Validation of the ADFICE_IT Models for Predicting Falls and Recurrent Falls in Geriatric Outpatients.

OBJECTIVES: Before being used in clinical practice, a prediction model should be tested in patients whose data were not used in model development. Previously, we developed the ADFICE_IT models for predicting any fall and recurrent falls, referred as Any_fall and Recur_fall. In this study, we externally validated the models and compared their clinical value to a practical screening strategy where patients are screened for falls history alone. DESIGN: Retrospective, combined analysis of 2 prospective cohorts. SETTING AND PARTICIPANTS: Data were included of 1125 patients (aged ≥65 years) who visited the geriatrics department or the emergency department. METHODS: We evaluated the models' discrimination using the C-statistic. Models were updated using logistic regression if calibration intercept or slope values deviated significantly from their ideal values. Decision curve analysis was applied to compare the models' clinical value (ie, net benefit) against that of falls history for different decision thresholds. RESULTS: During the 1-year follow-up, 428 participants (42.7%) endured 1 or more falls, and 224 participants (23.1%) endured a recurrent fall (≥2 falls). C-statistic values were 0.66 (95% CI 0.63-0.69) and 0.69 (95% CI 0.65-0.72) for the Any_fall and Recur_fall models, respectively. Any_fall overestimated the fall risk and we therefore updated only its intercept whereas Recur_fall showed good calibration and required no update. Compared with falls history, Any_fall and Recur_fall showed greater net benefit for decision thresholds of 35% to 60% and 15% to 45%, respectively. CONCLUSIONS AND IMPLICATIONS: The models performed similarly in this data set of geriatric outpatients as in the development sample. This suggests that fall-risk assessment tools that were developed in community-dwelling older adults may perform well in geriatric outpatients. We found that in geriatric outpatients the models have greater clinical value across a wide range of decision thresholds compared with screening for falls history alone.

Ultrasound-Guided Nerve Blocks as Analgesia for Nonoperative Management of Distal Radius Fractures-Two Consecutive Randomized Controlled Trials.

OBJECTIVES: To investigate whether a conventional fracture hematoma block (FHB) or an ultrasound-guided peripheral nerve block has more superior analgesic effect during nonoperative management of distal radius fractures in an emergency department setting. Two peripheral nerve block types were investigated, one at the level of the elbow, or cubital nerve block (CNB), and another an axillary nerve block (ANB). DESIGN: Two prospective randomized controlled studies were performed to compare the difference in pain intensity during closed reduction of a distal radius fracture between FHB-, CNB-, and, ANB-treated patients. SETTING: Level 2 trauma center. PATIENTS: One hundred ten patients with radiographic displaced distal radius fractures were randomized. Fifty patients were randomized between FHB and CNB, and 60 patients were randomized between CNB and ANB. INTERVENTION: FHB, CNB, or ANB. These were performed by 3 physicians new to ultrasound-guided peripheral nerve blocks and trained before onset of this study. MAIN OUTCOME MEASUREMENT: Pain was sequentially measured using an NRS during closed distal radius fracture reduction. RESULTS: CNB patients experienced less pain during block procedure (P = 0.002), finger trap traction (P = 0.007), fracture reduction (P = 0.00001), after plaster cast application (P = 0.01), and after control radiography (P = 0.01). In our second study, ANB-treated patients reported less pain during block procedure (P = 0.04), during finger trap traction (P < 0.0001), fracture reduction (P < 0.0001), after plaster cast application (P = 0.0001), and after control radiography (P = 0.0005). CONCLUSIONS: Although participating clinicians had minimal expertise using ultrasound-guided peripheral nerve blocks, nonoperative management of distal radius fracture using an ANB was less painful. These block types are expected to completely eradicate sensation the best. Future studies should address technical factors including adequate placement and time to let the block set up, as well as issues such as resource utilization including time and clinician availability to better determine the relative advantages and disadvantages to other analgesia techniques such as the FHB. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Fall-related healthcare use and mortality among older adults in the Netherlands, 1997-2016.

