Risk factors for hip fracture among institutionalised older people

Multidimensional characteristics of musculoskeletal pain and risk of hip fractures among elderly adults: the first longitudinal evidence from CHARLS

BACKGROUND

Hip fractures are a major public health concern among middle-aged and older adults. It is important to understand the associated risk factors to inform health policies and develop better prevention strategies. Musculoskeletal pain is a possible implicating factor, being associated with physical inactivity and risk of falls. However, the association between musculoskeletal pain and hip fractures has not been clearly investigated.

METHODS

A nationally representative sample of the Chinese population was obtained from the China Health and Retirement Longitudinal Study (CHARLS). The study collected patient information on their demographic characteristics, socioeconomic status, other health-related behavior, and history of musculoskeletal pain and hip fractures. Univariate and multivariate analyses were conducted to investigate the factors influencing the risk of hip fracture, including factors related to the individual and to musculoskeletal pain. P for trend test was performed to assess the trend of each continuous variable. The robustness and bias were assessed using the bootstrap method. Restricted cubic spline regression was utilized to identify linear or non-linear relationships.

RESULTS

Among the 18,813 respondents, a total of 215 individuals reported that they have experienced a hip fracture. An increased risk of hip fracture was associated with the presence of waist pain and leg pain (P < 0.05), as well as with an increased number of musculoskeletal pain sites (P < 0.05). For individuals aged 65 and above, a significant association was found between age and the risk of hip fracture (P < 0.05). Furthermore, respondents with lower education level had a higher risk of hip fracture compared to those with higher education levels (P < 0.05).

CONCLUSION

In the Chinese population, the risk of hip fracture was found to be associated with both the location and extent of musculoskeletal pain, as well as with other factors such as age and demographic characteristics. The findings of this study may be useful for informing policy development and treatment strategies, and provide evidence for comparison with data from other demographic populations.

Incidence of hip fracture among middle-aged and older Chinese from 2013 to 2015: results from a nationally representative study

China is experiencing remarkable changes in people aging and migration. Therefore, the incidence and associated factors for hip fracture might differ from previous results. A nationally representative study of hip fracture enables policymakers to formulate preventive strategies and provide information on resource allocation.

PURPOSE

To estimate the incidence of hip fracture, between 2013 and 2015, among the middle-aged and older Chinese population.

METHODS

Individuals with hip fractures between 2013 and 2015 were identified from the China Health and Retirement Longitudinal Study. The sex-specific incidence and the associated factors of hip fracture were assessed.

RESULTS

Among 19,112 individuals (51.4% women; mean age 60.5 years) included in the analysis, 408 (2.13%) had a hip fracture between 2013 and 2015. Moreover, the annual incidence of hip fracture for men and women were 1065 and 1069 per 100,000, respectively. The incidence of hip fracture increased with age (p < 0.001). A history of chronic disease, being unmarried, and individuals without insurance were associated with a higher incidence of hip fracture. Interestingly, the incidence of hip fracture was higher among individuals with fewer years of education (p = 0.002). The North-East regions of China had the lowest incidence of hip fracture (1022 per 100,000) between 2013 and 2015, followed by the North (1602 per 100,000), South-Central (2055 per 100,000), East (2173 per 100,000), and South-West (2537 per 100,000) regions. Finally, the incidence was highest among participants living in the North-West region (3244 per 100,000).

CONCLUSION

Between 2013 and 2015, the incidence of hip fracture is high among the middle-aged and older Chinese population. Furthermore, it varied significantly according to sociodemographic and geographic factors. Therefore, the support of targeted health policies and cost-effective preventive strategies are warranted in China.

Are people in residential care entitled to receive rehabilitation services following hip fracture? Views of the public from a citizens' jury

BACKGROUND

Access to rehabilitation services for people living in residential care facilities is frequently limited. A randomised trial of a hospital outreach hip fracture rehabilitation program in residential care facilities has demonstrated improvements in mobility at four weeks and quality of life at 12 months but was not considered cost-effective by standard health economic metrics. The current study aimed to explore the general public's views on issues involved in the allocation of rehabilitation resources for residents of care facilities.

METHODS

A citizens' jury comprising 13 purposively sampled members of the general public, representative of the South Australian age, gender and household income profile. The jury considered the questions "Should there be an investment of physical rehabilitation services in residential care for older people following a hip fracture? If so, what is the best way of providing this service (considering funding, models of service delivery and equity)?" Deliberations were in the context of a state-wide health reform program. The jury was conducted over two days with an experienced independent facilitator, addressing questions developed by a steering group of research academics and clinicians.

RESULTS

The mean age of the citizens' jury members was 43 (range 26 to 61). Eleven members voted for investment in outreach hospital rehabilitation services in residential aged care. All jurors agreed a number of strategies in addition to investment should be implemented, including health care planning and decision making, increased emphasis on hip fracture prevention, training of aged care staff in rehabilitation and routine provision of hospital discharge summaries to families. The jury further advocated for an increased focus on rehabilitation in residential care, potentially through accreditation criteria, increasing health literacy of residents and families, implementation of age friendly environment strategies and improving connections of care facilities with community, hospital and tertiary services.

CONCLUSIONS

This citizens' jury representative of the general public recommends that regardless of dementia and frailty, people who live in residential care and are walking and fracture their hips should have access to hospital outreach rehabilitation and recovery services.

[Functional and clinical outcomes in patients admitted to nursing homes after hip fractures. Implementation of a multi-level intervention program]

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the clinical and functional outcomes of patients discharged to nursing homes after a hip fracture.

