Shared decision-making for non-operative management versus operative management of hip fractures in selected frail older adults with a limited life expectancy: a protocol for a nationwide implementation study

BACKGROUND AND PURPOSE

Recent research has highlighted non-operative management (NOM) as a viable alternative for frail older adults with hip fractures in the final phase of life. This study aims to guide Dutch physicians and hospitals nationwide in a standardised implementation of shared decision-making regarding surgery or NOM in selected frail older adults with a hip fracture.

METHODS AND ANALYSIS

The patient population for implementation includes frail older adults aged ≥70 years with an acute proximal femoral fracture, nursing home care or a similar level of care elsewhere and at least one additional criterion (ie, malnutrition, severe mobility impairment or ASA≥4). The 2-year implementation study will be conducted in four phases. In phases 1 and 2, barriers and facilitators for implementation will be identified and an implementation protocol, educational materials and patient information will be developed. Phase 3 will involve an implementation pilot in 14 hospitals across the Netherlands. The protocol and educational material will be improved based on healthcare provider and patient experiences gathered through interviews. Phase 4 will focus on upscaling to nationwide implementation and the effect of the implementation on NOM rate will be measured using data from the Dutch Hip Fracture Audit.

ETHICS AND DISSEMINATION

The study was exempted by the local Medical Research Ethics Committee (MEC-2023-0270, 10 May 2023) and Medical Ethics Committee United (W23.083, 26 April 2023). The study's results will be submitted to an open access international peer-reviewed journal. Its protocols, tools and results will be presented at several national and international academic conferences of relevant orthogeriatric (scientific) associations.

TRIAL REGISTRATION NUMBER

NCT06079905 .

The value of preoperative diagnostic testing and geriatric assessment in frail institutionalized elderly with a hip fracture; a secondary analysis of the FRAIL-HIP study

PURPOSE

The aim of this study was to provide a comprehensive overview of (preoperative and geriatric) diagnostic testing, abnormal diagnostic tests and their subsequent interventions, and clinical relevance in frail older adults with a hip fracture.

METHODS

Data on clinical consultations, radiological, laboratory, and microbiological diagnostics were extracted from the medical files of all patients included in the FRAIL-HIP study (inclusion criteria: hip fracture, > 70 years, living in a nursing home with malnourishment/cachexia and/or impaired mobility and/or severe co-morbidity). Data were evaluated until hospital discharge in nonoperatively treated patients and until surgery in operatively treated patients.

RESULTS

A total of 172 patients (88 nonoperative and 84 operative) were included, of whom 156 (91%) underwent laboratory diagnostics, 126 (73%) chest X-rays, and 23 (13%) CT-scans. In 153/156 (98%) patients at least one abnormal result was found in laboratory diagnostics. In 82/153 (50%) patients this did not result in any additional diagnostics or (pharmacological) intervention. Abnormal test results were mentioned as one of the deciding arguments for operative delay (> 24 h) for 10/84 (12%) patients and as a factor in the decision between nonoperative and operative treatment in 7/172 (4%) patients.

CONCLUSION

A large number and variety of diagnostics were performed in this patient population. Abnormal test results in laboratory diagnostics were found for almost all patients and, in majority, appear to have no direct clinical consequences. To prevent unnecessary diagnostics, prospective research is required to evaluate the clinical consequences and added value of the separate elements of preoperative diagnostic testing and geriatric assessment in frail hip fracture patients.

The Association between Malnutrition and Physical Performance in Older Adults: A Systematic Review and Meta-Analysis of Observational Studies

In recent years the focus of healthcare and nutritional science in older adults has shifted from mortality towards physical performance and quality of life. The aim of this review was to summarize observational studies on physical performance in malnourished (MN) or at risk of malnutrition (RMN) older adults compared with well-nourished (WN) older adults. Eligible studies had to report on nutritional status and objectively measured physical performance in older adults (≥60 y). MN or RMN groups had to be compared with a WN group, measured with a validated nutrition screener. Ovid Medline and Web of Science were searched until 13 November, 2020. Study quality was scored using a modified Newcastle-Ottawa Scale (NOS). Results were analyzed by meta-analysis when possible, or narratively reviewed otherwise. Forty-five studies (16,911 participants in total) were included from studies in outpatient clinics (n = 6), nursing homes (n = 3), community-dwelling older adults (n = 20), hospitalized patients (n = 15), or a combination (n = 1). Studies used 11 different screeners of malnutrition, and 8 types of physical performance measures. Meta-analysis showed that compared with MN, WN groups had better hand grip strength (mean difference [MD] = 4.92 kg; 95% CI: 3.43, 6.41; P < 0.001; n = 23), faster gait speed (MD = 0.16 m/s; 95% CI: 0.05, 0.27; P = 0.0033; n = 7), performed faster on timed-up-and-go (MD = -5.94 s; 95% CI: -8.98, -2.89; P < 0.001; n = 8), and scored 1.2 more short physical performance battery points (95% CI: 1.32, 2.73; P < 0.001; n = 6). Results were less pronounced when compared with RMN. Narratively, all studies showed an association for knee extension strength, 6-min walking test, and multicomponent tests, except for the chair stand test. Study limitations include no studies scoring "good" on NOS, lack of confounder adjustment, and high heterogeneity. Overall, evidence from cross-sectional studies indicate an association between malnutrition and worse physical performance in older adults. This study is registered in PROSPERO as CRD42020192893.

