Israel Medical Association Journal

Background: Little is known regarding the impact of the coronavirus disease-2019 (COVID-19) pandemic on the incidence of hip fractures among older adults

Objectives: To compare the characteristics of patients with a hip fracture following a fall during the COVID-19 pandemic year and during the preceding year.

Methods: We conducted a retrospective cohort study of older patients who had undergone surgery for hip fracture repair in a major 495-bed hospital located in northern central Israel following a fall. Characteristics of patients who had been hospitalized in 2020 (pandemic year, n=136) and in 2019 (non-pandemic year, n=151) were compared.

Results: During the pandemic year, patients were less likely to have fallen in a nursing facility, to have had muscle or balance problems, and to have had a history of falls and fractures following a fall. Moreover, the average length of stay (LOS) in the hospital was shorter; however, the average time from the injury to hospitalization was longer. Patients were less likely to have acquired a postoperative infection or to have died. During the pandemic year, postoperative infection was only associated with prolonged LOS.

Conclusions: The COVID-19 pandemic may have had a positive impact on the behavior of older adults as well as on the management of hip fracture patients. However, healthcare providers should be aware of the possible reluctance to seek care during a pandemic. Moreover, further research on the impact of the change in management during COVID-19 on hip fracture survival is warranted

Background: Falls are a common complication in persons with stroke (PwS). Reliable assessment of balance responses to unexpected loss of balance has the potential to identify risk for falls. 

Objectives: To examine inter-observer reliability of balance responses to unannounced surface perturbations in PwS and to explore the concurrent validity of a balance recovery assessment protocol.

Methods: Two observers evaluated balance recovery strategies and fall threshold (a fall into a harness system) in 15 PwS and 15 healthy adults who were exposed to forward, backward, right, and left unannounced surface translations in six increasing intensities while standing. 

Results: Observer agreement was 100% for the fall threshold. Kappa coefficients for step strategies were 0.960–0.988 in PwS and 0.886–0.938 in healthy adults, 0.905–0.988 for arm reactions in PwS and 0.754–0.926 in healthy adults. Significant correlations were found between fall threshold and Berg Balance Scale (r = 0.691), 6-minute walk test (r = 0.599), and fall efficacy scale-international (r= -0.581). 

Conclusions: A trained examiner can reliably classify reactive balance responses to surface perturbations. The high frequency of falls observed in PwS highlights the importance of assessing reactive balance responses to different directions and intensities of surface translations.

Background: Falls while turning are associated with increased risk of hip fracture in older adults. Reliable and clinically valid methods for turn ability assessments are needed.

Objectives: To explore the inter-observer reliability and known group validity of the TURN 180 test.

Methods: We divided 78 independent older adults (mean age 76.6 ± 6.5 years) into three groups: non-fallers, infrequent fallers (1–2 falls per year), and recurrent fallers (> 2 falls per year). Participants underwent performance-based tests: Timed Up and Go (TUG), Performance Oriented Mobility Assessment (POMA), and Berg Balance Scale (BBS). TUG was videotaped for later analysis of the TURN 180 test by two blinded observers.

Results: A significant difference was found in the TURN 180 test parameters among the groups (P < 0.04). TURN 180 was highly correlated with TUG (r = 0.81–0.89, P < 0.001) and BBS (r = -0.704–0.754, P < 0.0001) and moderately with POMA (r = -0.641–0.698, P < 0.0001). The number of steps was found to be the strongest parameter to determine fallers among older adults (specificity 96.3%, sensitivity 40%). Inter-rater reliability (intraclass correlation coefficient 0.91–0.96, P < 0.0001) was found to be excellent for the number of steps, time taken to accomplish a turn, and total test score categories.

Conclusions: The TURN 180 test is highly reliable and can identify the older adults who fall. Our results show that the TURN 180 test can serve as a good performance-based examination for research or clinical setting.

