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de la Cova C, Mant M, Brickley MB. Structural violence and institutionalized individuals: A paleopathological perspective on a continuing issue. PLoS One 2023; 18:e0290014. [PMID: 37647256 PMCID: PMC10468073 DOI: 10.1371/journal.pone.0290014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 08/01/2023] [Indexed: 09/01/2023] Open
Abstract
Past and present institutions (e.g., state and public hospitals, assisted living facilities, public nursing homes) have struggled with structural issues tied to patient care and neglect, which often manifests in the form of fracture trauma, and may explain why institutionalized individuals are at higher risk for this injury. Six hundred individuals from the Robert J. Terry Anatomical Collection born between 1822-1877 were examined to investigate hip fracture prevalence. Analysis of associated records and documentary data, including death, morgue, and census records, revealed that 36.3% (n = 218) of these individuals died in institutions such as the St. Louis State Hospital, City Infirmary, and Missouri State Hospital No. 4. Of the institutionalized individuals, 4.3% had evidence of hip fracture, significantly higher than the non-institutionalized (2.3%). Records revealed that many hip fractures were suffered around the time of death in state hospitals and were preventable, resulting from structural issues tied to understaffing and underfunding. Forensic and clinical literature, as well as current news media, indicate that structural violence in the forms of underfunding and understaffing continues to manifest as hip fractures harming institutionalized individuals today. This paper demonstrates how an anthropological perspective using paleopathological analysis sheds light on the chronicity and time depth of this issue, with the aim of driving public policy to entrench the equitable care of institutionalized people as a human right.
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Affiliation(s)
- Carlina de la Cova
- Department of Anthropology, University of South Carolina, Columbia, South Carolina, United States of America
| | - Madeleine Mant
- Department of Anthropology, University of Toronto Mississauga, Mississauga, Ontario, Canada
| | - Megan B. Brickley
- Department of Anthropology, McMaster University, Hamilton, Ontario, Canada
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Korall AMB, Loughin TM, Feldman F, Cameron ID, Leung PM, Sims-Gould J, Godin J, Robinovitch SN. Determinants of staff commitment to hip protectors in long-term care: A cross-sectional survey. Int J Nurs Stud 2018; 82:139-148. [PMID: 29655133 DOI: 10.1016/j.ijnurstu.2018.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 03/14/2018] [Accepted: 03/16/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND If worn, certain models of hip protectors are highly effective at preventing hip fractures from falls in residents of long-term care, but modest acceptance and adherence have limited the effectiveness of hip protectors. Residents of long-term care are more likely to accept the initial offer of hip protectors and to adhere to recommendations concerning the use of hip protectors when staff are committed to supporting the application of hip protectors. Yet, we know very little about the nature of and factors associated with staff commitment to hip protectors in long-term care. OBJECTIVE To identify factors associated with staff commitment to hip protectors in long-term care. DESIGN A cross-sectional survey. SETTING Thirteen long-term care homes (total beds = 1816) from a single regional health district in British Columbia, Canada. PARTICIPANTS A convenience sample of 535 paid staff who worked most of their time (>50% of work hours) at a participating long-term care home, for at least one month, and for at least 8 h per week. We excluded six (1.1%) respondents who were unaware of hip protectors. Of the remaining 529 respondents, 90% were female and 55% were health care assistants. METHODS Respondents completed the Commitment to Hip Protectors Index to indicate their commitment to hip protectors. We used Bayesian Model Averaging logistic regression to model staff commitment as a function of personal variables, experiences with hip protectors, intraorganizational communication and influence, and organizational context. RESULTS Staff commitment was negatively related to organizational tenure >20 years (posterior probability = 97%; logistic regression coefficient = -0.28; 95% confidence interval = -0.48, -0.08), and awareness of a padded hip fracture (100%; -0.57; -0.69, -0.44). Staff commitment was positively related to the existence of a champion of hip protectors within the home (100%; 0.24; 0.17, 0.31), perceived quality of intraorganizational communication (100%; 0.04; 0.02, 0.05), extent of mutual respect between residents and staff and perceived contribution to quality of life of the residents they serve (100%; 0.10; 0.05, 0.15), and frequency of transformational leadership practices by respondents' primary supervisors (100%; 0.01; 0.01, 0.02). CONCLUSIONS We provide novel insight into the factors governing staff commitment to hip protectors in long-term care. Targeting of these factors could improve acceptance and adherence with hip protectors, thereby contributing to enhanced effectiveness of hip protectors to prevent hip fractures in long-term care.
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Affiliation(s)
- Alexandra M B Korall
- Injury Prevention and Mobility Laboratory (IPML), Department of Biomedical Physiology and Kinesiology, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada; Centre for Hip Health and Mobility, 7/F, 2635 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - Thomas M Loughin
- Department of Statistics and Actuarial Science, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
| | - Fabio Feldman
- Injury Prevention and Mobility Laboratory (IPML), Department of Biomedical Physiology and Kinesiology, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada; Patient Safety and Injury Prevention, Fraser Health Authority, Suite 400, 13450 102nd Avenue, Surrey, BC, V3T 5X3, Canada.
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Kolling Institute of Medical Research, University of Sydney, St. Leonards, NSW 2065, Australia.
| | - Pet Ming Leung
- Patient Safety and Injury Prevention, Fraser Health Authority, Suite 400, 13450 102nd Avenue, Surrey, BC, V3T 5X3, Canada; New Vista Care Home, 7550 Rosewood Street, Burnaby, BC, V5E 3Z3, Canada.
| | - Joanie Sims-Gould
- Centre for Hip Health and Mobility, 7/F, 2635 Laurel Street, Vancouver, BC, V5Z 1M9, Canada; Department of Family Practice, University of British Columbia, 3/F, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada.
| | - Judith Godin
- Geriatric Medicine Research, Nova Scotia Health Authority, 5955 Veteran's Memorial Lane, Halifax, NS, B3H 2E1, Canada.
| | - Stephen N Robinovitch
- Injury Prevention and Mobility Laboratory (IPML), Department of Biomedical Physiology and Kinesiology, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada; Centre for Hip Health and Mobility, 7/F, 2635 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
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Incidence Rates of and Mortality after Hip Fracture among German Nursing Home Residents. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15020289. [PMID: 29414914 PMCID: PMC5858358 DOI: 10.3390/ijerph15020289] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 02/01/2018] [Accepted: 02/04/2018] [Indexed: 11/17/2022]
Abstract
Little is known about hip fracture rates and post-fracture mortality among nursing home residents. This retrospective cohort study examined incidence rates (IR) of and mortality after hip fracture in this population focusing on sex differences. A cohort of >127,000 residents ≥65 years, newly admitted to German nursing homes between 2010 and 2014 were used to calculate age-, sex-, care-need- and time after admission-specific IR. To determine mortality, the Kaplan-Meier-method was applied. Using Cox regression, we studied mortality and estimated time-dependent hazard ratios (HRs). For this purpose, to each person with a hip fracture, one resident without a hip fracture was matched by sex, age and care-need using risk-set sampling. 75% were women (mean age: 84.0 years). During 168,588 person-years (PY), 8537 residents with at least one hip fracture were observed. The IR for women and men were 52.9 and 42.5/1000 PY. For both sexes, IR increased with rising age and decreased with increasing care-level. IR were highest in the first months after admission and subsequently declined afterwards. The impact of hip fractures on mortality was time-dependent. Mortality of residents with hip fracture was highest in the first two months after fracture compared to those without (HR): 2.82; 95% CI 2.57–3.11) and after six months, no differences were found (HR: 1.10; 95% CI 0.98–1.22) Further research should always include analyses stratified by sex, age and time period after admission.
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Korall AMB, Godin J, Feldman F, Cameron ID, Leung PM, Sims-Gould J, Robinovitch SN. Validation and psychometric properties of the commitment to hip protectors (C-HiP) index in long-term care providers of British Columbia, Canada: a cross-sectional survey. BMC Geriatr 2017; 17:103. [PMID: 28468679 PMCID: PMC5415742 DOI: 10.1186/s12877-017-0493-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 04/25/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND If worn during a fall, hip protectors substantially reduce risk for hip fracture. However, a major barrier to their clinical efficacy is poor user adherence. In long-term care, adherence likely depends on how committed care providers are to hip protectors, but empirical evidence is lacking due to the absence of a psychometrically valid assessment tool. METHODS We conducted a cross-sectional survey in a convenience sample of 529 paid care providers. We developed the 15-item C-HiP Index to measure commitment, comprised of three subscales: affective, cognitive and behavioural. Responses were subjected to hierarchical factor analysis and internal consistency testing. Eleven experts rated the relevance and clarity of items on 4-point Likert scales. We performed simple linear regression to determine whether C-HiP Index scores were positively related to the question, "Do you think of yourself as a champion of hip protectors", rated on a 5-point Likert scale. We examined whether the C-HiP Index could differentiate respondents: (i) who were aware of a protected fall causing hip fracture from those who were unaware; (ii) who agreed in the existence of a champion of hip protectors within their home from those who didn't. RESULTS Hierarchical factor analysis yielded two lower-order factors and a single higher-order factor, representing the overarching concept of commitment to hip protectors. Items from affective and cognitive subscales loaded highest on the first lower-order factor, while items from the behavioural subscale loaded highest on the second. We eliminated one item due to low factor matrix coefficients, and poor expert evaluation. The C-HiP Index had a Cronbach's alpha of 0.96. A one-unit increase in championing was associated with a 5.2-point (p < 0.01) increase in C-HiP Index score. Median C-HiP Index scores were 4.3-points lower (p < 0.01) among respondents aware of a protected fall causing hip fracture, and 7.0-points higher (p < 0.01) among respondents who agreed in the existence of a champion of hip protectors within their home. CONCLUSIONS We offer evidence of the psychometric properties of the C-HiP Index. The development of a valid and reliable assessment tool is crucial to understanding the factors that govern adherence to hip protectors in long-term care.