METHODS

The study included all patients admitted to a group of nursing homes after a hip fracture in 2016. A geriatric assessment protocol was applied, and patients were treated with a specific protocol for 90 days. They were assessed for nutritional status (Mini-Nutritional Assessment and Body Mass Index), pain (Visual Analogue Scale, and the PAINAD Scale), the presence of pressure ulcers, blood test (D vitamin, haemoglobin, proteins), and functional status (Barthel index and Functional Assessment Categories).

RESULTS

Out of a total of 175 patients, 116 (75%) met the inclusion criteria. The mean age was 84.9 years old (±6.7 SD), and 91 (78.4%) were women. At admission, 73.8% of 65 residents had anaemia, 76.7% hypovitaminosis D, 88% malnutrition or «at risk of malnutrition», and 15.3% had pressure ulcers. After 90 days, the moderate-severe functional status (Barthel index < 60) was reduced from 90.4 to 39.6%, dependence due to gait from 97.3 to 36.1%, and moderate-severe pain from 88.9 to 14.4%. Most of the pressure ulcers healed (94.4%).

CONCLUSIONS

Patients admitted to nursing homes after a hip fracture had poor clinical and functional status. This study shows that after 90 days from admission these patients had positive outcomes in terms of functionality, gait, pain control, and pressure ulcers healing.

Incidence Rates of and Mortality after Hip Fracture among German Nursing Home Residents

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.

An Even Distribution of Protein Intake Daily Promotes Protein Adequacy but Does Not Influence Nutritional Status in Institutionalized Elderly

OBJECTIVE

Although it has been established that sufficient protein is required to maintain good nutritional status and support healthy aging, it is not clear if the pattern of protein consumption may also influence nutritional status, especially in institutionalized elderly who are at risk of malnutrition. Therefore, we aim to determine the association between protein intake distribution and nutritional status in institutionalized elderly people.

DESIGN

Cross-sectional study among 481 institutionalized older adults.

METHODS

Dietary data from 481 ambulant elderly people (68.8% female, mean age 87.5 ± 6.3 years) residing in 52 aged-care facilities in Victoria, Australia, were assessed over 2 days using plate waste analysis. Nutritional status was determined using the Mini-Nutritional Assessment tool and serum (n = 208) analyzed for albumin, hemoglobin, and IGF-1. Protein intake distribution was classified as: spread (even distribution across 3 meals, n = 65), pulse (most protein consumed in one meal, n = 72) or intermediate (n = 344). Regression analysis was used to investigate associations.

RESULTS

Mean protein intakes were higher in the spread (60.5 ± 2.0 g/d) than intermediate group (56.0 ± 0.8 g/d, P = .037), and tended to be higher than those in the pulse group (55.9 ± 1.9 g/d, P = .097). Residents with an even distribution of protein intake achieved a higher level of the recommended daily intake for protein (96.2 ± 30.0%) than the intermediate (86.3 ± 26.2%, P = .008) and pulse (87.4 ± 30.5%, P = .06) groups, and also achieved a greater level of their estimated energy requirements (intermediate; P = .039, pulse; P = .001). Nutritional status (Mini-Nutritional Assessment score) did not differ between groups (pulse; 20.5 ± 4.5, intermediate; 21.0 ± 2.5, spread; 20.5 ± 3.5), nor did any other indices of nutritional status.

CONCLUSIONS

Meeting protein requirements is required before protein distribution may influence nutritional status in institutionalized elderly. Achieving adequate protein and energy intakes is more likely when protein is distributed evenly throughout the day. Provision of high protein foods especially at breakfast, and in the evening, may support protein adequacy and healthy aging, especially for institutionalized elderly.

Severe Spastic Contractures and Diabetes Mellitus Independently Predict Subsequent Minimal Trauma Fractures Among Long-Term Care Residents

OBJECTIVE

The study aimed to examine the epidemiology of hypertonic contractures and its relationship with minimal trauma fracture (MTF), and to determine the incidence and predictors of (MTF) in long-term care residents.

DESIGN

This was a longitudinal cohort study of prospectively collected data. Participants were followed from March 2007 to March 2016 or until death.

SETTING

A 300-bed long-term care hospital in Hong Kong.

PARTICIPANTS

All long-term care residents who were in need of continuous medical and nursing care for their activities of daily living.

MEASUREMENTS

Information on patients' demographic data, severe contracture defined as a decrease of 50% or more of the normal passive range of joint movement of the joint, and severe limb spasticity defined by the Modified Ashworth Scale higher than grade 3, medical comorbidities, functional status, cognitive status, nutritional status including body mass index and serum albumin, past history of fractures, were evaluated as potential risk factors for subsequent MTF.

RESULTS

Three hundred ninety-six residents [148 males, mean ± standard deviation (SD), age = 79 ± 16 years] were included for analysis. The presence of severe contracture was highly prevalent among the study population: 91% of residents had at least 1 severe contracture, and 41% of residents had severe contractures involving all 4 limbs. Moreover, there were a significant proportion of residents who had severe limb spasticity with the elbow flexors (32.4%) and knee flexors (33.9%) being the most commonly involved muscles. Twelve residents (3%) suffered from subsequent MTF over a median follow-up of 33 (SD = 30) months. Seven out of these 12 residents died during the follow-up period, with a mean survival of 17.8 months (SD = 12.6) after the fracture event. The following 2 factors were found to independently predict subsequent MTF in a multivariate Cox regression: bilateral severe spastic knee contractures (hazard ratio = 16.5, P < .0001, confidence interval 4.8-56.4) and diabetes mellitus (hazard ratio = 4.0. P = .018, confidence interval 1.3-12.7).

