The impact of the frequency, duration and type of physiotherapy on discharge after hip fracture surgery: a secondary analysis of UK national linked audit data.

Additional physiotherapy in the first postoperative week was associated with fewer days to discharge after hip fracture surgery. A 7-day physiotherapy service in the first postoperative week should be considered as a new key performance indicator in evaluating the quality of care for patients admitted with a hip fracture. INTRODUCTION: To examine the association between physiotherapy in the first week after hip fracture surgery and discharge from acute hospital. METHODS: We linked data from the UK Physiotherapy Hip Fracture Sprint Audit to hospital records for 5395 patients with hip fracture in May and June 2017. We estimated the association between the number of days patients received physiotherapy in the first postoperative week; its overall duration (< 2 h, ≥ 2 h; 30-min increment) and type (mobilisation alone, mobilisation and exercise) and the cumulative probability of discharge from acute hospital over 30 days, using proportional odds regression adjusted for confounders and the competing risk of death. RESULTS: The crude and adjusted odds ratios of discharge were 1.24 (95% CI 1.19-1.30) and 1.26 (95% CI 1.19-1.33) for an additional day of physiotherapy, 1.34 (95% CI 1.18-1.52) and 1.33 (95% CI 1.12-1.57) for ≥ 2 versus < 2 h physiotherapy, and 1.11 (95% CI 1.08-1.15) and 1.10 (95% CI 1.05-1.15) for an additional 30-min of physiotherapy. Physiotherapy type was not associated with discharge. CONCLUSION: We report an association between physiotherapy and discharge after hip fracture. An average UK hospital admitting 375 patients annually may save 456 bed-days if current provision increased so all patients with hip fracture received physiotherapy on 6-7 days in the first postoperative week. A 7-day physiotherapy service totalling at least 2 h in the first postoperative week may be considered a key performance indicator of acute care quality after hip fracture.

Effects of seeking compensation on the psychological health and recovery of injured patients: the role of stress vulnerability and injury-related disability.

BACKGROUND: Seeking compensation has been shown to have an adverse effect on the psychological health and recovery of injured patients, however, this effect requires clarification. METHODS: A total of 2019 adults sustaining a traffic injury were recruited. Of these, 709 (35.1%) lodged a compensation claim. Interviews occurred at 1-, 6- and 12-month post-injury. Outcomes were psychological distress (posttraumatic stress (PTS) and depressive symptoms) and health-related functioning (HrF) (quality of life measured by EQ-5D-3L and disability by WHODAS) over 12-months post-injury. Covariates included individual stress vulnerability (preinjury, injury-related factors). RESULTS: Compared with non-compensation participants, compensation groups had higher stress vulnerability (more severe injuries and negative reactions) and poorer baseline outcomes (psychological health and HrF). After adjustment, we found an effect of compensation on HrF [ß-0.09 (-0.11 to -0.07), p < 0.001] and PTS [ß = 0.36 (0.16 to 0.56), p = 0.0003], but not on depression [ß = -0.07 (-0.42 to 0.28), p = 0.7]. Both groups improved over time. Vulnerable individuals (ß = 1.23, p < 0.001) and those with poorer baseline outcomes (PTS: ß = 0.06, p = 0.002; HrF: ß = -1.07, p < 0.001) were more likely to lodge a claim. In turn, higher stress vulnerability, poor baseline outcomes and claiming compensation were associated with long-term psychological distress and HrF. Nevertheless, concurrent HrF in the model fully accounted for the compensation effect on psychological distress (ß = -0.14, p = 0.27), but not vice versa. CONCLUSIONS: This study provides convincing evidence that seeking compensation is not necessarily harmful to psychological health. The person's stress vulnerability and injury-related disability emerge as major risk factors of long-term psychological distress, requiring a whole-systems approach to address the problem.

Effect of inpatient rehabilitation treatment ingredients on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with unplanned admission: an overview review.

