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

Orem's Self-Care Model of Nursing Care: A Retrospective Study with Elders After Hip Arthroplasty

This retrospective study investigates the effectiveness of a nursing intervention based on Orem's self-care model of nursing with elderly patients with femoral head necrosis who underwent total hip arthroplasty. Postoperative outcomes in the intervention and control groups were assessed by the visual analog scale (VAS), Barthel index, and Harris Hip Score (HHS). Participants in the intervention group had significantly better outcomes in terms of VAS, Barthel index, and HHS. The occurrence of pneumonia was significantly different between the groups. Those who underwent Orem's self-care model of nursing intervention were highly satisfied with their status postoperatively compared with the control group.

Combined Systemic Immune-inflammatory Index (SII) and Geriatric Nutritional Risk Index (GNRI) predict survival in elderly patients with hip fractures: a retrospective study

PURPOSE

The Systemic Immune-inflammatory Index (SII) and Geriatric Nutritional Risk Index (GNRI) have undergone comprehensive examination and validation in forecasting the outcomes of diverse medical conditions. Nevertheless, the correlation between the combined use of GNRI and SII metrics and hip fractures has yet to be elucidated. This study aimed to determine whether the amalgamation of SII and GNRI scores constitutes an independent prognostic factor for elderly patients with hip fractures.

METHODS

We conducted a retrospective analysis of elderly patients admitted to our facility with hip fractures, encompassing both femoral neck and intertrochanteric fractures. Demographic information, experimental parameters, and postoperative complications were systematically recorded. The Geriatric Nutritional Risk Index (GNRI) and Systemic Immunoinflammatory Index (SII) were meticulously computed. Receiver operating characteristic (ROC) curves were generated, and optimal cutoff values for each parameter were determined. Subsequently, a multivariate Cox regression analysis was employed to assess the predictive utility of the SII-GNRI score in relation to 1-year postoperative mortality among elderly patients with hip fractures.

RESULTS

In a study involving 597 patients, 90 of whom experienced mortality within 1 year, it was observed that the SII-GNRI score in the group of patients who passed away was significantly higher compared to the group that survived. Following a multifactorial adjustment, it was established that a high SII-GNRI score served as an independent predictor of 1-year all-cause mortality in older patients with hip fractures. In addition to the SII-GNRI score, factors such as length of hospital stay, CCI > 2, and blood transfusion were also identified as independent risk factors for survival. Notably, the incidence of postoperative complications in patients with high SII-GNRI scores was significantly greater than in patients with low scores.

CONCLUSION

The SII-GNRI score proves valuable in predicting the 1-year survival rate for elderly patients with hip fractures who have undergone surgery.

Fruit and Vegetable Consumption and the Risk of Bone Fracture: A Grading of Recommendations, Assessment, Development, and Evaluations (GRADE)-Assessed Systematic Review and Dose-Response Meta-Analysis

Researchers have examined the link between consuming fruit and vegetables and the incidence of fractures for many years. Nevertheless, their findings have been unclear. Furthermore, the dose-dependent relationship has not been examined, and the level of certainty in the evidence was not evaluated. We carried out a dose-dependent meta-analysis examining the relation between fruit and vegetables intake and fracture incidence. PubMed, Web of Sciences, and Scopus were searched until April 2023 for cohort studies evaluating the relation between fruit and vegetables and fracture incidence. Summary relative risks (RRs) were computed from complied data by applying random effects analysis. To examine the level of evidence, we utilized the approach called the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Ten cohort studies comprising 511,716 individuals were entered. There was a nonsignificant relation between fruit and vegetables, as well as only fruit intake and any fracture risk. In contrast, high versus low analysis presented that vegetables consumption was linked to a 16% decrease in any type of fracture incidence (RR 0.84; 95% confidence interval [CI], 0.75 to 0.95; I 2 = 83.1%; n = 6). Also, per one serving/day (200 g/day) increments in vegetables consumption, there was a 14% decline in the fracture risk (RR 0.86; 95% CI, 0.77 to 0.97; I 2 = 84.7%; n = 5; GRADE = moderate). With moderate certainty, a greater consumption of only vegetables, but not total fruit and vegetables or only fruit, might reduce the risk of fracture. These associations were also evident in dose-response analysis. Large intervention trials are demanded to approve our findings. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

A machine learning-based scoring system and ten factors associated with hip fracture occurrence in the elderly

Hip fractures are fragility fractures frequently seen in persons over 80-years-old. Although various factors, including decreased bone mineral density and a history of falls, are reported as hip fracture risks, few large-scale studies have confirmed their relevance to individuals older than 80, and tools to assess contributions of various risks to fracture development and the degree of risk are lacking. We recruited 1395 fresh hip fracture patients and 1075 controls without hip fractures and comprehensively evaluated various reported risk factors and their association with hip fracture development. We initially constructed a predictive model using Extreme Gradient Boosting (XGBoost), a machine learning algorithm, incorporating all 40 variables and evaluated the model's performance using the area under the receiver operating characteristic curve (AUC), yielding a value of 0.87. We also employed SHapley Additive exPlanation (SHAP) values to evaluate each feature importance and ranked the top 20. We then used a stepwise selection method to determine key factors sequentially until the AUC reached a plateau nearly equal to that of all variables and identified the top 10 sufficient to evaluate hip fracture risk. For each, we determined the cutoff value for hip fracture occurrence and calculated scores of each variable based on the respective feature importance. Individual scores were: serum 25(OH)D levels (<10 ng/ml, score 7), femoral neck T-score (<-3, score 5), Barthel index score (<100, score 3), maximal handgrip strength (<18 kg, score 3), GLFS-25 score (≥24, score 2), number of falls in previous 12 months (≥3, score 2), serum IGF-1 levels (<50 ng/ml, score 2), cups of tea/day (≥5, score -2), use of anti-osteoporosis drugs (yes, score -2), and BMI (<18.5 kg/m2, score 1). Using these scores, we performed receiver operating characteristic (ROC) analysis and the resultant optimal cutoff value was 7, with a specificity of 0.78, sensitivity of 0.75, and AUC of 0.85. These ten factors and the scoring system may represent tools useful to predict hip fracture.

Rehabilitation after Hip Fracture Surgery Improves Physical and Cognitive Function in Patients with or Without Sarcopenia

Introduction

Sarcopenia is a prevalent risk factor for falls and fractures, and it affects the physical function and mortality of older people. The present study was performed to assess the prevalence of sarcopenia in patients who underwent rehabilitation after hip fracture surgery and to examine the association of sarcopenia with physical and cognitive function outcomes.