CONCLUSIONS

Severe spasticity and contractures are common morbidities in long-term care residents, and bilateral severe spastic knee contractures and diabetes mellitus are 2 independent predictors of subsequent MTF. Spasticity management and prevention of contractures, combined with educational programs for caregivers to identify the high-risk residents and apply proper handling techniques during routine care, may be helpful in reducing the risk of MTF in long-term care residents. Further large-scale longitudinal studies are needed to confirm these findings.

Geographic Variation in Hip Fracture Among United States Long-Stay Nursing Home Residents

INTRODUCTION

Despite high rates of hip fracture among United States (US) nursing home (NH) residents, little is known about geographic variation in hip fracture incidence. We used nationally representative data to identify geographic variation in hip fracture among US NH residents.

DESIGN AND SETTING

Retrospective cohort study using Part A claims for a 100% of Medicare enrollees in 15,289 NHs linked to NH minimum data set and Online Survey, Certification, and Reporting databases.

PARTICIPANTS

A total of 891,085 long-stay (continuous residence of ≥100 days) NH residents ≥65 years old.

MEASUREMENTS

Medicare Part A claims documenting a hip fracture. Mean incidence rates of hip fracture for long-stay NH residents were calculated for each state and US Census Division from 2007 to 2010.

RESULTS

The age-, sex-, and race-adjusted incidence rate of hip fracture ranged from 1.49 hip fractures/100 person-years (Hawaii) to 3.60 hip fractures/100 person-years (New Mexico), with a mean of 2.38 (standard deviation 0.43) hip fractures/100 person-years. The mean incidence of hip fracture was 1.7-fold greater in the highest quintile than the lowest.

CONCLUSIONS

We observed modest US state and regional variation in hip fracture incidence among long-stay NH residents. Future studies should assess whether state policies or NH characteristics explain the variation.

Risk factors for hip fracture in very old people: a population-based study

SUMMARY

Knowledge of risk factors for hip fracture among very old people is limited. Walking indoors with help from ≤1 person, Parkinson's disease, currently smoking, delirium in the previous month, underweight, and age were associated with increased risk of hip fracture and could be important for preventive strategy development.

INTRODUCTION

The purpose of this study is to investigate risk factors for hip fracture among a representative sample of very old people.

METHODS

In total, 953 participants from the Umeå 85+/Gerontological Regional Database population-based cohort study were interviewed and assessed during home visits. Associations of baseline characteristics with hip fracture during the maximum 5-year follow-up period were analyzed using Cox proportional hazards regression.

RESULTS

Participants had a mean age of 89.3 ± 4.7 years; 65.8% were women, 36.8% lived in residential care facilities, 33.6% had dementia, and 20.4% had histories of hip fracture. During a mean follow-up period of 2.7 years, 96 (10.1%) individuals sustained hip fracture. Walking indoors with help from no more than one person (hazard ratio [HR] = 8.57; 95% confidence interval [CI], 1.90-38.71), Parkinson's disease (HR = 5.12; 95% CI, 1.82-14.44), currently smoking (HR = 4.38; 95% CI 2.06-9.33), delirium in the previous month (HR = 2.01; 95% CI, 1.15-3.49), underweight (body mass index <22; HR = 1.74, 95% CI, 1.09-2.77), and age (HR = 1.09; 95% CI, 1.04-1.14) were associated independently with an increased risk of hip fracture. Hip prosthesis at baseline decreased the risk of hip fracture (HR = 0.37; 95% CI, 0.15-0.91), but only for those with bilateral hip prostheses.

CONCLUSIONS

Seven factors were associated independently with incident hip fracture during follow-up in this sample of very old people. These factors could have important clinical implications in identifying persons at high risk of hip fracture, as well as in the development of effective preventive strategies.

Comparative trends in incident fracture rates for all long-term care and community-dwelling seniors in Ontario, Canada, 2002-2012

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.

Algorithm of medication review in frail older people: Focus on minimizing the use of high-risk medications

AIM

Frail older people typically suffer several chronic diseases, receive multiple medications and are more likely to be institutionalized in residential aged care facilities. In such patients, optimizing prescribing and avoiding use of high-risk medications might prevent adverse events. The present study aimed to develop a pragmatic, easily applied algorithm for medication review to help clinicians identify and discontinue potentially inappropriate high-risk medications.

METHODS

The literature was searched for robust evidence of the association of adverse effects related to potentially inappropriate medications in older patients to identify high-risk medications. Prior research into the cessation of potentially inappropriate medications in older patients in different settings was synthesized into a four-step algorithm for incorporation into clinical assessment protocols for patients, particularly those in residential aged care facilities.

RESULTS

The algorithm comprises several steps leading to individualized prescribing recommendations: (i) identify a high-risk medication; (ii) ascertain the current indications for the medication and assess their validity; (iii) assess if the drug is providing ongoing symptomatic benefit; and (iv) consider withdrawing, altering or continuing medications. Decision support resources were developed to complement the algorithm in ensuring a systematic and patient-centered approach to medication discontinuation. These include a comprehensive list of high-risk medications and the reasons for inappropriateness, lists of alternative treatments, and suggested medication withdrawal protocols.

CONCLUSIONS

The algorithm captures a range of different clinical scenarios in relation to potentially inappropriate medications, and offers an evidence-based approach to identifying and, if appropriate, discontinuing such medications. Studies are required to evaluate algorithm effects on prescribing decisions and patient outcomes. Geriatr Gerontol Int 2016; 16: 1002-1013.

