  • Cognitive assessment

  • Nutritional assessment

  • Assessment for sensory impairment

  • Specialist fall assessment

  • ECG

  • Lying and standing blood pressures

  • Continence review

  • Assessment of bone health

  • Discharge planning

The skill, at the heart of orthogeriatric care, is developing a comprehensive picture of the potential impact of comorbidities and functional capacity to try to predict their potential impact on the patient’s recovery and rehabilitation following the fracture [9], and for this knowledge to direct care provision.

There is limited but evolving discussion about the role of nurses in the process of CGA. Nurses are integral to the interdisciplinary team, are often care coordinators and contribute to the assessment through their expertise in domains such as nutrition, pressure ulcers/injuries, cognition and continence. As demonstrated in both the Irish hip fracture and Scottish hip fracture guidelines, specialist nurses can undertake the key role of coordinator in CGA.The key features of CGA [3] are that it involves

  • Coordinated interdisciplinary assessment, so that each member of the team can contribute expertise; the team is commonly made up of a geriatrician/physician, nurse and therapists, but can involve other health professionals depending on clinical needs.

  • One team member leads the process as the coordinator or ‘case manager’.

  • Geriatric medicine expertise, so that the medical management of the patient’s health problems can lead to interdisciplinary interventions.

  • Identification of medical, physical, social and psychological problems so that a comprehensive picture can be obtained and the impact of each of these understood.

  • Formation of a plan of care that includes appropriate rehabilitation.

CGA should be initiated as soon as possible after admission by a skilled, senior member of the interdisciplinary team and used to identify reversible medical problems, target rehabilitation goals and plan all the components of discharge and post-discharge support needs [10]. But it is not a one-off process, so should continue throughout the care process with constant review and evaluation.

To facilitate recording and sharing of assessment findings, the interdisciplinary team should use and share documentation specifically developed for the purpose to help clinicians to follow the process comprehensively and logically and in a way that is easily communicated within the team. The same process and documentation should follow the older person after discharge to home care and other community-based care facilities.

Performing a comprehensive assessment is an ambitious undertaking that can be more complex than it may initially seem (Box 6.1). Older people can struggle to recall their past medical history, and temporary or long-standing cognitive impairment can make it difficult for them to reliably answer questions. Resolving this involves skilled communication with the patient and collaboration with family and other people who know the individual well. Maximising communication by resolving problems with hearing and sight beforehand is also central to successful assessment.

Box 6.1 Areas of Assessment that Team Members May Choose to Assess Depending on Patient Needs

  • Current symptoms and illnesses and their functional impact

  • Current medications, their indications and effects

  • Relevant past illnesses

  • Recent and impending life changes

  • Objective measure of overall personal and social functionality

  • Current and future living environment and its appropriateness to function and prognosis

  • Family situation and availability

  • Current caregiver network including its deficiencies and potential

  • Objective measure of cognitive status

  • Objective assessment of mobility and balance

  • Rehabilitative status and prognosis if ill or disabled

  • Current emotional health and substance abuse

  • Nutritional status and needs

  • Disease risk factors, screening status and health promotion activities

  • Services required and received

  • Spiritual needs

6.4 Dimensions of Comprehensive Geriatric Assessment

Comprehensive assessment involves looking not only at disease states as a standard medical assessment would do, or at functional ability as a standard rehabilitation assessment might do, but at a range of domains. By assessing each of these domains of health, a comprehensive assessment can be made, and the full nature of the individual’s problems identified. This process can be supported by using standardised scales and tools, or full formal assessment schemes such as the ‘interRAI’ assessment tools (www.interrai.org). Using standardised scales encourages consistent practice, helps to ensure safety (e.g. pressure ulcer/injury risk screening) and enables detection of serial changes. However, scales can also be time-consuming and clinically constraining. Clinicians undertaking CGA should consider the extent to which standardised approaches are helpful in their own setting [11]. Core components of CGA that should be considered during the assessment process are outlined in Table 6.1, and the following sections consider some of these in more detail.

Table 6.1 Domains and suggested items for comprehensive geriatric assessment [10]
Full size table

6.4.1 Functional Status

Functional status refers to the ability to perform activities necessary or desirable in daily life. It is directly influenced by health conditions, particularly in the context of an older person’s environment and social support network. Changes in functional status (e.g. not being able to bathe independently) should prompt further diagnostic evaluation and intervention. Measurement of functional status can be valuable in monitoring response to treatment and can provide prognostic information that assists in long-term care planning. With respect to the impact of functional status on activities of daily living (ADLs), an older person’s functional status can be assessed at three levels:

  1. 1.