BACKGROUND: To synthesise the evidence for the effectiveness of inpatient rehabilitation treatment ingredients (versus any comparison) on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with an unplanned hospital admission. METHODS: A systematic search of Cochrane Library, MEDLINE, Embase, PsychInfo, PEDro, BASE, and OpenGrey for published and unpublished systematic reviews of inpatient rehabilitation interventions for older adults following an unplanned admission to hospital from database inception to December 2020. Duplicate screening for eligibility, quality assessment, and data extraction including extraction of treatment components and their respective ingredients employing the Treatment Theory framework. Random effects meta-analyses were completed overall and by treatment ingredient. Statistical heterogeneity was assessed with the inconsistency-value (I2). RESULTS: Systematic reviews (n = 12) of moderate to low quality, including 44 non-overlapping relevant RCTs were included. When incorporated in a rehabilitation intervention, there was a large effect of endurance exercise, early intervention and shaping knowledge on walking endurance after the inpatient stay versus comparison. Early intervention, repeated practice activities, goals and planning, increased medical care and/or discharge planning increased the likelihood of discharge home versus comparison. The evidence for activities of daily living (ADL) was conflicting. Rehabilitation interventions were not effective for functional mobility, strength, or quality of life, or reduce length of stay or mortality. Therefore, we did not explore the potential role of treatment ingredients for these outcomes. CONCLUSION: Benefits observed were often for subgroups of the older adult population e.g., endurance exercise was effective for endurance in older adults with chronic obstructive pulmonary disease, and early intervention was effective for endurance for those with hip fracture. Future research should determine whether the effectiveness of these treatment ingredients observed in subgroups, are generalisable to older adults more broadly. There is a need for more transparent reporting of intervention components and ingredients according to established frameworks to enable future synthesis and/or replication. TRIAL REGISTRATION: PROSPERO Registration CRD42018114323 .

An 11-year review of hip fracture hospitalisations, health outcomes, and predictors of access to in-hospital rehabilitation for adults ≥ 65 years living with and without dementia: a population-based cohort study.

This study examined hip fracture hospitalisation trends and predictors of access to rehabilitation for adults aged ≥ 65 years living with and without dementia. The hospitalisation rate was 2.5 times higher for adults living with dementia and adults who lived in aged care were between 4.8 and 9.3 times less likely to receive rehabilitation. INTRODUCTION: To examine hip fracture hospitalisation temporal trends, health outcomes, and predictors of access to in-hospital rehabilitation for older adults living with and without dementia. METHODS: A population-based retrospective cohort study of adults aged ≥ 65 years hospitalised with a hip fracture during 2007-2017 in New South Wales, Australia. RESULTS: Of the 69,370 hip fracture hospitalisations, 27.1% were adults living with dementia. The hip fracture hospitalisation rate was 2.5 times higher for adults living with dementia compared with adults with no dementia (1186.6 vs 492.9 per 100,000 population). The rate declined by 6.1% per year (95%CI - 6.6 to - 5.5) for adults living with dementia and increased by 1.0% per year (95%CI 0.5-1.5) for adults with no dementia. Multivariable associations identified that adults living with dementia who experienced high frailty and increasing age were between 1.6 and 1.8 times less likely to receive in-hospital rehabilitation. Adults who were living in long-term aged care facilities were between 4.8 and 9.3 times less likely to receive in-hospital rehabilitation which varied by the presence of dementia or delirium. CONCLUSION: Consistent criteria should be applied to determine rehabilitation access, and rehabilitation services designed for older adults living with dementia or in aged care are needed. HIGHLIGHTS: • Adults living with dementia were able to make functional gains following hip fracture rehabilitation. • Need to determine consistent criteria to determine access to hip fracture rehabilitation. • Rehabilitation services specifically designed for adults living with dementia or in aged care are needed.

Outcomes after traffic injury: mental health comorbidity and relationship with pain interference.

