Utilization of inpatient care before and after hip fracture: a population-based study.

SUMMARY: Evaluation of hospitalizations in a 70+ population showed that hip fractures (HF) were associated with a significant increase in the utilization of inpatient care for a lengthy period. Hospital days attributable to several diagnostic classes still exceeded both prefracture and population levels in the second year after HF. INTRODUCTION: The goal was to assess effects of HF on the inpatient care utilization. METHODS: The study covered HF patients and the 70+general population (26,000) living in Central Finland. Hospitalization data categorized by the ICD-10 main classes were obtained from the nationwide discharge register. RESULTS: In 2002-2003, 498 residents (mean age 82 SD 7, 74.9% women) of the study area sustained HF. Among them, the number of hospital days was 23, 107, and 52 per person-year in the prefracture, first and second postfracture year, respectively. In the 70+ general population, the number was constantly 11 per year. The age- and gender-adjusted rate ratio of hospital days between the two groups was 1.30 (95% CI 1.27 to 1.32), 6.91 (95% CI 6.85 to 7.00), and 3.61 (95% CI 3.55 to 3.67) for the prefracture, first and second postfracture year, respectively. Hospital days due to injuries were more prevalent in the HF group throughout the period. Moreover, excess of days was seen in six other diagnostic classes in the first and in four classes in the second postfracture year. CONCLUSIONS: Hospital days in HF patients still exceeded both the prefracture and population levels in the second year after HF. Days attributable to several other causes than HF itself became also more prevalent indicating that HF can steeply decrease patients' coping capacity and launch a cascade of impairments in the function of different organ systems.

Incidence of second hip fractures. A population-based study.

UNLABELLED: We studied the incidence of second hip fractures and medication use among the patients with sequential hip fractures. This study shows that the incidence rate of second hip fractures is higher than that of the first hip fractures. Improvement in osteoporosis care and a more critical policy for prescription of psychotropic drugs are needed. INTRODUCTION: This study had two goals: (1) to determine incidence of second hip fractures; (2) to describe changes in pharmacotherapy between first and second hip fractures, especially the use of those psychotropics which increase the risk of falling and also pharmacotherapy for osteoporosis. METHODS: The residents of Central Finland Health Care District who had sustained a hip fracture in 2002-2003 were followed up for subsequent hip fractures until 2006. Hip fracture patients were identified and clinical data were obtained by using hospital registers and medical records. RESULTS: Five hundred and one persons aged >or= 60 years suffered their first hip fracture in 2002-2003. During the follow-up of 936 person-years, 34 second hip fractures occurred. The cumulative incidence of second hip fractures was 5.08% (95% CI: 3.30 to 7.78) at one year, and 8.11% (95% CI: 5.73 to 11.43) at two years after the first fracture. The second part of this study investigated 75 patients with two non-contemporaneous hip fractures. Between the first and second fractures, the number of psychotropic drug users rose from 27 (36%) to 44 (59%). At the time of second hip fracture, osteoporosis had been diagnosed in 17 (23%) patients only. Twelve (16%) patients used bisphosphonates or calcitonin, 15 (20%) used calcium and 9 (12%) vitamin D supplements. CONCLUSIONS: There is a high incidence of second hip fractures. Secondary prevention of hip fractures needs to be improved. In addition to adequate treatment for osteoporosis, more attention should be directed toward appropriate use of psychotropic drugs.

Life situation of spinal cord-injured persons in Central Finland.