Increased Mortality Amongst Patients Sustaining Neck of Femur Fractures as In-Patients in a Trauma Centre

Purpose:

Neck of Femur (NOF) fracture is a common injury with high mortality that all orthopaedic departments must contend with [1]. The aim of this study was to report incidence and mortality of NOF fractures occurring while patients were being admitted to hospital for other conditions.

Methods:

A retrospective review was performed of all NOF fracture admissions between 1^st of Jan 2010 to 31^st of Dec 2012 at a University Hospital trauma centre. Fractures were divided according to the location where the fracture occurred, either in the community (acute NOF) or in-hospital (in-hospital NOF).

Results:

In-hospital mortality, 30-day, 90-day and 1 year mortality were recorded. There were 1086 patients in the acute NOF fracture group (93.9%) and 70 patients in the in-hospital group (6.1%) over three years. The odds of inpatient death was 2.25 times higher for inpatient NOFs (p=0.012). 86% of all in-hospital NOF fractures occurred on medical and rehabilitation wards. NOF fractures result in increased mortality and morbidity.

Conclusion:

All patients in hospital should be assessed to identify those at high risk of falls and implemented measures should be taken to reduce this.

Predictive ability of heel quantitative ultrasound for incident fractures: an individual-level meta-analysis

The relationship between bone quantitative ultrasound (QUS) and fracture risk was estimated in an individual level data meta-analysis of 9 prospective studies of 46,124 individuals and 3018 incident fractures. Low QUS is associated with an increase in fracture risk, including hip fracture. The association with osteoporotic fracture decreases with time.

INTRODUCTION

The aim of this meta-analysis was to investigate the association between parameters of QUS and risk of fracture.

METHODS

In an individual-level analysis, we studied participants in nine prospective cohorts from Asia, Europe and North America. Heel broadband ultrasonic attenuation (BUA dB/MHz) and speed of sound (SOS m/s) were measured at baseline. Fractures during follow-up were collected by self-report and in some cohorts confirmed by radiography. An extension of Poisson regression was used to examine the gradient of risk (GR, hazard ratio per 1 SD decrease) between QUS and fracture risk adjusted for age and time since baseline in each cohort. Interactions between QUS and age and time since baseline were explored.

RESULTS

Baseline measurements were available in 46,124 men and women, mean age 70 years (range 20-100). Three thousand and eighteen osteoporotic fractures (787 hip fractures) occurred during follow-up of 214,000 person-years. The summary GR for osteoporotic fracture was similar for both BUA (1.45, 95 % confidence intervals (CI) 1.40-1.51) and SOS (1.42, 95 % CI 1.36-1.47). For hip fracture, the respective GRs were 1.69 (95 % CI, 1.56-1.82) and 1.60 (95 % CI, 1.48-1.72). However, the GR was significantly higher for both fracture outcomes at lower baseline BUA and SOS (p < 0.001). The predictive value of QUS was the same for men and women and for all ages (p > 0.20), but the predictive value of both BUA and SOS for osteoporotic fracture decreased with time (p = 0.018 and p = 0.010, respectively). For example, the GR of BUA for osteoporotic fracture, adjusted for age, was 1.51 (95 % CI 1.42-1.61) at 1 year after baseline, but at 5 years, it was 1.36 (95 % CI 1.27-1.46).

CONCLUSIONS

Our results confirm that quantitative ultrasound is an independent predictor of fracture for men and women particularly at low QUS values.

Cost-effectiveness of a multifactorial fracture prevention program for elderly people admitted to nursing homes

BACKGROUND

Fractures are one of the most costly consequences of falls in elderly patients in nursing homes.

OBJECTIVES

To compare the cost-effectiveness of a 'multifactorial fracture prevention program' provided by a multidisciplinary team with 'no prevention' in newly admitted nursing home residents.

METHODS

We performed a cost-utility analysis using a Markov-based simulation model to establish the effectiveness of a multifaceted fall prevention program from the perspective of statutory health insurance (SHI) and long-term care insurance (LCI). The rate of falls was used to estimate the clinical and economic consequences resulting from hip and upper limb fractures. Robustness of the results was assessed using deterministic and probabilistic sensitivity analyses.

RESULTS

Compared to no prevention a multifactorial prevention program for nursing home residents resulted in a cost-effectiveness ratio of 21,353 euro per quality-adjusted life-year. The total costs for SHI/LCI would result in 1.7 euro million per year. Results proved to be robust following deterministic and probabilistic sensitivity analyses.

CONCLUSION

Multifactorial fracture prevention appears to be cost-effective in preventing fractures in nursing home residents. Since the results were based on the number of falls further research is required to confirm the results.

Assessment of functional capability and on-going falls-risk in older institutionalized people after total hip arthroplasty for femoral neck fractures

PURPOSE

To estimate functional capability and attendant falls-risk in older institutionalized people after total hip arthroplasty (THA) for femoral neck fractures.

METHODS

The study population comprised 149 consecutive patients (F104, M45; mean age 83.4 years) who were permanent residents of nursing care facilities four weeks after THA for femoral neck fractures. Individual mental and functional capability status was assessed using the Mini Mental State Examination (MMSE), Timed Up and Go test (TUG) and Tinetti's Performance Oriented Mobility Assessment (POMA) which includes sub-scales for balance (B) and gait (G), in conjunction with identifying any concomitant disorders, reviewing individual pharmacotherapy and leisure time activities.

RESULTS

The subjects' mean MMSE was 23.1 points, whereas in Tinetti's POMA they scored 19 points on average, which translated into a five-fold greater falls-risk, whereas average TUG scores of 23.9s effectively corroborated this assertion. Multiple regression analysis effectively highlighted that TUG scores were strongly correlated with the actual number of concomitant disorders, number of regularly taken medications, and usual manner of spending leisure time.

