Joints

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.

Delirium in hip fracture patients admitted from home is associated with higher mortality, longer total length of stay, need for post-acute inpatient rehabilitation and readmission to acute services: The IMPACT Delirium study

RS Penfold1,2, AJ Hall2,3,4, A Anand5, ND Clement2,4, AD Duckworth4,6, AMJ MacLullich1,2

1. Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK 

2. Scottish Hip Fracture Audit, Edinburgh, UK 

3. Department of Orthopaedics, Golden Jubilee University National Hospital, Clydebank, UK 

4. Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK 

5. Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK 

6. Department of Orthopaedics & Usher Institute, University of Edinburgh, Edinburgh, UK 

Aim 

Delirium is associated with adverse outcomes following hip fracture, but specific associations in patients admitted directly from home are less well studied. Here we analysed relationships between delirium in patients admitted from home with: (i) mortality; (ii) total length of hospital stay; (iii) need for post-acute inpatient rehabilitation, and (iv) hospital readmission within 180 days. 

Methods 

This study utilised routine clinical data in a consecutive sample of hip fracture patients aged ≥50 years admitted to a single large trauma centre between 01/03/20-30/11/21. Delirium was prospectively assessed as part of routine care by the 4’A’s Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, level of social deprivation, and American Society of Anesthesiologists grade.  

Results 

A total of 1821 patients (mean age 80.7 years; 71.7% female) were admitted, with 1383 (mean age 79.5; 72.1% female) directly from home. 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1734): 14.1% (189/1340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20 day longer total length of stay (p<0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (Odds Ratio (OR) 1.69, 95% Confidence Interval (CI) 1.13-2.54; p=0.013), requirement for post-acute inpatient rehabilitation (OR 2.82, CI 1.99-4.00; p<0.001), and readmission to hospital within 180 days (OR 1.77, CI 1.01-3.11; p=0.046). 

Conclusions 

Delirium affects 1 in 7 patients with a hip fracture admitted directly from home and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care. 

Background: Foot pain in older adults may reduce physical activity, resulting in impaired mobility and an increased risk of falls. Orthotics, both with and without a metatarsal pad, may provide foot pain relief and improved stability. Objective: Compare the use of Aetrex orthotics with and without a metatarsal pad in decreasing pain and fear of falling in older adults. Methods: 206 participants over 60 years old were randomised into the intervention group, who received Aetrex L2305 Orthotics with a metatarsal pad, or the control group, who received Aetrex L2300 Orthotics with no metatarsal pad. At baseline and 6-week follow-up, musculoskeletal pain was reported via Numerical Rating Scales (NRS), foot pain and functionality via the Foot Health Status Questionnaire (FHSQ), and fear of falling via the Short Falls Efficacy Scale International. Results: Both groups reported significant improvements in pain in the back, hips, knees, ankles, and feet using the NRS (P < 0.001). Using the FHSQ, foot pain significantly improved in both the intervention (x̄= 18.47 ±20.58, P < 0.001) and control group (x̄= 17.21 ±18.74, P < 0.001). Function also improved significantly in both groups (x̄= 18.35 ±20.67, P < 0.001 and x̄ = 15.07 ±20.15, P < 0.001, respectively), as did fear of falling (x̄= 1.55 ±3.79, P < 0.001 and x̄= 1.23 ±3.53, P < 0.001, respectively). No statistically significant difference was observed between groups for any outcome (P > 0.05). Conclusion: Aetrex orthotics, with and without metatarsal pads, decrease pain and fear of falling in older adults.

Introduction: In Scotland, more than 18,000 older people are admitted to hospital after a fall each year. One in three people over the age of 65 experience a fall at least once each year (1). Neurological examination is an essential part of the initial assessment of these patients in hospital and can determine the cause of falls such as stroke, peripheral neuropathies and Parkinson’s disease. Local anecdotal evidence suggested that this was often not carried out, with the potential for delayed diagnosis and treatment.

Method: Baseline data was collected from clinical notes of admissions to the care of the elderly (COTE) wards at University Hospital Hairmyres (UHH) over a 1-month period. Multiple departmental education sessions were arranged to highlight to medical staff the importance of neurological examination in patients presenting to hospital following a fall. Following these sessions the data collection cycle was repeated. A poster has now been designed highlighting common causes of falls and in particular emphasising the importance of performing a neurological examination, with a further cycle of data collection planned.

Results: 36.8% of patients admitted to COTE wards in August 2022 were admitted with falls, with only 23% of patients having a neurological exam documented on admission. Following the initial intervention, 30 patients’ notes were reviewed in January 2023. 56.7% of patients were admitted with falls and frequency of documented neurological examination had increased to 58.8%.

Conclusion: Educational sessions resulted in a 156% increase in documented neurological examinations for patients admitted with falls. We hope this improvement will lead to earlier identification of causes of patients’ falls, allowing prompt management. Our project is ongoing, with planned implementation of posters as a secondary intervention, with further data collection in due course.