OBJECTIVES: Fall-related injuries are a leading cause of morbidity among older adults, leading to a high healthcare consumption and mortality. We aim to describe and quantify time trends of fall-related healthcare use and mortality among adults aged ≥65 years in the Netherlands, 1997-2016. DESIGN: Data were extracted from the Dutch Injury Surveillance System, Dutch Hospital Discharge Registry, and Cause-of-Death Statistics Netherlands, by age, sex, diagnosis, injury location, and year. MEASUREMENTS: Absolute numbers and age-standardized rates of fall-related Emergency Department (ED) visits, hospital admissions, and fatalities, as well as average length of hospital stay (LOS) were calculated. RESULTS: Between 1997 and 2016, absolute numbers of fall-related ED visits increased by 48%, hospital admissions increased by 59%, and mortality showed an almost threefold increase. These absolute numbers doubled among adults aged ≥85 years. A shift in fall-related injury diagnosis was observed over the years with a growing share of skull/brain injuries. In contrast to the increase in absolute numbers, standardized incidence rates of ED visits decreased by 30% (p = 0.00), whereas incidence rates of hospital admissions and mortality did not significantly change over time. Furthermore, the absolute number of hospital admission days almost halved, due to a reduced average LOS from 18.5 (95% confidence interval (CI): 18.2-18.8) days (1997) to 6.1 (95% CI, 6.1-6.2) days (2016). CONCLUSION: Even though the standardized incidence rates of ED visits decreased in the past twenty years, the absolute number of fall-related ED visits increased. The number of hospital admissions has also increased, but the total number of admission days has almost halved during the same period. If the observed trends would continue, this may have implications for healthcare resource allocation, as the burden of care in EDs increases, and the admission duration reduces.

Association of estimated glomerular filtration rate with muscle function in older persons who have fallen.

Background: studies suggest that estimated glomerular filtration rate (eGFR) is less reliable in older persons and that a low serum-creatinine might reflect reduced muscle mass rather than high kidney function. This study investigates the possible relationship between eGFR and multiple elements of physical performance in older fallers. Methods: baseline data of the IMPROveFALL-study were examined in participants ≥65 years. Serum-creatinine based eGFR was classified as normal (≥90 ml/min), mildly reduced (60-89 ml/min) or moderately-severely reduced (<60 ml/min). Timed-Up-and-Go-test and Five-Times-Sit-to-Stand-test were used to assess mobility; calf circumference and handgrip strength to assess muscle status. Ancova models adjusted for age, sex, Charlson comorbidity index and body mass index were performed. Results: a total of 578 participants were included. Participants with a normal eGFR had lower handgrip strength than those with a mildly reduced eGFR (-9.5%, P < 0.001) and those with a moderately-severely reduced eGFR (-6.3%, P = 0.033) with mean strengths of 23.4, 25.8 and 24.9 kg, respectively. Participants with a normal eGFR had a smaller calf circumference than those with a mildly reduced eGFR (35.5 versus 36.5 cm, P = 0.006). Mean time to complete the mobility tests did not differ. Conclusions: in this study we found that older fallers with an eGFR ≥ 90 ml/min had smaller calf circumference and up to 10% lower handgrip strength than those with a reduced eGFR. This lower muscle mass is likely to lead to an overestimation of kidney function. This outcome therefore supports the search for biomarkers independent of muscle mass to estimate kidney function in older persons.

Effectiveness of medication withdrawal in older fallers: results from the Improving Medication Prescribing to reduce Risk Of FALLs (IMPROveFALL) trial.

Objectives: To investigate the effect of withdrawal of fall-risk-increasing-drugs (FRIDs) versus 'care as usual' on reducing falls in community-dwelling older fallers. Design: Randomised multicentre trial Participants: Six hundred and twelve older adults who visited an Emergency Department (ED) because of a fall. Interventions: Withdrawal of FRIDs. Main Outcomes and Measures: Primary outcome was time to the first self-reported fall. Secondary outcomes were time to the second self-reported fall and to falls requiring a general practitioner (GP)-consultation or ED-visit. Intention-to-treat (primary) and a per-protocol (secondary) analysis were conducted. The hazard ratios (HRs) for time-to-fall were calculated using a Cox-regression model. Differences in cumulative incidence of falls were analysed using Poisson regression. Results: During 12 months follow-up, 91 (34%) control and 115 (37%) intervention participants experienced a fall; 35% of all attempted interventions were unsuccessful, either due to recurrence of the initial indication for prescribing, additional medication for newly diagnosed conditions or non-compliance. Compared to baseline, the overall percentage of users of ≥3 FRIDs at 12 months did not change in either the intervention or the control group. Our intervention did not have a significant effect on time to first fall (HR 1.17; 95% confidence interval 0.89­1.54), time to second fall (1.19; 0.78­1.82), time to first fall-related GP-consultation (0.66; 0.42­1.06) or time to first fall-related ED-visit (0.85; 0.43­1.68). Conclusion: In this population of complex multimorbid patients visiting an ED because of a fall, our single intervention of FRIDs-withdrawal was not effective in reducing falls. Trial Registration: Netherlands Trial Register NTR1593.

