[Pain management during pregnancy : An expert-based interdisciplinary consensus recommendation]. / Schmerztherapie in der Schwangerschaft : Eine expertInnenbasierte interdisziplinäre Konsensus-Empfehlung.

BACKGROUND: Pregnancy and pain of different origins is an unfavorable combination that presents all practitioners with special challenges. Pain negatively affects the homeostasis of humans. Patient compliance and in-depth knowledge of the fetotoxicity and teratogenicity of the substances are necessary to maintain a balance between therapy for the mother and safety of the unborn child. OBJECTIVES: Experts from various disciplines who are entrusted with the care of pregnant patients with pain have come together to develop drug and nondrug therapy concepts with the aim of providing adequate analgesia for pregnant pain patients. MATERIALS AND METHODS: Relevant questions were formulated by experts and subjected to a literature search. Combined with further national and international recommendations, treatment concepts were developed and discussed in an interdisciplinary manner. Core statements were then drawn up and given recommendation grades. RESULTS: Depending on the trimester, paracetamol, ibuprofen, diclofenac, metamizole, and opioids can be administered carefully in the event of pain; special care is required with nonsteroidal anti-inflammatory drugs (NSAIDs ) in the last trimester. COX­2 inhibitors are not recommended. For neuropathic pain, amitriptyline, duloxetine, and venlafaxine are considered safe. Non-pharmacological treatment concepts are also available, namely transcutaneous electrical nerve stimulation (TENS therapy), kinesio tapes, and acupuncture. Lymphatic drainage is recommended in cases of edema, if not caused by preeclampsia. CONCLUSIONS: A deliberated concept for pain therapy during pregnancy should be initiated with a non-pharmacological intervention and, if necessary, supplemented with pharmacological agents.

[Pain treatment in old age: special features and recommendations]. / Schmerztherapie im Alter: Besonderheiten und Empfehlungen.

BACKGROUND: For geriatric patients with chronic pain, a comprehensive well-coordinated pain management is pivotal to ensure the best possible pain relief and to minimize as far as possible preventable negative side effects of treatment. OBJECTIVE: Description of the difficulties in pain management of geriatric patients with respect to general basic rules that are worth paying attention to and presentation of pharmacological and non-pharmacological treatment options. METHODS: This article describes the special features of pain management in older patients and gives recommendations on the use of analgesics and potential drug interactions in geriatric patients with organ dysfunction. Furthermore, individual substance groups are described with respect to their use in geriatric patients based on the recent literature. CONCLUSION: The aim of an individualized pain treatment in older and multimorbid patients is the relief of pain to an appropriate level, preservation of mobility, self-reliance and autonomy of each individual. The ability to participate in social activities as well as improvement in the quality of life need to be the focus of pharmacological and non-pharmacological treatment.

[Pain and pain management in old age: special features and recommendations]. / Schmerzen und Schmerzerfassung im Alter: Besonderheiten und Empfehlungen.

INTRODUCTION: Pain is highly prevalent in older persons and has a variety of causes. In geriatric patients, especially in patients with dementia, pain is often not sufficiently recognized and therefore frequently remains untreated. For the affected patient group this can have far-reaching consequences for their functional and cognitive abilities and may consequently lead to loss of autonomy. OBJECTIVE: Existing deficits of pain assessment for geriatric patients are described, with a primary focus on those patients suffering from cognitive impairments and pain. In addition, the influence of multimorbidity on pain management in old age is considered in detail. METHODS: The diagnostics and measurement of pain in older individuals are described based on recent literature and corresponding instruments used in the assessment of pain are outloned. The authors pay special attention to the possibilities of pain measurement in patients with higher grade cognitive impairments and non-communicative patients. CONCLUSION: A standardized pain assessment should be an integral component in the care and treatment of geriatric patients and individuals suffering from dementia. Validated instruments for pain measurement exist for both groups and should be integrated into daily clinical practice.

[Physical medical aspects of early rehabilitation after proximal femoral fractures]. / Physikalisch-medizinische Aspekte der Frührehabilitation nach proximaler Femurfraktur.

