Spanish National Registry of Major Osteoporotic Fractures (REFRA) seen at Fracture Liaison Services (FLS): objectives and quality standards.

REFRA-FLS is a new registry in Spain aimed at identifying individuals over 50 years of age with a fragility fracture. Using this registry, we found hip fracture is the most prevalent fracture. Treatment for osteoporosis was 87.7%, with 65.3% adherence. REFRA-FLS provides fundamental data in the study of fragility fractures. PURPOSE: Fragility fractures are a growing public health concern in modern-aged societies. Fracture Liaison Services (FLS) have been shown to successfully lower rates of secondary fractures. A new registry (REFRA-FLS) has been created to monitor quality indicators of FLS units in Spain and to explore the occurrence and characteristic of fragility fractures identified by these centers. METHODS: We conducted a prospective cohort study based on fragility fractures recorded in the REFRA-FLS registry. Participants were individuals 50 years or above who suffered a low energy fragility fracture identified by the 10 participating FLS units during the study period. The type of FLS unit, the characteristics of the individuals at baseline, along with patient outcomes as quality indicators among those who completed 1 year of follow-up were analyzed. RESULTS: A total of 2965 patients and 3067 fragility fractures were identified, and the most frequent locations were hip (n = 1709, 55.7%) and spine (n = 492, 16.0%). A total of 43 refractures (4.5%) and 46 deaths (4.9%) were observed among 948 individuals in the follow-up analyses. Time from fracture to evaluation was less than 3 months in 76.7% of individuals. Osteoporosis treatment was prescribed in 87.7%, and adherence was 65.3% in Morisky-Green test. CONCLUSION: Our results provide a comprehensive picture of fragility fractures identified in FLS units from Spain. Overall, quality indicators are satisfactory although a much higher use of DXA would be desirable. As the registry grows with the incorporation of new FLS units and longer follow-up, incoming analyses will provide valuable insight.

[Prognostic factors of mortality one year after a hip fragility fracture. Anoia hip study]. / Factores pronósticos de mortalidad al año de una fractura de cadera por fragilidad ósea. Estudio Maluc Anoia.

INTRODUCTION: Most of the patients who had a hip fragility fracture are characterized by advanced age, frailty, multimorbidity and high mortality rate into the first year. Our aim is to describe the prognostic factors of mortality one year after a hip fragility fracture. MATERIAL AND METHODS: Observational prospective study. During the study period we included patients older than 69 years with hip fragility fracture who were admitted to the Acute Geriatric Unit. RESULTS: We have followed 364 patients, 100 of them died (27.5%). The independent prognostic factors of mortality one year after a hip fragility fracture had been: have a less basis score in Lawton and Brody Scale 0.603 (0.505-0.721) (p< 0.001); have a higher score in Charlson Comorbidity Index 2.332 (1.308-4.157) p = 0.04); have a surgical waiting time ≥ 3 days 3.013 (1.330-6.829) p = 0.008); finding hydroelectrolytic disorders and/or deterioration of glomerular filtration 1.212 (1.017-1.444) p = 0.031) during hospital stay; discriminatory capacity of the area under the curve (AUC) (± 95%): 0.888 (0.880-0.891). CONCLUSIONS: Prognostic predictors of mortality at one year after a hip fragility fracture are those variables that reflect a worse state of health, complications during hospital stay and a longer surgical waiting time.

Prognostic factors for discharge to home and residing at home 12 months after hip fracture: an Anoia hip study.

OBJECTIVES: Hip fracture is often associated with loss of physical function and institutionalization. The aim of this study is to describe the prognostic factors for discharge to home and residing there 12 months after a hip fracture. METHODS: A prospective study that includes patients aged ≥ 69 years that live at home before the fracture, admitted from June 1st, 2010, to May 31st, 2013. We registered the demographic data, presurgical function and cognitive assessment, surgical waiting time, type of fracture and complications during hospitalization. RESULTS: We included 273 patients (mean age 84.8 ± 6.1 years; 80% women), 130 (47.6%) were discharged directly to their own home. The predictors of discharge to home were a lower Geriatrics Dementia Scale score (OR 1.42; 95% CI 1.17-1.71; p < 0.001), a higher Barthel Index score at discharge (OR 1.07; 95% CI 1.05-1.10; p < 0.001) and a longer hospital stay (OR 1.14; 95% CI 1.02-1.27; p = 0.019). At 12 months, 169 (63.5%) were still residing at home. Predictors of residing at home 12 months after the hip fracture were age (OR 1.07; 95% CI 1.02-1.12; p = 0.010), the discharge Barthel Index score (OR 0.96; 95% CI 0.94-0.98; p < 0.001), the Geriatrics Dementia Scale score (OR 1.27; 95% CI 1.05-1.52; p = 0.013), the surgical waiting time (OR 3.42; 95% CI 1.077-10.89; p = 0.037) and Charlson comorbidity index (OR 1.27; 95% CI 1.05-1.55; p = 0.016). CONCLUSION: Prognostic factors for discharging to home and remaining there 12 months after a hip fracture are those that reflect a better health condition prior to the fracture and better functionality at the hospital discharge for hip fracture.

