Proximal femoral fracture: achievements and prospects

[Acute orthogeriatric care (I). Healthcare issues]

The present article reviews the historical development of several collaborative care models between orthopaedic and geriatrics departments for the care of patients with hip fracture. Subacute orthogeriatric units are described and special emphasis is placed on geriatric consulting teams and acute orthogeriatric units, as well as on their benefits for the patient and the healthcare service. We also review evidence-based studies that support this type of care for patients with acute hip fracture and guidelines from scientific associations involved in the care of these patients. The cost of care is also analyzed. Lastly, the term "orthogeriatrics" is proposed as a common term for this activity and the need for improved future care is discussed.

Bone mineral density and walking ability of elderly patients with hip fracture: a strategy for prevention of hip fracture

The main risk factors for proximal femoral fracture include the hazard of falling and osteoporosis. The change in walking ability of patients before injury was evaluated over the last 10 years in a rapidly advancing aging society in Tokyo, Japan. The bone quality of patients was clarified in order to develop a strategy for prevention of hip fractures. The subjects were 157 women with proximal femoral fractures treated between 1989 and 1993 (group A) and 216 women treated between 1999 and 2003 (group B). Bone mineral density (BMD) of the radius of the patients showed slightly lower values than those of the elderly general population, but no statistically significant difference was observed in each age group except for the 75-79-year-old age group (p<0.05). Many patients had problems in walking, and 27% of patients in group A and 44% in group B could not walk outdoors or go shopping alone before the injury, and their bone mineral density was reduced. For the prevention of hip fractures, it is important to improve the physical function to avoid falls, which directly cause hip fracture. Patients who have difficulty performing effective physical exercise because of reduced walking ability require medication for osteoporosis.

Zunehmende Bedeutung der Opioide in der Geriatrie

BACKGROUND

During the previous 20 years the prescription of opioids for medical use has increased steadily. Patients and professionals have great reservations about the use of opioids in the elderly. The aim of this study was to describe the changes in analgesic therapy in a geriatric clinic during the previous 10 years.

METHOD

The quality and quantity of prescriptions for opioids as well as the costs of the analgesic therapy in a large geriatric clinic between 1994 and 2003 were analyzed.

RESULTS

The use of opioids increased steadily from 0.72 mg per day and patient in 1994 to 9.50 mg in 2003 (1320%). The introduction of sustained release tilidine/naloxone and tramadol led to a change of the prescribed forms but only to a slight increase in the total consumption of these drugs. In 1994 the average daily cost of analgesic therapy was 15 cents per patient compared with 46 cents in 2003. The percentage of analgesics in the pharmacological budget increased from 5.6 to 10.8%.

CONCLUSION

Dealing with opioids should be a part of the training program for all members of the geriatric team. Analgesics have come to play an important role in the pharmacological budget at least in this geriatric clinic.

Acute and Chronic Pain in Geriatrics: Clinical Characteristics of Pain and the Influence of Cognition

OBJECTIVE

This study aimed to identify which of the well-known characteristics of chronic pain patients are seen even in older patients with multiple comorbidities and considerable functional impairments and how cognition influences patients' reports of acute and chronic pain.

DESIGN

A cross-sectional study.

SETTING

Inpatients of acute and rehabilitation wards of a German geriatric hospital.

PATIENTS

Patients with acute (N=36) or chronic (N=55) nonmalignant pain.

MEASUREMENTS

A comprehensive assessment was conducted, including a structured pain interview and pain assessments using Folstein's mini-mental state (MMS) examination, the Clock Drawing Test (CDT), a short form of Yesavage's Geriatric Depression Scale (GDS), and Spielberger's State-Trait Anxiety Inventory (STAI). The Barthel Index was used to measure the activities of daily living (ADL) at admittance and discharge.

RESULTS

Geriatric patients with chronic pain described more pain sites, used a larger number of pain descriptors, used more analgesics at discharge, and reported both a lower degree of pain reduction during therapy and a lower reduction of disability during hospital stay than did acute pain patients. Anxious and depressive symptoms and difficulty falling asleep tended to be higher in chronic pain patients than in acute pain patients. Cognitively impaired patients described the location of their acute pain as similar to patients with chronic pain and as less precise than did cognitively less-impaired patients. Report of pain intensity and in improvement in the ADL measure were independent of cognitive status.

CONCLUSIONS

Geriatric inpatients with chronic pain differ from acute pain patients in pain description, pain reduction during treatment, use of analgesics, and emotional distress. Cognitive impairment seems to change the ability to localize acute pain. In our study, the perception of pain intensity was independent of cognition. Because of the small sample size, further studies are needed to confirm these findings. Multiprofessional, intense rehabilitation programs for geriatric patients with chronic pain are considered of prime importance.

