The experience of feeling old after a fragility fracture.

BACKGROUND: There has been little exploration of the effect of fragility fractures on patient perceptions of their age. The common assumption is that fractures "happen to old people". In individuals with a fragility fracture, our objective was to explore the experience of feeling old after sustaining a fragility fracture. METHODS: A secondary analysis of data from 145 community-dwelling women and men participating in six qualitative primary studies was conducted relying on a phenomenological approach. Participants were English-speaking, 45 years and older, who had sustained a recent fragility fracture or reported a history of previous fragility fractures. Data for the analysis included direct statements about feeling old as well any discussions relevant to age post-fracture. RESULTS: We highlight two interpretations based on how individuals with a history of fragility fracture talked about age: (1) Participants described feeling old post-fracture. Several participants made explicit statements about being "old". However, the majority of participants discussed experiences post-fracture that implied that they felt old and had resigned themselves to being old. This appeared to entail a shift in thinking and perception of self that was permanent and had become a part of their identity; and (2) Perceptions of increasing age after sustaining a fracture were reinforced by health care providers, family, and friends. CONCLUSIONS: Our findings challenge the notion that fractures "happen to old people" and suggest that fractures can make people feel old. Careful consideration of how bone health messages are communicated to patients post-fracture by health care providers is warranted. (Word Count: 248).

Patients experience a need for informal care after a fragility fracture.

In this qualitative secondary analysis, patients with a fragility fracture described needing informal care post-fracture. A significant proportion reported receiving no care or not enough care, often devising strategies to care for themselves. Requesting help from multiple individuals allowed patients to minimize the burden to family and friends. INTRODUCTION: In individuals with fragility fractures, our objectives were to examine (1) the experience of receiving informal care post-fracture; and (2) how these care experiences influenced post-fracture recovery and subsequent management of bone health. METHODS: A secondary analysis of six primary qualitative studies was conducted. Individuals in the primary studies were English-speaking women and men, 45 years and older, who were living in the community and had sustained a recent fragility fracture or reported a history of previous fragility fractures. Participants who reported at least one instance of needing informal care were categorized as receiving "enough care", "insufficient care", or "no care". RESULTS: Of 145 participants in the primary studies, 109 (75%) described needing informal care after their fracture. Of those needing care, 62 (57%) were categorized as receiving enough care while 47 (43%) were categorized as receiving insufficient or no care. The care needed affected the management of participants' fracture and bone health, including access to health care services. Participants who received insufficient or no care, especially those living alone, devised strategies to care for themselves and often requested help from multiple individuals to minimize the burden to family and friends. Compared with men, women appeared to report needing help with personal daily activities, such as bathing, and transportation to appointments related to bone health. CONCLUSION: Informal care needs are an additional burden of fragility fractures. Post-fracture interventions should consider the broader context of patients' lives and potentially support the care needs of patients as part of their services.

Perspectives of patients with depression and chronic pain about bone health after a fragility fracture: A qualitative study.

BACKGROUND: Compromised bone health is often associated with depression and chronic pain. OBJECTIVE: To examine: (1) the experience of existing depression and chronic nonfracture pain in patients with a fragility fracture; and (2) the effects of the fracture on depression and pain. DESIGN: A phenomenological study guided by Giorgi's analytical procedures. SETTING AND PARTICIPANTS: Fracture patients who reported taking prescription medication for one or more comorbidities, excluding compromised bone health. MAIN VARIABLES STUDIED: Patients were interviewed within 6 weeks of their fracture, and 1 year later. Interview questions addressed the recent fracture and patients' experience with bone health and their other health conditions, such as depression and chronic pain, including the medications taken for these conditions. RESULTS: Twenty-six patients (5 men, 21 women) aged 45-84 years old with hip (n = 5) and nonhip (n = 21) fractures were recruited. Twenty-one participants reported depression and/or chronic nonfracture pain, of which seven reported having both depression and chronic pain. Two themes were consistent, based on our analysis: (1) depression and chronic pain overshadowed attention to bone health; and (2) the fracture exacerbated reported experiences of existing depression and chronic pain. CONCLUSION: Experiences with depression and pain take priority over bone health and may worsen as a result of the fracture. Health care providers treating fragility fractures might ask patients about depression and pain and take appropriate steps to address patients' more general emotional and physical state. PATIENT CONTRIBUTION: A patient representative was involved in the study conception, data interpretation and manuscript writing.

Narcolepsy Treatment: Voices of Adolescents.

