Michael W Davis

Postprandial Hypotension Predicts All‐Cause Mortality in Older, Low‐Level Care Residents

Objectives: To evaluate which indices of blood pressure (BP) homeostasis are the strongest predictors of mortality in older low‐level‐care residents in long‐term health facilities.

Trends in hip fracture epidemiology in Australia: Possible impact of bisphosphonates and hormone replacement therapy

The purposes of this study were to analyse trends in hip fracture (HF) epidemiology over a 13-year period (1994-2007) in the Australian Capital Territory (ACT), to assess the potential impact of concurrent changes in hormone replacement therapy (HRT) and bisphosphonate use and to present a new prediction of HFs in Australia up to 2021. Annual sex- and age-specific incidence rates (per 100,000 population) were determined and standardized using the Australian 2006 population. The projected number of HFs was estimated by two models applying age- and sex-specific HF rates averaged for 2002-2006 (model 1) or continuously changing as observed in this period (model 2, Poisson regression) to the projected population. In 2006 compared to 2001, the population > or = 60 years in the ACT increased by 19.7%. Over the last 5 years the average annual incidence HF rate compared to the previous 3-year period decreased in females > or = 60 years of age by 28.3%. Between 2001 and 2006 the number of prescriptions for HRT dispensed in the ACT declined by 54.6, while the number of prescriptions for bisphosphonate increased by 245%, accompanied by a decline in standardized incidence of HF rates of 36.4%, mainly in women (42.1%). This represents an annual cost for bisphosphonates per one prevented HF, of

Elevated Serum PTH Is Independently Associated with Poor Outcomes in Older Patients with Hip Fracture and Vitamin D Inadequacy

A45,250 or

Prolonged QT Interval, Syncope, and Delirium with Galantamine

A576 person/year. Compared to 2006 the total number of HFs in Australia according to model 1 will increase in 2011 by 20.1% and in 2021 by 58.8%, but according to model 2 will decrease by 15.5% in 2011 and 27.5% in 2021. Our data suggest that the previously predicted rising trend in HFs in elderly women reversed, but did not so for men. This was coincident with a significant fall in HRT use and increased prescribing of bisphosphonates, which is cost-effective. However caution should be used in attributing causation as this is an ecological study. If trends in HF observed in 2002-2006 continue, the absolute number of HFs in Australia in 2011-2021 will stabilise or decline (which is more likely), despite the rapid ageing of the population.

Elevated serum cardiac troponin I in older patients with hip fracture: incidence and prognostic significance

To determine whether serum 25(OH)D and/or PTH levels in older patients with hip fracture (HF) could predict short-term clinical outcomes, we conducted a prospective observational study of 287 consecutive HF patients (mean age 81.9xa0±xa07.5 [SD] years, 72% females). The prevalence of vitamin D inadequacy (25[OH]Dxa0<xa080xa0nmol/l) was 97.1%, that of vitamin D deficiency (25[OH]Dxa0<xa050xa0nmol/l) was 79.8%, and that of elevated PTH level (>6.8xa0pmol/l) was 35.5%. After adjustment for age and sex, PTH was significantly associated with in-hospital mortality (ORxa0=xa01.12, 95% CI 10.5–1.20, Pxa0<xa00.001), myocardial injury (ORxa0=xa01.05, 95% CI 1.03–1.15, Pxa0=xa00.002), prolonged length of stay (LOSxa0≥xa020xa0days; ORxa0=xa01.05, 95% CI 1.01–1.06, Pxa0=xa00.044), and being discharged to institutional care (ORxa0=xa01.07, 95% CI 1.01–1.18, Pxa0=xa00.48). Secondary hyperparathyroidism (SHPT), but not vitamin D deficiency, was associated with older age, a higher prevalence of trochanteric fracture, coronary artery disease, hypertension, previous stroke, renal impairment, increased levels of serum osteocalcin, bone-specific alkaline phosphatase, and adiponectin as well as a significantly higher in-hospital mortality (11.8 vs. 0.54%, Pxa0=xa00.001), perioperative myocardial injury (32.7 vs. 22.5%, Pxa0=xa00.043), LOSxa0≥xa020xa0days (40.2 vs. 26.9%, Pxa0=xa00.017), and being discharged to institutional care (29.5 vs. 14.6%, Pxa0=xa00.019). In multivariate regression analyses, SHPT was strongly associated with in-hospital mortality and LOSxa0≥xa020xa0days. We conclude that elevated PTH (but not vitamin D deficiency per se) is a strong independent predictor of poor outcomes in older patients.