Cost-utility of medication withdrawal in older fallers: results from the improving medication prescribing to reduce risk of FALLs (IMPROveFALL) trial.

BACKGROUND: The use of Fall-Risk-Increasing-Drugs (FRIDs) has been associated with increased risk of falls and associated injuries. This study investigates the effect of withdrawal of FRIDs versus 'care as usual' on health-related quality of life (HRQoL), costs, and cost-utility in community-dwelling older fallers. METHODS: In a prospective multicenter randomized controlled trial FRIDs assessment combined with FRIDs-withdrawal or modification was compared with 'care as usual' in older persons, who visited the emergency department after experiencing a fall. For the calculation of costs the direct medical costs (intramural and extramural) and indirect costs (travel costs) were collected for a 12 month period. HRQoL was measured at baseline and at 12 months follow-up using the EuroQol-5D and Short Form-12 version 2. The change in EuroQol-5D and Short Form-12 scores over 12 months follow-up within the control and intervention groups was compared using the Wilcoxon Signed Rank test for continuous variables and the McNemar test for dichotomous variables. The change in scores between the control and intervention groups were compared using a two-way analysis of variance. RESULTS: We included 612 older persons who visited an emergency department because of a fall. The mean cost of the FRIDs intervention was €120 per patient. The total fall-related healthcare costs (without the intervention costs) did not differ significantly between the intervention group and the control group (€2204 versus €2285). However, the withdrawal of FRIDs reduced medication costs with a mean of €38 per participant. Furthermore, the control group had a greater decline in EuroQol-5D utility score during the 12-months follow-up than the intervention group (p = 0.02). The change in the Short Form-12 Physical Component Summary and Mental Component Summary scores did not differ significantly between the two groups. CONCLUSIONS: Withdrawal of FRID's in older persons who visited an emergency department due to a fall, did not lead to reduction of total health-care costs. However, the withdrawal of FRIDs reduced medication costs with a mean of €38 per participant in combination with less decline in HRQoL is an important result. TRIAL REGISTRATION: The trial is registered in the Netherlands Trial Register ( NTR1593 - October 1st 2008).

Drug-induced falls in older persons: is there a role for therapeutic drug monitoring?

BACKGROUND: Falls are the leading cause of injuries among older persons. Because of ageing societies worldwide, falls are expected to become a prominent public health problem. The usage of several types of drugs has been associated with an increased fall and fracture risk. In order to reduce future falls, preventative measures are needed. Therapeutic drug monitoring may help to identify persons who are at risk for falls due to drug use. The aim was to demonstrate how drugs can contribute to falls and the role of therapeutic drug monitoring. METHODS: We present a descriptive case series of four patients. RESULTS: All patients were referred to the geriatric outpatient clinic of a university medical center. The presented cases contained different underlying mechanisms contributing to an increased fall risk in older adults, including renal failure, genetic variation, overdose and ageing. CONCLUSION/DISCUSSION: Older adults are more prone to the side effects of drug use, including falls. Therapeutic drug monitoring may be useful to identify the patients who have an increased drug-related fall risk and to prevent future falls by individualizing the drug regime.

A young woman with a jejuno-jejunal intussusception.

