A quality improvement initiative on the management of osteoporosis in older people with Parkinsonism

Hip Fracture Care in Parkinson Disease: A Retrospective Analysis of 1,239 Patients

Introduction

Compared to other patients, Parkinson disease (PD) patients may experience suboptimal outcomes after hip fracture. The purpose of this study was to describe and compare characteristics and outcomes of hip fracture patients with PD to those without PD.

Methods

This retrospective cohort study included all patients admitted for hip fracture within a large healthcare system between July 1, 2017 and June 30, 2019. Demographics, injury characteristics, Charlson Comorbidity Index (CCI), treatment characteristics, and outcomes including complications, readmissions, and mortality were extracted. Patients with PD were compared to those without PD. Chi-square tests, two-sample t-tests, and Fisher exact tests were conducted to identify group differences.

Results

A total of 1239 patients were included (4.0% PD and 96.0% non-PD). PD patients were mostly male (59.2%) compared to mostly female non-PD patients 69.4%, P < .001). PD patients on average had a higher CCI (2.3 vs 1.7, P = .040) and more frequently had dementia (42.9% vs 26.7%, P = .013). No PD patients were discharged home without additional assistance compared to 8.1% of patients without PD. More PD patients were discharged to a skilled nursing facility (SNF) than non-PD patients (65.3% vs 48.2%, P = .021). Only 22.4% of PD patients were previously prescribed osteoporosis medication, and only 16.3% were referred for osteoporosis follow-up after fracture. In-house complications, readmissions, and mortality up to 1 year were comparable between groups (P>.191).

Conclusions

Outcomes between PD patients and non-PD patients were mostly equivalent, but more PD patients required discharge to a higher-level care environment compared to non-PD patients. Although PD seems to be a risk factor for hip fracture regardless of age and sex, most patients had not undergone proper screening or preventative treatment for osteoporosis. These results emphasize the need for early bone health evaluation, multidisciplinary collaboration, and care coordination in preventing and treating hip fractures in PD.

Bone Mineral Density and Body Composition in Males with Motor Neuron Disease: A Study from Teaching Hospital in Southern Part of India

Background

Osteoporosis and sarcopenia are important aspects of motor neuron disease (MND). Individuals with amyotrophic lateral sclerosis (MND-ALS) have an increased risk of falls and fractures. Currently, the standard of care does not involve a routine assessment of bone mineral density (BMD) and body composition in these patients. We aimed to assess BMD, bone mineral parameters and body composition in men with MND and compared them with healthy controls.

Methods

Consecutive males between 50 and 80 years of age diagnosed as MND-ALS by revised El Escorial criteria and able to walk unassisted attending Neurology outpatient clinic were recruited into the study. Age, gender and body mass index (BMI) matched healthy controls were recruited from the local community. BMD and body composition were assessed by dual-energy x-ray absorptiometry (DXA). Bone mineral parameters and bone turnover markers (BTMs) were also assessed in them.

Results

A total of 30 subjects with MND-ALS and 33 controls were recruited. The mean age (years) was 59.2 in cases and 61.2 in controls. The mean BMD (g/cm²) between the two groups was similar; however, BTMs were significantly higher in the MND group (P < 0.05). Subjects with MND-ALS had significantly lower mean appendicular lean mass (ALM) (19.9 versus 22.4 kg; P = 0.007) and ALM corrected for BMI than the healthy control group (0.858 versus 0.934 kg/kg/m²; P = 0.034). Sarcopenic obesity (Percentage fat mass >27% + ALM/BMI <0.786 kg/kg/m²) was more prevalent in MND-ALS compared to controls (44.5% versus 16.7%; P = 0.03).

Conclusion

Although BMD was not significantly different between subjects with MND-ALS and healthy controls, BTMs were significantly higher in the MND group indicating a high bone turnover state. Sarcopenia and sarcopenic obesity were also more in MND-ALS group than controls. Routine assessment for bone health parameters and body composition indices may be included in management of the patients with MND.

The risk of hip and non-vertebral fractures in patients with Parkinson's disease and parkinsonism: A systematic review and meta-analysis

Parkinson's disease (PD) is a neurodegenerative disorder that is common in older individuals. PD patients have an increased risk of fractures compared to the general population, perhaps due to multiple falls. However, the fracture risk has not been fully assessed. To assess the impact of PD on the risk of hip and non-vertebral fractures, we conducted a systematic review and meta-analysis. Comprehensive searches of three key bibliographic databases were conducted to identify reviews and primary studies relating to the risk of fractures in patients with PD. Search terms included all relevant terms for Parkinson's disease and for fractures. We selected observational studies with data on the risk of fractures in adults with PD compared to controls without the diagnosis. Study quality was assessed using the Newcastle Ottawa Scale. The random-effects model was used to pool the results. Eighteen studies were included in the review. Seventeen independent studies (14 cohort and 3 case-control studies) were included in the hip fracture analysis. Nine studies (all cohorts, no case-control studies) were included in the non-vertebral fracture analysis. Study quality was judged to be moderate to good. Overall, PD patients had an increased risk for both hip fractures (2.40, 95% CI 2.04 to 2.82) and non-vertebral fractures (1.80, 95% CI 1.60 to 2.01) compared to controls. The relative risk for hip fractures was higher in men (2.93, 95% CI 2.05 to 4.18) than in women (1.81, 95% CI 1.61 to 2.04). There were no effects of the study design, geographical region, or criteria for diagnosing Parkinson's disease on these estimates of fracture risk. There is an increase in the risk of hip and non-vertebral fractures in patients with Parkinson's disease and we recommend a re-evaluation of the clinical guidelines on bone health in patients with PD to address this.

