fracture & trauma

Introduction:

Socio-economic costs of hip fractures are formidable. Despite osteoporosis and falls being major risk factors, preventative screening in Primary Care does not occur. Evidence shows screening older women for osteoporosis prevents hip fractures, but to make a greater clinical and economic impact simultaneous screening of falls and fracture risks is logical. This cross-sectional study evaluates an innovative digital questionnaire and computer programme to combine person-reported data with medical data, and auto-calculate fracture and falls risks without the need for clinician time.

Method:

Digital questionnaires were distributed via email or SMS to adults aged ≥65 who had consented to receive electronic correspondence over a 16-week period in one medical centre. Excluded were adults in nursing/residential care or receiving palliative care. A computer programme combined patient-reported information with existing medical data required to calculate FRAX® & FRAT scores. A robot computer function retrieved fracture risk scores from the FRAX® online tool. A weekly report showed those at high/medium risk of fracture and high risk of falls. Personalised bone health and lifestyle advice was automatically distributed.

Results:

632 (37%) of 1692 questionnaires were returned. Ages ranged from 65 to 92 years (M=72.5, SD=5.7), 47.8% identified as male and 52.2% female. Using NOGG UK Guidelines (2021), 217 (34%) adults were identified at amber and 46 (7%) at red fracture risk. 131 (20.7%) adults had fallen within the previous year and 122 (19%) had a high-risk FRAT score ≥3. Personalised bone health and lifestyle advice was delivered to all 632 adults.

Conclusion:

This automated screening process accurately identifies adults who are falling and/or at risk of osteoporosis and enables personalised bone health and lifestyle advice to be distributed without the need for clinician time. Prevention of falls and hip fractures would result in significant savings to the NHS and Social Care budgets.

Introduction: Around 10% of calls received by English ambulance services are for older adults who have fallen¹; with an ageing population there are significant care provision needs. Decision-making on the treatment for people who fall, can impact their future physical and mental health. Previous research in decision-making of ambulance staff found perception of role, confidence, service demands and training to be key drivers². The previous work highlighting drivers, but not the experiences that explain why they occur, leads this study aim to determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method: Online cross-sectional survey of frontline emergency clinicians from one English ambulance service in May 2023. Open questions generated qualitative data for thematic analysis³. Ethical and regulatory approvals, and informed consent, were obtained.

Findings: 81 participants completed the survey. Analysis identified three themes.

• Care Provision: Provision of hospital avoidance pathways varies throughout the region. Concerns arose from not knowing what different areas had and reduced accessibility out of hours.
• Communication: Decision-making confidence was impacted by the participants’ experiences of interactions with hospital and community colleagues; positive experiences encouraged use of hospital avoidance pathways, whilst negative experiences impeded willingness to avoid hospital for fear of repercussion.
• Shared Decision-Making: Patients, family and clinicians were all valued as part of shared decision-making, with past feedback on decision-making informing future practice.

Conclusion: Confidence of frontline ambulance staff was impacted by the challenge of a regional and 24/7 ambulance service not having consistent pathways available. Communication with other services impacts ambulance clinician’s future decision-making and confidence. This variation led to concerns when responding to patients outside of the clinician’s usual area, and further challenges ambulance clinicians must balance in their practice.

References:

1. Snooks, Anthony, Chatters, et al. (2017) Health Technology Assessment, 21; 1-218.

2. Simpson, Thomas, Bendall, et al. (2017) BMC Health Services Research. 17; 299.

3. Braun and Clarke. (2022) Thematic Analysis: A practical guide.

Toby Jack Ellmers (Imperial College London), Jodi Ventre (University of Manchester), Ellen Freiberger (Friedrich-Alexander-University Erlangen-Nürnberg), Klaus Hauer (AGAPLESION Bethanien Hospital Heidelberg/Geriatric Centre of the University of Heidelberg), David B Hogan (University of Calgary), Lisa McGarrigle (University of Manchester), Samuel Nyman (University of Winchester), Mae Ling Lim (Neuroscience Research Australia), Chris Todd (University of Manchester), Kim Delbaere (Neuroscience Research Australia), The World Falls Guidelines Working Group on Concerns About Falling

Background: Concerns (or, ‘fear’) about falling are common among older people. They have been reported to be associated with various negative outcomes, including activity restriction, depression, decreased quality-of-life and social isolation. Whilst prior conceptualisations have proposed an association between concerns about falling and future falls, the evidence base for such purported association is uncertain. We therefore conducted a systematic review to explore the association between concerns about falling and future prospective falls.

