Hip Fracture in the Elderly: Early Surgery Improves Survival

Aswan, Egypt (Dr. Noorali Bharwani)
Aswan, Egypt (Dr. Noorali Bharwani)

This month marks 20-years of writing this column. My thanks to the present and previous editors of the Medicine Hat News and of course the readers. Without readers there is no column. Thank you all.

Today, I want to discuss about a very debilitating problem amongst seniors. This is about seniors with hip fractures and what is the best time to operate on them.

In Canada, hospitals admit 30,000 older adults with hip fracture each year.

These patients face an increased risk of death, with up to five per cent of women and 10 per cent of men dying within 30 days. These statistics are published in the Canadian Collaborative Study of Hip Fractures published in the Canadian Medical Association Journal (CMAJ August 07, 2018).

Treatment for hip fracture usually involves a combination of surgery, rehabilitation and medication. Physical therapy and rehabilitation focus on range-of-motion and strengthening exercises. Depending on the type of surgery and whether you have assistance at home, you may need to go from the hospital to an extended care facility.

Timing of operation is very important. Surgery on admission day or the following day was estimated to reduce postoperative death rate among medically stable patients. That is why it is important for hospitals to expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons, says the CMAJ report.

It is generally accepted early operative intervention improves survival by reducing patients’ exposure to immobilization and inflammation.

In 2005, the federal, provincial and territorial governments established a benchmark of 48-hours from admission for 90 per cent of hip fracture surgeries to prevent potentially harmful delays.

However, delays to hip fracture surgery remain common. Patients who are medically stable at presentation may have to wait until a surgeon or an operating room becomes available.

If the hip surgery is done on the day of admission then the cumulative 30-day death rate was 48.9 deaths per 1000 surgeries.

For surgery carried out later, the death rate was significantly higher: 57.0 deaths per 1000 surgeries done on inpatient day three and 69.1 deaths per 1000 surgeries done after inpatient day three.

The study also found patients undergoing the procedure on inpatient day two rather than the day of admission did not change the risk of death.

If all surgeries were done on inpatient day three rather than the day of admission, there would be an additional 5.8 deaths for every 1000 surgeries, and the number of deaths would increase further, to 10.9 deaths for every 1000 surgeries, if all surgeries were done after inpatient day three.

What to expect in the future? Up to 10 percent of adults age 65 or older that have a hip fracture will have another hip fracture within two years. Bisphosphonates and other medications for osteoporosis may help reduce the risk of a second hip fracture.

The study recommends that all medically stable older adults with hip fracture undergo surgery on the day of their admission to hospital or the following day. This approach places the emphasis of managerial efforts on expediting operating room access for patients whose surgery might be delayed for nonmedical reasons.

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Medications That Put Our Seniors in the Hospital

Summer Flowers (Dr. Noorali Bharwani)
Summer Flowers (Dr. Noorali Bharwani)

I covered this topic about three years ago. It is never too early or too late to review the subject again.

A study published in the New England Journal of Medicine says 40 percent of people over 65 take five to nine medications every day. What this means is that hospitalizations for accidental overdoses and adverse side effects are likely to increase among this group.

The study found that every year, about 100,000 people in the United States over age 65 are taken to hospitals for adverse reactions to medications. Most of the patients are there because of accidental overdoses. Sometimes the amount of medication prescribed for them had a more powerful effect than intended.

The four most common groups of medications putting seniors in hospitals are: warfarin (a blood thinner), insulin injections for diabetes, antiplatelet drugs to thin the blood and oral diabetes drugs.

Warfarin accounts for the most visits due to adverse drug reaction. It accounted for 33 percent of emergency hospital visits. Warfarin (Coumadin) is an anticoagulant – popularly referred to as a “blood thinner.” In reality, it does not make the viscosity of the blood thin. What it does is that it acts on the liver to decrease the quantity of a few key proteins in blood that allow blood to clot.

It was initially marketed as a pesticide against rats and mice. Later it was found to be effective and relatively safe for preventing blood clots in humans. It was approved for use as a medication in the early 1950s and now it is the most widely prescribed oral “blood thinner” drug in North America.

Insulin injections were next on the list, accounting for 14 percent of emergency visits. Insulin is a hormone central to regulating carbohydrate and fat metabolism in the body.

Insulin causes cells in the liver, muscle, and fat tissue to take up glucose from the blood, storing it as glycogen in the liver and muscle. When control of insulin levels fails, diabetes mellitus will result. Patients with type 1 diabetes depend on insulin injections.

Antiplatelet drugs like aspirin, clopidogrel (Plavix) and others that help prevent blood clotting were involved in 13 percent of emergency visits. An antiplatelet drug is a member of a class of pharmaceuticals that decrease platelet aggregations and inhibit clot formation. They are effective in the arterial circulation, where “blood thinners” have little effect.

Lastly, diabetes drugs taken by mouth, called oral hypoglycemic agents, which were implicated in 11 percent of hospitalizations. Anti-diabetic medications treat diabetes mellitus by lowering glucose levels in the blood. There are different classes of anti-diabetic drugs, and their selection depends on the nature of the diabetes, age and situation of the person, as well as other factors.

The authors of the article say that in order to reduce the number of emergency hospitalizations in older adults we should focus on improving the safety of this small group of blood thinners and diabetes medications, rather than by trying to stop the use of drugs typically thought of as risky for this group. And patients should work with their physicians and pharmacies to make sure they get appropriate testing and are taking the appropriate doses.

