Should patients with exceptional longevity be treated for osteoporosis after a hip fracture?

BACKGROUND: There are no studies focusing on treatment for osteoporosis in patients with exceptional longevity after suffering a hip fracture. OBJECTIVE: To assess the advisability of initiating treatment for osteoporosis after a hip fracture according to the incidence of new fragility fractures after discharge, risk factors for mortality and long-term survival. DESIGN: Retrospective review. SETTING: A tertiary university hospital serving a population of ~425 000 inhabitants in Barcelona. SUBJECTS: All patients >95 years old admitted with a fragility hip fracture between December 2009 and September 2015 who survived admission were analysed until the present time. METHODS: Pre-fracture ambulation ability and new fragility fractures after discharge were recorded. Risk factors for 1-year and all post-discharge mortality were calculated with multivariate Cox regression. Kaplan-Meier survival curve analyses were performed. RESULTS: One hundred and seventy-five patients were included. Median survival time was 1.32 years [95% confidence interval (CI) 1.065-1.834], with a maximum of 9.2 years. Male sex [hazard ratio (HR) 2.488, 95% CI 1.420-4.358] and worse previous ability to ambulate (HR 2.291, 95% CI 1.417-3.703) were predictors of mortality. After discharge and up to death or the present time, 10 (5.7%) patients had a new fragility fracture, half of them during the first 6 months. CONCLUSIONS: Few new fragility fractures occurred after discharge and half of these took place in the first 6 months. The decision to start treatment of osteoporosis should be individualised, bearing in mind that women and patients with better previous ambulation ability will have a better chance of survival.

Indoor falls and number of previous falls are independent risk factors for long-term mortality after a hip fracture.

BACKGROUND: Hip fractures are almost always the result of a fall. Causes and circumstances of falls may differ between frail and vigorous patients. AIM: To describe the circumstances of falls causing hip fractures, number of falls during the previous year, and their association with long-term mortality. PATIENTS AND METHODS: The study is a retrospective review conducted in a tertiary university hospital serving a population of 425,000 inhabitants in Barcelona. All patients admitted with hip fractures with medical records describing the circumstances and number of previous falls were included. The number of falls in the previous 12 months was recorded, including the one causing the fracture. The circumstances of the index fall were dichotomized according to whether it was from the patient's own height or above; day or night; indoors or outdoors, due to intrinsic or extrinsic causes. Cumulative mortality was recorded for almost 5 years after hip fracture. RESULTS: Indoor falls were strongly associated with shorter survival. Falling more than once in the previous year was also a risk factor for long-term mortality (hazard ratio 1.461, p < 0.001 and hazard ratio 1.035, p = 0.008 respectively). CONCLUSION: Indoor falls and falling more than once in the previous year are long-term risk factors for mortality after hip fractures. It is always essential to take a careful patient history on admission to determine the number of falls and their circumstances, and special care should be taken to reduce mortality in patients at high risk.

Hip fracture and mortality: study of specific causes of death and risk factors.

The leading causes of mortality in our study were pneumonia, diseases of the circulatory system, and dementias. In patients with hip fractures, the emphasis should be placed not only on measures to prevent falls and osteoporosis, but also on preventing functional decline and pneumonia. PURPOSE: To describe the specific causes of death in patients who died up to 2 years after sustaining a hip fracture, how many of those deaths were directly related to the hip fracture, and the risk factors for mortality. METHODS: A retrospective review of the clinical data of all patients admitted with hip fractures between December 2009 and September 2015. Cause of death was classified according to the International Statistical Classification of Diseases and Related Health Problems (ICD10) RESULTS: In the first 2 years after hip fracture, 911 patients (32.7%) died. The leading causes of mortality were pneumonia 177 (19.4%), diseases of the circulatory system 146 (16%), and dementias 126 (13.9%). Thirty patients (3.2%) died from causes directly related to hip fracture or surgery. Mortality risk factors with a higher relative risk were advanced age, male sex, higher comorbidity, delirium, and medical complications during admission. CONCLUSIONS: Pneumonia and circulatory system diseases were the commonest causes of death in our study. In patients with hip fractures, emphasis should be placed on preventing functional decline and pneumonia. In a few patients, death was directly related to the hip fracture, although decompensation of chronic illness as a result of hip fracture and fracture-related functional decline may have been indirect causes. Patients with worse conditions at admission had the highest risk of mortality.