INTRODUCTION: Narcolepsy, characterized by excessive daytime sleepiness, is a debilitating lifelong sleep disorder for which there is no cure. Current pharmacological and nonpharmacological treatments directed toward symptom management may be suboptimal. This qualitative study explores the perspective of adolescents on therapeutic interventions for narcolepsy. METHODS: Semi-structured interviews with adolescents with narcolepsy were conducted from May to August 2019 at The Hospital for Sick Children in Toronto, Canada. Qualitative thematic analysis was utilized to generate themes emerging from the data. RESULTS: Eighteen adolescents with narcolepsy (age range = 10-17, mean age = 14.4 ± 2.0 years, 72% male) participated and 56% had cataplexy. Four prominent themes arose regarding therapeutic interventions for narcolepsy. Firstly, participants described that pharmacotherapy was moderately effective but did not fully relieve symptoms associated with narcolepsy. Secondly, while medications are the first line treatment for narcolepsy, many participants reported frustration regarding medication dependence and side effects. Thirdly, nonpharmacological strategies including scheduled sleep times and exercise were accepted and often employed. Lastly, adolescents desired more psychosocial support to address mental health sequelae of narcolepsy that were not fully managed by current treatment modalities. CONCLUSIONS: Medications were perceived as moderately effective for managing narcolepsy but almost all participants expressed concerns with taking medications due to side effects. Adolescents valued the importance of more holistic care for their narcolepsy treatment such as psychosocial support and nonpharmacological modalities. Further anticipatory guidance regarding pharmacological side effect profiles and better integration with nonpharmacological modalities are needed to improve disease control in adolescent patients.

Pain and fracture-related limitations persist 6 months after a fragility fracture.

Our objective was to examine the experience of pain after a fracture beyond the conventional healing duration of 6 months. We conducted a phenomenological study in participants who were deemed high risk for future fracture and recruited through an urban fracture clinic in Toronto, Canada. In-depth interviews were conducted with questions addressing the experience of pain, the status of recovery from the fracture, ways in which the fracture affected one's daily activities, and interactions with health care providers. Two researchers coded the transcripts within the phenomenological perspective to develop a structure of the pain experience, promoting rigour through the use of multiple analysts, searching for negative cases, and supporting claims with direct quotations from participants. We interviewed 21 participants who had sustained fractures of the wrist (n = 4), hip (n = 6), vertebrae (n = 2), and multiple or other locations (n = 9). All patients were ambulatory, had a range of socioeconomic status, and lived in the community. Eleven of the 21 participants reported persistent pain at the site of the fracture. Of the 10 participants who reported no pain, four indicated they had ongoing difficulties with range of motion and specific activities and two others described persistent pain from a previous fracture or reliance on a scooter for mobility. Our study demonstrated that over two-thirds of older adults reported fracture-related pain and/or limitations at, or beyond, 6 months post-fracture. We suggest that health care providers ask questions about post-fracture pain and/or limitations when assessing fracture status beyond 6 months.

Decision to take osteoporosis medication in patients who have had a fracture and are 'high' risk for future fracture: a qualitative study.

BACKGROUND: Patients' values and preferences are fundamental tenets of evidence-based practice, yet current osteoporosis (OP) clinical guidelines pay little attention to these issues in therapeutic decision making. This may be in part due to the fact that few studies have examined the factors that influence the initial decision to take OP medication. The purpose of our study was to examine patients' experiences with the decision to take OP medication after they sustained a fracture. METHODS: A phenomenological qualitative study was conducted with outpatients identified in a university teaching hospital fracture clinic OP program. Individuals aged 65+ who had sustained a fragility fracture within 5 years, were 'high risk' for future fracture, and were prescribed OP medication were eligible. Analysis of interview data was guided by Giorgi's methodology. RESULTS: 21 patients (6 males, 15 females) aged 65-88 years participated. All participants had low bone mass; 9 had OP. Fourteen patients were taking a bisphosphonate while 7 patients were taking no OP medications. For 12 participants, the decision to take OP medication occurred at the time of prescription and involved minimal contemplation (10/12 were on medication). These patients made their decision because they liked/trusted their health care provider. However, 4/10 participants in this group indicated their OP medication-taking status might change. For the remaining 9 patients, the decision was more difficult (4/9 were on medication). These patients were unconvinced by their health care provider, engaged in risk-benefit analyses using other information sources, and were concerned about side effects; 7/9 patients indicated that their OP medication-taking status might change at a later date. CONCLUSIONS: Almost half of our older patients who had sustained a fracture found the decision to take OP medication a difficult one. In general, the decision was not considered permanent. Health care providers should be aware of their potential role in patients' decisions and monitor patients' decisions over time.

