Epidemiological aspects of hip fractures in the elderly

Orientador: Djalma de Carvalho Moreira FilhoTese (doutorado) - Universidade Estadual de Campinas. Faculdade de Ciências MédicasResumo: As fraturas do fêmur proximal (FFP) correspondem a um importante problema de saúde pública em todo o mundo. Dentre todas as fraturas associadas à osteoporose são consideradas como as mais graves e correlacionam-se com os maiores índices de morbimortalidade, dependência funcional e custos para os indivíduos e os sistemas de saúde. O maior crescimento em sua incidência nos próximos anos é esperado nos países em desenvolvimento, todavia, estes também são os locais onde é maior a carência por dados acerca da epidemiologia dos pacientes acometidos por estas fraturas. A presente pesquisa teve como objetivo analisar alguns aspectos desta epidemiologia tanto no âmbito nacional como internacional. Como resultado foram confeccionados três artigos abordando esta temática. O primeiro artigo avaliou, a partir de uma base de dados de todas as hospitalizações por FFP na província de Quebec, no Canadá, a hipótese da equivalência do intervalo de tempo entre a fratura e a cirurgia e o intervalo entre a hospitalização e a cirurgia, enquanto preditores da ocorrência de óbito intra-hospitalar. Após controle para a presença de outras variáveis, nenhum dos intervalos mostrou associar-se com a mortalidade intra-hospitalar. Concluiu-se que, ao menos na medida em que a diferença entre os intervalos sejam pequenas como no caso observado, os mesmos podem ser utilizados de modo intercambiável sem comprometer a interpretação da associação entre o timing cirúrgico e a mortalidade intra-hospitalar, tal como pressuposto em diversos estudos prévios da literatura internacional. O segundo artigo buscou caracterizar o perfil clínico de idosos brasileiros hospitalizados em função de uma FFP, bem como os padrões de tratamento adotados, as complicações intra-hospitalares e a mortalidade ao longo de um ano. Dentre outros resultados de interesse, observou-se uma taxa de mortalidade em um ano de 13,4% (IC95%: 10,1 - 17,5%) e intervalos bastante elevados tanto entre a fratura e a hospitalização (média de 3,6 dias) como entre a internação e a cirurgia (média de 12,8 dias). O terceiro artigo procurou avaliar dentro do contexto brasileiro a associação entre o intervalo de tempo da fratura à cirurgia e a sobrevida dos idosos acomeditos por uma FFP. Após ajuste para variáveis de confundimento observou-se uma associação entre uma maior demora para a internação hospitalar e o óbito (HR: 1,08 , IC95%: 1,04 - 1,12, P < 0,001). Discute-se a questão das FFP enquanto objeto epidemiológico privilegiado, inclusive como um possível evento sentinela a ser monitorado no âmbito da saúde do idoso tanto no plano nacional como internacional.Abstract: Hip Fractures (HF) represent the most severe of all osteoporotic fractures and remain an important cause of mortality, morbidity, dependency and costs for older adults and healthcare systems worldwide. Even though the greatest increase regarding the incidence of HF is expected to occur in the developing countries of the World, those are also the regions from where less information is available regarding the epidemiology of those fractures. The present research aimed to analyze selected aspects of the epidemiology of those fractures both in Brazil and internationally. Three manuscripts were produced as a direct result of this investigation. The first manuscript assessed the widely adopted assumption of interchangeability between the gap from hospital admission to surgical HF repair and the actual gap from fracture to surgery as predictors of in-hospital mortality among HF patients. A database encompassing all HF hospital admissions in Quebec, Canada, was the primary source of data for the analyses undertaken in this study. After statistical adjustment for the presence of other covariates neither of the time intervals to surgery was a significant predictor of in hospital mortality. As a conclusion, at least to the extent of the small differences observed between both gaps, they might be used interchangeably without compromising the interpretation of the relationship between surgical timing and in-hospital mortality, as assumed by previous studies. The second manuscript aimed to describe the clinical profile, treatment patterns, in hospital complications and one-year mortality of elderly Brazilians with an incident HF. Among other findings 13.4% (95%CI: 10.1% - 17.5%) of patients died during the first year and large gaps from fracture to hospital admission (mean 3.6 days) and from hospital admission to surgery (mean 12.8 days) were noted. The third manuscript examined in the context of a developing country the association between surgical timing and the survival of older adults after a HF. After adjusting for the presence of other covariates a small association between delayed hospital admission and reduced survival (HR: 1.08, 95% CI: 1.04 - 1.12) was observed. The point is made that HF should be considered a privileged epidemiological object, which might be used strategically as a sentinel event to be monitored both locally and internationally as a marker of the quality of health care to the elderly.DoutoradoEpidemiologiaDoutor em Saude Coletiv

Cross-cultural conceptualization of a good end of life with dementia:A qualitative study