CONCLUSIONS

Institutionalized older people after THA for femoral neck fracture continue to be exposed to high risk of recurrent, possibly injurious falls, which is closely correlated with significantly diminished individual functional capabilities.

Total hospital stay for hip fracture: measuring the variations due to pre-fracture residence, rehabilitation, complications and comorbidities

BACKGROUND

Hospital treatment for hip fracture is complex, often involving sequential episodes for acute orthopaedics, rehabilitation and care of contingent conditions. Most reports of hospital length of stay (LOS) address only the acute phase of care. This study identifies the frequency and mean duration of the component episodes within total hospital stay, and measures the impacts of patient-level and clinical service variables upon both acute phase and total LOS.

METHODS

Administrative datasets for 2552 subjects hospitalised between 1 July 2008 and 30 June 2009 were linked. Associations between LOS, pre-fracture accommodation status, age, sex, fracture type, hospital separation codes, selected comorbidities and complications were examined in regression models for acute phase and total LOS for patients from residential aged care (RAC) and from the community.

RESULTS

Mean total LOS was 30.8 days, with 43 per cent attributable to acute fracture management, 37 per cent to rehabilitation and 20 per cent to management of contingent conditions. Community patients had unadjusted total LOS of 35.4 days compared with 18.8 days for RAC patients (p <0.001). The proportion of transfers into rehabilitation (57 per cent vs 17 per cent, p <0.001) was the major determinant for this difference. In multivariate analyses, new RAC placement, discharge to other facilities, and complications of pressure ulcer, urinary or surgical site infections increased LOS by at least four days in one or more phases of hospital stay.

CONCLUSION

Pre-fracture residence, selection for rehabilitation, discharge destination and specific complications are key determinants for acute phase and total LOS. Calculating the dimensions of specific determinants for LOS may identify potential efficiencies from targeted interventions such as orthogeriatric care models.

Is use of fall risk-increasing drugs in an elderly population associated with an increased risk of hip fracture, after adjustment for multimorbidity level: a cohort study

Background

Risk factors for hip fracture are well studied because of the negative impact on patients and the community, with mortality in the first year being almost 30% in the elderly. Age, gender and fall risk-increasing drugs, identified by the National Board of Health and Welfare in Sweden, are well known risk factors for hip fracture, but how multimorbidity level affects the risk of hip fracture during use of fall risk-increasing drugs is to our knowledge not as well studied. This study explored the relationship between use of fall risk-increasing drugs in combination with multimorbidity level and risk of hip fracture in an elderly population.

Methods

Data were from Östergötland County, Sweden, and comprised the total population in the county aged 75 years and older during 2006. The odds ratio (OR) for hip fracture during use of fall risk-increasing drugs was calculated by multivariate logistic regression, adjusted for age, gender and individual multimorbidity level. Multimorbidity level was estimated with the Johns Hopkins ACG Case-Mix System and grouped into six Resource Utilization Bands (RUBs 0–5).

Results

2.07% of the study population (N = 38,407) had a hip fracture during 2007. Patients using opioids (OR 1.56, 95% CI 1.34-1.82), dopaminergic agents (OR 1.78, 95% CI 1.24-2.55), anxiolytics (OR 1.31, 95% CI 1.11-1.54), antidepressants (OR 1.66, 95% CI 1.42-1.95) or hypnotics/sedatives (OR 1.31, 95% CI 1.13-1.52) had increased ORs for hip fracture after adjustment for age, gender and multimorbidity level. Vasodilators used in cardiac diseases, antihypertensive agents, diuretics, beta-blocking agents, calcium channel blockers and renin-angiotensin system inhibitors were not associated with an increased OR for hip fracture after adjustment for age, gender and multimorbidity level.

Conclusions

Use of fall risk-increasing drugs such as opioids, dopaminergic agents, anxiolytics, antidepressants and hypnotics/sedatives increases the risk of hip fracture after adjustment for age, gender and multimorbidity level. Fall risk-increasing drugs, high age, female gender and multimorbidity level, can be used to identify high-risk patients who could benefit from a medication review to reduce the risk of hip fracture.

Is use of fall risk-increasing drugs in an elderly population associated with an increased risk of hip fracture, after adjustment for multimorbidity level: a cohort study

BACKGROUND

Risk factors for hip fracture are well studied because of the negative impact on patients and the community, with mortality in the first year being almost 30% in the elderly. Age, gender and fall risk-increasing drugs, identified by the National Board of Health and Welfare in Sweden, are well known risk factors for hip fracture, but how multimorbidity level affects the risk of hip fracture during use of fall risk-increasing drugs is to our knowledge not as well studied. This study explored the relationship between use of fall risk-increasing drugs in combination with multimorbidity level and risk of hip fracture in an elderly population.

METHODS

Data were from Östergötland County, Sweden, and comprised the total population in the county aged 75 years and older during 2006. The odds ratio (OR) for hip fracture during use of fall risk-increasing drugs was calculated by multivariate logistic regression, adjusted for age, gender and individual multimorbidity level. Multimorbidity level was estimated with the Johns Hopkins ACG Case-Mix System and grouped into six Resource Utilization Bands (RUBs 0-5).

RESULTS

2.07% of the study population (N = 38,407) had a hip fracture during 2007. Patients using opioids (OR 1.56, 95% CI 1.34-1.82), dopaminergic agents (OR 1.78, 95% CI 1.24-2.55), anxiolytics (OR 1.31, 95% CI 1.11-1.54), antidepressants (OR 1.66, 95% CI 1.42-1.95) or hypnotics/sedatives (OR 1.31, 95% CI 1.13-1.52) had increased ORs for hip fracture after adjustment for age, gender and multimorbidity level. Vasodilators used in cardiac diseases, antihypertensive agents, diuretics, beta-blocking agents, calcium channel blockers and renin-angiotensin system inhibitors were not associated with an increased OR for hip fracture after adjustment for age, gender and multimorbidity level.