Methods

This case-control study involved 132 patients who were admitted to a convalescent rehabilitation ward at a single hospital after surgical treatment of hip fractures from April 2018 to March 2020. The skeletal muscle mass index was examined using whole-body dual-energy X-ray absorptiometry. The Asian Working Group for Sarcopenia 2019 diagnostic criteria were applied on admission. We compared the walking speed, Mini-Mental State Examination (MMSE) score, and Functional Independence Measure (FIM) score between the sarcopenia group and non-sarcopenia group on admission and on discharge.

Results

The prevalence of sarcopenia was 59.8%. In the non-sarcopenia group, the walking speed, MMSE score, FIM total score, FIM motor score, and FIM cognitive score were significantly lower on admission than those on discharge (P < .05). In the sarcopenia group, the walking speed, MMSE score, FIM total score, and FIM motor score were significantly lower on admission than those on discharge (P < .05); there was no significant difference in the FIM cognitive score between admission and discharge. On both admission and discharge, the MMSE score, FIM total score, FIM motor score, and FIM cognitive score were significantly better in the non-sarcopenia group than those in the sarcopenia group.

Conclusions

After postoperative rehabilitation of hip fractures in patients with and without sarcopenia, physical and cognitive function outcomes on discharge were significantly better than those on admission. Patients with sarcopenia had significantly worse physical and cognitive function outcomes than patients without sarcopenia both on admission and on discharge.

Geriatric nutritional risk index as the prognostic factor in older patients with fragility hip fractures

This study investigated the long-term survival and incidence of secondary fractures after fragility hip fractures. The 5-year survival rate was 62%, and the mortality risk was seen in patients with GNRI < 92. The 5-year incidence of secondary fracture was 22%, which was significantly higher in patients with a BMI < 20.

BACKGROUND

Malnutrition negatively influences the postoperative survival of patients with fragility hip fractures (FHFs); however, little is known about their association over the long term.

OBJECTIVE

This study evaluated the ability of the geriatric nutritional risk index (GNRI) as a risk factor for long-term mortality after FHFs.

METHODS

This study included 623 Japanese patients with FHFs over the age of 60 years. We prospectively collected data on admission and during hospitalization and assessed the patients' conditions after discharge through a questionnaire. We examined the long-term mortality and the incidence of secondary FHFs and assessed the prognostic factors.

RESULTS

The mean observation period was 4.0 years (range 0-7 years). The average age at the time of admission was 82 years (range 60-101 years). The overall survival after FHFs (1 year, 91%; 5 years, 62%) and the incidence of secondary FHFs were high (1 year, 4%; 5 years, 22%). The multivariate Cox proportional hazard analysis revealed the risk factors for mortality as older age (hazard ratio [HR] 1.04), male sex (HR 1.96), lower GNRI score (HR 0.96), comorbidities (malignancy, HR 2.51; ischemic heart disease, HR 2.24; revised Hasegawa dementia scale ≤ 20, HR 1.64), no use of active vitamin D3 on admission (HR 0.46), and a lower Barthel index (BI) (on admission, HR 1.00; at discharge, HR 0.99). The GNRI scores were divided into four risk categories: major risk (GNRI, < 82), moderate risk (82-91), low risk (92-98), and no risk (> 98). Patients at major and moderate risks of GNRI had a significantly lower overall survival rate (p < 0.001). Lower body mass index (BMI) was also identified as a prognostic factor for secondary FHFs (HR 0.88 [p = 0.004]).

CONCLUSIONS

We showed that older age, male sex, a lower GNRI score, comorbidities, and a lower BI are risk factors for mortality following FHFs. GNRI is a novel and simple predictor of long-term survival after FHFs.

Malnutrition is associated with six-month mortality in older patients admitted to the emergency department with hip fracture

Background

Hip fractures in older people are a common health problem often associated with malnutrition that might affect outcomes. Screening for malnutrition is not a routine examination in emergency departments (ED). This analysis of the EMAAge study, a prospective, multicenter cohort study, aimed to evaluate the nutritional status of older patients (≥ 50 years) with hip fracture, factors associated with malnutrition risk, and the association between malnutrition and the six-months mortality.

Methods

Risk of malnutrition was evaluated using the Short Nutritional Assessment Questionnaire. Clinical data as well as data on depression and physical activity were determined. Mortality was captured for the first six months after the event. To assess factors associated with malnutrition risk we used a binary logistic regression. A Cox proportional hazards model was used to assess the association of malnutrition risk with six-month survival adjusted for other relevant risk factors.

Results

The sample consisted of N = 318 hip fracture patients aged 50 to 98 (68% women). The prevalence of malnutrition risk was 25.3% (n = 76) at the time of injury. There were no differences in triage categories or routine parameters measured in the ED that could point to malnutrition. 89% of the patients (n = 267) survived for six months. The mean survival time was longer in those without malnutrition risk (171.9 (167.1-176.9) days vs. 153.1 (140.0-166.2) days). The Kaplan Meier curves and the unadjusted Cox regression (Hazard Ratio (HR) 3.08 (1.61-5.91)) showed differences between patients with and patients without malnutrition risk. In the adjusted Cox regression model, risk of death was associated with malnutrition risk (HR 2.61, 1.34-5.06), older age (70-76 years: HR 2.5 (0.52-11.99); 77-82 years: HR 4.25 (1.15-15.62); 83-99 years: HR 3.82 (1.05-13.88)) and a high burden of comorbidities (Charlson Comorbidity Index ≥3: HR 5.4 (1.53-19.12)).

Conclusion

Risk of malnutrition was associated with higher mortality after hip fracture. ED parameters did not differentiate between patients with nutritional deficiencies and those without. Therefore, it is particularly important to pay attention to malnutrition in EDs to detect patients at risk of adverse outcomes and to initiate early interventions.

What is the impact of daily oral supplementation of vitamin D3 (cholecalciferol) plus calcium on the incidence of hip fracture in older people? A systematic review and meta-analysis

INTRODUCTION

Hip fractures have a huge impact in reducing the quality of life and increasing mortality. This review aims to assess the impact of daily oral supplementation of vitamin D3 plus calcium on the incidence of hip fracture in people over 65 years.

METHODS

PRISMA guidelines were followed and RCTs that evaluated the effectiveness of daily oral supplementation of vitamin D3 plus calcium in preventing hip fracture in adults over 65 years were included in the study. The databases such as Cochrane Library, Embase, Medline, PubMed, CINAHL, Web of Science and Scopus were searched from October 2019- January 2020.The Cochrane risk of bias tool was used to check the quality of the included studies. A meta-analysis with fixed effect model using Review Manager (Revman 5.3) was used to analyse the data.