BACKGROUND: Mental health symptoms, like depressive mood (DM) and post-traumatic stress (PTS), and pain interference (PI) with daily functioning often co-occur following traffic injury and their comorbidity can complicate recovery. This study aimed to map the course and overlapping trajectories of mental health symptoms, and associations with PI in a traffic injury population. METHODS: In total, 2019 adults sustaining minor-to-moderate traffic injury were recruited within 28 days post-injury and assessed using phone interviews at 1, 6 and 12-months post-injury. Trajectories of DM, PTS and PI were established and relationships between DM, PTS and PI trajectories were explored using dual trajectory modelling. Bio-psychosocial predictors (e.g. pre-injury health, catastrophizing, acute distress, quality of life, social support) of mental health trajectories were investigated. RESULTS: Up to five typical post-trauma trajectories were identified for DM, PTS and PI. Most people were in a resilient mental health trajectory (over 60%, DM or PTS), or in a chronic PI trajectory (almost 60%) 12 months post-injury. While recovery/resilient mental health trajectories were strongly interrelated (73.4% joint probability and > 94% conditional probabilities), DM/PTS comorbidity in chronic trajectories was not straightforward, suggesting a possibly asymmetric relationship. That is, persistent DM was more likely associated with persistent PTS (90.4%), than vice versa (31.9%), with a 22.5% probability that persistent PTS was associated with none or milder depression (i.e. following a recovery/resilient DM trajectory). An asymmetrical relationship was also found between mental health and PI. The majority of those with persistent PI were likely to be in a recovery/resilient DM/PTS trajectory (almost 70%), but those in a non-resilient DM/PTS trajectory showed a high risk of persistent PI. Predictors of non-resilient mental health trajectories included poorer pre-injury health and social support, and shared factors like acute psychological distress and pain catastrophizing. CONCLUSIONS: Strong interrelations were confirmed between mental health symptoms and PI following traffic injury. However, persistent DM was more strongly linked to persistent PTS, than vice versa. Persistent PI was only linked with persistent DM/PTS in vulnerable subgroups. Early psychiatric/psychological interventions should target elevated psychological distress and negative appraisals in vulnerable individuals, to reduce long-term mental health morbidity/comorbidity and PI. TRIAL REGISTRATION: ACTRN12613000889752.

Inequity in rehabilitation interventions after hip fracture: a systematic review.

OBJECTIVE: to determine the extent to which equity factors contributed to eligibility criteria of trials of rehabilitation interventions after hip fracture. We define equity factors as those that stratify healthcare opportunities and outcomes. DESIGN: systematic search of MEDLINE, Embase, CINHAL, PEDro, Open Grey, BASE and ClinicalTrials.gov for randomised controlled trials of rehabilitation interventions after hip fracture published between 1 January 2008 and 30 May 2018. Trials not published in English, secondary prevention or new models of service delivery (e.g. orthogeriatric care pathway) were excluded. Duplicate screening for eligibility, risk of bias (Cochrane Risk of Bias Tool) and data extraction (Cochrane's PROGRESS-Plus framework). RESULTS: twenty-three published, eight protocol, four registered ongoing randomised controlled trials (4,449 participants) were identified. A total of 69 equity factors contributed to eligibility criteria of the 35 trials. For more than 50% of trials, potential participants were excluded based on residency in a nursing home, cognitive impairment, mobility/functional impairment, minimum age and/or non-surgical candidacy. Where reported, this equated to the exclusion of 2,383 out of 8,736 (27.3%) potential participants based on equity factors. Residency in a nursing home and cognitive impairment were the main drivers of these exclusions. CONCLUSION: the generalisability of trial results to the underlying population of frail older adults is limited. Yet, this is the evidence base underpinning current service design. Future trials should include participants with cognitive impairment and those admitted from nursing homes. For those excluded, an evidence-informed reasoning for the exclusion should be explicitly stated. PROSPERO: CRD42018085930.