Proximal femoral fractures in old age are known as fragility fractures. They are the sequelae of osteoporosis and an expression of a general reduced capacity and an increase in sensory and functional deficits against the background of multimorbidity. They are often caused by reduced compensation strategies. Simultaneously, for many older people they represent a life event. Despite modern osteosynthesis techniques and less stressful anesthesia procedures, the occurrence of a proximal femoral fracture shakes the labile equilibrium of those affected. Proximal femoral fractures are associated with a high risk of mortality. Only some 50% of those affected achieve the pretraumatic functional level again. Therefore, a comprehensive, multiprofessional and interdisciplinary management of these patients is required. The rehabilitation has to start at the time of diagnosis and at the latest after the operation with a comprehensive interdisciplinary management. Pain and complaints during the rehabilitation have to be clarified and targeted, mostly multimodal interventions, must be included.

Proof of Concept of a Partial Weight-Bearing Supporting Real-Time Feedback System.

BACKGROUND: Patient compliance with lower limb partial weight bearing (PWB) instructions during post-surgical early mobilization is often low and many are unable to adhere to the prescribed limits without the implementation of concurrent biofeedback. OBJECTIVES: A real-time feedback system based on eSHOE instrumented insoles was tested in order to preliminarily quantify its efficiency at improving geriatric patients' compliance. METHODS: In order to gain a proof of concept, measurements with one patient after a hip fracture were carried out. The compliance with the prescribed load restriction was measured on four measurement dates, first without and then with the feedback. The number of correctly loaded steps (NCS), the mean peak load (MPL) and the maximal load (ML) were considered. RESULTS: Preliminary results of one patient show that NCS was nearly doubled and the MPL was reduced to acceptable limits, while the ML was reduced on three of the four days. CONCLUSION: The results indicate that the developed system is easily implementable into the rehabilitative routine and has a positive effect on PWB performance of geriatric subjects while walking.

Mobile gait analysis via eSHOEs instrumented shoe insoles: a pilot study for validation against the gold standard GAITRite®.

Clinical gait analysis contributes massively to rehabilitation support and improvement of in-patient care. The research project eSHOE aspires to be a useful addition to the rich variety of gait analysis systems. It was designed to fill the gap of affordable, reasonably accurate and highly mobile measurement devices. With the overall goal of enabling individual home-based monitoring and training for people suffering from chronic diseases, affecting the locomotor system. Motion and pressure sensors gather movement data directly on the (users) feet, store them locally and/or transmit them wirelessly to a PC. A combination of pattern recognition and feature extraction algorithms translates the motion data into standard gait parameters. Accuracy of eSHOE were evaluated against the reference system GAITRite in a clinical pilot study. Eleven hip fracture patients (78.4 ± 7.7 years) and twelve healthy subjects (40.8 ± 9.1 years) were included in these trials. All subjects performed three measurements at a comfortable walking speed over 8 m, including the 6-m long GAITRite mat. Six standard gait parameters were extracted from a total of 347 gait cycles. Agreement was analysed via scatterplots, histograms and Bland-Altman plots. In the patient group, the average differences between eSHOE and GAITRite range from -0.046 to 0.045 s and in the healthy group from -0.029 to 0.029 s. Therefore, it can be concluded that eSHOE delivers adequately accurate results. Especially with the prospect as an at home supplement or follow-up to clinical gait analysis and compared to other state of the art wearable motion analysis systems.

[Quality assurance of pain care in Austria : Classification of management facilities]. / Qualitätssicherung der schmerzmedizinischen Versorgung in Österreich : Klassifikation schmerztherapeutischer Einrichtungen.