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Affiliation(s)
- Alexandra M B Korall
- Injury Prevention and Mobility Laboratory (IPML), Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada. .,Centre for Hip Health and Mobility, 7th Floor, 2635 Laurel Street, Vancouver, V5Z 1M9, BC, Canada.
| | - Judith Godin
- Geriatric Medicine Research Unit, Nova Scotia Health Authority, 5955 Veteran's Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Fabio Feldman
- Injury Prevention and Mobility Laboratory (IPML), Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.,Patient Safety and Injury Prevention, Fraser Health Authority, Suite 400, 13450 102nd Avenue, Surry, BC, V3T 5X3, Canada
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW, 2065, Australia
| | - Pet-Ming Leung
- Patient Safety and Injury Prevention, Fraser Health Authority, Suite 400, 13450 102nd Avenue, Surry, BC, V3T 5X3, Canada.,New Vista Care Home, 7550 Rosewood Street, Burnaby, BC, V5E 3Z3, Canada
| | - Joanie Sims-Gould
- Centre for Hip Health and Mobility, 7th Floor, 2635 Laurel Street, Vancouver, V5Z 1M9, BC, Canada.,Department of Family Practice, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Stephen N Robinovitch
- Injury Prevention and Mobility Laboratory (IPML), Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.,Centre for Hip Health and Mobility, 7th Floor, 2635 Laurel Street, Vancouver, V5Z 1M9, BC, Canada
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Abstract
This prospective, observational study characterizes the circumstances that led to falls in long-term care (LTC) residents and describes the characteristics of residents who fractured following a fall. Staff recorded the location of the fall, time of day, activity the participant was doing prior, and if an injury occurred. Descriptive statistics were used to describe the falls, and a generalized linear model was used to determine differences between the circumstances. Of the 101 LTC residents who participated, 41 per cent experienced at least one fall. Residents were significantly more likely to have fallen in the bedroom and while walking. Of the 17 falls resulting in fractures, most occurred in the bedroom and bathroom, during the early morning; most residents who fractured were female with cognitive impairment. To monitor falls comprehensively, ambulatory monitoring that avoids privacy issues in bedrooms or bathrooms may be needed. Interventions should target walking or the bedroom setting.
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Papaioannou A, Kennedy CC, Ioannidis G, Cameron C, Croxford R, Adachi JD, Mursleen S, Jaglal S. Comparative trends in incident fracture rates for all long-term care and community-dwelling seniors in Ontario, Canada, 2002-2012. Osteoporos Int 2016; 27:887-897. [PMID: 26801930 PMCID: PMC5096943 DOI: 10.1007/s00198-015-3477-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/29/2015] [Indexed: 01/25/2023]
Abstract
SUMMARY In this population-based study, we compared incident fracture rates in long-term care (LTC) versus community seniors between 2002 and 2012. Hip fracture rates declined more rapidly in LTC than in the community. An excess burden of fractures occurred in LTC for hip, pelvis, and humerus fractures in men and hip fractures only in women. INTRODUCTION This study compares trends in incident fracture rates between long-term care (LTC) and community-dwelling seniors ≥65 years, 2002-2012. METHODS This is a population-based cohort study using administrative data. Measurements were age/sex-adjusted incident fracture rates and rate ratios (RR) and annual percent change (APC). RESULTS Over 11 years, hip fracture rates had a marked decline occurring more rapidly in LTC (APC, -3.49 (95% confidence interval (CI), -3.97, -3.01)) compared with the community (APC, -2.93 (95% CI, -3.28, -2.57); p < 0.05 for difference in slopes). Humerus and wrist fracture rates decreased; however, an opposite trend occurred for pelvis and spine fractures with rates increasing over time in both cohorts (all APCs, p < 0.05). In 2012, incident hip fracture rates were higher in LTC than the community (RRs: women, 1.55 (95% CI, 1.45, 1.67); men, 2.18 (95% CI, 1.93, 2.47)). Higher rates of pelvis (RR, 1.48 (95% CI, 1.22, 1.80)) and humerus (RR, 1.40 (95% CI, 1.07, 1.84)) fractures were observed in LTC men, not women. In women, wrist (RR, 0.76 (95% CI, 0.71, 0.81)) and spine (RR, 0.52 (95% CI, 0.45, 0.61)) fracture rates were lower in LTC than the community; in men, spine (RR, 0.75 (95% CI, 0.57, 0.98) but not wrist fracture (RR, 0.91 (95% CI, 0.67, 1.23)) rates were significantly lower in LTC than the community. CONCLUSION Previous studies in the community have shown declining hip fracture rates over time, also demonstrated in our study but at a more rapid rate in LTC. Rates of humerus and wrist fractures also declined. An excess burden of fractures in LTC occurred for hip fractures in women and for hip, pelvis, and humerus fractures in men.
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Affiliation(s)
- A Papaioannou
- GERAS Centre, Hamilton Health Sciences, 88 Maplewood Avenue, Hamilton, ON, L8M 1W9, Canada.
- Division of Geriatrics, Department of Medicine, McMaster University, 88 Maplewood Avenue, Hamilton, ON, L8M 1W9, Canada.
| | - C C Kennedy
- GERAS Centre, Hamilton Health Sciences, 88 Maplewood Avenue, Hamilton, ON, L8M 1W9, Canada
| | - G Ioannidis
- GERAS Centre, Hamilton Health Sciences, 88 Maplewood Avenue, Hamilton, ON, L8M 1W9, Canada
- Division of Geriatrics, Department of Medicine, McMaster University, 88 Maplewood Avenue, Hamilton, ON, L8M 1W9, Canada
- Division of Rheumatology, Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - C Cameron
- International Centre for Disability and Rehabilitation, University of Toronto, 500 University Avenue, Toronto, ON, M5G 1V7, Canada
| | - R Croxford
- Institute for Clinical Evaluative Sciences, University of Toronto, 155 College Street, Suite 424, Toronto, ON, M5T 3M6, Canada
| | - J D Adachi
- Division of Rheumatology, Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - S Mursleen
- GERAS Centre, Hamilton Health Sciences, 88 Maplewood Avenue, Hamilton, ON, L8M 1W9, Canada
| | - S Jaglal
- Department of Physical Therapy, University of Toronto, 160-500 University Avenue, Toronto, ON, M5G 1V7, Canada
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van Dijk PAD, Bot AGJ, Neuhaus V, Menendez ME, Vrahas MS, Ring D. Admission From Nursing Home Residence Increases Acute Mortality After Hip Fractures. Geriatr Orthop Surg Rehabil 2015; 6:123-9. [PMID: 26328224 PMCID: PMC4536497 DOI: 10.1177/2151458515570477] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Little is known about the effect of preinjury residence on inpatient mortality following hip fracture. This study addressed whether (1) admission from a nursing home residence and (2) admission from another hospital were associated with higher inpatient mortality after a hip fracture. METHODS Using the National Hospital Discharge Survey database, we analyzed an estimated 2 124 388 hip fractures discharges, from 2001 to 2007. Multivariable logistic regression analysis was performed to identify whether admission from a nursing home and admission from another hospital were independent risk factors for inpatient mortality. Our primary null hypothesis is that there is no difference in inpatient mortality rates after hip fracture in patients admitted from a nursing home, compared to other forms of admission. The secondary null hypothesis is that there is no difference in inpatient mortality after hip fracture in patients whose source of admission was another hospital, compared to other sources of admission. RESULTS Almost 4% of the patients were admitted from a nursing home and 6% from another hospital. The mean age was 79 years and 71% were women. The majority of patients were treated with internal fixation. Admission from a nursing home residence (odds ratio [OR] of 2.1, confidence interval [CI] 1.9-2.3) and prior hospital stay (OR 3.4, CI 3.2-3.7) were associated with a higher risk of inpatient mortality after accounting for other comorbidities and type of treatment. CONCLUSIONS Patients transferred to an acute care hospital from a long-term care facility or another acute care hospital are at particularly high risk of inpatient death. This subset of patients should be considered separately from patients admitted from other sources. LEVEL OF EVIDENCE Prognostic level II.
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Affiliation(s)
- Pim A. D. van Dijk
- Orthopaedic Hand and Upper Extremity Service, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Arjan G. J. Bot
- Orthopaedic Hand and Upper Extremity Service, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Valentin Neuhaus
- Orthopaedic Hand and Upper Extremity Service, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Mariano E. Menendez
- Orthopaedic Hand and Upper Extremity Service, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Mark S. Vrahas
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
- Partners Orthopaedic Trauma Service, Massachusetts General Hospital, Boston, MA, USA
| | - David Ring
- Orthopaedic Hand and Upper Extremity Service, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Amrein K, Dobnig H, Wagner D, Piswanger-Sölkner C, Pieber TR, Pilz S, Tomaschitz A, Dimai HP, Fahrleitner-Pammer A. Sclerostin in Institutionalized Elderly Women: Associations with Quantitative Bone Ultrasound, Bone Turnover, Fractures, and Mortality. J Am Geriatr Soc 2014; 62:1023-9. [DOI: 10.1111/jgs.12791] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Karin Amrein
- Division of Endocrinology and Metabolism; Medical University of Graz; Graz Austria
| | - Harald Dobnig
- Division of Endocrinology and Metabolism; Medical University of Graz; Graz Austria
| | - Doris Wagner
- Division of Transplantation Surgery; Department of Surgery; Medical University of Graz; Graz Austria
| | | | - Thomas R. Pieber
- Division of Endocrinology and Metabolism; Medical University of Graz; Graz Austria
| | - Stefan Pilz
- Division of Endocrinology and Metabolism; Medical University of Graz; Graz Austria
| | - Andreas Tomaschitz
- Division of Cardiology; Department of Internal Medicine; Medical University of Graz; Graz Austria
| | - Hans Peter Dimai
- Division of Endocrinology and Metabolism; Medical University of Graz; Graz Austria
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Finsterwald M, Sidelnikov E, Orav EJ, Dawson-Hughes B, Theiler R, Egli A, Platz A, Simmen HP, Meier C, Grob D, Beck S, Stähelin HB, Bischoff-Ferrari HA. Gender-specific hip fracture risk in community-dwelling and institutionalized seniors age 65 years and older. Osteoporos Int 2014; 25:167-76. [PMID: 24136101 DOI: 10.1007/s00198-013-2513-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 09/11/2013] [Indexed: 11/25/2022]
Abstract
UNLABELLED In this study of acute hip fracture patients, we show that hip fracture rates differ by gender between community-dwelling seniors and seniors residing in nursing homes. While women have a significantly higher rate of hip fracture among the community-dwelling seniors, men have a significantly higher rate among nursing home residents. INTRODUCTION Differences in gender-specific hip fracture risk between community-dwelling and institutionalized seniors have not been well established, and seasonality of hip fracture risk has been controversial. METHODS We analyzed detailed data from 1,084 hip fracture patients age 65 years and older admitted to one large hospital center in Zurich, Switzerland. In a sensitivity analysis, we extend to de-personalized data from 1,265 hip fracture patients from the other two large hospital centers in Zurich within the same time frame (total n = 2,349). The denominators were person-times accumulated by the Zurich population in the corresponding age/gender/type of dwelling stratum in each calendar season for the period of the study. RESULTS In the primary analysis of 1,084 hip fracture patients (mean age 85.1 years; 78% women): Among community-dwelling seniors, the risk of hip fracture was twofold higher among women compared with men (RR = 2.16; 95% CI, 1.74-2.69) independent of age, season, number of comorbidities, and cognitive function; among institutionalized seniors, the risk of hip fracture was 26% lower among women compared with men (RR = 0.77; 95% CI: 0.63-0.95) adjusting for the same confounders. In the sensitivity analysis of 2,349 hip fracture patients (mean age 85.0 years, 76% women), this pattern remained largely unchanged. There is no seasonal swing in hip fracture incidence. CONCLUSION We confirm for seniors living in the community that women have a higher risk of hip fracture than men. However, among institutionalized seniors, men are at higher risk for hip fracture.