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Sarcopenia Among Seniors can be Prevented

A senior doing push-ups at a gym. (iStockphoto/Thinkstock)
A senior doing push-ups at a gym. (iStockphoto/Thinkstock)

Sarcopenia is not a disease. But it may kill you. It makes you frail because there is incremental loss of strength, increasing the risk of hospitalization and death. Sarcopenia is a Greek word which means “poverty of flesh.” It is part of aging. The skeletal muscles degenerate 0.5 to one per cent per year after the age of 25. Older adults lose about three per cent of their lean body mass each decade.

In the United States, an estimated 53 percent of men and 43 percent of women over 80 are sarcopenic, says an article in the New York Times.

The European Working Group on Sarcopenia in Older People (EWGSOP) says that for the diagnosis of sarcopenia, there should be presence of low muscle mass and low muscle function (strength or performance). The exact reason for sarcopenia is not known. Lack of exercise increases the likelihood of sarcopenia. Muscle fibres are replaced with fat and there is an increase in fibrous tissue – akin to scar tissue.

As the aging process keeps marching on, there is a tendency to be less physically active. That should be avoided if you want your muscles to maintain bulk and strength. Studies have shown exercise in the very old can increase strength and muscle function and improve balance. This will reduce the risk of falling and breaking bones. Your capacity to live independently will increase.

It has been shown sarcopenia is an important independent predictor of disability, linked to poor balance, gait speed, falls, and fractures. Sarcopenia is very similar to osteoporosis where there is loss of bone caused by inactivity. Osteoporosis can be prevented with regular exercise just like sarcopenia. Combination of sarcopenia and osteoporosis in old age causes significant frailty and risk of falling.

There are two ways to prevent and treat sarcopenia. One is regular exercise and second one is intake of adequate amount of dietary protein.

Regular exercise increases the ability and capacity of skeletal muscle to synthesize proteins in response to short term resistance exercise. Thirty minutes of walking three times a week and light resistance exercise three times a week can do wonders for physical strength in frail individuals. For an elderly person who is not able to lift light weights, should try water aerobics.

Having a good high protein diet is important. In the elderly, it should be more than the amount recommended to prevent deficiency disease, says the Times article quoting one of the experts interviewed by the paper. For older adults, four ounces of fish, chicken or turkey a day, and an additional protein snack in the afternoons to combat a dip in energy will help. Also include vegetarian protein sources like soy or quinoa, to provide variety without dietary fat, says the expert.

Other strategies include: use of testosterone or anabolic steroids, agents such as DHEA and human growth hormone, selective androgen receptor modulators (SARMs), and the fatty acids EPA and DHA contribute to increased muscle strength. Some of these treatments have side effects and some have not proven to be of benefit. So, high protein intake (if there is no kidney disease) and regular exercise to build strength remains the main therapy to prevent and treat sarcopenia.

Remember, November is Seniors’ Falls Prevention Month.

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Danger of Falls in Seniors Reminds Me of My Mother

A senior that fell down a flight of stairs. (iStockphoto/Thinkstock)
A senior that fell down a flight of stairs. (iStockphoto/Thinkstock)

Talking about seniors falling reminds me of my mother. She wanted to be independent and mobile. Her children helped her achieve that goal by finding people to assist her at home. My brother and sister were in the same city so they made sure she was safe and comfortable.

My mother had multiple medical problems. She was in her 80s. Her peripheral vision was diminished. This blinded her to furniture as she was walking. She had right foot drop from neurological problems. This made it difficult to lift her foot often causing her to trip. She used a walker to aid her unsteady gait. She had osteoarthritis and osteoporosis. She was lucky to never break a bone from falling.

The shower area was equipped with handles. This made it easy for her to maintain balance while getting in and out of the tub. Sometimes she would get dizzy spells. She also had mild congestive heart failure. Once a month her wonderful family physician would make an old-fashioned house-call to check her blood pressure and give a vitamin B injection.

To maintain her safety and independence we hired in-home help twice daily. In addition to this, a physiotherapist would come once-a-month to assess and advise her on mobility and balance. A massage therapist would come once-a-week to take care of her aches and pains. She also subscribed to an emergency call system that utilized a neck pendant with an emergency call button. Help was always only a button-push away. It was also nice to have wonderful, helpful, and caring neighbours.

The worst part of the year is winter. Icy roads, parking lots and sidewalks are dangerous for young and old alike. We must be vigilant at all times. If it takes a village to raise a child then it takes a community to care for a senior. This involves family, friends, neighbours, volunteers and health care professionals. A team effort.

When we fall the consequences can be serious. Particularly in seniors. Many of them are on blood thinners. Statistics show that 50 per cent of seniors who fall do so repeatedly. Almost half of seniors that fall experience minor injury and five to 25 per cent experience serious injury. About 40 per cent of nursing home admissions are the result of falls. Falls cause more than 95 per cent of hip fractures among seniors, 20 per cent will die within the first year and 50 per cent will never regain their pre-hip fracture functioning. These are serious statistics.

There is a lot we can do to prevent our seniors from falling. Some steps were covered earlier in this article. Also, we should remember to keep our seniors active. Activity improves muscle strength which improves balance. Exercise at least 30 minutes a day. It does not have to be all at once. For example, 10 minutes three times a day. You can walk, dance or take an exercise class. Tell your doctor if you feel lightheaded while exercising. You may have a blood pressure problem or something more serious. Do not ignore these warning signs.

I can go on and on but you get the point. Slow down, be careful, watch your surroundings and ask for help if you cannot do something. Children, keep an eye on our precious experienced “young” folks. One day we will be wearing their shoes, my friend. Remember, November is Seniors’ Falls Prevention Month.

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