    Basic activities of daily living (BADLs)

  2. 2.

    Instrumental or intermediate activities of daily living (IADLs)

  3. 3.

    Advanced activities of daily living (AADLs)

BADLs consider self-care tasks including bathing, dressing, toileting and maintaining continence, grooming, feeding and transferring. IADLs consider the ability to maintain an independent household including shopping for groceries, driving or using public transportation, using the telephone, performing housework, home maintenance, preparing meals, doing laundry, taking medication and handling finances.

Such is the importance of information about mobility and functional status that several national hip fracture audits have incorporated standardised assessment: for example, the New Mobility Score [12] to assess pre-fracture mobility and the Cumulative Ambulatory Score [13] to capture functional progress (Chap. 8). Some audits have created a national clinical standard for mobilisation. Early mobilisation for hip fracture patients has been shown to increase the number of patients going home and reduce the number going into long-term care and dying as an inpatient [14].

In addition to considering ADLs, gait speed alone predicts functional decline and early mortality in older adults. Assessment of gait speed is usually the domain of the physiotherapist within the team (Chaps. 8 and 14) and may identify patients who need further evaluation, such as those at increased risk of falls (Chap. 4). Assessing gait speed may also help identify frail patients who might not benefit from treatment of chronic asymptomatic diseases such as hypertension. For example, elevated blood pressure in individuals aged 65 and older is associated with increased mortality only in individuals with a walking speed ≥0.8 m/s (measured over 6 m or 20 feet) [15].

6.4.2 Falls

Most falls occur in the home or where the person is residing (e.g. residential home) [16, 17]. Approximately one-third of community-dwelling people over 65 years and half of those over 80 years of age fall each year [18]. Older people are much more likely to suffer harm from a fall. Those who have fallen or have a gait or balance problem are at higher risk of having a subsequent fall and losing independence. An assessment of fall risk should be integrated into the history and physical examination of all older patients. A home safety assessment or advice about how to keep safe in the home and make the home safe to prevent falls should be shared with patients. Chapter 4 considers fall assessment and prevention in more detail.

6.4.3 Cognition

The incidence of dementia and delirium increases with age, particularly among those over 85 years; yet, many older people with cognitive impairment remain undiagnosed. Delirium is very common in orthopaedic patients and should be proactively screened for initially and then regularly throughout admission (Chap. 12). The value of making an early diagnosis includes the possibility of uncovering treatable causes. The evaluation of cognitive function can include a thorough history, brief cognition screening, a detailed mental status examination, neuropsychological testing and other tests to evaluate medical conditions that may contribute to cognitive impairment. The introduction of the 4AT assessment tool (Chap. 9) has been adopted and reported in several hip fracture audits. This is a very short but sensitive test (takes less than 2 min) for delirium and, crucially, can be carried out by any member of the healthcare team https://www.the4at.com/ [19].

6.4.4 Mood

Depressive illness in older people is a serious health concern leading to unnecessary suffering, impaired functional status, increased mortality and excessive use of healthcare resources (Chap. 13). It can also have a negative impact on recovery from fragility fracture. Depression in later life remains underdiagnosed and inadequately treated. It may present atypically and may be masked in those with cognitive impairment. Screening is easily administered and can identify patients at risk if both of the following questions are answered affirmatively:

  1. 1.

    ‘During the past month, have you been bothered by feeling down, depressed or hopeless?’

  2. 2.

    ‘During the past month, have you been bothered by little interest or pleasure in doing things?’

6.4.5 Polypharmacy

There are different definitions of what constitutes polypharmacy; some say that it is taking four or more medications. It is linked to an increased risk of falls. Older people are often prescribed multiple medications by different healthcare providers, placing them at increased risk of drug interactions and adverse medication events. A medical practitioner would usually review medications at each visit, but nursing roles such as advanced nurse practitioners (ANPs) now carry out some of these tasks and are often best placed to do this as they are most familiar with the patient. The best method of detecting potential problems with polypharmacy is to have patients provide all medications (prescription and non-prescription) in their packaging. Otherwise, practitioners should contact the patient’s primary care practice, particularly if the patient cannot remember their medications. As some health systems have moved towards electronic health records and electronic prescribing, the possibility of detecting potential medication errors and interactions has increased. Older people should also be asked about alternative medical therapies such as herbal medicine use with the question: What prescription medications, over-the-counter medicines, vitamins, herbs or supplements do you use?

