Risk Analysis for Second Hip Fracture in Patients After Hip Fracture Surgery: A Nationwide Population-Based Study

Objectives

The current treatment program for fragility hip fractures (HFx) emphasizes a combination of early surgery, rehabilitation, and tertiary prevention strategy for osteoporosis; however, the effect is unclear and little information is available on the risk factors predicting the occurrence of a second hip fracture (SHFx). The aim of this study was to explore the incidence, risk factors, and subsequent mortality of SHFx in patients after their first hip fracture surgery (HFxS).

Design, Setting, and Participants

We performed a nationwide population-based longitudinal observational study using the National Health Insurance Research Database (NHIRD) of Taiwan with a logistic regression model analysis. Of 87,415 patients undergoing HFxS during the period 2004 to 2007, we identified 8027 patients who had sustained an SHFx for analyses.

Measurements

Data collected included patient characteristics (demographics, comorbidities, and concurrent medication use), incidence and hazard ratios of SHFx after HFxS, and subsequent age-specific mortality.

Results

The overall incidence of SHFx was 9.18% and the age-specific mortality was increased 1.6- to 2.2-fold in patients with SHFx compared with those without after HFxS in this 7-year longitudinal study. The identified risk factors included age (AOR = 1.84, 95% CI: 1.24–2.89), female gender (AOR = 1.12, 95% CI: 1.03–2.30), obesity (AOR = 2.89, 95% CI: 1.81–3.01), diabetes (AOR = 3.85, 95% CI: 2.54–4.05), arterial hypertension (AOR = 2.45, 95% CI: 1.83–2.62), hyperlipidemia (AOR = 2.77, 95% CI: 1.27–3.19), stroke/TIA (AOR = 2.85, 95% CI: 2.20–3.23), blindness/low vision (AOR = 3.09, 95% CI: 2.54–3.73), and prolonged use of analgesics and anti-inflammatory medications (all AOR ≥ 3.05, all P values ≤.012). Bisphosphonate therapy after HFxS had a significant negative risk association with the development of an SHFx (20.8% vs 32.3%, P = .023; AOR = 2.24, 95% CI: 1.38–2.90).

Conclusion

We concluded that the occurrence of an SHFx and subsequent mortality in patients after HFxS is rather high. An understanding of the risk factors predicting the occurrence of an SHFx provides a valuable basis to improve health care for geriatric populations.     

老年人髋部骨折术后并发症预防及康复护理

随着人口老龄化的迅速发展，生活水平的提高，长寿之人也随之增多，老年人髋部骨折临床较多见，主要包括股骨颈及股骨粗隆间骨折。人工髋关节置换术、DHS及PFNA已被认为是治疗老年人髋部骨折的最佳治疗手段。其除了能改善患者关节活动度及稳定性外，还能够有效地缓解疼痛，提高肢体的功能状态，改善总体生存质量。老年人髋部骨折术后并发症包括感染、坠积性肺炎，肺栓塞、髋关节脱位、下肢静脉血栓形成、褥疮等，及时的处理、预防，减少并发症及康复护理是骨科治疗和护理的重要部分，护理人员必须运用科学的方法，对不同患者，不同训练时期的康复训练有针对性指导，并加强与医生、患者及家属的沟通，才能保证病人手术的成功。此外还要掌握老年人护理的特殊性，从而提高老年人护理工作效果，使这类病人术后得到早日康复。     

Postoperative Dehydration Is Associated with Frailty and Decreased Survival in Older Patients with Hip Fracture

Background: Hyperosmolar dehydration (HD) is a risk factor for severe complications in hip fracture in older patients. However, evidence for recommending screening of dehydration is insufficient and its relation with frailty and mortality is unclear. We tested the hypothesis that postoperative HD is associated with frailty and increased mortality. Methods: We recruited 625 older (>65 years) patients surgically treated for hip fracture and co-managed by an orthogeriatric team over one year in 2017. Pre- and postoperative HD (serum osmolarity > 300 mmol/L) was diagnosed. Frailty and associated mortality risk were assessed by the Multidimensional Prognostic Index (MPI). Results: The prevalence of preoperative HD was 20.4%. Compared with no-HD, MPI was similar in HD patients despite higher (p < 0.05) prevalence of polypharmacy, arterial hypertension, diabetes, chronic kidney disease and heart failure. After surgery the incidence of HD decreased to 16.5%, but increased (p = 0.003) in the MPI high-risk subgroup. Postoperative HD was associated with more complications and was an independent determinant of adjusted hospital length of stay (LOS) and of 60- to 365-days mortality. Conclusions: Older frail patients with hip fracture are prone to developing postoperative HD, which independently predicts prolonged hospital LOS and mortality. Systematically screening older patients for frailty and dehydration is advisable to customize hydration management in high-risk individuals.     

