Introduction

The evidence does not support asking whether geriatric or orthogeriatric care is “better” in general. It supports a narrower answer: for the older patient with a fragility fracture, an orthogeriatric service integrated into trauma and orthopaedics has the strongest evidence, while broader geriatric medicine has the stronger evidence for the frail older person whose main problem is medical, and for intensive inpatient rehabilitation.

The question matters because of scale. In the UK, around 70,000 to 75,000 hip fractures occur each year; about 10% of patients die within a month and about a third within a year, and most of these deaths reflect coexisting illness rather than the fracture itself [1]. Who leads the medical care of these patients is therefore a question about survival, function and independence, not about professional territory.

This article defines the two disciplines, summarises the randomised trials, meta-analyses and national registry studies that compare them, and sets out where each model is preferred.

Geriatric medicine and orthogeriatrics: what each term means

Geriatric medicine is the medical specialty concerned with older people, particularly those living with frailty, multimorbidity, cognitive impairment and functional decline. Its core tool is comprehensive geriatric assessment (CGA): a multidimensional, multidisciplinary diagnostic and therapeutic process that identifies a person’s medical, mental and functional problems and builds a coordinated plan for treatment and follow-up [2]. CGA is delivered on geriatric wards, by mobile inpatient teams, in day hospitals and in the community, across the whole range of acute and chronic illness.

Orthogeriatrics applies those same principles to one defined population: older patients with fractures, above all hip fracture, cared for jointly by orthopaedic surgeons and physicians with expertise in older people. Its distinguishing feature is not a different philosophy but a different setting and focus. The orthogeriatric clinician works inside the trauma pathway, from the emergency department to theatre, ward rehabilitation, discharge and secondary fracture prevention.

In the UK this is formalised in the NICE Hip Fracture Programme, which includes orthogeriatric assessment, rapid optimisation of fitness for surgery, early rehabilitation goals and continued orthogeriatric and multidisciplinary review [3]. The relationship is therefore one of parent and subspecialty: every orthogeriatric service draws on geriatric medicine, but not every geriatric service is organised around the surgical pathway.

How the care can be organised

Any comparison depends on which model is meant, because “geriatric input” for fracture patients is delivered in at least three ways. Systematic reviews group them as follows [4, 5]:

• Geriatric consultation service: the patient stays on an orthopaedic ward under the surgeon, and a geriatric team visits on request or proactively.
• Geriatric ward with orthopaedic consultation: the patient is admitted to a geriatric ward under the geriatrician, and the surgeon visits.
• Integrated (shared) orthogeriatric care: a dedicated orthogeriatric clinician is part of the trauma unit, shares responsibility from admission, and works to agreed protocols with surgeons, anaesthetists, nurses and therapists.

In a review of 21 studies, the integrated model showed the lowest in-hospital mortality (1.14%), the shortest length of stay (7.39 days) and the shortest mean time to surgery (1.43 days), although the authors could not name a single best model [5]. They noted a clear trend towards integrated care, which combines a physician embedded in the trauma unit, a multidisciplinary team, prioritisation of older fracture patients and shared guidelines [5].

This distinction is central to what follows. Much of the evidence often quoted for “geriatric care” in hip fracture actually comes from geriatric-ward models, while the UK pathway is built mainly on integrated orthogeriatric care.

Where orthogeriatric care is preferred

For the older patient with a hip fracture, orthogeriatric collaboration is consistently associated with lower mortality, shorter stays and less delirium. The evidence comes from two meta-analyses, a randomised trial and two large English population studies.

Survival and length of stay

A meta-analysis of 18 studies (9,094 patients) found orthogeriatric collaboration was associated with lower in-hospital mortality (relative risk 0.60; 95% CI 0.43 to 0.84) and lower long-term mortality (RR 0.83; 0.74 to 0.94) [4]. Length of stay also fell, most clearly in shared-care models, although heterogeneity limited interpretation [4].