Mejorando la atención del paciente mayor ingresado por fractura de cadera. ¿Hemos de avanzar? / Improving the care of the elderly patient admitted for hip fracture. Should we move forward?

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Advantages of care for patients with hip fractures in the acute geriatric unit: Hip study Anoia.

AIM: Hip fracture as a result of bone fragility is characterized by poor health outcomes in the medium and long term. Our goal was to compare a new orthogeriatric model with the old trauma model and evaluate improvements in clinical management. METHODS: We carried out a comparative unicentric study, a historical sample (trauma model) collected from 1 June 2007 to 31 May 2010, versus a prospective sample (orthogeriatric model) collected from 1 June 2010 until 31 May 2013. We included all patients aged >69 years with hip fracture as a result of bone fragility. RESULTS: A total of 792 patients were evaluated (mean age 84.3 years). The surgical waiting period went from 2.70 days in the trauma model to 1.86 days in the orthogeriatric model (P < 0.001); the average stay was 15.76 days in the trauma model, and for the orthogeriatric model was reduced to 5.90 days (P < 0.001); mortality went from 4.5% to 1.3% (P ≤ 0.010); 1 month readmission for hip dislocation was reduced from 2.3% to 0.5% (P = 0.032). After a 6-month follow up, we had 302 trauma model patients and 287 orthogeriatric model patients. After 1 year, we had 288 patients in the trauma model and 264 patients in the orthogeriatric model. The main cause of abandonment was death, 108 patients (27.3%) in the trauma model and 100 patients (27.5%) in the orthogeriatric model (P = 0.951). CONCLUSIONS: When we compared the two models, we found statistically significant better results in the preoperative waiting period, average stay, hospital mortality and 1 month readmission as a result of hip prosthesis luxation in favor of the orthogeriatric model. Geriatr Gerontol Int 2018; 18: 407-414.

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.

Clinical evidence of diabetes mellitus end-organ damage as risk factor for falls complicated by hip fracture: A multi-center study of 1225 patients.

AIMS: To identify the differential characteristics of patients with type 2 diabetes mellitus (T2DM) complicated by end-organ damage who experience a fall-related hip fracture. METHODS: We analyzed the socio-demographic data and index fall clinical characteristics of a group of patients with nephropathy, neuropathy or retinopathy related to T2DM consecutively admitted to six hospitals in Barcelona, Spain because of a fall-related hip fracture. RESULTS: Out of 1225 patients admitted because of a fall-related hip fracture, 107 (8.7%) had clinical evidence of end-organ damage related to T2DM. Among this cohort the mean number of falls during the year prior to the index admission was 2.6±3.2; and 29 of them (27.1%) had already experienced three or more falls. Most falls leading to the index admission took place at the patients' home, from a standing position, and during daylight time. An intrinsic cause of falling was identified in all but one of these patients. Multiple stepwise logistic regression analysis showed that, compared to patients without this diagnosis, patients with complicated T2DM were younger (odds ratio 0.762), had less prevalence of dementia (odds ratio 0.078), but had experienced a higher number of falls in the previous year (odds 1.183). CONCLUSIONS: A significant amount of patients with clinical evidence of end-organ damage due to T2DM who experience a fall-related hip fracture have a history of recurrent falling in the previous year. These patients should be identified and offered preventive actions aimed at reducing their risk of falling.

Utilización de benzodiacepinas según el motivo de ingreso / Use of benzodiazepines according to the admission diagnosis

Fundamento y objetivo. El consumo crónico de benzodiacepinas es frecuente en los pacientes ancianos. El objetivo del estudio es evaluar posibles diferencias entre los pacientes que toman benzodiacepinas y los que no. Además, se analiza si hay diferencias entre los tratados con benzodiacepinas según si el motivo del ingreso hospitalario era médico o quirúrgico. Pacientes y metodo. Se realizó un estudio prospectivo y multicéntrico de 393 pacientes ingresados por causa médica en 6 unidades geriátricas de agudos y se compararon con datos previos de 1.225 ingresados por fractura de fémur. Se recogieron datos sociodemográficos, la capacidad funcional mediante el índice de Barthel (IB), la comorbilidad (índice de Charlson), y de detección de deterioro cognitivo (test de Pfeiffer). Resultados. Se incluyeron 1.618 pacientes, con una media (DE) de edad de 82,9 (6,5) años. Tomaban de forma crónica benzodiacepinas un total de 581 (35,9%) pacientes, 132 (33,6%) de los ingresos por causa médica y 449 (36,6%) de los ingresos por fractura de fémur (p=0,27). En el análisis multivariante se asoció a la toma de benzodiacepinas una mayor edad, el estar institucionalizado y un mayor consumo total de fármacos. Entre los pacientes que tomaban benzodiacepinas de forma crónica destacaba que los que ingresaban por causa médica vivían más en la comunidad, caían menos, tenían un peor IB, y mayor comorbilidad y polifarmacia. Conclusiones. Más de una tercera parte de los pacientes mayores ingresados por causa médica o traumatológica tomaban benzodiacepinas de forma crónica. Existen diferencias en los perfiles de los pacientes según tomaran o no benzodiacepinas, así como entre los que tomaban benzodiacepinas según cuál fuera el motivo de ingreso hospitalario(AU)

