Systems modelling as an approach for eliciting the mechanisms for hip fracture recovery among older adults in a participatory stakeholder engagement setting.

Introduction: Due to an aging population, the rising prevalence and incidence of hip fractures and the associated health and economic burden present a challenge to healthcare systems worldwide. Studies have shown that a complex interplay of physiological, psychological, and social factors often affects the recovery trajectories of older adults with hip fractures, often complicating the recovery process. Methods: This research aims to actively engage stakeholders (including doctors, physiotherapists, hip fracture patients, and caregivers) using the systems modeling methodology of Group Model Building (GMB) to elicit the factors that promote or inhibit hip fracture recovery, incorporating a feedback perspective to inform system-wide interventions. Hip fracture stakeholder engagement was facilitated through the Group Model Building approach in a two-half-day workshop of 25 stakeholders. This approach combined different techniques to develop a comprehensive qualitative whole-system view model of the factors that promote or inhibit hip fracture recovery. Results: A conceptual, qualitative model of the dynamics of hip fracture recovery was developed that draws on stakeholders' personal experiences through a moderated interaction. Stakeholders identified four domains (i.e., expectation formation, rehabilitation, affordability/availability, and resilience building) that play a significant role in the hip fracture recovery journey.. Discussion: The insight that recovery of loss of function due to hip fracture is attributed to (a) the recognition of a gap between pre-fracture physical function and current physical function; and (b) the marshaling of psychological resilience to respond promptly to a physical functional loss via uptake of rehabilitation services is supported by findings and has several policy implications.

Hip fractures in elderly patients with non-dialysis dependent chronic kidney disease: Outcomes in a Southeast Asian population.

ABSTRACT: Chronic kidney disease (CKD) causes bone and mineral disorders and alterations in vitamin D metabolism that contribute to greater skeletal fragility. Hip fracture in elderly is associated with significant morbidity and mortality. The aim of this study was to investigate the outcome of elderly patients with non-dialysis dependent CKD and hip fracture undergoing surgery.Retrospective study with IRB approval of patients above 65 years of age, with hip fractures admitted between June 2014 to June 2016 in a Southeast Asian cohort. Data collected included demographic variables and the haematological and biochemical parameters HBA1c, estimated glomerular filtration rate (eGFR), serum calcium, phosphorous, and 25(OH) Vitamin D. Co-morbidities investigated were ischemic heart disease, congestive heart failure, peripheral vascular disease, malignancy, chronic obstructive pulmonary disease, cerebro vascular accident, hypertension and hyperlipidaemia. All patients were followed up from index date to either death or June 1, 2018.Of the 883 patients, 725 underwent surgery and 334 had CKD. Death rates for CKD patients with hip fractures and those with normal renal function did not differ significantly [8.08% vs 6.54%, (HR= 1.33, 95% CI: 0.95, 1.86; P = .102)], whilst median hospital length of stay was significantly higher in CKD patients [10.5 vs 9.03 days (P = .003)]. Significant risk factors associated with higher risk of mortality in the elderly with hip fracture were male gender, age ≥80 years and serum albumin < 30 g/L (all, P < .0001).In summary, in elderly, non-dialysis dependent CKD patient with hip fracture we found that male gender, age ≥80 years, low serum albumin and eGFR < 30 mL/min/1.73 m2 were associated with higher risk of death. The hospital stay in the CKD group was also longer. Additional studies are needed to validate our findings.

Rivaroxaban withdrawal and rebound hypercoagulability leading to upper extremity deep vein thrombosis: a case report.

As the newer oral anticoagulants (NOACs) are increasingly used in older patients, clinical scenarios when they may need to be discontinued temporarily or indefinitely, may be encountered. Similarly with increasing use of permanent pacemakers and other intra-cardiac devices, there is an increased risk of upper limb venous thrombosis even few years after their insertion. We report a case of a patient with a permanent pacemaker, on rivaroxaban (NOAC) for atrial fibrillation, who developed an upper extremity deep vein thrombosis after its temporary withdrawal following a traumatic acute subdural haematoma. Physicians should be aware of the possibility of rebound hypercoagulability and venous thrombosis soon after the withdrawal of NOACs.

Offering older hospitalised patients the choice to die in their preferred place.

BACKGROUND: A significant proportion of older people state a preference to die at home. However, the vast majority of people in hospital recognised as dying subsequently die there. OBJECTIVES: To identify the proportion of older people dying in hospital where the possibility of ending life elsewhere was explored. To identify factors that could support hospital staff to enable patients' wishes to be met. METHODS: Retrospective case-note review of 100 older patients (>75 years) who died during 2009 in an English Hospital. RESULTS: Age range 75-97 years. Time from admission to death ranged from 0-118 days (median 8.5). 16% died within the first 48 h, rising to 30% for those from care homes. In only 8 patients was a potential alternative place of death discussed. Although subjective, in 10 patients it was considered admission could have been avoided through Advance Care Planning (ACP) to allow patients with poor prognosis to die in their normal place of residence or a hospice. 55% of Do-Not-Attempt-Resuscitation orders were made within 48 h of admission. 38% were commenced on the Liverpool Care Pathway (LCP), 1-504 h before death (median 16). CONCLUSIONS: In few cases are the preferred places of death discussed in older people who die in our hospital. Although hospital admission was largely appropriate, in a minority judicious ACP could have avoided death in hospital. We recommend (1) increased use of ACP, with appropriate practicalities planned in advance (2) wide-scale introduction of the 'Rapid Discharge Home of the Dying Patient pathway' (3) routinely discussing preferred place of death in appropriate key situations (eg, discussion of resuscitation status or commencing the LCP).

The journey of care for the frail older person.

The elderly have diverse health-care needs and the frail elderly, because of associated co-morbidities, carry a significantly high mortality during their journey of care. Adequate planning and coordination between teams and an accessible and flexible interface between services will help ensure a safe, smooth journey for these people.