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: Hypertrophic cardiomyopathy (HCM) is a familial disease with autosomal dominant inheritance and age-dependent penetrance, caused primarily by mutations of sarcomere genes. Because the clinical variability of HCM is related to its genetic heterogeneity, genetic studies may improve the diagnosis and prognostic evaluation in HCM.

Objectives: To analyze the impact of genetic diagnosis on the clinical management of HCM.

Methods: Genetic studies were performed for either research or clinical reasons. Once the disease-causing mutation was identified, the management plan was reevaluated. Family members were invited to receive genetic counseling and encouraged to be tested for the mutation.

Results: Ten mutations in sarcomere protein genes were identified in 9 probands: 2 novel and 8 previously described. Advanced heart failure or sudden death in a young person prompted the genetic study in 8 of the 9 families. Of 98 relatives available for genotyping, only 53 (54%) agreed to be tested. The compliance was higher in families with sudden death and lower in what appeared to be sporadic HCM or elderly-onset disease. Among the healthy we identified 9 carriers and 19 non-carriers. In 6 individuals the test result resolved an uncertainty about "possible HCM." In several cases the genetic result was also used for family planning and played a role in decisions on cardioverter-defibrillator implantation.

Conclusions: Recurrence of a same mutation in different families created an opportunity to apply the information from the literature for risk stratification of individual patients. We suggest that the clinical context determine the indication for genetic testing and interpretation of the results.

Objectives: To examine the difference in motor function and behavioral symptoms between patients with severe dementia who wander and those who do not.

Methods: We conducted a retrospective study reviewing the medical records of 72 patients with severe dementia, all residents of a dementia special care unit. Motor and behavioral aspects were compared between "wanderers" and “non-wanderers.”

Results: No difference was found in motor performance including the occurrence of falls between the wanderers and non-wanderers. A significant difference was found in aggressiveness and sleep disturbances, which were more frequent among the wanderers. There was no preference to wandering at a certain period of the day among the patients with sleep disturbances who wander.

Conclusions: In a protected environment wandering is not a risk factor for falls. Sleep disturbances and wandering co-occur, but there is no circumstantial association between the two symptoms.

Background: Falls are common events among hospital inpatients and constitute a major health problem in the rehabilitation setting. Many risk factors for falls have been identified for stroke patients, such as muscle weakness, medication side effects, hypoglycemia, hypotension, etc.

Objectives: To assess the risk factors for falls among patients hospitalized for rehabilitation following acute stroke.

Methods:  In a retrospective study of 56 falls over a period of 5 years in 41 stroke patients hospitalized for rehabilitation we surveyed the nurses’ safety risk assessment of the fall. Thirty patients fell once, 9 patients twice and 2 patients four times. The data were obtained from the medical and nursing records. Safety precautions were taken by the nurses for the entire group of patients.

Results: Most of the falls occurred among male patients who had reduced muscular tone (70%), paralysis (54%) and/or hypoesthesia in the involved side of the body. Patients who suffered from hemiplegia fell more often than those with hemiparesis (Wilcoxon rank sum test, P = 0.04, one-sided). Forty-eight percent of the falls occurred during the first month after the last stroke onset, 70% during the morning or the afternoon, and 62% occurred close to the patient’s bed. In 89% of falls the patients used hypoglycemic, antihypertensive, tranquilizing or neuroleptic drugs. Communication disorders (29%), hemianopia or blindness (21%) and visuospatial agnosia (18%) were incremental risk factors for falls. Fifty percent of the falls were caused by either an intrinsic or extrinsic mechanism.

Conclusions: These data suggest that the group of stroke patients at risk for falls in a rehabilitation department can be identified by a variety of impairment and functional assessments. The information may be potentially useful for designing interventions directed at reducing fall frequency among stroke survivors. 

Background: Falls are a common problem among hospitalized patients, having a significant impact on quality of life and resource utilization.

Objectives: To develop and validate a fall-risk assessment tool for patients hospitalized in the department of medicine that will combine simplicity with adequate accuracy for routine use.

Methods: This observational cohort study was conducted on the medical wards of an urban tertiary teaching hospital, and included all patients who fell in the medical wards during a 1 year period (n=140) compared to other hospitalized patients.

