fracture & trauma

Introduction

Sarcopenia is common in patients with hip fracture, but few studies have examined whether assessment of sarcopenia improves prediction of adverse post-operative outcomes. We examined whether sarcopenia, diagnosed using handgrip strength (HGS), could predict outcomes after hip fracture.

Methods

Routinely collected data from the National Hip Fracture Database were combined with locally collected HGS data from a high-volume orthopaedic trauma unit. Patients aged ≥65years with surgically managed, non-pathological hip fracture with grip strength measured on admission were included. The European Working Group on Sarcopenia in Older People (EWGSOP2) thresholds were used to identify patients with or without sarcopenia; those unable to complete grip strength testing were also included in analyses. Outcomes examined were 30-day and 120-day mortality, residential status and mobility, prolonged length of stay (>15 days) and post-operative delirium. Binary logistic regression models were used to examine prognostic value of HGS, and discriminant ability for the Nottingham Hip Fracture Score (NHFS) alone and on adding sarcopenia status were compared using c-statistics.

Results

We analysed data from 282 individuals; mean age 83.2 (SD 9.2) years; 200 (70.9%) were female. 99 (35.1%) patients had sarcopenia and 109 (38.7%) were unable to complete testing. Sarcopenia predicted higher 120-day mortality (OR 13.0, 95%CI 1.7-101.1, p=0.014), but not 30-day mortality (OR 1.5, 95%CI 0.1-16.9, p=0.74). Patients unable to complete HGS testing had higher 30-day mortality (OR 13.5, 95%CI 1.8-103.8, p=0.012) and 120-day mortality (OR 34.5, 95%CI 4.6-258.7, p<0.001). Sarcopenia status did not significantly improve discrimination for mobility but improved prediction of 120-day residential status (c-statistic 0.89 [95%CI 0.85-0.94] for NHFS+sarcopenia vs 0.82 [95%CI 0.76-0.87] for NHFS alone) and post-operative delirium (c-statistic 0.91 [95%CI 0.87-0.94] vs 0.78 [95%CI 0.73-0.84]).

Conclusion

Sarcopenia assessment via HGS testing may provide additional prognostic information to existing risk scores in older patients with hip fracture.

Objectives: Older adults hospitalized with a hip fracture are at risk for adverse health outcomes depending on their level of frailty. This study examined how frailty levels prior to admission impacted length of stay (LOS), requirement for alternative level of care (ALC), returning home post-discharge, and mortality.

Methods: A random sample was generated from all hip fracture patients aged 65 and older admitted to a Level One Trauma Centre in New Brunswick, Canada from 2015-2019. This sample had their frailty level determined retrospectively using the Pictorial Fit-Frail Scale and the patients’ hospital electronic health record.

Results: Our study included 189 patients (mean age: 83.2 ± 8.2, 73.0% female), representing 91 not frail to mildly frail (48.2%; NF-MF), 32 moderately frail (16.9%; ModF), and 66 severely frail (34.9%; SF) patients. The ModF patients had a longer LOS (median: 20.0 days, IQR=22.5) compared to NF-MF patients (median: 11.0 days, IQR=10.0, p=0.039, Kruskal-Wallis test) and SF patients (median: 8 days, IQR=5.5, p<0.0001, Kruskal-Wallis test). More ModF patients (56.3%) required an ALC stay in acute care compared to NF-MF (30.8%) and SF (28.8%) patients (p=0.016, Chi-square test). More SF patients (28.8%) died in hospital or within six months post-discharge compared to NF-MF (8.8%) patients (p=0.005, Chi-square test). Logistic regression revealed that both NF-MF (OR=8.11, 95% CI: [3.12-21.06], p<0.001) and ModF (OR=5.18, 95% CI: [0.85-0.95], p=0.007) patients had greater odds of returning home compared to SF patients when accounting for sex, age, and time to surgery.

Conclusions: A patient’s level of frailty prior to hospital admission impacts various health outcomes following a hip fracture and may provide helpful information for guiding treatment as well as discussions about health care.  

Introduction

Fall-related injuries such as fractures are on the rise as the older adult population grows in New Brunswick, Canada. These injuries can lead to hospitalization and transitions in care that are complicated for patients and families. The objective was to investigate the impact of patient navigators (PNs) working alongside the healthcare team on patient and family experiences, as compared to the usual standard of care (SOC), for adults aged 65 and older admitted with a fracture to an Orthopedic Unit at one hospital in New Brunswick.

