Socioeconomic and living conditions are determinants of hip fracture incidence and age occurrence among community-dwelling elderly.

UNLABELLED: In this prospective, 10-year study in community-dwelling elderly aged 50 years and over, hip fracture incidence and accordingly age at hip fracture were inversely associated with the area-level income, independently of the geographical area. Age at hip fracture also depended of marital status but in a gender-specific way. PURPOSE: The purpose of this study is to investigate the impact of socioeconomic and living conditions on hip fracture incidence and age occurrence among community-dwelling elderly. METHOD: Between January 1991 and December 2000, 2,454 hip fractures were recorded in community-dwelling adults aged 50 years and over in the Geneva University Hospital, State of Geneva, Switzerland. Median annual household income by postal code of residence (referred to as area-level income) based on the 1990 Census was used as a measure of socioeconomic condition and was stratified into tertiles (< 53,170; 53,170-58,678; and ≥ 58,678 CHF). Hip fracture incidence and age occurrence were calculated according to area-level income categories and adjusted for confounding factors among community-dwelling elderly. RESULTS: Independently of the geographical area (urban versus rural), community-dwelling persons residing in areas with the medium income category presented a lower hip fracture incidence [OR 0.91 (0.82-0.99), p = 0.049] compared to those from the lowest income category. Those in the highest income category had a hip fracture at a significant older age [+1.58 (0.55-2.61) year, p = 0.003] as compared to those in the lowest income category. Age at hip fracture also depended on marital status but in a gender-specific way, with married women fracturing earlier. CONCLUSIONS: These results indicate that incidence and age occurrence of hip fracture are influenced by area-level income and living conditions among community-dwelling elderly. Prevention programs may be encouraged in priority in communities with low income.

Reversal of the hip fracture secular trend is related to a decrease in the incidence in institution-dwelling elderly women.

UNLABELLED: In this prospective 10-year study in elderly aged 60 years and over, there was a 1.3% per year reduction in the standardized incidence of hip fracture in women but not in men. This decrease was mainly due to changes in the standardized incidence of hip fracture in institution-dwelling women. INTRODUCTION: A decrease in age-adjusted hip fracture incidence has been recently demonstrated in some countries. Since a large proportion of hip fractures occur in nursing homes, we analyzed whether this decreasing trend would be more detectable in institution-dwelling elderly compared with community-dwelling elderly. METHODS: All hip fracture patients aged 60 years and over were identified in a well-defined area. Incidence of hip fracture, age- and sex-adjusted to the 2000 Geneva population, was computed in community- and institution-dwelling elderly. RESULTS: From 1991 to 2000, 1,624 (41%) hip fractures were recorded in institutionalized-dwelling elderly and 2,327 (59%) in community-dwelling elderly. The standardized fracture incidence decreased by 1.3% per year in women (p = 0.039), but remained unchanged in men (+0.5%; p = 0.686). Among institution-dwelling women, hip fracture incidence fell by 1.9% per year (p = 0.044), whereas it remained stable among community-dwelling women (+0.0%, p = 0.978). In men, no significant change in hip fracture incidence occurred among institution- or community-dwelling elderly. CONCLUSIONS: The decrease in the standardized hip fracture incidence in institution-dwelling women is responsible for the reversal in secular trend. Future research should include stratification according to the residential status to better identify the causes responsible for the trend in hip fracture incidence.

Incidence of hip fracture over a 10-year period (1991-2000): reversal of a secular trend.

INTRODUCTION: Hip fractures are a major cause of burden associated with osteoporosis in terms of mortality, disability, and costs. With the ageing of the population, a marked increase in the number of fractures is expected. Furthermore, many studies reveal an increase of the age-adjusted hip fracture incidence. We specifically examined secular changes in the incidence of hip fracture in women and men aged 50 years and over in the well-defined area of Geneva, Switzerland. MATERIALS AND METHODS: All hip fractured patients were retrospectively identified from the computer medical records of the main hospital, which is receiving 95% of hip fractures occurring in a well-defined area. RESULTS: From 1991 to 2000, 4115 hip fractures were recorded in 2981 women and 822 men with a mean age (+/-S.D.) of 83.1+/-8.9 and 78.3+/-11.6 years, respectively. A second hip fracture occurred in 276 women (9.3%) and 36 men (4.4%), on average 2.1+/-1.9 (median 1.44) years after the first event without gender difference. The overall incidence of hip fractures was 455 (95% CI: 439-471) per 100,000 person-years in women and 153 (95% CI: 143-163) in men. The number of hip fractures remained constant (412 (95% CI: 397-426)), but the mean age of these patients increased each year by 0.13 year in women (p=0.019) and by 0.04 year in men (NS). Furthermore, the age-adjusted incidence of hip fractures, standardized to the 2000 Geneva population, decreased significantly by 1.4% (95% CI: -2.6 to -0.1) per year in women (p=0.021), but remained stable in men (0.5% (95% CI: -1.7 to +2.8) per year, p=0.66). The overall female/male ratio of hip fracture incidence was 2.99 (95% CI: 2.80-3.18, p<0.001) and significantly decreased by 0.07 (95% CI: -0.13 to -0.01) per year (p=0.024). CONCLUSION: Despite an increase in the population at risk and in the mean age of hip fractured women, there was a significant decrease in age-adjusted incidence in women but not in men. These results may suggest a reversal of the previously observed secular trend.

