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42. Fragility Fracture Network (2020) Fragility fracture network policy toolkit. Fragility Fracture
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Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
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indicate if changes were made.
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the copyright holder.
The Nursing Role inOrthogeriatric
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Comprehensive Geriatric Assessment
(CGA)
LouiseBrent, LinaSpirgienė, NiamhO’Regan,
andBridDiggin
6.1 Introduction
In 2023, the population of the world exceeded eight billion for the rst 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 specic 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,
6
L. Brent (*)
National Ofce of Clinical Audit, Dublin, Ireland
e-mail: louisebrent@noca.ie
L. Spirgienė
Medical Academy, Faculty of Nursing, Department of Nursing, Lithuanian University of
Health Sciences, Kaunas, Lithuania
e-mail: lina.spirgiene@lsmuni.lt
N. O’Regan
University Hospital Waterford, Waterford, Ireland
e-mail: Niamh.oregan5@hse.ie
B. Diggin
University Hospital Kerry, Kerry, Ireland
e-mail: brid.diggin@hse.ie
© The Author(s) 2024
K. Hertz, J. Santy-Tomlinson (eds.), Fragility Fracture and Orthogeriatric
Nursing, Perspectives in Nursing Management and Care for Older Adults,
https://doi.org/10.1007/978-3-031-33484-9_6
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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 comanagement 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 t into distinct organ-specic 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 decits, 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 specic 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
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Fig. 6.1 The three pillars of the fragility fracture care continuum (Adapted from Fragility Fracture
Network https://fragilityfracturenetwork.org/)
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 signicant part of this process.
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 per-
son with fragility fracture.
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6.3 The Purpose ofCGA
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) dened 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, com-
municated and person-centred and involves ve 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. It focuses on older adults with complex problems.
2. It emphasises functional status and quality of life.
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 identied. 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
rst step in effective care [6]. This reects the APIE (assessment, planning, implementation and evaluation) approach familiar to nurses. Comprehensive assessment
can also facilitate the identication of individual needs and identication of risks
that might impact care outcomes and inform effective discharge planning [7].
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The rst step in CGA is to identify those individuals who are likely to benet
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 3days 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 clini-
cal needs.
• One team member leads the process as the coordinator or ‘case manager’.
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• Geriatric medicine expertise, so that the medical management of the patient’s
health problems can lead to interdisciplinary interventions.
• Identication 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 postdischarge 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 ndings, the interdisciplinary
team should use and share documentation specically 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 communitybased 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 difcult 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 deciencies 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
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6.4 Dimensions ofComprehensive 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 identied. 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 encour-
ages 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 Table6.1, and the following sections consider some
of these in more detail.
Table 6.1 Domains and suggested items for comprehensive geriatric assessment [10]
Domain Suggested items for assessment
Physical health and
medical conditions
Mental health and
psychological status
Functioning Functional capacity: core functions such as mobility and balance,
Social circumstances Social support and networks
Environment Living situation: housing, comfort, facilities and safety, use or
Comorbid conditions and disease severity
Medical review
Nutritional status
Polypharmacy
Urinary continence
Sexual function
Vision/hearing
Dentition
Cognition
Mood and anxiety
Fears
Goals of care
Advance care preferences
Spirituality
fall risk
Activities of daily living
Life roles that are important to the patient
Informal support available from family, wider network of friends
and contacts, statutory care
Financial concerns and poverty
potential use of ‘telehealth’ technology, transport facilities
Accessibility to local resources
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6.4.1 Functional Status
Functional status refers to the ability to perform activities necessary or desirable in
daily life. It is directly inuenced 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. Basic activities of daily living (BADLs)
2. Instrumental or intermediate activities of daily living (IADLs)
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
nances.
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 benet 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 6m or
20feet) [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 65years and
half of those over 80years of age fall each year [18]. Older people are much more
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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.
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6.4.3 Cognition
The incidence of dementia and delirium increases with age, particularly among
those over 85years; 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 2min) 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 afrmatively:
1. ‘During the past month, have you been bothered by feeling down, depressed or
hopeless?’
2. ‘During the past month, have you been bothered by little interest or pleasure in
doing things?’
6.4.5 Polypharmacy
There are different denitions 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,
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