RESULTS

The meta-analysis of seven RCTs on vitamin D3 plus calcium supplementation and hip fracture (n = 12,620) identified odds ratio (OR) of 0.75; 95% Confidence interval (CI): 0.64, 0.87; p = .0003. Daily oral supplementation of 800 IU of Vitamin D3 plus 1200 mg of calcium was found more effective (n = 5676 participants; OR = 0.69; 95% CI: 0.58, 0.82; p < .0001) than daily oral supplementation of 800 IU of Vitamin D3 plus 1000 mg of calcium (n = 6555,OR = 1.08; 95% CI: 0.74, 1.56; p = .70) in reducing hip fracture. A meta-analysis of the seven RCTs to identify the incidence of non-vertebral fracture gave the OR of 0.80; 95% CI: 0.72, 0.89; p < .0001. A meta-analysis of three RCTs on femoral neck bone mineral density (BMD) (n = 483) gave a mean difference of 1.21; 95% CI: -0.79, 3.20; p = .24.

CONCLUSION

Daily oral supplementation 800 IU of vitamin D3 plus 1200 mg of calcium reduces hip fracture and non-vertebral fracture in older people. Administering vitamin D3 and calcium supplements had no effect in increasing the femoral neck BMD.

IMPLICATIONS FOR PRACTICE

Even though it is evident from the review that optimal daily intake of vitamin D3 plus calcium supplementation help in the prevention of fracture, it is only one essential element in fracture prevention. Also, people who are on dietary supplements should be compliant with same for better result. Efforts to prevent bone loss and osteoporosis should begin from an early age. It includes maintaining a healthy lifestyle, optimal intake of calcium and vitamin D3, proper nutrition, adequate exposure to sunlight, exercise etc. Proper education on healthy lifestyle, avoiding risk factors like smoking, caffeine, alcohol and awareness of bone health should continue throughout life with emphasis during menopause when increased bone loss is expected.

Comprehensive Geriatric Assessment in the Emergency Department for Identifying Elderly Individuals at Risk of Hip Fracture

BACKGROUND

Hip fracture (HF) is a major challenge for healthcare systems in terms of increased costs and lengths of stay, and it has been estimated that by 2050, half of the projected 6.26 million global HFs will occur in Asia. Owing to the high morbidity and mortality associated with HF in elderly individuals, it is crucial to recognize at-risk elderly patients in the ED so that special precautions and preventive measures can be taken. While comprehensive geriatric assessment (CGA) has been shown to improve outcomes and prevent secondary fractures in elderly individuals with HF in outpatient settings, there is a lack of data to identify elderly Asian patients who are at risk of HF via using CGA in the emergency department (ED). The aim of this study is to identify the characteristics of elderly Asian patients in the ED who have an increased risk of HF via CGA.

METHODS

A case-control study was conducted in the ED at Taipei Veterans General Hospital, a medical center located in Taipei, Taiwan, from October 2018 to December 2019. Patients > 75 years old with and without HF were compared using data obtained from CGAs conducted by trained nurses.

RESULTS

A total of 85 HF patients (cases) and 680 non-HF patients were enrolled, among whom 340 non-HF control individuals (controls) were selected by simple random sampling. HF occurred more frequently in women and in patients with depressive symptoms. An association between decreased handgrip strength and HF risk, especially in men, was also identified ( p = 0.011). The variables independently associated with the presence of HF in the multivariate analysis were female sex (odds ratio [OR]: 2.229; 95% confidence interval [CI]: 1.332-3.728) and decreased handgrip strength (OR: 2.462; 95% CI: 1.155-5.247).

CONCLUSIONS

By performing CGAs in the ED, we found that female sex and decreased handgrip strength were associated with HF risk. Therefore, we propose that targeted assessment of handgrip strength in female patients aged > 75 years in the ED may identify those at greatest risk of HF, resulting in improved emergency care for geriatric patients.

Rehabilitation interventions for persons with hip fracture and cognitive impairment: A scoping review

Background

Hip fractures are common fall-related injuries, with rehabilitation and recovery often complicated by cognitive impairment. Understanding what interventions exist, and in what settings, for people with hip fracture and co-occurring cognitive impairment is important in order to provide more evidence on rehabilitation and related outcomes for this population.

Objective

To examine the extent, nature, and range of literature on rehabilitation interventions for adults with hip fracture and cognitive impairment.

Methods

Articles were required to: include an adult population with hip fracture and cognitive impairment, include a rehabilitation intervention, and be published between January 1, 2000 and November 19, 2021. Articles were excluded if they were opinion pieces, study protocols, conference abstracts, or if they did not describe the rehabilitation intervention. Relevant articles were searched on the following electronic databases: MEDLINE, EMBASE, CINAHL Plus, APA PsycINFO, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database. All articles were double-screened by two reviewers and disagreements were resolved through consensus. Data were extracted and synthesized using descriptive approaches.

Results

Seventeen articles were included in this scoping review. We identified a variety of interventions targeting this population; about half were specific to physical rehabilitation, with the other half incorporating components that addressed multiple aspects of the care journey. Interventions had varying outcomes and no studies qualitatively explored patient or family experiences. All intervations were initiated in hospital, with less than half including cross-sectoral components. About half of the articles described modifying or tailoring the intervention to the participants’ needs, but there was limited information on how to adapt rehabilitation interventions for individuals with cognitive impairment.

Conclusions

More work is need to better understand patient, family, and provider experiences with rehabilitation interventions, how to tailor interventions for those with cognitive impairment, and how to successfully implement sustainable interventions across sectors.

Proximal femoral fracture outcomes in inpatients and community patients: A comparative study

Objectives:

7% of proximal femoral fractures occur in patients admitted to hospital for unrelated medical and surgical presentations. This comparative study will assess morbidity and mortality in patients sustaining proximal femoral fractures both as inpatients and in the community.

Methods:

Retrospective review of patients admitted to a regional specialist hip unit with fracture of the proximal femur sustained both from the community and other inpatient settings. Patient demographics, risk factors and outcomes were recorded and analysed – with focus on 30-day and 1-year mortality.

Results:

3445 patients were admitted over a 10-year period, 292 of which sustained proximal femoral fractures as an inpatient. 30-day and 1-year mortality was 23.7% and 47.9% respectively in the inpatient group, compared to 6.9% and 22.4% respectively in the community group. Mean time from presentation to operating room was 27.8 hours for the inpatient group, compared to 25.2 hours for the community group.

Conclusion:

Inpatients who sustain a proximal femoral fracture have significantly higher 30-day and 1-year mortality rates when compared to patients in the community sustaining the same injury. There is also a noted delay to theatre in this patient group.

Fracture, nonunion and postoperative infection risk in the smoking orthopaedic patient: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to analyse negative effects of smoking in orthopaedic and trauma patients.