Zinc status of healthy elderly adults: response to supplementation.

The zinc status of 53 healthy elderly subjects was evaluated. The dietary Zn intake estimated by 24-h recall was 9.2 mg/d and 65% of subjects had intakes less than two-thirds of the RDA. Mean serum Zn concentration (13.0 mumol/L) and urinary Zn excretion (7.0 mumol/d) were normal. The Zn content of platelets, mononuclear cells, and polymorphonuclear cells was 5.8, 147, and 135 nmol/10(9) cells, respectively. Seventeen subjects were supplemented for 28 d with 30 mg Zn/d. The mean concentration of Zn in serum and urine increased 24% and 2.5-fold, respectively. Zn content of platelets and leukocytes did not change with Zn supplementation. The concentration of visceral proteins (ie, albumin, prealbumin, transferrin, and retinol-binding protein) and immunoglobulins (ie, IgG, IgA, and IgM) did not change with Zn supplementation. The data indicate that aging per se does not necessarily imply poor Zn status.

Nutrition and oral health.

Reduced chewing function in community-dwelling older people with adequate general health is linked to having fewer than 20 teeth present or to wearing removable dentures. By chewing for longer periods of time or swallowing larger food particles they are normally able to compensate for the impaired function. The masticatory function can be restored by adequate prosthetic therapy, which results in increased activity of the masticatory muscles during chewing and reduces the chewing time and the number of chewing strokes until swallowing. In frail or dependent elderly people undernutrition is prevalent because of health problems, reduced appetite and poor quality of life. Poor oral health and xerostomia are often associated with a reduced body mass index and serum albumin level and the avoidance of difficult-to-chew foods. Maintenance or re-establishment of masticatory function is an integral part of the medical health care of these patients, with the aim of improving their nutritional status and quality of life.

Metabolic and hormonal changes induced by hypodermoclysis of glucose-saline solution in elderly patients.

BACKGROUND: Hypodermoclysis, i.e., infusion of solutions into the subcutaneous tissues, is an alternative method for hydration. The aim of our study was to describe the metabolic changes induced by hypodermoclysis of a glucose-saline solution in elderly patients. METHODS: Twelve experiments were conducted in a random cross-over study, intravenous infusion (IV) vs subcutaneous infusion (SC), in 6 hospitalized patients (81.5 +/- 9.8 years). The solution (1000 mL of 5% glucose solution containing 4 g NaCl) was infused over 6 hours in fasted patients who remained in bed. Blood was sampled at -10, 0, 30, 60, 90, 120, 180, 240, 300, and 360 minutes for measurement of plasma concentrations of glucose, insulin, free fatty acids, and beta-hydroxybutyrate. Plasma concentration of cortisol was analyzed only at T-10, T0, T180, and T360. RESULTS: The increases in glucose and insulin and the decrease in plasma concentrations of free fatty acids were lower with SC infusion than with IV infusion. The decrease in beta-hydroxybutyrate plasma concentration was lower at T300 with SC infusion than with IV infusion. The decrease in cortisol did not differ with the route. Plasma concentrations of all compounds were similar at T360. CONCLUSION: We conclude that hypodermoclysis of glucose-saline solution induced similar but smaller metabolic and hormonal changes than the IV infusion.

Dehydration in dying patients: study with physicians in French-speaking Switzerland.

We surveyed physicians in French-speaking Switzerland to assess the perception of suffering resulting from dehydration and its relation to the clinical choice between oral and artificial hydration. A questionnaire describing hypothetical cases of dehydration in an elderly terminal cancer patient in different clinical situations (conscious, demented, comatose) was sent to 978 physicians. The physicians were asked to assess the discomfort due to dehydration and the treatment they would propose in order to correct this situation (oral or artificial hydration). The return rate was 41%. The results show that there is no consensus with respect to the assessment of suffering (it gets a "low" score from 33% of replies and a "high" score from 41% of replies) or of thirst ("low": 30%, "high": 43%). Only 28% of the replies indicated artificial hydration for conscious patients while 44% chose this treatment for comatose patients. Physicians choosing artificial hydration were significantly more prone to consider suffering and thirst as "serious" than those preferring hydration by mouth. It can be concluded that two thirds of the physicians who responded think that artificial hydration is not the best way to respond to dehydration in dying patients. The choice depends partly on the assessment of the suffering and thirst resulting from terminal dehydration.