Hip fracture type: Important role of parathyroid hormone (PTH) response to hypovitaminosis D

Objective: TO describe a case of QT interval prolongation, syncope, and delirium associated with galantamine use and to analyze similar cases related to acetylcholinesterase inhibitors (AChls) reported to the Australian Adverse Drug Reaction Advisory Committee (ADRAC). Case Summary: An 85–year-old man with dementia was treated with prolonged release galantamine 8 mg daily for 1.5 years. Three months prior to the current admission, he had a syncopal episode with low blood pressure and bradycardia. Two months later, galantamine was withdrawn, but within 2 weeks, the man developed marked cognitive, behavioral, and functional deterioration and galantamine was restarted. Three weeks later, he developed syncope, delirium, hypotension, and prolonged QT interval with serious cardiac arrhythmias, in addition to vomiting and diarrhea. A complete blood cell count and biochemistry panel performed on admission were normal. No infection was detected. Galantamine and irbesartan were ceased. The delirium fully resolved in 6 days, and the QT interval shortened from 503 to 443 msec (corrected by Bazetts formula) 4 days after discontinuation of galantamine and remained normal. Discussion: In the ADRAC reports, galantamine was associated with 18 cases of delirium/confusion. 8 of syncope, 13 of bradycardia, 6 of other arrhythmias or conducton abnormalities, and 6 of hypotension. Donepezil was associated with 56, 15, 26, 15, and 5, and rivastigmine with 21, 8, 6, 2, and 2, respectively, of these reactions. Five fatal outcomes were reported in association with galantamine, 11 with donepezil, and 3 with rivastigmine, including 3, 6, and 0 sudden deaths, respectively. This case, along with previously published reports and cases identified from the ADRAC database, illustrates that AChls may lead to delirium, syncope, hypotension, and life-threatening arrhythmias. The Naranjo probability scale indicated that galantamine was the probable cause of QT interval prolongation, syncope, and delirium in this patient. Conclusions: Administration of galantamine and other AChls requires vigilance and assessment of risk (actors that may precipitate QT interval prolongation, syncope, and delirium.

Clinical profiles and risk factors for outcomes in older patients with cervical and trochanteric hip fracture: similarities and differences

IntroductionCardiovascular complications are the main causes of morbidity and mortality in patients with osteoporotic hip fracture (HF). The aim of this prospective study was to evaluate the incidence and prognostic significance of elevated cardiac troponin I (cTnI) in the early peri-operative period in older patients with HF.Materials and methodsA blind evaluation of myocardial injury as detected by cTnI elevation in 238 consecutive older patients with low-trauma HF (mean age 81.9xa0±xa07.8 (SD)xa0years; 72% females). Data on demographic and clinical characteristics, in-hospital mortality, hospital length of stay and discharge destination were collected prospectively. Serum cTnI level was analysed from blood collected routinely in the first 72xa0h of hospital admission.ResultsSixty-nine (29%) patients had elevated cTnI (>0.06xa0μg/l) but myocardial injury was clinically recognised in only 23 (33%) and only 24 (34.8%) had a history of coronary artery disease (CAD). Patients with elevated cTnI were significantly older, more often had American Society of Anaesthesiologist status score ≥3, a history of CAD or stroke and more often were current smokers than the patients without cTnI elevation. In multivariate regression analysis only age was an independent predictor of cTnI elevation. Patients with cTnI release were twice as likely to have a length of stay ≥20xa0days (Pxa0=xa00.047) and 2.7 times more likely to be discharged to a long-term residential care facility (RCF) (Pxa0=xa00.013). cTnI levelxa0≥1xa0μg/l was a strong independent predictor of all-cause mortality with 98.3% specificity and 89.1% negative predictive value.ConclusionPeri-operative myocardial injury is common in older HF patients but is frequently unrecognised clinically. Elevated blood cTnI level is an independent predictor of prolonged length of hospital stay (≥20xa0days), need for long-term RCF and mortality (if cTnI ≥1xa0μg/l).

Trends in stroke survival incidence rates in older Australians in the new millennium and forecasts into the future.

