Israel Medical Association Journal

Background: There is little evidence about awareness and functional outcome of hip fracture-related falls among patients with a history of recurrent falling.

Objectives: To measure the awareness of recurrent falling in patients and to compare their functional outcomes with those who suffered hip fracture after a sporadic isolated fall.

Methods: A prospective comparative study of patients after a hip fracture-related fall was conducted. Awareness of falls was measured and functional outcome was assessed by total and motor Functional Independence Measure (FIM) score changes and efficiency and scores at admission and on discharge.

Results: Of 97 eligible participants, 49 (50.5%) were recurrent fallers. Of these recurrent falls, 19 (38.8%) were not reported, 16 (32.7%) were reported but no action was taken, and 7 (14.3%) were reported and a partial assessment performed. A full assessment was performed in only 7 cases (14.3%). FIM scores on admission and discharge were significantly higher in once-fallers. A multiple linear regression analysis showed that being a once-faller was independently associated with higher total FIM at admission (β coefficient = 0.290, P = 0.004), higher motor FIM at admission (β coefficient = 0.295, P = 0.003), higher total FIM at discharge (β Coefficient = 0.264, P = 0.009), and higher motor FIM at discharge (β coefficient = 0.230, P = 0.023).

Conclusions: Awareness of the syndrome of recurrent falling is extremely low. Recurrent falls before a hip fracture-related fall is associated with substantial loss of functional independence. Being a recurrent faller adversely affects rehabilitation outcome of hip fracture patients.

Background: The optimal approach to the evaluation of asymptomatic bacteruria in stroke patients is uncertain. 

Objectives: To compare elderly patients after an acute stroke with and without asymptomatic bacteriuria for the development of symptomatic urinary tract infections (UTI).

Methods: We prospectively monitored patients over 65 years of age admitted to our rehabilitation hospital after an acute stroke, with and without asymptomatic bacteriuria, for the development of symptomatic UTIs. The prevalence of bacteriuria was determined by urine cultures obtained 2 and 4 weeks after admission. Patients with and without persistent bacteriuria were compared to identify variables associated with bacteriuria.

Results: Fifty-five patients were included in the study. The prevalence of asymptomatic bacteriuria at baseline was 20%. Of all 55 stroke patients, 13 (23.6%) developed a symptomatic UTI during the 30 day follow-up. Patients with stroke and asymptomatic bacteriuria at baseline had an increased risk of developing a symptomatic UTI (54.5% with asymptomatic bacteriuria vs. 15.9% without, P = 0.011). To exclude the effects of several confounders, we performed multivariate Cox regression analysis, which showed that bacteruria remained a significant covariate for symptomatic UTI (hazard ratio 2.86, 95% confidence interval 0.71–10.46, P = 0.051). When subjects who experienced symptomatic urinary infection were included, the prevalence of bacteriuria in the study cohort declined to about 45.5% by 30 days. 

Conclusion: Elderly patients with stroke and asymptomatic bacteriuria have an increased risk of developing a symptomatic UTI compared to those without asymptomatic bacteriuria during a 30 day post-stroke follow-up.

 

Background: Dysphagia is a common disorder among the elderly population. As many as 50% of nursing home residents suffer from dysphagia. It is important to identify patients at increased risk for colonization of dental and denture plaque by pathogenic organisms for prevention of associated disease.

Objectives: To quantify the prevalence and evaluate the effect of dental and denture plaque colonization by Candida albicans in hospitalized elderly dysphagic patients as a complication of stroke, as well as the effect of systemic antimicrobial therapy on C. albicans colonization in these patients.

Methods: We evaluated dysphagia and antibiotic therapy as risk factors for dental and denture plaque colonization by C. albicans in elderly stroke rehabilitating patients with dysphagia, as compared to elderly non-dysphagic stroke and non-stroke rehabilitating patients on days 0, 7 and 14 following admission to the Fliman Geriatric Rehabilitation Hospital.