Results: Significant correlates of falls were previous falls, impairing medical conditions, impaired mobility, and altered mental state. In multivariate logistic regression analyses, only previous falls (odds ratio 3.8 with 95% confidence interval 2.65–5.45, P < 0.0001) and acute impairing medical conditions (OR[1] 1.56, CI[2] 1.06–2.29, P < 0.05) correlated independently with a higher risk for falls. Impaired mobility retained an OR of 1.46 (CI 0.95–2.24, P = 0.084). Accordingly, defining patients with either a history of previous falls or both acute impairing medical state and impaired mobility as fall-prone patients provided a sensitivity and specificity of 67% and 63%, respectively. In a subsequent prospective validation trial on 88 patients who fell during hospitalization and 436 controls, the sensitivity and specificity of this fall-risk grouping were 64% and 68% respectively.

Conclusions: Our new simple and easy-to-use fall-risk assessment tool identified most of the fall-prone patients. These findings suggest that using this tool may enable us to prevent two-thirds of falls on the medical ward by providing effective fall-prevention facilities to only one-third of the patients.

Background: In the western world, trauma is the leading cause of disability and mortality in the 1–39 years age group. Road accidents constitute the most frequent cause of mortality among children older than 1 year and falls from a height are the most frequent cause of injuries requiring hospitalization.

Objectives: To analyze the epidemiology and characteristics of severe pediatric trauma due to falls from a height in northern Israel. This analysis should aid in planning an effective intervention plan.

Methods: This observational study included all patients aged 0–14 who died or were admitted to an intensive care unit in northern Israel following a steep fall. Demographic and clinical data were collected retrospectively for 3 years and prospectively for 1 year.

Results: A total of 188 children were severely injured or died following such a fall, with an annual rate of 11.4 per 100,000 children. Over 85% of severe injuries due to falls occurred among non-Jewish children, with an incidence rate 6.36 times higher than among Jewish children (20.17 and 3.17 per 100,000 children, respectively). In the non-Jewish sector 93.7% of the falls occurred at or around the child’s home, mainly from staircases, balconies and roofs.

Conclusions: A very high incidence of severe trauma due to domestic falls from a height was found among non-Jewish children in northern Israel. Domestic falls represent an important epidemiological problem in the non-Jewish pediatric sector, and an effective prevention plan should include measures to modify parents’ attitudes towards safety issues and the creation of a safe domestic environment.
 

Adjustment disorder is a common diagnosis in psychiatric settings and carries a significant rate of morbidity and mortality. However, both current and previous diagnostic criteria are vague and lead to many difficulties in terms of validity and reliability. This review is based on a thorough literature search and a systematic evaluation of the empiric and theoretic data. The various pitfalls inherent in the process of diagnosing this disorder are discussed in light of the diagnostic criteria for the disorder.

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: Proximal femur fractures represent a challenging medical problem worldwide. In recent years numerous reports have documented. a progressive increase in the incidence of hip fractures. In Jordan, this problem has not received sufficient attention, and to my knowledge, this is the first study to address the problem.

Objective: To analyze the predisposing factors involved in the occurrence of proximal femur fractures seen at a major medical center in Jordan.

Methods: A retrospective analysis was conducts of all patient admitted with hip fractures to King Hussein Hospital and the Royal Jordanian Rehabilitation Center at the King Hussein Medical Center over a 2 year period (1 January 1995 to 31 December 1996). We determined the associated chronic diseases and medications, mechanisms of injury, types of fractures and other circumstances in order to suggest preventive measures to decrease the incidence of this clinical problem.

Results: We identified 216 cases of fracture: 43% occurred in people over the age of 80 years, 95% were due to low energy injuries (falls), and 69.5% occurred in females. Two or more co-morbid medical conditions were present in 70% of the cases.

Conclusion: Since fractures of the hip in the study population in Jordan occurred predominantly as low energy injuries in the elderly, preventive measures should focus on fall avoidance.