Bone Health

Introduction

Hip fracture is the most common fracture in adults over 60 years, affecting approximately 70,000 people in the UK in 2019. Mortality after hip fracture continues to be high and the cost of hip fracture is estimated at £1.1 billion per year for the NHS. It has been shown that there are key clinical indicators which can improve patient outcomes. These are monitored annually in the UK by the national hip fracture database (NHFD).

Methods

Our aim was to look at the demographics and clinical codes for patients admitted with hip fracture, codes when they are readmitted and cause of death. Information analysts at both hospitals provided authors with these data from hip fracture admissions in 2020. Inclusion criteria reflected the inclusion criteria for the NHFD. Cause of death was identified from records in the medical examiner's offices for inpatient deaths. Data were viewed and analysed in Microsoft Excel.

Results

In total, there were 878 admissions for hip fracture in 2020, 312 at Barnsley Hospital (BH) and 566 Sheffield Teaching Hospitals (STH). Average age was 80.9 at BH and 82.6 at STH. The most frequent codes on admission were 'fall' and the most common complication was pneumonia, coded in 23% of patients. 174 (56%) individuals at BH had at least one readmission in the first year and 318 (57%) at STH. The codes for readmission were varied, most commonly for musculoskeletal or orthopaedic conditions, including fracture. 85 died within one year (27.2%) and 26 died within 30 days (8.3%) at BH. 186 died within one year (32.7%) and 69 within 30 days (12.1%) at STH. The commonest cause of death was pneumonia, in 26 of 66 inpatient deaths.

Conclusions

This analysis of coding data confirms known complications following hip fracture. Morbidity and mortality following hip fracture remains extremely high.

Hip fractures tend to affect older, frailer people and are associated with high morbidity and mortality. The Best Practice Tariff (B PT) was introduced to recognise gold standard care. Features of the BPT include prompt surgical and orthogeriatric input, with multidisciplinary working throughout. Subsequent service changes have led to the creation of specialist hip fracture wards. However, it is not always possible to admit patients with a fractured neck of femur to a specialist hip fracture ward.

We reviewed data for 691 patients admitted with a primary neck of femur fracture to a district general hospital in Sussex between 01/02/2023 and 29/02/2024. We compared the demographics and outcomes of patients admitted to a specialist hip fracture ward (SHFW) and a general surgical ward (GSW) using data available from the National Hip Fracture Database. 570 patients were admitted to the SHFW, 121 to the GSW.

BPT achievement was significantly higher on the SHFW (74% SHFW, 53% GSW, p<0.00001). 30-day mortality was lower on the SHFW, although this was not statistically significant (2.98% SHFW, 5.79% GSW, p=0.126). We found no significant difference in patient age, time to surgery, time to orthogeriatrician review, or length of stay.

This analysis highlights the importance of a specialist multidisciplinary team approach in the management of patients presenting with fractured neck of femur. While not a perfect metric, non-achievement of the BPT is likely to result in worse patient care, with higher mortality and poorer longer term functional outcomes. BPT non-achievement is also associated with significant loss of income to NHS trusts. We suggest that, wherever possible, beds on specialist hip fracture wards should be ring fenced for patients with primary neck of femur fracture.

Introduction: Musculoskeletal (MSK) injuries are a common factor in acute presentations to the emergency department (ED). Effective pain management is crucial for patient comfort and recovery, yet pain control for MSK injuries admitted under the medical team often falls short of optimal standards. This quality improvement project aims to evaluate and enhance the prescription practices for pain relief in elderly patients with MSK injuries at the Wrexham Maelor Hospital (WMH) ED. Methods:  A two cycle project was completed in which patients with MSK injuries were identified and reviewed regarding any pain relief they may have been prescribed (regular or PRN). Following cycle 1, interventions were put in place and prescribing practices were reassessed. Inclusion criteria: >60 years of age, MSK injury described in notes. Each cycle of data collection lasted a week, with a sample size of 17 and 14 patients respectively. Results: Cycle 1 No pain relief- 33% PRN Only- 6% Regular Only- 50% Both- 11% A significant number of patients were not receiving adequate pain relief, highlighting the need for improved pain management protocols. Interventions Educational posters were displayed around the emergency department and the frailty hub, and a presentation was given to the frailty team. Cycle 2 (post intervention) No pain relief- 14% PRN Only- 29% Regular Only- 21% Both- 36% Post-intervention results showed a marked improvement in pain management, with fewer patients receiving no pain relief and an increase in the combined use of PRN and regular pain relief. Conclusion: The quality improvement project highlights the necessity for targeted interventions to enhance pain management for elderly patients with MSK injuries in the ED. Preliminary results suggest that increased awareness and education among medical staff can potentially improve pain relief prescription rates.