Methods

A concurrent embedded mixed methods design, in which the quantitative randomized control trial had an embedded qualitative component. The results for the family caregiver qualitative component, which used an interpretive description approach, are presented.

Results

Semi-structured interviews were conducted and thematically analyzed for 15 family caregivers (8 PN group, 7 SOC group). The SOC caregivers, six women and one man, had a mean age of 64.6 years (SD=6.9 years). The mean age of the 8 women in the PN group was 61.3 years (SD=10.1). All participants in both SOC and PN groups self reported their ethnicity as white. Thematic analysis found that SOC group caregivers discussed patients relying on support from family and friends throughout their care journey, whereas caregivers in the PN group predominantly discussed finding PNs supportive and helpful. Both groups discussed the ongoing stress that they felt throughout the care journey of the patient for which they cared for; however, for the PN group this topic was less prevalent.

Conclusions

This study provides an understanding of the positive impacts a patient navigator can have on older adult inpatient care and transitions in care. Patient Navigators were shown to be helpful to families, particularly those of patients with higher care needs and fewer family supports.

Abstract Content - Introduction Falls are the leading cause of preventable death in older adults and can also lead to psychological consequences, including concerns about future falls. Although literature traditionally focuses on those over 65 yrs, recent research shows adults as young as 50 yrs could be at risk. Most falls occur at home and are often due to environmental hazards. Despite evidence supporting a 38% reduction in falls through home modifications, their efficacy in not fully understood. Exploring barriers and facilitators to home modifications aimed at reducing falls and concerns about falling, could better inform future interventions. Methods As part of a mixed-methods systematic review, six electronic databases were searched on February 4th 2024: Scopus, PubMed, CINAHL, MEDLINE, SportsDiscus and Psycinfo. The search explored studies on home modifications for adults over 50 living at home, without residential health or rehabilitation services, specifically aimed at reducing falls incidences and concerns about falling. Barriers and facilitators to home modifications were explored from the perspectives of fallers, those at risk of falling, families, caregivers and key stakeholders. Results Thirteen of the 31 papers included in the full systematic review were focused on barriers and facilitators to home modifications. For barriers, five themes were identified: cost; stigma associated with ageing and disability; lack of awareness; fear of change and professional incompetence and inconsistency. Five themes were identified for facilitators: support from family and caregivers; early planning; involvement in decision making professional collaboration and enhanced caregiver well-being. Conclusion These findings underscore the need for multi-faceted approaches to home modifications, addressing both practical and psychological issues. Only three studies included adults 50+ yrs, with little known about the barriers and facilitators for this age onwards. Future interventions should encompass a person-centered approach, focus on increasing affordability, raising early awareness, fostering supportive networks, and ensuring high-quality professional services.

Abstract Content - Introduction. When required to multitask while walking, older adults (OA) will walk slower and use maladaptive stepping strategies such as cross-steps that may increase the risk of falling. However, most studies to date have been limited to steady-state straight-line walking, which requires limited to no visual planning, which is unrepresentative of common outdoor environments. Therefore, this study aimed to (i) investigate the impact of dual-tasking during walking of complex routes, and (ii) assess if such impact can be reduced when older adults deliberately preview their route to improve planning. Methods. We aim to recruit 45 community-dwelling OA. Preliminary results are reported for 19 (13F & 6M) community-dwelling OA without neurological or musculoskeletal diagnosis (Mean age = 75.7, range = 64–84). Participants walked along different winding paths on an 8-meter-long walkway under three conditions for 6 trials per condition: Single-task (ST), Dual-task (counting backwards) without previewing their route (DT) and Dual-task with deliberate previewing of the walking route (DTP). For each condition, we recorded walking speed, stepping errors (deviations from the pathway), and cross-steps. Results. Participants walked significantly slower during the DT condition (M=58.3 cm/s, SD=15.4) vs. ST condition (M=82.6 cm/s, SD=12.6; p<.001). during the dt condition participants also made more errors (m="1.3/trial," sd="1.4;" p=".029)" and frequent cross-steps compared to ST (no noted; m="0.4" />trial, SD=0.4). However, when allowed to preview their route prior to dual-tasking (DTP condition), participants walked faster (M=69.9 cm/s, SD=18.7; p=.002) and with fewer errors (M=0.1/trial, SD=0.1; p=.006). Conclusions. The imposition of an attentional load during adaptive walking reduces speed and increases the likelihood of potentially risky stepping strategies. Taking the time to deliberately preview the walking route seems to reverse some of these negative changes, and particularly to allow older adults to walk faster with fewer stepping errors.