In Austria there is no nationwide coverage of pain management, which meets even approximately international criteria. At present there are about 30 interdisciplinary pain management offices and clinics providing care according to a concept of the Austrian Pain Society (ÖSG), about 10 other outpatient pain clinics are located in district and country hospitals. A few years ago, there still were about 50 pain clinics. Yet closure of outpatient clinics and cost-cutting measures in the health sector jeopardize adequate pain relief for patients with chronic pain conditions.Hence, the supply of care for approx. 1.8 mio. Austrians with chronic pain is not guaranteed due to lack of a comprehensive demand planning of pain care facilities. Furthermore, existing structures such as specialized clinics or emergency services in hospitals are primarily based on the personal commitment of individuals. At present, the various centres for pain management in Austria are run with very different operating times, so that for 74% of the chronic pain patients the desired requirements for outpatient pain management are not met and about 50 full-time pain clinics are missing.Under the patronage of the Austrian Pain Society, various national specialist societies have defined the structure and quality criteria for pain management centres in Austria, include, among others, proof of training, cooperation in interdisciplinary teams or minimum number of new patients per year, depending on the classification of the institution.This stepwise concept of care provision for pain patients is intended as first step to help improve the care of pain patients in Austria!

Aspects of physical medicine and rehabilitation in geriatrics.

Specialists in physical medicine and rehabilitation are important partners during the ageing process: health promotion and prevention for fit elderly people, training and rehabilitation for prefrail people and support for frail people focusing on usage of what is left and dignity in the latest period of life. The main focus is the relationship between IC diagnoses and functioning in everyday life based on the International Classification of Functioning (ICF). The diseases lead to possible treatments; functioning shows the importance of rehabilitative strategies in a team approach. Physiatrists are experts on this complex issue.The main goal of rehabilitative strategies during life course is to maintain function, improve quality of life and delay dependency and need of care.Three settings are chosen to show the different aspects of physical medicine and rehabilitation: health promotion and prevention, rehabilitation and palliative-rehabilitative procedures in long-term care. The non-pharmaceutical treatment of pain, the geriatric assessment, knowledge in discharge management and team communications are important skills.

[Procedural organisation: surgical and anaesthesiological management in hip fractures]. / Ablauforganisation - unfallchirurgisches und anästhesiologisches Management bei Hüftfrakturen.

In patients with hip fractures, in order to reduce the high number of general complications and those associated with the specific treatment, the functional loss and cognitive impairment, implementation of co-ordinated, multidisciplinary treatment pathways, and rehabilitation, is mandatory. The imminent treatment of proximal femoral fracture consists of major orthopaedic surgery in most cases (total or partial hip arthroplasty, osteosynthesis). After the diagnosis of a hip fracture, an adequate pain medication should be initiated. The decision making for the fracture treatment includes fracture type, patient's age, cognitive function, mobility before the fall and functional demands of the patient in the context of patients life expectancy and goals of care. The anaesthesiological evaluation focuses on risk assessment. Medical abnormalities should be optimized within 24 to 48 h, or an increased perioperative risk due to comorbidities has to be accepted. The timing and the course of further preoperative diagnostic examinations and therapeutic interventions should be co-ordinated between the involved medical disciplines. After the operation a structured screening for delirium should be initiated and further evaluation of patient's nutrition, fall-associated medication, living conditions and osteoporosis treatment has to be performed.

Rehabilitation after hip fracture.

Low-trauma hip fracture in old age leads to impairment, increased need of care and mortality. Rehabilitation should start in the department for traumatology and accompany the patient through different settings until the pretraumatic status is reached. Besides the surgical procedure and the medical management of an aged person with complex disease and polypharmacy, the multidisciplinary rehabilitation process is an important factor for regaining ability for self-care and autonomous decisions. Pain management supports the process. The ideal setting is not clear yet. Besides established rehabilitation facilities for elderly people, including the departments for 'Akutgeriatrie/Remobilisation', the 'Outreach Geriatric Remobilisation' project offers new perspectives. It was designed to remobilise patients with multimorbidity in their own homes.

Stress ulcer prophylaxis, thromboprophylaxis and coagulation management in patients with hip fractures.

