Incidence of fragility hip fracture across the Asia-pacific region: A systematic review.

PURPOSE: This systematic review aimed to update fragility hip fracture incidences in the Asia Pacific, and compare rates between countries/regions. METHOD: A systematic search was conducted in four electronic databases. Studies reporting data between 2010 and 2023 on the geographical incidences of hip fractures in individuals aged ≥50 were included. Exclusion criteria were studies reporting solely on high-trauma, atypical, or periprosthetic fractures. We calculated the crude incidence, age- and sex-standardised incidence, and the female-to-male ratio. The systematic review was registered with PROSPERO (CRD42020162518). RESULTS: Thirty-eight studies were included across nine countries/regions (out of 41 countries/regions). The crude hip fracture incidence ranged from 89 to 341 per 100,000 people aged ≥50, with the highest observed in Australia, Taiwan, and Japan. Age- and sex-standardised rates ranged between 90 and 318 per 100,000 population and were highest in Korea and Japan. Temporal decreases in standardised rates were observed in Korea, China, and Japan. The female-to-male ratio was highest in Japan and lowest in China. CONCLUSION: Fragility hip fracture incidence varied substantially within the Asia-Pacific region. This observation may reflect actual incidence differences or stem from varying research methods and healthcare recording systems. Future research should use consistent measurement approaches to enhance international comparisons and service planning.

Reducing the burden of dizziness in middle-aged and older people: A multifactorial, tailored, single-blind randomized controlled trial.

BACKGROUND: Dizziness is common among older people and is associated with a cascade of debilitating symptoms, such as reduced quality of life, depression, and falls. The multifactorial aetiology of dizziness is a major barrier to establishing a clear diagnosis and offering effective therapeutic interventions. Only a few multidisciplinary interventions of dizziness have been conducted to date, all of a pilot nature and none tailoring the intervention to the specific causes of dizziness. Here, we aimed to test the hypothesis that a multidisciplinary dizziness assessment followed by a tailored multifaceted intervention would reduce dizziness handicap and self-reported dizziness as well as enhance balance and gait in people aged 50 years and over with dizziness symptoms. METHODS AND FINDINGS: We conducted a 6-month, single-blind, parallel-group randomized controlled trial in community-living people aged 50 years and over who reported dizziness in the past year. We excluded individuals currently receiving treatment for their dizziness, those with degenerative neurological conditions including cognitive impairment, those unable to walk 20 meters, and those identified at baseline assessment with conditions that required urgent treatment. Our team of geriatrician, vestibular neuroscientist, psychologist, exercise physiologist, study coordinator, and baseline assessor held case conferences fortnightly to discuss and recommend appropriate therapy (or therapies) for each participant, based on their multidisciplinary baseline assessments. A total of 305 men and women aged 50 to 92 years (mean [SD] age: 67.8 [8.3] years; 62% women) were randomly assigned to either usual care (control; n = 151) or to a tailored, multifaceted intervention (n = 154) comprising one or more of the following: a physiotherapist-led vestibular rehabilitation programme (35% [n = 54]), an 8-week internet-based cognitive-behavioural therapy (CBT) (19% [n = 29]), a 6-month Otago home-based exercise programme (24% [n = 37]), and/or medical management (40% [n = 62]). We were unable to identify a cause of dizziness in 71 participants (23% of total sample). Primary outcome measures comprised dizziness burden measured with the Dizziness Handicap Inventory (DHI) score, frequency of dizziness episodes recorded with monthly calendars over the 6-month follow-up, choice-stepping reaction time (CSRT), and gait variability. Data from 274 participants (90%; 137 per group) were included in the intention-to-treat analysis. At trial completion, the DHI scores in the intervention group (pre and post mean [SD]: 25.9 [19.2] and 20.4 [17.7], respectively) were significantly reduced compared with the control group (pre and post mean [SD]: 23.0 [15.8] and 21.8 [16.4]), when controlling for baseline scores (mean [95% CI] difference between groups [baseline adjusted]: -3.7 [-6.2 to -1.2]; p = 0.003). There were no significant between-group differences in dizziness episodes (relative risk [RR] [95% CI]: 0.87 [0.65 to 1.17]; p = 0.360), CSRT performance (mean [95% CI] difference between groups [baseline adjusted]: -15 [-40 to 10]; p = 0.246), and step-time variability during gait (mean [95% CI] difference between groups [baseline adjusted]: -0.001 [-0.002 to 0.001]; p = 0.497). No serious intervention-related adverse events occurred. Study limitations included the low initial dizziness severity of the participants and the only fair uptake of the falls clinic (medical management) and the CBT interventions. CONCLUSIONS: A multifactorial tailored approach for treating dizziness was effective in reducing dizziness handicap in community-living people aged 50 years and older. No difference was seen on the other primary outcomes. Our findings therefore support the implementation of individualized, multifaceted evidence-based therapies to reduce self-perceived disability associated with dizziness in middle-aged and older people. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000379819.