A larger and more recent meta-analysis of 37 studies (37,294 patients) confirmed the pattern [6]. Orthogeriatric care reduced length of stay by a mean of 1.55 days, in-hospital mortality by 28% and one-year mortality by 14% [6]. The authors graded this as moderate-quality evidence and found limited data suggesting the model is cost-effective [6].

Delirium

Delirium is one of the most common and damaging complications after hip fracture. In a randomised trial of 126 patients on an orthopaedic service, proactive geriatric consultation starting before or within 24 hours of surgery reduced delirium from 50% to 32% (RR 0.64) [7]. Severe delirium fell from 29% to 12%, and one case of delirium was prevented for roughly every six patients treated [7]. The pooled meta-analysis likewise found a 19% lower risk of delirium with orthogeriatric care [6].

Evidence from the English national pathway

In 11 English hospitals (33,152 patients, 2003 to 2013), appointing an orthogeriatrician was associated with lower 30-day mortality (hazard ratio 0.73; 0.65 to 0.82) and lower one-year mortality (HR 0.81; 0.75 to 0.87) [8]. Across 150 hospitals and 196,401 patients, each extra 2.5 orthogeriatrician hours per patient was associated with a 3.4% relative reduction in 30-day mortality, independent of faster surgery [9].

Why the integrated model fits the fracture pathway

The trials measure outcomes rather than mechanisms, so the following is reasoned interpretation rather than proven fact. An orthogeriatric clinician embedded in trauma sees the patient early, knows the surgical timetable, and can optimise fitness for surgery without generating avoidable delay. The same clinician can then carry the patient through delirium prevention, early mobilisation, discharge planning and bone health assessment, which is the continuity the NICE Hip Fracture Programme describes [3].

Bone health is a natural extension of this role. Introducing a fracture liaison service in the same English hospitals was also associated with lower mortality, although neither model reduced the rate of second hip fracture within two years [8].

Where geriatric-led care is preferred

Geriatric medicine has the stronger evidence in two areas: the frail older person admitted with medical illness, and intensive, ward-based rehabilitation aimed at recovering mobility and independence.

The frail older inpatient with medical illness

The Cochrane review of inpatient CGA pooled 29 trials and 13,766 participants [2]. Patients who received CGA were more likely to be alive and living in their own homes at 3 to 12 months (RR 1.06; 1.01 to 1.10) and less likely to be admitted to a nursing home (RR 0.80; 0.72 to 0.89), both with high-certainty evidence [2]. CGA made little or no difference to mortality, and the review could not tell whether geriatric wards or mobile teams work better [2].

This is the core strength of the general geriatrician: managing multimorbidity, falls, cognitive impairment, polypharmacy and functional decline across every type of acute illness, not only fractures.

Mobility and function after hip fracture

The Trondheim Hip Fracture Trial randomised 397 home-dwelling patients aged 70 or over, who could walk before the fracture, to CGA in a dedicated geriatric ward or to usual orthopaedic care [10]. At four months, mobility on the Short Physical Performance Battery was better in the geriatric ward group (5.12 versus 4.38; difference 0.74, 95% CI 0.18 to 1.30) [10].

In a Swedish trial of 199 patients aged 70 or over with femoral neck fracture, team-based rehabilitation applying CGA improved independence in activities of daily living at 4 months (odds ratio 2.51) and 12 months (OR 3.49), despite a shorter hospital stay [11]. More patients also regained independent indoor walking without aids (OR 3.01) [11].

An important limit

The Oslo Orthogeriatric Trial randomised 329 hip fracture patients to an acute geriatric ward or a standard orthopaedic ward [12]. It found no difference in cognitive function at four months, in delirium (49% versus 53%) or in four-month mortality [12]. Only home-dwelling patients showed better mobility on the geriatric ward (median SPPB 6 versus 4) [12].

Taken together, admission to a geriatric ward appears to help selected, previously mobile patients regain function. It has not been shown to reduce delirium or death more than good orthopaedic-ward care, and the Trondheim authors themselves concluded that hip fracture care should be organised as orthogeriatric care [10].