Background and objective. Chronic consumption of benzodiazepines is common in elderly patients. The aim of the study was to analyse the possible differences between patients taking benzodiazepines and those without them. We also determined, among patients on benzodiazepines, if any differences were related to medical or surgical admissions. Patients and methods. We performed a prospective and multicentre study of 393 patients admitted consecutively for medical reasons to 6 geriatrics acute units; these patients were compared to 1,225 patients hospitalized for a hip fracture. We collected sociodemographic data, functional capacity by the Barthel's index (BI), comorbidity by the Charlson's index and cognitive impairment by the Pfeiffer test. Results. We evaluated 1,618 patients, with a median age of 82.9 (6.5) years. Among patients admitted for medical causes, 581 (35.9%) were taking benzodiazepines chronically as did 449 (36.6%) patients in the hip fracture group (p=0.27). In the multivariate analysis, factors associated with the use of benzodiazepines included older age, institutionalization and a higher number of drug consumption. Differences according to the admission reason showed that patients admitted for medical causes lived more frequently in the community and had less falls, worse BI as well as a higher number of comorbidities and polypharmacy. Conclusions. More than one third of elderly patients hospitalized for medical or traumatology causes were taking benzodiazepines chronically. Different patients’ profiles can be observed according to whether they are or not taking benzodiazepines and to the admission's cause in the subgroup of patients on benzodiazepines(AU)

[Use of benzodiazepines according to the admission diagnosis]. / Utilización de benzodiacepinas según el motivo de ingreso.

BACKGROUND AND OBJECTIVE: Chronic consumption of benzodiazepines is common in elderly patients. The aim of the study was to analyse the possible differences between patients taking benzodiazepines and those without them. We also determined, among patients on benzodiazepines, if any differences were related to medical or surgical admissions. PATIENTS AND METHODS: We performed a prospective and multicentre study of 393 patients admitted consecutively for medical reasons to 6 geriatrics acute units; these patients were compared to 1,225 patients hospitalized for a hip fracture. We collected sociodemographic data, functional capacity by the Barthel's index (BI), comorbidity by the Charlson's index and cognitive impairment by the Pfeiffer test. RESULTS: We evaluated 1,618 patients, with a median age of 82.9 (6.5) years. Among patients admitted for medical causes, 581 (35.9%) were taking benzodiazepines chronically as did 449 (36.6%) patients in the hip fracture group (p=0.27). In the multivariate analysis, factors associated with the use of benzodiazepines included older age, institutionalization and a higher number of drug consumption. Differences according to the admission reason showed that patients admitted for medical causes lived more frequently in the community and had less falls, worse BI as well as a higher number of comorbidities and polypharmacy. CONCLUSIONS: More than one third of elderly patients hospitalized for medical or traumatology causes were taking benzodiazepines chronically. Different patients' profiles can be observed according to whether they are or not taking benzodiazepines and to the admission's cause in the subgroup of patients on benzodiazepines.

Unidades de prevención de caídas y de fracturas osteoporóticas. Propuesta del Grupo de Osteoporosis, Caídas y Fracturas de la Sociedad Española de Geriatría y Gerontología / Falls and osteoporotic fractures prevention units. Proposed Osteoporosis, Falls and Fractures Group of the Spanish Society of Geriatrics and Gerontology

En el marco del Grupo de Osteoporosis, Caídas y Fracturas (GOCF) de la Sociedad Española de Geriatría y Gerontología (SEGG) se realiza una revisión de la epidemiología de las caídas, junto a la descripción de aquellas medidas que han mostrado cierto grado de efectividad en prevenirlas. También se expone la propuesta de un modelo básico común de actuación en las unidades de prevención de caídas, dirigido principalmente a la comunidad. Finalmente se presenta un modelo consensuado de registro de caídas, común a nivel de los ámbitos comunitario e institucional, con el objetivo de que sea útil y fácil de cumplimentar en cualquiera de los niveles asistenciales(AU)