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Affiliation(s)
- M Finsterwald
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid, Zurich, Switzerland
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11
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Risk of Hip Fracture in Community-dwelling and Institutionalized Osteoporotic Patients: A 3-year Study. INT J GERONTOL 2013. [DOI: 10.1016/j.ijge.2012.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Labronici PJ, Blunck SS, Lana FR, Esteves BB, Franco JS, Fukuyama JM, Pires RES. Vitamin D and its Relation to Bone Mineral Density in Postmenopause Women. Rev Bras Ortop 2013; 48:228-235. [PMID: 31214537 PMCID: PMC6565868 DOI: 10.1016/j.rboe.2012.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 07/23/2012] [Indexed: 11/30/2022] Open
Abstract
Objective Compare the level of vitamin D with the bone mineral density (BMD) in postmenopausal women, with or without fractures. Methods 250 women with mean age of 71.1 were evaluated. The serum levels of vitamin D considered sufficient were ≥ 30 ng/mL, insufficient between 20 and 30 ng/mL and deficient < 20 ng/mL. The bone mineral density was measured and considered osteopenia when T value total of lumbar spine or hip was between -1 and -2.5 and osteoporosis < 2.5. The patients with fractures accounted for 25.2%. Results There was no significant difference in the vitamin D (ng/mL) levels among the age groups (p = 0.25), the levels of fractures (p = 0.79) and the levels of BMD (p = 0.76). Conclusion 82% of the patients presented deficient and insufficient blood levels of vitamin D. Ours results showed any significant correlation between vitamin D levels and bone mineral density after adjusting for age.
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Affiliation(s)
- Pedro José Labronici
- PhD in Medicine at Escola Paulista de Medicina, at Universidade Federal de São Paulo; Clinical Head of the Orthopedics and Traumatology Service of Prof. Dr. Donato D'Ângelo, Hospital Santa Teresa, Petrópolis, RJ, Brazil
| | - Saulo Santos Blunck
- Resident Physician of the Orthopedics and Traumatology Service of Prof. Dr. Donato D'Ângelo, Hospital Santa Teresa, Petrópolis, RJ, Brazil
| | - Flavius Ribeiro Lana
- Resident Physician of the Orthopedics and Traumatology Service of Prof. Dr. Donato D'Ângelo, Hospital Santa Teresa, Petrópolis, RJ, Brazil
| | - Bruno Bandeira Esteves
- Resident Physician of the Orthopedics and Traumatology Service of Prof. Dr. Donato D'Ângelo, Hospital Santa Teresa, Petrópolis, RJ, Brazil
| | - José Sergio Franco
- Head of Department, Associate Professor and Doctor of the Orthopedics and Traumatology Service of the Department of the Medical School at UFRJ, Rio de Janeiro, RJ, Brazil
| | | | - Robinson Esteves Santos Pires
- Assistant Professor of the Department of the Locomotor System of the Universidade Federal de Minas Gerais and Coordinator of the Specialization Course in Orthopedics and Traumatology of the Hospital Felício Rocho, Belo Horizonte, MG, Brazil
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Vitamina D e sua relação com a densidade mineral óssea em mulheres na pós-menopausa. Rev Bras Ortop 2013. [DOI: 10.1016/j.rbo.2012.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Rolland Y, de Souto Barreto P, Abellan Van Kan G, Annweiler C, Beauchet O, Bischoff-Ferrari H, Berrut G, Blain H, Bonnefoy M, Cesari M, Duque G, Ferry M, Guerin O, Hanon O, Lesourd B, Morley J, Raynaud-Simon A, Ruault G, Souberbielle JC, Vellas B. Vitamin D supplementation in older adults: searching for specific guidelines in nursing homes. J Nutr Health Aging 2013; 17:402-12. [PMID: 23538667 DOI: 10.1007/s12603-013-0007-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prevalence of vitamin D insufficiency is very high in the nursing home (NH) population. Paradoxically, vitamin D insufficiency is rarely treated despite of strong clinical evidence and recommendations for supplementation. This review aims at reporting the current knowledge of vitamin D supplementation in NH and proposing recommendations adapted to the specificities of this institutional setting. DESIGN Current literature on vitamin D supplementation for NH residents was narratively presented and discussed by the French Group of Geriatrics and Nutrition. RESULT Vitamin D supplementation is a safe and well-tolerated treatment. Most residents in NH have vitamin D insufficiency, and would benefit from vitamin D supplement. However, only few residents are actually treated. Current specific and personalized protocols for vitamin D supplementation may not be practical for use in NH settings (e.g., assessment of serum vitamin D concentrations before and after supplementation). Therefore, our group proposes a model of intervention based on the systematic supplementation of vitamin D (1,000 IU/day) since the patient's admission to the NH and throughout his/her stay without the need of a preliminary evaluation of the baseline levels. Calcium should be prescribed only in case of poor dietary calcium intake. CONCLUSION A population-based rather than individual-based approach may probably improve the management of vitamin D insufficiency in the older population living in NH, without increasing the risks of adverse health problems. The clinical relevance and cost effectiveness of this proposal should be assessed under NH real-world conditions to establish its feasibility.
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Affiliation(s)
- Y Rolland
- Department of Geriatric Medicine, CHU Toulouse, Institute of aging, F-31059 Toulouse, France.
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15
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Rapp K, Becker C, Cameron ID, Klenk J, Kleiner A, Bleibler F, König HH, Büchele G. Femoral fracture rates in people with and without disability. Age Ageing 2012; 41:653-8. [PMID: 22431152 DOI: 10.1093/ageing/afs044] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE to estimate femoral fracture rates in community-dwelling older people without care need (CCN(-)), in community-dwelling older people with care need (CCN(+)) and in residents of nursing homes (RNH) and to determine their contribution to the overall burden of femoral fractures. METHODS routine data of more than 1.2 million German people aged 65 years and more were used to calculate sex- and age-specific femoral fracture rates in the three groups CCN(-), CCN(+) and RNH. Those people receiving benefits of the long-term care insurance were defined as having care need. The percentile contribution of the three subpopulations to the overall burden of femoral fractures was determined. RESULTS during 5,319,438 person-years, 44,000 femoral fractures were recorded. In each of the three subpopulations female and male fracture rates increased with increasing age. Femoral fracture rates of the total subpopulations were 6.13, 34.53 and 43.05 femoral fractures/1,000 person-years in CCN(-), CCN(+) and RNH in women and 2.66, 20.34 and 31.09 in men, respectively. The contribution of people with care need to the overall burden of femoral fractures in older people was about 50%. CONCLUSION the incidence of femoral fractures was considerably higher in people with care need than in people without care need. This should be considered when planning medical care or targeting preventive measures.
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Colón-Emeric CS, Lyles KW, Su G, Pieper CF, Magaziner JS, Adachi JD, Bucci-Rechtweg CM, Haentjens P, Boonen S. Clinical risk factors for recurrent fracture after hip fracture: a prospective study. Calcif Tissue Int 2011; 88:425-31. [PMID: 21331567 DOI: 10.1007/s00223-011-9474-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 01/25/2011] [Indexed: 11/28/2022]
Abstract
Additional fractures after hip fracture are common, but little is known about the risk factors associated with these events. We determined the clinical risk factors associated with fracture following a low-trauma hip fracture and whether clinical risk factors for subsequent fracture were modified by zoledronic acid (ZOL). In this post hoc analysis of the HORIZON Recurrent Fracture trial, 2,127 men and women were randomized within 90 days of surgical hip fracture repair to receive intravenous ZOL 5 mg yearly or placebo. All patients received a loading dose of vitamin D and daily oral calcium and vitamin D supplements. In the multivariable model age, sex, BMI, femoral neck T score, and one or more fall risk factors were significant predictors of subsequent fracture. Race, history of prior fracture other than the index hip fracture, T score < -2.5 as a dichotomous variable, and type of index hip fracture were not associated with a different risk of subsequent fractures. Treatment with ZOL did not modify the impact of these risk factors. Well-established risk factors for fracture risk such as age, sex, BMI, and fall risk factors will also contribute to fracture risk in patients who have already suffered a hip fracture, while other prior fractures and T score < -2.5 are not predictive of subsequent fractures. Baseline risk factors in hip fracture patients were predictive of fracture in both ZOL- and placebo-treated participants, and there is no difference in the risk of subsequent fractures based on index hip fracture type.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Duke University Medical Center and the Geriatrics Research Education and Clinical Center, Veterans Affairs Medical Center, 508 Fulton St GRECC 182, Durham, NC 27705, USA.
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17
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Brennan SL, Henry MJ, Kotowicz MA, Nicholson GC, Zhang Y, Pasco JA. Incident hip fracture and social disadvantage in an Australian population aged 50 years or greater. Bone 2011; 48:607-10. [PMID: 21040808 DOI: 10.1016/j.bone.2010.10.175] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 10/07/2010] [Accepted: 10/24/2010] [Indexed: 11/25/2022]
Abstract
AIMS There is an inverse association between socioeconomic status (SES) and most causes of morbidity. Hip fractures pose a significant public health burden on society. However, the association between quintiles of area-based SES and incident hip fractures has not been examined in Australia. Using a comprehensive register of hip fractures for the entire Barwon Statistical Division (BSD), we assessed the association between area-based SES and incident hip fractures over a two-year period in residents aged ≥ 50years. METHODS Incident hip fractures were identified using a computerized keyword search of all radiological reports from all the radiological centers serving the BSD. Pathological fractures were excluded. SES was determined by cross-referencing residential addresses with Australian Bureau of Statistics census data and categorized in quintiles based upon the BSD reference range. Homogeneity of population at risk in each SES quintile was tested using chi square comparison. Hip fractures in each quintile and within each age strata for the entire BSD region were defined as rates per 1000 person-years. RESULTS During 2006-2007, there were 495 hip fractures (336 female). An inverse pattern of association was observed between SES and hip fracture incidence, with a peak in fracture numbers observed in the second quintile of SES, with differences between SES quintiles observed for both females (p = 0.005) and males (p = 0.007). CONCLUSION The association between incident hip fractures and quintiles of area-based SES provides evidence that those of greater social disadvantage should be a specific target population for intervention to reduce the burden of hip fracture within Australia.