Side-by-side comparison

Question	Orthogeriatric (integrated with T&O)	Geriatric-led (ward or general service)	Key evidence
Main population	Older patients with fragility fractures	Frail older people with any acute or chronic illness	[2, 3]
Mortality after hip fracture	Lower in-hospital and 1-year mortality in pooled studies	No mortality advantage over orthopaedic ward shown in RCT	[4, 6, 8, 9, 12]
Length of stay	Reduced, especially in shared care	Not consistently reduced	[4, 6]
Delirium	Reduced with proactive consultation and in pooled data	No reduction on acute geriatric ward in RCT	[6, 7, 12]
Mobility and ADL recovery	Inconsistent effect on function	Better mobility and ADL in selected home-dwelling patients	[6, 10, 11, 12]
Living at home, avoiding care homes	Not the main outcome studied	Higher chance of living at home after CGA	[2]
Medically complex, non-fracture admission	Outside core scope	Core strength	[2]
Fit with the UK pathway (NICE, NHFD)	Built into the Hip Fracture Programme	Contributes through CGA principles and rehabilitation	[3]

The table reflects the strength of evidence for each outcome, not the competence of individual clinicians. Where a cell says an effect was not shown, it means the trials did not demonstrate it, not that the effect is absent.

What this means in practice

The two models answer different clinical questions, so the choice should follow the patient’s dominant problem rather than professional preference.

Orthogeriatric care is preferred when:

• the patient has a hip or other fragility fracture and is on the surgical pathway;
• the priorities are safe, timely surgery, delirium prevention, early mobilisation and prompt discharge;
• the service must deliver and record national standards, such as the NICE Hip Fracture Programme and NHFD measures;
• secondary fracture prevention needs to start during the same admission.

Geriatric-led care is preferred when:

• acute medical illness, not the fracture, drives the admission;
• multimorbidity, cognitive impairment or polypharmacy needs a full CGA beyond the perioperative period;
• a previously mobile patient needs an intensive, ward-based rehabilitation programme;
• the main goal is avoiding long-term care and returning home.

The gaps in the evidence matter as much as the findings. Most trials are single-centre, staff and patients could not be blinded, and models overlap, so “geriatric ward” and “orthogeriatric” care are sometimes the same thing described differently [6, 10, 12]. Neither model has yet been shown to improve long-term function consistently, and the best model of orthogeriatric care remains undecided [4, 6].

The most defensible position is collaboration rather than competition. A strong service uses an embedded orthogeriatric clinician for the fracture pathway, with clear routes to geriatric medicine for complex medical and rehabilitation needs.

Conclusion

Orthogeriatrics and geriatric medicine share one philosophy: the older patient is more than the diagnosis that brought them to hospital. For the patient with a fragility fracture, integrated orthogeriatric care has the strongest evidence for lower mortality, shorter stays and less delirium, and it is the model the UK national pathway is built on. For the frail older person whose problems are mainly medical, or who needs intensive rehabilitation to get home, the broader skills of geriatric medicine carry the stronger evidence.

The practical message for hospitals is to stop framing this as a choice between specialties. Patients do best when each model is used where its evidence is strongest, and when the two work side by side.

References

1. National Institute for Health and Care Excellence. Hip fracture: management. Clinical guideline CG124. London: NICE; 2011 (updated 2023). org.uk/guidance/cg124
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3. National Institute for Health and Care Excellence. Hip fracture in adults. Quality standard QS16, quality statement 1: multidisciplinary management. org.uk/guidance/qs16
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11. Stenvall M, Olofsson B, Nyberg L, Lundström M, Gustafson Y. Improved performance in activities of daily living and mobility after a multidisciplinary postoperative rehabilitation in older people with femoral neck fracture: a randomized controlled trial with 1-year follow-up. J Rehabil Med. 2007;39(3):232-8. doi:10.2340/16501977-0045
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