Therapeutic use of compression stockings for orthostatic hypotension: an assessment of patient and physician perspectives and practices.

BACKGROUND: Elastic compression stockings (ECS) can be used as a non-pharmacological therapeutic option for older patients with orthostatic hypotension (OH). We aimed to investigate the practices and views of patients and physicians regarding the use of ECS for OH. METHODS: Two surveys were designed. The first was sent to 90 patients known to have been prescribed ECS for OH. This questionnaire included items related to the frequency of use and issues related to non-compliance. The second was sent to 69 consultant physicians in geriatric medicine. This included items related to prescribing practices and perceived patient compliance. RESULTS: Sixty-seven patients responded (response rate, 74%) and of those 64% were female. Mean age (SD) was 75.1 years (10.5), range 45-91 years. Thirty-three per cent wore ECS daily, whereas 43% never used them. Over half (51%) of the patients reported difficulty in application and 31% reported discomfort. Those aged 75 or older were more likely to report difficulty in application (P=0.003). Forty-eight physicians responded (response rate, 70%). Eighty-nine per cent prescribe ECS for OH. There were significant differences between the frequency of use reported by patients and predicted by physicians (P<0.001), with physicians less likely to predict daily or non-use. Eighty-nine per cent of physicians predicted that difficulty in application was the main reason for non-compliance. CONCLUSION: Although prescribed frequently, the use of ECS in patients with OH is often limited by issues related to practicality. Physicians correctly predicted the main reasons for non-compliance although underestimated the scale of patient compliance with ECS.

Specialist medication review does not benefit short-term outcomes and net costs in continuing-care patients.

OBJECTIVES: to evaluate specialist geriatric input and medication review in patients in high-dependency continuing care. DESIGN: prospective, randomised, controlled trial. SETTING: two residential continuing care hospitals. PARTICIPANTS: two hundred and twenty-five permanent patients. INTERVENTION: patients were randomised to either specialist geriatric input or regular input. The specialist group had a medical assessment by a geriatrician and medication review by a multidisciplinary expert panel. Regular input consisted of review as required by a medical officer attached to each ward. Reassessment occurred after 6 months. RESULTS: one hundred and ten patients were randomised to specialist input and 115 to regular input. These were comparable for age, gender, dependency levels and cognition. After 6 months, the total number of medications per patient per day fell from 11.64 to 11.09 in the specialist group (P = 0.0364) and increased from 11.07 to 11.5 in the regular group (P = 0.094). There was no significant difference in mortality or frequency of acute hospital transfers (11 versus 6 in the specialist versus regular group, P = 0.213). CONCLUSION: specialist geriatric assessment and medication review in hospital continuing care resulted in a reduction in medication use, but at a significant cost. No benefits in hard clinical outcomes were demonstrated. However, qualitative benefits and lower costs may become evident over longer periods.

What is the optimal duration of tilt testing for the assessment of patients with suspected postural tachycardia syndrome?

AIMS: The aim of this study is to define the optimal duration of tilt testing for the assessment of patients with suspected postural tachycardia syndrome (POTS). METHODS AND RESULTS: This was a case-control study. Cases were identified retrospectively from a database of patients referred with orthostatic intolerance (OI). All met the diagnostic criteria for POTS. Controls were enrolled prospectively. All subjects underwent tilting to 70 degrees for 40 min if tolerated. Continuous monitoring was provided by a Finometer. Analysis of responses to tilting was performed on 28 cases and 28 controls. The mean age in the case group was 23.6 and in the control group was 26.2. The majority was female in both groups (cases = 4F:3M, controls = 2F:1M). All cases met the criteria for POTS within 7 min of orthostasis. No controls demonstrated a sustained tachycardia. The prevalence of vasovagal syncope (VVS) was 36% in cases vs. 7% in controls (P = 0.02) and 25% in the remaining patients (n = 233) on the OI database (P = 0.259). CONCLUSION: A 10 min tilt will diagnose POTS in the majority of patients. It will not, however, be sufficient to identify the overlap that exists between POTS and VVS. The optimal duration of tilt testing in patients suspected of POTS is 40 min.

Hip protectors in fracture prevention for aging adults at risk of falling: a study of user compliance.

PURPOSE: A compliance survey was conducted to establish factors that influence low user compliance with hip protectors amongst aging adults at risk of hip fracture. Medical professionals who deal with patients at risk of hip facture were also included in this survey. METHODS: For this descriptive study 2 questionnaires were designed, 1 for community dwelling aging adults at high risk of fall and hip fracture and 1 for medical professionals dealing with these patients. The questionnaires were presented, completed, and collected at individual appointments with aging adults and by group appointments with medical professionals. All data was statistically analysed to detect the most significant factors related to poor user compliance with hip protectors. For this descriptive study, frequency tests were used to analyse the data and therefore percentage of response was also reported. Certain demographic data such as age and gender was also collected. RESULTS: The outcomes in both interviewed groups were very similar. The main findings demonstrate that 51% of users find hip protectors very valuable while 41% reported the product to be uncomfortable and 29% of users found them difficult to put on. For potential users the high cost of the product and its appearance remains an issue. Also negative psychological aspects of wearing the hip orthoses appear to be common reasons for not wearing a hip protector. CONCLUSION: The study confirmed poor user compliance with hip protectors (18.9%). The information gathered from users and medical professionals regarding hip protectors provides valuable information which allows for the identification and development of new design features.

Does the crack silently break the back? Long-term follow-up and assessment of risk factors for regional osteoporosis following tibial shaft fractures.

The aim of this study is to determine the incidence and to quantify the risk factors for developing long-term regional osteopenia/osteoporosis (RO) following tibial fractures. We studied 42 adult subjects (8 females and 34 males) who had sustained a tibial fracture 16 yr prior to the study. Mechanism and type of injury, method of treatment, length of immobilization, weight-bearing status, and healing time were determined from the patient records. A questionnaire covering known causes of generalized osteoporosis (GO), including history of smoking, alcohol consumption, medications, other fractures, thyroid/parathyroid disorders, epilepsy, and renal disorders, was answered by all the subjects. Bone mineral density (BMD) of lumbar vertebrae 1-4 and both proximal femurs was assessed using dual-energy X-ray absorptiometry (DXA) scanning. T- and Z-scores were generated. Assessment of risk factors was done by calculating the odds ratio (OR) and 95% confidence interval (CI). The incidence of significant loss of BMD as defined by the World Health Organization (T-score <-1) of the ipsilateral neck of femur and/or lumbar spine was found to be 40%. None of our subjects had any known cause for GO. The following risk factors were found to be statistically significant in unadjusted models: smoking (OR 22, 95% CI = 4 - >40), alcohol >20 units/wk (OR 11, 95% CI 2 = 2-54), open fracture (OR 17, 95% CI = 2.9 - >40), nonweight bearing >4 wk (OR 15, 95% CI 2.9- >40), and delayed union defined as healing time more than 6 mo (OR 15, 95% CI 1.54 - >40). Permanent regional loss of BMD occurs in a significant proportion of tibial shaft fracture patients. Modern fracture management should include identifying "at-risk" patients and appropriate preventive measures to prevent fragility fractures.