Fracture risk in people with developmental disabilities: results of a large claims data analysis.

Age- and sex-specific fracture rates of 18,000 people with developmental disabilities aged 0-69 years were compared to the general population. Age-standardized incidence of femoral fracture was 4.8- and 7.1-fold higher in women and men, respectively. Comparable fracture risks to the general population occurred 10-15 years earlier in females and 20-40 years earlier in males. INTRODUCTION: Previous studies suggested that fracture risks in people with developmental disabilities (DD) may be higher than in people in the general population. However, there are no current sufficiently large studies to compare age- and sex-specific fracture rates of single fracture types. METHODS: People with DD and incident fractures were identified by routine data of a health insurance company. Fractures in the general population were derived from the official fracture statistics. Age-specific and age-standardized fracture incidences were analyzed. To compare fracture risks in people with DD with that of the general population incidence ratios were calculated. RESULTS: Between 2008 and 2010, 148 femoral fractures and 469 other fractures were observed in nearly 18,000 people with DD aged 0-69 years. The three most frequent fracture types leading to hospital admission were fractures of the femur, lower leg/ankle, and shoulder/arm. For femoral fractures, a particularly high risk was observed in children and adolescents with DD. In adults with DD, the risk of femoral fractures increased with increasing age. Even if the youngest age category was not considered, the age-standardized incidence was 4.8- and 7.1-fold higher in women and men, respectively. For all other fracture types, except fractures of forearm/hand and of pelvis, people with DD had also higher fracture incidences than the general population. CONCLUSIONS: People with DD have a high fracture burden. Comparable risks of femoral fracture, for example, occurred about 10-15 years earlier in females and even 20-40 years earlier in males with DD than in the general population.

The reliability of measuring wound undermining in people with spinal cord injury.

OBJECTIVE: The objective of this study was to determine the reliability of measuring wound undermining in people with spinal cord injury (SCI). STUDY DESIGN: A psychometric study. SETTING: The study was conducted at the Indian Spinal Injuries Centre, New Delhi, India. PARTICIPANTS: Thirty people with a complete or incomplete SCI and a pressure ulcer with wound undermining were recruited. METHODS: Wound undermining was measured using the four cardinal points from a clock face (with 12 O'clock defined as towards the head). Inter-rater reliability was tested by comparing the wound undermining scores from two different assessors. Intra-rater reliability was tested by comparing the wound undermining scores from the same assessor on two different days. RESULTS: The intraclass correlation coefficients (95% confidence interval) for inter-rater and intra-rater reliability were 0.996 (0.992-0.999) and 0.998 (0.996-0.999), respectively. Repeat measurements by the same and different assessor were within 0.3 cm of each other, 80% and 83% of the time, respectively. CONCLUSION: Measurements of wound undermining have excellent reliability.

Telephone-based management of pressure ulcers in people with spinal cord injury in low- and middle-income countries: a randomised controlled trial.

STUDY DESIGN: A multicentre, prospective, assessor-blinded, parallel randomised controlled trial. OBJECTIVES: The objective of the trial was to determine the effectiveness of telephone-based management of pressure ulcers in people with spinal cord injury (SCI) in low- and middle-income countries. METHODS: One hundred and twenty people with SCI living in the community were recruited through three hospitals in India and Bangladesh between November 2013 and March 2016. Participants had sustained an SCI >3 months prior and had a pressure ulcer. Participants were randomly allocated (1:1) to a control or intervention group. Participants in the control group received no intervention. Participants in the intervention group received weekly advice by telephone for 12 weeks about the management of their pressure ulcers from a trained health-care professional. Outcomes were measured by a blinded assessor at baseline and 12 weeks. There was one primary outcome, namely, the size of the pressure ulcer and 13 secondary outcomes. RESULTS: The mean between-group difference for the size of the pressure ulcer at 12 weeks was 2.3 cm2 (95% confidence interval -0.3 to 4.9; favouring the intervention group). Eight of the 13 secondary outcomes were statistically significant. CONCLUSION: The results of our primary outcome (that is, size of pressure ulcer) do not provide conclusive evidence that people with SCI can be supported at home to manage their pressure ulcers through regular telephone-based advice. However, the results from the secondary outcomes are sufficiently positive to provide hope that this simple intervention may provide some relief from this insidious problem in the future.

