Organization of care surrounding frail elderly people

Question

How to organise the care for frail elderly people who are eligible for a total hip prostheses?

Recommendation

Screen all patients 70 years and older on frailty using a validated tool (in the Netherlands possibly the VMS-criteria screening bundle).

In case of positive screening, pre-operative judgement is recommended by means of a comprehensive geriatric assessment by a medical specialist with competency in geriatric medicine.

Considerations

In addition to the choice of treatment, there are other important aspects that play a part in the performance of treatment of vulnerable elderly people. This concerns the concept of frailty. This is a condition associated with an increased risk of loss of function and which is distinguished from aging, constraints and multi-morbidity (NVKG, 2010).

The geriatric patient distinguishes himself from other patients through (NVKG, 2010):

a (greater risk of) frailty or ”the uncertain physical, psychological and social equilibrium”;
usually a higher age;
Illnesses and / or handicaps associated with high age;
the inter-acting multi-morbidity;
the bigger (inter-)individual variability;
they often prefer improvement of self-reliance, mobility and quality of life instead of extension of life.

So, in the category of patients with osteoarthritis of the hip there must be specific attention for:

functioning in general and self-reliance;
complications or diseases, which present themselves through geriatric syndromes (delirium, falling);
a decreased amount of social support;
a decreased awareness of problems by the patient due to cognitive impairment or visual impairment during the treatment;
polypharmacy.

In summary, it is important – in addition to the orthopaedic problem - to judge the extent of vulnerability of the person in question. The complexity of co-morbidity, polypharmacy and cognitive disturbances emphasises the importance of co-operation between the orthopaedic surgeons and geriatricians when setting the operation indication (or rejecting it). This can be done by selecting specific patient categories for more intensive peri-operative guidance by a geriatric team or a generalistic medical specialist with experience in elderly care.

The Comprehensive Geriatric Assessment (CGA) should be used to judge the frailty of a patient. Tools for screening might possibly give an indication of vulnerability, but are unable to screen adequately and give a competent advice. The CGA is an extensive clinical geriatric examination, defined as a "multidisciplinary research that identifies and explains the multiple problems of an elderly as much as possible, examines a patient’s abilities and needs, in order to achieve a coordinated and comprehensive care plan for the individual". A CGA has an added value with regard to vulnerable older people, especially in the areas of survival, quality of life, self-reliance and institutionalisation.

Screening lists are available for the various domains within the CGA. Some of these lists screen for vulnerability or risk of functional decline (i.e. the ISAR-HP), others focus more on geriatric syndromes, such as a delirium risk assessment or the Patient Safety Management System (“Veiligheidsmanagementsysteem”) criteria (VMS-criteria screening bundle). The latter looks at four domains: delirium, risk of falling, malnutrition and functionality.

A CGA is not required for every elderly patient. It is advised to initially perform a screening for vulnerability in patients 70 years and older. Almost all hospitals in the Netherlands have implemented the screening according to the VMS criteria screening bundle. This screening is preferably done when the indication for hip arthroplasty therapy is set and can be performed during pre-operative screening (POS) in an outpatient clinic setting (NVKG, 2013; Partridge, 2014).

It is of great importance that screening for frailty takes places systematically. Additionally, on indication, judgement by a geriatrician should be performed. In case of positive screening, it is useful to refer the patient pre-operatively to the outpatient clinic for further assessment by a CGA. Based on the outcome of the CGA, a programme can be drawn up. Pre-operative and peri-operative recommendations (id est prevention of delirium) can be given and advice about the care after the hospital admission. In the case of frail elderly people with a high risk of (geriatric) complications, structural co-treatment between the orthopaedic surgeon and the geriatrician should be considered. Then, the geriatrician is jointly responsible for ensuring that good protocols are in place to use geriatric expertise.

In short, the orthopaedic surgeon sets the indication for the treatment, the anaesthesiologist assesses the operation risk and the clinical geriatrician maps the vulnerability and co-morbidity. In the majority of patients, the attention of the orthopaedic surgeon and the anaesthesiologist before an operation is sufficient. All persons 70 years and older should be screened. In case of positive screening (id est: increased vulnerability, possibly frailty) there is an indication for additional screening according to a comprehensive geriatric assessment to map frailty, co-morbidity and possible contra-indications and give advice leading to a better outcome.

