Eliyahu H. Mizrahi

Meperidine analgesia and delirium in aged hip fracture patients

Delirium is quite frequent in elderly patients who sustain hip fractures. The use of Meperidine by physicians, unaware of the possible emergence of delirium in elderly patients, is very popular. We have retrospectively examined the incidence of delirium in 181 consecutive patients admitted to the orthogeriatric ward with hip fractures. We used the confusion assessment method to establish the presence of delirium in all patients. A database search was conducted to identify which patients were treated by Meperidine, or Morphine, prior to delirium onset. We identified 92 cases, 44 of whom were treated by Meperidine alone, and the other 48 treated by Morphine alone. Delirium was diagnosed in 13 (27.1%) Morphine treated patients as compared with 19 (43.2%) treated by Meperidine (P<0.001). Age, cognitive status and opiate use were associated with perioperative delirium. A subset regression analysis showed that exposure to Meperidine was significantly associated with delirium (odds ratio 2.5, P<0.01), in contrast with Morphine. Our results confirm the association between exposure to Meperidine and delirium, suggesting that this drug should be withdrawn in elderly hip fractured patients undergoing surgery, and substituted by low dose Morphine analgesia. Reducing the incidence of delirium, by adopting such an approach, may result in a significant potential of savings in direct costs, related to treatment of delirium in this population.

The unfavorable nature of preoperative delirium in elderly hip fractured patients.

The onset of delirium is frequent in elderly patients who sustain hip fractures. The purpose of this study was to characterize different patterns of preoperative and postoperative delirium, to study factors associated with preoperative delirium and to evaluate the possible different outcome of these patients. This retrospective study comprised 281 elderly patients with hip fractures undergoing surgical fixation. Data collection included age, sex, length of stay, type of fracture, cognitive status by mini mental state examination (MMSE), assessment of possible delirium by the confusion assessment method (CAM) and functional outcome assessed by functional independence measure (FIM). A database search was conducted to identify whether delirium onset occurred prior to or following surgery. About 31% of the total sample developed delirium. Delirious patients tended to be more disabled (P = 0.03) and cognitively impaired (P = 0.018), compared with non-delirious patients. Most delirious cases (53%) had their onset in the preoperative period. Patients with preoperative delirium were older (P = 0.03), had a lower prefracture mobility (P < 0.01), impaired cognition (P = 0.04) and showed an adverse functional outcome in terms of FIM score. Regression analysis showed that prefracture dementia, prefracture mobility and low MMSE scores were strongly associated with higher probability of having preoperative delirium, with no additional effect of other variables. It is concluded that preoperative delirium should be viewed as a separate entity with unfavorable nature and adverse outcome. Careful preventive measures and better treating strategies should be employed to avoid this clinical condition.

Exposure to opioid analgesia in cognitively impaired and delirious elderly hip fracture patients.

The objectives of this study were to characterize patterns of opioid analgesia in elderly hip fracture patients, to investigate the possible differences in the treatment of cognitively impaired, delirious, or cognitively intact patients, and to study the factors that may affect the doses received by such patients. This retrospective study comprised 184 elderly patients with hip fractures undergoing surgical fixation. Data collection included age, sex, length of stay, type of fracture, cognitive status by mini-mental state examination, assessment of possible delirium by the confusion assessment method, type and doses of opioid received by these patients. We found that the amount of morphine equianalgesic dose differed significantly between demented and non-demented patients (7.5 +/- 1.8 vs. 14.1 +/- 4.9, P<0.001). Patients with cognitive decline or with delirium received only 53 and 34%, respectively, of the amount of opioid that was administered to cognitively intact patients. A significant association was observed between cognitive status, or delirium, and amount of opioid analgesia (P<0.001 and P=0.003, respectively). Other parameters such as age, length of stay and type of fracture, had no effect on the use of opioid analgesia. It is concluded that the management of pain in older persons with hip fracture surgery is suboptimal with regards to insufficient administration of opioid analgesia in demented and delirious patients. The adoption of a standardized protocol for pain control may help in reducing the extent of this problem.

Admission albumin levels and functional outcome of elderly hip fracture patients: is it that important?

