The social consequences of surgical complications for patients with proximal femoral fractures.

A case-matched study was performed to assess the social effects of surgical complications of operative fixation of fractures of the proximal femur. Fifty-two patients aged over sixty-five, half with deep wound infection, the remainder with serious early mechanical problems requiring revision surgery to correct these, had their hospital fatality, length of stay, mobility and social dependency at admission and on discharge compared with patients free from such complications. Deep wound infection was associated with a high fatality and in the survivors a prolonged period in hospital, a marked decline in mobility and without exception a great increase in social dependency; patients having revision surgery had a longer hospital admission, considerable alteration in social circumstances but a little decline in mobility and no significant increase in fatality when compared with matched cases.

Delayed diagnosis of femoral-neck fractures in the elderly.

A survey of a district population presenting to a trauma unit with fractured femoral necks over a year, showed that, out of a total of 374 elderly patients with this fracture, in 33 the diagnosis was delayed for over 24 hours from the onset of disabling symptoms. This was due to late presentation in eight patients, difficulty in confirming the suspected diagnosis in five, and in 20 to initial failure of doctors to make the diagnosis. By comparing this latter group with controls, it was found that medical error was most likely in patients who were either confused, dependent and subject to falls, or alternatively had suffered a spontaneous fracture which had not displaced.

Postural influences on urinary incontinence in the elderly.

To evaluate the requirement for provocative cystometry in urodynamic investigation in the elderly with urinary incontinence, 100 consecutive patients, who were referred on the basis of defined clinical criteria, were first studied by supine cystometry followed by provocative tests where necessary. The most satisfactory means of performing these in the elderly is discussed and the common incontinence patterns, which may point to their need, are described. Arising from the results, the different causes of acute onset from chronic stress incontinence in elderly female patients are emphasised.

Urinary incontinence in the disabled elderly male.

A combined approach between Departments of Urology and Geriatric Medicine to the diagnosis and management of urinary incontinence in disabled elderly men with neurological lesions where outflow obstruction is thought to be a contributory factor is described. After a dual out-patient assessment, patients have a planned admission to a geriatric ward where urodynamic studies and cystoscopy are performed, followed, where necessary, by appropriate surgery. The results in 75 patients are presented. Single urodynamic studies alone are effective in establishing the diagnosis in only 20% of cases. The largest group needing surgical treatment are those with combined cerebrovascular disease and prostatic enlargement. The degree of disability, but not age, influences the outcome of surgery in such cases. The benefits of collaboration to such patients and to the departments are discussed.

Urinary incontinence in the elderly female: prediction in diagnosis and outcome of management.

An algorithmic approach to the diagnosis of urinary incontinence in elderly females has been evaluated in a prospective series of 65 patients by comparing the clinical diagnosis arrived at using a modified form of a published algorithm with the subsequent urodynamic findings. The general validity of the concept was confirmed. The major errors in clinical diagnosis occurred in subjects with stress incontinence, emphasizing that presentation with this symptom was likely to warrant urodynamic study. In patients with detrusor instability it was shown to be possible to predict the likely response to conventional management of their incontinence after three months, on the basis of an arithmetic score derived from the cystometric findings.

Raised respiratory rate in elderly patients: a valuable physical sign.

Measurements of respiratory rate in 82 long-stay patients aged 67-101 years yielded a normal range of 16-25 breaths a minute. In a prospective study of 60 consecutive acute admissions to a geriatric unit, 19 out of 21 patients diagnosed as lower respiratory tract infections had respiratory rates above the upper limit of normal on the day of diagnosis; the rise in respiratory rate preceded the clinical diagnosis. All eight patients who were diagnosed on admission as having a lower respiratory tract infection had a respiratory rate greater than 26, with a mean of 29.7 breaths a minute. Patients admitted for other conditions-for example, urinary tract infection-rarely had respiratory rates outside the normal range. Accurate measurement of respiratory rate is a valuable diagnostic aid in elderly patients.

Urodynamic studies in the management of urinary incontinence in the elderly.

An outline is given of simple urodynamic investigations applicable to elderly subjects. The type of patient presenting primarily to geriatric departments with urinary incontinence, whose management is aided by such studies, is described under various clinical groupings. The requirement for urodynamic studies and the best means of providing these for the elderly patient is discussed.

Routine screening for venous thrombosis by ultrasound in the elderly.

One hundred admissions to a geriatric assessment unit were screened over a three-week period with a Sonicaid Ultrasound apparatus for the development of venous thrombosis in the legs, as denoted by an abnormal ultrasound scan. Any patients with suggestive physical signs were also noted and all such patients, together with those with abnormal ultrasound findings, were investigated at the same time by the 125I-fibrinogen test. Eight patients developed an abnormal ultrasound scan confirmed with the fibrinogen method, and of these three developed abnormalities bilaterally, giving an incidence of thrombosis expressed in terms of legs of 5.5 per cent. Technical difficulties were encountered with this group of elderly patients, these being that in some there was difficulty in positioning the ultrasound probe and in others of producing an adequate flow noise to monitor changes effectively.