Vitamin D deficiency has become commonplace, especially in older people. Given the role it plays in bone health and falls prevention, as well as the growing evidence of its extra-skeletal actions, it is important to treat vitamin D deficiency adequately. Our practice has been 2 to 3 weeks of daily treatment with 50,000IU ergocalciferol as a loading dose. However, recent guidelines recommend half this total cumulative dose given over a period of 6 to 8 weeks. Rather than promptly following the guidelines and changing our practice, we opted to conduct a quality improvement project (QIP) looking at the effectiveness of our protocol for treating Vitamin D deficiency in older patients. In the initial project patients admitted to an acute geriatric ward and found to have vitamin D deficiency were prescribed a 2 weeks course of daily ergocalciferol. In the second project, patients with severe deficiency (<20 IU/ml) received 3 weeks of treatment. In all patients pre- and post-treatment vitamin D levels were done. In total 76 patients were included. Results: all patients demonstrated significant improvement. Post-treatment serum vitamin D levels returned to normal in 66%. The median change in vitamin D level was 265%. Importantly no side effects were noted and no patient reached toxic serum vitamin D levels. Conclusion: Our results show that doses higher than the current recommendations for treating vitamin D deficiency are needed to replenish depleted vitamin D stores in older people. Compared to recommended strategies which generally span over 6 to 8 weeks, our daily protocol provides rapid replacement over 2 to 3 weeks. It is effective and safe with no side-effects. The short course of daily treatment should also increase patient compliance

Introduction.

In older adults, dizziness is often experienced as a vague feeling of subjective unsteadiness, where people perceive themselves to be swaying more than they actually are. One factor that potentially drives such distorted perceptions of instability is (hyper)vigilance towards balance. This study aimed to investigate if older adults who report higher levels of trait balance vigilance (i) are more likely to report sensations of general unsteadiness when their balance is acutely threatened, and (ii) if this is accompanied by maladaptive changes in postural control.

Methods.

Forty-eight healthy older adults without vestibular diagnosis (Mean age = 71.0, range = 60–83) completed the recently validated Balance-Vigilance Questionnaire to quantify trait balance vigilance. Participants were fitted a VR headset and completed 60-second, narrow-stance balance trials on a force platform, under conditions designed to create a threatening (standing at a 20-meter virtual height) or non-threatening (virtual ground level) environment. For each condition, we assessed self-reported stability (0-100%) and fear of falling (0-100%), postural control (sway amplitude and frequency), muscular control (tibialis anterior activity), and prefrontal and somatosensory cortical activity using fNIRS.

Results.

Preliminary results are reported. When presented with a postural threat, high-vigilant older adults (Balance Vigilance Score≥18; N=13) reported significantly greater fear of falling (+25%; p=.027) and more reduced perceived stability (-25%; p=.006) compared to low-vigilant older adults – despite there being no differences in actual sway amplitude (p=.157). Only the low-vigilant group showed evidence of an adaptive ‘stiffening’ strategy in response to threat: i.e. increased sway frequency (p=.028) and tibialis anterior activity (p=.027). fNIRS analysis is ongoing.

Conclusions.

These preliminary findings suggest that, in response to a postural threat, older adults with high balance-vigilance are more likely to experience excessive fear of falling and perceptions of instability, and may fail to make adaptive changes to their postural control. Screening for excessive balance vigilance may therefore be recommended.

