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To study the prevalence of eighteen geriatric conditions in older patients at admission, their reporting rate in discharge summaries and the impact of these conditions on mortality and functional decline one year after admission. A prospective multicenter cohort study conducted between 2006 and 2008 in two tertiary university teaching hospitals and one regional teaching hospital in the Netherlands. Patients of 65 years and older, acutely admitted and hospitalized for at least 48 hours, were invited to participate. Eighteen geriatric conditions were assessed at hospital admission, and outcomes (mortality, functional decline) were assessed one year after admission. 639 patients were included, with a mean age of 78 years. IADL impairment (83%), polypharmacy (61%), mobility difficulty (59%), high levels of primary caregiver burden (53%), and malnutrition (52%) were most prevalent. Except for polypharmacy and cognitive impairment, the reporting rate of the geriatric conditions in discharge summaries was less than 50%. One year after admission, 35% had died and 33% suffered from functional decline. A high Charlson comorbidity index score, presence of malnutrition, high fall risk, presence of delirium and premorbid IADL impairment were associated with mortality and overall poor outcome (mortality or functional decline). Obesity lowered the risk for mortality. Geriatric conditions were highly prevalent and associated with poor health outcomes after admission. Early recognition of these conditions in acutely hospitalized older patients and improving the handover to the general practitioner could lead to better health outcomes and reduce the burden of hospital admission for older patients.

Objectives Opportunistic screening for osteoporosis using computed tomography (CT) examinations that happen to visualise the spine can be used to identify patients with osteoporosis. We sought to verify the diagnostic performance of vertebral Hounsfield unit (HU) measurements on routine CT examinations for diagnosing osteoporosis in a separate, external population. Methods Consecutive patients who underwent a CT examination of the chest or abdomen and had also received a dual-energy X-ray absorptiometry (DXA) test were retrospectively included. CTs were evaluated for vertebral fractures and vertebral attenuation (density) values were measured. Diagnostic performance measures and the area under the receiver operator characteristics curve (AUC) for diagnosing osteoporosis were calculated. Results Three hundred and two patients with a mean age of 57.9 years were included, of which 82 (27 %) had osteoporosis according to DXA and 65 (22 %) had vertebral fractures. The diagnostic performance for vertebral HU measurements was modest, with a maximal AUC of 0.74 (0.68 – 0.80). At that optimal threshold the sensitivity was 62 % (51 – 72 %) and the specificity was 79 % (74 – 84 %). Conclusions We confirmed that simple trabecular vertebral density measurements on routine CT contain diagnostic information related to bone mineral density as measured by DXA, albeit with substantially lower diagnostic accuracy than previously reported. Key Points • We externally validated the value of vertebral trabecular bone attenuation for osteoporosis • These diagnostic performance measures were, however, substantially lower than previously reported • This information might be useful when considering the implementation of opportunistic osteoporosis screening

Objective The objective is to evaluate the effect of intravenous contrast media on bone mineral density (BMD) assessment by comparing unenhanced and contrast-enhanced computed tomography (CT) examinations performed for other indications. Methods One hundred and fifty-two patients (99 without and 53 with malignant neoplasm) who underwent both unenhanced and two contrast-enhanced (arterial and portal venous phase) abdominal CT examinations in a single session between June 2011 and July 2013 were included. BMD was evaluated on the three examinations as CT-attenuation values in Hounsfield Units (HU) in the first lumbar vertebra (L1). Results CT-attenuation values were significantly higher in both contrast-enhanced phases, compared to the unenhanced phase ( p  < 0.01). In patients without malignancies, mean ± standard deviation (SD) HU-values increased from 128.8 ± 48.6 HU for the unenhanced phase to 142.3 ± 47.2 HU for the arterial phase and 147.0 ± 47.4 HU for the portal phase ( p  < 0.01). In patients with malignancies, HU-values increased from 112.1 ± 38.1 HU to 126.2 ± 38.4 HU and 130.1 ± 37.3 HU ( p  < 0.02), respectively. With different thresholds to define osteoporosis, measurements in the arterial and portal phase resulted in 7-25 % false negatives. Conclusions Our study showed that intravenous contrast injection substantially affects BMD-assessment on CT and taking this into account may improve routine assessment of low BMD in nonquantitative CT. Key Points • Routine CT may gain a role in bone attenuation measurements for osteoporosis • Contrast media injection has substantial influence on CT - derived bone density • Contrast - enhanced CT leads to underestimation of osteoporosis compared to unenhanced CT • Adjusting for contrast injection phase may improve CT screening protocols for osteoporosis .

