Characteristic Analysis Of The Adverse Effects Of Depression On Bone Metabolism And Fracture Prognosis In Elderly Patients With Femoral Neck Fractures

Part Ⅰ:Analysis of demographic and clinical characteristics of elderly inpatients with osteoporotic femoral neck fractureObjective China has the largest population of older people in the world and is experiencing rapid population aging and facing great challenges from an increasing number of hip fractures.Femoral neck fracture is the most destructive type of osteoporotic fracture because of its considerable morbidity,excess mortality,great risk of disability,and high societal healthcare costs,and its pathological changes are irreversible.Prevention is more important than treatment.Clinically,it is more important to identify the risk factors of osteoporotic femoral neck fractures(OFNF)in elderly patients and screen the high-risk population of OFNF,which is more important for early diagnosis and prevention.Therefore,the purpose of this study is:(1)to observe the changing trend of OFNF constituent ratio and age in our hospital in the past ten years;(2)to analyze the differences of demographic and clinical characteristics between different genders;and(3)to evaluate the changing trend of average hospitalization time and hospitalization expenses of OFNF patients.Methods The clinical data of 1227 patients with OFNF treated in the Department of Orthopedics of Beijing Hospital from January 2010 to December 2019 were analyzed retrospectively,including 377 males and 850 females,with a male-to-female ratio of 2.25.The average age was(79.01±7.79)years old,male(78.51±8.15)years old and female(79.23±7.62)years old.The patients divided into four groups according to age:60-69 years old,70-79 years old,80-89 years old,≥90 years old;uneducated,primary school,junior high school,senior high school and above according to educational level;spring(March-May),summer(June-August),autumn(September-November),winter(December-February)according to the season of onset;urban and rural areas according to the place of long-term residence.According to AO classification,the types of fractures were divided into 31-B1,31-B2 and 31-B3.According to the causes of injury,they were divided into fall and indoor activity injury,fall from height injury,traffic injury and other external injuries.Concomitant diseases include hypertension,diabetes,cerebrovascular disease,coronary heart disease,arrhythmia,knee and hip osteoarthritis.The trends of OFNF constituent ratio,age change,average length of stay and hospitalization expenses in recent ten years were observed,and the differences of demographic and clinical characteristics between different genders were analyzed.Results From 2010 to 2017,the number and constituent ratio of OFNF patients increased year by year,and the number of OFNF patients decreased slightly in 2018 and 2019.The age of onset in both male and female patients was the highest at the age of 80-89.In the distribution of educational level,the proportion of uneducated people is the highest.The seasonal distribution of the disease was the highest in autumn and winter.The constituent ratio of urban areas is higher than that of rural areas.In the distribution of fracture types,the constituent ratio of 31-B2 fracture was the highest in both male and female patients.Among the causes of injury,the constituent ratio of fall and indoor activity injury was the highest.Among the concomitant diseases,hypertension,spinal degenerative diseases and knee and hip osteoarthritis ranked in the top three.The constituent ratio of previous fractures in females was significantly higher than that in males.In the past ten years,the average hospitalization time of OFNF patients showed a decreasing trend,and the change of average hospitalization cost showed a broken line fluctuation.From 2009 to 2016,the hospitalization cost showed an upward trend,the highest in 2016,and then decreased year by year.Conclusion In the past ten years,the number and constituent ratio of OFNF patients increased year by year,but decreased slightly or reached a plateau in the past two years.The education level,history of bone fracture,hypertension,spinal degenerative disease and knee and hip osteoarthritis of OFNF patients were correlated with sex,while age distribution,seasonal distribution,urban and rural distribution,cause of injury,fracture classification and other concomitant diseases were not correlated with sex.In the past ten years,the average hospitalization time of OFNF patients showed a decreasing trend,the average hospitalization cost showed an upward trend from 2009 to 2016,and decreased year by year after 2016.The medical policy reform in 2016 played a significant role in controlling medical expenses.Part Ⅱ:Bone mineral density and bone metabolism in elderly males with femoral neck fractures and