STUDY DESIGN: Individual interview and questionnaire of a regional spinal cord-injured (SCI) population. OBJECTIVE: Local health care centres are mainly responsible for the SCI patients health care and rehabilitation after initial hospitalization in Finland. The purpose of the present study was to study aspects of the SCI patients life situation and their opinion of the health care services after 1 year since the injury. SETTING: Regional study in Central Finland. METHODS: Subjects were individually interviewed in their homes using a semi-structured questionnaire, the Functional Independence Measure (FIM) and the Beck Depression Inventory (BDI). RESULTS: The female/male ratio was 1:4. The mean age at the time of injury was 34 years in female and 40 in male. Traffic accidents accounted for 46% of the injuries. In all, 48 subjects (63%) used electrical or manual wheelchair or both. Most subjects regarded their living conditions as good having enough personal assistance in their everyday life. Only 10% of the subjects were employed. Half of the subjects had had out-patient physiotherapy, but no other therapies after 1 year since the injury. More than half of the subjects were dissatisfied with the current health care services. Many had experienced complications after the initial hospitalization, especially urinary tract infections, decubitus ulcers and neurogenic-type pain. FIM classified well according to the disability groups. The motor complete tetraplegic group had the lowest mean scores (63) and the recovered group the highest ones (122). There was no association between the FIM and the BDI results. There was a correlation between the BDI and the subject's age at the time of the injury and the year of the injury. The older the subjects were when injured, the higher were the BDI scores, that is, they had more depressive symptoms. Those injured in the 1990s had the highest BDI scores. Nearly one-third of the subjects had mild, moderate or severe depression. CONCLUSIONS: The reported medical complications, depression and dissatisfaction with the health care services support a life-long care for SCI patients in Jyväskylä Central hospital, not in the local health care centres. The psychological services, for example, prevention and treatment of depression, in particular, require more attention.

Randomized, double-blind, clinically controlled trial of intranasal calcitonin treatment in patients with hip fracture.

The objective of this study was to evaluate the short-term outcome of intranasal calcitonin treatment of elderly hip fracture patients on pain, bone loss, functional recovery, and length of hospital stay. In addition, we wanted to compare the effect of calcitonin with placebo on fusion of hip fractures treated with internal fixation using a screw or a nail. In a randomized, double-blind, clinically controlled trial, 260 independently living patients (aged 65 years or older) with acute hip fracture were randomly assigned to intranasal calcitonin 200 IU daily for 3 months or matching placebo nasal spray. Analyses were completed on an intention-to-treat basis. Three months after the operation, the median intensity of pain in visual analog scale was 0 mm (IQR 0.20) in the calcitonin group and 4 mm (IQR 0.33) in the placebo group (P = 0.15). The mean change in calcaneal bone mineral density from baseline to 3 months was not statistically significant between the groups -0.004 (95% CI -0.008 to -0.001) in the calcitonin group and -0.007 (95% CI -0.012 to -0.003) in the placebo group (P = 0.28). There were no significant differences in mortality, side effects, length of hospital stay, and functional recovery. Among patients with internal fixation using a screw or a nail (n = 99), fusion of the fracture was observed in an X-ray 3 months after the operation in 84% in the calcitonin group and in 63% in the placebo group (P = 0.029, difference 20% [95% CI 2 to 39]). We conclude that intranasal calcitonin might be useful for hip fracture patients but the clinical significance of this finding needs to be confirmed by studies with more participants, a longer treatment period, a longer follow-up, and perhaps a higher dose of calcitonin.

Coping with activities of daily living in different care settings.

OBJECTIVE: To measure the functional capacity of elderly people cared for in different health and welfare care settings, with functional capacity defined in terms of activities of daily living. SUBJECTS AND METHODS: We assessed all people aged > or =65 in health-centre hospitals or nursing homes or receiving home nursing and home help services in Central Finland (n=5652) using the Evergreen activities of daily living index, which comprises nine physical and nine instrumental activities of daily living. RESULTS: Assessments of functional capacity were obtained for nearly all subjects: only 33 forms (0.6%) were returned with incomplete data. The mean activities of daily living sum score (range 0-54) was lowest for women receiving home nursing (17.3), and highest for women in long-term care at health-centre hospitals (48.4). Low scores described good and high scores poor functional capacity. Age showed no association with the mean activities of daily living sum score in any of the care settings. CONCLUSION: The Evergreen activities of daily living index was easy to use and successfully distinguishes between people in different care settings. Policies of assigning older people to different settings appear to be sound and sensible as the main defining criterion is level of functional capacity rather than age.

Threefold increased risk of hip fractures with rheumatoid arthritis in Central Finland.

OBJECTIVES: To evaluate the impact of rheumatoid arthritis (RA) on the incidence of hip fractures. METHODS: All patients with acute hip fractures admitted to Jyväskylä Central Hospital in 1991-93 (n=517) were selected from the hospital discharge register. Medical records of these patients were studied retrospectively for RA fulfilling the American Rheumatism Association criteria. The prevalence of RA in patients with hip fractures was compared with the prevalence rates of RA obtained from the nearby city of Tampere. RESULTS: 29 (5.6%; 95% CI 3.8 to 8.0) of the patients with hip fracture in Jyväskylä Central Hospital had RA. The age and sex adjusted risk of hip fractures was increased by RA (risk ratio 3.26; 95% CI 2.26 to 4.70). CONCLUSIONS: Patients with RA are at increased risk of osteoporotic hip fractures.

Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia.

OBJECTIVE: To evaluate the effect of intensive geriatric rehabilitation on demented patients with hip fracture. DESIGN: Preplanned subanalysis of randomised intervention study. Settting: Jyväskylä Central Hospital, Finland. PARTICIPANTS: 243 independently living patients aged 65 years or older admitted to hospital with hip fracture. INTERVENTION: After surgery patients in the intervention group (n=120) were referred to the geriatric ward whereas those in the control group were discharged to local hospitals. MAIN OUTCOME MEASURES: Length of hospital stay, mortality, and place of residence three months and one year after surgery for hip fracture. RESULTS: The median length of hospital stay of hip fracture patients with moderate dementia (mini mental state examination score 12-17) was 47 days in the intervention group (n=24) and 147 days in the control group (n=12, P=0.04). The corresponding figures for patients with mild dementia (score 18-23) were 29 days in the intervention group (n=35) and 46.5 days in the control group (n=42, P=0.002). Three months after the operation, in the intervention group 91% (32) of the patients with mild dementia and 63% (15) of the patients with moderate dementia were living independently. In the control group, the corresponding figures were 67% (28) and 17% (2). There were no significant differences in mortality or in the lengths of hospital stay of severely demented patients and patients with normal mini mental state examination scores. CONCLUSIONS: Hip fracture patients with mild or moderate dementia can often return to the community if they are provided with active geriatric rehabilitation.

Significant changes in the surgical methods and length of hospital stay of hip fracture patients occurring over 10 years in Central Finland.

BACKGROUND AND AIMS: The objective of this study is to determine the changes occurring in the treatment chain and mortality of hip fracture patients in Central Finland over a ten-year period. In order to cope with an aging population and increasing cutbacks in the health care system, health-center hospitals run by general practitioners have taken a more active role in the rehabilitation of elderly patients. MATERIAL AND METHODS: Patients with acute hip fracture admitted to Jyväskylä Central Hospital in 1982-1983 (n = 317) and in 1992-1993 (n = 351) were collected from the hospital discharge register and the medical records of these patients were studied retrospectively. RESULTS: The median length of central hospital stay diminished from 18 days to 5 days and the percentage of hip fracture patients discharged to cope on their own diminished from 22 % to only 7 %. The percentage of trochanteric fractures treated by osteosynthesis increased from 83 % to 96 % and the percentage of cervical fractures treated by hemiprosthesis increased from 35 % to 76 %. First-year mortality has remained almost unchanged. CONCLUSIONS: There has been a dramatic change in surgical methods, in the length of hospital stay on the traumatology ward, and in discharge patterns and no change in mortality during the last 10 years in Central Finland.

The changing picture of hip fractures: dramatic change in age distribution and no change in age-adjusted incidence within 10 years in Central Finland.

The objective of this study was to find out if the age-standardized incidence of hip fractures has changed in 10 years in Central Finland. Patients with acute hip fracture admitted to Jyväskylä Central Hospital in 1982-1983 (n = 317) and in 1992-1993 (n = 351) were selected from the hospital discharge register and from contemporaneous records of the Department of Anesthesiology and the ward of traumatology. Earlier studies in Finland have indicated that there has been an increase in incidence rates. The results of this study show no change in the age-standardized incidence of hip fractures of men and women during the last 10 years. However, because of the change in the age distribution of the population, the number of hip fractures has increased by 11%. The mean age of the hip fracture patients increased from 75.4 years in 1982-1983 to 78.4 years in 1992-1993. In 1982-1983, 18.0% of the patients were > or =85 years. The corresponding figure in 1992-1993 was 30.2%. Therefore, we summarize that there has been a dramatic change in age distribution and no change in age-adjusted incidence within the last 10 years in central Finland.

Why is the pain relief of dying patients often unsuccessful? The relatives' perspectives.

