Preventing falls in elderly people living in hospitals and care homes.
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Accidental Falls↗
Biomedical subjects
Ian D Cameron
Publications and source records attributed to Ian D Cameron.
Safety and efficacy of routine postoperative ibuprofen for pain and disability related to ectopic bone formation after hip replacement surgery (HIPAID): randomised controlled trial.
OBJECTIVES: To determine the benefits and risks of a non-steroidal anti-inflammatory drug (NSAID) as prophylaxis for ectopic bone formation in patients undergoing total hip replacement (or revision) surgery. DESIGN: Double blind randomised placebo controlled clinical trial, stratified by treatment site and surgery (primary or revision). SETTING: 20 orthopaedic surgery centres in Australia and New Zealand. PARTICIPANTS: 902 patients undergoing elective primary or revision total hip replacement surgery. INTERVENTION: 14 days' treatment with ibuprofen (1200 mg daily) or matching placebo started within 24 hours of surgery. MAIN OUTCOME MEASURES: Changes in self reported hip pain and physical function 6 to 12 months after surgery (Western Ontario and McMaster University Arthritis index). RESULTS: There were no significant differences between the groups for improvements in hip pain (mean difference -0.1, 95% confidence interval -0.4 to 0.2, P = 0.6) or physical function (-0.1, -0.4 to 0.2, P = 0.5), despite a decreased risk of ectopic bone formation (relative risk 0.69, 0.56 to 0.83) associated with ibuprofen. There was a significantly increased risk of major bleeding complications in the ibuprofen group during the admission period (2.09, 1.00 to 4.39). CONCLUSIONS: These data do not support the use of routine prophylaxis with NSAIDs in patients undergoing total hip replacement surgery. TRIAL REGISTRATION: NCT00145730.
Anti-Inflammatory Agents, Non-Steroidal↗
High bone turnover is an independent predictor of mortality in the frail elderly.
UNLABELLED: Osteoporotic fractures are associated with accelerated bone turnover and excess mortality. In a prospective study of 1112 frail subjects (79% female; mean age, 86 years), high bone turnover was an independent predictor of all-cause mortality. This association seemed to be mainly manifested in deaths from cardiovascular causes. INTRODUCTION: Osteoporotic fractures are associated with accelerated bone turnover and excess mortality. In a prospective cohort study of elderly men and women, we assessed whether the rate of bone turnover measured by markers of bone remodeling is a direct predictor of mortality. MATERIALS AND METHODS: We measured serum concentrations of the aminoterminal propeptide of type I collagen (PINP), a marker of bone formation, and of the carboxyterminal telopeptide of type I collagen (CTX-I), a marker of bone resorption, along with serum PTH and 25-hydroxyvitamin D [25(OH)D] levels in 1112 subjects (79% female; mean age, 86 years) living in residential care. Co-morbidity was measured using the Implicit Illness Severity Scale. Fracture data were validated by a radiology report. Mortality and causes of death were ascertained from death certificates. RESULTS: Over a median follow-up of 817 days, 559 (50.3%) subjects died. In univariate analyses, time to death from all causes was significantly (p < 0.01) associated with age (HR = 1.62 per 10 years), male sex (HR = 1.33), immobility (HR = 1.94), co-morbidity (HR = 0.31, mild versus severe), lower weight (HR = 0.83 per 10-kg increase), impaired cognitive function (HR = 2.14, severe versus normal), number of medications (HR = 1.05 each), hip fracture (HR = 2.26), log serum creatinine (HR = 1.67), log PTH (HR = 1.29), CTX-I (HR = 1.70, highest 25% versus lowest 75%), and PINP (HR = 1.46, highest 25% versus lowest 75%). In multivariate analysis adjusting for age, sex, immobility, co-morbidity, weight, cognitive function, number of medications, PTH, and hip fracture status, the highest quartile was significantly more likely to die than the rest for both serum CTX-I (HR = 1.39; 95% CI: 1.14-1.70; p = 0.002) and PINP (HR = 1.25; 95% CI: 1.02-1.52; p = 0.03). For individual causes of death, CTX-I was significantly associated with deaths from cardiac causes (HR = 1.78: 95% CI: 1.27-2.50; p < 0.001). CONCLUSIONS: We conclude that in the frail elderly, high bone turnover is associated with all cause mortality independently of age, sex, health status, serum PTH levels, and hip fracture status. The mechanism of the effect of bone turnover on mortality seems to be mainly manifested in deaths from cardiovascular causes.
Aged↗
Dysautonomia and heart rate variability following severe traumatic brain injury.