A PubMed search was carried out for studies published until July 2020 regarding effects of smoking on fracture risk, nonunion, infection after orthopaedic surgery, and persisting nonunion after scaphoid nonunion surgery. Random effects models calculated for outcome parameters, and relative risks (RR) with 95% confidence intervals are provided. No adjustments for covariates were made. Heterogeneity was assessed with Higgins’ I2, publication bias with Harbord’s p (Hp), sensitivity analysis performed on funnel plots and quality of studies was analysed using the Newcastle-Ottawa Scale.

Of 3362 retrieved entries, 69 were included in the final analysis. Unadjusted RR for smokers to develop vertebral (six studies, seven entries; RR: 1.61; p = 0.008; I2 = 89.4%), hip (11 studies, 15 entries; RR: 1.28; p = 0.007; I2 = 84.1%), and other fractures (eight studies, 10 entries; RR: 1.75; p = 0.019; I2 = 89.3%) was significantly higher. Postoperative infection risk was generally higher for smokers (21 studies; RR: 2.20; p < 0.001; I2 = 58.9%), and remained upon subgroup analysis for elective spinal (two studies; RR: 4.38; p < 0.001; I2 = 0.0%) and fracture surgery (19 studies; RR: 2.10; p < 0.001; I2 = 58.5%). Nonunion risk after orthopaedic (eight studies; RR: 2.15; p < 0.001; I2 = 35.9%) and fracture surgery (11 studies; RR: 1.85; p < 0.001; I2 = 39.9%) was significantly higher for smokers, as was persisting nonunion risk after surgery for scaphoid nonunion (five studies; RR: 3.52; p < 0.001; I2 = 0.0%). Sensitivity analysis for each model reduced heterogeneity whilst maintaining significance (all I2 < 20.0%).

Smoking has a deleterious impact on fracture incidence, and (subsequent) development of nonunions and postoperative infections.

Cite this article: EFORT Open Rev 2021;6:1006-1019. DOI: 10.1302/2058-5241.6.210058

Loss of skeletal muscle mass can be predicted by sarcopenia and reflects poor functional recovery at one year after surgery for geriatric hip fractures

INTRODUCTION

Hip fractures in the elderly impact negatively on functional dependence, and carry great social costs and morbidity. We assessed the decline in muscle mass and functional outcomes following hip fracture surgery .

MATERIAL AND METHODS

Thirty patients with a hip fracture (mean age: 80.8 years) were assessed using dual-energy X-ray absorptiometry and reassessed for changes in body composition 1 year after hip surgery. Baseline demographic data, sarcopenia, and bone mineral density were recorded. Body mass index (BMI), handgrip strength, appendicular skeletal muscle mass (ASM), total body fat percentage, and responses to questionnaires measuring quality of life and activities of daily living (ADL) before injury and 1 year after hip surgery were analyzed to identify changes. Associations with changes in ADL or quality of life were analyzed with time-variant independent variables.

RESULTS

Significant losses in ADL were identified at the 1-year follow-up, at which time only 43% of patients had regained their preinjury ADL status. Additionally, the participants had lost an average of 4.63% of ASM. ASM loss was significantly higher in patients with baseline sarcopenia than in those without (mean loss: 9.18% and 1.15%, respectively). When confounders were controlled for, a greater loss of ASM and handgrip strength and larger increase in BMI were associated with greater decrease in ADL 1 year after hip surgery.

CONCLUSION

Geriatric hip fracture patients may experience a significant loss of muscle mass, associated with impaired functional recovery 1 year after hip surgery, highlighting a potential treatment target of maintaining muscle mass to improve prognosis in these patients.

Reduced Risk of Reoperation Using Intramedullary Nailing with Femoral Neck Protection in Low-Energy Femoral Shaft Fractures

BACKGROUND

In Sweden, approximately 1 in 4 women who are ≥50 years of age will sustain a hip fracture. Patients treated for a femoral shaft fracture are likely to have an even higher risk. We hypothesized that intramedullary nails protecting the femoral neck reduce the risk of subsequent hip fracture and allow the patient to avoid a challenging reoperation.

METHODS

Between 2008 and 2010, 5,475 fractures of the femoral shaft, in patients who were ≥55 years of age, were registered in a national registry in Sweden. Of these patients, 897 fulfilled the inclusion criteria. We used radiographs and register data to identify the reasons for and the types of reoperation that occurred between the index surgical procedure and December 31, 2014. The categories of implants were determined through a review of radiographs as intramedullary nails with and without femoral neck protection. Reoperations related to peri-implant fractures (including hip fractures) were analyzed as a subgroup of all major reoperations. Multivariable-adjusted, cause-specific hazard ratios (HRs) were calculated to compare the risk of reoperation between cases with nails with and without femoral neck protection.

RESULTS

Among the 897 patients, a total of 82 reoperations were performed. In 640 patients who were treated with intramedullary nails with femoral neck protection, there were 7 peri-implant fractures (no hip fractures) and 27 major reoperations. Among the 257 patients who were treated with intramedullary nails without femoral neck protection, 14 peri-implant hip fractures and 24 major reoperations were identified. Patients who received nails with femoral neck protection had a lower hazard for any peri-implant fracture (multivariable-adjusted cause-specific HR, 0.19 [95% confidence interval (CI), 0.07 to 0.5]) and major reoperation (multivariable-adjusted cause-specific HR, 0.51 [95% CI, 0.28 to 0.92]).

CONCLUSIONS

Intramedullary nails with femoral neck protection in the treatment of low-energy femoral shaft fractures prevent secondary hip fractures and decrease the overall risk of reoperation for 4 to 6 years postoperatively.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Differential Impact of Cigarette Smoking on Fracture Risks in Subjective Cognitive Decline and Dementia: A Nationwide Longitudinal Study

OBJECTIVE

We aimed to explore the differential impact of cigarette smoking on fracture risks in SCD and dementia.

METHODS

A nationwide population-based cohort study design was used. Out of all the people aged 66 (n=1,555,103) who went through the National Screening Program from 2009-2014, 968,240 participants with eligible data were included in the study. Time-to-event was calculated as the duration between the NSPTA and fracture incidence. Cox proportional-hazard regression analyses were conducted to evaluate the risk of fractures.

RESULTS

Increased risk of all [adjusted hazard ratio (aHR)=1.184; 95% confidence interval (CI)=1.184, 1.093-1.283], hip (aHR=1.518; 95% CI=1.168-4.972), vertebral (aHR=1.235; 95% CI=1.101-1.386) fractures were increased in current smokers with more than 20 or more pack years (≥20 py) of SCD group, after adjusting for all relevant confounding factors. In dementia group, however, current smokers ≥20 py were at reduced risk of hip fractures (aHR=0.249; 95% CI=0.089-0.97).