In order to determine relatives' opinions of the pain relief of dying patients a postal questionnaire was sent to close relatives (n = 371) of aged patients (mean age 80.1 years) who had died one to two years earlier. In the relatives' opinions, 57% of the patients (n = 211) had suffered from moderate to severe pain and in 22% (n = 46) of these the pain relief was unsuccessful. Inadequate pain relief was associated with a feeling of helplessness in the patients (odds ratio 2.6), insufficient self-determination of analgesic use (9.4), unsatisfactory care of daily needs such as nutrition (8.3), and insufficient care of concomitant symptoms such as dry mouth (6.2). The pain relief was also evaluated as having been unsuccessful when the relatives received limited information about the forthcoming death (5.7), when it was difficult to discuss with the clinical staff (5.7), and when the relatives were not supported by, for example, comforting and heartening (7.9) or encouraging to participate in the care (7.2). In the multivariate analysis, the self-determination of the patients about their pain medication (5.7), difficulties of the relatives to discuss issues with the nursing staff (3.7) and poor atmosphere of the treatment environment (2.8) emerged as the most significant associates of unsuccessful pain relief. The results show that dissatisfaction with the pain management is associated with low appreciation of the treatment of other discomforts and complaints. Successful pain management therefore requires a holistic approach to the wider spectrum of problems in dying patients.

Outcome of aged patients in Finnish supervised home care.

The purpose of this study was to identify predictors of mortality and institutionalization in aged patients receiving Finnish supervised home care. The study was carried out in Central Finland, whose area and population is 5% of the total of the country. The subjects consisted of a sample of 312 patients (65 years or more). They were originally assembled to assess the effectiveness of a geriatric inpatient unit, the results of which have been published previously. Deaths were ascertained over at least three years and long-term care institutionalization over two years. The most powerful predictor of mortality was impaired ADL functioning. Predictors of long-term institutional care were impaired ADL functioning, impaired cognition and depression. These data may be helpful in resource allocation and targeting patients for the supervised home care programmes.

Effectiveness of a Finnish geriatric inpatient assessment. Two-year follow up of a randomized clinical trial on community-dwelling patients.

OBJECTIVE: To determine whether need for services could be reduced and functional status and satisfaction improved by assessing and rehabilitating aged patients on a geriatric inpatient ward. DESIGN: A randomized clinical trial with a two-year follow-up. SETTING: Geriatric unit with 8 beds in a Finnish central hospital. PATIENTS: 312 selected community-dwelling patients were assigned to the intervention group (N = 104) and the control group (N = 208). INTERVENTIONS: The intervention patients were individually assessed and rehabilitated in a geriatric ward. The control group received usual home care. MAIN OUTCOME MEASURES: Services, institutionalization, mortality, ADL, IADL and satisfaction. RESULTS: At one year, the intervention group had fewer days in health centre hospitals than controls (13.7 vs. 22.7), but only the intervention group had the geriatric inpatient stay (16.5 days). No significant differences were found for cumulative institutionalization or mortality over 24 months. At three months, the intervention group experienced a more positive change than controls in continence (P < 0.05), housekeeping (P < 0.05) and satisfaction (P < 0.01). CONCLUSION: The effectiveness of comprehensive geriatric inpatient assessment and rehabilitation on community-dwelling patients is mild. More targeting and more follow-up interventions are needed.

Effects of a geriatric inpatient unit on elderly home care patients: a controlled trial.

This was the first controlled trial to test the value of bringing elderly community-dwelling home care program patients into a hospital geriatric assessment unit. Elderly community-dwelling patients (N = 312; mean age = 78 years) who belonged to a supervised home-care population were randomized into intervention (N = 104) and control groups (N = 208). Patients in the intervention group underwent a comprehensive multidisciplinary geriatric assessment in an inpatient geriatric assessment unit (mean length of stay, 16.5 days). Controls continued with usual home care. At baseline, the two groups were comparable. By three months, the intervention group had more positive changes in general health, continence, housekeeping and satisfaction with care. However, by 12 months, these differences were no longer statistically significant. During the follow-up year, the intervention group had fewer days in health center hospitals. However, since controls had no initial days in the geriatric unit, there was no net difference in cumulative institutional days. We conclude that the benefits of this assessment approach were relatively mild and apparently temporary. More studies of alternative assessment schemes are needed, and different targeting models should be studied.