Methods: We searched 4 databases for articles that included concerns about falling as a baseline predictor for future falls over a 6-month period or longer. Following the removal of duplicates, we screened the abstract and titles of 10,554 articles; and the full text of 172 articles.

Results: We included and extracted data from 58 articles. A significant association between baseline concerns about falling and future falls was reported in 76% of the articles assessed (44/58); with higher concerns associated with a greater risk/odds of future falls. This significant association remained when controlling for confounding variables (n=16 articles).

Conclusion: These findings support previous conceptualisations and identify concerns about falling as an independent risk factor for future falls. As part of the World Falls Guidelines, we recommend that clinicians working with older people regularly screen for concerns about falling, using the short 7-item Falls Efficacy Scale-International (FES-I). Further analysis is currently ongoing to conduct meta-analyses based on specific outcomes (e.g., recurrent vs. single falls) and assessment tools (e.g., FES-I vs. single-item measures).

Background and Aim: Falls are a significant public health concern, with literature primarily concentrating on older adults due to their perceived higher fall risk. However, recent studies indicate similar prevalence rates of fall-related injuries between older adults (>65 years) and middle-aged adults. Despite this, there is a scarcity of literature examining the differences in experiences of falls and concerns about falling between middle-aged adults and older adults who have experienced falls. The COVID-19 pandemic and the resulting lockdown measures created an unprecedented setting to explore these experiences due to the unexpected period of physical deconditioning and heightened risk of falling among adults aged 50 and above. This current qualitative study aimed to evaluate the variations in falls and concerns about falling among middle-aged and older adults during the pandemic. Methods: Semi-structured interviews were conducted with 10 middle-aged fallers (Mage = 59 years) and 10 older fallers (Mage = 73 years), following an online falls survey. All participants had experienced one or more injurious fall(s) during the COVID-19 pandemic. Reflexive thematic analysis was used to analyse the transcribed interview data. Results: Both middle-aged and older adults demonstrated a level of age acceptance and vulnerability to falls. These experiences prompted older adults to adopt protective behavioural adaptations, while middle-aged adults potentially adopted maladaptive behavioural adaptations in situations that posed balance threats. The pandemic restrictions affected both middle-aged and older adults similarly, with reports of both groups experiencing changes in physical activity levels. Conclusion: These findings provide a new perspective on the disparities in falling experiences and concerns about falling between middle-aged and older adults during the COVID-19 pandemic. They highlight the significance of investigating concerns about falling from middle age (>45 years) to help develop intervention strategies that mitigate detrimental outcomes in later stages of life.

Introduction

Keeping our standing balance is a crucial capability in preventing falls. Nevertheless, older adults may focus attention internally to their movement mechanisms during stance, through conscious movement processing (CMP), when facing balance difficulties. However, this may interfere with movement automaticity that could cause balance problems. The primary aim of this pilot study is to examine the effects of attention focus balance training on CMP propensity in older adults at risk of falling.

Method

Twenty-four older adults (mean age = 79.92 ± 7.61) with moderate to high risk of falling were included in this preliminary analysis. Participants were randomly assigned to either the No Specific Attention Focus Balance Training Group (NBTG; n=8), External Attention Focus Balance Training Group (EBTG; n=8), or the Internal Attention Focus Balance Training Group (IBTG; n=8). Participants in different groups participated in twelve tailor-made 45-minute training sessions with different attention focus instructions during standing balance training. The primary outcome measure of the real-time (state) CMP propensity (T3-Fz Electroencephalogram (EEG) coherence) at the baseline (T0) and after completion of all balance training sessions (T1) was evaluated. A 3x2 Group (NBTG, EBTG, IBTG) x Time (T0, T1) mixed Analysis of Variance (ANOVA) was conducted.

Results

We discover a decreasing trend of the real-time (state) CMP propensity (T3-Fz EEG coherence) in the EBTG but an increasing trend of the T3-Fz EEG coherence in the IBTG from T0 to T1. The T3-Fz EEG coherence for the NBTG remains similar from T0 to T1.