Results: The risk of C. albicans colonization of dental plaque was greater in dysphagic patients than in those without dysphagia on day 0 (50% vs. 21%, P = 0.076), day 7 (58 vs. 15.2%, P = 0.008) and day 14 (58 vs. 15.2%, P = 0.08). Similarly, patients on antibiotic therapy were at greater risk for C. albicans colonization of dental plaque on day 0 (56 vs. 11%, P = 0.002), day 7 (44 vs. 14.8%, P = 0.04) and day 14 (39 vs. 19%, P = 0.18). The risk of C. albicans colonization of denture plaque as opposed to dental plaques in non-dysphagic patients was significantly greater on day 0 (45.7 vs. 21.2%, P = 0.03), day 7 (51.4 vs. 15.1%, P = 0.0016) and day 14 (54.3 vs. 15.1%, P = 0.0007). Dysphagia did not increase the risk of denture plaque colonization by C. albicans.

Conclusiona: Both dysphagia and antibiotic therapy are risk factors for C. albicans colonization of dental plaque, and although dysphagia does not significantly increase colonization of denture plaque, denture wearers are at greater risk of such colonization.

Background: Risk factors for injurious falls among elderly people differ from those for falls in general. The characteristics of falls play an important role in determining the risk of hip fracture.

Objective: To investigate the risk factors associated with the fall characteristics known to be associated with the majority of hip fractures, e.g., a lateral fall and a subsequent impact on the greater trochanter.

Methods: In this 6 month prospective observational case-control study 101 individuals aged 65 years and over hospitalized following a hip fracture were interviewed 7–14 days after the accident. Data were also obtained from medical records, focusing on known predisposing and situational risk factors for the fall. We compared the risk factors between two groups: patients who suffered a lateral fall and subsequent impact on the greater trochanter of the femur, and patients who suffered other types of falls.

Results: Only 51.5% of the hip fracture patients reported that they had fallen directly to the side. Apart from age, there were no significant differences between the groups in other factors studied. When considering both fall direction and the area that took the main impact, we found that the majority of patients (85%) reported having fallen onto the posterolateral aspect and/or a fall with an impact on the greater trochanter.

Conclusion: Our findings did not show differences (except for age) in the factors studied between the groups. This study suggests that both fall direction and the area that takes the main impact should be considered in the characteristics of falls that might cause a hip fracture. Characteristics associated with greatest fracture risk include a fall onto the posterolateral aspect and/or a fall with an impact on the greater trochanter. More studies are needed to evaluate potential risk factors associated with this type of injury.

Background: Transfer to an emergency room and hospitalization of nursing home residents is a growing problem that is poorly defined and reported.

Objectives: To assess the clinical effectiveness of a pilot project involving hospitalization of nursing home residents directly to an acute-care geriatric department.

Methods: We retrospectively compared the hospitalization in an acute-care geriatric unit of 126 nursing home residents admitted directly to the unit and 80 residents admitted through the emergency room. The variables measured included length of stay, discharge disposition, mortality, cause of hospitalization, chronic medical condition, cognitive state, functional status at admission, and change of functional status during the hospital stay. Follow-up data were obtained from medical records during the 2 year study.

Results: No significant differences between the groups were found for length of stay, mortality, discharge disposition and most characteristics of the hospital stay. The only significant difference was in patients’ mean age, as emergency room patients were significantly older (86 vs. 82.9 years). The most common condition among nursing home patients admitted via the emergency room was febrile disease (36.9%) ,while functional decline was the most common in those coming directly from the nursing home (32.5%). The prevalence of functional dependence and dementia were similar in both groups. Functional status did not change throughout the hospital stay in most patients.

Conclusions: Treatment of selected nursing home residents admitted directly from the nursing home to an acute- care geriatric unit is feasible, medically effective, results in the safe discharge of almost all such patients and provides an alternative to transfer to an emergency room. This study suggests that quality gains and cost-effective measures may be achieved by such a project, although a randomized controlled trial is necessary to support this hypothesis.