CONCLUSIONS

Use of fall risk-increasing drugs such as opioids, dopaminergic agents, anxiolytics, antidepressants and hypnotics/sedatives increases the risk of hip fracture after adjustment for age, gender and multimorbidity level. Fall risk-increasing drugs, high age, female gender and multimorbidity level, can be used to identify high-risk patients who could benefit from a medication review to reduce the risk of hip fracture.

Fracture risk in long term care: a systematic review and meta-analysis of prospective observational studies

BACKGROUND

The risk factors associated with fractures have been well-characterized in community dwelling populations, but have not been clearly defined in long-term care (LTC) settings. The objective of this review was to identify risk factors for fractures in LTC settings.

METHODS

We searched MEDLINE, the Cochrane Library, EMBASE and CINAHL up to June 2014, scanned reference lists of articles and consulted with experts in the field to identify relevant prospective cohort studies that evaluated risk factors associated with fracture incidence in LTC. We included studies that assessed the association between risk factors included in the WHO-Fracture Risk Assessment Tool (FRAX®) or other predictors relevant to LTC (psychotropic medications, cognitive impairment, mobility, and falls). All articles were screened and extracted by two authors. Available data on the association between a given risk factor and fracture incidence were pooled when possible. We used the GRADE criteria to provide a summary of evidence. The GRADE approach defines the quality of a body of evidence as the extent to which one can be confident that an estimate of effect or association is close to the quantity of specific interest.

RESULTS

We identified 13 prospective cohort studies which examined fracture incidence among LTC residents. Most predictors showed moderate increases in fracture risk, but the quality of the evidence was often low. Moderate quality evidence showed that prior fractures and falls may moderately increase the risk of fractures. Being a woman and cognitive impairment are probably associated with a small increase. The effect of mobility and psychotropic medication use is still uncertain primarily due to the various definitions used in the studies and difficulty summarising the results.

CONCLUSIONS

In addition to criteria used in the FRAX assessment tool, such as a previous fracture and female gender, we found that falls and cognitive impairment are also associated with a small to moderate increases in the risk of fractures in LTC. Developing an assessment tool that includes risk factors that are specific to LTC may improve the identification of individuals who can benefit from fracture prevention programs in these settings.

The risk of major and any (non-hip) fragility fracture after hip fracture in the United Kingdom: 2000-2010

The risk of a subsequent major or any fracture after a hip fracture and secular trends herein were examined. Within 1 year, 2.7 and 8.4% of patients sustained a major or any (non-hip) fracture, which increased to 14.7 and 32.5% after 5 years. Subsequent fracture rates increased during the study period both for major and any (non-hip) fracture.

INTRODUCTION

Hip fractures are associated with subsequent fractures, particularly in the year following initial fracture. Age-adjusted hip fracture rates have stabilised in many developed countries, but secular trends in subsequent fracture remain poorly documented. We thus evaluated secular trends (2000-2010) and determinants for the risk of a subsequent major (humerus, vertebral, or forearm) and any (non-hip) fracture after hip fracture.

METHODS

Patients ≥50 years with a hip fracture between 2000 and 2010 were extracted from the UK Clinical Practice Research Datalink (n = 30,516). Incidence rates, cumulative incidence probabilities, and adjusted hazard ratios (aHRs) were calculated.

RESULTS

Within 1 year following hip fracture, 2.7 and 8.4% of patients sustained a major or any (non-hip) fracture, which increased to 14.7 and 32.5% after 5 years, respectively. The most important risk factors for a subsequent major fracture within 1 year were the female gender [aHR 1.90, 95% confidence interval (CI) 1.51-2.40] and a history of secondary osteoporosis (aHR 1.54, 95% CI 1.17-2.02). The annual risk increased during the study period for both subsequent major (2009-2010 vs. 2000-2002: aHR 1.44, 95% CI 1.12-1.83) and any (non-hip) facture (2009-2010 vs. 2000-2002: aHR 1.80, 95% CI 1.58-2.06).

CONCLUSION

The risk of sustaining a major or any (non-hip) fracture after hip fracture is small in the first year. However, given the recent rise in secondary fracture rates and the substantial risk of subsequent fracture in the longer term, fracture prevention is clearly indicated for patients who have sustained a hip fracture.

Hip fracture risk factors and the discriminability of hip fracture risk vary by age: a case-control study

AIMS

To determine the important risk factors for hip fracture and the discriminability of hip fracture risk in different age cohorts (≤80 years, >80 years).

METHODS

Consecutive admissions of hip fracture over 24 months in those aged >60 years, and an age- and sex-matched control derived from admissions under a medical unit were prospectively assessed. The risk factors and the discriminabilty of hip fracture risk by age were investigated for each sex in univariate and multivariate models. The area under the curve (AUC) statistics from the receiver operating characteristic curve analysis was used to estimate the ability of the independent risk factors to discriminate hip fracture risk.

RESULTS

The important risk factors in women aged ≤80 years were lower bodyweight, previous osteoporotic fracture, hip fracture in first-degree relatives and lower plasma 25OHD, and their discriminative effect was (AUC) 0.69. Previous osteoporotic fracture and lower plasma 25OHD were the important risk factors in men aged ≤80 years, with a discriminative effect of 0.83. In the >80-year age cohorts, only falls was independently associated with hip fracture in both sexes, with discriminative effects of 0.60 and 0.62 in females and males, respectively.