6.4.6 Social and Financial Support

The existence of a strong social support network in an older person’s life can be the determining factor in whether they can remain at home or need to be in a residential care setting. A brief screen of social support includes taking a social history and determining who is available to help them. Early identification of problems with social support can help planning and timely development of resource referrals. For patients with functional impairment, the practitioner should ascertain who the person has available to help with ADLs. It is also important to assess the financial situation of a functionally impaired older adult; some may qualify for state or local financial benefits, and there may be other sources such as long-term care insurance or veteran’s benefits that can help in paying for caregivers and avoid the need for residential care.

Gathering information can be complex [20], particularly collecting accurate baseline information from patients who may have cognitive difficulties, especially if the environment is noisy such as in the ED or busy trauma unit, or in the presence of pain, opioid analgesia or anaesthesia. In the first few hours following admission, the patient is more likely to recall the history of the injury due to more recent recall, but this period is also very stressful. Collecting detailed and accurate information needs specialised skills in communication and an expert understanding of the process of assessment.

6.4.7 Spiritual Needs

Spirituality is an important source of inner strength and is fundamental to giving meaning to life, dealing with adversity and experience of ageing, ill health and injury. For older people, it is equally as important as physical considerations [21].

Developing familiarity with a person’s spiritual needs during the comprehensive assessment assists health professionals to identify their specific needs, and spiritual coping strategies can be applied by individuals to deal with the challenges related to hip fractures. Once older adults’ spiritual needs are recognised, a collaborative team approach typically provides the best method to address these needs. Interprofessional collaboration often plays an indispensable role in addressing the spiritual needs and concerns of older adults.

Poor quality of life and health status experienced by persons following a hip fracture have been identified, which persists for a long period of time following this life-changing event. The use of spiritual coping strategies has been shown to be an effective coping mechanism by which older adults adapt to the stressors imposed by hip fractures [22].

6.5 Assessment Tools

Although the amount of potentially important information may seem overwhelming, formal assessment tools and shortcuts can reduce this burden on the clinician performing the initial CGA. An advance questionnaire given to the patient or caregiver prior to the initial assessment can be time-saving when there is a need to gather a large amount of information and timing allows, although this is rarely an option when there is an acute admission and urgent surgery. Questionnaires can be used to gather information about general history (e.g. past medical history, medications, social history, review of systems) as well as gather information specific to CGA. These frequently form part of an integrated care pathway and can be completed by nurses or other professionals during their initial assessments and should include information such as:

  • Ability to perform functional tasks and need for assistance

  • Fall history and previous fractures

  • Urinary and/or faecal incontinence

  • Pain

  • Sources of social support, particularly family or friends

  • Depressive symptoms

  • Vision or hearing difficulties

  • Whether the patient has specified a ‘lasting power of attorney’ for healthcare

Support staff and assistants can be trained to administer screening instruments to both save time and help the clinician to focus on specific disabilities that need more detailed evaluation. If there is an advanced nurse practitioner (ANP) in place, they would be ideally placed to carry out and act on the findings of these assessments and, in doing so, provide a more seamless service. Within their scope of practice, ANPs with advanced competencies in their area of expertise provide holistic care to patients [23].

6.6 Post-hospital Discharge CGA

Key elements of post-hospital discharge CGA include targeting criteria to identify vulnerable patients, a programme of multidimensional assessment, comprehensive discharge planning and home follow-up. This can be conducted by nurses with specialised geriatric practitioner skills or ANPs who visit patients during hospitalisation and can provide follow-up after discharge by either home visit, review at a clinic or more recently, due to the COVID-19 pandemic, remotely. Ideally, there should be contact within the first few days after discharge and ongoing support or review planned with the patient and/or family as required. Patients often cannot absorb information during the hospital admission due to illness, so these subsequent reviews provide an opportunity to reiterate information that will support their recovery, e.g. bone health medication compliance, fall prevention strategies and any unresolved or ongoing issues. This process should integrate with physical therapy, occupational therapy, social work and/or home nursing services when indicated in the community (Chap. 16).

6.7 Secondary Prevention

Secondary fracture prevention is an important aspect of orthogeriatric assessment and is discussed in Chap. 2.