Cost-effectiveness analysis of telephone-based support for the management of pressure ulcers in people with spinal cord injury in India and Bangladesh.

OBJECTIVE: To determine from a societal perspective the cost-effectiveness and cost-utility of telephone-based support for management of pressure ulcers. STUDY DESIGN: Cost-effectiveness and cost-utility analysis of a randomised clinical trial. SETTING: Tertiary centre in India and Bangladesh. METHODS: An economic evaluation was conducted alongside a randomised clinical trial comparing 12 weeks of telephone-based support (intervention group) with usual care (control group). The analyses evaluated costs and health outcomes in terms of cm2 reduction of pressure ulcers size and quality-adjusted life years (QALYs) gained. All costs were in Indian Rupees (INR) and then converted to US dollars (USD). RESULTS: The mean (95% confidence interval) between-group difference for the reduction in size of pressure ulcers was 0.53 (-3.12 to 4.32) cm2, favouring the intervention group. The corresponding QALYs were 0.027 (0.004-0.051), favouring the intervention group. The mean total cost per participant in the intervention group was INR 43 781 (USD 2460) compared to INR 42 561 (USD 2391) for the control group. The per participant cost of delivering the intervention was INR 2110 (USD 119). The incremental cost-effectiveness ratio was INR 2306 (USD 130) per additional cm2 reduction in the size of the pressure ulcer and INR 44 915 (USD 2523) per QALY gained. CONCLUSION: In terms of QALYs, telephone-based support to help people manage pressure ulcers at home provides good value for money and has an 87% probability of being cost-effective, based on 3 times gross domestic product. Sensitivity analyses were performed using the overall cost data with and without productivity costs, and did not alter this conclusion.

A telephone-based version of the spinal cord injury-secondary conditions scale: a reliability and validity study.

OBJECTIVE: The objective of this study was to determine the inter-rater reliability and validity of using a telephone-based version of the spinal cord injury-secondary conditions scale (SCI-SCS). TRIAL DESIGN: A psychometric study was conducted. SETTING: The study was conducted in Royal North Shore Hospital, Sydney, Australia. PARTICIPANTS: Forty people with a complete or an incomplete spinal cord injury. METHODS: Inter-rater reliability was tested by comparing the telephone-based version of the SCI-SCS administered on two different days by two different telephone assessors. Validity was tested by comparing the telephone-based version of the SCI-SCS with the paper-based version of the SCI-SCS. RESULTS: The median (interquartile range) age and time since injury were 54 (48-63) years and 28 (14-35) years, respectively. The intraclass correlation coefficient (95% confidence interval) reflecting the agreement between the telephone-based version of the SCI-SCS administered on two different days by two different assessors was 0.96 (0.93-0.98). The corresponding value reflecting agreement between the telephone-based assessment and the paper-based assessment was 0.90 (0.83-0.95). CONCLUSION: The telephone-based version of the SCI-SCS is a simple and a quick questionnaire to administer that has both inter-rater reliability and validity. It may be useful as a way to screen for secondary health conditions in low- and middle-income countries where it is not always feasible to provide routine face-to-face follow-ups and where literacy may be a problem.

Statin utilisation patterns in older Australians living in residential care: 1-year prevalence study.

Despite controversy over the risks and benefits of statin therapy, statins continue to be commonly used medicines by older people. In a cohort study of participants aged ≥70 years (n = 540) living in residential care, Sydney, we found that the proportion of statin users decreased gradually from the baseline of 33.1% to 31.3% at 6 months (P = 0.13) and to 28.7% over 1 year (P = 0.002). Prevalence of statin use decreased with increasing age, with individuals aged ≥90 years being more likely to discontinue or deprescribe statins. The patterns of statin use did not change according to increasing baseline dose or baseline indication.