Percutaneous vertebroplasty is increasingly used for treatment of pain in patients with osteoporotic vertebral compression fractures, but the efficacy, cost-effectiveness, and safety of the procedure remain uncertain. We aimed to clarify whether vertebroplasty has additional value compared with optimum pain treatment in patients with acute vertebral fractures. Patients were recruited to this open-label prospective randomised trial from the radiology departments of six hospitals in the Netherlands and Belgium. Patients were aged 50 years or older, had vertebral compression fractures on spine radiograph (minimum 15% height loss; level of fracture at Th5 or lower; bone oedema on MRI), with back pain for 6 weeks or less, and a visual analogue scale (VAS) score of 5 or more. Patients were randomly allocated to percutaneous vertebroplasty or conservative treatment by computer-generated randomisation codes with a block size of six. Masking was not possible for participants, physicians, and outcome assessors. The primary outcome was pain relief at 1 month and 1 year as measured by VAS score. Analysis was by intention to treat. This study is registered at ClinicalTrials.gov, number NCT00232466. Between Oct 1, 2005, and June 30, 2008, we identified 431 patients who were eligible for randomisation. 229 (53%) patients had spontaneous pain relief during assessment, and 202 patients with persistent pain were randomly allocated to treatment (101 vertebroplasty, 101 conservative treatment). Vertebroplasty resulted in greater pain relief than did conservative treatment; difference in mean VAS score between baseline and 1 month was −5·2 (95% CI −5·88 to −4·72) after vertebroplasty and −2·7 (−3·22 to −1·98) after conservative treatment, and between baseline and 1 year was −5·7 (−6·22 to −4·98) after vertebroplasty and −3·7 (−4·35 to −3·05) after conservative treatment. The difference between groups in reduction of mean VAS score from baseline was 2·6 (95% CI 1·74–3·37, p<0·0001) at 1 month and 2·0 (1·13–2·80, p<0·0001) at 1 year. No serious complications or adverse events were reported. In a subgroup of patients with acute osteoporotic vertebral compression fractures and persistent pain, percutaneous vertebroplasty is effective and safe. Pain relief after vertebroplasty is immediate, is sustained for at least a year, and is significantly greater than that achieved with conservative treatment, at an acceptable cost. ZonMw; COOK Medical.

Background and aims : Insufficient vitamin D status, commonly found in older people, has been associated with muscle weakness which, in old age, impairs mobility and is a risk factor for falling. In a randomized, double-blind placebo-controlled trial, we tested the hypothesis that vitamin D + calcium supplementation improves muscle strength and mobility, compared with calcium mono-therapy in vitamin D-insufficient female geriatric patients. Methods : Seventy female geriatric patients >65 years of age with serum 25-hydroxyvitamin D 3 (25OHD) concentrations between 20 and 50 nmol/L, visiting an outpatient geriatric department, were included. Participants received either cholecalciferol 400 IU/day + calcium 500 mg/day (D/Cal group) or a placebo + calcium 500 mg/day (Plac/Cal group) for 6 months. At baseline and 6 months, muscle strength, power and functional mobility were tested. Results : At baseline, 25OHD was significantly (p<0.05) associated with knee extension strength (r=0.42), handgrip strength (r=0.28), leg extension power (r=0.34), Timed Get Up and Go (r=−0.31) and Modified Cooper test (r=0.44). At 6 months, a significant difference in 25OHD (77.2 vs 41.6 nmol/L, p<0.001) and 1,25OHD was found between the two groups. Significantly improving vitamin D status in the D/Cal group compared with the Plac/Cal group did not result in a significant difference in strength or functional mobility between the two groups. Conclusions : Daily 400IU vitamin D + 500 mg calcium supplementation is not enough to significantly improve strength or mobility in vitamin D-insufficient female geriatric patients.