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Affiliation(s)
- S L Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne 3004, Australia.
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18
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Ip TP, Leung J, Kung AWC. Management of osteoporosis in patients hospitalized for hip fractures. Osteoporos Int 2010; 21:S605-14. [PMID: 21058000 PMCID: PMC2974929 DOI: 10.1007/s00198-010-1398-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 09/08/2010] [Indexed: 12/31/2022]
Abstract
Hip fracture is associated with high morbidity, mortality, and economic burden worldwide. It is also a major risk factor for a subsequent fracture. A literature search on the management of osteoporosis in patients with hip fracture was performed on the Medline database. Only one clinical drug trial was conducted in patients with a recent hip fracture. Further studies that specifically address post-fracture management of hip fracture are needed. The efficacy of anti-osteoporosis medication in older individuals and those at high risk of fall is reviewed in this paper. Adequate nutrition is vital for bone health and to prevent falls, especially in malnourished patients. Protein, calcium, and vitamin D supplementation is associated with increased hip BMD and a reduction in falls. Fall prevention, exercise, and balance training incorporated in a comprehensive rehabilitation program are essential to improve functional disability and survival. Exclusion of secondary causes of osteoporosis and treatment of coexistent medical conditions are also vital. Such a multidisciplinary team approach to the management of hip fracture patients is associated with a better clinical outcome. Although hip fracture is the most serious of all fractures, osteoporosis management should be prioritized to prevent deterioration of health and occurrence of further fracture.
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Affiliation(s)
- T. P. Ip
- Department of Medicine, Tung Wah Eastern Hospital, Hong Kong, China
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - J. Leung
- Department of Medicine, Ruttonjee Hospital, Hong Kong, China
| | - A. W. C. Kung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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Nakamura K, Oyama M, Takahashi S, Yoshizawa Y, Kobayashi R, Oshiki R, Saito T, Tsuchiya Y. Fracture incidence in nursing homes in Japan. Osteoporos Int 2010; 21:797-803. [PMID: 19618096 DOI: 10.1007/s00198-009-1015-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Accepted: 06/18/2009] [Indexed: 10/20/2022]
Abstract
UNLABELLED We conducted the first study to determine fracture incidence in institutionalized elderly people in East Asia. Fracture incidence was generally higher than in the general population but was not for all fracture types. Specific fracture prevention strategies for institutionalized people are needed. Ethnic differences in fracture incidence are also discussed. INTRODUCTION The aim of this study was to determine the incidence of fractures in nursing homes in Japan, where fracture is becoming an increasingly problematic health issue. METHODS We conducted a cohort study with a 1-year follow-up. Subjects were 8,905 residents (average age, 84.3 years) in nursing homes. Caregivers assessed activities of daily living levels using Barthel's index, and we collected demographic data of each resident. Fracture diagnosis was based on medical records from the hospitals where patients were admitted. RESULTS Incidence of hip fracture was 14.9 per 1,000 person-years for women and 9.7 for men. Incidence of forearm and upper-arm fractures was 1.9 and 5.1 for women and 0.5 and 2.1 for men, respectively. Hip and upper-arm fracture rates were higher than in the general population, but forearm fracture rates were lower. Hazard ratio of fracture incidence in totally dependent to partially dependent or independent subjects was 0.14 (95%CI 0.05-0.33) for hip fracture and 0.34 (95%CI 0.23-0.50) for all fractures. CONCLUSIONS Fracture incidence in institutionalized elderly people is generally higher but is not higher for all types of fractures than the general population. In addition, totally dependent persons had a much lower risk of hip fracture.
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Affiliation(s)
- K Nakamura
- Department of Community Preventive Medicine, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata, Japan.
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20
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Sawka AM, Ismaila N, Cranney A, Thabane L, Kastner M, Gafni A, Woodhouse LJ, Crilly R, Cheung AM, Adachi JD, Josse RG, Papaioannou A. A scoping review of strategies for the prevention of hip fracture in elderly nursing home residents. PLoS One 2010; 5:e9515. [PMID: 20209088 PMCID: PMC2831075 DOI: 10.1371/journal.pone.0009515] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 02/08/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Elderly nursing home residents are at increased risk of hip fracture; however, the efficacy of fracture prevention strategies in this population is unclear. OBJECTIVE We performed a scoping review of randomized controlled trials of interventions tested in the long-term care (LTC) setting, examining hip fracture outcomes. METHODS We searched for citations in 6 respective electronic searches, supplemented by hand searches. Two reviewers independently reviewed all citations and full-text papers; consensus was achieved on final inclusion. Data was abstracted in duplicate. FINDINGS We reviewed 22,349 abstracts or citations and 949 full-text papers. Data from 20 trials were included: 7--vitamin D (n = 12,875 participants), 2--sunlight exposure (n = 522), 1--alendronate (n = 327), 1--fluoride (n = 460), 4--exercise or multimodal interventions (n = 8,165), and 5--hip protectors (n = 2,594). Vitamin D, particularly vitamin D(3) > or = 800 IU orally daily, reduced hip fracture risk. Hip protectors reduced hip fractures in included studies, although a recent large study not meeting inclusion criteria was negative. Fluoride and sunlight exposure did not significantly reduce hip fractures. Falls were reduced in three studies of exercise or multimodal interventions, with one study suggesting reduced hip fractures in a secondary analysis. A staff education and risk assessment strategy did not significantly reduce falls or hip fractures. In a study underpowered for fracture outcomes, alendronate did not significantly reduce hip fractures in LTC. CONCLUSIONS The intervention with the strongest evidence for reduction of hip fractures in LTC is Vitamin D supplementation; more research on other interventions is needed.
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Affiliation(s)
- Anna M Sawka
- Division of Endocrinology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.
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21
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Zimmerman S, Magaziner J, Birge SJ, Barton BA, Kronsberg SS, Kiel DP. Adherence to hip protectors and implications for U.S. long-term care settings. J Am Med Dir Assoc 2010; 11:106-15. [PMID: 20142065 DOI: 10.1016/j.jamda.2009.09.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Accepted: 09/23/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Determine nursing home characteristics related to adherence to use of a hip protector (HP) to prevent fracture; also describe adherence and related resident characteristics. DESIGN A multicenter, randomized controlled trial of a HP in which adherence to wearing the HP was monitored by research staff 3 times a week for up to 21 months; data were collected by interviews and chart review. SETTING Thirty-five nursing homes in Boston, St. Louis, and Baltimore. PARTICIPANTS A total of 797 eligible residents, 633 (79%) of whom passed the run-in period, 397 (63%) of whom remained in the study until the end of follow-up. INTERVENTION Residents wore a single HP on their right or left side. MEASUREMENTS In addition to regular monitoring of adherence, data were collected regarding facility characteristics, staffing, policies and procedures, perception of HPs and related experience, and research staff ratings of environmental and overall quality; and also resident demographic characteristics, and function, health, and psychosocial status. RESULTS Facility characteristics related to more adherence were not being chain-affiliated; less Medicaid case-mix; fewer residents wearing HPs; more paraprofessional staff training; more rotating workers; and having administrators who were less involved in meetings. CONCLUSION Efforts to increase adherence to the use of HPs should focus on facilities with more Medicaid case-mix to reduce disparities in care, and those that have less of a culture of training. Staff may need support to increase adherence, and when adherence cannot be maintained, HP use should be targeted to those who remain adherent.
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Affiliation(s)
- Sheryl Zimmerman
- Program on Aging, Disability and Long-Term Care, Cecil G. Sheps Center for Health Services Research, and the School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC 27590-7599, USA.
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22
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Berry SD, Samelson EJ, Bordes M, Broe K, Kiel DP. Survival of aged nursing home residents with hip fracture. J Gerontol A Biol Sci Med Sci 2009; 64:771-7. [PMID: 19414511 DOI: 10.1093/gerona/glp019] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Little is known about mortality in nursing home residents with hip fracture. This study examined the effect of pre-fracture characteristics, hospital complications, and post-fracture complications on mortality in residents with hip fracture. METHODS This is a retrospective cohort study of 195 long-term care residents (153 women, 42 men) with hip fracture (1999-2006) followed for mortality until June 30, 2007. Pre-fracture characteristics (age, sex, cognition, functional status, comorbidities, body mass index), hospital complications (acute myocardial infarction, congestive heart failure, delirium, infection) and 6-month complications (delirium, pneumonia, pressure ulcer, urinary tract infection [UTI]) were evaluated as potential predictors of mortality. RESULTS During a median follow-up of 1.4 years, 150 participants (76.9%) died. Male residents were nearly twice as likely to die compared with female residents (hazard ratio [HR] = 1.9, 95% confidence interval [CI] 1.2-3.0). Other pre-fracture characteristics associated with increased mortality included older age (HR per 5 years = 1.3, 95% CI 1.1-1.6), low functional status (HR = 1.7, 95% CI 1.0-3.0), anemia (HR = 1.6, 95% CI 1.1-2.5), and coronary artery disease (HR = 2.0, 95% CI 1.3-2.9). Mortality was 70% greater among residents with a pressure ulcer or pneumonia within 6 months of hip fracture (pressure ulcer, HR = 1.7, 95% CI 1.2-2.6; pneumonia, HR = 1.7, 95% CI 1.1-2.7). Individual hospital complications and post-fracture delirium and UTI were not significant predictors of mortality. CONCLUSIONS In addition to pre-fracture characteristics, potentially modifiable post-fracture complications including pressure ulcer and pneumonia were associated with increased mortality in nursing home residents with hip fracture. Prevention strategies to reduce pressure ulcers and pneumonia may help reduce mortality in this frail population.
