Secondary hyperparathyroidism in patients from Western Australia with hip fracture: relationship to type of hip fracture, renal function, and vitamin D deficiency.

OBJECTIVES: To determine the frequency of vitamin D deficiency and secondary hyperparathyroidism in Australian hip fracture patients living in the community. PATIENTS: A total of 283 consecutive patients with hip fracture admitted over a 15-month period to a university teaching hospital in Western Australia. Included were residents of hostels for the elderly, and excluded were nursing home residents and those with malignant fractures. METHOD: Data collected included biochemistry (25 hydroxyvitamin D, parathyroid hormone and creatinine levels), measurements of function and disability (Barthel Index, Frenchay Activity Index), sunshine exposure, and basic demographics. RESULTS: Vitamin D deficiency occurred in 31.7% and secondary hyperparathyroidism occurred in 17.7% of cases. The major determinants of vitamin D deficiency were outdoor sunshine exposure, ambient daily sunshine, and disability (low Frenchay Activity Index or ADL difficulty). Secondary hyperparathyroidism was related to older age, renal dysfunction, and vitamin D deficiency. Secondary hyperparathyroidism was associated with an excess of trochanteric over subcapital hip fractures. CONCLUSIONS: Secondary hyperparathyroidism appears to be a heterogeneous condition, caused in approximately equal proportions by vitamin D deficiency and renal dysfunction, that may confer increased cortical bone fragility and trochanteric fractures. Renal dysfunction in old age may be an important additional determinant of senile osteoporosis, which has implications for preventive therapy. Vitamin D deficiency occurs in disabled and, presumably, housebound older people despite near optimal climatic conditions.

Seasonal variation, hip fracture and vitamin D levels in Southern Tasmania.

AIMS: To determine the frequency of vitamin D deficiency in older patients admitted with a hip fracture and to look for seasonal variation in vitamin D levels and hip fracture in Southern Tasmania. METHODS: This was a case series of patients admitted to the Royal Hobart Hospital, Tasmania with a hip fracture from July 1996-June 1997. Information was collected on demographic data, functional activity, associated medical disorders and drug history. RESULTS: There were 91 patients, 66 female with a mean age of 81.3 years. Vitamin D deficiency, defined as a serum 1,25 hydroxyvitamin D level <28 nmol/L was present in 67% of subjects. Vitamin D levels were low throughout the year without significant seasonal variation. There was no seasonal variation in admissions with a hip fracture. The majority of patients (68%) either lived in institutional care or were dependent on a carer and 43% reported going outdoors less than once a week. CONCLUSIONS: The high incidence of vitamin D deficiency in these subjects admitted with a hip fracture reflects reduced sunlight exposure and poor diet and is probably a marker of frailty. The absence of seasonal variation reflects a frailer population likely to be housebound, less mobile and more likely to have falls and sustain a fracture. Older and frailer people may benefit from routine screening for vitamin D deficiency, and replacement therapy should be considered for those found to be deficient.

Measuring blood pressure in the elderly: does atrial fibrillation increase observer variability?

OBJECTIVE: To compare the interobserver and intraobserver variability of blood pressure measurements in geriatric patients in atrial fibrillation and in sinus rhythm. DESIGN: Prospective assessment of blood pressure measurements carried out in random order in two groups of elderly patients by five doctors unaware of the aims of the study. SETTING: Acute assessment wards for geriatric medicine, Cardiff Royal Infirmary. PATIENTS: 50 Elderly patients in sinus rhythm and 50 in atrial fibrillation. MAIN OUTCOME MEASURES: Interobserver and intraobserver variability of blood pressure measurements in the two groups expressed as the coefficient of variability and compared by the Mann-Whitney U test. RESULTS: Interobserver variability was significantly greater in the patients with atrial fibrillation for both systolic and diastolic pressures. Intraobserver variability was significantly greater in the atrial fibrillation group for diastolic pressures but the difference was not significant for systolic pressures. These differences were not related to pulse rate, age, or level of blood pressure. CONCLUSIONS: The findings suggest that in the presence of atrial fibrillation physicians' interpretations of Korotkoff sounds are less uniform, which may have important clinical implications. Possibly a standardised methodology may overcome this problem.

The use of pamidronate in hypertrophic pulmonary osteoarthropathy (HPOA).

BACKGROUND: Hypertrophic pulmonary osteoarthropathy (HPOA) secondary to bronchogenic carcinoma can be associated with severe, disabling pain which is not always responsive to conventional treatment. AIM: To report on the use of pamidronate to control resistant pain in HPOA in three cases. METHODS: A retrospective review of reported pain, chest X-ray and radionuclide bone scans was made. RESULTS: Pain relief was achieved in all three cases together with reduced radiolabel uptake in two cases. CONCLUSIONS: Pamidronate appears to be an effective therapy for HPOA. Further investigation is warranted.