depressionObjective:Osteoporosis is the most common bone disease.It is a systemic bone disease characterized by low bone mass,damage of bone tissue microstructure,increased bone brittleness and prone to fracture.Fracture is the most serious consequence of osteoporosis.Osteoporotic fracture(or brittle fracture)refers to a fracture that occurs during minor trauma or daily activities.Femoral neck fracture is the most destructive osteoporotic fracture because of its high incidence,high mortality,high risk of disability and high social medical costs.Acute and chronic musculoskeletal diseases are often accompanied by psychological disorders,such as depression and anxiety.Depression is a mood disorder or affective disorder dominated by depression mood.In middle-aged and elderly patients with musculoskeletal pain,the prevalence rate of depression is more than 3 times higher than that of the general population,but also much higher than that of patients with medical diseases.At the same time,depressive symptoms have extremely adverse effects on the physical function and quality of life of the elderly.However,depressive symptoms in middle-aged and elderly patients are usually not found or adequately treated,and less attention has been paid to the depressive symptoms associated with musculoskeletal diseases.The purpose of this study was to analyze the changes of bone mineral density and biochemical markers of bone metabolism in elderly male patients with femoral neck fracture and depression,and to investigate the effect of depression on bone metabolism and osteoporosis.Methods:Between January 2017 and January 2019 in Beijing hospital,one hundred and two elderly males with femoral neck fractures were enrolled in the study.Pathological fracture and cognitive impairment were excluded.All patients were divided into depression group(52 cases)and control group(50 cases)by Geriatric Depression Scale(GDS).Bone mineral density(BMD)was detected using dual X-ray densitometry(DEXA).Bone metabolism biochemical markers(P1NP,β-CTX,OC,25-OH-VitD,ALP,calcium,phosphorus)were measured using enzyme linked immunosorbent assay(ELISA)method.Correlation of depression,bone metabolism and BMD was analyzed.The data were analyzed by chi-square test,t test,and Pearson correlation analysis.P<0.05 was considered as statistically difference.Results:BMD of depression group was significantly lower than that of control group(Lumbar t=5.964,Hip neck t=2.845,P<0.05).Depression group(Compared with control group):the serum levels of 25(OH)D,OC,ALP and calcium were lower with statistically significant differences(t=3.077,2.013,2.111,2.020,respectively,P<0.05);β-CTX and phosphorus level were higher(t=2.938,3.099,respectively,P<0.05);no significant differences in P1NP(t=0.684,P>0.05).Depression scores were negatively correlated with BMD(r=-0.456,P<0.05),25(OH)D(r=-0.546,P<0.05),OC(r=-0.215,P<0.05)and positively correlated with β-CTX(r=0.372,P<0.05),but not significantly correlated with P1NP(r=-0.115,P>0.05).Conclusion:Depression is accompanied by the decrease of bone formation and increase of bone resorption,which is a risk factor for low bone density and fractures.We should pay attention to the detection of bone metabolism makers and 25(OH)D in elderly patients with depression,timely interventing in the treatment of osteoporosis.Part Ⅲ:Adverse effect of depression on surgical outcome of artificial femoral head replacement in elderly patientsObjective:Hip fracture can be divided into intracapsular fracture(femoral neck and femoral head)and extracapsular fracture(intertrochanteric and subtrochanteric)according to the anatomical position.Femoral neck fracture is a special type of intracapsular fracture of hip joint.The femoral neck connects the femoral head and the proximal end of the femoral shaft and is connected with the trochanter.The hip joint is a "ball socket" joint composed of the femoral head and the acetabulum,and the cross position makes the femoral neck prone to fracture.Femoral neck fracture is also the most destructive osteoporotic fracture because of its high incidence,high mortality,high risk of disability,and high social medical costs.The probability of nonunion or malunion of femoral neck fracture in the elderly is very high,and the elderly patients often undergo artificial joint replacement.Acute and chronic musculoskeletal diseases are often accompanied by psychological disorders,such as depression and anxiety.Depression is a kind of mood disorder or affective disorder dominated by depression mood,which is mainly manifested as low mood,anhedonia,irritability and self-negation.Depression has become a common disease around the world and the leading cause of disability around the world.The prevalence rate of depression among middle-aged and elderly people in China is 20.3%in urban areas and 31.8%in rural areas.In