Evidence

Background

In the next decades, the total number of elderly people in society will increase, as well as the life-expectancy, leading to more and more of the “oldest old”. Elderly people are more active than they used to be in the past and will probably ask for hip arthroplasty at more advanced ages. A substantial part of the patients above the age of 70 years will be “frail” (due to co-morbidity, polypharmacy and cognitive disturbances) so specific considerations have to be taken into account on the one hand to avoid the need for joint arthroplasty surgery and on the other hand, when this is indicated to minimise the length of stay in the hospital, to reduce the risk of complications and minimise the functional decline and the duration of rehabilitation.

In addition to the joint problems, elderly people often have additional diseases, id est diabetes and cardiovascular diseases. Nearly 70% of the Dutch elderly aged from 65 to 79 years have serious, life-shortening co-morbidities when they attend the out-patient clinic. Above the age of 80 years this figure rises to almost 80% Piccirillo, (2008). Co-morbidity influences the chance of success of an operation, the length of stay in the hospital and the duration of the period of rehabilitation. Patients with cognitive disturbances and/or sensory deprivation have a greater chance of serious delirious episodes postoperatively. The presence and extent of co-morbidity can thus influence the choice of treatment and therefore personalised care adjusted to the frail elderly is needed.

Frailty increases with age: in the age group of 65 to 69 years about 4% can be considered frail; 7% from 70 to 74 years of age; 9% from 75 to 79 years of age; 16% from 80 to 84 years of age; and 26% above the age of 85 years Clegg, (2013). In the year 2010, it was estimated that there were around 690,000 frail persons in the age range of 65 years and older in the Netherlands and - based on a demographic estimation - the number of frail elderly will increase by another 470,000 people to a total of 1,160,000 persons in the year 2030 van Campen, (2011).

Search and select

No systematic literature review was performed for this question.

References

Campen C van. Kwetsbare ouderen. Rapport van het Sociaal en Cultureel Planbureau, Den Haag 2011. Link: http://www.scp.nl/Publicaties/Alle_publicaties/Publicaties_2011/Kwetsbare_ouderen 2011.
Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet, 381, 752-762. Erratum in: Lancet 2013;382:1328. PubMed PMID: 23395245.
Nederlandse Vereniging voor Klinische Geriatrie (2010). Richtlijn Comprehensive Geriatric Assessment. Link: http://richtlijnendatabase.nl/richtlijn/comprehensive_geriatric_assessment_cga/risicofactoren_functionele_achteruitgang_cga.html. 2010.
Nederlandse Vereniging voor Klinische Geriatrie (2013). Addendum Comprehensive Geriatric Assessment bij consult en medebehandeling. Link: http://www.kwaliteitskoepel.nl/kwaliteitsbibliotheek/richtlijnen/addendum-comprehensivegeriatric-assessment-bij-consult-en-medeb.html. 2013.
Partridge JS, Harari D, Martin FC, et al. The impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review. Anaesthesia 2014;5 69(S1):8-16. PubMed PMID: 24303856.
Piccirillo JF, Vlahiotis A, Barrett LB, et al. The changing prevalence of comorbidity across the age spectrum. Crit Rev Oncol Hematol 2008;67:124-132. PubMed PMID: 18375141.
Rapport Ouderdom komt met gebreken. Gezondheidsraad. 2008.

Methods

Authorization date and validity

Last review : 12-02-2019

Last authorization : 12-02-2019

Planned reassessment : 01-01-2024

Module	Party in control	Year of authorization	Next assessment of actuality	Frequency of assessment actuality	Which party/parties monitors actuality	Important factors that might lead to change in recommendations
Organisation of the care surrounding frail elderly people who are eligible for a total hip arthroplasty	NVKG	2018	2023	Eens in de vijf jaar	NVKG	-

Initiative and authorization

Initiative:

Nederlandse Orthopaedische Vereniging

Authorized by:

Koninklijk Nederlands Genootschap voor Fysiotherapie
Nederlandse Orthopaedische Vereniging
Nederlandse Vereniging voor Klinische Geriatrie
Nederlandse Vereniging voor Medische Microbiologie

General details

The development of this guideline was funded by the Stichting Kwaliteitsgelden Medisch Specialisten (SKMS; Foundation for Quality Funding for Medical Specialists).

Scope and target group

Aim of the guideline

The main purpose of the guideline is to provide the best possible care to patients with osteoarthritis of the hip, by informing optimal treatment decisions and reducing unwarranted variation in the delivery of care and long-term failure of the implants.

Envisaged users of the guideline

This guideline was developed for all Dutch healthcare providers of patients with osteoarthritis of the hip.

