Older people with hip fracture and IADL disability require earlier surgery

Background: Hip fractures represent a major challenge for physicians as well as society as a whole. Both poor functional status and delay to surgery are well known risk factors for negative outcomes. We hypothesized that the timing of the operation is more important for frail older people than older people without functional limitations before fracture. Methods: We performed a prospective multicenter cohort study on 806 consecutive patients, 75 years of age or older, admitted with a fragility hip fracture to three hospitals in the Emilia-Romagna Region (Italy). All three hospitals had a comanaged care model, and the patients were under the shared responsibility of an orthopedic surgeon and a geriatrician. Results: Functional status assessed as instrumental activities of daily living was an important predictor of survival after 1 year from fracture. After adjusting for confounders, the hazard ratios per 1 point score of increase from 0 to 8 was 1.30 (95% confidence interval 1.19-1.42, p =. 000). Time to surgery increased 1-year mortality in patients with a low instrumental activities of daily living score (hazard ratios per day of surgical delay 1.14, 95% confidence interval 1.06-1.22, p <. 001) and intermediate instrumental activities of daily living score (hazard ratios 1.21, 95% confidence interval 1.09-1.34, p <. 001) but was an insignificant risk factor in functionally independent patients (hazard ratios 1.05 95% confidence interval 0.79-1.41, p =. 706). Conclusions: Surgery delay is an independent factor for mortality in older patients after hip fracture but only for the frail older people with prefracture functional impairment. If our results are confirmed, a more intensive approach should be adopted for older people with hip fractures who have disabilities. © 2012 The Author

Time to surgery and rehabilitation resources affect outcomes in orthogeriatric units

Objective: To compare the pathways of care and clinical results for patients admitted for hip fracture (HF) in 3 orthogeriatric co-managed care centers in order to estimate the effect of system factors on mortality and functional outcome. Design: Prospective inception multicenter cohort study. Setting: Three tertiary Hospitals. Participants: 806 patients consecutively admitted with HF. Measurements: 1-Year mortality, the loss of 1 or more functional abilities in activities of daily living (ADLs), and the recovery/maintenance of independent ambulation at 6 months from the fracture. Results: On the whole sample, 71.1% of patients survived 1 year from the fracture. In one hospital the risk of 1-year mortality was significantly higher even after adjusting for age, sex, comorbidity, prefracture functional status and cognitive impairment (odd ratio (OR) 1.56, 95% confidence interval (CI) 1.15-2.18, p = 0.01). This was principally explained by a longer time to surgery (5.2 days +/- 3.2 vs 2.7 +/- 2.3 and 2.7 +/- 2.2, p < 0.001). The three hospitals also differed in the rate of subjects losing the ability in ADLs after 6 months from the fracture (54.2%, 61%, 43.5%, p = 0.016), while no statistical differences were found in the recovery of independent ambulation. On the basis of multivariate models, a lower access to post-acute rehabilitation could account for lower outcome in functional status. Conclusions: This study suggests that system factors such as time to surgery and rehabilitation resources can affect functional recovery and 1-year mortality in orthogeriatric units and they could explain different outcomes when comparing care models. (C) 2011 Elsevier Ireland Ltd. All rights reserved

Handgrip strength predicts persistent walking recovery after hip fracture surgery

Background In older people, hip fractures often lead to disability and death. We evaluated handgrip strength, an objective measure of physical function for bedridden patients, as a predictor of walking recovery in the year after fracture surgery. Methods This multicenter prospective cohort study included 504 patients aged 70 years and older, who were admitted to the hospital for hip fracture surgery and were formerly able to walk independently. A multidimensional geriatric evaluation that included a physical examination, Short Portable Mental Status Questionnaire (SPMSQ), Geriatric Depression Scale (GDS), Charlson Index, Basic Activities of Daily Living (BADL), and grip strength was administered at the time of admission. Follow-ups were performed every three months for one year after surgery to assess functional status and survival. The walking recovery probability was evaluated using multivariable logistic regression models. Results The mean age of the participants was 85.3±5.5 years, and 76.1% of the participants were women. The mean grip strength was greater in men (β: 6.6±0.62, p<0.001) and was directly related to the SPMSQ results (p<0.001), BADL results (p<0.001), serum vitamin D levels (p=0.03), and time before surgery (p<0.001), whereas it was inversely related to age (p<0.001), GDS score (p<0.001), and Charlson Index (p<0.001). After adjusting for confounders, the grip strength was directly associated with the probability of both incident and persistent walking recovery (OR highest tertile vs. lowest tertile: 2.84, C.I. 1.76; 4.59 and 2.79, C.I. 1.35; 5.79, respectively). Conclusions In older patients with hip fractures, early grip strength evaluation might provide important prognostic information regarding the patient’s future functional trajectory

Medico-legal assessment of personal damage in older people: report from a multidisciplinary consensus conference