Conclusion

This preliminary result suggests that the external attention focus balance training has a potential to mitigate the real-time (state) CMP propensity in older adults at risk of falling. Consequently, it could further benefit the standing balance of the at-risk older adults after their rehabilitation.

Fractures occurring after “low energy trauma” are described as fragility fractures. They most commonly happen in the spine, hip and wrist due to osteoporosis and its associated risk factors, including gender, age, medications (e.g. steroids), etc (1). Menopause in women also has a drastic impact on the risk of osteoporosis. In 2019, 3,775,000 UK citizens had a diagnosis of osteoporosis - 820,000 men and 2,955,000 women. In the same year, there were 527,000 new fragility fractures in the UK (2). Nevertheless, osteoporosis and fragility fractures do not only pose a problem within the UK. It is estimated that the number of hip fractures worldwide will increase by 4,600,000 between 1990 and 2050 as a result of an ageing population (3). The percentage of the world's population over the age of 60 is projected to rise from 12% to 22% between 2015 and 2050 (6). This age shift in particular will bring on challenges as the risk of hip fractures doubles every 10 years after the age of 50 (3). Fragility fractures can have a drastic effect on patient well-being. Surgery for hip fractures for instance has a 4% mortality rate and approximately 20% of patients die within a year (3). Patient mobility, housing conditions and quality of life all deteriorate after hip fractures (4). The impact on health economics is also significant. Direct medical costs resulting from fragility fractures in the UK were approximated at £1.8 billion in 2000 and were projected to rise to £2.2 billion by 2025 (1). However, newer reports have shown that we underestimated this burden with the total annual cost of fragility fractures in the UK reaching £4.4 billion in 2022 (5).

Introduction:

The number one reason for older people to be taken to hospital emergency departments is a fall¹.

An “Ambulance Improvement Programme Pillar”² is trying to reduce conveyance to hospital for falls, however it is not understood how the attending clinician’s confidence impacts decision-making.

The objectives were to assess recruitment rate and feasibility of online survey delivery, and determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method:

Online cross-sectional survey, undertaken in one English ambulance service in May 2023. 

Demographics were collected from participants and their role, with 5-point Likert scales of confidence.

Descriptive statistics and Chi-square analyses were used for quantitative data.

Results:

81 responses were received from across the regional ambulance service’s 16 localities.

76% of respondents were paramedics, and 53% were aged 25-34.

60% of respondents rated being ‘somewhat confident’ to ‘How confident do you feel in assessing older adults who have fallen?’, responses ranged between ‘Neither confident nor unconfident’ to ‘Completely confident’.

No significant difference was found between the locality and confidence levels for assessing this patient population. However, there appeared to be significant variation between confidence levels relating to utilisation of hospital pathways and localities (p-value=.0045).

Length of experience in both frontline ambulance and overall healthcare provision was not significantly associated with different levels of confidence.

Conclusion:

The overarching confidence of clinicians did not significantly vary around the region.

Locality of work had a relationship with confidence in utilising hospital avoidance pathways, however, did not relate to confidence in assessing this patient population.

Confidence was not found to increase for either total years providing healthcare, nor providing emergency frontline care.

References

1. Dewhirst. (2023). National Falls Prevention Coordination Group. https://committees.parliament.uk/writtenevidence/117837/pdf/

2. NHS England and NHS Improvement. (2019). Ambulance Improvement Programme. https://www.england.nhs.uk/wp-content/uploads/2019/09/planning-to-safetly-reduce-avoidable-conveyance-v4.0.pdf

Introduction:

Dizziness and vestibular symptoms are common in older adults. However, many older adults do not seek assistance for these symptoms. This study set out to explore the barriers and enabling factors to accessing healthcare in this population.