Samenstelling werkgroep

This guideline was developed and sponsored by the Netherlands Orthopaedic Association (NOV), using government funding from the Quality Funding for Medical Specialists (Stichting Kwaliteitsgelden Medisch Specialisten in the Netherlands, SKMS). Patient participation was cofinanced by the Quality Funding Patient Consumers (Stichting Kwaliteitsgelden Patiënten Consumenten, SKPC) within the program ‘Quality, insight and efficiency in medical specialist care’ (Kwaliteit, Inzicht en Doelmatigheid in de medisch specialistische Zorg, KIDZ). The early preparative phase started in October 2016. The guideline was officially authorised by the Netherlands Orthopaedic Association on February 12, 2019. Decisions were made by consensus. At the start of guideline development, all working group members completed conflict of interest forms.

Members of the guideline development working group

Dr. B.A. Swierstra, orthopaedic surgeon, Sint Maartenskliniek, Nijmegen, NOV, Chair
Dr. R.H.M. ten Broeke, orthopaedic surgeon, Maastricht University Medical Centre, NOV
Drs. P.D. Croughs, medical microbiologist, Erasmus University Medical Center, NVMM
Dr. R.A. Faaij, geriatrician, Diakonessen Hospital, Utrecht, NVKG
Dr. P.C. Jutte, orthopaedic surgeon, University Medical Center Groningen, NOV
D.E. Lopuhaä, policy worker patient advocacy, Dutch Arthritis Society
Dr. W.F.H. Peter, physiotherapist, Leiden University Medical Center, KNGF
Dr. B.W. Schreurs, orthopaedic surgeon, Radboud University Medical Centre, Nijmegen, NOV
Dr. S.B.W. Vehmeijer, orthopaedic surgeon, Reinier de Graaf Hospital, Delft, NOV
Dr. A.M.J.S. Vervest, orthopaedic surgeon, Tergooi Hospital, Hilversum, NOV
J. Vooijs†, patient with osteoarthritis, National Association ReumaZorg Nederland
Drs. G. Willemsen-de Mey, chairperson, National Association ReumaZorg Nederland

Readers:

S. Nijssen, medical microbiologist, VieCuri Medical Center, Venlo, NVMM
R.J. Rentenaar, medical microbiologist, University Medical Center, Utrecht, NVMM
Dr. A.T. Bernards, medical microbiologist, Leiden University Medical Center, NVMM

With the help of:

Dr. M.A. Pols, senior advisor, Knowledge Institute of the Dutch Association of Medical Specialists
Dr. M.L. Molag, advisor, Knowledge Institute of the Dutch Association of Medical Specialists
A.L.J. Kortlever- van der Spek, junior advisor, Knowledge Institute of the Dutch Association of Medical Specialists
M.E. Wessels MSc, clinical librarian, Knowledge Institute of the Dutch Association of Medical Specialists

Declaration of interest

At the start of the project, the members of the working group have declared in writing if, in the last five years, they have held a financially supported position with commercial businesses, organisations or institutions that may have a connection with the subject of the guidelines. Enquiries have also been made into personal financial interests, interests pertaining to personal relationships, interests pertaining to reputation management, interests pertaining to externally financed research, and interests pertaining to valorisation of knowledge. These declarations of interest can be requested from the secretariat of the Knowledge Institute of the Dutch Association of Medical Specialists. See below for an overview.