Role of the physiotherapist in palliative care.

Physiotherapists, whether trained in intensive care or internal medicine, must be attentive to patients at the end of their lives. Palliative-care physiotherapy requires basic training in rehabilitation techniques; the integration of a rehabilitation professional in a caregivers team; a profound communication with the patient, leading to an effective accompaniment and direct response to the patient's needs; and recognition of the patient's functional needs. The involvement of the physiotherapist can extend to the very end of life. In a series of 56 geriatric patients (35 suffering from cancer, 21 from other pathologic conditions) who died at the Center of Continuous Care, 44 (79%) had a treatment of respiratory physiotherapy until their last 24 hr.

Elevated serum vitamin B12 levels associated with CRP as a predictive factor of mortality in palliative care cancer patients: a prospective study over five years.

The relationship between vitamin B12 levels and survival was studied in a group of 161 terminally ill cancer patients who were recruited consecutively between 1988 and 1989. Their average age was 74.7 years. The length of survival decreased with the increase in serum vitamin B12 levels (P = 0.0015, Cox model). In multivariate analyses, C-reactive protein (CRP) was the most important prognostic factor in this population, and vitamin B12 provided information independent of CRP in predicting survival. These data indicate that an elevated serum vitamin B12 level is a predictive factor for mortality in patients with cancer, independent of CRP or other factors. Multiplying it by the CRP makes it possible to create a new, easy-to-use prognostic index, which can distinguish different levels of mortality risk at three months.

An observational study of the role of pain control and food adaptation of elderly patients with terminal cancer.

Anorexia and a distaste for food are common in patients with terminal cancer and often lead to the use of invasive therapeutic measures. In our prospective study involving 116 elderly patients with terminal cancer, we found that this nutritional behavior could be modified by making certain changes in the treatment. The most important of these are control of pain and distressing symptoms and nutritional adaptation to the condition and tastes of the patients. Ninety-two percent of the subjects could eat until the day they died. The eating pattern of these patients was found to be identical to that observed in elderly patients without cancer. Only 15 patients who had cancer (13%) refused food containing meat.

Guidelines on artificial nutrition versus hydration in terminal cancer patients. European Association for Palliative Care.

Whether a terminally ill cancer patient should be actively fed or simply hydrated through subcutaneous or intravenous infusion of isotonic fluids is a matter of ongoing controversy among clinicians involved in the care of these patients. Under the auspices of the European Association for Palliative Care, a committee of experts developed guidelines to help clinicians make a reasonable decision on what type of nutritional support should be provided on a case-by-case basis. It was acknowledged that part of the controversy related to the definition of the terminal cancer patient, since this is a heterogeneous group of patients with different needs, expectations, and potential for a medical intervention. A major difficulty is the prediction of life expectancy and the patient's likely response to vigorous nutritional support. In an attempt to reach a decision on the type of treatment support (artificial nutrition vs. hydration) which would best meet the needs and expectations of the patient, we propose a three-step process: Step 1: define the eight key elements necessary to reach a decision; Step II: make the decision; and Step III: reevaluate the patient and the proposed treatment at specified intervals. Step I involves assessing the patient concerning the following: 1) oncological/clinical condition; 2) symptoms; 3) expected length of survival; 4) hydration and nutritional status; 5) spontaneous or voluntary nutrient intake; 6) psychological profile; 7) gut function and potential route of administration; and 8) need for special services based on type of nutritional support prescribed. Step II involves the overall assessment of pros and cons, based on information determined in Step I, in order to reach an appropriate decision based on a well-defined end point (i.e., improvement of quality of life; maintaining patient survival; attaining rehydration). Step III involves the periodic reevaluation of the decision made in Step II based on the proposed goal and the attained result.

Prognostic role of serum albumin and prealbumin levels in elderly patients at admission to a geriatric hospital.

The incidence of biological malnutrition is very high in geriatric hospitalized patients. The aim of the present study was to investigate the nutritional status of elderly patients at the time of hospital admission in an effort to identify variables which influence the outcome of hospital stay. Forty-six percent (244/552) of the admitted patients had a serum albumin level less than 35 g/l. Cancer patients had a significantly (p < 0.0001) lower serum albumin and prealbumin values than other patients. The patients, who died, had even lower albumin values as compared to the cancer patients. None of the studied nutritional and social parameters showed correlation with the length of hospital stay in any group of patients. No significant correlation could be found between age and nutritional values. No significant correlation could be established between the social parameters and nutritional variables. By using variance analysis statistically significant association was found between cancer and serum albumin (p < 0.0001) as well as between the death occurring during the hospital stay and nutritional values (p < 0.0001). By the discriminant analysis model, the mortality during hospital stay could be predicted with 78.8% certainty when the presence of cancer, the albumin and prealbumin values were known. In addition, cancer status may be suspected in the case of low nutritional values at admission in these elderly patients. Our results indicate that by the measurement of these simple parameters an accurate prediction can be achieved in the prognosis of hospitalized geriatric patients already at the time of admission.