Hip fracture in older patients is a major health concern. 20-25 % of hip fracture patients will die in the first year after the trauma (Lane, Clin Orthop Relat Res 471(8):2711, 2013). Postoperative venous thrombosis and gastrointestinal stress-ulcer bleeding are frequent complications with a high case-fatality rate particularly in older patients. Thromboprophylaxis and stress ulcer prophylaxis are important and well established measures to decrease postoperative complications and the mortality rate in this high-risk population.The working group on orthogeriatrics of the Austrian Society on Geriatrics and Gerontology (ÖGGG) is composed of geriatricians who work as trauma surgeons, internists, anaestesists and nurses. A thorough literature search was done, using the terms "orthogeriatrics" and "hip fracture" in combination with "stress ulcer", "gastrointestinal bleeding" and "thrombosis", "thromboprophylaxis". The data was collected, discussed and evaluated in several adjustment meetings of the group and summarized in this article.

Treatment and prevention of postoperative complications in hip fracture patients: infections and delirium.

The course of older patients with hip fractures is often complicated by infections and delirium. Accurate care and high suspicion for these complications are essential, since these conditions are associated with an increase in mortality, length of hospital stay and nursing home placement, poorer mobility, and functional decline. Because of immunosenescence and higher infection rates, older patients need specific care, immediate diagnosis, and treatment of infections. Numerous guidelines of various medical societies outline the management of nosocomial infections, but there is a need of an individualized treatment plan because of comorbidities and polypharmacy. Hygiene measures have first priority to reduce the rate of infections. Treatment of geriatric syndromes like malnutrition, exsiccosis, gait disorders, falls, delirium, urine incontinence, and organ insufficiency are as important as immunization against pneumococci and influenza. Advanced age, cognitive impairment, hearing loss, peripheral vascular disease, prior delirium episodes, sight disorders, and polypharmacy are established risk factors for delirium; thus, older people with several chronic diseases are prone to delirium. A multifactorial approach, comprising standardized screening, oxygen support, intravenous fluid administration and augmented nutrition, monitoring of vital signs, pain treatment, optimized medication, and modification in perioperative management, significantly reduces delirium incidence during hospitalization for hip fracture. An interdisciplinary approach between surgeons and geriatricians may warrant optimized satisfaction of patients' needs.

Development and validation of a patient safety culture questionnaire in acute geriatric units.

BACKGROUND: Older patients (≥65 years) are exposed to more harm resulting from adverse events in hospitals than younger patients. Theoretical considerations and empirical findings suggest that safety culture is the key to improving the quality of health care. OBJECTIVE: To describe the development of a German-language instrument for assessing patient safety culture (PSC) and its reliability and validity; to verify criterion validity by means of a cross-sectional analysis of the impact of PSC on clinical quality that compares acute geriatric units with a sample from intensive care, surgery and trauma surgery departments, and to report variations in the PSC profile between these groups. METHODOLOGY: Using a review of existing safety culture surveys, multidimensional scaling procedures and expert interviews, we tested the content and convergent validity of a 158-item questionnaire completed by 508 physicians and nurses from 31 acute geriatric units and 7 comparison departments. Criterion validity was verified by various regression models with a self-reported measure of adverse events. Differences in PSC profiles were analyzed using a one-factorial ANOVA and regression models. RESULTS: We identified 7 constructs of PSC and demonstrated substantial convergent and criterion validity. In the acute geriatric units, higher levels of 'management commitment to patient safety' and lower levels of 'error fatalism' were associated with a reduced incidence of medical errors. In the comparison group, only the variable 'active learning from mistakes' was relevant for safety performance. Our results also indicate that acute geriatric units display higher standards than the comparison group in all the aspects of patient safety examined. CONCLUSION: It is possible to measure salient features of PSC using a valid and reliable survey. Some aspects of PSC are more closely related to safety events than others. In acute geriatric units, patient safety appears to be influenced mainly by management's determination of how things are done whereas improvement of the system itself in a more incremental manner is required in the other high-risk ward types.

Pharmacologic undertreatment of osteoporosis in Austrian nursing homes and senior's residences.