Adverse drug events as a cause of hospital admission in the elderly.

BACKGROUND: Previous studies of adverse drug events (ADE) as a cause of hospital admission in the elderly have often been limited in their ability to assess fully the impact and potential for prevention because they either did not include all categories of ADE and/or did not assess severity and preventability. AIMS: To assess the frequency, severity and preventability of ADE causing emergency medical admissions in the elderly. METHODS: Cross-sectional survey of 219 patients aged 75 years and over who were consecutive unplanned admissions to acute medical units of the Royal Hobart Hospital in an 8-week period during August and September 1998. RESULTS: Seventy-three of 240 (30.4%) admissions may have been a result of ADE. Patients admitted because of ADE were taking more drugs than those admitted for other reasons. Most ADE were adverse drug reactions to a single (46%) or multiple drugs (25%). Non-compliance, omission or cessation of indicated treatment accounted collectively for 26% of admissions. Of all ADE admissions 53.4% were considered definitely preventable. The commonest causative drugs were cardiovascular drugs (48.4%), and the commonest manifestations were falls and postural hypotension (24.1%), heart failure (16.9%) and delirium (14.5%). ADE categories in which a high proportion of admissions was both severe and definitely preventable were non-compliance and omission of indicated treatment. CONCLUSIONS: Adverse drug events are a common preventable cause of unplanned medical admissions in the elderly. Non-compliance and omission of indicated treatment are causes of ADE-related admissions that are both preventable and frequently associated with severe ADE.

The effect of hemiplegia on blood pressure measurement in the elderly.

The blood pressure in both arms of 103 unselected hemiplegic patients was measured using a random-zero sphygmomanometer. Although for the whole sample the mean blood pressure in the paretic and unaffected arm was similar, a significant difference was found when the patients were subdivided according to the tone of the arm. The blood pressure was higher in paretic arms of patients with a spastic stroke and lower in the affected arm if the tone was flaccid. No other characteristics were associated with significant blood pressure differences, so that the findings appear to be directly related to changes in muscle tone. After a stroke the blood pressure should always be measured in the unaffected arm because changes in tone make measurements unreliable.

Use of patient restraints in four Australian teaching hospitals.

To examine the patterns of use of patient restraints in Australian hospitals and the level of adherence to accepted guidelines, we undertook a point-prevalence study in four teaching hospitals in three different States. This involved ward inspections and review of case notes. Overall, 51 (12.5%) of the 408 people audited were being restrained with a variety of physical and chemical agents. The rate of restraint use varied from 8.5% to 18.5% between hospitals. Although the overall prevalence of restraint use increased with age, the hospital with the oldest patients used restraints least. At all hospitals, there was scant documentation in the case notes concerning the use of restraints. The prevalence of restraint use varies widely in different hospitals. As this is not explained by the patient profile, it probably reflects different philosophies of care. Documentation of the use of restraints needs to be improved in all the centres studied.

Vitamin D deficiency and secondary hyperparathyroidism: clinical and biochemical associations in older non-institutionalised Southern Tasmanians.

AIM: To determine the prevalence and associations of vitamin D (25-OHD) deficiency in a sample of older Tasmanian subjects. METHODS: A cross-sectional survey of: 109 patients with a mean age of 79 years (range 60-101 years) consecutively admitted to a short stay geriatric rehabilitation ward; 52 community dwelling subjects with a mean age of 75 years (range 64-88 years). Subjects answered a questionnaire, had anthropometric measurements and underwent venepuncture. RESULTS: The main outcome measure was 25 hydroxy vitamin D (25-OHD) level with deficiency defined as <28 nmol/L. Vitamin D deficiency was found in 67% and secondary hyperparathyroidism in 49% of the hospitalised group. Vitamin D deficiency was also found in 17% of the community group, in particular one in three residents of Independent Living Units was deficient. Subjects who were deficient were older (80 years vs 76 years [p<0.001]), had lower body mass index (23.7 kg/m2 vs 25.9 kg/m2 [p<0.001]) and had a lower serum albumin (35 gm/L vs 39 gm/L [p<0.001]). Deficient subjects had poorer physical functional status (p=0.02) and lower activity levels (p<0.001) and reported less habitual sun exposure (p<0.001). Biochemical measures such as parathyroid hormone, alkaline phosphatase and calcium were weakly predictive of vitamin D levels. By stepwise multiple regression analysis, the only significant predictors of vitamin D levels were the Frenchay Activity Index, albumin and calcium. CONCLUSION: Vitamin D deficiency and secondary hyperparathyroidism is common in community living older people who are hospitalised in Southern Tasmania and is associated with increasing age, poor physical function and activity and low reported sun exposure.