Nutritional Strategies in the Management of Alzheimer Disease: Systematic Review With Network Meta-Analysis

Background

Alzheimer disease (AD) is the major cause of dependency and disability in the elderly. Numerous studies have sought to achieve its prevention and/or management examining a role for modifiable risk factors, such as nutrition. This work aims to investigate the effects of food and/or nutrients in the management of AD at different stages.

Independent,Differential Effects of Delirium on Disability and Mortality Risk After Hip Fracture

ObjectivesTo assess the independent effect of delirium on mortality and disability after 1 year of follow-up, in consecutive older patients with hip fracture hospitalized for surgical repair.DesignThis is a prospective observational study.Setting and ParticipantsPatients aged older than 65 years consecutively admitted for hip fracture to the Trauma and Orthopedics Centre of a third-level hospital, between March and October 2014.MethodsPatients were evaluated by a multidisciplinary team. A comprehensive geriatric assessment was performed on admission. Delirium was assessed before and after surgical repair according to the Confusion Assessment Method. Mortality and disability status were collected at 3 months and 1 year after hospital discharge.ResultsOf 411 patients with hip fracture, 387 (mean age 82 years, female 72%) were enrolled. Delirium was assessed in 50% of the enrolled population. Patients with delirium were older, frequently affected by dementia, severe prefracture disability, history of falls, and polypharmacy. One-year mortality was 19% in all populations, and higher in patients with delirium, although delirium did not show an independent association with mortality, in multivariable analysis. Conversely, delirium was identified as an independent prognostic factor of long-term disability (B-1.605, SE 0.211, P < .001).Conclusion and ImplicationsThis study identifies delirium as an independent long-term disability generator, regardless of associated clinical conditions and premorbid cognitive and functional status. This emphasises the importance of delirium prevention through a multidisciplinary approach and the potential role of systematic treatment of risk factors in reducing functional decline, even in subjects with preexistent disability and dementia. Moreover, these data call for research on rehabilitation interventions specifically targeted to these complex patients, with the aim of identifying approaches effective in reducing long-term disability. Conversely, a high level of clinical alertness is required in patients with delirium, as an appropriate treatment of acute diseases should reduce their high mortality risk.     

Hip Fracture as a Predictive Marker for the Risk of Dementia: A Population-Based Cohort Study

ObjectivesThis study aimed to investigate the association between hip fracture and the risk of dementia.DesignA retrospective real-world propensity score–matched cohort study was conducted using the real-world hip fracture cohort (RHFC).Setting and ParticipantsElectronic health record data from the Clinical Data Analysis and Reporting System (CDARS) in Hong Kong were used. A total of 52,848 patients aged ≥65 years and with at least an event of fall from 2006 to 2015 were included in the RHFC.MethodsThe incidence of fall, hip fracture, and dementia was determined using their International Classification of Diseases, Ninth Revision (ICD-9) codes. Competing risk regression models were used to estimate hazard ratios (HRs) and 95% CIs.ResultsHip fracture was associated with an increased risk of dementia (HR 1.09, 95% CI 1.04-1.15, P < .001). The subgroup analysis showed that association was significant in women but not in men.Conclusions and ImplicationsHip fracture was associated with the increased risk of dementia among older adults. Further studies investigating the potential roles of hip fracture in the development of dementia could benefit the management of both conditions in older adults.     

Machine Learning Algorithms to Predict Mortality and Allocate Palliative Care for Older Patients With Hip Fracture