PRIMARY OBJECTIVE: To investigate disconnection theories postulated as the cause of dysautonomia following severe traumatic brain injury (TBI) through analysis of heart rate variability (HRV). METHODS AND PROCEDURES: Data were collected on age-matched subjects with and without dysautonomia (eight subjects in each group) and 16 non-injured controls. Data included injury details, continuous electrocardiograph recordings and rehabilitation outcome. MAIN OUTCOMES AND RESULTS: The TBI group revealed significant differences in HRV parameters both compared to controls and between dysautonomic and non-dysautonomic subjects. Additionally, HRV parameters for dysautonomic subjects showed evidence of an uncoupling of the normal relationship between heart rate and sympathetic/parasympathetic balance. HRV changes persisted for the dysautonomia group for a mean of 14 months post-injury. CONCLUSIONS: Dysautonomic subjects revealed prolonged uncoupling of heart rate and HRV parameters compared to non-dysautonomic subjects and controls. These findings represent direct pathophysiological evidence supporting the disconnection theory postulated to produce dysautonomia following TBI.
Adolescent↗
Effect of age-related chronic immobility on markers of bone turnover.
UNLABELLED: The effects of acute immobilization on bone turnover are well known, but the effects of chronic hypomobility with aging have not been studied. In a cohort of 1064 frail elderly subjects, immobility was significantly associated with serum PINP but not serum CTx after adjusting for confounders. The effect of immobility may be more marked on bone formation than on bone resorption. INTRODUCTION: Accelerated bone turnover and rapid bone loss caused by acute immobilization is well recognized, but the effects of age-related chronic reduction in mobility on bone turnover have been less well studied. We assessed the associations between bone turnover and measures of mobility in a cohort of elderly subjects. MATERIALS AND METHODS: We measured serum levels of the aminoterminal propeptide of type I collagen (PINP), a marker of bone formation, and serum concentrations of the carboxyterminal telopeptide of type I collagen (CTx), a marker of bone resorption, as well as serum intact PTH, serum 25 hydroxyvitamin D (25OHD), mobility, and static balance in a well-characterized sample of 1064 elderly men and women living in residential aged care facilities. Serum creatinine, phosphate, albumin, and calcium were measured in a randomly selected subgroup of 447 subjects. RESULTS: The subjects were elderly and frail; their mean age was 86.0 years (range, 65-101 years); 69% used a walking aid; and 77% were vitamin D deficient (serum 25OHD level < 39 nM). Both serum PINP and CTx increased with age in both sexes. Elevated PINP or CTx was significantly correlated with high PTH, creatinine, and albumin in both genders, except for albumin in women. Age- and gender-adjusted serum CTx and PINP were significantly higher in those with poorer mobility and those with worse static balance. In multivariate analyses, higher serum PINP but not CTx was associated with poorer mobility and worse static balance. CONCLUSIONS: Our findings suggest that poor mobility contributes to the state of accelerated bone turnover usually seen in the elderly. The effect of chronic relative immobility may be more marked on bone formation than bone resorption.
Age Factors↗
Calcium metabolism in the frail elderly.
Elderly residents of aged care facilities are usually considered at high risk of osteoporosis not only due to their age, but also due to nutritional factors, poor sunlight exposure and renal insufficiency. This study aimed to describe calcium metabolism and related hormones in this high-risk population. A total of 1280 elderly residents of hostels and nursing homes in the northern Sydney area (aged 65 years or over) had serum analysis for clinical chemistry including serum 25-hydroxy vitamin D (25OHD) and parathyroid hormone (PTH). Moderate renal impairment (creatinine clearance 30-60 ml/min) was common (62%), but hypocalcaemia was uncommon (7.0%). Mild hypoalbuminaemia was common (34% below 40 g/l, but only 3.2% below 35 g/l); 77.5% of the cohort had low serum 25OHD levels (<39 nmol/l) and 41.7% had elevated PTH levels (>66 pg/ml). Independent predictors of low serum 25OHD levels included gender, age, serum PTH, season, mobility and creatinine clearance. Use of vitamin D supplementation conferred modestly higher serum 25OHD levels (45.5 vs 27.1 nmol/l in non-supplemented residents, p < 0.0001) and lower PTH levels (50.0 vs 78.1 pg/ml, p < 0.0001). Despite adequate overall nutrition, vitamin D deficiency is present in the majority of this population. Vitamin D deficiency remains a significant public health problem in the institutionalized frail elderly. Currently available supplements are not adequate or utilized frequently enough to address this problem.
Aged, 80 and over↗
Atypical antipsychotic medications and risk of falls in residents of aged care facilities.