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Affiliation(s)
- Sarah D Berry
- Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
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23
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Parikh S, Avorn J, Solomon DH. Pharmacological management of osteoporosis in nursing home populations: a systematic review. J Am Geriatr Soc 2009; 57:327-34. [PMID: 19207148 DOI: 10.1111/j.1532-5415.2008.02119.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Nursing home (NH) residents fall 11 times as frequently as their age-matched community-dwelling counterparts. The benefits of fall prevention strategies and hip protectors in terms of fracture risk in this setting are unclear. Moreover, there is no consensus on the efficacy of osteoporosis medication in NH residents. A systematic review was conducted to evaluate the efficacy of medications for osteoporosis in this population and to examine utilization studies in the NH setting to define prescribing practices. Electronic searches of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were supplemented with a hand search of bibliographies. All English-language studies published between January 1, 1974, and December 31, 2006, that studied osteoporosis pharmacotherapy in the NH environment were obtained, and studies of medication benefits and utilization patterns were identified. No restrictions were placed on study method. Studies required inclusion of NH patients and extractable data with bone mineral density (BMD) or fracture outcomes. Forty full-text articles were retrieved, of which 15 studies met selection criteria. In the nine studies examining medication effects, calcium (1,200 mg) and vitamin D (800 IU) supplementation were shown to reduce fracture risk and improve BMD. One study supported the role of alendronate, but none documented the utility of raloxifene, calcitonin, or teriparatide in NH residents. All six medication utilization studies reported infrequent use of osteoporosis medications (9-25%). Prescribing for elderly NH patients is difficult, considering the risk:benefit ratio and issues of longevity, but these medications may be underused in the NH environment.
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Affiliation(s)
- Seema Parikh
- Brigham and Womens' Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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24
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Guilley E, Chevalley T, Herrmann F, Baccino D, Hoffmeyer P, Rapin CH, Rizzoli R. Reversal of the hip fracture secular trend is related to a decrease in the incidence in institution-dwelling elderly women. Osteoporos Int 2008; 19:1741-7. [PMID: 18484149 DOI: 10.1007/s00198-008-0610-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2007] [Accepted: 02/27/2008] [Indexed: 10/22/2022]
Abstract
UNLABELLED In this prospective 10-year study in elderly aged 60 years and over, there was a 1.3% per year reduction in the standardized incidence of hip fracture in women but not in men. This decrease was mainly due to changes in the standardized incidence of hip fracture in institution-dwelling women. INTRODUCTION A decrease in age-adjusted hip fracture incidence has been recently demonstrated in some countries. Since a large proportion of hip fractures occur in nursing homes, we analyzed whether this decreasing trend would be more detectable in institution-dwelling elderly compared with community-dwelling elderly. METHODS All hip fracture patients aged 60 years and over were identified in a well-defined area. Incidence of hip fracture, age- and sex-adjusted to the 2000 Geneva population, was computed in community- and institution-dwelling elderly. RESULTS From 1991 to 2000, 1,624 (41%) hip fractures were recorded in institutionalized-dwelling elderly and 2,327 (59%) in community-dwelling elderly. The standardized fracture incidence decreased by 1.3% per year in women (p = 0.039), but remained unchanged in men (+0.5%; p = 0.686). Among institution-dwelling women, hip fracture incidence fell by 1.9% per year (p = 0.044), whereas it remained stable among community-dwelling women (+0.0%, p = 0.978). In men, no significant change in hip fracture incidence occurred among institution- or community-dwelling elderly. CONCLUSIONS The decrease in the standardized hip fracture incidence in institution-dwelling women is responsible for the reversal in secular trend. Future research should include stratification according to the residential status to better identify the causes responsible for the trend in hip fracture incidence.
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Affiliation(s)
- E Guilley
- Centre for Interdisciplinary Gerontology, University of Geneva, Geneva, Switzerland
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25
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Abstract
It is assumed that nursing homes are the setting with the highest incidence of hip fractures. This observation is, however, based on very little data. The aim of this study was to analyze hip fracture rates and the associated excess mortality in a large nursing home population. A cohort of >69,000 women and men newly admitted to German nursing homes were used to calculate sex- and age-specific incidence rates of hip fractures. To calculate excess mortality, a retrospective cohort study was conducted. To each patient with a hip fracture (n = 4342), four residents without hip fracture (n = 17,368) were matched by sex, age, and level of care (measure for the need of care). Hazard regression models were applied. During 91,850 person-years, 4342 hip fractures were observed. The crude incidence rates for hip fractures were 50.8/1000 person-years in women and 32.7/1000 person-years in men. The incidence rates increased with increasing age categories and were highest in the first months after admission to the nursing home. Increasing care need reduced the risk of hip fracture. Mortality in patients with a hip fracture was increased (women: hazard rate ratio for the first 3 mo after fracture, 1.72; 95% CI, 1.59-1.86; men: hazard ratio, 2.14; 95% CI, 1.80-2.53), but excess mortality was limited to the first months after injury. Data are presented for hip fracture rates and excess mortality after a hip fracture. Our results have implications on the timing and the allocation of specific measures for hip fracture prevention.
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26
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Berry SD, Samelson EJ, Ngo L, Bordes M, Broe KE, Kiel DP. Subsequent fracture in nursing home residents with a hip fracture: a competing risks approach. J Am Geriatr Soc 2008; 56:1887-92. [PMID: 18721221 DOI: 10.1111/j.1532-5415.2008.01918.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the incidence and predictors of subsequent fracture in nursing home residents with a hip fracture, accounting for the competing risk of death. DESIGN Dynamic cohort study. SETTING Hebrew Rehabilitation Center, a 725-bed, long-term care facility in Boston, Massachusetts. PARTICIPANTS Long-term care residents with a surgically repaired hip fracture (1999-2006) followed through June 30, 2007, for the occurrence of subsequent fracture at any skeletal site. MEASUREMENTS Information on age, sex, anatomic location, type of repair, body mass index (BMI), comorbidities, functional status, cognitive status, and medication use were evaluated as potential risk factors for subsequent fracture. RESULTS The study included 184 residents with a baseline hip fracture. Thirty-nine residents (7 men, 32 women) experienced a subsequent fracture over a median follow-up of 1.1 years. After the baseline hip fracture, 6% of residents experienced a subsequent fracture within 6 months, 12% within 1 year, and 21% within 5 years. In addition, 23% of residents died within 6 months, 31% within 1 year, and 60% within 5 years. High functional status was associated with a five times greater risk of subsequent fracture (high vs low functional status, hazard ratio=5.10, P<.005). Age, sex, BMI, comorbidities, cognitive status, and medication use were not associated with subsequent fracture. CONCLUSION Hip fractures are a sentinel event in nursing home residents, with a high incidence of subsequent fracture and death occurring within 1 year. Identification of prefracture characteristics and postfracture complications associated with mortality should help guide secondary prevention efforts in nursing home residents.
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Affiliation(s)
- Sarah D Berry
- Hebrew SeniorLife, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts 02131, USA.
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27
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Rolland Y, Abellan van Kan G, Bénétos A, Blain H, Bonnefoy M, Chassagne P, Jeandel C, Laroche M, Nourhashémi F, Orcel P, Piette F, Ribot C, Ritz P, Roux C, Taillandier J, Trémollières F, Weryha G, Vellas B. Frailty, osteoporosis and hip fracture: causes, consequences and therapeutic perspectives. J Nutr Health Aging 2008; 12:335-46. [PMID: 18443717 DOI: 10.1007/bf02982665] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The aim of this review of the literature is to report the factors which both contribute to the frailty syndrome and increase hip fracture risk in the elderly. This work is the fruit of common reflection by geriatricians, endocrinologists, gynecologists and rheumatologists, and seeks to stress the importance of detection and management of the various components of frailty in elderly subjects who are followed and treated for osteoporosis. It also sets out to heighten awareness of the need for management of osteoporosis in the frail elderly. DESIGN The current literature on frailty and its links with hip fracture was reviewed and discussed by the group. RESULTS The factors and mechanisms which are common to both osteoporosis and frailty (falls, weight loss, sarcopenia, low physical activity, cognitive decline, depression, hormones such as testosterone, estrogens, insulin-like growth factor-I (IGF-I), growth hormone (GH), vitamin D and pro-inflammatory cytokines) were identified. The obstacles to access to diagnosis and treatment of osteoporosis in the frail elderly population and common therapeutic pathways for osteoporosis and frailty were discussed. CONCLUSION Future research including frail subjects would improve our understanding of how management of frailty can can contribute to lower the incidence of fractures. In parallel, more systematic management of osteoporosis should reduce the risk of becoming frail in the elderly population.
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Affiliation(s)
- Y Rolland
- Inserm U558, F-31073, Université de Toulouse III, France.
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Sawka AM, Gafni A, Boulos P, Beattie K, Papaioannou A, Cranney A, Hanley DA, Adachi JD, Cheung A, Papadimitropoulos EA, Thabane L. Could a policy of provision of hip protectors to elderly nursing home residents result in cost savings in acute hip fracture care? The case of Ontario, Canada. Osteoporos Int 2007; 18:819-27. [PMID: 17221294 DOI: 10.1007/s00198-006-0307-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Accepted: 11/22/2006] [Indexed: 10/23/2022]
Abstract
UNLABELLED Hip fractures are an important problem in nursing homes. Hip protectors are external devices that decrease the risk of hip fracture in elderly nursing home residents. We estimated the overall healthcare cost savings from a hypothetical strategy of provision of hip protectors to elderly nursing home residents in Ontario, Canada. In a recent meta-analysis, we determined that a strategy of provision of hip protectors decreases the risk of hip fracture in nursing home residents. INTRODUCTION Our objective was to determine whether the provision of hip protectors to all Ontario nursing home residents aged > or =65 years could result in cost savings, stemming from reductions in initial hospitalizations for hip fracture. METHODS We conducted a cost analysis from a Ministry of Health perspective (one year cycle length). The efficacy of the intervention was estimated from a meta-analysis of randomized controlled trials. RESULTS A strategy of provision of hip protectors to all 60,775 elderly Ontario nursing home residents could result in an overall mean cost savings of 6.0 million Canadian dollars in one year (95% credibility interval, -26.4 million, 39.7 million), with a probability of cost savings of 0.63 (assuming no additional labor costs). In sensitivity analyses, decreasing hip protector price increased cost savings, whereas additional labor expenditures for application for hip protectors decreased cost savings. CONCLUSION In conclusion, if hip protectors can be provided to elderly Ontario nursing home residents without additional labor expenditures, there is a reasonable probability that such a strategy may result in healthcare cost savings.