Method:

Semi-structured, one to one interviews were undertaken via video conference. Older adults (≥65 years old) were recruited organisations that support older adults, via purposeful sampling to recruit participants with a range of severity of vestibular symptoms (measured using the dizziness handicap inventory) alongside those who had and hadn’t sought help for their symptoms. Data was analysed using a reflective thematic analysis approach. Findings: 16 older adults (Mean age 74) were interviewed via zoom. The majority were female (76.5%) and White British (88.3%). The following themes were identified in the data set. 1) “Sometimes I feel dizzy if the vertigo is really bad” This theme describes the challenges with describing dizziness and vertigo, alongside the range of presentations experienced by participants. 2) Accessing Healthcare: This broad theme describes a range of personal and systemic barriers that participants experienced when accessing healthcare for their vestibular symptoms. This theme has been split into subthemes exploring the personal, service level and health professional barriers experienced by participants

Conclusion:

This study has highlighted that dizziness and vertigo are ambiguous terms and therefore clear communication is needed to ensure a shared understanding between health professionals and older adults. Barriers to healthcare exist at a personal, service level and health professional level for this population. Further work is needed to break down these barriers and improve access to healthcare for this population.

Introduction: In the current European guidelines, sarcopenia is diagnosed on the basis of low muscle strength, with low muscle mass used to confirm diagnosis. The added value of measuring muscle mass is unclear. We performed a systematic review to assess whether muscle mass was independently associated with adverse outcomes in patients with hip fracture.

Method: The systematic review protocol was registered on the PROSPERO database (CRD42021274981). Electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL, Clinicaltrials.gov) were searched for observational studies of patients with hip fracture aged ≥60 who had muscle mass or strength assessment perioperatively. Two reviewers independently screened titles/abstracts for inclusion. The association of muscle mass or strength with postoperative outcomes (mortality, Barthel Index, mobility, physical performance measures, length of stay, complications) was recorded. Risk-of-bias was assessed using the AXIS or ROBINS-I tool as appropriate. Due to the degree of study heterogeneity, data were analysed by narrative synthesis.

Results: The search strategy identified 3,007 records. Ten studies were included (n=2281 participants), containing 27 associations between muscle mass assessment and hip fracture postoperative outcomes. Four studies had intermediate risk of bias; 6 studies had high risk of bias. Lower muscle mass was associated with higher mortality and worse physical performance measures in univariate analyses but there was no significant association between muscle mass and mobility, length of stay and postoperative complication scores in any included study. Six studies assessed both muscle mass and strength. Muscle mass was not a significant independent predictor of any adverse outcome in any included study after adjustment for muscle strength and other predictor variables.

Conclusion: Data on the clinical utility of muscle mass measurement in patients with hip fracture are limited in volume and quality, but available studies suggest muscle mass does not offer additional prognostic benefit to muscle strength measures.

Introduction:
Risk prediction tools help guide prognostic conversations and benchmarking in hip fracture care. The Nottingham Hip Fracture Score (NHFS) shows only moderate predictive ability for 30-day mortality. We assessed whether routine markers of inflammation could improve the discriminant ability of the NHFS to predict 30-day mortality following hip fracture surgery.

Methods:
We studied consecutive patients admitted with hip fractures at a large-volume trauma unit between 2015 and 2020. Baseline NHFS and postoperative outcome data were extracted from a local registry and linked to routine laboratory data from patients’ electronic clinical records. We selected measurements taken closest to admission pre-operatively. The biomarkers studied were albumin (negative acute-phase reactant), C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR). Univariate and multivariate logistic regression analyses were performed separately for each combination of NHFS and inflammatory marker. C-statistics were calculated to assess the discriminant ability of the NHFS with and without each inflammatory marker for 30-day mortality.

Results:
We included 1710 patients, mean age 82.5 years (SD 8.2). 1199 (70.1%) were women. 104 (6.1%) patients died within 30 days of admission. In univariate analysis, admission NHFS, albumin, CRP and NLR were significantly different between those alive and dead at 30 days. Higher admission albumin was an independent predictor of 30-day mortality in multivariate analysis (OR=0.86 [95%CI 0.81-0.91], p≤0.001) as was higher CRP (OR=1.93 [95%CI 1.04-1.44], p=0.013). The addition of albumin significantly improved the discriminant ability of the NHFS for 30-day mortality (p≤0.001) (c-statistic 0.742 [95%CI 0.683-0.800] vs 0.681 [95%CI 0.617-0.745] for the NHFS alone). Other inflammatory biomarkers did not significantly improve discrimination of 30-day mortality when added to the NHFS.

Conclusions:
Admission albumin improves the discrimination of 30-day mortality in patients undergoing hip fracture surgery when combined with the NHFS, whereas other markers of inflammation including CRP, MLR and NLR did not.