Nonoperative management of hip fractures in very frail elderly patients may lead to a predictable short survival as part of advance care planning

Background and purpose - Surgical treatment is still the mainstay of care even in very frail elderly hip fracture patients. However, one may argue whether surgery is in the best interest of all patients. We elucidated mortality rates of nonoperative management (NOM) of a hip fracture after shared decision-making in a cohort of very frail elderly patients.Patients and methods - Orthogeriatric patients (age > 70 years) admitted with a hip fracture between 2011 and 2019 were included. In the presence of fragility features the motivation for surgery or NOM was supported by advance care planning (ACP) and shared decision-making through geriatric assessment. Mortality rates after NOM were assessed and also presented for the remaining surgical group for reference.Results - In 1,279 out of 3,467 patients, geriatric assessment was indicated and subsequently 1,188 (93%) had surgery versus 91 (7%) NOM. The motivation for NOM was based on patient and family preferences in only 20% of patients, medical grounds in 54%, and a combination of both in 26%. The 30-day and 1-year mortality in the frail NOM group was 87% and 99% respectively, whereas this was 7% and 28% in the surgery group. No statistical comparison between groups was performed due to profound bias by indication.Interpretation - This study provides further insight into the predictable and high short-term mortality after NOM in carefully selected very frail elderly hip fracture patients. This information may help to consider NOM as an alternative treatment option to surgery when no significant gain from surgery is anticipated.

Quetiapine in the elderly with parkinsonism and psychosis

In the present open prospective study the effects of quetiapine were investigated in two elderly patients with parkinsonism and psychosis. Treatment induced a marked antipsychotic effect that coincided with an improvement of general motor functioning. These findings support the idea that quetiapine may be preferentially of use in the elderly with parkinson’s disease and psychotic symptoms.

Assessment and treatment of malnutrition in Dutch geriatric practice: consensus through a modified Delphi study

OBJECTIVE

scientific evidence regarding the optimal management of malnutrition in geriatric patients is scarce. Our aim was to develop a consensus statement for geriatric hospital practice concerning six elements: (i) definition of malnutrition, (ii) screening and assessment, (iii) treatment and monitoring, (iv) roles and responsibilities of involved health care professionals, (v) communication and coordination of care between hospital and community health care professionals, (vi) quality indicators for malnutrition management.

DESIGN

a modified Delphi study.

METHODS

eleven geriatricians with special interest in malnutrition participated. In four rounds the experts rated the relevance of 204 statements, which were based on a literature review, on a five-point Likert scale. From the responses, means and 95% CIs were calculated. Consensus was defined as a lower 95% confidence limit ≥4.0.

RESULTS

the panel reached consensus that malnutrition should be considered a geriatric syndrome. The nutritional status should be assessed using the Mini Nutritional Assessment combined with comprehensive geriatric assessment. Nutritional interventions should be combined with interventions targeting underlying factors. Specific goals for nutritional therapy and ways to achieve them were agreed upon. According to the experts, malnutrition is best managed by a multidisciplinary team for whom roles and responsibilities were specified. At discharge written information about the nutritional problem, treatment plan and goals should be provided to the patient, caregiver and community health care professionals.

CONCLUSION

this study shows that a qualitative study based on a modified Delphi technique can result in national consensus on essential ingredients for a practical malnutrition guideline for geriatric patients.

Group therapy for patients with mild cognitive impairment and their significant others: results of a waiting-list controlled trial

BACKGROUND

Patients with mild cognitive impairment (MCI) have to deal with an uncertain prognosis and also face a multitude of memory-related problems and psychosocial consequences. A newly developed group programme proved to be feasible, however, it needed confirmation by a controlled study.

AIM

This controlled study evaluates this group therapy for MCI patients aimed to help them accept and manage the memory problems and the psychosocial consequences. The programme combines elements from psychoeducation, cognitive rehabilitation and cognitive-behavioural therapy.

PATIENTS AND METHODS

Ninety-three MCI patients received treatment, with 30 patients being first assigned to a waiting list, thus serving as their own control group. Pre- and post-treatment acceptance and helplessness were assessed using subscales of the Illness Cognition Questionnaire, while distress and general well-being were gauged with the Geriatric Depression Scale and subscales of the RAND-36.

RESULTS

Linear mixed model analyses showed that, relative to the controls, acceptance had increased more in the intervention group compared to the waiting-list period (p = 0.034). Distress and general well-being showed no changes. Treatment responders demonstrating a clinically significant effect on acceptance and two of three secondary outcome measures had higher baseline levels of helplessness and fewer self-reported memory complaints in daily life than patients who did not improve.

CONCLUSION

The intervention helped the patients deal better with their uncertain future in that they were overall better able to accept their condition, with especially the female patients showing a decrease in helplessness cognitions, although the effects were relatively small.

[Hyponatraemia during the use of selective serotonin re-uptake inhibitors (SSRIs): reports from 1992-2002]

OBJECTIVE

To describe the reports of serotonin re-uptake inhibitor (SSRI)-induced hyponatraemia that were sent to The Netherlands Pharmacovigilance Centre Lareb and the Inspectorate for Health Care.

DESIGN

Descriptive study.

METHOD

Reports of SSRI-induced hyponatraemia received by Lareb and the Inspectorate for Health Care during the period 1 January 1992 to 1 July 2002 were described on the basis of symptoms, co-medication and comorbidity. RESULTS; A total of 42 cases were reported, 38 (90%) of which concerned women and 21 (50%) of which concerned the concomitant use of SSRIs and diuretics. The mean age was 74 years (range: 30-91). The mean serum sodium concentration was 115 mmol/l (range: 97-132). The most important symptoms were reduced consciousness, confusion, falls, nausea and vomiting. 3 patients (7%) died in the period of the reported adverse drug reaction and 27 patients (64%) were hospitalised, of which 4 (10%) to the intensive care unit.

CONCLUSION

These reports of suspected SSRI-induced hyponatraemia were attended with significant morbidity and substantial mortality. The considerable morbidity and substantial mortality in combination with the increasing use of SSRIs necessitates a clarification of the actual incidence and severity of SSRI-induced hyponatraemia.