A 27-year-old woman presented at the emergency department, with pain in the epigastric region. Because physical examination, blood results, urine tests and an X-ray of the thorax showed no abnormalities, she was discharged. Twelve hours later, she presented again at the emergency department, with intense abdominal pain. The blood results, an X-ray and ultrasound of the abdomen were now aberrant. A CT of the abdomen showed an extensive intussusception. During an emergency laparotomy, the intussusception of the proximal jejunum was confirmed. Owing to gangrene of the proximal jejunum, a resection was inevitable. A polyp in the resected part of the jejunum was the lead point of the intussusception. This case report shows the challenges of diagnosing an 'intussusception' and gives a short overview of this condition in adults.

Parameters of bone health and fracture risk in older female fall victims: what do they tell us?

INTRODUCTION: A common and severe osteoporotic type fracture in older women is a hip fracture. It is not clear whether bone turnover parameters measured in blood can be a useful tool to predict fracture risk in older persons. The aim of the current study was to assess the association between serum vitamin D (25OHD) levels, parathyroid hormone (PTH), total osteocalcin, carboxy-terminal collagen crosslinks (CTX) and hip fractures in older fallers. MATERIAL AND METHODS: A single centre, prospective cohort study of bone parameters was carried out in 400 female patients aged > 70 years including 200 with a hip fracture and 200 without fractures, admitted after a fall between January 2005 and December 2007. RESULTS: Serum total osteocalcin levels were significantly lower in the fracture group compared to the non-fracture group (20.4 ng/ml vs 26.1 ng/ml, respectively, p = 0.01). This finding remained significant after exclusion of the patients on bisphosphonates (p = 0.003). There were no significant differences in 25OHD, PTH or CTX levels between the two groups. CONCLUSION: In the current study there was an association between the presence of a hip fracture and lower total serum osteocalcin concentrations. This could be indicative of low bone turnover osteoporosis in these women. An association for other bone turnover markers was lacking.

Physical performance and quality of life in single and recurrent fallers: data from the Improving Medication Prescribing to Reduce Risk of Falls study.

AIM: Although guidelines regarding falls prevention make a clear distinction between single and recurrent fallers, differences in functional status, physical performance, and quality of life in single and recurrent fallers have not been thoroughly investigated. Therefore, we investigated the differences in functional status, physical performance and health-related quality of life (HRQoL) between single and recurrent fallers. METHODS: From October 2008 to October 2011, 616 community-dwelling older adults who visited the emergency department as a result of a fall were enrolled. Physical performance was assessed with the Timed Up & Go (TUG) test, the Five Times Sit to Stand (FTSS) test, handgrip strength and the tandem stand test. Functional status was measured using the activities of daily living and instrumental activities of daily living scales. HRQoL was measured using the European Quality of Life five dimensions (EQ-5D), and the Short Form-12 version 2. A general linear model was used to compare the means of the scores. RESULTS: Recurrent falls in community-dwelling older adults were associated with poorer physical performance as measured by the TUG test (P < 0.001), FTSS test (P = 0.011), handgrip strength (P < 0.001) and tandem stand (P < 0.001), and lower HRQoL scores as measured by the EQ-5D (P = 0.006) and SF-12 (P = 0.006 and P = 0.012). CONCLUSION: The present findings provide further evidence that recurrent fallers have poorer physical performance and quality of life than single fallers. Recurrent falls might be a symptom of underlying disease and frailty, and reason for further assessment.

Circumstances leading to injurious falls in older men and women in the Netherlands.

BACKGROUND: Fall-induced injuries in persons aged 65 years and older are a major public health problem. Data regarding circumstances leading to specific injuries, such as traumatic brain injury (TBI) and hip fractures in older adults are scarce. OBJECTIVE: To investigate the activity distributions leading to indoor and outdoor falls requiring an emergency department (ED) visit, and those resulting in TBIs and hip fractures. PARTICIPANTS: 5880 older adults who visited the ED due to a fall. METHODS: Data is descriptive and stratified by age and gender. RESULTS: Two-thirds of all falls occurred indoors. However, there were higher proportions of outdoor falls at ages 65-79 years (48%). Walking up or down stairs (51%) and housekeeping (17%) were the most common indoor activities leading to a TBIs. Walking (42%) and sitting or standing (16%) was the most common indoor activities leading to a hip fracture. The most common outdoor activities were walking (61% for TBIs and 57% for hip fractures) and cycling (10% for TBIs and 24% for hip fractures). CONCLUSION: In the present study we found that the indoor activities distribution leading to TBIs and hip fractures differed. Notably, about half of the traumatic brain injuries and hip fractures in men and women aged 65-79 years occurred outdoors. This study provides new insights into patterns leading to injurious falls by age, gender and injury type, and may guide the targeting of falls prevention at specific activities and risk groups, including highly functional older men and women.