Assessing nutritional status in the elderly evaluation of Chumlea equations for weight.

BACKGROUND: Weight is one of the most important parameters in assessing nutritional status. However, weight can be difficult to measure in elderly people who are unable to stand. Chumlea et al. created two equations to estimate weight in non-ambulatory patients using readily available body measurements. OBJECTIVE: The aim of the study is to analyze the usefulness of Chumlea equations in assessing nutritional status of elderly hospitalized patients. METHODS: We measured weight, height, arm and calf circumference, subscapular skinfold and knee height of 82 hospitalized elderly patients, all of whom were able to stand. Estimated weight (EW) was obtained by Chumlea equations. Body mass index (BMI) and Mini Nutritional Assessment test (MNA) were calculated using actual weight and EW. Bland-Altmann analysis and intraclass correlation coefficient (ICC) between real and estimated parameters were assessed. RESULTS: We found a statistically significant ICC between actual weight and EW (r = 0.926), real BMI and estimated BMI (r = 0.910) and real MNA and estimated MNA (r = 0.982) (p < 0.001). Chumlea equations, however, underestimated weight: 54.05 (DS 11.88) vs 61.46 (DS 13.08); BMI: 22.30 (DS 4.61) vs 25.36 (DS 5.17) and MNA: 22.73 (DS 4.43) vs 23.30 (DS 4.33) (P<0.001). In spite of this underestimation, estimated MNA detected 100% of patients malnourished and 96% of those at risk of malnutrition. CONCLUSIONS: Results obtained by Chumlea equations showed a good ICC with actual body weight and real BMI and MNA, but values were underestimated. These equations can be useful to detect undernourished hospitalized elderly patients.

[Anemia in the elderly]. / Anemia en el anciano.

Anemia is a common disorder in the elderly and is associated with increased morbidity and mortality. In elderly subjects, in whom anemia is highly prevalent, there are several aspects, such as a hemoglobin at a level which should concern us limit, or identifying its causes, that are not easy to establish. This review focuses on knowing what is considered to be normal hemoglobin levels in adults and the common causes and potential consequences of anemia in elderly patients. It provides a diagnostic algorithm and an approach to treatment that addresses new treatments such as parenteral iron drugs and erythropoiesis-stimulating agents.

[Hospitalizations due to chronic obstructive pulmonary disease in the elderly]. / Hospitalizaciones por EPOC en el paciente anciano.

INTRODUCTION: Hospitalizations for decompensation of chronic obstructive pulmonary disease (COPD) mainly occur in the elderly. The aim of this study was to describe the characteristics of octogenarians admitted for COPD and to compare these characteristics with those in a younger group. MATERIAL AND METHODS: All patients hospitalized for COPD in an acute care hospital over three time periods were studied. All patients met spirometric criteria for COPD. A questionnaire evaluating items on prior admissions, days of hospital stay and readmissions in the subsequent year was completed. Data on comorbidity (the Charlson index), functional dependency (Katz index), depression (Yesavage scale), domiciliary medication, socioeconomic position, social resources, and quality of life, among other factors, were gathered. RESULTS: We studied 390 patients, with a mean age of 72 years (SD 9.6), of whom 88 (22%) were aged more than 80 years old. The mean length of hospital stay was 11.4 days, FEV(1) at discharge was 39% of the theoretical value, and 55% of the patients were readmitted in the following year, with no differences between age groups. Patients older than 80 years had a lower body mass index (P<.03), greater comorbidity (P<.001), greater functional dependency (P<.001) and worse scores on the Pffeifer (P<.001) and Yesavage scales (P<.01). CONCLUSIONS: Octogenarians hospitalized for COPD exacerbations have greater comorbidity, depressive features and functional dependency than younger patients. Nevertheless, no differences were found in the length of hospital stay or in readmissions in the following year.