General practitioners' knowledge of whiplash guidelines improved with online education.

OBJECTIVE: The primary objective of this study was to evaluate the effect of an online education program used to implement the Australian (New South Wales) whiplash guidelines with general practitioners (GP). The secondary aim was to identify factors associated with learning. METHODS: An online educational and evaluation activity was developed to reflect the key messages for GP from the Australian whiplash guidelines. The educational activity was hosted on the Royal Australian College of General Practitioners' website (www.gplearning.com.au) for a period of 3 years. Participants were recruited through advertisement and media releases. Participants completed a baseline evaluation of their knowledge, participated in the interactive educational activity and completed a post-knowledge questionnaire. The primary outcome was change in professional knowledge, predictors of learning were computed using linear regression. RESULTS: Two hundred and fifteen GP participated. Knowledge significantly improved between baseline and post-knowledge questionnaire scores (P < 0.00001). A total of 57.2% of participants improved their knowledge by more than 20%, indicating a large effect. Low baseline knowledge predicted learning, accounting for 71% of the variance. CONCLUSIONS: Online education of GP significantly improved their knowledge in relation to guidelines for whiplash. Those with low baseline knowledge improved their knowledge the most, suggesting that implementation strategies should be targeted at this group.

Does increased sunlight exposure work as a strategy to improve vitamin D status in the elderly: a cluster randomised controlled trial.

SUMMARY: Sunlight exposure by improving vitamin D status could be a simple public health strategy in reducing falls among frail elder people. In a randomised controlled trial, adherence to sunlight exposure was low (median adherence, 26%) and no effect of increased UV exposure on falls risk was observed (incidence rate ratio (IRR) 1.06, P = 0.73). INTRODUCTION: This study aimed to determine whether increased sunlight exposure was effective to improve vitamin D status and reduce falls in the elderly. METHODS: In a cluster randomised controlled trial (NCT00322166 at ClinicalTrials.gov), 602 residents aged 70 or more (mean age, 86.4 years; 71% female) were recruited from 51 aged care facilities in Northern Sydney, Australia. Participants were randomised by facility to receive either increased sunlight exposure (additional 30-40 min/day in the early morning) with (UV+) or without (UV) calcium supplementation (600 mg/day) or neither (control) for a year. The co-primary endpoints were change in serum 25 hydroxy vitamin D (25OHD) and falls incidence after 12 months. RESULTS: Adherence to sunlight exposure was low (median adherence, 26%; IQR, 7%-45%). Serum 25OHD levels were low at baseline (median, 32.9 nmol/L) and increased only slightly depending on the number of sunlight sessions attended over 12 months (P = 0.04). During the study, 327 falls occurred in 111 (54%) subjects in the control group, 326 falls in 111 (58%) subjects in the UV only group and 335 falls in 108 (52%) subjects in the UV+ group. By intention-to-treat analysis, there was no significant effect of increased UV exposure on falls risk (IRR, 1.06; 95% CI, 0.76-1.48; P = 0.73). However, in 66 participants who attended ≥130 sessions per year (adherence, ≥50% of 260 sessions-five per week), falls were significantly reduced (IRR, 0.52; 95% CI, 0.31-0.88; P = 0.01) compared with the control group. CONCLUSIONS: Increased sunlight exposure did not reduce vitamin D deficiency or falls risk in frail older people. This public health strategy was not effective most likely due to poor adherence to the intervention.

Measures of physical functioning after hip fracture: construct validity and responsiveness of performance-based and self-reported measures.