ObjectivesTo evaluate a machine learning model designed to predict mortality for Medicare beneficiaries aged >65 years treated for hip fracture in Inpatient Rehabilitation Facilities (IRFs).DesignRetrospective design/cohort analysis of Centers for Medicare & Medicaid Services Inpatient Rehabilitation Facility–Patient Assessment Instrument data.Setting and ParticipantsA total of 17,140 persons admitted to Medicare-certified IRFs in 2015 following hospitalization for hip fracture.MeasuresPatient characteristics include sociodemographic (age, gender, race, and social support) and clinical factors (functional status at admission, chronic conditions) and IRF length of stay. Outcomes were 30-day and 1-year all-cause mortality. We trained and evaluated 2 classification models, logistic regression and a multilayer perceptron (MLP), to predict the probability of 30-day and 1-year mortality and evaluated the calibration, discrimination, and precision of the models.ResultsFor 30-day mortality, MLP performed well [acc = 0.74, area under the receiver operating characteristic curve (AUROC) = 0.76, avg prec = 0.10, slope = 1.14] as did logistic regression (acc = 0.78, AUROC = 0.76, avg prec = 0.09, slope = 1.20). For 1-year mortality, the performances were similar for both MLP (acc = 0.68, AUROC = 0.75, avg prec = 0.32, slope = 0.96) and logistic regression (acc = 0.68, AUROC = 0.75, avg prec = 0.32, slope = 0.95).Conclusion and ImplicationsA scoring system based on logistic regression may be more feasible to run in current electronic medical records. But MLP models may reduce cognitive burden and increase ability to calibrate to local data, yielding clinical specificity in mortality prediction so that palliative care resources may be allocated more effectively.     

Sundown Syndrome,Sleep Quality,and Walking Among Community-Dwelling People With Alzheimer Disease

Purposes

Sundown syndrome and sleep disturbances cause people with Alzheimer disease (PAD) and caregivers suffering. Studies have indicated that physical exercise could have a positive impact on sundown syndrome, yet no research has ever explored the relationship between walking and sundown syndrome. The aims of this study were to examine the relationship between sundown syndrome and sleep quality, and determine whether the severity of dementia, sleep quality, and weekly duration of walking influenced sundown syndrome, and to assess differences in sundown syndrome and sleep quality in relation to the accompanying walker and weekly duration of walking among people with Alzheimer disease living in the community.

Effect of 800 IU Versus 2000 IU Vitamin D3 With or Without a Simple Home Exercise Program on Functional Recovery After Hip Fracture: A Randomized Controlled Trial

ObjectivesTo evaluate 2 simple strategies, vitamin D₃ and a home exercise program, in functional recovery during the first year after hip fracture.DesignSecondary analysis of a factorial clinical trial. Patients were randomly allocated to 800 IU (standard of care) or 2000 IU vitamin D₃ and a daily instruction of a simple home exercise program (SHEP) or standard physiotherapy alone during acute care.Setting and participantsAcute hip fracture patients aged ≥65 years, after hip fracture surgery, admitted to a large hospital in Zurich, Switzerland.MeasuresThree objective measures of lower extremity function were assessed at baseline and 6 and 12 months, with the Timed Up and Go test (TUG) as the primary endpoint, and knee flexor and extensor strength, and a self-reported physical function score (PF-10) as secondary endpoints. Linear mixed model regression analyses were based on intention to treat, adjusting for baseline function, time, age, sex, and baseline 25-hydroxyvitamin D level.ResultsWe enrolled 173 patients (79.2% women; mean age 84 years; 77.5% living at home). A significant interaction was found between vitamin D₃ dose and SHEP for TUG (P = .045). Thus, findings compared the standard of care reference arm with 800 IU vitamin D₃ without SHEP to 3 interventions arms (800 IU vitamin D₃+SHEP; 2000 IU vitamin D₃ without SHEP; 2000 IU vitamin D₃+SHEP). For TUG, over 12 months the 800 IU vitamin D₃+SHEP group performed significantly better than the standard-of-care group (13.8 vs 19.5 seconds; P = .01). Findings for knee flexor strength were in line with TUG results and approached significance (P = .07), whereas knee extensor strength and PF-10 did not differ by treatments.Conclusions/ImplicationsFor functional recovery after hip fracture, combining home exercise with 800 IU vitamin D₃ is superior to no home exercise or 2000 IU vitamin D₃. None of the interventions improved subjective physical functioning.     

The Risk of Alzheimer's Disease After Acute Appendicitis With or Without Appendectomy