Predictive items of functional decline and 2-year mortality in nonagenarians--the NonaSantfeliu study.

BACKGROUND: Few studies have prospectively evaluated predictors of mortality or decline in functional capacity in nonagenarians. The aim of this study is to determine predictors of death or functional decline in basic activities of daily living in nonagenarians after 2 years of follow-up. METHODS: One hundred and seventy-six nonagenarians were prospectively evaluated. Functional status was determined by the Lawton-Brody index (LI) and the Barthel Index (BI), and cognition by the Spanish version of the Mental State Examination. The Charlson score was used to measure co-morbidity. Nutritional status was evaluated by the short version of the Mini Nutritional Assessment questionnaire. RESULTS: The sample comprised 135 women (76.3%) and 41 men. Mean age was 93 +/- 3.2 years. Mortality after 2 years was 36.3%. Forty-six (41%) of the 112 survivors presented BI losses >19%. One hundred and ten subjects (63%) presented the combined negative outcome item (death or functional decline). A multiple stepwise logistic regression analysis identified two variables associated with a fall of >19% on the BI or death: a low LI (odds ratio 0.785, 95% CI 0.656-0.940) and a low score at baseline on the Spanish version of the Mental State Examination (odds ratio 0.950, 95% CI 0.914-0.987). CONCLUSION: Better cognitive status and higher capacity to perform instrumental activities of daily living (ADL) at baseline are the best predictors to identify which nonagenarians survived without major functional decline after a 2-year follow-up period.

Predictive items of one-year mortality in nonagenarians. The NonaSantfeliu Study.

BACKGROUND AND AIMS: Few studies have prospectively evaluated predictors of mortality in nonagenarian cohorts. Our objective was to determine a set of predictors of all-cause mortality in a cohort of nonagenarians after one year of follow-up. METHODS: 186 nonagenarians were evaluated prospectively, 137 of whom lived in their own homes (74%) and 49 (26%) were institutionalized. Functional status was determined by the Lawton-Brody (LI) and Barthel Index (BI), and cognition by the Spanish version of the Mini Mental State Examination (MEC). The Charlson score was used to measure global comorbidity. Nutritional status was evaluated by the short version of the Mini Nutritional Assessment questionnaire (short- MNA). RESULTS: The sample was composed of 143 women (76.5%) and 43 men, with a mean age of 93.06 (3.1) years. The rate of mortality was 19.3%. There were no differences in mortality between men and women. Although the BI and LI were both related to 1-year mortality in bivariate, unadjusted analysis, their contribution was minimal in multivariate analyses. Age, heart failure and short-MNA remained associated with mortality in the multivariate analyses. CONCLUSIONS: This study supported the importance of age, heart failure and nutritional status in predicting 1- year mortality in nonagenarians.

No correlation between mini-nutritional assessment (short form) scale and clinical outcomes in 73 elderly patients admitted for hip fracture.

BACKGROUND AND AIMS: Malnutrition in general and protein deficiency in particular, both upon admission and during the recovery period, may adversely influence the clinical outcome after hip fracture. This study investigates the relationship between nutritional status measured by the Mini-Nutritional Assessment short form (MNA-SF) and biological markers in elderly hip-fractured patients. METHODS: A prospective study in a university hospital. The MNA-SF nutritional scale and laboratory values (serum albumin, cholesterol, total lymphocyte count) were assessed within three days after hip fracture surgery. RESULTS: Seventy-three patients were included: 61 (84%) were women and 12 men. Mean age was 81.5+/-7.1 years. Inhospital mortality was 10%. The mean MNA-SF score was 11+/-0.5 (range 3-14); according to these values, 39 patients (53%) were at risk of malnutrition. MNA-SF scores were not significantly correlated to patients' laboratory values. Fourteen episodes of nosocomial infection were diagnosed in 11 patients, and 6 patients developed pressure ulcers during hospitalization. CONCLUSIONS: MNA-SF test scale values reflect a clinical process in post-operative hip-fractured patients which is different from serum albumin, cholesterol or lymphocyte count.