Introduction

Stair falls cause approximately 230,000 injuries and 500 fatalities each year (Roys, 2001). Falls cost the NHS £4.6 million every day (AgeUK, 2010), and approximately £2 billion each year (GOV.UK, 2022), with falls on stairs accounting for the majority of these costs. However, the evidence about how to reduce stair falls is unclear. The aim of this systematic review was to establish which interventions are effective or show greatest potential to improve safety on stairs and reduce falls.

Methods

Five databases were searched: Medline, Scopus, Web of Science, PubMed and CINAHL. Papers were included if they were interventions or provided proof-of-principle to inform an intervention design. Papers were excluded if participants were under the age of 18, or were diagnosed with any clinical condition (disease outside that which we can expect from healthy ageing).

Results

No study reported fall occurrence as an outcome measure. Step-edge highlighters were the only intervention tested in real-world environments, as well as laboratories, and showed good proof of principle, feasibility and acceptability. Five intervention types were found that reduced fall risk in laboratory trials: lighting, horizontal-vertical illusions in ascent, stair dimensions (riser, going and pitch), avoiding multi-tasking and handrail use. These were successful in reducing mechanical demand (reducing or redistributing joint moments) and improving stepping behaviours associated with fall risk (reductions in magnitude and variability of foot clearances and overhang on the step).

Conclusion

This review has established there is no definitive evidence that any intervention reduced fall rates, but that some interventions show good proof-of-principle and feasibility: step-edge highlighters flush to the step edge, increased lighting levels, horizontal-vertical illusions in ascent, use of handrails, avoiding multi-tasking, riser heights 10.2-19cm, going lengths 22.5-32.5cm and reduced pitch angles. Future research must translate these interventions into real world settings and evaluate effectiveness to reduce fall rates.

Introduction: Concerns about falling (CaF) is a psychosocial concept, precipitating a spiral of increasing inactivity, social isolation and falls, and is common in those who have experienced, or are at risk of, a fall. One method of assessing CaF is the Falls Efficacy Scale International version (FES-I),with previous studies finding associations between higher FES-I scores and poor scoring on commonly used clinical assessments of functional mobility and balance (Gait speed (GS), Timed up and Go test (TUG), and Five time sit to stand (FTSS)). Using the FES-I to predict poor functional mobility and balance has the potential to identify those at risk before an initial fall, at which point an intervention may be provided.

Methods: A prospective study was carried out over 24 weeks, in which 119 participants were recruited from the North Tyneside Community Falls Prevention Service (NTCFPS). Participants completed questionnaires and underwent physical testing whilst attending the falls clinic (baseline) and at week 24, completing bi-weekly falls diaries throughout. Participants were users of the NTCFPS, and residents of North Tyneside.

Results: Findings showed (i) the FES-I had a limited ability to predict poor scores on GS, TUG and FTSS; (ii) attending referred Age UK strength and balance classes was significantly associated with improvements in FES-I score and FTSS; (iii) CaF at the outset of Age UK training was not significantly associated with clinically significant improvements in GS, FTSS and TUG.

Conclusions: Whilst the predictive capabilities of the FES-I were limited, the measure showed an ability to track improvements in participants CaF in the short to medium term. Further work is needed to explore the measures applications within the general population of community dwelling older adults, rather than a cohort of falls service users.

Introduction

The fall risk factors in older adults living in residential care homes for the elderly (RCHEs) are multifactorial. In Hong Kong, around 9.5% of RCHEs have a fall rate over 30% (Elderly Health Service, 2022)1. The objective of this survey is to identify the common fall risk factors among frequent fallers in RCHEs in biological, environmental, and behavioural domains, based on the World Health Organization (WHO)’s risk factor model for fall (World Health Organization, 2021)2.