OBJECTIVES: this study aimed to investigate the construct validity and responsiveness of performance-based and self-reported measures of strength, mobility and balance after hip fracture. DESIGN: secondary analysis of clinical trial data. SUBJECTS: a total of 148 older people undergoing hip fracture rehabilitation. METHODS: correlation coefficients assessed construct validity. Internal responsiveness was assessed by calculating effect sizes (ES) I and II. Area under the receiver operating characteristic curve (AUC) assessed external responsiveness with change in EuroQol as the reference. RESULTS: correlations between performance-based and self-reported measures were small to medium (strength r = 0.17, mobility r = 0.45 and balance r = 0.37). The most responsive performance-based measures included walking speed (ESI 1.7, ESII 1.2), Physical Performance and Mobility Examination (ESI 1.3, ESII 1.0) and chair-rise test (ESI 1.1, ESII 0.8). Self-reported mobility (ESI 0.8, ESII 0.6) and strength (ESI 0.8, ESII 0.6) were more responsive than self-reported balance (ESI 0.3, ESII 0.2). External responsiveness (AUC) was greatest for walking speed (0.72) and lowest for the measures of body sway (0.53). CONCLUSION: self-reported and performance-based indices appear to assess different constructs and may provide complementary information about physical functioning in people after hip fracture. Measures of strength and mobility showed greater ability to detect change than measures of balance.

Oral bisphosphonates are associated with reduced mortality in frail older people: a prospective five-year study.

UNLABELLED: In a study of 2005 institutionalized older people, use of oral bisphosphonates was associated with a 27% reduction in risk of death compared to non-users after adjusting for potential confounders. INTRODUCTION: This study investigated whether reductions in mortality reported in a trial of intravenous zoledronate after hip fracture could be seen in older people taking oral bisphosphonates. METHODS: Two thousand and five institutionalized older people (mean age 85.7 years) were assessed at baseline and followed up for hip fracture and death for at least 5 years. Cox proportional hazards regression was used to estimate effects of bisphosphonates on risk of death. RESULTS: At baseline, 78 subjects were taking oral bisphosphonates. Over 5 years of follow-up, 1,596 participants (80%) died. Use of bisphosphonates was associated with a 27% reduction in risk of death compared to non-users after adjusting for age, gender, type of institution, immobility, number of medications, weight, cognitive function, co-morbidities, and hip fracture incidence during the follow-up period (hazard ratio 0.73; 95% CI, 0.56 to 0.94; P = 0.02). CONCLUSION: Oral bisphosphonates are associated with a reduction in the risk of death in the elderly. The mechanism of effect requires further investigation.

Increasing adherence with the use of hip protectors for older people living in the community.

UNLABELLED: For people at high risk of hip fracture living in community settings, providing hip protectors at no cost increased adherence, but the additional effect of an educational programme was limited. Overall, the level of adherence was modest. INTRODUCTION: The objective of the study was to increase adherence with hip protector use by older people at high risk of hip fracture. The study included two randomised controlled trials with 308 older people recruited from three hospital rehabilitation wards and 171 older people recruited from the community. METHODS: Participants were randomised into three groups. The control group received a brochure about hip protectors. The no cost group were fitted with free hip protectors and asked to use them. The combined group received free hip protectors and education sessions about their use. Adherence with the use of hip protectors at 3 and 6 months after recruitment was measured. Secondary outcomes were falls, fractures and hospitalisations. RESULTS: Very few participants in the two control groups bought a hip protector. Overall adherence in the four intervention groups was modest, but higher in the community recruitment setting (49%) than in the hospital recruitment setting (36%) at 6 months. In the community recruitment group, at 3 months of follow-up, a significantly higher number of participants in the combined group (62%) were wearing hip protectors compared to the no cost group (43%, p=0.04). Five hip fractures occurred during the study, with four sustained whilst not wearing the hip protectors. CONCLUSION: Providing hip protectors at no cost to community living older people at high risk of hip fractures modestly increases initial acceptance and adherence with hip protector use. Additional education may further increase hip protector use in people living in the community in the short term.