ObjectivePrevious epidemiologic studies have suggested an association between appendectomy and Parkinson's disease. The aim of the current study was to examine the risk of Alzheimer's disease (AD) and other types of dementia following appendicitis or appendectomy for appendicitis.DesignPopulation-based cohort study.Setting and participantsWe used claims data from the Taiwan National Health Insurance Research Database. Participants aged ≥45 years with acute appendicitis or who received appendectomy for appendicitis were enrolled and followed up for more than 15 years. Cases and controls underwent 1:1 matching by age, sex, index date, and dementia-related comorbidities.MethodsThe primary outcome was AD, and secondary outcomes included other dementia types. Adjusted hazard ratios (aHRs) were calculated, and a competing risk regression model was created. The E value for causality of evidence was calculated.ResultsPatients developing appendicitis (0.6% vs 0.1%, P = .005) and those receiving appendectomy for appendicitis (0.4% vs 0.1%, P = .003) had higher incidences of AD than the controls during the follow-up period. A Cox regression analysis with adjustment for potential confounders showed that patients with appendicitis [aHR 6.68, 95% confidence interval (CI) 1.84-24.48] and those receiving appendectomy for appendicitis (aHR 5.01, 95% CI 1.33-18.85) were more likely to develop AD than the controls. These 2 groups also had higher risks for unspecified dementia and all types of dementia but not for vascular dementia than the controls. The age at dementia diagnosis was 88.51 years in the controls; however, among people who developed dementia following appendicitis, the mean age at diagnosis was 70.18 years, and dementia occurred 5.84 years after appendicitis. The competing risk regression models and the E values support the study findings.Conclusions and implicationsAfter recovery from appendicitis, these patients should be followed up for signs of AD.     

Weight Loss and Nutritional Considerations in Alzheimer Disease

ABSTRACT

Weight loss is a common problem among both community-dwelling and institutionalized older adults with Alzheimer disease (AD) and is associated with mortality, morbidity, disease progression, and poor quality of life. The causes of weight loss in this population are multifaceted and include loss of appetite secondary to deterioration of brain regions associated with feeding behavior and functional and behavioral problems associated with AD that make it difficult for individuals to consume adequate energy. The most common weight management strategy is to provide high-energy nutritional supplements to individuals at risk of weight loss. Supplementation is generally effective but tends to be least beneficial for those with the lowest body mass indices. Environmental and social interventions related to mealtimes and feeding are also important.     

The Role of Prefracture Health Status in Physical and Mental Function After Hip Fracture Surgery

Objectives

To examine the associations of 3 measures of prefracture health status (physical function, mental function, and comorbidity count) with trajectories of physical and mental function at 1.5, 3, 6, and 12 months after hip fracture surgery.

人工髋关节置换术在老年股骨粗隆间骨折治疗中的应用效果观察

目的观察人工髋关节置换术治疗老年股骨粗隆间骨折的效果。方法选取我院2016年1月至2018年1月间收治的65例老年股骨粗隆间骨折患者,随机分为两组。对照组32例患者采用动力髋螺钉内固定治疗,观察组33例患者采用人工髋关节置换术治疗,比较两组的治疗效果。结果观察组的手术优良率为93.9%,显著高于对照组的75.0%(P <0.05);观察组的手术时间、术中出血量、术后负重时间、骨折愈合时间及住院时间均显著优于对照组(P <0.05);观察组的并发症发生率为6.1%,显著低于对照组的25.0%(P <0.05)。结论人工髋关节置换术治疗老年股骨粗隆间骨折的效果显著,安全性高,值得临床推广应用。     

Effectiveness of Hip Protectors to Reduce Risk for Hip Fracture from Falls in Long-Term Care

ObjectiveTo generate evidence of the effectiveness of hip protectors to minimize risk of hip fracture at the time of falling among residents of long-term care (LTC) by contrasting rates of hip fractures between falls with and without hip protectors.DesignA 12-month, retrospective cohort study. We retrospectively reviewed fall incident reports recorded during the 12 months prior to baseline in participating homes.Setting and participantsA population-based sample comprising all residents from 14 LTC homes owned and operated by a single regional health authority, who experienced at least 1 recorded fall during the 12-month study.ResultsAt baseline, the pooled mean (standard deviation) age of residents in participating homes was 82.7 (11.3) years and 68% were female. Hip protectors were worn in 2108 of 3520 (60%) recorded falls. Propensity to wear hip protectors was associated with male sex, cognitive impairment, wandering behavior, cardiac dysrhythmia, use of a cane or walker, use of anti-anxiety medication, and presence of urinary and bowel incontinence. The incidence of hip fracture was 0.33 per 100 falls in falls with hip protectors compared with 0.92 per 100 falls in falls without hip protectors, representing an unadjusted relative risk (RR) of hip fracture of 0.36 (95% confidence interval 0.14–0.90, P = .029) between protected and unprotected falls. After adjusting for propensity to wear hip protectors, the RR of hip fracture was 0.38 (95% confidence interval 0.14–0.99, P = .048) during protected vs unprotected falls.Conclusions and implicationsHip protectors were worn in 60% of falls, and the risk of hip fracture was reduced by nearly 3-fold by wearing a hip protector at the time of falling. Given that most clinical trials have failed to attain a similar level of adherence, our findings support the need for future research on the benefits of dissemination and implementation strategies to maximize adherence with hip protectors in LTC.     

