Prevention and management of hip fracture in older patients

The average age at hip fracture is 83 for women and 84 for men, with about 80% of cases in women. The 30% mortality and 20% new institutionalisation rates at 12 months reflect the high prevalence of comorbidity and to some extent suboptimal management at the time of the fracture. With timely intervention and better clinical management many fractures can be prevented and when they do occur their human and economic costs can be greatly reduced. Fragility fractures occur in those with demonstrable osteoporosis or osteopaenia and/or risk factors. The goal of prevention is to identify and treat those at risk UK clinicians lack a single universally endorsed, decision support resource. The prudent strategy is to become familiar with all three available risk measures, introduce fracture risk assessment into routine practice, and allow clinical judgement to prevail in cases of doubt (perhaps, especially in very elderly people, more often in the direction of intervention). The classical signs after a fall by an older person, of severe pain, shortening and external rotation of the affected limb, and loss of mobility, should result in immediate and rapid transfer to hospital. It is not rare in the case of intracapsular fractures for mobility to be deceptively maintained on a moderately or minimally painful hip.     

Treatment of pain for older hip fracture patients across settings

PURPOSE: To examine the treatment of pain following hip fracture across settings (hospital to nursing home or rehabilitation facility). DESIGN: This was a secondary data analysis of two survey design studies that collected data on hip fracture patients in the hospital and for posthospital days at an institutional setting. SAMPLE: 115 subjects, 65 years or older, who had undergone surgical treatment of a hip fracture. METHODS: Medical records were reviewed to compare the amount of pain medication administered to postoperative hip fracture elders during the last 24 hours in the hospital with that of the first 24 hours in the nursing home (NH). FINDINGS: The mean length of stay following surgery was 4.8 days. Subjects received significantly less medication during the first 24 hours in the NH as compared with the last 24 hours of hospitalization. Over one third (37.4%) of the subjects received no opioid analgesic and 18.3% (n = 21) received no analgesic of any kind during the first 24 hours of NH stay. IMPLICATIONS: Rather than simply listing medications orders, hospital nursing staff should communicate type, amount, frequency and efficacy of pain medication in transfer notes to nursing home staff. Nursing home staff would benefit from postoperative pain management education.     

Diabetes-associated bladder dysfunction in the older adult (CE)

Diabetic cystopathy is a chronic complication of diabetes with a classic triad of symptoms: decreased bladder sensation, increased bladder capacity, and impaired detrusor contractility. This article discusses age- and diabetes-related changes that affect lower urinary tract function. The article also reviews bladder function in the older adult diabetic, explores bladder dysfunction prevention, and suggests management strategies for diabetic cystopathy. Little research has been published to date to guide practice in this area, and opportunities exist for nursing research to fill the gap in knowledge.     

Functional status in older women following hip fracture

BACKGROUND: Women aged 65 years and over are at high risk for a fractured hip because of osteoporosis. One of the devastating effects of a fracture is the loss of ability to live independently. AIM: The major aim of this study was to describe the functional status, or ability to perform activities of daily living, of women aged 65 years and older who had experienced a fractured hip in the recent past and to explore possible differences in selected variables (e.g. age and length of rehabilitation) for those who were fully performing activities of daily living at least 6 months after fracture and those who were not. DESIGN: Following Institutional Review Board approval, data were collected from 23 Caucasian women ranging from 65 to 95 years of age (M = 82, SD = 6.83) who had experienced fractured hips related to a fall in the recent past (6 months to 4 years). All were living independently prior to their fractures. Three Registered Nurses, in a structured interview, collected the data using a Demographic Data Form, an Osteoporosis Risk Factor Checklist, the Katz Index of Independence in Activities of Daily Living, and the Lawton Instrumental Activities of Daily Living Scales. RESULTS: Nine of the participants reported prior fractures, suggesting that this could have been a risk factor for this group. Eighteen achieved the maximum independence score of six on the Katz Index of Independence in Activities of Daily Living; help with bathing was required by the other five. Of the Instrumental Activities of Daily Living, those requiring physical activity for home maintenance were the most problematic. Ability to perform Instrumental Activities of Daily Living was significantly related to ability to perform the activities required to live independently. CONCLUSIONS: Results suggest that achieving a functional level that will support independence is possible for older women who were residing independently prior to a hip fracture.     