References: 1. NHS Inform. Why Falls Matter. Available from: https://www.nhsinform.scot/healthyliving/preventing-falls/why-falls-mat… (accessed 27 November 2022)

Introduction: Oral nutritional supplement (ONS) prescription is commonly recommend for malnourished patients in hospital. However, compliance to ONS is often low. Ice cream may be a promising nutritional intervention. We undertook a study designed to compare the acceptability of high protein, fortified, ice cream called Nottingham-Ice Cream (N-ICE CREAM) with routinely prescribed milkshake ONS.

Methods: Fifty older (≥ 65 years) inpatients with hip or spine fractures were recruited from Queens Medical Centre, Nottingham. Patients were randomised into two groups, receiving two days of N-ICE CREAM and milkshake ONS. Group A received N-ICE CREAM first and Group B, milkshake ONS first. We measured compliance, acceptability (hedonic characteristics; rating 0 dislike a lot to 7 like a lot), attitudes towards length of prescription (rating 0 very unconfident to 4 very confident) and preference.

Results: Mean (standard deviation, SD) age of patients was 80.6 (7.7) years. The majority (n = 21, 67.7%) preferred N-ICE CREAM. Mean compliance to N-ICE CREAM was greater in both Groups (Group A (n = 22) 69.9 (30.0) % and Group B (n = 26) 56.3 (39.3)%) compared to the milkshake ONS (Group A (n = 22) 43.4 (4.7) % and Group B (n = 26) 53.6 ± (40.2) %). This was statistically significant in Group A (p < 0.05). Mean hedonic ratings were higher for N-ICE CREAM with an overall impression score of 5.8 compared with 4.6 for milkshake ONS. Confidence score for both products decreased with increasing time length. Both had an overall confidence score of 2.9.

Conclusions: High protein N-ICE CREAM is more accepted and preferred by older patients with a hip or spine fracture compared to standard milkshake ONS. Further research should explore optimal timing for N-ICE CREAM administration and long-term compliance, as well as clinical outcomes.

Background & Aim: While the significance of prehospital trauma care is increasingly recognised for older patients, limited research has been conducted to gain in-depth understanding of current paramedic practice. We aimed to explore Saudi paramedics and emergency medical technicians’ understanding of impacts of ageing changes, how they acquire and apply relevant knowledge as well as the barriers and facilitators to providing improved care for older trauma patients.

Methods: We undertook semi-structured qualitative interviews with 20 paramedics and ambulance technicians from the Saudi Red Crescent Authority’s ambulance stations. We used MAXQDA software to manage and code data, and framework approach’s five stages for analysis.

Results: Participants identified ageing, societal, behavioural, and organisational challenges when responding to older trauma patients. They perceived that older and younger trauma patients receive care differently due to comorbidities and polypharmacy, along with the influence of organisational and societal challenges on geriatric care. They identified a lack of adequate acquired relevant knowledge prior to employment in ambulance services, and no relevant courses or sponsors providing such courses after employment but were reluctant to admit their own knowledge gaps. They reported that family members and local culture can create challenges in applying acquired knowledge and experience when responding to female older patients.

Conclusion: Few studies have explored the challenges encountered while responding to and caring for older trauma patients. Prehospital trauma care could be improved through the development of clear guidelines, trauma care pathways, training for paramedics and EMTs, and increased awareness of cultural barriers.

Introduction

Many elderly patients presenting to ED with falls and suspected head injury are anticoagulated. The current National Institute for Health and Care Excellence (NICE) guideline recommends patients on anticoagulation should have a CT head scan within 8 hours of head injury. An updated guideline was drafted for consultation in November 2022. The indication for CT head scan has not changed for patients on anticoagulation. There is currently a lack of evidence to inform best practice in the management of anticoagulated older patients who present with falls and head injury.

The Older Persons Assessment Service (OPAS) in Morriston Hospital offers Comprehensive Geriatric Assessment to patients age >65 years who have presented with frailty syndromes, including falls. The aim of this study is to evaluate the risk of ICH in the elderly population presented to OPAS on anticoagulation following falls and suspected head injury.

Method

A retrospective study was conducted on consecutive patients who presented to OPAS from 1^st June 2020-18th May 2022. Data were collected on demographics, anticoagulant therapy, Rockwood Clinical Frailty Scale (CFS), Glasgow Coma Score (GCS) on presentation, evidence of external head injury and CT head findings.

Results

215 of 838 patients were on anticoagulation (median age 86(IQR: 81-90),56% Female).

The risk of ICH in patients presenting to OPAS who were on anticoagulation is 0.0186 (4/215, 95% CI 0.0051–0.0469); one patient’s CFS was 4(vulnerable) and three patients’ CFS were 5(mildly frail), all presented at their baseline GCS. Only one patient presented with evidence of external head injury.

Conclusion

The risk of ICH in elderly patients on anticoagulation presented to OPAS with falls is low. Those who had ICH were categorised as vulnerable and mildly frail. This study could support individualised decision-making for CT head scans, especially in moderate to severely frail patients following falls and head injury.

