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While eHealth can help improve outcomes for older patients receiving geriatric rehabilitation, the implementation and integration of eHealth is often complex and time-consuming. To use eHealth effectively in geriatric rehabilitation, it is essential to understand the experiences and needs of healthcare professionals. In this international multicentre cross-sectional study, we used a web-based survey to explore the use, benefits, feasibility and usability of eHealth in geriatric rehabilitation settings, together with the needs of working healthcare professionals. Descriptive statistics were used to summarize quantitative findings. The survey was completed by 513 healthcare professionals from 16 countries. Over half had experience with eHealth, although very few (52 of 263 = 20%) integrated eHealth into daily practice. Important barriers to the use or implementation of eHealth included insufficient resources, lack of an organization-wide implementation strategy and lack of knowledge. Professionals felt that eHealth is more complex for patients than for themselves, and also expressed a need for reliable information concerning available eHealth interventions and their applications. While eHealth has clear benefits, important barriers hinder successful implementation and integration into healthcare. Tailored implementation strategies and reliable information on effective eHealth applications are needed to overcome these barriers.

Purpose To describe a guidance on the management of post-acute COVID 19 patients in geriatric rehabilitation. Methods The guidance is based on guidelines for post-acute COVID-19 geriatric rehabilitation developed in the Netherlands, updated with recent insights from literature, related guidance from other countries and disciplines, and combined with experiences from experts in countries participating in the Geriatric Rehabilitation Special Interest Group of the European Geriatric Medicine Society. Results This guidance for post-acute COVID-19 rehabilitation is divided into a section addressing general recommendations for geriatric rehabilitation and a section addressing specific processes and procedures. The Sect. "General recommendations for geriatric rehabilitation" addresses: (1) general requirements for post-acute COVID-19 rehabilitation and (2) critical aspects for quality assurance during COVID-19 pandemic. The Sect. "Specific processes and procedures", addresses the following topics: (1) patient selection; (2) admission; (3) treatment; (4) discharge; and (5) follow-up and monitoring. Conclusion Providing tailored geriatric rehabilitation treatment to post-acute COVID-19 patients is a challenge for which the guidance is designed to provide support. There is a strong need for additional evidence on COVID-19 geriatric rehabilitation including developing an understanding of risk profiles of older patients living with frailty to develop individualised treatment regimes. The present guidance will be regularly updated based on additional evidence from practice and research. Key summary pointsAim To describe a guidance on the management of post-acute COVID 19 patients in geriatric rehabilitation. Findings This guidance addresses general requirements for post-acute COVID-19 geriatric rehabilitation and critical aspects for quality assurance during the COVID-19 pandemic. Furthermore, the guidance describes relevant care processes and procedures divided in five topics: patient selection; admission; treatment; discharge; and follow-up and monitoring. Message This guidance is designed to provide support to care professionals involved in the geriatric rehabilitation treatment of post-acute COVID-19 patients.

Background There is much focus on the dearth of resources within healthcare systems, with a focus on health services. In 2018, we held a speed networking event for two local areas of a HSE Community Healthcare Organisation. This highlighted the vast array of supports available to assist older people to live well. This, alongside a Listening to Older Person’s Workshop, highlighted the need for a local directory of services. Methods In considering potential networking attendees, a social determinants of health approach (Dahlgren and Whitehead, 1991) was adopted to scope all supports available across community, acute, voluntary and statutory health and social care services within the area. This was expanded on further to develop the directory. Results The directory provides details of 358 organisations, individuals and groups available to support older persons within a catchment area with a population of 13,833 older persons (CSO Census, 2016). Hospital services comprised 27 of these while community HSE and GP health services made up 130. The remaining 201 were local and national NGOs and community groups ranging in service provision, a sample of which as follows: 39 provided some level of social/education engagement, three befriending, 18 counselling, five housing specific, 11 substance dependency, 12 provided supports to persons impacted by abuse. A further 20 national NGOs provided a local service or helpline with a focus on a particular health diagnosis. Conclusion This exercise shows the vast number of services available within just one small region, to support older persons to live well at home. The directory has been approved as a template for other networks in the CHO. It is being adapted into an online version by an interagency group. Using this template nationally has the potential to overcome gaps in health service resources, and support true integration, in line with the ICPOP (2016) 10 step framework.