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Affiliation(s)
- A M Sawka
- Division of Endocrinology and Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
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Dobnig H, Piswanger-Sölkner JC, Obermayer-Pietsch B, Tiran A, Strele A, Maier E, Maritschnegg P, Riedmüller G, Brueck C, Fahrleitner-Pammer A. Hip and nonvertebral fracture prediction in nursing home patients: role of bone ultrasound and bone marker measurements. J Clin Endocrinol Metab 2007; 92:1678-86. [PMID: 17311861 DOI: 10.1210/jc.2006-2079] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
CONTEXT Absolute fracture risk in nursing home patients is the highest among the communities studied. Screening for high-risk patients in such an environment is usually difficult. OBJECTIVE The objective was to investigate whether quantitative bone ultrasound measurements and/or markers of bone turnover/metabolism help in predicting which patients will incur hip or nonvertebral fractures. DESIGN, SETTING, AND PARTICIPANTS In this prospective study, mobile teams enrolled 1664 female patients from 95 nursing homes in Austria. MAIN OUTCOME MEASURES Calcaneal stiffness (n = 1117), radial speed of sound (SOS) (n = 1332), and phalangeal SOS (n = 1498) measurements were performed at baseline. Serum samples (n = 960) were analyzed for serum calcium and phosphate, 25 hydroxyvitamin D, PTH, osteocalcin, C-terminal telopeptide crosslinks, and osteoprotegerin (OPG). Patients were prospectively followed for hip and other nonvertebral fractures for 2 yr. RESULTS A total of 117 hip fractures and 269 nonvertebral fractures developed during a mean observation period of 2 yr. Prevalence of vitamin D deficiency and secondary hyperparathyroidism was high. A history of a past fracture was significantly associated with a hazard ratio (HR) of 1.47 (95% confidence interval, 1.01-2.15) and 1.65 (1.26-2.16) for the development of hip and nonvertebral fractures, respectively. Cox regression analysis revealed a multivariate adjusted elevation in both hip [HR 1.30 (1.12-1.43)] and nonvertebral [HR 1.14 (1.02-1.25)] fracture risk for each sd decrease in calcaneal stiffness. Patients in the lowest quartile for calcaneal stiffness Z-score had 2.5 and 1.2 times higher rates of hip and nonvertebral fractures when compared with patients in the highest quartile. Fracture rates were not statistically associated with baseline radial or phalangeal SOS measurements or with serum osteocalcin, C-terminal telopeptide crosslinks, and OPG concentrations. When adjusted for bone mass, higher serum OPG levels were associated with fewer hip as well as nonvertebral fractures [HR 0.85 (0.73-0.99) and 0.89 (0.80-0.99) per increment of 1]. Higher serum phosphate levels indicated an increased hip [HR 1.54 (1.07-2.21)] and nonvertebral fracture risk [HR 1.40 (1.10-1.78) per increase of 1 mg/dl]. Body mass index was protective of hip fractures [HR 0.94 (0.90-0.98) per increase of 1] as well as medication with acetylsalicylic acid [HR 0.59 (0.36-0.95) for hip and 0.72 (0.52-0.99) for nonvertebral fractures]. In contrast, current use of glucocorticoids [HR 5.65 (1.77-18.0)] and opiates [HR 1.85 (1.18-2.92)] exerted a negative effect on prospective hip fracture risk. CONCLUSION Calcaneal stiffness measurements proved to be useful in predicting hip fractures and to a lesser extent nonvertebral fractures in nursing home residents. Radial and phalangeal bone ultrasound measurements and baseline markers of bone turnover, however, were not indicative of future fracture risk in this population.
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Affiliation(s)
- Harald Dobnig
- Department of Internal Medicine, Division of Endocrinology and Nuclear Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036 Graz, Austria.
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The use of hip protectors in long-term care facilities: a survey of nursing home staff. J Am Med Dir Assoc 2007; 8:229-32. [PMID: 17498606 DOI: 10.1016/j.jamda.2006.12.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Revised: 12/13/2006] [Accepted: 12/18/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To determine the level of exposure to hip protectors and barriers to their use in nursing homes. DESIGN, SETTING, AND PARTICIPANTS We conducted a written survey of 160 staff (including administrators) in 5 nursing homes in the Hamilton-Wentworth region, Ontario, Canada. MEASUREMENTS The results of primary analyses were expressed as percentage of respondents. RESULTS Among respondents of respective institutions, the rate of prior exposure to hip protectors varied from 40.9% to 100.0% and the rate of prior experience applying these devices varied from 14.3% to 80.0%. The most frequently cited main barriers to the use of hip protectors in long-term care facilities included physicians not thinking to prescribe them, expense, lack of evidence of benefit in this population, wearer discomfort, and wearer removal. A lack of staff time to apply these devices was rarely cited. The majority of staff believed that nursing home residents with a prior history of fracture, those who fall frequently, or those who are unsteady on their feet should wear hip protectors. CONCLUSIONS The exposure of surveyed nursing home staff to hip protectors was variable but most agreed that residents who are at increased risk of hip fracture should wear them. Some identified barriers to the use of hip protectors in long-term care facilities were physicians not thinking to prescribe them, expense, lack of evidence of benefit in this population, wearer discomfort, and wearer removal. Such barriers need to be addressed for hip protector implementation strategies to be successful in nursing homes.
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Duque G, Mallet L, Roberts A, Gingrass S, Kremer R, Sainte-Marie LG, Kiel DP. To Treat or Not To Treat, That Is the Question: Proceedings of the Quebec Symposium for the Treatment of Osteoporosis in Long-Term Care Institutions, Saint-Hyacinthe, Quebec, November 5, 2004. J Am Med Dir Assoc 2007; 8:e67-73. [DOI: 10.1016/j.jamda.2006.12.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sawka AM, Boulos P, Beattie K, Papaioannou A, Gafni A, Cranney A, Hanley DA, Adachi JD, Papadimitropoulos EA, Thabane L. Hip protectors decrease hip fracture risk in elderly nursing home residents: a Bayesian meta-analysis. J Clin Epidemiol 2006; 60:336-44. [PMID: 17346606 PMCID: PMC5110322 DOI: 10.1016/j.jclinepi.2006.07.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2005] [Revised: 07/14/2006] [Accepted: 07/14/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To design a Bayesian random effects model for pooling binary outcome data from cluster randomized trials (CRTs) with individually randomized trials (IRTs) and then use this model to determine if hip protectors decrease the risk of hip fracture in elderly nursing home residents. STUDY DESIGN AND SETTING Eight electronic databases were searched; abstracts and papers were reviewed in duplicate. Randomized controlled trials of hip protectors in nursing homes were included. The pooled mean odds ratio (OR) of a hip fracture in an individual allocated to hip protectors with 95% credibility interval (CRI) was calculated. RESULTS We included four trials of 1,922 individuals (including three CRTs). The pooled OR of an elderly nursing home resident sustaining one or more hip fractures with hip protector allocation was 0.40 (95% CRI 0.25, 0.61). The model was robust in multiple sensitivity analyses assuming alternative intracluster correlation coefficient values. CONCLUSION The Bayesian approach may be used in meta-analyses of IRTs and CRTs. Using this approach, we have determined that hip protectors decrease the risk of hip fracture in elderly nursing home residents. Methodologic limitations of the included trials and a possible herd effect in CRTs may have influenced these results.
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Affiliation(s)
- Anna M Sawka
- Division of Endocrinology and Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Duque G, Mallet L, Roberts A, Gingrass S, Kremer R, Sainte-Marie LG, Kiel DP. To Treat or Not To Treat, That Is the Question: Proceedings of the Quebec Symposium for the Treatment of Osteoporosis in Long-Term Care Institutions, Saint-Hyacinthe, Quebec, November 5, 2004. J Am Med Dir Assoc 2006; 7:435-41. [PMID: 16979088 DOI: 10.1016/j.jamda.2006.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Revised: 03/28/2006] [Accepted: 05/03/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Patients in long-term care institutions (LTCI) are especially at risk for osteoporotic fractures owing to their lack of mobility, poor nutrition, and limited sun exposure. Previous reports have shown that osteoporosis is underdiagnosed and undertreated in LTCI despite the high incidence of osteoporotic fractures in these settings. This document has been developed to assist clinicians practicing in LTCI with the diagnosis and treatment of osteoporosis in their institutionalized patients. These proceedings offer an overview of the particular characteristics of patients at LTCI. Management strategies include both nonpharmacological and pharmacological interventions for the prevention and treatment of osteoporotic fractures in very frail older subjects. PARTICIPANTS This guide is an edited review of presentations and discussions held by specialists in osteoporosis in the elderly together with physicians and pharmacists practicing in LTCI in the province of Quebec. This symposium was held in Saint-Hyacinthe, Quebec on November 5, 2004. VALUES The value of a given diagnostic test or treatment option was determined based on the clinical experiences and opinions of the participants and a review of the literature from an evidence-based perspective. RECOMMENDATIONS All patients located at LTCI are at potential risk for osteoporotic fractures. Global interventions should include vitamin D, calcium, and a comprehensive exercise program. In patients who are at high risk for osteoporotic fractures or with previous fractures, pharmacological treatment should be started. VALIDATION These recommendations were approved during the final plenary of the symposium. All the prevailing opinions were summarized and included in this article.
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Affiliation(s)
- Gustavo Duque
- Division of Geriatric Medicine, McGill University-Jewish General Hospital, 3755 Côte Sainte Catherine, Montreal, Quebec, Canada.