CONCLUSIONS

The overall discrimination of hip fracture risk appears less adequate in those aged >80 years when compared with those aged ≤80 years. Although skeletal factors have a greater risk association with hip fracture in patients aged ≤80 years, it is falls that is important in those aged >80 years. The relative importance of risk factors also appears to vary between the sexes in those aged ≤80 years.

Hip fracture in hospitalized medical patients

Background

The aim of the present study is to analyze the incidence of hip fracture as a complication of admissions to internal medicine units in Spain.

Methods

We analyzed the clinical data of 2,134,363 adults who had been admitted to internal medicine wards. The main outcome was a diagnosis of hip fracture during hospitalization.

Outcome measures included rates of in-hospital fractures, length of stay and cost.

Results

A total of 1127 (0.057%) admittances were coded with an in-hospital hip fracture. In hospital mortality rate was 27.9% vs 9.4%; p < 0.001, and the mean length of stay was significantly longer for patients with a hip fracture (20.7 days vs 9.8 days; p < 0.001). Cost were higher in hip-fracture patients (6927€ per hospitalization vs 3730€ in non fracture patients). Risk factors related to fracture were: increasing age by 10 years increments (OR 2.32 95% CI 2.11-2.56), female gender (OR 1.22 95% CI 1.08-1.37), admission from nursing home (OR 1.65 95% CI 1.27-2.12), dementia (1.55 OR 95% CI1.30-1.84), malnutrition (OR 2.50 95% CI 1.88-3.32), delirium (OR 1.57 95% CI 1.16-2.14), and anemia (OR 1.30 95%CI 1.12-1.49).

Conclusions

In-hospital hip fracture notably increased mortality during hospitalization, doubling the mean length of stay and mean cost of admission. These are reasons enough to stress the importance of designing and applying multidisciplinary plans focused on reducing the incidence of hip fractures in hospitalized patients.

Consuming two additional serves of dairy food a day significantly improves energy and nutrient intakes in ambulatory aged care residents: a feasibility study

OBJECTIVES

[corrected] Low-level aged-care residents are at risk of malnutrition. Oral supplements and fortified foods used to treat malnutrition in the elderly require special preparation and administration by staff. Therefore we aimed to determine if increasing dairy food intake in residents by two serves per day would improve energy and nutrient intakes and prevent malnutrition in residents.

DESIGN

Prospective intervention study.

SETTING

2 intervention and 2 control low-level aged-care facilities in Melbourne, Australia.

PARTICIPANTS

130 residents (n = 68 intervention, 78% female, mean age 86.5 years).

INTERVENTION

This feasibility study was a 4-week intervention where menus were modified to include at least two additional serves of dairy food/day. Control facilities consumed from their regular menus.

MEASUREMENTS

Mean macro- and micro-nutrient intakes before and after intervention and over the same time period in controls were recorded using observed intake (food served minus waste) and changes over time determined using paired t-tests. Comparison in proportion of residents meeting nutritional requirements was determined using Chi-square distribution test.

RESULTS

Following intervention, daily increases in mean energy intake (900kJ, P<0.001), protein intake (+25g, P<0.0001), proportion of energy from protein (+4%, P<0.0001) and proportion of estimated energy requirements (EER) (+18%, P<0.0001) were observed, while proportion of energy from fat decreased (-3%, P<0.0001). In controls mean energy intake remained below the EER, and protein intake remained unchanged. Increases in mean daily micronutrient intakes were observed for numerous nutrients including calcium (+679mg, P<0.0001), vitamin D (+1.4μg, P<0.0001), phosphorus (+550mg, P<0.0001), and zinc (+2.8mg, P<0.0001), which remained unchanged in control residents. Calcium and zinc intakes achieved recommended intake levels on the higher dairy diet, but were below recommended levels in controls. Mean sodium intakes remained unchanged. During intervention a greater proportion of residents achieved the EER for energy and the RDI for protein and calcium compared to controls.

CONCLUSION

Two additional serves of dairy food can significantly improve nutrient intake in aged-care residents and its ease of provision makes it a viable option to potentially prevent malnutrition.

Meeting the nutritional needs of elderly residents in aged-care: are we doing enough?

OBJECTIVES

[corrected] Institutionalized elderly are at high risk of malnutrition, including those residing in low-level aged-care and able to self-feed. We used comprehensive dietary intake assessments to determine the nutritional adequacy of food served to residents and if food waste contributed to insufficient nutrient intakes.

DESIGN

Cross sectional.

SETTING

18 low-level aged care facilities.

PARTICIPANTS

199 residents (mean age 86.7 yrs, 76% females).

MEASUREMENTS

Dietary data using 3-6 day weighed food records. Foods were categorized into main food groups (grains, fruit, vegetables, meats, dairy and 'extra') and quantified based on recommended serving sizes. Chi squared test was used to determine sex differences in proportion of residents below recommended intake levels.

RESULTS

Residents were provided with sufficient serves of fruit (>2) and meats (>1), but not dairy (<3), vegetables (<5) and grain foods (women only, <4), and excess serves of 'extra' foods (>2). Mean dietary intakes did not meet recommendations for calcium, zinc, magnesium, potassium, folate and dietary fibre with many residents not meeting energy and protein requirements. Sodium intake was up to 3 times higher than recommended, and sugars consumed in excess. Food waste was 0-15% and resulted in men not consuming recommended serves of grain foods. 'Extra' foods contributed substantially to energy intake but provided few of the required nutrients.