Since forming the Osteoporosis, Falls and Fractures Group of the Spanish Society (GOCF) of Geriatrics and Gerontology (SEGG) a review was performed of the epidemiology of falls, along with a description of measures that have shown a degree of effectiveness in prevention. We also present the proposal of a common basic model of action in fall prevention units, mainly addressed to the community. Finally, a consensus model falls register is presented, common to community level and institutional areas, with the objective of being useful and easy to fill in at any care level(AU)

[Falls and osteoporotic fractures prevention units: proposed Osteoporosis, Falls and Fractures Group of the Spanish Society of Geriatrics and Gerontology]. / Unidades de prevención de caídas y de fracturas osteoporóticas. Propuesta del Grupo de Osteoporosis, Caídas y Fracturas de la Sociedad Española de Geriatría y Gerontología.

Since forming the Osteoporosis, Falls and Fractures Group of the Spanish Society (GOCF) of Geriatrics and Gerontology (SEGG) a review was performed of the epidemiology of falls, along with a description of measures that have shown a degree of effectiveness in prevention. We also present the proposal of a common basic model of action in fall prevention units, mainly addressed to the community. Finally, a consensus model falls register is presented, common to community level and institutional areas, with the objective of being useful and easy to fill in at any care level.

[Geriatric assessment in the emergency departments of acute hospitals]. / Abordaje del anciano en el servicio de urgencias de un hospital de agudos.

Elderly people use often and in an appropriate way the Emergency Department (ED). However, we don't dispose of evidences that demonstrate utility of a specific model of geriatric assessment (GA) applied in ED. Nowadays; GA in ED should be used being adapted to the environment and with some clear objectives that allow to carry out a multidimensional diagnosis and to establish therapeutic priorities. GA contributes benefits in the continuity of care on the part of the Primary Attention when elderly people are discharged from an ED.

Abordaje del anciano en el servicio de urgencias de un hospital de agudos / Geriatric assessment in the emergency departments of acute hospitals

Los ancianos utilizan mucho y de forma adecuada los servicios de urgencias (SU). No existen evidencias que demuestren la efectividad de un modelo concreto de valoración geriátrica (VG) aplicado en los SU. Sin embargo, la VG en los SU debería utilizarse adecuándola al entorno y con unos objetivos claros que permitan realizar un diagnóstico multidimensional y establecer prioridades terapéuticas. La VG aporta beneficios en la continuidad de cuidados por parte de la atención primaria cuando los ancianos son dados de alta de un SU (AU)

Elderly people use often and in an appropriate way the Emergency Department (ED). However, we don’t dispose of evidences that demonstrate utility of a specific model of geriatric assessment (GA) applied in ED. Nowadays; GA in ED should be used being adapted to the environment and with some clear objectives that allow to carry out a multidimensional diagnosis and to establish therapeutic priorities. GA contributes benefits in the continuity of care on the part of the Primary Attention when elderly people are discharged from an ED (AU)

Predictive items of 2-year mortality in nonagenarians with cognitive impairment at baseline: the NonaSantfeliu study.

We aimed to identify a set of predictors of mortality at 2-year follow-up in a cohort of nonagenarians with cognitive impairment at baseline. The following variables were evaluated; functional status determined by the indices of Barthel Index for basic and Lawton and Brody for instrumental activities of daily living, while cognition was assessed using the Spanish version of the mini-mental state examination (MEC). Cognitive impairment was graded as severe for those having MEC scores of 0-17 and mild for scores of 18-23. A total of 77 nonagenarians with a MEC score of 23 or below were included: 61 women (79.25%) and 16 men, with a mean age of 93.7 (3.4) years. The rate of mortality was 55.8%. According to MEC scores the proportion of deaths during the 2-year follow-up period ranged from 35.2% (6 out of 17) among mildly impaired participants to 61.6% (37 out of 60) among severely impaired participants (p=0.05). Multivariate regression analysis showed that the risk of dying in this cohort was associated with being older (p<0.01, OR 1.23, 95% CI 1.03-1.4) and having a previous history of heart failure (p<0.0001, OR 8.72, 95% CI 2.66-28.5). In conclusion age and heart failure predict mortality among nonagenarians with prior cognitive impairment.

Tratamiento farmacológico del delirium / Pharmacological treatment of delirium

El abordaje del delirium exige una actuación compleja e interdisciplinar sobre distintas fases, entre las que podemos destacar la identificación de los factores predisponentes y de los desencadenantes, el cálculo del riesgo de padecer delirium, las actuaciones preventivas y el tratamiento etiológico y sintomático (AU)

Delirium is a complex clinical problem requiring a multidisciplinary approach in distinct phases. The main objectives in delirium management are to identify and control of predisposing and precipitating factors, calculate the patient’s risk score for developing delirium and, finally, apply preventive measures and etiologic and symptomatic treatment (AU)