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Law M, Withers H, Morris J, Anderson F. Vitamin D supplementation and the prevention of fractures and falls: results of a randomised trial in elderly people in residential accommodation. Age Ageing 2006; 35:482-6. [PMID: 16641143 DOI: 10.1093/ageing/afj080] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES To determine whether vitamin D supplementation reduces the risk of fracture or falls in elderly people in care home accommodation. DESIGN A randomised controlled trial of cluster design. SETTING AND SUBJECTS 223 Residential units (mainly identical 30-bedded units), within 118 homes for elderly people throughout Britain, with 3,717 participating residents (76% women, average age 85 years). The units provided mainly or entirely residential care (35% of residents), nursing care (42%) or care for elderly mentally infirm (EMI) residents (23%). METHODS Participants were randomly allocated by residential unit (cluster design) to a treated group offered ergocalciferol 2.5 mg every 3 months (equivalent to a daily dose of 1,100 IU), or to a control group. Fractures were reported by staff and confirmed in hospital, and routinely collected data on reported falls were obtained. RESULTS After median follow-up of 10 months (interquartile range 7-14 months), 64 (3.6%) of 1,762 vitamin D-treated residents and 51 (2.6%) of 1,955 controls had one or more non-vertebral fractures, and 24 (1.3%) and 20 (1.0%), respectively, had a hip fracture. The proportion reporting at least one fall was 44% in vitamin D-treated and 43% in control residents. The differences between the vitamin D and control groups were not statistically significant. The incidence of all non-vertebral fractures in the care homes (3.2% per year) and of hip fractures (1.1% per year) was low, similar to rates in elderly people in sheltered accommodation, and the pre-treatment serum 25-hydroxy vitamin D concentration was high [median 47 nmol/l, measured in a 1% (n = 18) sample]. CONCLUSIONS We found no evidence that vitamin D prevents fractures or falls in elderly people in care home accommodation.
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Affiliation(s)
- Malcolm Law
- Centre for Environmental and Preventive Medicine, Wolfson Institute of Preventive Medicine, Barts and The London, Queen Mary's School of Medicine and Dentistry, Charterhouse Square, London EC1M 6BQ, UK.
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Dobnig H, Piswanger-Sölkner JC, Roth M, Obermayer-Pietsch B, Tiran A, Strele A, Maier E, Maritschnegg P, Sieberer C, Fahrleitner-Pammer A. Type 2 diabetes mellitus in nursing home patients: effects on bone turnover, bone mass, and fracture risk. J Clin Endocrinol Metab 2006; 91:3355-63. [PMID: 16735485 DOI: 10.1210/jc.2006-0460] [Citation(s) in RCA: 167] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT Fractures are a major health burden in elderly institutionalized persons. Type 2 diabetes mellitus (DM) has a high prevalence in nursing home patients and has been associated with positive effects on bone mass in younger, community-dwelling elderly. OBJECTIVE The objective of this study was to investigate whether type 2 DM affects bone mass, bone turnover, or prospective fracture rates in frail, elderly women living in nursing homes. DESIGN, SETTING, AND PARTICIPANTS This study was a prospective cohort of 583 patients with type 2 DM and 1081 control (CTR) individuals above age 70 recruited from 95 nursing homes in Austria. Patients were enrolled and followed up by mobile study teams. MAIN OUTCOME MEASURES We performed quantitative bone ultrasound measurements at the calcaneus, radius, and proximal third phalanx, measurements of quadriceps strength, and biochemical parameters of mineral metabolism and bone turnover. Patients were prospectively followed for hip and other nonvertebral fractures over 2 yr. RESULTS Patients with type 2 DM had significantly higher age-, weight-, and mobility score-adjusted calcaneal stiffness (P < 0.0001), radial speed of sound (P < 0.005), and phalangeal speed of sound (P < 0.05) measurements when compared with CTRs. Mean serum PTH (-20.7%) and osteocalcin levels (-22.3%) were significantly lower (both P < 0.0001) in patients with treated type 2 DM despite comparable low serum 25-hydroxyvitamin D levels and slightly higher adjusted total serum calcium levels compared with CTRs. Important independent determinants of bone turnover in both patient groups were PTH, creatinine clearance, alanine aminotransferase, as well as glycosylated hemoglobin levels, together accounting for 30-40% of its variance. A total of 110 hip fractures occurred during the observation period, corresponding to a hip fracture rate of 3.1% (in CTRs) and 3.4% (in type 2 DM) per 100 patient years; this was not significantly different for CTRs and diabetics. CONCLUSIONS Decreased PTH levels and higher levels of glycemia independently contribute to lower bone turnover in elderly nursing home patients with type 2 DM. Despite higher bone mass and lower bone turnover, hip fracture risk is comparable with women without DM.
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Affiliation(s)
- Harald Dobnig
- Department of Internal Medicine, Division of Endocrinology and Nuclear Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036 Graz, Austria.
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Lawrenson R, Nicholls P, Rivers-Latham R, Brown T, Barnardo J, Gray R. PIXI bone density screening for osteoporosis in postmenopausal women. Maturitas 2006; 53:245-51. [PMID: 15985347 DOI: 10.1016/j.maturitas.2005.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2004] [Revised: 05/03/2005] [Accepted: 05/17/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate a pragmatic screening programme for osteoporosis based on the identification of known risk factors. A secondary aim was to assess the validity of peripheral instantaneous X-ray imager (PIXI) scanning against dual energy X-ray absorptiometry (DEXA) in women identified as having osteopenia. METHODS A cross-sectional two stage screening programme. The study was carried out in 14 practices in Surrey. Women aged 60-80 years of age were screened with a questionnaire. Those identified with one or more risk factors were offered a PIXI scan of the ankle in their own surgery. Those with an intermediate score on PIXI scan were offered a DEXA scan of hip, spine and forearm. RESULTS Four thousand six hundred and forty-six women completed questionnaires, 2688 had a PIXI scan and 553 were found to be at high risk of osteoporosis. Multivariate analysis identified the three most important risk factors associated with increased risk of osteoporotic fracture as age, a previous fracture and the presence of a stooped posture. Hormone replacement therapy (HRT) was shown to be protective. Twenty three percent of women with an intermediate score on PIXI scan were found to have osteoporosis on DEXA scan of hip and spine. CONCLUSIONS PIXI scanning proved acceptable, practicable but only had moderate comparability with DEXA. The findings suggest that patients over the age of 60 years with a history of a fracture or evidence of spinal collapse are likely to have osteoporosis and should be offered screening. HRT past the menopause would seem to confer benefit and the recent reduction in its use may lead to increasing numbers of women suffering osteoporotic fractures.
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Affiliation(s)
- Ross Lawrenson
- Postgraduate Medical School, University of Surrey, Guildford, Surrey, UK.
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Elliott ME, Drinka PJ, Krause P, Binkley NC, Mahoney JE. Osteoporosis assessment strategies for male nursing home residents. Maturitas 2005; 48:225-33. [PMID: 15207888 DOI: 10.1016/j.maturitas.2003.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2003] [Revised: 11/06/2003] [Accepted: 11/24/2003] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Twenty-five to thirty percent of hip fractures occur in men, and nursing home residents have a 5-10-fold greater fracture risk than community-dwellers. Osteoporosis prevalence in men in long-term care, however, is poorly defined. Our objectives were to determine the prevalence of osteoporosis, as assessed by peripheral bone mineral density (BMD), in a group of institutionalized veterans, and to determine how many men with low BMD had received a prior diagnosis of osteoporosis. METHODS Subjects were residents in a 740-bed skilled nursing facility (78% men). Male residents (n = 103) competent to give informed consent underwent bilateral calcaneal and forearm BMD by dual-energy X-ray absorptiometry (DXA). Prior osteoporosis documentation was sought in medical records. RESULTS Twenty percent of veterans (95% confidence interval (CI) 12-28%) exhibited calcaneal osteoporosis (T-score < -2.5), and 62% (CI 52-72%) were osteoporotic at the forearm. Forearm and calcaneal BMD were correlated (r = 0.678, P < 0.001). BMD of the left and right forearm, and of left and right calcaneus, were highly correlated (r = 0.880, P < 0.001 and r = 0.931, P < 0.001, respectively). Documentation of osteoporosis existed for one of 20 men with calcaneal osteoporosis and four of 59 men with forearm osteoporosis. CONCLUSIONS Osteoporosis was prevalent but poorly documented in institutionalized veterans. Discordance in T-scores between forearm and heel was similar to that reported in other studies. The broad range of T-scores among subjects suggests that peripheral BMD measurement may be useful for clinical fracture risk stratification. Correlation among skeletal sites indicates that measuring a single site may be practical.
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Affiliation(s)
- Mary E Elliott
- University of Wisconsin School of Pharmacy, 777 Highland Avenue, Madison, WI 53705, USA.
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Honkanen LA, Schackman BR, Mushlin AI, Lachs MS. A Cost-Benefit Analysis of External Hip Protectors in the Nursing Home Setting. J Am Geriatr Soc 2005; 53:190-7. [DOI: 10.1111/j.1532-5415.2005.53102.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nuti R, Martini G, Valenti R, Gambera D, Gennari L, Salvadori S, Avanzati A. Vitamin D status and bone turnover in women with acute hip fracture. Clin Orthop Relat Res 2004:208-13. [PMID: 15187859 DOI: 10.1097/01.blo.0000129163.97988.06] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hypovitaminosis D is common in elderly women. Few data are available on vitamin D status and bone turnover in women with acute hip fracture. The aims of this study were to determine whether elderly Italian women with an acute hip fracture also had low vitamin D levels and an increase of bone turnover compared with elderly women with osteoporosis but without fractures. Seventy-four women with acute osteoporotic hip fracture and 73 women with postmenopausal osteoporosis were studied. All women were self-sufficient and had adequate sunlight exposure. To exclude the effect of trauma on serum 25-hydroxycolecalciferol levels and bone markers (bone alkaline phosphatase and C-terminal telopeptides of Type I collagen as indices of bone formation and bone resorption), blood samples were drawn within 24 hours of the fracture. Current data indicated that in our patients the prevalence of hypovitaminosis D is common although to a lesser extent than in women who are housebound. Women with acute hip fractures had a higher prevalence of vitamin deficiency defined as serum 25-hydroxycolecalciferol lower than 12 ng/mL, compared with women with osteoporosis. Moreover, the presence of fracture did not influence the rate of bone formation, whereas the increase in bone resorption could be attributed to an older age of women with acute hip fracture because of similar values of parathyroid hormone levels in the two groups.
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Affiliation(s)
- Ranuccio Nuti
- Metabolic Disease Unit, University of Siena, Siena, Italy.