Musculoskeletal effects of the recombinant human IGF-I/IGF binding protein-3 complex in osteoporotic patients with proximal femoral fracture: a double-blind, placebo-controlled pilot study

The administration of recombinant human IGF-I complexed with its predominant binding protein IGF binding protein-3 (rhIGF-I/IGFBP-3) may allow the safe administration of higher doses of IGF-I than can be accomplished with rhIGF-I alone. The aim of this randomized, double-blind, placebo- controlled pilot study was to evaluate the short-term safety and musculoskeletal effects of rhIGF-I/IGFBP-3 in older women (aged 65-90 yr) with recent hip fracture. Within 72 h after the event, 30 patients received continuous administration of either placebo (n = 10), 0.5 mg/kg.d rhIGF-I/IGFBP-3 (n = 9), or 1 mg/kg.d rhIGF-I/IGFBP-3 (n = 11). Treatment was administered by sc infusion through a portable mini-pump for a total of 8 wk after hip fracture surgery, with patient follow-up to 6 months after surgery. Efficacy evaluations included a contralateral hip bone density determination, markers of bone turnover (including serum osteocalcin and urinary excretion of N-telopeptide), grip strength, and tests of functional ability. During the administration of rhIGF-I/IGFBP-3, mean serum levels of IGF-I significantly (P < 0.001) increased from 83 ng/ml to 289 ng/ml (0.5 mg/kg.d) and 393 ng/ml (1 mg/kg.d), respectively. Both doses were well tolerated, and no hypoglycemia or other therapy-induced side effects were observed. After an initial loss of hip bone density after hip fracture surgery, patients treated with 1 mg/kg.d rhIGF-I/IGFBP-3 regained a substantial portion of their femoral bone mass. At 6 months postfracture (4 months after the 2-month infusion), they showed a statistically not significant decrease from baseline in hip bone density (-2.6%, P = 0.53). Placebo-treated patients, on the other hand, failed to regain lost bone: at 6 months postfracture, bone density in the placebo group had declined by 6.1% (P = 0.04). Additionally, in patients treated with 1.0 mg/kg.d rhIGF-I/IGFBP-3, grip strength had increased from baseline by 11.4% by the end of the study (P = 0.04) whereas patients on placebo lost 11.6% from baseline (P = 0.16). This increase in muscle strength in the high-dose group was associated with a positive effect on functional recovery. We conclude that a 2-month infusion of rhIGF-I/IGFBP-3 in patients with recent hip fracture is feasible, safe, and well tolerated. Analyzing the effects on bone mass, muscle strength, and functional ability, we observed beneficial trends. In the context of a small exploratory study, these findings should be interpreted with caution, but they support the need for future trials to further assess the therapeutic potential of rhIGF-I/IGFBP-3 in elderly subjects with osteoporosis.

Neglected bilateral femoral neck fractures in a patient with end-stage renal disease before chronic dialysis

Bilateral femoral neck fractures are rarely reported in patients with end-stage renal disease before chronic dialysis. We report on a 39-year-old woman with neglected bilateral femoral neck fractures, who presented with severe uremic complications prior to chronic dialysis. Three years before admission, she had injured herself in a trivial slip with subsequent bilateral hip pain. She had progressively waddled since then. Pelvic X-ray taken after admission revealed bilateral femoral neck fractures. Bilateral hip hemiarthroplasties were subsequently performed. Displaced femoral neck fractures were found intraoperatively. Pathologic findings and results of examinations supported the coexistence of osteoporosis and high turnover renal osteodystrophy, rendering this woman at high risk of bilateral femoral neck fractures. Therefore, preventing a simple fall or trivial accident and treating renal osteodystrophy and osteoporosis are paramount in patients with chronic renal failure even before the start of dialysis therapy. We also emphasize the need to seek any possible underlying metabolic bone disease once a patient presents with unusual fractures.

[Geriatric management of the frail elderly with hip fracture may improve their clinical outcome]

BACKGROUND

The treatment of osteoporotic hip fracture requires the intervention of different medical specialties. The purpose of this study was to know the clinical profile of patients with an acute hip fracture referred for assessment and management to a geriatric assessment team (GAT) and the influence of this kind of geriatric care in their hospital outcome.

PATIENTS AND METHOD

All patients 65 year-old or older admitted in a teaching hospital for a hip fracture in a 12 month period were included. The clinical, functional, cognitive and social status were assessed at admission and at discharge in both groups: the patients managed by the GAT and the patients that were not. The patients' characteristics of both groups were compared, and a multivariant analysis was applied to search the variables independently associated wit a better clinical course.

RESULTS

On admission, the GAT patients (n = 202) were significantly (p < 0.05) older (84.4 vs 81.7 years), had more previous functional impairment (Barthel index 72 vs 79), more previous diseases (5.4 vs 3.3) and medications (3.2 vs 1.9), presented more frequency of cognitive impairment (52 vs 41%), of high surgical risk (54 vs 26%) and more need of social assistance at home (57 vs 38%) than non-referred patients (n = 200). At discharge, GAT patients had better functional status (Barthel index 38.5 vs 34), had been surgically treated (92 vs 84%), had received physiotherapy (83.7 vs 66.5%) and walked more (56.1% vs 33.8%) than others. In the multivariant analysis, the GAT intervention shows like an independent variable associated to higher frequency of surgical treatment (OR 4.21; CI, 2.80-6.34), to recovery of walking ability (OR, 8.26; CI, 5.23-13.04) and to receive more medical diagnosis (OR, 79.69; CI: 55.48-114.45). The GAT intervention was not associated to a longer hospital stay.

CONCLUSIONS

The patients with hip fracture in acute phase required for management by a GAT are more complex than those who were not consulted. In these patients GAT intervention improve their clinical outcome and the efficiency of hospital admission.