Excess Mortality After Hip Fracture in Older Men and Women.
Haentjens P, Magaziner J, ET AL: ANNALS OF INTERNAL MEDICINE 2010; 152 (MARCH): 380-390
Background: Although an increased risk for death after hip fracture is well established, whether this excess mortality persists over time is unclear.
Purpose: To determine the magnitude and duration of excess mortality after hip fracture in older men and women.
Study Selection: Following an electronic search of MEDLINE and EMBASE for articles from 1957 to May 2009, prospective cohort studies were selected by two independent reviewers. The studies had to assess mortality in women and men aged 50 years or older with hip fracture, carry out a life-table analysis, and display the survival curves of the hip fracture group and age- and sex-matched controls.
Data Synthesis: Time-to-event meta-analyses showed that the relative hazard for all-cause mortality in the first three months after hip fracture was 5.75 in women and 7.95 in men. Relative hazards decreased substantially over time but did not return to rates seen in age- and sex-matched groups. Caucasian women having a hip fracture at age 80 years have excess annual mortality compared with Caucasian women of the same age without fracture of 8%, 11%, 18%, and 22% at one, two, five and ten years after injury respectively. Men with a hip fracture at age 80 years have excess annual mortality of 18%, 22%, 26%, and 20% at one, two, five and ten years after injury• Conclusion: Older adults have a five-to-eight fold increased risk for all-cause mortality during the first three months after hip fracture. Excess annual mortality persists over time for both men and women, but at any given age, excess annual mortality is higher in men than in women.
Kevin’s comments: Falls represent a huge public health problem and are one of the most frequent issues encountered in geriatric health care. One in three persons over age 65 and one in two persons over age 80 will fall annually. Studies suggest that as many as 10% of these persons suffer a major complication such as a hip fracture, head trauma, or spine injury. Relatively minor problems such as sprains, strains, and bruises may cause significant functional disability in an older adult and lead to other complications. Currently major efforts are being expended to educate older adults and health providers about prevention of falls. It is much more cost-effective and much better for the older adult to identify risks for falls (impaired balance and gait, medications, visual and hearing deficits, peripheral neuropathy, etc.) and intervene early than to wait for the fall and fracture to occur.
Hospital Characteristics Associated with Feeding Tube Placement in Nursing Home Residents with Advanced Cognitive Impairment.
TENO JM, MITCHELL SL, ET AL: JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION; 2010; 303 (FEBRUARY): 544-550
Background: The placement of a feeding tube in patients with advanced dementia does not improve survival, prevent aspiration, heal or prevent pressure ulcers, or improve clinical outcomes. In spite of this information, more than one-third of skilled nursing home residents with advanced dementia have a feeding tube inserted.
Objective: To determine the association between hospital characteristics and the placement of feeding tubes in seniors with advanced dementia admitted from skilled nursing facilities.
Methods: This study was a review of information on seniors who had information in the U.S. Nursing Home Minimum Data Set (MDS) from 1999 to 2007. All patients were living at a skilled nursing facility. This database was matched with Medicare claims data on approximately one-fifth of the Medicare population. The study group was comprised of previously non–tube-fed nursing home residents aged ≥66 years who had been hospitalized between 2000 and 2007. Seniors who were included had no feeding tube and had adequate information in their MDS to define the presence of advanced cognitive impairment. Hospitals included in the analysis had at least 30 admissions during which a feeding tube was placed in an older patient with advanced dementia. Investigators used multivariate analysis of the hospital characteristics associated with placement of a feeding tube in this clinical setting.
Results: During the seven-year study period at the hospitals meeting the study criteria, >280,000 admissions occurred among 163,000 seniors with advanced dementia. This reflects one-fifth of the total national admissions. The average age of the seniors was 85 years, and two-thirds were older women. A total of 19,847 feeding tubes were placed in the study sample of Medicare beneficiaries. The rate of feeding tube insertion decreased during the study period. The larger hospitals were more likely to place feeding tubes in seniors with advanced dementia admitted from nursing facilities. Furthermore, for-profit hospitals and those that used more intensive care beds for patients with chronic illnesses during the last six months of life were more likely to place tubes in skilled nursing home residents with advanced dementia.
Conclusions: Feeding tubes continue to be placed in skilled nursing home residents with advanced dementia, in spite of evidence that does not support this practice.
Kevin’s Comments: In the December issue of Geriatric News I reviewed an article from The New England Journal of Medicine that detailed the poor prognosis of persons with advanced dementia. Yet burdensome interventions such as placement of feeding tubes are still performed frequently. Studies have consistently demonstrated that feeding tubes do not improve clinical outcomes in these situations. Candid discussions with health care proxies can help address the futility of these interventions. Referral for palliative care and hospice can allow persons with advanced dementia to be spared interventions that do no good, and in fact may be associated with even more complications.
Primary Medication Non-Adherence: Analysis of 195,930 Electronic Prescriptions.
FISCHER MA, STEDMAN MR, ET AL: J Gen Intern Med; 2010; (February)
Background: There are no extensive data available on the extent of primary prescription medication adherence.
Objective: To identify the extent and factors associated with primary medication non-adherence.
Methods: The authors examined all electronic prescriptions written over a one-year period and used pharmacy insurance claims to locate filled prescriptions. They then calculated the primary adherence rates for all those electronic prescriptions.
Results: 195,930 electronic prescriptions were written during the one-year study, with a fill rate of 77.5%. Approximately 54% of all prescriptions were new prescriptions; 71.7% of these new prescriptions were actually filled, corresponding with a 28% primary non-adherence rate. The adherence rate for prescriptions written by primary care physicians was higher than for other specialties (83% vs 57%). Electronic prescriptions were filled much more often for children than any other age group (87.3%). Among adults, antimicrobials and antihypertensives were the most commonly prescribed medications (together, 27% of all prescriptions). Analgesics had clearly higher primary non-adherence rates than all other classes (only 45% of analgesics were filled). Within the group of newly prescribed medications, it appeared that medications used to treat chronic conditions such as antihypertensives (28.4% non-adherence), hypoglycemics (31.4% non-adherence), and lipid lowering agents (28.2 % non-adherence) had a higher non-adherence rate.
Conclusions: Many electronic prescriptions are never filled. Efforts should be bundled to specifically target certain medication classes.
Kevin’s Comments: All of us are familiar with the problems of prescription drug abuse and adverse drug events. However, another very serious problem is non-compliance—not taking medication that has been prescribed. This may include not filling the prescription or taking fewer doses than are prescribed. Current research demonstrates that 55% of older adults do not take their medication as prescribed by the doctor. There are many factors that may contribute to non-compliance. Often personal financial challenges are cited. However, there may be physical factors involved. A person with visual difficulties may not be able to read the label on a drug bottle; a hearing deficit may impede the understanding of instructions. Mobility issues make it difficult for older adults to get to a pharmacy. The most important thing in enhancing compliance is education. It is vitally important that physicians, pharmacists, and nurses do a better job in education of their patients about proper administration of medication. Supplying clearly written and readable instructions is essential. Compliance aids such as medication reminder charts and pill boxes should also be considered.
Dr. Kevin O’Neil is the Medical Director for Brookdale Senior Living Inc., the largest senior housing provider in the United States. He is board certified in both Internal Medicine and Geriatric Medicine. Dr. O’Neil is also a Fellow of the American College of Physicians and a member of the American Geriatrics Society as well as being a member of the American Medical Directors Association and a certified medical director.
NOTE: Brookdale associates who serve as nurses, therapists, lifestyle directors or on a community dining team are invited to submit questions for Geriatric News You Can Use directly to GeriatricNews@brookdaleliving.com.
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