Introduction: Procollagen-N-terminal-peptide(P1NP) is a bone formation marker. Bisphosphonates lead to a reduction in P1NP levels and levels are significantly elevated shortly after fracture. In older patients taking bisphosphonates who have had a further osteoporotic fracture there is a lack of evidence to guide ongoing osteoporotic management.

Objectives: To assess if measuring P1NP in patients receiving Bisphosphonates treatment who develop neck of femur fractures helps guide further management in regards to long term bone protection treatment.

Methodology: Retrospective descriptive cohort study of P1NP levels for the patients who presented with NOF# (>60yrs) and who were taking anti-resorptive medications. Cases were discussed in our complex bone health MDM and patient specific plans made accordingly.

Results: 60 patients were identified between March 2017 and Sept 2021 had P1NP tested(2.6 % of the 2,303 total fractures in this time). Mean age 83 years(F:M – 54:6 / # type - IC:EC – 34:26).

Overall: 17(28%) patients had significantly elevated PINP with identifiable reasons. 39(65%) patients had supressed P1NP levels(< 35mcg/L) and 5(7 %) between 36-39 mcg/L.

Of those with supressed P1NP: Patients taking treatment >5 years(n=9) – Treatment stopped for 6 patients, 2 changed treatment following DXA and 1 continued. On treatment 3-5 years(n=8) – 5 continued with treatment, 1 had further ix and 2 treatments changed On treatment 1-3 years(n=17) – 14 continued treatment, 2 treatments stopped, 1 treatment changed On treatment <1 year(n=16) – all continued the same treatment

Conclusion: The measurement of P1NP has been helpful in making patient centred decisions in this cohort. It has added to the detailed discussions in the hip fracture bone health MDM and for 23% of patients with supressed bone turnover contributed to a change in management. Most changes occurred in those patients taking treatment for more than 5 years where the evidence of bone turnover suppression gives confidence to stop or change treatment.

Introduction

Vertebral fragility fractures (VFF) are the most common osteoporotic fracture. VFF can result in significant pain requiring hospitalisation. However, there is little data on patient numbers, hospital bed days and costs, contributed to by these patients.

Methodology

We report a retrospective analysis of patients aged 55 years and over admitted to hospitals across England from 2017-2019. ICD-10 classifications for VFF and OPCS codes were used to identify admissions and patients who had undergone vertebral augmentation (VA).

Results

There were a total of 99,240 patients (61% Female) admitted during this period, with 64,370 (65%) patients aged 75 and over. On average, there was a 14.3% increase in admissions annually. The increasing trend was more notable in those aged 75 years and over. Patients aged over 75 years accounted for 1.5 million bed days, costing £465million (median length of stay (MLOS) 14.4 days). In comparison, those aged 55-74 years, accounted for 659,000 bed days, costing £239 million (MLOS 10.7 days). The majority of patients (84%) were admitted under a non-surgical speciality and were primarily older (median age 76.8 vs 67.6 years, MLOS 8.2 vs 6.0 days). 1755 patients underwent VA (1.8% of the total cohort). 775 (44.2%) of these were aged 75 years and over. The MLOS and cost per patient admission was lower in the VA group compared to those managed non-surgically (MLOS 2.4 vs 10.8 days, p=<0.01, cost £4737 vs £7250)

Conclusion

Patients aged 75 years and over hospitalised with VFF represented a significant number, cost, use of bed days and associated longer MLOS. Those undergoing VA had a significantly shorter length of stay. Further studies are necessary to identify older patients with VFF who may benefit from early VA.

Introduction: Hip Fracture Surgery (HFS) can result in balance impairment which is associated with an increased risk of falls in the elderly as well as limitations in their mobility. Balanced Training (BT) is a rehabilitation method used aiming to minimize the balance impairments post HFS. BT options include stepping, balance task-specific exercise, standing on one leg, yoga.

Our main outcome is to evaluate the effect of BT on the physical functioning of elderly patients post an HFS.

Methods: We conducted a systematic review using the PubMed-Medline, Cochrane Library and Embase databases to locate randomized controlled trials which compared BT with standard care post HFS. The Cochrane’ Library Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used as our template for the review.

Results: Overall, nine randomized controlled trials were selected, comprising a total of 712 patients, all aged 65 years of age and older. With regards to the type of BT rehabilitation: four trials used step-ups (n=500), three trials used balance task-specific exercise (n=170) and two studies used standing on one leg (n=42). The BT group demonstrated improvement in physical functioning post HFS compared to the control group (Standardized Mean Difference (SMD) = 0.410). Moreover, all functional parameters which include, lower limb strength, performance task and health related quality of life, were also improved in the BT group.

Conclusion: Evidently, the results demonstrate an improvement of physical functioning by BT post HFS. Furthermore, the positive effects on all functioning parameters were apparent. As a result, the implementation of BT in postoperative rehabilitation programs in elderly patients with hip fractures should be considered. References: Monticone M, Ambrosini E, Brunati R, et al. How balance task-specific training contributes to improving physical function in older subjects undergoing rehabilitation following hip fracture: a randomized controlled trial. Clin Rehabil. 2018;32:340–351