Increasing rates of pelvic fractures among older adults: The Netherlands, 1986-2011.

BACKGROUND: age-related issues are expected to rise in the coming decades. Osteoporosis, falls and fractures are major public health issues among elderly. Pelvic fractures are associated with a serious morbidity and hospitalisation rate. We therefore performed a study to determine trends in incidence and age-specific rates of pelvic fracture-related hospitalisations among elderly (≥65 years). METHODS: a secular trend analysis of all hospitalisations due to a pelvic fracture among older adults, using the National Medical Registration, 1986-2011, The Netherlands. RESULTS: the total number of hospitalisations due to a pelvic fracture increased from 887 in 1986 to 2,013 admissions in 2011 (127% increase). The overall age-adjusted incidence rate increased from 5.19 in 1986 to 7.14 per 10,000 population in 2011 (37.5% increase). The incidence rate increased with age and was higher for females. The Percentual Annual Change was 1.2% (95% CI: 0.9;1.5) for older males, and 1.0% (95% CI: 0.9;1.2) for females, respectively. The mean length of hospital stay decreased between 1991 and 2011 to 12.0 days (53.4% decrease). The total number of hospital-bed-days decreased from 29,002 days in 1991 to 17,283 days in 2011 (40.4% decrease), despite an increase in absolute number of admissions. CONCLUSION: absolute numbers and incidence rates of pelvic fractures are increasing among the older Dutch population. Considering the fact the general population is growing older, an increasing number of elderly suffer from pelvic fractures. Attention on osteoporosis screening and prevention of falls in elderly remains important, in order to limit-related healthcare costs in the future.

[A woman with a wound on her hand]. / Een vrouw met een wond op haar hand.

A 37-year-old woman came to the Emergency Room. Since 7 days she had a growing wound of the left hand with a necrotic centre. She had increasing erythema and edema of the left arm, and a fever. PCR-investigation revealed the cow pox virus. Cow pox are rare but self-limiting.

Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies.

Falls are the leading cause of injuries among older adults, aged 65 years and older. Furthermore, falls are an increasing public health problem because of ageing populations worldwide due to an increase in the number of older adults, and an increase in life expectancy. Numerous studies have identified risk factors and investigated possible strategies to prevent (recurrent) falls in community-dwelling older people and those living in long-term care facilities. Several types of drugs have been associated with an increased fall risk. Since drugs are a modifiable risk factor, periodic drug review among older adults should be incorporated in a fall prevention programme.

Costs of falls in an ageing population: a nationwide study from the Netherlands (2007-2009).

BACKGROUND: Falls are a common mechanism of injury in the older population, putting an increasing demand on scarce healthcare resources. The objective of this study was to determine healthcare costs due to falls in the older population. METHODS: An incidence-based cost model was used to estimate the annual healthcare costs and costs per case spent on fall-related injuries in patients ≥ 65 years, The Netherlands (2007-2009). Costs were subdivided by age, gender, nature of injury, and type of resource use. RESULTS: In the period 2007-2009, each year 3% of all persons aged ≥ 65 years visited the Emergency Department due to a fall incident. Related medical costs were estimated at €675.4 million annually. Fractures led to 80% (€540 million) of the fall-related healthcare costs. The mean costs per fall were €9370, and were higher for women (€9990) than men (€7510) and increased with age (from €3900 at ages 65-69 years to €14,600 at ages ≥ 85 year). Persons ≥ 80 years accounted for 47% of all fall-related Emergency Department visits, and 66% of total costs. The costs of long-term care at home and in nursing homes showed the largest age-related increases and accounted together for 54% of the fall-related costs in older people. DISCUSSION: Fall-related injuries are leading to a high healthcare consumption and related healthcare costs, which increases with age. Programmes to prevent falls and fractures should be further implemented in order to reduce costs due to falls in the older population and to avoid that healthcare systems become overburdened.