动力髋螺钉治疗老年人股骨转子间骨折的疗效评价

目的评价动力髋螺钉（DHS）治疗老年人股骨转子间骨折的临床疗效。方法对天津医科大学第二医院收治并采用DHS治疗的43例老年股骨转子间骨折患者进行随访,分析其治疗效果。结果随访6～18个月,术后6月所有患者骨折愈合良好,平均临床愈合时间为3．9个月,患髋关节功能优27例（62．8％）,良15例（34．9％）,差1例（2．3％）,优良率达97．7％。结论运用DHS治疗老年人股骨转子间骨折,能取得理想的治疗效果,是值得推广的内固定方法。     

Nutritional Therapy in Older Patients With Hip Fractures Undergoing Rehabilitation: A Systematic Review and Meta-Analysis

ObjectiveOlder people with hip fractures are often undernourished, which adversely affects their functional prognosis. A previous review reported that oral multinutritional supplements may prevent complications after hip fracture surgery. However, it is unclear whether interventions that combine rehabilitation and nutritional therapy have prognostic benefits. The objective of this study was to determine whether nutritional therapy is effective for patients with hip fractures undergoing rehabilitation.DesignSystematic literature review and meta-analysis.Setting and ParticipantsRandomized controlled trials involving patients at least 65 years of age with hip fracture undergoing rehabilitation with or without nutritional therapy. Older patients with hip fractures undergoing rehabilitation were included.MethodsA systematic literature search using 5 databases (PubMed, Cochrane Central Register of Controlled Trials, EMBASE, WHO ICTRP, and Ichu-shi Web) was conducted in December 2018 and identified all randomized controlled trials. Outcome variables include mortality, complications, activities of daily living, quality of life, and muscle strength.ResultsOf the 1431 studies found, 10 met the inclusion criteria, involving a total of 1119 patients. Four studies reported mortality, 5 studies reported complications, and 4 studies reported grip strength. Nutritional therapy showed a significant reduction in mortality [relative risk (RR) 0.61, 95% confidence interval (CI) 0.39, 0.93; I² = 0%] and complications (RR 0.67, 95% CI 0.44, 1.03; I² = 79%), and improved grip strength (mean difference = 2.01, 95% CI 0.81, 3.22; I² = 0%). The effects of nutritional therapy on activities of daily living, quality of life, and knee extension strength are unknown. The majority of studies were assessed as low quality.Conclusions and ImplicationsOur study showed that the combination of rehabilitation and nutritional therapy for older patients with hip fractures reduced mortality and postoperative complications and enhanced grip strength, although the quality of the evidence was low. A well-designed controlled study is needed for further investigation.     

The Association of Oral Bisphosphonate Use With Mortality Risk Following a Major Osteoporotic Fracture in the United Kingdom: Population-Based Cohort Study

ObjectivesBisphosphonates (BPs) might have extra benefits in reducing mortality because of their anti-atherosclerotic effects, but studies reported conflicting results. We investigated the association between oral BP use and mortality risk following a major osteoporotic fracture (MOF) in the United Kingdom.DesignThis was a population-based cohort study.Setting and ParticipantsIn total, 163,273 adults aged 50 years and older with an MOF between 2000 and 2018 from the Clinical Practice Research Datalink in the United Kingdom.MethodsCox proportional hazards models were used to estimate the risk of all-cause mortality in current (0‒6 months), recent (7‒12 months), and past (>1 year) exposures to oral BPs after nonhip MOF and hip fracture. In addition, stratification by sex, BP type, and duration of follow-up was performed.ResultsCompared with never users of oral BPs, current BP use was associated with a 7% higher all-cause mortality risk after nonhip MOF, whereas a 28% lower all-cause mortality risk was observed after hip fracture. Past BP exposure was associated with a 14% and 42% lower risk after nonhip MOF and hip fracture, respectively. When considering only the first 5 years of follow-up, mortality risk associated with current BP use was significantly lower for both fracture groups, and the greatest reduction in mortality risk was observed within the first year. Women had slightly lower risk compared with men.Conclusions and ImplicationsWe found a slight increased risk of all-cause mortality with current BP exposure after a nonhip MOF; however, a protective effect was observed following a hip fracture. Both the timing and the effect size of an association based on the anti-atherosclerotic hypothesis of BPs are not supported by our results. The decreasing trend of the mortality risk with shorter durations of follow-up suggests that the observed association is likely due to unknown distortion or unknown pleiotropic properties of BPs.