Excess mortality after pelvic fractures in institutionalized older people.

UNLABELLED: Mortality after pelvic fracture was calculated in residents of nursing homes. Compared with a matched comparison nonfracture group, excess mortality was found during the first 2 months after pelvic fracture. INTRODUCTION: Low energy pelvic fractures are mainly observed in people of advanced older age. The incidence of these fractures has increased considerably during the last decades. Information about excess mortality after pelvic fractures in older people is not available. METHODS: To calculate excess mortality, a retrospective cohort study was conducted. Data from residents institutionalized in Bavarian nursing homes between 2001 and 2006 were used. For each patient with a pelvic fracture (n=1,154), five residents without pelvic fracture (n=5,770) were matched by sex, age, date of admission to the nursing home, and level of care (measure for the need of care). Hazard regression models were applied. RESULTS: An excess mortality was found during the first months after pelvic fracture. In women, the increased mortality risk was limited to the first (hazard rate ratio (HR) 1.83, 95% confidence interval (CI) 1.42-2.37) and second (HR 1.52, 95% CI 1.13-2.04) months after the injury. In men, excess mortality was more pronounced (HR 2.95, 95% CI 1.57-5.54 for the first month) and appeared to last longer than in women. The majority of deaths due to pelvic fractures in the first 2 months after injury occurred following discharge from the hospital to the nursing home. CONCLUSION: Pelvic fractures are associated with an increased mortality. These results should encourage the development of preventive measures to reduce this excess mortality.

Hip protectors: recommendations for conducting clinical trials--an international consensus statement (part II).

INTRODUCTION: While hip protectors are effective in some clinical trials, many, including all in community settings, have been unable to demonstrate effectiveness. This is due partly to differences in the design and analysis. The aim of this report is to develop recommendations for subsequent clinical research. METHODS: In November of 2007, the International Hip Protector Research Group met to address barriers to the clinical effectiveness of hip protectors. This paper represents a consensus statement from the group on recommended methods for conducting future clinical trials of hip protectors. RESULTS AND CONCLUSIONS: Consensus recommendations include the following: the use of a hip protector that has undergone adequate biomechanical testing, the use of sham hip protectors, the conduct of clinical trials in populations with annual hip fracture incidence of at least 3%, a run-in period with demonstration of adequate adherence, surveillance of falls and adherence, and the inclusion of economic analyses. Larger and more costly clinical trials are required to definitively investigate effectiveness of hip protectors.

Role of quantitative ultrasound to predict fracture among institutionalised older people with a history of fracture.

UNLABELLED: The fracture predictive value of quantitative ultrasound (QUS) may be modified by previous fracture status. Non-significant associations between QUS parameters and fracture risk were observed among frail older people with a history of fracture. These findings suggest that QUS measurements for frail older people might be more useful in those without a fracture history. INTRODUCTION: Quantitative ultrasound has been shown to predict risk of fracture in various populations. However, this ability may be modified by the presence of previous fracture in very frail older people. METHODS: We assessed bone strength by QUS and clinical risk factors at baseline for 1,982 institutionalised older people. Fractures were ascertained for 2 years from baseline and validated by X-ray reports. RESULTS: Study participants were very old (mean age = 85.7 +/- 7.1 years) and frail (70% using walking aids). Forty-five percent reported a history of fracture. During a mean follow-up period of 1.64 years, 335 participants suffered a fracture or fractures. Fracture rates were significantly higher in participants with a history of fracture compared with those without a history of fracture (16.0 vs 9.2 per 100 person years, p < 0.001). Significant associations between fracture risk and QUS parameters (broadband ultrasound attenuation and velocity of sound) were observed among participants without a history of fracture (both p < 0.01), but not among those who had a fracture history (both p >/= 0.7). CONCLUSIONS: In very frail older people, QUS measurements may be more useful for assessing fracture risk in those without a history of fracture after age 50.