Case study of hip fracture in an older person

PURPOSE: To discuss proximal femoral (hip) fractures as the leading cause of hospitalization for injuries among older persons, using a case example that illustrates not only the orthopedic injury but also how an older person's chronic problems complicate the acute event. DATA SOURCES: Extensive review of scientific literature on the conditions discussed, supplemented by the case study. CONCLUSIONS: Hip fractures in older adults can present multiple challenges to care when complicated by preexisting or coexisting conditions. This case of an older man with a hip fracture emphasizes the resuscitation priorities for the patient found after a "long lie" and the impact of chronic alcoholism and malnutrition, which lead to serious complications. IMPLICATIONS FOR PRACTICE: Careful physical and psychosocial assessment is important for determining the presenting problem and comorbid conditions. Priorities for postoperative management of hip fracture and its complications guide the nurse practitioner through the successful return of the patient to the community.     

Care of the older adult following hip fracture

Proximal femoral (hip) fractures are the leading cause of hospitalization for injuries among older persons and constitute a serious health problem. Research shows significant functional losses among older persons following surgery for hip fracture related to a wide range of problems. Because of the physiological, emotional, social, and psychological complications inherent in this particular population, a team approach using a holistic model of care is efficacious when attempting to improve functional outcomes and reduce morbidity and mortality.     

Sleep in the older adult: implications for nurses (CE)

Normal aging is accompanied by sleep pattern changes that may result in daytime sleepiness and affect the quality of life in older adults. These changes also can signal more serious sleep problems, which become more prevalent with aging. More than half of adults older than 65 living at home and about two-thirds of those in long-term care facilities have some difficulties with sleep. It is important for nurses to understand the normal changes in sleep that accompany aging and be able to differentiate them from the symptoms of serious sleep disorders to ensure holistic care for older adults.     

高龄髋部骨折合并脑卒中后遗症患者的治疗对策

目的探讨高龄髋部骨折合并脑卒中后遗症患者的治疗方案,探讨其预后的影响因素。方法回顾性分析62例高龄髋部骨折合并脑卒中后遗症患者的临床资料,根据治疗方法分为保守治疗组（12例）、关节置换组（18例）、内固定组（32例）。综合分析比较美国麻醉师协会（ASA）评分、日常生活活动能力指数（Barthel生活指数）、合并症、简易精神状态量表（MMSE）、股骨近端骨小梁类型指数（Singh指数）、骨折后并发症（感染、再发脑卒中、褥疮、深静脉血栓、心力衰竭）等指标。结果3组患者年龄及性别、ASA评分、合并症比较差异均无统计学意义。保守治疗组、关节置换组、内固定组Barthel生活指数分别为52．1±11．4、74．5±21．3、63．84-15．7;骨折后并发症分别为10、3、13例。3组患者组间Barthel生活指数、并发症比较差异均有统计学意义（F=2．45,P〈0．05;X2=9．32,P〈0．05）。保守治疗组与手术治疗的两组Singh指数（X2=11．10,P〈0．05）及MMSE量表（X2=7．40,P〈0．05）比较差异均有统计学意义,而手术治疗的两组间比较差异均无统计学意义（P均〉0．05）。ASA评分、合并症、MMSE量表、治疗策略、骨折前Barthel生活指数均与骨折后Barthel生活指数存在相关性（OR值分别为5．726、7．152、0．047、1．221、5．312,P均〈0．05）。结论对于高龄髋部骨折合并脑卒中后遗症患者应首选关节置换术治疗,预后受患者身心整体状态的影响较大,完整的评估是选择治疗方案前必不可少的步骤。     

Clinical outcomes in transition program for older adults with hip fracture

Measuring and managing outcomes across the continuum of care has been a major task for healthcare organizations over the past decade. Care of older adults with hip fracture and their transition to the community is particularly challenging. This article describes a program designed specifically to meet these challenges. The goals of the transition program were to promote improved clinical outcomes, reduce acute care resource utilization through early discharge and provision of cost-effective home care, and maintain or improve patient satisfaction. Results of the outcome analysis demonstrated successful goal attainment. The strength of the outcome evaluation is that it links both a qualitative and quantitative approach, providing a richer and more holistic view of the client experience.     

Reducing pressure ulcers in hip fracture patients

This article describes how a collaborative project within an NHS hospital reduced the incidence of pressure ulcers in hip fracture patients by 79.8%, thus improving outcomes of care and patient experience. The impetus for the project came from the negative effects on functional recovery that pressure ulcers can cause, a prevalence of 9.3% in the existing patient group, and the trust's commitment to reduce pressure ulcers for all patients by 50%, as per local quality indicators. Using a multiprofessional collaborative team approach, issues with current practice and how improvements could be made were identified. Following this, a best practice guideline and educational session based on national guidelines, but tailored to the local and holistic needs of hip fracture patients, was developed. The author proposes that the tailoring of an intervention to the specific needs of high risk patient groups is transferable to any area of practice where pressure ulcers are prevalent.