Objective
To determine the effect of an early intervention program in an acute care setting on the length of stay in hospital of elderly patients with proximal femoral fractures.
Setting
Acute orthopaedic ward of a large teaching hospital.
Design and participants
A randomised controlled trial comparing 38 Intervention patients with 33 Standard Care patients.
Intervention
Early surgery, minimal narcotic analgesia, intense daily therapy and close monitoring of patient needs via a multidisciplinary approach versus routine hospital management.
Main outcome measures
Length of stay (LOS); deaths; level of independent functioning.
Results
Mean LOS was shorter in the Intervention group than in the Standard Care group (21 days v. 32.5 days; P <0.01). After adjusting for other factors that could affect LOS (eg, age, sex, pre‐trauma functional levels, pre‐trauma comorbidity and postsurgical complications), the Intervention program was significantly predictive of shorter LOS (P = 0.01). The Intervention group did not experience greater numbers of deaths, deterioration in function or need for social support than the Standard Care group.
Conclusion
This early intervention program in an acute care setting results in significantly shorter length of hospital stay for elderly patients with femoral fractures.
We have investigated the association of age and frailty with the pharmacokinetics and pharmacodynamics of the conjugated drug, metoclopramide. Six healthy young, six healthy elderly (> 65 years), and six frail elderly (> 65 years) subjects were studied on two occasions, receiving 10 mg metoclopramide by intravenous bolus and orally, in random order. Blood and urine were collected for measurement of pharmacokinetic parameters. Liver volume was measured by ultrasound. Sedation and contentment were self-recorded on visual analogue scales. Liver volume was not significantly different in the three groups, nor was bio-availability of metoclopramide. Clearance was similar in the young and fit elderly but reduced in the frail elderly subjects when compared with the young (p < 0.05), both when expressed in absolute terms and per unit liver volume. There were no differences in percentages cleared as the free drug or as the sulphate or glucuronide metabolite within or between groups, suggesting that frailty can produce a general impairment of conjugation pathways. The frail elderly subjects reported more sedation after intravenous dosage than the other subjects, whilst only young subjects reported akathisia. This did not relate to pharmacokinetic differences and seemed therefore to reflect associated pharmacodynamic changes in specific receptor or target sites.
The kinetics of the phase I enzyme aspirin esterase were estimated in plasma from ten young volunteers, seven healthy elderly volunteers, and in ten frail elderly subjects. Maximal reaction velocity at enzyme saturation (vmax) was similar in young and healthy elderly volunteers, but was significantly reduced in the frail elderly. The Michaelis constant (Km) was similar in all three groups. The results suggest that impaired in vitro aspirin metabolism in frail elderly people is due to a reduction in the quantity of enzyme present, rather than a qualitative change in enzyme proteins.
The number of patients attending acute care hospitals with a diagnosis of dementia is increasing. The impact of hospitalization on function and adverse events is perceived to be greater for patients with dementia than those without. This study compared adverse events (falls, wounds, delirium, medication errors, infections, and incontinence), functional decline, and allied health therapy for patients with and without dementia ( n = 240). Patients with dementia experienced significantly more adverse events and constant observation by staff, were more dependent with mobility, hygiene and feeding, more often nil by mouth, confused, and incontinent. Patients with dementia were significantly more likely to receive speech and physiotherapy, although they did not significantly improve in function during their hospital stay. Conversely, patients without dementia significantly improved in mobility and continence. The unique health care needs of patients with dementia need to inform models of care, policy, and practice to support safe health care delivery in this vulnerable population.
The activity of the phase 1 enzyme aspirin esterase was studied in liver tissue from 16 patients, aged 45-88 years. No correlation between age and enzyme activity was found in post-mitochondrial, cytosolic and microsomal fractions. These results provide further evidence that age is not a major determinant of the activity of hepatic drug-metabolizing enzymes in man.
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