Werkgroeplid	Mogelijke conflicterende belangen met betrekking tot deelname werkgroep	Toelichting
Dr. B.W. Schreurs	Presentaties voor Stryker over de Exeter totale heupprothese (educational fee naar afdeling) Doet reviews voor DEKRA KEMA (betaald) Voorzitter European Hip Society (onbetaald) Voorzitter wetenschappelijke adviesraad LROI (onbetaald) Voorzitter adviesraad botbank Sanquin (onbetaald) Lid Commissie Orthopedisch Implantaten Classificatie NOV (onbetaald)
Dr. P.C. Jutte	Hoofdonderzoeker LEAK-studie (ZonMW) Voorzitter werkgroep weke delen en bottumoren Lid werkgroep orthopedische infecties NOV Lid werkgroep bottumoren NOV Lid commissie beentumoren Nederland Lid onderwijscommissie NOV Lid medische adviesraad patientvereniging Sarcoma NL
D.E. Lopuhaä	Geen belangen
Dr. R.H.M. ten Broeke	Voorzitter werkgroep "Heup" (Dutch Hip Society) NOV sinds 2015 (onbetaald) Daarvoor gedurende 3 jaar reeds bestuurslid van deze werkgroep (onbetaald) Klinisch onderzoek gefinancierd door firma Stryker (RSA en PET-CT-onderzoek bij vergelijking van 2 ongecementeerde cupdesigns) (onbetaald)
Dr. W.F.H. Peter	Geen belangen
Dr. P.D. Croughs	Geen belangen
Dr. S.B.W. Vehmeijer	Directeur Orthoparc (onbetaald) Bestuurslid Dutch Hip Society (onbetaald) National Representative European Hip Society (onbetaald) Consulent Zimmer Biomet (betaald)
Dr. B.A. Swierstra	Voorzitter Stichting OrthoResearch (onbetaald) Advisory Board Arthroplasty Watch (onbetaald) Lid Wetenschappelijke Advies Raad Landelijke Registratie Orthopaedische Implantaten (onbetaald) Board of Directors International Society of Orthopaedic Centers (onbetaald) Coeditor Acta Orthopaedica (onkostenvergoeding)
Dr. R.A. Faaij	Geen belangen
Dr. A.M.J.S. Vervest	Lid-beroepsgenoot Regionaal Tuchtcollege voor de Gezondheidszorg Den Haag (betaald) Voorzitter Centrale Opleidings Commissie Tergooi (onbetaald)
J. Vooijs	Geen belangen
Drs. G. Willemsen – de Mey	Geen belangen
Meelezers
Drs. S. Nijssen	ISO 15189 auditor, betaald door RvA
Dr. R.J. Rentenaar	Commissie bacteriologie Stichting Kwaliteitsbewaking Medische Laboratoria (SKML) (tegen onkostenvergoeding). Verschillende producenten stellen soms kleine hoeveelheden van producten ter beschikking kosteloos of tegen gereduceerd tarief t.b.v. verificatie doeleinden
Dr. A.T. Bernards	Geen belangen

Patient involvement

Attention was paid to the patients’ perspective by participation in the working group of the Dutch Arthritis Society and National Association ReumaZorg Nederland. In addition, the Patients Federation Netherlands assessed the draft guideline during the consultation phase and made suggestions for improvement of the guideline.

Method of development

evidence based

Implementation

Recommendation

Time needed for implementation:
<1 year,

1 to 3 years or

>3 years

Expected effects on costs

Conditions for implementation

Possible barriers to implementation¹

Actions for implementation²

Reponsibility for these actions³

Other remarks

All

<1 year

Unknown

n.a.

n.a

n.a.

Is already implemented in most hospitals

Methods and proces

The guideline was developed in agreement with the criteria set by the advisory committee on guideline development of the Dutch Association of Medical Specialists (Medisch Specialistische Richtlijnen 2.0; OMS 2011), which are based on the AGREE II instrument (Brouwers (2010); www.agreetrust.org). The guideline was developed using an evidence-based approach endorsing GRADE methodology, and meeting all criteria of AGREE-II. Grading of Recommendations Assessment, Development and Evaluation (GRADE) is a systematic approach for synthesising evidence and grading of recommendations offering transparency at each stage of the guideline development (Guyatt, 2011; Schünemann, 2013).

The guideline development process involves a number of phases: a preparatory phase, development phase, commentary phase, and authorisation phase. After authorisation, the guideline has to be disseminated and implemented and its uptake and use have to be evaluated. Finally, the guideline has to be kept up-to-date. Each phase involves a number of practical steps Schünemann, (2014).

As a first step in the early preparatory phase, a broad forum discussion was held and all relevant stakeholders were consulted to define and prioritise the key issues the recommendations should address. Subsequently, the methodologist together with the chairman of the working group created a draft list of key issues, which was extensively discussed in the working group.

Despite aiming for an update of the guideline from 2010, due to financial constraints not all clinical questions from the former edition could be updated, so it was decided to perform a so-called modular update. Selecting modules with a higher priority for update formed part of this discussion and selection process. This resulted in the following approach.

Modules that were updated:

Indications for primary total hip arthroplasty.
Type of bearing (part of the module surgical techniques).
Diameter of the head (part of the module surgical techniques).
Surgical approach (part of the module surgical techniques).
Systemic antibiotics (part of the module perioperative care in primary total hip arthroplasty).
Antibiotic-impregnated bone cement (part of the module perioperative care in primary total hip arthroplasty).
Preoperative decolonisation (part of the module perioperative care in primary total hip arthroplasty).
Routine follow-up (part of the module postoperative care).

Modules considered still valid:

cemented versus uncemented hip prosthesis (part of the module surgical techniques in primary total hip arthroplasty).