Cerebrospinal Fluid Apolipoprotein E Levels in Delirium.

BACKGROUND/AIMS: Delirium and the apolipoprotein E ε4 allele are risk factors for late-onset Alzheimer disease (LOAD), but the connection is unclear. We looked for an association. METHODS: Inpatients with delirium (n = 18) were compared with LOAD outpatients (n = 19), assaying blood and cerebrospinal fluid (CSF) using multiplex ELISA. RESULTS: The patients with delirium had a higher Confusion Assessment Method (CAM) score (5.6 ± 1.2 vs. 0.0 ± 0.0; p < 0.001) and Delirium Index (13.1 ± 4.0 vs. 2.9 ± 1.2; p = 0.001) but a lower Mini-Mental State Examination (MMSE) score (14.3 ± 6.8 vs. 20.8 ± 4.6; p = 0.003). There was a reduction in absolute CSF apolipoprotein E level during delirium (median [interquartile range]: 9.55 µg/mL [5.65-15.05] vs. 16.86 µg/mL [14.82-20.88]; p = 0.016) but no differences in apolipoprotein A1, B, C3, H, and J. There were no differences in blood apolipoprotein levels, and no correlations between blood and CSF apolipoprotein levels. CSF apolipoprotein E correlated negatively with the CAM score (r = -0.354; p = 0.034) and Delirium Index (r = -0.341; p = 0.042) but not with the Acute Physiology and Chronic Health Evaluation (APACHE) index, or the MMSE or Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). CONCLUSION: Reduced CSF apolipoprotein E levels during delirium may be a mechanistic link between two important risk factors for LOAD.

Tailored multifactorial intervention to improve dizziness symptoms and quality of life, balance and gait in dizziness sufferers aged over 50 years: protocol for a randomised controlled trial.

BACKGROUND: Dizziness is a frequently reported symptom in older people that can markedly impair quality of life. This manuscript presents the protocol for a randomised controlled trial, which has the main objective of determining the impact of comprehensive assessment followed by a tailored multifaceted intervention in reducing dizziness episodes and symptoms, improving associated impairments to balance and gait and enhancing quality of life in older people with self-reported significant dizziness. METHODS: Three hundred people aged 50 years or older, reporting significant dizziness in the past year will be recruited to participate in the trial. Participants allocated to the intervention group will receive a tailored, multifaceted intervention aimed at treating their dizziness symptoms over a 6 month trial period. Control participants will receive usual care. The primary outcome measures will be the frequency and duration of dizziness episodes, dizziness symptoms assessed with the Dizziness Handicap Inventory, choice-stepping reaction time and step time variability. Secondary outcomes will include health-related quality of life measures, depression and anxiety symptoms, concern about falling, balance and risk of falls assessed with the physiological fall risk assessment. Analyses will be by intention-to-treat. DISCUSSION: The study will determine the effectiveness of comprehensive assessment, combined with a tailored, multifaceted intervention on dizziness episodes and symptoms, balance and gait control and quality of life in older people experiencing dizziness. Clinical implications will be evident for the older population for the diagnosis and treatment of dizziness. TRIAL REGISTRATION: The study is registered with the Australia New Zealand Clinical Trials Registry ACTRN12612000379819 .

Transcranial Doppler to measure cerebral blood flow in delirium superimposed on dementia. A cohort study.

OBJECTIVE: Delirium superimposed on dementia (DSD) is frequently not diagnosed, at great cost. Both delirium and dementia are associated with cerebral hypoperfusion. A switch to anaerobic glycolysis in the central nervous system during delirium compared to Alzheimer's dementia (AD) suggests greater hypoperfusion in DSD. The main aims of this study were to investigate whether cerebral hypoperfusion could differentiate DSD from related entities, and the characteristics of that hypoperfusion. METHODS: Prospective cohort study of 44 Geriatric Medicine patients in 4 groups: (1) delirium, no history of dementia; (2) DSD; (3) acute illness without delirium or dementia; and (4) AD, no delirium. We measured CBF using transcranial Doppler to assess flow velocity (FV) and pulsatility index in the middle cerebral artery (MCA). RESULTS: DSD has lower FV than either AD or delirium alone, or acute illness (28.2 ± 4.7 vs AD: 41.3 ±15.7; P = .040; vs delirium 37.7 ± 8.2; P =.009; vs acute illness 43.0 ± 8.3; P <.001). A mean MCA FV cut-off of 32.25 cm/s diagnoses DSD with a sensitivity of 0.875 and specificity of 0.788, area under the curve 0.884; P = .001. Resolution of delirium improves FV (P = .005). FV correlates with delirium severity (delirium index R = -0.39; P = .009) and dementia (Mini-Mental State Examination, R = 0.33; P = .029, and Informant Questionnaire on Cognitive Decline in the Elderly, R = -0.41; P = .005). CONCLUSIONS: Transcranial Doppler is a potential diagnostic and monitoring test for DSD. Correlation with clinical indicators of delirium suggests pathophysiological significance.