Objectives To investigate the accuracy of bone mineral density (BMD) quantification using dual-layer spectral detector CT (SDCT) at various scan protocols. Methods Two validated anthropomorphic phantoms containing inserts of 50–200 mg/cm 3 calcium hydroxyapatite (HA) were scanned using a 64-slice SDCT scanner at various acquisition protocols (120 and 140 kVp, and 50, 100 and 200 mAs). Regions of interest (ROIs) were placed in each insert and mean attenuation profiles at monochromatic energy levels (90–200 keV) were constructed. These profiles were fitted to attenuation profiles of pure HA and water to calculate HA concentrations. For comparison, one phantom was scanned using dual energy X-ray absorptiometry (DXA). Results At both 120 and 140 kVp, excellent correlations (R = 0.97, P < 0.001) were found between true and measured HA concentrations. Mean error for all measurements at 120 kVp was -5.6 ± 5.7 mg/cm 3 (-3.6 ± 3.2%) and at 140 kVp -2.4 ± 3.7 mg/cm 3 (-0.8 ± 2.8%). Mean measurement errors were smaller than 6% for all acquisition protocols. Strong linear correlations (R 2  ≥ 0.970, P < 0.001) with DXA were found. Conclusions SDCT allows for accurate BMD quantification and potentially opens up the possibility for osteoporosis evaluation and opportunistic screening in patients undergoing SDCT for other clinical indications. However, patient studies are needed to extend and translate our findings. Key points • Dual - layer spectral detector CT allows for accurate bone mineral density quantification . • BMD measurements on SDCT are strongly linearly correlated to DXA . • SDCT , acquired for several indications , may allow for evaluation of osteoporosis . • This potentially opens up the possibility for opportunistic osteoporosis screening .

To determine the effect of oral testosterone supplementation on systemic low-grade inflammation measured by high-sensitive C-reactive protein (hs-CRP) in aging men with low testosterone levels. Two hundred thirty-seven men aged 60 to 80 years with a testosterone level of <13.7 nmol/L (below the 50th percentile of the population distribution) were recruited into a double-blind randomized placebo-controlled trial. Participants were randomized to either 4 capsules of 40 mg testosterone undecanoate (Andriol Testocaps, NV Organon, Oss, The Netherlands) or placebo daily for 26 weeks. Serum levels of hs-CRP were measured at baseline and at 26 weeks using a near-infrared particle immunoassay of the Synchron LX System (Beckman Coulter, Fullteron, CA). The median baseline hs-CRP level was 1.95 mg/L (0.30-6.43) in the testosterone group compared with 1.90 mg/L (0.40-5.91) in the placebo group. After 26 weeks of testosterone supplementation therapy, the 2 intervention groups were not statistically significantly different (median hs-CRP 2.20 vs 2.00 mg/L, interquartile range 0.40-6.54 vs 0.50-5.70, P = .36). In subgroup analysis, neither baseline testosterone level, nor age, nor baseline CRP-level modified the effect of testosterone supplementation on CRP levels. Oral testosterone undecanoate supplementation, in dosage of 160 mg daily for 26 weeks, does not increase hs-CRP levels in elderly men.