OBJECTIVES: To determine whether use of atypical antipsychotics (olanzapine and risperidone) is associated with lower risk of falls than use of typical antipsychotics. DESIGN: Prospective cohort study with 1-month follow-up. SETTING: Residential aged care facilities in Sydney, Australia. PARTICIPANTS: Two thousand five people aged 65 to 104 (mean age 86). MEASUREMENTS: Medication use at baseline was collected from medical records. Data on potential confounders were collected at interview and physical examination and from medical records. The outcome was accidental falls (one or more). RESULTS: One thousand one hundred seven subjects (55%) used at least one type of psychotropic medication, with 289 (14%) using an antipsychotic. There were 82 olanzapine users, 38 risperidone users, and 181 users of typical antipsychotics. Eleven percent of subjects (n=226) had at least one fall during follow-up. After adjusting for a comprehensive range of falls risk factors, hazard ratios (HRs) for falls were 1.35 (95% confidence interval (CI)=0.87-2.09) for typical antipsychotics, 1.32 (95% CI=0.57-3.06) for risperidone, and 1.74 (95% CI=1.04-2.90) for olanzapine. Antidepressants were also associated with falls (adjusted HR=1.45, 95% CI=1.09-1.93). CONCLUSION: Despite fewer extrapyramidal side effects, atypical antipsychotic medications are not associated with fewer falls than the older, more-established antipsychotics.
Accidental Falls↗
Severe traumatic brain injury in New South Wales: comparable outcomes for rural and urban residents.
OBJECTIVE: To compare differences in functional outcomes between urban and rural patients with traumatic brain injury (TBI). DESIGN: A longitudinal, prospective, multicentre study of a 2-year cohort from the Brain Injury Rehabilitation Program (BIRP) for New South Wales, with follow-up at 18 months after injury. PARTICIPANTS: 198 patients (147 urban, 51 rural) with severe TBI from the 11 participating rehabilitation units. MAIN OUTCOME MEASURES: Demographic and injury details collected prospectively using a standardised questionnaire, and measures from five validated instruments (Disability Rating Scale, Mayo-Portland Adaptability Inventory, Sydney Psychosocial Reintegration Scale, Medical Outcomes Study Short Form and the General Health Questionnaire--28-item version) administered at follow-up to document functional, psychosocial, emotional and vocational outcomes. RESULTS: Demographic details, injury severity, lengths of stay in intensive and acute care wards were similar for both rural and urban groups. There were no significant group differences in functional outcomes, including return to work, at follow-up. CONCLUSIONS: Our findings contrast with previous research that has reported poorer outcomes after TBI for rural residents, and suggest that the integrated network of inpatient, outpatient and outreach services provided throughout NSW through the BIRP provides effective rehabilitation for people with severe TBI regardless of where they live.
Adult↗
Prevalence of use of hip protectors in NSW residential aged-care facilities.
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Aged↗
How to manage musculoskeletal conditions: when is 'rehabilitation' appropriate?
Multidisciplinary rehabilitation has established efficacy in few musculoskeletal conditions. It is likely to be effective in the context of chronic back pain and possibly other types of chronic pain, and in frail older people with hip fractures. The principles of multidisciplinary rehabilitation, which include time-limited and goal-directed interventions, can be used in other musculoskeletal interventions but there have not yet been sufficient randomized trials to determine its effectiveness. Multidisciplinary rehabilitation is relatively costly and therefore is not likely to be cost effective unless it achieves return to work in people in the working-age group, or averts the need for residential care in frail older people.
Activities of Daily Living↗
Pharmacological management of Dysautonomia following traumatic brain injury.
PRIMARY OBJECTIVE: To document and critically evaluate the likely effectiveness of pharmacological treatments used in a sample of patients with Dysautonomia and to link these findings to previously published literature. RESEARCH DESIGN: Retrospective case control chart review. METHODS AND PROCEDURES: Data were collected on age, sex and GCS matched subjects with and without Dysautonomia (35 cases and 35 controls). Data included demographic and injury details, physiological parameters, medication usage, clinical progress and rehabilitation outcome. Descriptive analyses were undertaken to characterize the timing and frequency of CNS active medications. MAIN OUTCOMES AND RESULTS: Dysautonomic patients were significantly more likely to receive neurologically active medications. A wide variety of drugs were utilised with the most frequent being morphine/midazolam and chlorpromazine. Cessation of morphine/midazolam produced significant increases in heart rate and respiratory rate but not temperature. Chlorpromazine may have modified respiratory rate responses, but not temperature or heart rate. CONCLUSIONS: The features of Dysautonomia are similar to a number of conditions treated as medical emergencies. Despite this, no definitive treatment paradigm exists. The best available evidence is for morphine (especially intravenously), benzodiazepines, propanolol, bromocriptine and possibly intrathecal baclofen. Barriers to improving management include the lack of a standardized nomenclature, formal definition or accepted diagnostic test. Future research needs to be conducted to improve understanding of Dysautonomia with a view to minimizing disability.
Adult↗
Predictors of adherence with the recommended use of hip protectors.
