Editor's view |
Editor's view
Editor, Age and Ageing
There is growing awareness of the importance of both the medical and surgical management of older patients with hip fracture. This has been reflected in the UK by the publication of the joint British Orthopaedic Association and British Geriatrics Society ‘Blue Book’ on the care of patients with fragility fracture, the introduction of the National Hip Fracture Database and the anticipated development of the National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on hip fracture management. A research letter in this issue examines the relationship between perioperative myocardial ischaemia and subsequent cardiac events and mortality after hip fracture repair (pp. 473–476). The authors measured troponin Ic on each of the first 3 postoperative days in 75 patients undergoing surgery for hip fractures in the hospitals in France. There was evidence of perioperative myocardial ischaemia in 20 patients (26.7%), as reflected by a raised troponin Ic. Over the subsequent 6-month follow-up period, patients with biochemical evidence of perioperative myocardial ischaemia had a 6.6-fold increased risk of major cardiac events and a 3.6-fold increase in all-cause mortality. Although the study is small and may not be representative of other centres, another recent paper also reported raised troponin concentration in patients after emergency orthopaedic surgery (Age and Ageing 2009; 38: 168–174). An accompanying editorial (pp. 360–361) highlights that we should be vigilant for myocardial infarction in patients undergoing hip fracture surgery, but reminds us that many cases of raised troponin in this situation are due to co-morbid physiological stress in frail patients, requiring good holistic care rather than any specific intervention.
A number of studies in community-dwelling older people show that the risk of hip fractures is determined not only by skeletal risk factors, such as bone density, bone turnover and skeletal geometry, but also by non-skeletal risk factors related to propensity for falling. Risk factors for fracture have been less extensively studied in older people living in residential or nursing homes, despite their high incidence of hip and other fragility fractures. We should therefore welcome a research paper (pp. 429–434) examining risk factors for hip fracture in 1,894 older people living in nursing homes or intermediate-care facilities in Australia. The overall incidence of hip fractures was 4.0% per person year, with a higher rate in those living intermediate care (4.6%) than in the nursing home residents (3.0%). Multivariate analysis showed a significant increase in the risk of hip fracture with older age, cognitive impairment, prior fracture since the age of 50 years, low body weight, longer lower leg length and poor balance in intermediate care residents. Bone fragility was assessed by quantitative ultrasound measurements at the calcaneus. Although the mean broadband ultrasound attenuation (BUA) was low, suggesting a high prevalence of osteoporosis and skeletal fragility, there was no independent association of BUA with hip fracture risk. The authors conclude that there are differences in the risk factors for hip fracture in institutionalised older people compared with community-dwelling subjects, which should be addressed by appropriate prevention measures. The role of specific osteoporosis treatment in this population is unclear, as anti-fracture studies of bisphosphonates and strontium ranelate have not been performed in this population.
An editorial in the last issue (Age and Ageing 2009; 38: 254–255) reviewed the potential risks and benefits of whole body vibration (WBV) for bone health and neuromuscular function in older people. This issue includes a research paper reporting the results of a randomised controlled trial of WBV training on cardiorespiratory fitness and muscle strength in older people (pp. 448–454). The study randomised 220 community-dwelling people above the age of 60 years to the WBV group, a fitness group or control group. The WBV group exercised on a vibration platform, whereas the fitness group performed cardiovascular, resistance, balance and stretching exercises. After 1 year, peak oxygen uptake, time to peak exercise and muscle strength increased significantly in both the WBV and fitness groups, but the increase in time to exercise peak was even greater in the fitness group than in the WBV group. Although these results are interesting, there is no direct comparison with a similar training regimen performed on a static platform. Further studies of WBV on cardiorespiratory fitness and muscle strength are required to examine safety, efficacy and acceptability in older people. In the meanwhile, we should probably continue to advocate appropriate exercise programmes, under the guidance of suitably qualified individuals.
There has long been interest in the effects of the adrenal androgen dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulphate (DHEAS) on the ageing process, which at one extreme has resulted in the internet marketing of DHEA as an ‘elixir of youth’. A research paper has examined the relationship between DHEAS and physical frailty assessed in 898 older people (pp. 401–406). The authors found an association between frailty and DHEAS levels, but in a cross-sectional study like this, it is unclear if the DHEAS contributes to the development of frailty or the association is due to co-morbid conditions resulting in lower DHEAS and frailty.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||