Background As to who should manage osteoporotic spine fractures presenting to Emergency departments (ED) is sometimes debated. We sought to review practice regarding their management in our institution that might inform a clinical pathway. Methods We conducted a search of radiology reports for a consecutive series of thoracic or lumbar spine x-rays ordered by ED team only, i.e. a series of patients whose presenting complaint was a suspected acute fracture. We narrowed search to include terms ‘compression’ or ‘wedge’ or ‘end-plate’. Results Over 7 months, there were 1,505 such reports; narrowed search and excluding duplicates yielded 168 patients of whom 84 had a fracture. We looked at the acute management of those >50yrs, excluding one metastatic fracture leaving n=64. Of these, 65% occurred following a fall, 14% on twisting/bending/coughing, 14% spontaneous, 7% unclear onset. ED first consulted orthopaedics for 10 cases, neurosurgeons for 2, physicians for 18. A total of 21 were discharged from ED (5 having speciality review pre-discharge). A further 11 were sent home from ED with fracture diagnosis made only when x-ray subsequently reported. Of those admitted, 28 went to physicians with consult to surgeons in 39%, 2 went to orthopaedic surgery, 2 to other specialists. Admission was complicated by pressure ulcer in 13% (4/32), pneumonia in 13%. Overall 24/64 (38%) went on to have MRI/CT (mainly admitted cases). At least 12 were managed with a brace (all records not available). N=7 (11%) had later vertebroplasty. More than half had no documented osteoporosis treatment plans nor GP instruction to address. Conclusion Care of spine fractures presenting acutely varies; a high proportion managed by ED solely. Whether outcomes vary as a result is not answered by this audit but there is a need for a pathway to inform best practice. Osteoporosis is inadequately-addressed in this high risk group, highlighting need for fracture liaison services in post-acute management.

The medical and legal risks associated with prescribing unlicensed vitamin D products were recently highlighted in the article by Davies et al. 1. This prompted a letter from Rhein who raised the concern that this may dissuade practitioners from prescribing vitamin D 2, and exacerbate the failure to address adequately the widespread problem of vitamin D deficiency and insufficiency 3. Rhein asks whether European licensed preparations could be used in the absence of suitable or affordable UK licensed preparations, with appropriate checks. We address this point with a practical approach to understanding the licensed status of different preparations of vitamin D and the relevance with respect to prescribing and dispensing them, particularly with the recent licensing of vitamin D. We are not setting out to provide guidance on the specific requirements for vitamin D replacement in vitamin D deficiency and insufficiency, or advice on specific dosing regimens, or selection of specific vitamin D preparations, for which we encourage the reader to consult their local or national guidelines. However, when following such guidelines, the prescriber should be reasonably satisfied that the likely benefits of prescribing higher doses of vitamin D products exceed the likely risks of harm. For example, with respect to evidence of benefit in terms of mortality, the Cochrane Review on vitamin D supplementation for prevention of mortality in adults by Bjelakovic et al. 4 which included 32 trials of vitamin D3, found that a dose of vitamin D3 below 800 units a day significantly decreased mortality (RR 0.92, 95% CI 0.87, 0.97, P = 0.005, I2 = 0%). However, a dose of vitamin D3 ≥ 800 units a day had no significant effect on mortality (RR 0.96, 95% CI 0.92, 1.00, P = 0.07, I2 = 0%). No effect on mortality was found with vitamin D2. In this commentary we present the risks of different categories of vitamin D products, with respect to their licensed status, within the context of the medico-legal framework.