OBJECTIVEnTo investigate whether clinical and laboratory characteristics, including serum 25-hydroxyvitamin D (25(OH) D), PTH and parameters of mineral and bone metabolism, differ by hip fracture (HF) type.nnnPATIENTS AND METHODSnWe studied prospectively 761 consecutively admitted older patients (mean age 82.3+8.8(SD) years; 74.9% women) with low trauma non-pathological HF. A detailed clinical examination was performed, haematologic, renal, liver and thyroid function tests, serum 25(OH)D, PTH, calcium, phosphate, magnesium, C-reactive protein (CRP) and cardiac troponin I (cTnI) measured. In a subset of 294 patients markers of bone formation (serum osteocalcin, OC; bone specific alkaline phosphatase, BAP) and bone resorption (urinary deoxypyridinoline, DPD/Cr; N-terminal cross-linked telopeptide of type 1 collagen, NTx/Cr; both corrected to urinary creatinine, Cr) were also measured.nnnRESULTSnIn the trochanteric compared to the cervical group, females were older than males and the prevalence of Parkinsons disease, mean haemoglobin and albumin levels were lower. Incidence and degree of myocardial injury (cTnl rise) and inflammatory reaction (CRP elevation) as well as length of hospital stay, need of institutionalisation or in-hospital mortality were similar in both groups. Hypovitaminosis D (25(OH)D <50 mmol/L) was present in 77.8% of patients with cervical and in 82.1% with trochanteric HF, elevated PTH (>6.8 pmol/L) in 30.2% and 41.3%, respectively. The associations between 25(OH)D, PTH, and parameters of mineral metabolism and bone turnover were site-specific. In multivariate analyses, PTH (both as a continuous or categorical variable) response to hypovitaminosis D was a strong independent predictor of HF type. Coexistence of vitamin D deficiency (25(OH) D< 25 nmol/L) and elevated PTH predicts trochanteric HF while blunted PTH response predicts cervical HF (OR=3.5; 95% CI 1.5-80; p=0.005). PTH response and phosphate status (above or below median level) correctly discriminated HF type in 73.8% of patients with vitamin D deficiency.nnnCONCLUSIONSnHF type is significantly associated with PTH response to hypovitaminosis D and impaired phosphate homeostasis. We detected only minor differences between two main HF types with regard to a wide range of clinical and routine laboratory variables as well as short-term outcomes.

Serum resistin in older patients with hip fracture: Relationship with comorbidity and biochemical determinants of bone metabolism.

BackgroundData on clinical characteristics and outcomes in regard to hip fracture (HF) type are controversial. This study aimed to evaluate whether clinical and laboratory predictors of poorer outcomes differ by HF type.MethodsProspective evaluation of 761 consecutively admitted patients (mean age 82.3 ± 8.8 years; 74.9% women) with low-trauma non-pathological HF. Clinical characteristics and short-term outcomes were recorded. Haematological, renal, liver and thyroid status, C-reactive protein, cardiac troponin I, serum 25(OH) vitamin D, PTH, leptin, adiponectin and resistin were determined.ResultsThe cervical compared to the tronchanteric HF group was younger, have higher mean haemoglobin, albumin, adiponectin and resistin and lower PTH levels (all P < 0.05). In-hospital mortality, length of hospital stay (LOS), incidence of post-operative myocardial injury and need of institutionalisation were similar in both groups. Multivariate analysis revealed as independent predictors for in-hospital death in patient with cervical HF male sex, hyperparathyroidism and lower leptin levels, while in patients with trochanteric HF only hyperparathyroidism; for post-operative myocardial injury dementia, smoking and renal impairment in the former group and coronary artery disease (CAD), hyperparathyroidism and hypoleptinaemia in the latter; for LOS > 20 days CAD, and age > 75 years and hyperparathyroidism, respectively. Need of institutionalisation was predicted by age > 75 years and dementia in both groups and also by hypovitaminosis D in the cervical and by hyperparathyroidism in the trochanteric HF.ConclusionsClinical characteristics and incidence of poorer short-term outcomes in the two main HF types are rather similar but risk factors for certain outcomes are site-specific reflecting differences in underlying mechanisms.

ALTERED BLOOD PRESSURE HOMEOSTASIS IN THE OLDEST OLD AND SURVIVAL

AIMSnThe objective of this study is (i) to evaluate trends in the incidence rates of stroke survivors aged 60 years and older over a 11-year period in the Australian Capital Territory (ACT) and (ii) to forecast future trends in Australia until 2051.nnnMETHODSnAnalysis of age- and sex-specific standardized incidence rates of older first-ever stroke survivors in ACT from 1999-2000 to 2009-2010 and projections of number of stroke survivors (NSS) in 2021 and 2051 using 2 models based only on (i) demographic changes and (ii) assuming changing of both incidence rates and demography.nnnRESULTSnIn the ACT in the first decade of the 21st century, the absolute numbers and age-adjusted standardized incidence rates of stroke survivors (measured as a function of age and period) increased among both men and women aged 60 years or older. The trend toward increased survival rates in both sexes was driven mainly by population aging, whereas the effect of stroke year was more pronounced in men compared with women. The absolute NSS (and the financial burden to the society) in Australia is predicted to increase by 35.5%-59.3% in 2021 compared with 2011 and by 1.6- to 4.6-fold in 2051 if current only demographic (first number) or both demographic and incidence trends (second number) continue.nnnCONCLUSIONSnOur study demonstrates favorable trends in stroke survivor rates in Australia in the first decade of the new millennium and projects in the foreseeable future significant increases in the absolute numbers of older stroke survivors, especially among those aged 70 years or older and men.