Geriatric Co-Management

Older adults comprise a large proportion of hospitalized patients; many of them are frail and require complex care. Managing dementia, delirium, depression, and falls frequently associated with older adults hospitalized in nongeriatric wards are challenging. These patients have a high risk of developing complications, prolonged hospital stays, disability, and unplanned readmissions.[1] As per availability, the treating team seeks geriatric or medical consultation. However, these consultations fail to affect the functional status, length of stay, and readmission rate due to the nonadherence to recommendations and lack of control over patient care.[2] The comprehensive geriatric assessment (CGA) is the core tool geriatricians use across diverse clinical settings. CGA is characterized by a “multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of an older person with frailty, followed by the implementation of a coordinated and integrated plan for treatment and follow-up.”[3] Geriatric co-management is an alternative approach to treating older adults in nongeriatric wards. It is defined as a shared responsibility and decision-making between at least a treating physician (e.g. surgeon) and a geriatrician who provides complementary medical care to prevent and manage geriatric-oriented problems. Co-management greatly varies among different health-care systems and has been reported to be associated with low in-hospital mortality rate, length of stay, and time to surgery.[1] The effect of co-management depends mainly on the way the programs are organized and implemented and their context. Hip fracture, a common complication of fall injuries in older adults, often results in a high rate of mortality, increased debility, functional loss, and worse quality of life.[4] Recognizing hip and other fragility fractures as an adverse event of chronic geriatric conditions led to orthogeriatric co-management (OGC).[5] OGC today represents various forms of structural cooperation between orthopedic trauma surgeons and multiprofessional geriatric teams caring for frail elderly patients. The orthogeriatric approach has been shown to favor functional recovery and reduce mortality, but its implementation in clinical practice greatly varies among different health-care systems. The models are country specific.[6] Orthogeriatric collaboration has been proven effective globally, with positive studies from Brazil, Argentina, Germany, Belgium, China, Australia, and other countries. Geriatric co-management has demonstrated the potential to improve functional status, significantly shorten the time from admission to surgery, and length of stay, reduce the postoperative complications for elderly patients with hip fractures, save labor costs, and reduce patient mortality.[4,5,7,8,9,10,11] The multidisciplinary team for hip fracture co-management includes geriatricians, orthopedics, anesthesiologists, geriatric nurse, occupational therapist, physiotherapists (physiatrists), and general practitioners. It involves optimal care path of older subjects with hip fracture; management of comorbidities and preoperative alteration of physiological parameters; management of selected categories of patients at expected increased risk of adverse outcomes; continuity of care out of hospital; screening and correction of risk factors for hip fracture in older subjects; and information and divulgation of shared management strategies.[12] As the number of older patients with cancer is increasing, oncology disciplines face the challenge of managing patients with multiple chronic conditions, functional dependence, cognitive impairment, and frailty with an increased risk of complications and mortality. Collaboration between geriatricians and oncologists with a more accurate evaluation of prognostic indicators that includes CGA parameters could lead to more older patients being included in clinical cancer trials and being treated effectively in practice to maintain function and community living.[13] Bhatt et al. demonstrated the feasibility of co-management patients with community oncologists by integrating geriatric assessment and genetic risk categories to define fitness for intensive chemotherapy and personalize the selection of intensive versus low-intensity chemotherapy in older adults ≥60 years with acute myeloid leukemia.[14] Frail older adults with colorectal cancer benefit through pretreatment assessment, perioperative management, discharge planning, and rehabilitation with geriatric co-management.[15] Shahrokni et al. found that geriatric co-management was associated with significantly lower 90-day postoperative mortality among older patients with cancer.[16] Most older patients admitted to a cardiology unit present with at least one geriatric syndrome, and the complex needs of frail older patients are being recognized. Van Grootven et al. found implementing the “Geriatric Co-management for Cardiology Patients in the Hospital” program acceptable and feasible.[17] Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. Trauma patients older than 80 years of age have higher mortality rates compared to younger peers. Geriatrics trauma co-management of trauma patients above 80 years may reduce mortality and deserve formal study.[18] Geriatric care for surgical patients is mainly reactive, although geriatricians favor more proactive services. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. The Co-management of Older Operative Patients En Route Across Treatment Environments program is a clinical and educational collaboration between geriatrics and several surgical specialties at Veterans Affairs Health Care Connecticut. General surgery, urology, vascular surgery, orthopedics, cardiothoracic surgery, and neurosurgery, participate in the program, with geriatrics expertise provided by a geriatrician, geriatric nurse practitioner, and a geriatric clinical pharmacist. Walke et al. found geriatrics co-management with various surgical specialties feasible and associated with higher discharge rates back to the community.[19] Geriatric co-management is advocated to manage frail patients in the hospital, but there needs to be guidance on implementing such programs. There are several organizational challenges to adapting co-management, with a lack of shared management protocols and poor awareness of the problem. Implementation of geriatric co-management requires an engaged steering committee to oversee the program and the need to take proactive steps to improve multidisciplinary communication.[20] Further research is needed to study the performance indicators to monitor the implementation and efficacy of geriatric co-management in different health conditions and health-care systems.