The treatment of pain in the elderly patient. The use of oral morphine in the treatment of pain.

These reports concern 117 elderly patients suffering from cancerous pain and demonstrate the efficacy of oral morphine treatment, more often associated with adjuvants. The score relief is good. The frequent side effects have been in the most cases rapidly controlled by appropriate measures. Being old is not an obstacle for a safe and efficient analgesic treatment. The useful dosage of morphine, the scores of relief, and the frequency of side effects are comparable to those observed in non-geriatric groups.

The paradoxes of quality of life and its phenomenological approach.

Although evaluation scales for quality of life (QOL) represent considerable progress in medicine, clinical experience shows striking discrepancies between QOL as evaluated by caregivers and QOL from the patient's point of view. Such paradoxes of QOL are analyzed and discussed. Autonomy is universally advocated but may be denied, especially in the hospital setting, where caregivers, family members, and doctors act as a pressure group. Circumstances that deepen the contradictions in QOL assessment include (a) a high degree of patient dependence, (b) a professional judgement that a patient is incompetent (c) professional values being placed over a patient's values, (d) a multidisciplinary team acting as a pressure group, (e) a lack of effective communication with the patient, and (f) a determination to minimize the symptoms at evaluation. QOL is multidimensional, complex, difficult to measure in clinical practice, and sometimes paradoxical.

New perspectives in the treatment of decubitus ulcers.

Although the consequences of prolonged lying on a hard surface are as old as the human race, publications on this subject are scarce. This is due to the fact that a decubitus ulcer never occurs in isolation but is nearly always a complication of some other condition. The term "decubitus" was already used by Hildnaus in 1590 and is derived from the Latin word decumbere which means "lying down". The most important fact to keep in mind is that pressure sores can be prevented. This is the reason why this article not only discusses the management of pressure sores but also the importance of preventive measures. The basis of effective treatment is early detection and an adequate knowledge of the fundamental pathological process. Only adequate preventive measures, careful examination of the lesions, and a thorough knowledge of the products used can avoid unnecessary suffering by patients.

Is there a relationship between psychological well-being and patient-carers consensus? A clinical pilot study.

Does communication with terminal cancer patients about their disease influence their psychological well-being? The degree of patient-carer consensus about the disease was compared to psychological well-being related to acceptance of the disease, emotional state, and hope. These were evaluated and scored from 6 (good) to 0 (poor) through a semi-structured interview of 10 open-ended questions. Nineteen palliative care patients were studied, 18 of whom were suffering from advanced cancer. Overall, 57 interviews were conducted with the patients, staff nurses, and medical doctors. The answers of the carers (staff nurses and doctors) were compared to the patients' answers to determine the degree of consensus in terms of communication about disease, aim of treatment, and ultimate objective of hospitalization. The consensus between patients and carers was scored from 6 (satisfactory) to 0 (unsatisfactory). A significant positive correlation between the scores of consensus and those of psychological well-being (r = 0.90, p < 0.001) was found. These results suggest that good and truthful communication may improve patients' psychological well-being.

[Protein-calorie malnutrition in the elderly patient]. / La malnutrition protéino-énergétique chez le malade âgé.

Protein-energetic malnutrition is frequent in geriatric practice and particularly among hospitalized patients. It has many different causes and its consequences frequently hinder medical and surgical treatments. It is difficult to diagnose and the measures to take belong to the field of social medicine, nutrition, biological research and education. A multidisciplinary approach is therefore essential in this field which needs to be developed.

[Weight of practical, conceptual and ethical problems related to spoon feeding of aged patients with diminished mental capacity]. / Poids des problèmes pratiques, conceptuels et éthiques liés à l'alimentation à la cuiller des patients âgés en perte de capacités.

This qualitative study is based on twenty observations. Problems with spoon feeding of hospitalized, elder, demented patients are rarely considered. This study aims at analyzing their practical, conceptual and ethical specificities. Ten patients were directly observed and their ten nurses of reference responded to structured interviews. We established three significant observations: 1. The use of spoon feeding appeared inoperative as it did not help resolve the problems that were invoked to justify its implementation. 2. Three months after the observations six patients were deceased, three were able to feed themselves and one did not improve. 3. In all observed cases, spoon feeding was initiated as a tacit evolution, with no formal decision process. To avoid this dead end we consider it indispensable to evolve this feeding practice from its current state of unchallengeable humane duty to the conceptual level of patient care, and to develop evaluation tools which will enable its integration into a structured strategy of nursing interventions.