Osteoporosis is a classical age-related disease. Although significant progress in treatment has been achieved and antifracture efficacy proven over the past years undertreatment is still a general problem. There are only few published data available regarding osteoporosis and its treatment encountered in Austrian nursing homes and seniors' residences where fractures are especially frequent. We therefore conducted a survey in 89 participating institutions in order to assess frequency of documented osteoporosis as well as prevalence status of anti-osteoporotic drug usage in this special population. Data were acquired using a questionnaire and analyzed in a descriptive manner. Mean age of the residents was 82 years and the majority was female (76%). Half of the subjects took 5-8 different drugs per day and 23% received more than 8. Almost one-fourth (21.2%) of the residents had a diagnosis of osteoporosis. A history of hip fracture or other fractures was documented in 10.4% and 13.2%, respectively. Only 8.2% of the residents were treated with calcium, 6.2% with vitamin D and 9.3% received a combination of vitamin D and calcium. Specific osteoporosis treatment was prescribed to 7.2% only. In conclusion, this study reflects a high degree of continuing unawareness toward a diagnosis of osteoporosis in Austrian nursing homes and seniors' residences. The data of this survey further indicate that undertreatment is still very common in this population at very high risk of fractures.

[Problems of pain measurement and pain therapy in the elderly]. / Problemfelder in der Schmerzmessung und Schmerztherapie im Alter.

Due to complex physical and psychological changes in aging, pain measurement and therapeutic treatment of older and geriatric patients present a special challenge. Nevertheless, even for this category of patients, good treatment results are achievable if age-related particulars and problems are consistently heeded and accounted for. That includes adverse sensory and cognitive effects as much as multimorbidity and the polypharmacy that is frequently related to it. An essential prerequisite for adequate pain therapeutic care in elderly patients is consistent pain measurement. While numerical and verbal scales have also proven their usefulness for patients in advanced age who are not cognitively impaired, instruments must be applied for older people with communicative and/or cognitive restrictions with which the observed behavior of those involved can be surveyed in a multidimensional way.

[Falls and osteoporoses]. / Stürze und Osteoporose.

Falls are common in each period of life. They become more important in old age as they may lead to impairment and handicap, as well as to an increased need for social and financial support, or to admission to nursing homes. Although geriatric syndromes are well known, the entity of osteoporoses, gait disturbances and falls is not established in community based health services. There are many reasons for the negotiation--lack of awareness in professionals as well in the people themselves, lack of time and lack of financing by health insurance, fear of consequences, as admission to a nursing home. Therefore it would be of interest to raise the awareness in medical professions, especially in general practitioners. Cochrane data analysis proves the efficiency of fall prevention programmes, mainly of exercise and environmental adaptations.

Health-related quality of life of patients with hip fracture before and after rehabilitation therapy: discrepancies between physicians' findings and patients' ratings.

BACKGROUND AND AIMS: Health-related quality of life (HrQoL) is broadly accepted as an evaluation criterion of medical therapy effects. The major objectives of this work are a) measuring of the effects of rehabilitation therapy on the HrQoL of elderly patients after hip fracture, and b) study of discrepancies between the physician's findings on one hand and subjective ratings of patients on the other, and their influence on HrQoL, depression, and independence in activities of daily living. METHODS: The study sample consisted of 95 patients surgically treated after a fall-induced hip fracture (mean age=82 years; range=61-97). Using the median as splitting criterion, ratings of patients and physicians concerning disturbance-specific functional capacity were subdivided into positive and negative. This led to separation of the sample into four subgroups: the fortunate (congruent positive ratings), satisfaction paradox (positive subjective, negative objective ratings), dissatisfaction dilemma (negative subjective, objective positive ratings), and the unfortunate (congruent negative ratings). RESULTS: The four patient subgroups diverged in their estimations. The subgroups of the fortunate and satisfaction paradox have had the highest subjective gains in HrQoL. The subgroups of dissatisfaction dilemma and the unfortunate estimated their gains as similarly low on most of the tested scales. CONCLUSIONS: Results stress the importance of subjective factors in processes concerning therapy evaluations and their influence on HrQoL. The objective success of therapy is not of primary importance for the extent of the HrQoL, but subjective evaluation of it is.