CONCLUSION

There was a disparate influence of cigarette smoking on the fracture risks in SCD and dementia group. Further studies are warranted to explicate this phenomenon, and personalized preventive measures according to one's cognitive status are imperative, since risk factors of fractures can exert disparate influence on patients at different stage of cognitive trajectory.

Effects of Orem's Self-Care Model on the Life Quality of Elderly Patients with Hip Fractures

Background

Hip fractures of elderly patients are a public health problem worldwide, mostly lying in bed for a long time; therefore, the importance of life quality in such patients is an issue beyond question. Orem's self-care model is a nursing pattern which is introduced with the purpose of improving the self-care ability of individuals, especially the patients suffering from diseases with limits on activity.

Objective

The aim of this study was to determine the effects of Orem's self-care program on life quality of senile patients with hip fractures.

Methods

A randomized clinical trial study was conducted on 130 eligible old patients suffering from hip fractures who were selected using easy sampling methods and allocated randomly into two groups of experiment and control. The data were collected through validated questionnaires including visual analogue scale (VAS) and Barthel index for them. The experiment group was treated according to Orem's self-care model, and the control group was treated on the basis of the traditional care model. The data of complications including pneumonia, deep venous thrombosis, urinary infection, wound problem, and bedsore were also gathered.

Results

As revealed, mean scores of VAS and Barthel index one week after operation in the experiment group were significantly different from the control one (P < 0.05, P ≤ 0.001). The changes of VAS and Barthel index six weeks postoperatively of the two groups were also statistically significant (P < 0.05, P ≤ 0.001). Compared with the control group, the difference of complications reduced significantly in the experiment group (P < 0.05). Accordingly, educational intervention according to Orem's self-care model seemed to be effective in promoting self-care ability for these senile patients.

Conclusions

According to the obtained results, a self-care program based on Orem's model for elderly patients with hip fractures can improve life quality and reduce perioperative complications significantly. Therefore, it is recommended that this nursing program should be taken into account as a part of treatment measures for these patients.

Intensive Care Unit Resource Utilization After Hip Fracture Surgery in Elderly Patients: Risk Factor Identification and Risk Stratification

The objective of this study was to develop a risk stratification index (RSI) system to guide intensive care unit (ICU) resource use for elderly patients after hip fracture surgery. The authors' first study cohort consisted of 302 elderly patients with hip fractures who had surgical treatment at their hospital. The authors conducted multivariate logistic regression analysis to investigate relevant risk factors for ICU resource utilization postoperatively. An RSI system was developed based on the significant risk factors from regression analysis. A second study cohort consisted of 205 elderly patients, among whom the authors applied the RSI system to guide ICU resource assignment. Among the first cohort of 302 hip fracture patients, 89 were transferred to ICU postoperatively, of whom 81 were planned to be transferred to ICU and 8 were not. Multivariate stepwise regression analysis revealed that age (≥80 years), preoperative pulmonary disease, perioperative anemia (hemoglobin <8 g/dL), and perioperative lactic acid level (>2 mmol/L) were independent risk factors for postoperative ICU management. The authors then constructed a weighted RSI with these risk factors. In addition, they manually added American Society of Anesthesiologists classification (III/IV) and types of anesthesia as additional risk factors based on their clinical experience. It was determined that an RSI score greater than 4 required postoperative ICU care. The RSI system was then prospectively applied to an independent cohort of 205 elderly surgical patients with hip fractures, among whom only 40 required ICU care. More importantly, there were no later transfers from the general ward to ICU after the application of RSI. The RSI system is effective for guiding postoperative ICU transfer without compromising patient care and minimizes unexpected transfers from the general ward to the postoperative ICU. [Orthopedics. 2020;43(3):e159-e165.].

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.

The high prevalence of sarcopenia and its associated outcomes following hip surgery in Taiwanese geriatric patients with a hip fracture

BACKGROUND

Sarcopenia, which is a common risk factor for falls and fractures, affects the functional outcome and mortality in geriatric populations. However, the prevalence of sarcopenia among geriatric Taiwanese patients with a hip fracture is unknown, nor is the effect of sarcopenia on the outcome of hip surgery.

METHODS

From December 2017 to February 2019, geriatric patients who underwent surgery for a hip fracture were prospectively enrolled. Basic demographic data, responses to questionnaires for dementia screening and quality of life (QoL) and daily living activities (ADL) before the injury were analyzed to identify any association with sarcopenia. The QoL and ADL were monitored at six months after the operation to determine the difference between hip fracture patients with or without sarcopenia.

RESULTS

Of 139 hip fracture patients, 70 (50.36%) were diagnosed with sarcopenia. Accounting for all confounding factors in the multivariate logistic regression, lower body mass index (BMI), male gender and a weaker handgrip are the risk factors that are most strongly associated with a diagnosis of sarcopenia in geriatric patients with a hip fracture. Hip fracture patients with sarcopenia also have poor ADL and a lower QoL than patients without sarcopenia before the injury and six months after the operation.

CONCLUSION

A high prevalence of sarcopenia among geriatric hip fracture patients is associated with a poor mid-term outcome following hip surgery. Clinicians must recognize the risk of sarcopenia, especially for male hip fracture patients with a lower BMI and a weaker handgrip.

Unstable Intertrochanteric Hip Repair With Short Cephalomedullary Nail

INTRODUCTION

Approximately half of all hip fractures are intertrochanteric femur fractures. This video demonstrates the technique of repair of an unstable intertrochanteric hip fracture using a cephalomedullary device.

METHODS

The patient is an 88-year-old woman presenting with an intertrochanteric hip fracture secondary to a low-energy injury. The patient was indicated for surgery due to the unstable nature of the fracture.

RESULTS

This video demonstrates the cephalomedullary nailing technique for the repair of an unstable intertrochanteric hip fracture after a low-energy injury. Anatomical reduction and stable fixation were obtained with this technique.

CONCLUSIONS

The case demonstrates a cephalomedullary technique of intertrochanteric fracture fixation using a cephalomedullary nail. The technique has significant advantages including minimal intraoperative blood loss, shorter operative times, potential for more biological healing with a load-sharing device, and low infection rate.