The BMD muddle: the disconnect between bone densitometry results and perception of bone health.

We conducted a phenomenological qualitative study to examine fracture patients' interpretations of their most recent bone densitometry results and perceptions of their current bone health. English-speaking outpatients who had sustained a fragility fracture in the previous 18-24 mo and reported having at least 1 previous bone mineral density (BMD) test were eligible. Data were collected through semistructured interviews in patients' homes. Patients were asked to describe their most recent BMD test results and perception of their bone health status based on these results. Eighteen patients (14 women and 4 men) aged 49-82 yr were recruited. BMD results showed bone density in patients to be normal (n=4), osteopenic (n=9), and osteoporotic (n=5). A correct diagnosis was recalled by 6 patients. Two common interpretations of BMD test results emerged: (1) no news was considered to be good news (n=9) and (2) evidence of compromised bone health was not considered to be serious or accurate (n=6). Medication adherence did not appear to be associated with perception of bone health or actual BMD results. Patients' perceptions of their current bone health did not correspond to the results of their most recent BMD test. Standardized bone densitometry reporting may improve patients' understanding of their bone health.

Perspectives of orthopaedic surgeons on patients' appropriateness for total joint arthroplasty: a qualitative study.

RATIONALE, AIMS AND OBJECTIVES: As total joint arthroplasty (TJA) rates rise, there is need to ensure appropriate use. Our objective was to elucidate surgeons' perspectives on appropriateness for TJA. METHODS: Semi-structured telephone interviews were conducted in a sample of orthopaedic surgeons that perform TJA in three Canadian Provinces. Surgeons were asked to discuss their criteria for TJA appropriateness for osteoarthritis; potential value of a decision-support tool to select appropriate candidates; and the role of other stakeholders in assessing appropriateness. RESULTS: Of 17 surgeons approached for participation, 14 completed interviews (12 males; 7 aged <50 years; 5 academic; 8 in urban practices). Surgeons agreed that pain and pain impact on patients' quality of life and function were the key criteria to assess appropriateness for TJA, but that these concepts were difficult to assess and not always congruent with structural changes on joint radiography. Some used a wider range of criteria, including their assessments of patient expectations, ability to cope and readiness for surgery. While patient age was not identified as a criterion itself, surgeons did acknowledge that appropriateness criteria may differ for younger versus older patients. Most agreed that a decision-support tool would help ensure that all elements of appropriateness are assessed in a standardized manner, albeit the ultimate decision to offer surgery must be left to the discretion of surgeons, within the context of the doctor-patient relationship. CONCLUSIONS: Surgeons recognized the need for a tool to support decision making for TJA, particularly in the context of increasing surgical demand in younger patients with less severe arthritis. The work to develop and test such a decision-support tool is underway.

Bone Mineral Density Reporting Underestimates Fracture Risk in Ontario.

OBJECTIVE: Analysis of clinical documents such as bone mineral density (BMD) reports is an important component of program evaluation because it can provide insights into the accuracy of assessment of fracture risk communicated to patients and practitioners. Our objective was to compare fracture risk calculations from BMD test reports to those based on the 2010 Canadian guidelines. METHODS: We retrieved BMD reports from fragility fracture patients screened through a community hospital fracture clinic participating in Ontario's Fracture Clinic Screening Program. Fracture risk was determined according to the 2010 Canadian guidelines using age, sex, and T-score at the femoral neck, in addition to three clinical factors. Three researchers classified patients' fracture risk until consensus was achieved. RESULTS: We retrieved reports for 17 patients from nine different BMD clinics in the Greater Toronto Area. Each patient had a different primary care physician and all BMD tests were conducted after the 2010 Canadian guidelines were published. The fracture risk of 10 patients was misclassified with 9 of the 10 reports underestimating fracture risk. Nine reports acknowledged that the prevalence of a fragility fracture raised the risk category by one level but only four of these reports acknowledged that the patient had, or may have sustained, a fragility fracture. When we raised fracture risk by one level according to these reports, eight patients were still misclassified. Fracture risk in the majority of these patients remained underestimated. Inconsistent classification was found in the majority of cases where reports came from the same clinic. Four reports described risk levels for two different types of risk. CONCLUSIONS: More than half of patients received BMD reports which underestimated fracture risk. Bone health management recommendations based on falsely low fracture risk are likely to be sub-optimal.