Incidence, circumstances, treatment and outcome of high-level cervical spinal fracture without associated spinal cord injury in New South Wales, Australia over a 12 year period.

BACKGROUND: No Australian population-based studies have examined temporal trends in the incidence of fracture of the first or second cervical vertebra (C1 or C2 fractures), their aetiology, treatment and outcome for younger (15-64 years) compared to older (65+ years) individuals. The aim of this research is to examine the circumstances, treatment and outcomes including mortality for C1 or C2 fractures without associated spinal cord injury by age group in New South Wales (NSW), Australia. METHOD: A retrospective review of C1 or C2 vertebra fractures in individuals aged 15 years and over in the NSW Admitted Patient Data Collection from 1 July 1998 to 30 June 2010. Direct age standardised admission rates were calculated by cervical fracture type and by age group. Negative binomial regression was used to examine the statistical significance of changes in trend over time of hospitalised cervical fractures by age group. RESULTS: The annual rate of hospitalised C1 and C2 fractures without associated spinal cord injury for individuals aged 15 years and over in NSW was 2.3 per 100,000 population, with the rate estimated to increase by 5.3% each year. Those aged 85+ years had the highest rates of hospitalisation. For those aged 15-64 years, road trauma was the most common mechanism of injury, while for those aged 65+ years, a fall was the dominant mechanism of injury. The in-hospital mortality for individuals aged 65+ years was 11.8% compared to 0.7% for those aged 15-64 years. CONCLUSIONS: This study identified an estimated increasing trend in C1 and C2 fractures over time, particularly for older individuals. While younger individuals are commonly injured in road traffic accidents, older individuals are predominantly injured following a fall. Injury prevention strategies should be targeted to the different age groups and injury mechanisms. Implementation of effective falls prevention strategies is likely to reduce these injuries in older people whilst road and vehicle safety including vehicle rollover protection standards may improve rates in younger people.

Depressive symptomatology as a risk factor for falls in older people: systematic review and meta-analysis.

OBJECTIVES: To conduct a systematic literature review and meta-analysis to evaluate studies that have addressed depressive symptoms as a risk factor for falls in older people. DESIGN: Systematic review with meta-analysis. SETTING: Community and residential care. PARTICIPANTS: Individuals aged 60 and older. MEASUREMENTS: Depressive symptoms, incidence of falls. RESULTS: Twenty-five prospective studies with a total of 21,455 participants met inclusion criteria for the systematic review. Twenty studies met criteria for the meta-analyses. Recruitment of participants was conducted randomly or by approaching groups with identified healthcare needs. Eleven measures were used to assess depressive symptoms, and length of follow-up for falls ranged from 90 days to 8 years. Reporting of antidepressant use was variable across studies. The pooled effect of 14 studies reporting odds ratios (ORs) indicated that a higher level of depressive symptoms at baseline resulted in a greater likelihood of falling during follow-up (OR = 1.46, 95% confidence interval (CI) = 1.27-1.67, P < .001, I(2) = 77.2%). In six studies reporting relative risks (RRs) or hazard ratios, a higher level of depressive symptoms at baseline resulted in a greater likelihood of falling during follow-up (RR = 1.52, 95% CI = 1.19-1.84, P < .001). There was no difference between community samples and those with identified healthcare needs with respect to depressive symptoms being a risk factor for falls. CONCLUSION: Depressive symptoms were found to be consistently associated with falls in older people, despite the use of different measures of depressive symptoms and falls and varying length of follow-up and statistical methods. Clinicians should consider management of depression when implementing fall prevention initiatives, and further research on factors mediating depressive symptoms and fall risk in older people is needed.

Vascular dementia: prevention and treatment.

BACKGROUND: Vascular dementia (VaD) is the most common cause of dementia in the elderly, second only to Alzheimer's disease (AD). Between 1% and 4% of people of 65 years of age suffer from VaD and the prevalence appears to double every 5-10 years after the age of 65. SUMMARY: Prevention aims to reduce the disease by eliminating its cause or main risk factors, particularly hypertension as well as diabetes mellitus, atherosclerosis, coronary artery disease, smoking, lipid abnormalities, and hyperhomocystinemia. Initial studies of several agents for symptomatic treatment were disappointing. However, there is growing evidence for cholinergic involvement in VaD and recent studies with cholinesterase inhibitors have shown improvement in cognitive, global function, and activities of daily living as compared with placebo and have been well tolerated. CONCLUSION: VaD is a common condition and its prevalence is likely to increase. As physicians we need to be diligent with regards to recognition of risk factors and vigorous intervention. Promising results have been seen in several clinical trials of cholinesterase inhibitors and no safety of tolerability issues have been noted.