Perfil psicosocial de adultos mayores mexicanos hospitalizados por fractura de cadera secundaria a caída

Objetivo Definir el perfil psicosocial de adultos mayores de 65 años hospitalizados por fractura de cadera secundaria a caída.Métodos Se realizó un estudio de prevalencia, descriptivo, cuantitativo; reclutándose 55 sujetos mayores de 65 años hospitalizados de marzo 2017 a febrero 2018. Los datos fueron recolectados a través de un cuestionario socioeconómico y el índice de Barthel para Actividades de la Vida Diaria.Resultados El promedio de edad fue de 80,8 años, de los cuales 76,36% eran mujeres. El 58,2% de pacientes eran viudos; 61,8% habían cursado solo la educación primaria y 29,1% no contaban con estudios. El 69,1% de la muestra se encontraba desempleada y 56,36% subsistía con un ingreso mensual menor a US$101,77, dependiendo de programas de apoyo social gubernamental como fuente de ingreso. Los hallazgos en las condiciones de vivienda fueron homogéneos entre la población estudiada. El 67.3% de la muestra presentaba un grado variable de dependencia en las actividades cotidianas.Discusión Los resultados permiten generar la hipótesis de que el riesgo de complicaciones médicas y socioeconómicas durante el periodo de recuperación puede ser mayor en nuestra población debido a las condiciones premórbidas descritas.

Association Between Antidepressant Drug Use and Hip Fracture in Older People Before and After Treatment Initiation

IMPORTANCE

Treatment with antidepressants has been associated with hip fracture. This association could restrict the treatment options, especially in older patients.

OBJECTIVE

To investigate the association between antidepressant drug treatment and hip fracture starting 1 year before the initiation of treatment.

DESIGN, SETTING, AND PARTICIPANTS

In this nationwide cohort study, 204 072 individuals in the Prescribed Drugs Register of Sweden's National Board of Health and Welfare aged 65 years or older who had a prescription of antidepressants filled between July 1, 2006, and December 31, 2011, were matched by birth year and sex to 1 control participant who was not prescribed antidepressants (for a total of 408 144 people in the register). Outcome data were collected from 1 year before to 1 year after the index date (date of prescription being filled). Data analysis was performed from July 1, 2005, to December 31, 2012.

EXPOSURES

First filled prescription of an antidepressant drug.

MAIN OUTCOMES AND MEASURES

Incident hip fractures occurring in the year before and year after initiation of antidepressant therapy were registered. Associations were investigated using multivariable conditional logistic regression models and flexible parametric models.

RESULTS

Of the 408 144 people in the register who were included in the study, 257 486 (63.1%) were women, with a mean (SD) age of 80.1 (7.2) years. Antidepressant users sustained more than twice as many hip fractures than did nonusers in the year before and year after the initiation of therapy (2.8% vs 1.1% and 3.5% vs 1.3%, respectively, per actual incidence figures). In adjusted analyses, the odds ratios were highest for the associations between antidepressant use and hip fracture 16 to 30 days before the prescription was filled (odds ratio, 5.76; 95% CI, 4.73-7.01). In all separate analyses of age groups, of men and women, and of individual antidepressants, the highest odds ratios were seen 16 to 30 days before initiation of treatment, and no clear dose-response relationship was seen.

CONCLUSIONS AND RELEVANCE

The present study found an association between antidepressant drug use and hip fracture before and after the initiation of therapy. This finding raises questions about the association that should be further investigated in treatment studies.

The Effects of Exercise on Falls in Older People With Dementia Living in Nursing Homes: A Randomized Controlled Trial

OBJECTIVES

To investigate exercise effects on falls in people with dementia living in nursing homes, and whether effects were dependent on sex, dementia type, or improvement in balance. A further aim was to describe the occurrence of fall-related injuries.

DESIGN

A cluster-randomized controlled trial.

SETTING AND PARTICIPANTS

The Umeå Dementia and Exercise study was set in 16 nursing homes in Umeå, Sweden and included 141 women and 45 men, a mean age of 85 years, and with a mean Mini-Mental State Examination score of 15.

INTERVENTION

Participants were randomized to the high-intensity functional exercise program or a seated attention control activity; each conducted 2-3 times per week for 4 months.

MEASURES

Falls and fall-related injuries were followed for 12 months (after intervention completion) by blinded review of medical records. Injuries were classified according to severity.

RESULTS

During follow-up, 118 (67%) of the participants fell 473 times in total. At the interim 6-month follow-up, the incidence rate was 2.7 and 2.8 falls per person-year in exercise and control group, respectively, and at 12-month follow-up 3.0 and 3.2 falls per person-year, respectively. Negative binomial regression analyses indicated no difference in fall rate between groups at 6 or 12 months (incidence rate ratio 0.9, 95% confidence interval (CI) 0.5-1.7, P = .838 and incidence rate ratio 0.9, 95% CI 0.5-1.6, P = .782, respectively). No differences in exercise effects were found according to sex, dementia type, or improvement in balance. Participants in the exercise group were less likely to sustain moderate/serious fall-related injuries at 12-month follow-up (odds ratio 0.31, 95% CI 0.10-0.94, P = .039).

CONCLUSIONS/IMPLICATIONS

In older people with dementia living in nursing homes, a high-intensity functional exercise program alone did not prevent falls when compared with an attention control group. In high-risk populations, in which multimorbidity and polypharmacy are common, a multifactorial fall-prevention approach may be required. Encouraging effects on fall-related injuries were observed, which merits future investigations.

Number, Location, and Time Since Prior Fracture as Predictors of Future Fracture in the Elderly From the General Population

Prognostic tools are available to identify individuals at high risk of osteoporotic fracture and to assist physicians in management decisions. Some authors have suggested improving the predictive ability of these tools by integrating characteristics of prior fractures (number, location, and time since prior fracture). The objectives of this study were: (1) to evaluate the sex- and age-specific associations between characteristics of prior fractures and the occurrence of a future osteoporotic fracture; and (2) to assess whether the characteristics of prior fractures could increase the discriminative ability of fracture risk prediction tools. A retrospective cohort study was conducted using administrative data. Men and women aged ≥66 years were selected and grouped into two cohorts. In cohort #1 (N = 759,500), history of fractures was measured between fiscal years 1997-1998 and 2003-2004, and future fractures were identified between 2004-2005 and 2013-2014. In cohort #2 (N = 807,245), history of fractures was measured between 1997-1998 and 2008-2009, and future fractures were identified between 2009-2010 and 2013-2014. Time until a first hip/femur and major osteoporotic fracture were the outcomes of interest. Adjusted HRs and c-indices were calculated. The association between history of prior fractures and future fracture was stronger in men and younger individuals. The locations of prior fractures associated with the lowest and highest risks were foot/ankle/tibia/fibula (maximal HR = 1.64) and hip/femur (maximal HR = 9.02), respectively. The association was stronger for recent fractures (maximal HR = 4.93), but was still significant for fractures occurring 10 to 12 years prior to the beginning of follow-up (maximal HR = 1.99). Characteristics of prior fractures did not increase model discrimination. Our study confirms that the risk of future fracture increases with the number of prior fractures, varies according to prior fracture location, and decreases with time since prior fracture. However, the integration of these characteristics in current fracture risk prediction tools is not required because it does not improve predictive ability. © 2018 American Society for Bone and Mineral Research.