Under-Recognition of Fractures as Osteoporosis Indicators

After the first fracture, the risk of subsequent fractures increases significantly. Medical treatment can reduce the risk of a second fracture by about 50%, but many older adults do not receive osteoporosis medication following their first fracture. This observational study aimed to understand primary care management patterns of older adults after osteoporotic fractures at the Miami Veterans Affairs (VA) Healthcare System. A retrospective review of 219 fracture cases selected by International Classification of Disease (ICD-9) codes between October 2015 and September 2016 identified 114 individuals age ≥50 years who had a non-traumatic fracture code entered in their medical record for the first time. Among them, 72 (63%) did not undergo a bone mineral density (BMD) test or receive treatment in the 12 months following their fracture. Of the 40 individuals who had a BMD test post-fracture, 17 (100%) received or were considered for anti-osteoporosis treatment if their T-score indicated osteoporosis (T-score ≤−2.5), but only 8/23 (35%) if the T-score was >−2.5. Physicians are more likely to prescribe osteoporosis therapy based on a BMD T-score diagnosis of osteoporosis, rather than a clinical diagnosis of osteoporosis based on a low-trauma fracture. A change in practice patterns is necessary to decrease the incidence of fractures.

Selecting best-suited "patient-related outcomes" in older people admitted to an acute geriatric or emergency frailty unit and applying quality improvement research to improve patient care

The population is aging worldwide, and hospitals are admitting a higher proportion of acutely unwell older people. Population-specific factors such as multimorbidity and frailty in older people compounded by deficient expertise contribute to longer lengths of stay, higher readmission rates, and increased rates of institutionalization. A wide range of acute geriatric care models are currently providing acute care to frail older people and these have been shown to provide a cost-effective high-quality service. In this review, population-specific factors, service models, and a wide range of patient-related outcomes of "at risk" older people admitted to an acute geriatric care unit are explored. In addition, we also discuss data measurements and a quality improvement methodology to improve the delivery of care based on the patient outcome data. We hope, in addition to ensuring effectiveness and sustainability of our current services, this may also enhance academic research. Regular monitoring and evaluation of patient-related clinical outcomes not only improve the patient care and reduce the caregiver burden but also help in implementing quality initiatives to develop existing services.

Fragility Fractures and Parkinsonism: Relationship of Fractures with Demography, Severity and Predictors of Adverse Outcomes

Background: The risk of falls is higher in patients with Parkinsonism (PwP) as compared to other older adults, leading to adverse outcomes including fragility fractures. Osteoporosis is under-recognised and the current prevalence of fragility fractures is not well-studied. The objectives of this study are to determine the prevalence of fragility fractures in PwP, to measure the relationship of fractures with demography, severity and to measure predictors of adverse outcomes in this population. Method/Description: This was a retrospective observational cohort study based on the analysis of existing data for all the patients attending Caerphilly Movement Disorder Clinic. Information on demographics, the severity of Parkinsonism and fragility fractures was extracted electronically from the clinical workstation, clinic letters and coding from January 2015 to October 2016. Results: 397 people (mean age = 77.1 ± 9.4, 46% females) were studied. Of these, 77% (306/397) had Parkinsonism and 80% (244/306) had idiopathic Parkinson’s disease (PD). The mean Hoehn & Yahr Score at the time assessment was 3.09 ± 1.16. Additionally, 23.5% (72/306) were deemed to have osteoporosis based on the radiological evidence of fragility fractures. The PwP who sustained fractures were comparatively older (80.4 ± 12.1) and 70% (50/72) were females. The most common site for fractures was vertebral (47.2%; 34/72). Also, 22.2% of the sample (16/72) had suffered a fragility fracture before the diagnosis of PD. However, a majority (77.8%; 56/72) had sustained a fracture during the course of PD with a mean lapse of 6 years (range = 0–13 years) from initial diagnosis. Only 40% (29/72) of patients were prescribed osteoporosis drugs as per guidelines. There is a significant correlation of advancing age, severity and duration of PD with fragility fractures. The single best predictor of mortality is severity of PD, followed by age and fractures. Conclusions: There is a high prevalence of fragility fractures in patients attending movement disorder clinics, although 60% do not receive evidence-based medical treatment for the underlying osteoporosis. The prevalence of fragility fractures is positively correlated with the duration and severity of PD. We acknowledge the relatively small sample size as the study’s limitation.