Methods

197 frequent fallers from 67 RCHEs with fall prevalence over 30% in Hong Kong were included in this cross-sectional retrospective survey. Twenty fall risk factors in biological, environmental and behavioural domains were investigated through tailor-made questionnaires and staff interviews. The most common fall risk factors, the time period and places of fall of all fallers were identified. The fall management strategy including fall risk assessment and fall incident report of RCHEs were also examined and compared.

Results

In the biological domain, chronic illnesses, decreased mobility, gait instabilities, lack of physical activities and cognitive impairment are the most common fall risk factors. In the behavioural domain, unsafe behaviour such as over-estimation of self-ability and hesitation to seek assistance are the most prevalent. Key environmental fall risk factors include movable furniture and poor lighting. The most common places of falls are bedsides while the peak hours of falls occurs around meal times. Nearly 24% of RCHEs did not perform fall risk assessments for residents.

Conclusions

Behavioural and biological fall risk factors play a more important role than environmental risk factors in these frequent fallers, and many of them are modifiable. Large variations exist in the fall management of different RCHEs. Interventions to prevent falls in RCHEs should target at improving the fall management protocol and addressing the specific fall risk factors of frequent fallers. 
 

Introduction:

Older patients attending the Emergency Department (ED) and discharged home are at higher risk of adverse outcomes. Geriatric Ambulatory ED services were developed with the aim to deliver goal-directed care of older patients from ED using onward referral to Community Providers.

Method:

A retrospective review was undertaken from 13th January 2022 to 23rd December 2022 in older patients discharged from the ED following a targeted geriatric assessment and recommended community follow-up interventions. Demographic information, functional ability, hospital utilisation and mortality (up to one year), and any post-visit fragility fractures were reviewed. Data collection included identification of osteoporosis or osteopenia during or following the index ED visit.

Results:

108 patients were assessed, of whom, 74% were female, average age 76 years, range 61-93 years. 65% of patients were CFS scored, 9% were CFS 6 or 7, 15% CFS 4 or 5 and 41% CFS 1-3. GP review was advised for 76% of patients and 61% attended and therapy interventions were recommended for 9.3%, of whom, 3% attended. The majority presented with falls (82%) and half of those who fell, sustained a fracture. Osteoporosis or osteopenia was newly identified in 30% but in 44% of patients bone health remained unevaluated and only 8% had newly initiated anti-resorptive and 9% existing treatment. 4% experienced fragility fracture following their ED visit. Uptake was low for therapy (30%) and nursing interventions (14%). Following the index ED visit, 7% patients attended ED within 7-days, and 5% admitted to hospital within 30-days. 35% of patients re-attended ED and 22% were hospitalised within one year. One year mortality was 5%.

Conclusion:

ED targeted geriatric assessment can identify patients with falls and fragility fractures but better collaboration and communication between primary and secondary care is needed. Recommended bone health assessment occurred in a relatively small proportion of patients.

Purpose

To investigate physiotherapists’ perspectives of effective community provision following hip fracture.

Methods

Qualitative semi-structured interviews were conducted with 17 community physiotherapists across England. Thematic analysis drawing on the Theoretical Domains Framework identified barriers and facilitators to implementation of effective provision. Interviews were complemented by process mapping community provision in one London borough, to identify points of care where suggested interventions are in place and/or could be implemented.

Results

Four themes were identified: ineffective coordination of care systems, ineffective patient stratification, insufficient staff recruitment and retention approaches and inhibitory fear avoidance behaviours. To enhance care coordination, participants suggested improving access to social services and occupational therapists, maximising multidisciplinary communication through online notation, extended physiotherapy roles, orthopaedic-specific roles and seven-day working. Participants advised the importance of stratifying patients on receipt of referrals, at assessment and into appropriately matched interventions. To mitigate insufficient staff recruitment and retention, participants proposed return-to-practice streams, apprenticeship schemes, university engagement, combined acute-community rotations and improving job description advertisements. To reduce effects of fear avoidance behaviour on rehabilitation, participants proposed the use of patient-specific goals, patient and carer education, staff education in psychological strategies or community psychologist access. Process mapping of one London borough identified points of care where suggested interventions to overcome barriers were in place and/or could be implemented.

Conclusion

Physiotherapists propose that effective provision of community physiotherapy following hip fracture could be improved by refining care coordination, utilising stratification techniques, employing enhanced recruitment and retainment strategies and addressing fear avoidance behaviours.