Until the 1940s, when Albright associated osteoporosis with a defect of bone anabolism, it was not considered a disease entity but an inevitable consequence of the ageing process for which there was little remedy.1 Bisphosphonates, first synthesised in the 1800s but in clinical use only since the 1960s, demonstrated that this process of age-related decline in bone was, in fact, modifiable.2 More recently, a wealth of basic and clinical research has greatly enhanced our understanding of the complexity of bone metabolism, enabling the development of novel therapeutic strategies. The resultant reduction in fracture risk is greatest in those with more severe osteoporosis, suggesting that older people can have considerable gains from bone-sparing treatments. Osteoporosis, now acknowledged as the most prevalent bone disorder in the world, is characterised by low bone mass, microarchitectural deterioration of bone tissue and decreased bone strength. Adult bone mass results from peak bone mass achieved during adolescence and subsequently maintained until perturbations in the bone remodelling cycle – usually a very tightly coupled process – occur and alter the balance between bone-forming osteoblasts and bone-resorbing osteoclasts. In a normal remodelling cycle, the amount of bone lost is the same as the amount of new bone formed. When this process becomes ‘uncoupled’ – as is the case in people with oestrogen deficiency, high levels of glucocorticoids, changes in serum calcium levels, fluctuations in levels of parathyroid hormone (PTH) and changes in levels of growth hormone – there is a net loss of bone. Estimates indicate that 50% of women and 20% of men aged over 50 years will experience an osteoporosis-related fracture; hip fracture is the most devastating of these due to the consequent disability, mortality and costs – both personal and societal. Due to changing population demographics, estimates suggest a doubling of the number of people with osteoporosis in the next 20 years. Consequently, an exponential increase in the numbers of fractures is anticipated, with an inevitable increased financial burden for healthcare systems – the total economic burden of osteoporosis in the European Union in 2010 was estimated at A39 billion (about £32 billion).3 Without taking into account the personal cost to the individual, one can see why prevention and treatment of osteoporosis should be a priority for all those who care for older people. Osteoporosis is underdiagnosed and undertreated, particularly in those aged over 75 years, in whom treatment is probably most beneficial and cost effective.4 This fact suggests that treatment of the older cohort remains a challenge, not helped by the limited representation of older adults in major trials of osteoporosis treatments.

As the number of aged patients presenting with hip fractures continues to rise [1], the substantial mortality associated with this pathology must continue to be an area of scrutiny and improvement. While some dismiss the high mortality as an inevitable consequence of the comorbidities inherent in the original injury and the patient population, data suggest that at 2 years post-hip fracture, survivors’ risks have regressed significantly and in fact, return to the same mortality risk as the non-fracture population [2]. This indicates that the risk of death is largely created specifically by the hip fracture and its treatment per se rather than the comorbidities of the hip fracture population, and offers scope for the potential reduction of these causes of death if we can identify and manage them appropriately. At a time when the incidence of hip fracture worldwide is on a steady rise, this review considers why and how these older patients die, and whether our developing guidelines and continuing research is adequately addressing these causes of death.

Falls are a common and serious, but potentially preventable, problem after stroke. Avoiding falls requires balance, which is a fluid and dynamic physical skill. There are a number of perceptual, neurological, and mechanical mechanisms underlying our ability to balance, and they are complex and heterogeneous. Depending on where strokes occur in the brain, balance may be affected in different ways. It is important to identify stroke patients who are at risk of falls in order to optimize prevention, and a number of stroke-specific risk factors have been identified, but the available assessment scales have only limited sensitivity and specificity. If management of falls risk in stroke is to be effective, assessments have to identify the precise and individual mechanisms underlying balance problems, and then specific management has to be targeted at these deficits. The consequences of falls after stroke can be severe and include loss of confidence and loss of independence, as well as serious injury including fractures. Stroke patients are at greater risk of osteoporosis, particularly on the hemiplegic side, which occurs rapidly following paresis. Management of falls risk post-stroke should also include timely assessment of bone health and the associated fracture risk.

Summary Background: Enhanced external counterpulsation (EECP) is a noninvasive treatment for angina that acutely augments diastolic pressure and reduces cardiac afterload. However, the mechanism of the sustained clinical benefit seen with this therapy is not known. Hypothesis: The study aimed to determine whether EECP leads to an improvement in arterial stiffness. Methods: In all, 22 men and 1 woman with angina (age 63.6 ± 6.7 years, mean ± SD) were studied prior to and after 35 h of EECP therapy over 7 weeks. We measured carotid-radial (C-R) pulse wave velocity (PWV), and aortic augmentation index (AI) was derived from radial and carotid artery waveforms using applanation tonometry. Seventeen patients underwent treadmill exercise testing before and after the 7 weeks of EECP. Results: After EECP therapy, despite a significant improvement in treadmill exercise time and a reduction in systolic and diastolic blood pressures, there was no significant change in any arterial stiffness parameters: Mean C-R PWV was 8.4 ± 0.8 m/s at baseline and 8.0 ± 1.2 m/s after 7 weeks of EECP, mean change: ‐ 0.4, 95% confidence interval (CI): � 1.0, + 0.2, p = 0.17. Mean radial-derived AI was 25.7 ± 10.4% before and 24.6 ± 10.8% after, mean change: + 1.1%, 95% CI: � 2.3, + 4.5, p = 0.53. Median AI-carotid was 31.5% before and 28.7% after; median change: � 0.5, interquartile range: � 9.5, + 3.5, p = 0.32. Nineteen patients returned for 6-month recordings; neither blood pressure nor arterial stiffness readings were significantly different from baseline. Conclusion: Enhanced external counterpulsation therapy does not significantly alter arterial stiffness. Other than an initial reduction in blood pressure, the sustained clinical benefit seen with this therapy is unlikely to be effected through alterations in arterial wall mechanical properties.