BACKGROUND: Hip protectors can prevent many hip fractures in older persons at high risk for falling. Few published studies have investigated the use of hip protectors in community-dwelling older persons, and the level of adherence with their use, and predictors of adherence in this setting, are not clear. The aim of this study was to report the predictors of adherence and the level of adherence with the use of hip protectors in frail community-dwelling older women. METHODS: This cohort study of the intervention group of a randomized, controlled trial recruited participants from aged care health services in urban areas of northern Sydney, Australia. Participants were 302 women who were 74 years or older (mean age, 83 years) and who had 2 or more falls or 1 fall requiring hospital admission in the previous year and who lived in their own homes. The main outcome measure was adherence with the use of hip protectors. RESULTS: Adherence was approximately 53% during the 2 years of the study, and hip protectors were worn at the time of 51% of falls. The significant independent predictors of nonadherence with hip protector use were lower self-efficacy for hip protector use (odds ratio [OR], 0.51; 95% confidence interval [CI],.33 to.79), higher number of perceived barriers to hip protector use (OR, 0.52; 95% CI, .38 to.72), and lower self-rated health (OR, 0.71; 95% CI, .55 to.93). CONCLUSIONS: Three easily measured factors independently predicted subsequent adherence with hip protector use. These findings may form the basis for strategies to improve adherence with the use of hip protectors and with other types of treatment or preventive strategies in older persons.
Accidental Falls↗
Treadmill training and body weight support for walking after stroke.
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Body Weight↗
Evidence-based guidelines for fixing broken hips: an update.
OBJECTIVE: To update evidence-based guidelines for the treatment of proximal femoral fractures published in the Journal in 1999. DATA SOURCES: Systematic literature search of MEDLINE, CINAHL and EMBASE from January 1996 to September 2001 and the Cochrane Database of Systematic Reviews (most recent issue searched - Issue 2, 2002). STUDY SELECTION: Randomised controlled trials and meta-analyses of all aspects of acute-care hospital treatment and rehabilitation of proximal femoral fractures among subjects aged 50 years and over with proximal femoral fractures not associated with metastatic disease or multiple trauma. DATA EXTRACTION: All studies were read independently by two reviewers. Reviewers recorded individual study results, and an assessment of study quality and treatment conclusions according to Cochrane Collaboration protocols. If necessary, a third review was performed to reach consensus. RESULTS: 93 new studies were identified and 82 met our inclusion criteria. Recommendations for thromboprophylaxis, anaesthesia, surgical fixation of fractures and nutritional status have been altered to incorporate new evidence. Recommendations have been added regarding postoperative blood transfusion, the management of subtrochanteric fractures, and the type of surgical swabs which should be used. CONCLUSIONS: Although there have been few significant changes to the previous recommendations, updating the guidelines has required substantial effort. The common clinical problem of hip fracture should be treated according to the most up-to-date evidence to achieve the best possible outcomes and optimal utilisation of limited resources. Guideline updates also require resourcing.
Anticoagulants↗
Disability in older Australians: projections for 2006-2031.
OBJECTIVES: To provide detailed projections for the prevalence of disability and associated common health conditions for older Australians for the period 2006-2031. DESIGN: Secondary analyses of datasets (national 1998 Survey of Disability, Ageing and Carers; and projections of Australia's population from 2006-2031) collected by the Australian Bureau of Statistics. OUTCOME MEASURES: (i) The projected number of people with differing levels of disability (core activity restrictions in self-care, mobility or communication) up to 2031; (ii) The projected number of people with the main health conditions associated with disability in 2006 and 2031. RESULTS: Projections indicate a 70% increase in the number of older people with profound disability over the next 30 years. The main conditions associated with profound or severe core activity restriction in older Australians are musculoskeletal, nervous system, circulatory and respiratory conditions and stroke. CONCLUSIONS: In the future, there will be many more older Australians requiring assistance because of disability. This will present a challenge to families, friends, volunteers and paid service providers. The Australian planning ratio for residential aged-care services and community aged care services should be changed to take account of the shift to an older population with greater need of support.
Activities of Daily Living↗
Effectiveness of hip protectors. Some clarifications would be useful.
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Costs and Cost Analysis↗
4: Rehabilitation after traumatic brain injury.
Traumatic brain injury (TBI) commonly affects younger people and causes life-long impairments in physical, cognitive, behavioural and social function. The cognitive, behavioural and personality deficits are usually more disabling than the residual physical deficits. Recovery from TBI can continue for at least 5 years after injury. Rehabilitation is effective using an interdisciplinary approach, and close liaison with the patient, family and carers. The focus is on issues such as retraining in activities of daily living, pain management, cognitive and behavioural therapies, and pharmacological management. The social burden of TBI is significant, and therefore family education and counselling, and support of patient and carers, is important. General practitioners play an important role in providing ongoing support in the community, monitoring for medical complications, behavioural and personality issues, social reintegration, carer coping skills and return-to-work issues.
Activities of Daily Living↗