Modules removed from the guideline:

Resurfacing hip prosthesis (part of the module surgical techniques in primary total hip arthroplasty).
Minimally invasive surgery (part of the module surgical techniques in primary total hip arthroplasty).
Guidelines for MRSA carriers (part of the module perioperative care in primary total hip arthroplasty).

Modules that were replaced by a reference to related guidelines:

Hematogenous infection (part of the module postoperative care).
Prevention of thrombo-embolic complications (part of the module perioperative care in primary total hip arthroplasty).
Physcial therapy (part of the module perioperative care in primary total hip arthroplasty).

Modules not updated because guidelines are expected soon:

Anaesthesiological technique (part of the module perioperative care in primary total hip arthroplasty).

Modules that were added:

Patient Reported Outcome Measures.
Place and organisation of fasttrack.
Organization of care for frail elderly.

The selected (high priority) issues were translated into carefully formulated clinical questions, defining patient/problem, intervention, and prioritising the outcomes relevant for decision-making.

The literature was systematically searched using the databases MEDLINE (Ovid), Embase and the Cochrane Database of Systematic Reviews. Selection of the relevant literature was based on predefined inclusion and exclusion criteria and was carried out by a member of the working group in collaboration with the methodologist. For each of the clinical questions, the evidence was summarised by the guideline methodologist using the GRADE approach: a systematic review was performed for each of the relevant outcomes and the quality of evidence was assessed in one of four grades (high, moderate, low, very low) by analysing limitations in study design or execution (risk of bias), inconsistency of results, indirectness of evidence, imprecision, and publication bias. The evidence synthesis was complemented by a working group member considering any additional arguments relevant to the clinical question. Evidence synthesis, complementary arguments, and draft recommendations were extensively discussed in the working group and final recommendations were formulated. Final recommendations are based on the balance of desirable and undesirable outcomes, the quality of the body of evidence across all relevant outcomes, values and preferences, and (if relevant) resource use. The strength of a recommendation reflects the extent to which the guideline panel was confident that desirable effects of the intervention outweigh undesirable effects, or vice versa, across the range of patients for whom the recommendation is intended. The strength of a recommendation is determined by weighting all relevant arguments together, the weight of the body of evidence from the systematic literature analysis, as well as the weight of all complementary arguments. Guideline panels must use judgment in integrating these factors to make a strong or weak recommendation. Thus, a low quality of the body of evidence from the systematic literature analysis does not exclude a strong recommendation, and weak recommendations may follow from high quality evidence Schünemann, (2013).

After reaching consensus in the working group, the draft guideline was subjected to peer review by all relevant stakeholders. Amendments were made and agreed upon by the working group, and the final text was presented to the Netherlands Orthopaedic Association (NOV), the Royal Dutch Society for Physical Therapy (KNGF), the Dutch Society of Medical Microbiology (NVMM) and the Dutch Geriatrics Society (NVKG) for formal authorisation and to the National Association ReumaZorg Nederland and the Dutch Arthritis Society for approval. The final guideline was approved by the National Association ReumaZorg Nederland and the Dutch Arthritis Society, and was officially authorised by the Netherlands Orthopaedic Association, the Royal Dutch Society for Physical Therapy, the Dutch Society of Medical Microbiology and the Dutch Geriatrics Society. The guideline was published and is freely accessible in the Dutch guideline database (Richtlijnendatabase, www.richtlijnendatabase.nl). The Dutch guideline database has a modular structure, with each clinical question as a separate entry, thus allowing for modular updates.

References

Brouwers M, Kho ME, Browman GP, et al. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Can Med Assoc J. Dec;182:E839-842; doi: 10.1503/cmaj.090449.

Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. Journal of Clinical Epidemiology. 2011;64 383–394. (doi:10.1016/j.jclinepi.2010. 04.026).

Schünemann H, Brożek J, Guyatt G, et al. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from https://www.gradepro.org/

Schünemann HJ, Wiercioch W, Etxeandia I, et al. Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise. CMAJ. 2014;186(3):E123-42. doi: 10.1503/cmaj.131237. Epub 2013 Dec 16. PubMed PMID: 24344144.

OMS, Orde van Medisch Specialisten. Eindrapport Medisch Specialistische Richtlijnen 2.0. Available from: https://www.demedischspecialist.nl/onderwerp/raad-kwaliteit. 2011.

Attachments

Related guidelines

Guidelines
- Totale heupprothese (THP)

Richtlijnendatabase

Total hip prosthesis (THP)