Ultrasound-guided femoral nerve blocks are not superior to ultrasound-guided fascia iliaca blocks for fractured neck of femur

OBJECTIVE

To determine if an ultrasound-guided femoral nerve block (FNB) is superior to an ultrasound-guided fascia iliaca compartment block (FICB) in providing pain relief to patients with a neck of femur or proximal femoral fracture.

METHODS

A double-blind randomised controlled trial was conducted. All participants received two blocks, one active and one placebo. An active FICB was administered to 52 participants and 48 participants received an active FNB.

RESULTS

Analysis was completed on data collected from 100 participants. Most patients were elderly and the majority were female. Both FICB and FNB achieved clinically significant mean reductions in pain scores (2.62 for FICB and 2.3 for FNB). There was no significant difference in reduction in pain scores between the two cohorts, P = 0.408.

CONCLUSIONS

Ultrasound-guided FNB is not superior to ultrasound-guided FICB, with both facilitating an equivalent analgesia effect in patients with a neck of femur or proximal femur fracture.

Parkinson's disease and risk of hip fracture: systematic review and meta-analysis

The relationship between Parkinson's disease (PD) and risk of hip fracture yielded inconsistent results. Therefore, we conducted the present systematic review and meta-analysis of published observational studies to assess the association between PD and risk of hip fracture. PubMed, ISI, EMBASE, and Cochrane databases were searched systematically to identify studies assessing the relationship between PD and the risk of hip fracture up to July 01, 2017. In addition, to find related articles, the reference section of retrieved articles was checked. Random-effects model was used for calculation of pooled hazard ratio (HR) and 95% confidence intervals (CI). Thirteen independent studies containing 564,947 participants were included in the meta-analysis. The overall results of included studies showed PD to be associated with the risk of hip fracture (HR_overall = 3.13, 95% CI 2.53-3.87) in women 3.11 (2.51-3.86) and men 2.60 (2.19-3.09). Our meta-analysis showed the direct association between PD and the risk of hip fracture in both men and women. However, due to the limitations of this study, further well-designed studies are required to confirm our findings.

Nutritional Status and Nutritional Treatment Are Related to Outcomes and Mortality in Older Adults with Hip Fracture

Malnutrition is very prevalent in geriatric patients with hip fracture. Nevertheless, its importance is not fully recognized. The objective of this paper is to review the impact of malnutrition and of nutritional treatment upon outcomes and mortality in older people with hip fracture. We searched the PubMed database for studies evaluating nutritional aspects in people aged 70 years and over with hip fracture. The total number of studies included in the review was 44, which analyzed 26,281 subjects (73.5% women, 83.6 ± 7.2 years old). Older people with hip fracture presented an inadequate nutrient intake for their requirements, which caused deterioration in their already compromised nutritional status. The prevalence of malnutrition was approximately 18.7% using the Mini-Nutritional Assessment (MNA) (large or short form) as a diagnostic tool, but the prevalence was greater (45.7%) if different criteria were used (such as Body Mass Index (BMI), weight loss, or albumin concentration). Low scores in anthropometric indices were associated with a higher prevalence of complications during hospitalization and with a worse functional recovery. Despite improvements in the treatment of geriatric patients with hip fracture, mortality was still unacceptably high (30% within 1 year and up to 40% within 3 years). Malnutrition was associated with an increase in mortality. Nutritional intervention was cost effective and was associated with an improvement in nutritional status and a greater functional recovery. To conclude, in older people, the prevention of malnutrition and an early nutritional intervention can improve recovery following a hip fracture.

Facility and State Variation in Hip Fracture in U.S. Nursing Home Residents

OBJECTIVES

To quantify the variation in hip fracture incidence across U.S. nursing home (NH) facilities and states and examine how hip fracture incidence varies according to facility- and state-level characteristics.

DESIGN

Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims.

SETTING

U.S. NHs with 100 or more beds.

PARTICIPANTS

Long-stay NH residents between May 1, 2007, and April 30, 2008, from 1,481 facilities and 46 U.S. states (N = 201,892).

MEASUREMENTS

Incident hip fractures were ascertained using Medicare Part A diagnostic codes. Each resident was followed for up to 2 years.

RESULTS

The mean adjusted incidence rate of hip fractures for all facilities was 3.13 (95% confidence interval (CI) = 3.01-3.26) per 100 person-years (range 1.20, 95% CI = 1.15-1.26 to 6.40, 95% CI = 6.07-6.77). Facilities with the highest rates of hip fracture had greater percentages of residents taking psychoactive medications (top tertile 27.2%, bottom tertile 24.8%), and fewer nursing (top tertile 3.43, bottom tertile 3.53) and direct care (top tertile 3.22, bottom tertile 3.29) hours per day per resident. The combination of state and facility characteristics explained 6.7% of the variation in hip fracture, and resident characteristics explained 7.6%.

CONCLUSION

Much of the variation in hip fracture incidence remained unexplained, although these findings indicate that potentially modifiable state and facility characteristics such as psychoactive drug prescribing and minimum staffing requirements could be addressed to help reduce the rate of hip fracture in U.S. NHs.

Bone Turnover Status: Classification Model and Clinical Implications

Aim: To develop a practical model for classification bone turnover status and evaluate its clinical usefulness. Methods: Our classification of bone turnover status is based on internationally recommended biomarkers of both bone formation (N-terminal propeptide of type1 procollagen, P1NP) and bone resorption (beta C-terminal cross-linked telopeptide of type I collagen, bCTX), using the cutoffs proposed as therapeutic targets. The relationships between turnover subtypes and clinical characteristic were assessed in1223 hospitalised orthogeriatric patients (846 women, 377 men; mean age 78.1±9.50 years): 451(36.9%) subjects with hip fracture (HF), 396(32.4%) with other non-vertebral (non-HF) fractures (HF) and 376 (30.7%) patients without fractures. Resalts: Six subtypes of bone turnover status were identified: 1 - normal turnover (P1NP>32 μg/L, bCTX≤0.250 μg/L and P1NP/bCTX>100.0[(median value]); 2- low bone formation (P1NP ≤32 μg/L), normal bone resorption (bCTX≤0.250 μg/L) and P1NP/bCTX>100.0 (subtype2A) or P1NP/bCTX<100.0 (subtype 2B); 3- low bone formation, high bone resorption (bCTX>0.250 μg/L) and P1NP/bCTX<100.0; 4- high bone turnover (both markers elevated ) and P1NP/bCTX>100.0 (subtype 4A) or P1NP/bCTX<100.0 (subtype 4B). Compared to subtypes 1 and 2A, subtype 2B was strongly associated with nonvertebral fractures (odds ratio [OR] 2.0), especially HF (OR 3.2), age>75 years and hyperparathyroidism. Hypoalbuminaemia and not using osteoporotic therapy were two independent indicators common for subtypes 3, 4A and 4B; these three subtypes were associated with in-hospital mortality. Subtype 3 was associated with fractures (OR 1.7, for HF OR 2.4), age>75 years, chronic heart failure (CHF), anaemia, and history of malignancy, and predicted post-operative myocardial injury, high inflammatory response and length of hospital stay (LOS) above10 days. Subtype 4A was associated with chronic kidney disease (CKD), anaemia, history of malignancy and walking aids use and predicted LOS>20 days, but was not discriminative for fractures. Subtype 4B was associated with fractures (OR 2.1, for HF OR 2.5), age>75 years, CKD and indicated risks of myocardial injury, high inflammatory response and LOS>10 days. Conclusions: We proposed a classification model of bone turnover status and demonstrated that in orthogeriatric patients altered subtypes are closely related to presence of nonvertebral fractures, comorbidities and poorer in-hospital outcomes. However, further research is needed to establish optimal cut points of various biomarkers and improve the classification model.