6.8 The Nursing and Interdisciplinary Team Role

Traditionally, the various components of the CGA process are completed by different members of the team, with considerable variability in the way assessments are conducted and recorded. However, recently, there have been more conscious efforts to reduce the fragmented approach to trauma care for older people and create a more seamless approach [18]. The medical assessment of older people may be conducted by a physician (usually a geriatrician), nurse practitioner, physiotherapist or physician assistant. The core team (geriatrician/physician, nurse, therapist and social worker) may conduct only brief initial assessments or screening for some dimensions. These may be subsequently augmented with more in-depth assessments by additional professionals such as a dietitian/nutritionist who may be needed to assess dietary intake and make recommendations for optimising nutrition, or an audiologist who may need to conduct a more extensive assessment of hearing loss and evaluate an older person for a hearing aid.

Because of the 24-h nature of their practice and the wide range of care, nurses are often expected to take a leading role in the care of older people and to coordinate the assessment process. Despite this, the role of the nurse in CGA is ill defined and is not considered in detail in the literature, particularly in the orthogeriatric setting. The potential for nurses, particularly those with advanced assessment skills, to act as a fulcrum for the CGA process is largely untapped. The nursing role in managing and caring for these patients is an integral one, acting like a hub-and-spoke model of care—with the nurse being in the centre as the key professional working with the patient, who then interacts with the other specialities and implements recommendations, prescriptions and interventions and liaises continuously with all specialities, the patient and their family.

Nursing is already directed by the nursing process: incorporating APIE. Clarke [23] suggested that this traditional view of the nursing process focuses on identifying need deficit and that a more effective philosophy is to assess the resources of older people themselves and jointly plan care alongside the MDT, patients and carers so that as much self-management is retained as possible. Nurses place importance on coming to know a person as an individual through a continuous and ongoing assessment process that will support the rest of the nursing process (planning, implementation and evaluation) and help them to provide effective care. This knowledge can only be achieved by a comprehensive assessment process that incorporates the biological, psychological, social and spiritual dimensions of the person [10].

While the CGA process has not been specifically developed to capture patients’ nursing needs, it is becoming more common for it to be a holistic interdisciplinary assessment for the whole team and to ensure that the complex needs of patients with fragility fractures are fully met through a continuous process while looking for changes in the patient’s condition. The whole team need to work together to further develop this process from a collaborative perspective so that the many different forms of mono-disciplinary assessment processes and associated documentation can be brought together as a single, effective process [20]. New or adapted assessment tools may be required for use by all professionals in the team that can be used to facilitate interdisciplinary and interagency working [17] but also with a view for seamless transfers between primary and secondary care settings. All practitioners should be able to use the information generated during CGA to develop treatment and long-term follow-up plans, arrange for primary care and rehabilitative services, organise and facilitate the intricate process of case management, determine long-term care requirements and optimal placement and make the best use of healthcare resources.

The assessment process in most units is not perfect, and there is a need to identify ways to both improve the assessment process and demonstrate the value of nursing in this central aspect of care.

Summary of Key Points

  • Timely and comprehensive assessment is essential in understanding the needs of older people and ensuring that their needs are met through care and treatment.

  • CGA is a person-centred, holistic, interdisciplinary process that helps to assess the frail older person so that their medical conditions, mental health, functional capacity and social circumstances can be considered in detail and from which patients with fragility fractures can benefit significantly.

  • The process should begin on admission and be followed through to post-discharge care in primary and residential care settings: it is not a one-off process but should be subjected to constant review and evaluation.

  • The CGA process should, as a minimum, consider the domains of physical health and medical conditions, mental health and psychological status, functioning, social circumstances and environment so that MDT care and treatment can be based on the needs generated by these.

  • Assessment tools need to be developed, or adapted, to meet the needs of this interdisciplinary process and can include existing assessment and screening tools. Interdisciplinary team collaboration will be needed in making this process work in the best interests of patients with fragility fractures.

6.9 Suggested Further Study

Think about how you currently conduct assessment in your place of work:

  • Does it fit in with the CGA approach discussed here?

  • Do you have shared documentation?

  • Are all assessments available to the interdisciplinary team, avoiding repetition?

  • What skills do you/your team need for you to improve how you make assessments using the CGA approach?

  • How might you learn these skills, and how would you use and assess what you have learned?

Discuss with other members of the interdisciplinary team within which you work how you might move towards a full-team approach to the CGA process and what changes might be needed for this to happen.

6.10 Self-Assessment

  • Examine the current assessment documentation used in your unit and consider:

Whether it reflects

  • Comprehensiveness

  • Patient-centredness

  • Interdisciplinary team working