Background: the red cell distribution width (RDW), an automated measure of variability in the red blood cell size on full blood count (FBC) is an independent predictor of mortality in several disease states and in healthy older people. Objective: we wanted to determine the prognostic value of RDW in patients following a hip fracture—a condition associated with high mortality. Design: we examined the relationship between admission RDW and mortality in 698 consecutive patients admitted with hip fracture. Method: regression analysis was used to examine admission RDW and subsequent mortality, adjusting for admission haemoglobin, mean corpuscular volume, age, gender, pre-morbid residence and independence level, Charlson co-morbidity index and post-operative complications. Results: the mean age was 78 ± 13 years. Unadjusted 1-year mortality was 12, 15, 29 and 36% across quartiles of increasing RDW. Along with age and post-operative complications, RDW remained significantly associated with in-hospital, 120-day and 1-year mortality [adjusted hazard ratios: HR: 1.119, 95% CI: (1.000–1.253), P= 0.05, 1.134 (1.047–1.227), P= 0.004 and 1.131 (1.067–1.199), P< 0.001, respectively]. These relationships remained significant at all three time points on repeat analysis in non-anaemic patients (n= 548). Conclusion: RDW, a widely available parameter on FBC, is independently associated with an increased risk of short- and long-term mortality following hip fracture.

Rigler's sign is a radiological sign of free intraperitoneal air, generally from a perforated viscus. It is the appearance of air on both sides of the bowel wall due to a large quantity of free air in the abdomen. It is important to be aware of the non-surgical causes of this appearance, one of which we describe here. An 87-year-old man whose only medical history was of a long-standing, seemingly asymptomatic, diaphagramatic hernia (figure 1, preoperative film), underwent a total hip replacement with …

The authors report two cases of pyroglutamic acidosis as a result of paracetamol and flucloxacillin therapy in patients with prosthesis infection following hemiarthroplasty for neck of femur fractures. Pyroglutamic acidosis is an important and often unrecognised cause of refractory metabolic acidosis that disproportionately affects older women, and can be caused by drugs such as paracetamol and flucloxacillin in the setting of sepsis, renal failure and malnutrition. Although relatively rare, the widespread use of these drugs in orthopaedic patients confirms the importance of this disorder.

To assess the relationship between endogenous androgen levels and arterial stiffness in older men.A retrospective, cross-sectional study.A London hospital-based, clinical research unit for the elderly.Fifty-five men (mean age+/-standard deviation=71.1+/-8.0).Sex hormone-binding globulin (SHBG), testosterone, and dehydroepiandrosterone sulfate (DHEAS) were measured in all subjects who had a stored serum sample drawn the same day as arterial stiffness measures were performed. Free testosterone index (FTI) was calculated ((total testosterone/SHBG) x 100 (%)). The measures of arterial stiffness used were pulse wave velocity (PWV) using the Complior system and systemic arterial compliance (SAC) using the area method.Relationship between arterial stiffness and serum androgens.: FTI showed a strong positive relationship with SAC (r=0.507, P.001) and, correspondingly, an inverse relationship with carotid-femoral (C-F) and carotid-radial (C-R) PWV (r=-0.427 and -0.402, respectively, Por=.002). With multiple regression, including age, blood pressure, cholesterol, body mass index, and waist/hip ratio, FTI remained a significant determinant of SAC and C-R PWV but not C-F PWV. In the subgroup of men without cardiovascular disease or vasoactive medication use (n=37), all three relationships remained significant. DHEAS was inversely related to C-F PWV only (r=-0.304, P=.041).The known association between lower androgenicity and increased cardiovascular risk in men might be explained by altered vascular stiffness.