Ageing of the global population represents a challenge for national healthcare systems and healthcare professionals, including medico-legal experts, who assess personal damage in an increasing number of older people. Personal damage evaluation in older people is complex, and the scarcity of evidence is hindering the development of formal guidelines on the subject. The main objectives of the first multidisciplinary Consensus Conference on Medico-Legal Assessment of Personal Damage in Older People were to increase knowledge on the subject and establish standard procedures in this field. The conference, organized according to the guidelines issued by the Italian National Institute of Health (ISS), was held in Bologna (Italy) on June 8, 2019 with the support of national scientific societies, professional organizations, and stakeholders. The Scientific Technical Committee prepared 16 questions on 4 thematic areas: (1) differences in injury outcomes in older people compared to younger people and their relevance in personal damage assessment; (2) pre-existing status reconstruction and evaluation; (3) medico-legal examination procedures; (4) multidimensional assessment and scales. The Scientific Secretariat reviewed relevant literature and documents, rated their quality, and summarized evidence. During conference plenary public sessions, 4 pairs of experts reported on each thematic area. After the last session, a multidisciplinary Jury Panel (15 members) drafted the consensus statements. The present report describes Conference methods and results, including a summary of evidence supporting each statement, and areas requiring further investigation. The methodological recommendations issued during the Conference may be useful in several contexts of damage assessment, or to other medico-legal evaluation fields

The association of indwelling urinary catheter with delirium in hospitalized patients and nursing home residents: an explorative analysis from the "Delirium Day 2015"

BackroundUse of indwelling urinary catheter (IUC) in older adults has negative consequences, including delirium.AimThis analysis, from the Delirium Day 2015, a nationwide multicenter prevalence study, aim to evaluate the association of IUC with delirium in hospitalized and Nursing Homes (NHs) patients.MethodsPatients underwent a comprehensive geriatric assessment, including the presence of IUC; inclusion criteria were age>65 years, being Italian speaker and providing informed consent; exclusion criteria were coma, aphasia, end-of-life status. Delirium was assessed using the 4AT test (score4: possible delirium; scores 1-3: possible cognitive impairment).ResultsAmong 1867 hospitalized patients (mean age 82.07.5 years, 58% female), 539 (28.9%) had IUC, 429 (22.9%) delirium and 675 (36.1%) cognitive impairment. IUC was significantly associated with cognitive impairment (OR 1.60, 95% CI 1.19-2.16) and delirium (2.45, 95% CI 1.73-3.47), this latter being significant also in the subset of patients without dementia (OR 2.28, 95% CI 1.52-3.43). Inattention and impaired alertness were also independently associated with IUC. Among 1454 NHs residents (mean age 84.47.4 years, 70.% female), 63 (4.3%) had IUC, 535 (36.8%) a 4AT score4, and 653 (44.9%) a 4AT score 1-3. The multivariate logistic regression analysis did not show a significant association between 4AT test or its specific items with IUC, neither in the subset of patients without dementia.DiscussionWe confirmed a significant association between IUC and delirium in hospitalized patients but not in NHs residents.ConclusionEnvironmental and clinical factors of acute setting might contribute to IUC-associated delirium occurrence

Understanding Factors Associated With Psychomotor Subtypes of Delirium in Older Inpatients With Dementia

Objectives: Few studies have analyzed factors associated with delirium subtypes. In this study, we investigate factors associated with subtypes of delirium only in patients with dementia to provide insights on the possible prevention and treatments. Design: This is a cross-sectional study nested in the “Delirium Day” study, a nationwide Italian point-prevalence study. Setting and Participants: Older patients admitted to 205 acute and 92 rehabilitation hospital wards. Measures: Delirium was evaluated with the 4-AT and the motor subtypes with the Delirium Motor Subtype Scale. Dementia was defined by the presence of a documented diagnosis in the medical records and/or prescription of acetylcholinesterase inhibitors or memantine prior to admission. Results: Of the 1057 patients with dementia, 35% had delirium, with 25.6% hyperactive, 33.1% hypoactive, 34.5% mixed, and 6.7% nonmotor subtype. There were higher odds of having venous catheters in the hypoactive (OR 1.82, 95% CI 1.18-2.81) and mixed type of delirium (OR 2.23, CI 1.43-3.46), whereas higher odds of urinary catheters in the hypoactive (OR 2.91, CI 1.92-4.39), hyperactive (OR 1.99, CI 1.23-3.21), and mixed types of delirium (OR 2.05, CI 1.36-3.07). We found higher odds of antipsychotics both in the hyperactive (OR 2.87, CI 1.81-4.54) and mixed subtype (OR 1.84, CI 1.24-2.75), whereas higher odds of antibiotics was present only in the mixed subtype (OR 1.91, CI 1.26-2.87). Conclusions and Implications: In patients with dementia, the mixed delirium subtype is the most prevalent followed by the hypoactive, hyperactive, and nonmotor subtype. Motor subtypes of delirium may be triggered by clinical factors, including the use of venous and urinary catheters, and the use of antipsychotics. Future studies are necessary to provide further insights on the possible pathophysiology of delirium in patients with dementia and to address the optimization of the management of potential risk factors