Fractures, mostly of the hip and pelvis, wrist, and sometimes of the vertebra, account for nearly half of emergency department treatments for elderly individuals seen because of a fall. Bone density measurements show that more than half of these patients have osteoporosis. The notion that it is too late to start treatment in a late stage of the disease forms a barrier to treatment. The aim of this article is to evaluate the effectiveness of therapeutic options for osteoporosis in the elderly, with a view to reducing the incidence of fractures. Although most studies of fracture reduction with medical treatment were not designed for the “geriatric” population, the average age of participants in most clinical trials was about 70 years. Nowadays, clinicians can choose from several effective treatments for the prevention of osteoporotic fractures in high- risk postmenopausal women. Data on the antifracture potential of calcium/vitamin D, raloxifene, bisphosphonates, strontium ralenate, and parathyroid hormone are now available. In all major studies patients also received calcium and vitamin D supplements. Bisphosphonates and strontium ranelate are good choices for first- or second- line treatment, while for the time being parathyroid hormone should only be used for the second- line treatment of osteoporosis in the elderly. The ease of use of bisphosphonates, with once weekly, once monthly, or intravenous administration, may be advantageous for elderly patients already taking multiple medications.

Background Postmenopausal women are prone to develop functional disabilities as a result of reduction in muscle strength and muscle mass caused by diminished levels of female sex hormones. While hormone replacement therapy may counteract these changes, conventional hormone replacement therapy is associated with potential harmful effects, such as an increased risk of breast cancer, and its prescription is not recommended. For this reason newer alternative drugs, such as tibolone, a synthetic steroid with estrogenic, progestogenic and androgenic activity, and raloxifene, a selective estrogen receptor modulator, may be more appropriate. This trial investigates the effect of tibolone and raloxifene on muscle strength. Methods We recruited 318 elderly women in our single-center randomized, double-blind, double-dummy, placebo-controlled trial. Participants were randomized to tibolone 1.25 mg (Org OD 14, Organon NV, the Netherlands) plus placebo, raloxifene 60 mg (Evista ® , Eli Lilly, United States) plus placebo or two placebo tablets daily for 24 months. The primary aim is to determine if there is a difference between tibolone and placebo or if there is a difference between raloxifene and placebo. Primary endpoints are muscle strength and bone mineral density. The secondary endpoints are postural balance, body composition, cognitive function, anxiety, mood and quality of life. The secondary aim is to determine if there is a difference between tibolone and raloxifene. The measure of effect is the change from the baseline visit to the visits after 3 months, 6 months, 12 months, and 24 months. A follow-up measurement is planned at 30 months to determine whether any effects are sustained after cessation of the study. By December 2007 the blind will be broken and the data analyzed. Trial registration number NTR: 1232

Mobility impairment and falling have a multifactorial etiology in frail older people. Muscle weakness is one of the risk factors and is accessible to intervention. The aim of this study was to determine the most important contributors of mobility and indicators of fall occurrence in women referred to a geriatric outpatient clinic. Mobility was assessed using the Timed 'Get-Up-and-Go' test (TGUG) and the modified Coopertest (COOP). Falling was assessed retrospectively and isometric knee extension force was measured using fixed dynamometry. Habitual physical activity was quantified using a questionnaire for the elderly. Height, weight, medical conditions and current medication were recorded. Isometric knee extension strength and habitual physical activity, which consisted predominantly of household work, were independent variables of performance on TGUG and COOP and together explained 57% of the variance in TGUG (r=0.75, p<0.001), and 64% of that in COOP, (r=0.80, p<0.001). Age, total number of medical conditions, and presence of cardiovascular disease were not significant in the model. Women in the lowest tertile of knee extension strength had a significantly higher probability of falling (0.75, 95% CI 0.56-0.91) compared with women in the highest tertile (0.27, 95% CI 0.14-0.50). Knee extension strength remains a strong determinant of mobility and fall occurrence in women referred to a geriatric outpatient clinic. Performing light to moderate household work remains independently associated with functional mobility.