Background: Research on the nature of a “good death” has mostly focused on dying with cancer and other life-limiting diseases, but less so on dementia. Conceptualizing common cross-cultural themes regarding a good end of life in dementia will enable developing international care models. Methods: We combined published qualitative studies about end of life with dementia, focus group and individual interviews with the researchers, and video-conferencing and continuous email discussions. The interviews were audio-recorded and transcribed verbatim. The data were analyzed thematically, and the researchers developed common themes referring to their original studies. Results: Fourteen qualitative researchers representing 14 cross-cultural studies covering qualitative data of 121 people with dementia and 292 family caregivers. The researchers and data were from eight countries UK, The Netherlands, Japan, Portugal, Germany, Canada, Brazil, and Ireland. Three focus groups, five individual interviews, and video-conferencing were conducted and feedback on multiple iterations was gained by 190 emails between May 2019 and April 2020 until consensus was achieved. Nine cross-culturally common themes emerged from the discussions and shared interpretation of the data of persons with dementia and family caregivers. Three represent basic needs: “Pain and Symptoms Controlled,” “Being Provided Basic Care,” and “A Place like Home.” Other themes were “Having Preferences Met,” “Receiving Respect as a Person,” “Care for Caregivers,” “Identity Being Preserved,” “Being Connected,” and “Satisfaction with Life and Spiritual Well-being.” “Care for Caregivers” showed the greatest difference in emphasis across cultures. Good relationships were essential in all themes. Conclusions: The common cross-cultural themes comprise a framework underpinned by value placed on personhood and dignity, emphasizing that interdependency through relationships is essential to promote a good end of life with dementia. These themes and valuing the importance of relationships as central to connecting the themes could support care planning and further development of a dementia palliative care model.info:eu-repo/semantics/publishedVersio

Evaluation of the Interrater Reliability of End-of-Life Medical Orders in the Physician Orders for Life-Sustaining Treatment Form

IMPORTANCE Despite its spread in much of the United States and increased international interest, the Physician Orders for Life-Sustaining Treatment (POLST) paradigm still lacks supporting evidence. The interrater reliability of the POLST form to translate patients’ values and preferences into medical orders for care at the end of life remains to be studied. OBJECTIVE To assess the interrater reliability of the medical orders documented in POLST forms. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was conducted in a public university hospital in southeastern Brazil. Two independent researchers interviewed the same patients or decision-making surrogates (n = 64) during a single episode of hospitalization within a time frame of 1 to 7 days. Eligible participants were hospitalized adults aged 21 years or older who were expected to remain hospitalized for at least 4 days and whose attending physician responded no to the question, Would I be surprised if this patient died in the next year? Data collection occurred between November 1, 2015, and September 20, 2016, and first data analyses were performed on October 3, 2016. MAIN OUTCOMES AND MEASURES Interrater reliability as measured by κ statistics. RESULTS Of the 64 participants interviewed in the study, 53 (83%) were patients and 11 (17%) were surrogates. Patients’ mean (SD) age was 64 (14) years, and 35 patients (55%) and 8 surrogates (73%) were women. Overall, in 5 cases (8%), disagreement in at least 1 medical order for life-sustaining treatment was found in the POLST form, changing from the first interview to the second interview. The κ statistic for cardiopulmonary resuscitation was 0.92 (95% CI, 0.80-1.00); for level of medical intervention, 0.89 (95% CI, 0.76-1.00); and for artificially administered nutrition, 0.92 (95% CI, 0.83-1.00). CONCLUSIONS AND RELEVANCE The high interrater reliability of the medical orders in POLST forms appears to offer further support for this advance care planning paradigm; in addition, the finding that this interrater reliability was not 100% underscores the need to ensure that patients or their surrogates have decision-making capacity and to confirm that the content of POLST forms accurately reflects patients’ current treatment preferences

To what extent does frailty mediate the association between age and the outcomes of brain reperfusion following acute ischemic stroke?

ObjectiveWe evaluated the extent to which frailty mediated the association between age, poor functional outcomes, and mortality after acute ischemic stroke when patients were treated with brain reperfusion (thrombolytic therapy and/or thrombectomy).Materials and methodsThis retrospective cohort study included patients diagnosed with ischemic stroke who had undergone intravenous cerebral reperfusion therapy and/or mechanical thrombectomy. We created a mediation model by analyzing the direct natural effect of an mRS score &gt; 2 and death on age-mediated frailty according to the Frailty Index.ResultsWe enrolled 292 patients with acute ischemic stroke who underwent brain reperfusion. Their mean age was 67.7 ± 13.1 years. Ninety days after the stroke ictus, 54 (18.5%) participants died, and 83 (28.4%) lived with moderate to severe disability (2 &lt; mRS &lt; 6). In the mediation analysis of the composite outcome of disability (mRS score &gt; 2) or death, frailty accounted for 28% of the total effect of age. The models used to test for the interaction between age and frailty did not show statistically significant interactions for either outcome, and the addition of the interaction did not significantly change the direct or indirect effects, nor did it improve model fit.ConclusionFrailty mediated almost one-third of the effect of age on the composite outcome of disability or death after acute ischemic stroke

Frailty in older adults: perspectives for research and practice in Public Health

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES