Margarita Navarro

Factors associated with hip fracture-related falls among patients with a history of recurrent falling

BACKGROUND People who have suffered falls are at greater risk of falling again. We study the characteristics of falls leading to hip fracture in people with a history of recurrent falls, comparing them with those of people with a history of sporadic falling. MATERIALS AND METHODS Analysis of the characteristics of a sample of 1225 patients consecutively admitted to six hospitals because of a hip fracture secondary to a fall (index fall) - index fall characteristics (location, time and the possible cause of the fall: intrinsic, extrinsic or combined risk factors) were also determined. Patients with a history of three or more falls (recurrent fallers) in the year prior to the index fall were identified as high-risk fallers; those with less than three falls were considered to be sporadic fallers. RESULTS The mean number of falls in the year prior to the index fall was 1.7+/-6.5; 227 patients (22%) had experienced three or more falls within that period. Most index falls (880, 71.8%) took place at the patients home, 232 (18.95%) in the street and 113 (9.2%) elsewhere; most (892, 72.9%) took place during daytime. Multiple stepwise logistic regression analysis showed that recurrent fallers were characterized by poorer baseline independence for activities of the daily living, a prior diagnosis of dementia, greater use of prescription drugs and a greater use of neuroleptics. For frequent fallers, the index fall was more often associated with an intrinsic factor than for sporadic fallers. CONCLUSIONS A significant percentage of patients experiencing a fall followed by hip fracture have a history of recurrent falling in the year prior to a fall-related hip fracture. Poorer functional and cognitive status, polypharmacy and the use of neuroleptics are more prevalent in this subgroup of patients, and intrinsic factors as a cause of the fall are more common in this group. Whether these circumstances associated with recurrent falling are responsible for this higher prevalence of intrinsic, non-accidental falls should be addressed prospectively in order to implement preventive strategies.

Dying in hospital of terminal heart failure or severe dementia: the circumstances associated with death and the opinions of caregivers

Background: Improving the care provided to elderly patients affected by end-stage chronic diseases dying in acute hospitals is a health priority. We evaluated the circumstances related to death in end-stage non-cancer patients dying in two acute care hospitals, and their caregiver’s opinions about the death. Methods: Some 102 patients, over 64 years of age, with end-stage dementia (37%) or congestive heart failure (64%), were included in the study. Caregiver’s opinions on the circumstances of death were obtained using a questionnaire. In addition, we collected data regarding written instructions on several items, including do not resuscitate (DNR) orders, decisions about care in terms of the level or intensity of interventions, information provided to relatives about the prognosis, total withdrawal of normal drug therapy, and provision of palliative care. Results: Caregivers stated that the clinical information was accurate in 67.6% of cases, and the control of symptoms was good in 55%. However, the perception of pain persisted in 14% and uncontrolled dyspnoea in 45%. The end-of-life care was assessed as: excellent 30.5%, good 36%, fairly good 25.5%, bad 6%, and very bad 2%. DNR orders were specified in 89% of patients, decisions concerning the intensity of care in 64%, and 80% of relatives were aware of the prognosis. Drug therapy was withdrawn in 64% of cases, and terminal palliative care was initiated in 79.5%. Conclusion: Our results suggest that some aspects of the palliative care provided to elderly patients with end-stage chronic diseases, admitted to acute care hospitals, could be improved. Such aspects include the clinical information provided and the successful control of specific symptoms.

Hospital Deaths of People Aged 90 and Over: End-of-Life Palliative Care Management

Background: In developed countries, hospital deaths at very advanced age are increasingly common.Few studies have addressed end-of-life care in very elderly patients with non-cancer chronic diseases. Objective: To evaluate the circumstances related to end-stage death of non-cancer nonagenarians in an acute care hospital. The results were compared with those from a sample of younger patients. Methods: We conducted a prospective assessment in two teaching hospitals of the written instructions for the following actions: do not resuscitate (DNR) orders, the graduation of therapeutic decisions, information provided to relatives about prognosis, total withdrawal of normal drug therapy and provision of palliative care. Results: 80 patients over 89 years of age with end-stage congestive heart failure (57.5%) or dementia (42.5%) were included. The control group comprised 52 younger patients (65–74 years). DNR orders were specified in 56% of cases, graduation of therapeutic decisions in 35%, and knowledge of relatives regarding the prognosis in 61%. Drug therapy was withdrawn in 66% of cases and terminal palliative care was initiated in 69%. In the nonagenarians who died, we detected a predominance of females (p = 0.001), a higher percentage of DNR orders (p = 0.02) and a higher percentage of graduation of therapeutic measures (p = 0.02) in comparison with younger patients. Conclusion: Our results indicate that there are marked differences according the palliative care provided to oldest-old patients with end-stage non-cancer chronic diseases admitted to an acute care hospital. In any case, care should be improved for both age groups.

Characteristics of fall-related hip fractures in community-dwelling elderly patients according to cognitive status

Background and aims: Falls are a major cause of morbidity and mortality in older people who have cognitive impairment. The present study compared the characteristics of community-dwelling patients, with and without previous diagnosis of dementia, hospitalized because of a hip fracture. Methods: 1024 consecutive patients >65 years (77.2% women, mean age 82.9 yrs) admitted for fall-related hip fracture to six Spanish hospitals during a 20-month period were included. Sociodemo-graphic data, geriatric assessment and characteristics (location, time and possible cause: intrinsic, extrinsic or combined risk factor) of falls leading to hip fracture were evaluated. Results: A total of 154 (15%) patients had a previous diagnosis of dementia. Analysis showed a greater number of previous falls before admission for hip fracture in demented patients. Moreover, in non-demented patients, we found both a predominance of falls during the day and of extrinsic factors. Conclusion: Some differences were observed, according to the cognitive status of elderly patients suffering a hip fracture due to a fall. A high percentage of dementia patients had suffered repeated falls prior to the fall-related hip fracture.

Characteristics of falls producing hip fracture in patients on oral anticoagulants

Objective: To analyze the demographic and clinical characteristics of patients on chronic anticoagulant therapy (CAT) admitted because of a hip fracture secondary to a fall, and to compare with patients not receiving CAT. Methods: A prospective, observational study realized in six hospitals in the Barcelona area. Demographic and clinical characteristics of patients were collected. The index fall characteristics – cause, height, location, and time of occurrence – were evaluated. Results: Of the 1225 patients included, 99 (8%) patients were on CAT. When we compare with the rest logistic regression analysis showed that patients receiving CAT were more likely to be male (odds ratio 3.7), not institutionalized (odds ratio 3.5), to take more number of drugs (odds ratio 1.3), to have dementia (odds ratio 2.1) and stroke (odds ratio 1.7). Results revealed a higher prevalence of combined factors as the cause of the index fall in the group of patients on anticoagulants. Conclusions: Characteristics of falls were very similar when comparing the group of patients receiving CAT with those who did not. A prior history of falls should lead physicians to take actions for preventing falls causing hip fracture, in all patients and particularly in these on CAT.

Posttraumatic dysphagia due to a cervical vertebral fracture.

characterized mainly by inflammation of the small and medium-sized arteries and veins that affect any viscera. Renal involvement most often occurs as microscopic hematuria with or without red blood cell or mixed cellular casts, proteinuria, and a high serum creatinine concentration. During the course of WG, gross hematuria is uncommon. WG with macroscopic hematuria due to glomerular bleeding has been reported rarely in the literature. WG may also involve the lower urinary tract organs, such as the penis, testes, seminal vesicles, bladder, and prostate. A case of macroscopic hematuria with WG due to prostate involvement has been reported. Hematuria may be a symptom of one of several underlying diseases, some of which are life threatening, and some of which are treatable, but there is an appreciable risk of malignancy in older patients with hematuria, even if transient. In women aged 50 and older, malignancy was found in 8.9% with macroscopic hematuria versus 1.9% with microscopic hematuria. The authors suggested that all patients with macroscopic hematuria should be evaluated using ultrasonography, intravenous pyelography, urinary cytology, and cystoscopy. In the present case, a CT scan and cystoscopy were performed to exclude urinary tract disorders. In this case, it was suggested that macroscopic hematuria had developed because of WG according to the clinical findings with laboratory and imaging studies. After immunosuppressive therapy, clinical manifestations including macroscopic hematuria, malaise, and generalized weakness resolved in the following 3 weeks. In conclusion, the clinician should consider WG in the differential diagnosis of macroscopic hematuria in elderly patients in addition to urinary tract malignancy. In elderly patients with macroscopic hematuria, upper and lower respiratory tract symptoms such as hearing loss, cough, and dyspnea should be evaluated carefully and WG kept in mind in the differential diagnosis.