Abstract Content - Introduction. When required to multitask while walking, older adults (OA) will walk slower and use maladaptive stepping strategies such as cross-steps that may increase the risk of falling. However, most studies to date have been limited to steady-state straight-line walking, which requires limited to no visual planning, which is unrepresentative of common outdoor environments. Therefore, this study aimed to (i) investigate the impact of dual-tasking during walking of complex routes, and (ii) assess if such impact can be reduced when older adults deliberately preview their route to improve planning. Methods. We aim to recruit 45 community-dwelling OA. Preliminary results are reported for 19 (13F & 6M) community-dwelling OA without neurological or musculoskeletal diagnosis (Mean age = 75.7, range = 64–84). Participants walked along different winding paths on an 8-meter-long walkway under three conditions for 6 trials per condition: Single-task (ST), Dual-task (counting backwards) without previewing their route (DT) and Dual-task with deliberate previewing of the walking route (DTP). For each condition, we recorded walking speed, stepping errors (deviations from the pathway), and cross-steps. Results. Participants walked significantly slower during the DT condition (M=58.3 cm/s, SD=15.4) vs. ST condition (M=82.6 cm/s, SD=12.6; p<.001). during the dt condition participants also made more errors (m="1.3/trial," sd="1.4;" p=".029)" and frequent cross-steps compared to ST (no noted; m="0.4" />trial, SD=0.4). However, when allowed to preview their route prior to dual-tasking (DTP condition), participants walked faster (M=69.9 cm/s, SD=18.7; p=.002) and with fewer errors (M=0.1/trial, SD=0.1; p=.006). Conclusions. The imposition of an attentional load during adaptive walking reduces speed and increases the likelihood of potentially risky stepping strategies. Taking the time to deliberately preview the walking route seems to reverse some of these negative changes, and particularly to allow older adults to walk faster with fewer stepping errors.

Introduction

The Action Falls programme has demonstrated effectiveness in reducing falls amongst care home residents in a trial but has not been implemented widely (Logan et al, BMJ, 2021, 375, e066991). Co-production of implementation has been identified as a mechanism for achieving buy-in. This study aimed to co-produce an implementation model.

Methods

Systemic action research with an appreciative approach framed co-production workshops in three stakeholder groups: residents and relatives, care home staff and representatives from health and social care organisations. Topics explored were stakeholder priorities, design of the implementation model and evaluation outcomes. Data collection and analysis occurred concurrently to identify key themes. Participating stakeholders were invited to a celebration event to discuss key themes, share ideas and finalise the model.

Results

One action research cycle was completed. Eighteen workshops were undertaken with 16 stakeholders (7 care staff, 7 health and social care representatives, 1 resident and 1 relative). Falls training was reported as an area requiring improvement. The main priority identified was the need for a shared approach to learning about falls. Other themes were: tailoring training to individual and care home learning needs, involving key people in falls learning, safe spaces to share experiences and build relationships, providing regular learning opportunities, confidence in falls management as an appropriate measure of implementation success, and the need for a mixed methods approach to evaluate the model. A shared learning model was developed at the celebration event. The model included three components: accessible information for residents and relatives, bespoke training for each care home, and provision of ongoing support.

Conclusions

A shared learning model was co-produced as part of the Action Falls implementation strategy. This now needs evaluation.

BACKGROUND

Counter-intuitively, a systematic review identified general walking aid use to be a risk factor for falling; some research even linked falls directly to use of walking aids. Hence walking aids’ effectiveness remains suboptimal. Yet a lack of innovation, especially with regard to indoor walking frames, persists: the front-wheeled Zimmer frame has not changed in design for decades. It was the aim of this work to completely re-think and innovate indoor walking frame design for enhanced user stability and mobility. New features include: 1) swivel wheels at the front to help turning, but which self-align straight during straight line walking, 2) glider feet at the rear to go over thresholds, 3) brakes inside the glider feet to prevent the frame from “running away”.