Background and aims: Low serum albumin level is considered a marker of poor health outcome in various medical conditions. A relationship between low albumin levels and poor functional outcome has been found in the elderly, lower albumin predicting a greater functional decline. The objective of this study was to evaluate to what extent admission albumin levels may affect the functional outcome of elderly hip fracture patients. Methods: This retrospective chart review study was conducted in an orthogeriatric unit of a university-affiliated referral hospital. The participants were 449 elderly patients with hip fractures, admitted for a standard rehabilitation course. Functional outcome of patients with normo-albuminemia and hypo-albuminemia was assessed by Functional Independence Measurement (FIM™ at admission and discharge. Data were analyzed by t-test, Pearson’s correlation, Chi-square test and Linear Regression. Results: 38.8% of patients were hypoalbuminemic upon admission. These patients were older (p<0.001) and had lower Mini-Mental State Examination (MMSE) scores (p=0.003), compared with normo-albuminemic patients. Discharge FIM scores were higher in normo-albuminemic compared with hypo-albuminemic patients (total FIM 86.1±23.9 and 77.0±26.4, respectively; p<0.001; motor-FIM 60.0±16.3 and 53.4±18.0, respectively; p<0.001). Linear regression analysis showed that total FIM at discharge was inversely associated with pre-fracture function (beta −0.13; p<0.001). A high MMSE score (beta 0.16; p<0.001), female gender (beta 0.05; p=0.02) and higher admission total FIM scores (beta 0.69; p<0.001) emerged as predictors of higher total FIM scores upon discharge. Albumin levels did not independently predict better total FIM scores upon discharge (beta −0.02; p=0.36). Conclusions: Normo-albuminemic patients present with better admission FIM scores and have higher discharge FIM scores. After controlling for possible confounders, albumin remains a non-significant predictor of higher discharge FIM scores. We suggest that low albumin levels should not be considered as adversely affecting the rehabilitation of elderly hip fracture patients.

Prevalence and correlates of psychotropic medication use among older adults in Israel: Cross-sectional and longitudinal findings from two cohorts a decade apart

Objectives: To assess: (1) changes in use of psychotropic medications across two cohorts, 10 years apart, of community-dwelling elderly and the socio-demographic, physical and mental health correlates of their use; and (2) changes in psychotropic medication use over 3.5 years follow-up. Methods: Data were taken from two national surveys of the Israeli Jewish population aged 75–94, which, respectively, sampled two cohorts in 1989 (n = 1200) and again in 1999 (n = 421). Psychotropic medications were assessed from the list of all medications recorded during a face-to-face interview. The current analysis focused on two medication groups: anxiolytics and sedatives/hypnotics and antidepressants. Results: Sedatives/hypnotics and anxiolytics use increased from 22.2% in 1989 to 25.4% in 1999 and antidepressants from 3.8% to 4.8% (both nonsignificantly) corresponding to a decline in the health profile of community-dwelling older adults. Similar patterns of associations were observed for socio-demographics, physical, and mental health status indicators with the use of psychotropic medications across the two cohorts. The pooled multivariate analysis showed significantly higher use of sedative/hypnotics and anxiolytics among women and lower use among religious elderly. Additional risk factors were sleeping problems, number of other medications, depressive symptoms, and traumatic life events. Antidepressants use was related to a higher education, ADL disability, and depressive symptoms. Longitudinally, use of psychotropic medications was not significantly different among participants who were followed again after 3.5 years. Conclusions: Sedative/hypnotics and anxiolytics use was relatively high while antidepressants use was low even among depressed elderly suggesting that some depressed elderly were treated inappropriately with benzodiazepines.

Atrial fibrillation predicts cognitive impairment in patients with ischemic stroke.

Background: Atrial fibrillation (AF) is considered as a risk factor for cognitive impairment. Methods: This retrospective chart review study was conducted in a patient stroke rehabilitation ward of a university-affiliated referral hospital. The participants were 707 patients admitted for a standard rehabilitation course after an ischemic stroke. Cognitive status was assessed by the Mini-Mental State Examination (MMSE), and scores lower than 24 points were considered as suggestive of cognitive impairment. Results: Atrial fibrillation, age, gender, diabetes, and dementia emerged as the only statistically significant parameters differing between those with MMSE score lower than 24 or higher. In a multiple logistic regression analysis, AF (odds ratio 1.6, 95% confidence interval 1.03-2.47, P = .03) was associated with an increased risk of cognitive impairment. Conclusions: Our findings suggest that atrial fibrillation upon admission is independently associated with lower MMSE scores in patients with ischemic stroke.

Serum albumin levels predict cognitive impairment in elderly hip fracture patients.