CONCLUSION

Substituting some 'extra' foods for serves of dairy, vegetables and wholegrain foods would improve the nutritional quality of foods, without altering food volume, so is feasible to improve nutritional status in elderly aged-care residents.

Outcomes of polypharmacy in nursing home residents

This article provides a comprehensive review of the outcomes of polypharmacy in nursing homes. Our review had some limitations. First, we only included studies beginning in 1990, and significant earlier studies are not included. Only English language articles were included. We only researched studies from MEDLINE, and may have missed studies based on our search terms and search tools. There are many definitions of polypharmacy in the literature, including number of medications or inappropriate medications. In this review, we defined polypharmacy as a high number of medications, but not inappropriate medications. It was not surprising that polypharmacy was consistently associated with an increased number of potentially inappropriate drugs. The majority of studies were viewed showed that polypharmacy was associated with increased ADEs, increased DDIs, and increased hospitalizations. We were surprised that polypharmacy was not consistently linked with falls, fractures, and mortality. For the mortality studies, it has been postulated that perhaps some patients receiving 10 or more medications may have been moribund or receiving end-of-life or hospice care. It is possible that the number of medications is not as important as the number of potentially in appropriate drugs. There need to be more studies on these outcomes, using different definitions of polypharmacy. Polypharmacy was associated with increased costs. The drug-related morbidity and mortality, including those resulting from inappropriate medications and increased staff time, led to increased costs. Use of consultant pharmacists has been shown to decrease polypharmacy costs.

Preventing falls and fractures in long-term care

The prevalence of falls and associated injuries increases with age and dependency. The highest occurs among individuals living in long-term care institutions. Preventing falls results in reduced physical and psychological morbidity as well as having cost-saving implications. This review explores both uni- and multifactorial approaches to reducing fall rates and risk in individuals in long-term care, as well as highlighting the differences in this group from community-dwelling individuals.

Epidemiology of Falls in Older Age

Les chutes chez les personnes agées sont une préoccupation de la santé publiquedans le monde entier en raison de leur fréquence et les conséquences néfastes en terms de morbidité, mortalité et de la qualité de vie, ainsi que leur impact sur les services et les coûts du système de santé. Cette étude épidémiologique décrit la charge de la santé publique de chutes et de blessures liées aux chutes et l’impact sur les chutes du vieillissement de la population. L’ampleur du problème est décrit en termes du classement des chutes et la mesure des résultats, y compris l’incidence des chutes et des blessures liées dans tous les milieux, les déterminants socio-démographiques, les tendance internationales, et le coût des chutes et des blessures liées aux chutes. Enfin, des approches de santé publique afin de minimiser les risques de chutes et la demande conséquente sur les ressources de soins de santé sont récommandés.

Low-trauma fractures indicate increased risk of hip fracture in frail older people

This study aims to investigate the risk of subsequent fractures after low-trauma fracture in frail older people. A total of 1412 elderly residents (mean age 86.2 years, SD 7.0 years, female 77%) were recruited from aged care facilities in Australia. Residents were assessed and then followed for any fracture for 2 years and hip fractures for at least 5 years. Residents with and without a newly acquired fracture in the first 2 years were compared for risk of subsequent hip fracture. Residents with a nonhip fracture in the first 2 years had an increased risk of subsequent hip fracture for about 2.5 years, whereas those with a hip fracture had a similar risk over the whole period compared with those with no fracture. During these 2.5 years, 60, 28, and 6 subsequent hip fractures occurred in the nonfracture group (n = 953), the nonhip fracture group (n = 194), and the hip fracture group (n = 101), respectively, resulting in the probability of subsequent hip fracture of 8.0%, 19.9%, and 10.4%, respectively. Compared with the nonfracture group, the hazard ratio (HR) was 2.82 [95% confidence interval (CI) 1.73-4.59; p < .001] for the nonhip fracture group and 1.48 (95% CI 0.63-3.49, p = .37) for the hip fracture group after adjusting for age, sex, residence type, calcaneal broadband ultrasound attenuation, fracture history, weight, lower leg length, immobility, cognitive function, and medications. Frail institutionalized older people with newly acquired fractures are at increased risk of subsequent hip fracture for the next few years. Accordingly, despite their advanced age, they are a high-priority target group to investigate interventions that might reduce the risk of hip fracture.

Hip fractures in long-term care: is the excess explained by the age and gender distribution of the residents?

Introduction. This study compares hip fracture rates in Long Term Care (LTC) residents with those in the community to determine if their high rate of fracturing reflects the extreme age and predominantly female nature of that population. Methods. Hospital discharge data in London Ontario (population 350,000) and Statistics Canada data were used to correct the hip fracture rate in the LTC setting for age and gender. Results. The risk of hip fracture is 1.8 times greater in LTC than in the community for people of similar age and gender. The rate in women is 1.5 times higher whereas in men it is 4.3 times higher. In the oldest residents, the risk in men exceeds that of women in LTC. Conclusion. The high hip fracture rate in LTC is not just a reflection of the age and predominantly female nature of this population. The oldest men in LTC are a particularly high risk group, deserving more attention.

Clinical practice in nursing homes as a key for progress

With the aging of the world's population there has become a major need for the development of nursing homes throughout the world. While some countries provide high quality care for the disabled elderly, in others this is not the case. Education of a medical director has been shown to improve the quality of the nursing home. Physicians need to have knowledge of how to implement continuous quality improvement and culture change. Key medical issues include moving to a restraint free environment, subsyndromal delirium, behavioral disturbances, weight loss, pain management, pressure ulcers, falls, hip fractures, polypharmacy, depression and frailty.