Comprehensive geriatric assessment for identifying older people at risk of hip fracture: cross-sectional study with comparative group

BACKGROUND

Hip fracture (HF) is by far the most common serious fragility fracture. Its care is a major challenge to all healthcare systems.

AIM

To determine whether there are characteristics of older people identified via comprehensive geriatric assessment (CGA) that help identify those with an increased risk of HF.

METHODS

The demographic, functional, cognitive and nutritional data of a cohort of patients admitted for acute HF were compared with those of a population cohort representing community-dwelling older people in the same urban district without HF. Bivariate analysis was performed on the variables in both the complete samples and in a subsample of age and sex paired subjects, followed by logistic regression analysis.

RESULTS

A total of 509 HF patients and 1315 community-dwelling older people were included. The HF patients were older and more frequently women and had more frequent disability and cognitive impairment, lower handgrip strength, lower body mass index (BMI) and a higher frequency of vitamin D deficiency compared with the community controls (P < 0.001). The variables most strongly associated with the presence of HF in the multivariate analysis, aside from age and female sex, were BMI<22 kg/m2 [odds ratio (OR) = 5.11], disability (OR = 4.32), muscle weakness (OR = 3.01), and vitamin D deficiency (OR = 2.13).

CONCLUSIONS

There are easily obtained CGA determinants that are strongly associated with fragility HF. The detection of low weight, disability, malnutrition, muscle weakness, and vitamin D deficiency can help identify at-risk older people to implement prevention strategies.

Prospective Associations of Dietary and Nutrient Patterns with Fracture Risk: A 20-Year Follow-Up Study

Studies on long-term exposure to foods/nutrients and its associations with fracture risk are scarce. Using data from the China Health and Nutrition Survey (CHNS), we determined the prospective association of dietary and nutrient patterns with fractures. Data from 15,572 adults aged ≥18 years were analyzed. Fracture occurrence was self-reported and dietary intake data were collected using a 24-h recall method for three consecutive days, for each individual across nine waves (1989–2011). We used cumulative and overall mean, recent and baseline dietary and nutrient exposures. Hazard ratios (HR) were used to determine the associations. Two dietary (traditional and modern) and two nutrient (plant- and animal-sourced) patterns were identified. After adjusting for potential confounders, study participants in the third tertiles (highest intake) of the modern dietary and animal-sourced nutrient patterns’ cumulative scores had a 34% (HR = 1.34; 95% CI: 1.06–1.71) and 37% (HR = 1.37; 95% CI: 1.08–1.72) increase in fracture risks compared to those in the first tertiles, respectively. While the overall mean factor scores of dietary and nutrient patterns had a similar (or stronger) pattern of association as the cumulative scores, no association between recent and baseline scores and fracture was found. Greater adherence to a modern dietary and/or an animal-sourced nutrient pattern is associated with a higher risk of total fractures. This suggests that a modern animal based diet is related to bone fragility. A repeated three-day 24-h recall dietary assessment provides a stronger association with fracture compared to a recent or baseline exposure.

Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial

INTRODUCTION

The number of elderly people with hip fracture and dementia is increasing, and many of these patients suffer from pain. Opioids are difficult to adjust and side effects are common, especially with increased age and among patients with dementia. Preoperative femoral nerve block is an alternative pain treatment.

AIM

To investigate whether preoperative femoral nerve block reduced acute pain and opioid use after hip fracture among elderly patients, including those with dementia.

PATIENTS AND METHODS

In this randomised controlled trial involving patients aged ≥70years with hip fracture (trochanteric and cervical), including those with dementia, we compared femoral nerve block with conventional pain management, with opioid use if required. The primary outcome was preoperative pain, measured at five timepoints using a visual analogue scale (VAS). Preoperative opioid consumption was also registered.

RESULTS

The study sample comprised 266 patients admitted consecutively to the Orthopaedic Ward. The mean age was 84.1 (±6.9)years, 64% of participants were women, 44% lived in residential care facilities, and 120 (45.1%) had dementia diagnoses. Patients receiving femoral nerve block had significantly lower self-rated pain scores from baseline to 12h after admission than did controls. Self-rated and proxy VAS pain scores decreased significantly in these patients from baseline to 12h compared with controls (p<0.001 and p=0.003, respectively). Patients receiving femoral nerve block required less opioids than did controls, overall (2.3±4.0 vs. 5.7±5.2mg, p<0.001) and in the subgroup with dementia (2.1±3.3 vs. 5.8±5.0mg, p<0.001).

CONCLUSION

Patients with hip fracture, including those with dementia, who received femoral nerve block had lower pain scores and required less opioids before surgery compared with those receiving conventional pain management. Femoral nerve block seems to be a feasible pain treatment for elderly people, including those with dementia.

Informed Consent to Research with Cognitively Impaired Adults: Transdisciplinary Challenges and Opportunities

Due to issues related to informed research consent, older adults with cognitive impairments are often excluded from high-quality studies that are not directly related to cognitive impairment, which has led to a dearth of evidence for this population. The challenges to including cognitively impaired older adults in research and the implications of their exclusion are a transdisciplinary issue. The ethical challenges and logistical barriers to conducting research with cognitively impaired older adults are addressed from the perspectives of three different fields-social work, emergency medicine, and orthopaedic surgery. Issues related to funding, study design, intervention components, and outcomes are discussed through the unique experiences of three different providers. A fourth perspective-medical research ethics-provides alternatives to exclusion when conducting research with cognitively impaired older adults such as timing, corrective feedback and plain language, and capacity assessment and proxy appointments. Given the increasing aging population and the lack of evidence on cognitively impaired older adults, it is critical that researchers, funders, and institutional review boards not be dissuaded from including this population in research studies.