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Gupta G, Aronow WS. Underuse of Procedures for Diagnosing Osteoporosis and of Therapies for Osteoporosis in Older Nursing Home Residents. J Am Med Dir Assoc 2003. [PMID: 12837141 DOI: 10.1016/s1525-8610(04)70346-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Brennan nee Saunders J, Johansen A, Butler J, Stone M, Richmond P, Jones S, Lyons RA. Place of residence and risk of fracture in older people: a population-based study of over 65-year-olds in Cardiff. Osteoporos Int 2003; 14:515-9. [PMID: 12730755 DOI: 10.1007/s00198-003-1404-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2002] [Accepted: 02/11/2002] [Indexed: 11/24/2022]
Abstract
Fracture prevention strategies will be most cost-effective if targeted on groups of frail elderly people who are at particularly high risk of falls and fractures. Elderly people living in care homes are one potential target population, but fracture incidence in this setting remains poorly defined in many countries. We used the All Wales Injury Surveillance System (AWISS) in a population-based study of people aged over 65 years living in the city of Cardiff. We linked a postcode-based register of all sheltered accommodation and all residential and nursing homes in the city with injury data from Cardiff's single Accident and Emergency Department. Cardiff has 47,700 residents aged over 65 years with 1918 (4.0%) living in residential or nursing homes and 1868 (3.9%) in sheltered accommodation. In 1999 we identified a total of 1305 fractures including 366 hip fractures, giving a crude fracture incidence of 27.4/1000 per year and 7.7/1000 per year, respectively. Care home residents suffered 213 fractures, 95 of which were of the hip, giving a crude fracture incidence of 111.1/1000 per year and 49.5/1000 per year, respectively. People living in sheltered accommodation suffered 94 fractures, including 28 at the hip, giving a crude fracture incidence of 51.4/1000 per year and 15.3/1000 per year, respectively. People in care homes and sheltered accommodation tend to be older than those living in the community, and we adjusted for this by calculating age- and gender-standardized relative ratios for each setting. Compared with the community dwelling population, care home residents had an overall fracture risk of 2.9 (95% CI 2.5-3.3) and a hip fracture risk of 3.3 (95% CI 2.6-4.2). People in sheltered accommodation had a total fracture risk of 1.7 (95% CI 1.4-2.1), and a hip fracture risk of 1.6 (95% CI 1.1-2.4). Such figures support the potential cost-effectiveness of strategies that seek to prevent fractures in care homes and sheltered accommodation, and are of special interest to those planning intervention studies in these settings.
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Elliott ME, Binkley NC, Carnes M, Zimmerman DR, Petersen K, Knapp K, Behlke JM, Ahmann N, Kieser MA. Fracture risks for women in long-term care: high prevalence of calcaneal osteoporosis and hypovitaminosis D. Pharmacotherapy 2003; 23:702-10. [PMID: 12820811 DOI: 10.1592/phco.23.6.702.32182] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To determine the prevalence of osteoporosis as assessed by peripheral bone mineral density (BMD) in women living in a nursing home, to determine how many women with low BMD had received a diagnosis of osteoporosis, to assess the prevalence of vitamin D deficiency, and to seek reasons for vitamin D deficiency. DESIGN Measurement of calcaneal BMD and serum 25-hydroxyvitamin D. SETTING Skilled nursing facility. PATIENTS Forty-nine women aged 68-100 years. MEASUREMENTS AND MAIN RESULTS Bilateral calcaneal BMD was measured by dual-energy x-ray absorptiometry and serum 25-hydroxyvitamin D by radioimmunoassay. Medical records were reviewed to assess osteoporosis risk factors, previous documentation of osteoporosis or malabsorption, and supplemental vitamin D intake. Fifty-nine percent of the 39 women with calcaneal BMD measurements (95% confidence interval [CI] 44-74%) exhibited calcaneal osteoporosis (T score < -2.5). Sixty percent (95% CI 46-74%) had 25-hydroxyvitamin D levels of 20 ng/ml or less, which is associated with secondary hyperparathyroidism; only 4% of women had levels above 30 ng/ml, recently recommended as optimal. Vitamin D status was suboptimal even in most women taking multivitamins. Osteoporosis was documented in the records of 17% of 23 women with calcaneal osteoporosis. CONCLUSION Osteoporosis was prevalent but poorly documented in women living in the nursing home. Peripheral BMD measurements have the potential to improve the recognition and management of osteoporosis in women in long-term care facilities. The high prevalence of vitamin D deficiency, even in those taking multivitamins, indicates that practical new approaches for vitamin D repletion in this population are urgently needed.
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Affiliation(s)
- Mary E Elliott
- School of Pharmacy, University of Wisconsin, Madison 53705, USA.
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Waldegger L, Cranney A, Man-Son-Hing M, Coyle D. Cost-effectiveness of hip protectors in institutional dwelling elderly. Osteoporos Int 2003; 14:243-50. [PMID: 12730792 DOI: 10.1007/s00198-002-1354-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2001] [Accepted: 09/18/2002] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To assess the effectiveness and cost-effectiveness of hip protectors in the prevention of hip fracture in an elderly population living in institutions. DESIGN AND SETTING Meta-analysis followed by economic analysis. METHODS The meta-analysis of randomized controlled clinical trials was based on the recommendations of the Cochrane Collaboration. Model-based economic analysis was conducted using estimates of transition probabilities, costs, and utilities relevant to Canada. RESULTS The results indicate that hip protectors compared with control results in a relative risk of hip fracture of 0.40 (95% Confidence Interval 0.23-0.70). The economic analysis found that the use of hip protectors is expected to be both effective and cost saving. Results were robust to a range of analysis exploring the uncertainty of input parameters. CONCLUSIONS There is sufficient clinical and economic evidence to support the use of hip protectors for institutional dwelling elderly.
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Affiliation(s)
- Lisa Waldegger
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
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Sugarman JR, Connell FA, Hansen A, Helgerson SD, Jessup MC, Lee H. Hip fracture incidence in nursing home residents and community-dwelling older people, Washington State, 1993-1995. J Am Geriatr Soc 2002; 50:1638-43. [PMID: 12366616 DOI: 10.1046/j.1532-5415.2002.50454.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To establish and validate a method of linking data from the Minimum Data Set (MDS) and Medicare hospital claims, to estimate hip fracture incidence rates for Medicare beneficiaries aged 65 and older in Washington State, and to compare the incidence rates of hip fractures in nursing home and non-nursing home residents. DESIGN Retrospective analysis of Medicare population-based enrollment, hospital claims, and nursing home administrative data sets. SETTING Nursing home and non-nursing home setting. PARTICIPANTS Medicare beneficiaries in Washington State residing in the community or in skilled nursing facilities. MEASUREMENTS Crude age- and sex-specific and standardized age- and sex-adjusted hip fracture incidence for persons residing and not residing in nursing homes. RESULTS From October 1, 1993, through September 30, 1995, 7,812 Medicare beneficiaries aged 65 or older were hospitalized for hip fractures (6,566 fractures for 1,155,234 person-years of exposure in non-nursing home residents and 1,246 fractures for 42,986 person-years of exposure in nursing home residents). The standardized age- and sex-adjusted hip fracture rate of nursing home residents (23.0 per 1,000 person-years) substantially exceeded that of non-nursing home residents (5.7 per 1,000 person-years) (incidence rate ratio = 4.0, 95% confidence interval = 3.7-4.5). CONCLUSION The incidence of hip fracture in nursing home residents far exceeds that in noninstitutionalized older people. Linkage of MDS and Medicare hospital claims data is a useful tool for epidemiological surveillance regarding events in nursing homes that are likely to result in hospitalization.
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Lips P. Vitamin D deficiency and secondary hyperparathyroidism in the elderly: consequences for bone loss and fractures and therapeutic implications. Endocr Rev 2001; 22:477-501. [PMID: 11493580 DOI: 10.1210/edrv.22.4.0437] [Citation(s) in RCA: 1044] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Vitamin D deficiency is common in the elderly, especially in the housebound and in geriatric patients. The establishment of strict diagnostic criteria is hampered by differences in assay methods for 25-hydroxyvitamin D. The synthesis of vitamin D3 in the skin under influence of UV light decreases with aging due to insufficient sunlight exposure, and a decreased functional capacity of the skin. The diet contains a minor part of the vitamin D requirement. Vitamin D deficiency in the elderly is less common in the United States than elsewhere due to the fortification of milk and use of supplements. Deficiency in vitamin D causes secondary hyperparathyroidism, high bone turnover, bone loss, mineralization defects, and hip and other fractures. Less certain consequences include myopathy and falls. A diet low in calcium may cause an increased turnover of vitamin D metabolites and thereby aggravate vitamin D deficiency. Prevention is feasible by UV light exposure, food fortification, and supplements. Vitamin D3 supplementation causes a decrease of the serum PTH concentration, a decrease of bone turnover, and an increase of bone mineral density. Vitamin D3 and calcium may decrease the incidence of hip and other peripheral fractures in nursing home residents. Vitamin D3 is recommended in housebound elderly, and it may be cost-effective in hip fracture prevention in selected risk groups.
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Affiliation(s)
- P Lips
- Department of Endocrinology, Institute for Endocrinology, Reproduction and Metabolism, EVM-Institute, Vrije Universiteit Medical Center, 1007 MB Amsterdam, The Netherlands.
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Stein MS, Flicker L, Scherer SC, Paton LM, O'Brien ML, Walton SC, Chick P, Di Carlantonio M, Zajac JD, Wark JD. Relationships with serum parathyroid hormone in old institutionalized subjects. Clin Endocrinol (Oxf) 2001; 54:583-92. [PMID: 11380488 DOI: 10.1046/j.1365-2265.2001.01182.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE AND BACKGROUND Old people in residential care are at the highest risk of any group for hip fracture. This may relate to their high prevalence of hyperparathyroidism. There are few data, however, on relationships with serum parathyroid hormone (PTH) in these individuals. This study therefore examined complex associations with serum PTH in nursing home and hostel residents. DESIGN Cross-sectional analysis. PATIENTS One hundred and forty-three nursing home and hostel residents of median age 84 years. MEASUREMENTS Serum PTH, 25-hydroxyvitamin D (25OHD), 1,25-dihydroxyvitamin D (1,25-(OH)2D), plasma creatinine, phosphate, calcium, albumin, Bsm-1 vitamin D receptor genotype, age, weight and use of frusemide or thiazide. RESULTS The statistical models determined accounted for half the interindividual variation in serum PTH. Heavier weight was associated with both the prevalence of secondary hyperparathyroidism and the serum concentration of PTH. Novel interactions with serum PTH were identified between: weight and 25OHD; 25OHD and phosphate; and phosphate and thiazide diuretic use. Plasma phosphate was associated with PTH independently of calcium and 1,25-(OH)2D. There was no independent association between PTH and nuclear vitamin D receptor genotype. CONCLUSIONS Heavier weight is associated with both the prevalence and severity of secondary hyperparathyroidism and consistent with animal models of secondary hyperparathyroidism, phosphate may relate to serum PTH independently of 1,25-(OH)2D or calcium.
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Affiliation(s)
- M S Stein
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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