METHODS

Four proof-of-concept studies investigated the standard versus the new frame design:

Study 1. A gait lab-based study quantified stability (9 healthy older adults, walking repeated trials).

Study 2. A care-home based study investigated unstable usage patterns and body weight transfer (9 older frame users).

Study 3. An interview study investigated perceptions of 7 frame users regarding usability and safety.

Study 4. A clinical trial assessed safety and efficacy of use (10 clinicians, 10 inpatients, 8 outpatients, use of a questionnaire).

RESULTS

The novel frame increased stability during performance of complex everyday tasks (p<0.05). It also facilitated safer usage patterns whilst providing greater and more continuous body weight support. Users found the new design enjoyable; “That’s better than what I am using at the moment” and “I enjoyed using this one {new frame} compared to the other.” and clinicians perceived it to be safe and effective and hence more usable.

CONCLUSIONS

The four studies combined let us conclude that the new frame design is an improvement on the status quo.

Background:

Use of bisphosphonates following NOF fracture in patients over the age of 60 has extensive evidence showing up at a 50% relative reduction in fracture risk. However this is variably recorded on the immediate discharge letter (IDL) and subsequently poorly communicated to Primary Care via the emergency care summary (ECS).

Aim:

To review how often IV Zoledronate is used in hospital, documented in the IDL and on ECS, leading to an improvement of documentation and communication between primary and secondary/tertiary care and therefore the safer management and usage of medicines. Method: Retrospective analysis of inpatient administration of IV Zolendronate and its documentation in the IDL text, medication script and ECS for all patients with hip fracture admitted to RAH in October, November and December 2023. Exclusion criteria were patients who died during admission and those without an IDL completed.

Results:

There were 114 patients who met inclusion criteria. Only 25.4% received IV Zoledronate, 72.4% of these patients had this documented in the IDL text however only 6.9% on the IDL medication script. Where IV Zoledronate was on the medication script there was 100% transfer to a patients ECS.

Conclusion and discussion:

The data highlights that when IV Zoledronate is put on their discharge script this is transferred to ECS by community pharmacists, identifying a key part of the documentation pathway to target. On further review of the data we also looked at reasons why patients were not given IV Zoledronate e.g. CrCl <30, previous bisphosphonate course or alternative drug, pathological fractures and patients referred for dental review, accounting for a large portion of the data set, which going forward are other areas to target to increase use of IV Zoledronate. We have implemented a change and aim to re audit and assess whether this has led to any improvement.

Background:

OPAL Team cares for elderly patients arriving at hospital front door. 80% of referrals to OPAL team are related to Falls. Early assessment and intervention reduce future risk of falls improving health outcomes. OPAL assessment proforma used for falls assessment varies widely depending on local resources. In our trust Multifactorial risk assessment (MFRA) is included in OPAL proforma to assess any patient presenting with a fall or has had two or more falls in the past six months or needs hospitalisation due to fall. Our MFRA includes assessment of Vision, Continence, Cognition, Footwear, Medication review, Lying Standing Blood Pressure (LSBP), Range of Movement (ROM), Strength, Gait, Balance, and Functional assessment.

Methods:

A retrospective review of health records of 100 patients seen by OPAL in June 2022 assessed compliance with MFRA. This revealed 100% compliance in documenting patients falls history but only 20% had vision assessment, 17% Footwear assessment and 40% has LSBP checked. Emphasis on adherence to proforma and regular departmental teaching targeted toward components of MFRA was held every month during this study period (June 2022-June 2023). The retrospective audit was repeated in June 2023 after these interventions.

Result: Visual assessment improved from 20% to 66%, footwear from 17% to 60%, LSBP increased from 40% to 53% but there was decrease in assessment of ROM 67% to 38%, Strength 71% to 44%, and Balance 71% to 60. While other components assessment was around average 75%.

Conclusion: Reduction in some MFRA risk factors is relating to time and space constraints in ED environment. A dedicated OPAL assessment area in ED is anticipated to improve these parameters. Reinforcement in MDT meetings, buddy system for fresh staff and adherence to proforma for documentation will help in achieving 100% in all components.