The aim of this study was to investigate the possible interrelation of serum albumin levels and cognitive function of elderly hip fracture patients. The study involved 331 elderly patients with hip fractures, admitted for rehabilitation. Cognition was assessed by Mini-Mental State Examination (MMSE). MMSE scores less than 24 points were considered suggestive of cognitive impairment. Age, serum albumin levels, and previous stroke emerged as the only statistically significant parameters differing between those with MMSE score less than 24 or higher. After adjusting for confounding variables, the middle and lowest tertiles of serum albumin levels were associated with an increased risk of cognitive impairment (odds ratio 1.97, 95% confidence interval 1.15-3.38, P < .01 vs 3.06 and 1.79-5.23, P < .001, respectively). This study shows that lower serum albumin levels are independently associated with lower MMSE scores in hip fractured elderly patients, supporting the possible role of chronic low-grade inflammation in age-related cognitive decline.

Functional outcome of ischemic stroke: A comparative study of diabetic and non-diabetic patients

Background and purpose. Diabetes is associated with more ischemic strokes and diabetic patients have up to a three-fold increased risk for suffering a stroke, compared with non-diabetics. The aim of this study is to evaluate whether diabetes mellitus may also affect the functional outcome of patients with acute ischemic stroke, undergoing post-acute care rehabilitation. Methods. A retrospective charts analysis of consecutive older patients with acute ischemic stroke admitted for rehabilitation at a tertiary hospital with post-acute care geriatric rehabilitation wards. Functional outcome of diabetics and non-diabetics was assessed by the Functional Independence Measurement scale (FIM™) at admission and discharge. Data were analysed by t-tests, Pearson correlation, and Chi-square test, as well as by linear regression analysis. Results. A total number of 527 patients were admitted, of whom 39% were diabetics. Compared with non-diabetics, diabetic stroke patients were slightly younger (p = 0.0001) but had similar admission FIM scores. FIM gain parameters (total FIM gain, motor FIM gain, daily total and motor FIM gains) upon discharge were similar in both groups. A linear regression analysis showed that higher MMSE scores (β = 0.08; p = 0.01) and higher admission total FIM scores (β = 0.87; p < 0.001) predicted higher total FIM scores upon discharge. Diabetes mellitus was not interrelated, whatsoever, with better total FIM scores upon discharge (β = −0.03; p = 0.27). Conclusions. The findings suggest that there is no difference in the functional outcome of diabetic and non-diabetic patients, presenting for rehabilitation after acute ischemic stroke. Diabetes should not be considered as adversely affecting rehabilitation of such patients.

Diabetes Mellitus Predicts Cognitive Impairment in Patients With Ischemic Stroke

Background: Non-insulin-dependent diabetes mellitus (NIDDM) is associated with an increased incidence of cognitive impairment. Methods: A retrospective chart review study involving 707 patients admitted for rehabilitation after an ischemic stroke. Cognitive status was assessed by the Mini-Mental State Examination (MMSE), and scores lower than 24 points were considered suggestive of cognitive impairment. Results: Age, gender, NIDDM, dementia, and previous stroke emerged as the only statistically significant parameters differing between those with MMSE score lower than 24 or higher. After adjusting for confounding variables, NIDDM (odds ratio 1.46, 95% CI 1.05-2.05, P = .02) was associated with an increased risk of cognitive impairment. Conclusions: Our findings suggest that NIDDM is independently associated with lower MMSE scores in ischemic stroke patients. It identifies individuals in need of specifically targeted interventions and may assist in selecting and developing resources for cognitively impaired diabetic patients.

ULTRASONOGRAPHY AND CLINICO-FUNCTIONAL PARAMETERS OF HEMIPLEGIC UPPER EXTREMITY IN A REHABILITATION SETTING

Background and aims: To study possible interrelations of clinical and functional parameters with ultrasonographic findings of shoulders of hemiplegic stroke patients. This would assist in determining the need for a possible ultrasound evaluation of hemiplegic shoulders. Methods: Prospective case series were studied in the Department of Geriatric Medicine and Rehabilitation, at a university-affiliated referral hospital. We studied a total of 26 consecutive stroke patients with hemiplegic shoulders undergoing a standard rehabilitation course. Hemiplegic shoulders were studied by ultrasound and scored for the number of pathological (positive) findings. Shoulder scores were correlated with various clinical and functional parameters (Ashworth score, Fugl-Meyer score, Functional Independence Measure) as non-dependent variables. Results: No correlation was found between any of the parameters we have studied and the ultrasonographic score, except for shoulder pain (p = 0.012). A regression analysis documented painful shoulder (p = 0.002) and spasticity (p = 0.039) as significantly associated with higher ultrasonographic scores. Conclusions: Ultrasound investigation of hemiplegic upper extremities does not interrelate with any of the parameters associated with rehabilitation outcome and should be reserved for those suffering painful and spastic hemiplegic shoulders.