middle-aged and elderly patients with musculoskeletal pain,the prevalence rate of depression is more than 3 times higher than that of the general population,but also much higher than that of patients with medical diseases.At the same time,depressive symptoms have extremely adverse effects on the physical function and quality of life of the elderly,and lead to the difficulty of treatment of concomitant diseases and the increase of mortality.However,little attention has been paid to the depressive symptoms of musculoskeletal disease.Therefore,this study investigated the prevalence of depressive symptoms in elderly patients with femoral neck fracture,and to explore the effect of depressive symptoms on the curative effect of artificial femoral head replacement in elderly patients with femoral neck fracture.Methods:Between January 2015 and January 2019 in Beijing Hospital,artificial femoral head replacement was performed in 434 elderly patients with femoral neck fracture that were enrolled in the study.There were 133 males and 301 females with an average age of(75.0±4.4)years.Patients with pathological fracture and cognitive impairment were excluded.All patients were divided into depression group(226 cases)and non-depressed group(208 cases)by geriatric depression scale(GDS).The Harris hip joint score and visual analogue scale(VAS)were compared after three months and 12 months postoperatively.The data were analyzed by chi-square test,t test and repeated measure ANOVA.Results:there was no significant difference in preoperative demographic data between depression group and non-depression group.However,patients with preoperative depression showed poorer improvement than non-depressed patients in the surgery outcome:Harris scores improved(73±3)versus(85±5)at three months(t=29.614,P<0.001)and(82±4)versus(93±4)at 12 months(t=32.252,P<0.001).VAS scores increased at 12 months(2.7±0.7)versus(0.7±0.4)(t=35.739,P<0.001).Conclusion:Preoperative depression has adverse effects on functional recovery and pain relief after artificial femoral head replacement in the elderly.Routine screening for depressive symptoms during the initial hip fracture assessment can identify patients with low recovery potential.To avoid the adverse effects of depression on prognosis,it may be necessary to use multidisciplinary methods to solve the patient’s physical function and mental state at the same time.If necessary,psychological and/or drug treatment can be started as early as possible,which may change the adverse effects of depressive symptoms on short-term and long-term functional prognosis of hip fracture.Part Ⅳ:The effect of vitamin D supplementation on depressive symptoms in the elderlyObjective:Depression is a mood disorder or affective disorder mainly characterized by depressed mood,mainly manifested as low mood,anhedonia,irritability and self-denial.Depression has become a common disease worldwide which is the leading cause of disability.On World Health Day of 2017 the statistics released by MHO showed that there are more than 350 million people with depression in the world.The prevalence of depression among middle-aged and elderly people in China is 20.3%in urban areas and 31.8%in rural areas.The incidence of depression in middle-aged and elderly patients with acute and chronic musculoskeletal pain is significantly higher than that in patients with internal diseases,which is more than 3 times that in the general population.On the contrary,depressive symptoms have an extremely negative impact on the physical function and quality of life of the elderly,including functional decline,physical disability,decreased quality of life,and increased mortality associated diseases.But depressive symptoms that occur in middle-aged and elderly patients are often undetected or undertreated.Vitamin D plays an important role in body function.Central nervous system,including hippocampus and amygdala,which control human mood and behavior,has receptors of vitamin D and its enzyme activators.Vitamin D may affect depressive symptoms,but its efficacy and safety remain controversial.In view of the fact that the prevention and treatment of depressive symptoms in the elderly is a vital issue,vitamin D may have a potential effect on depressive symptoms,and there are few randomized controlled trials in China to test the effect of vitamin D supplementation on depression in the elderly.Therefore,this study investigated the status of depression in elderly patients with chronic musculoskeletal pain and explored the effect of vitamin D supplementation on depressive symptoms in the elderly.Methods:Between October 2019 to October 2020 in the Department of Orthopedics and Neurology of Beijing Hospital,a total of 152 patients with chronic musculoskeletal pain and depression who were hospitalized were selected,aged 60-87 years old.The patients were divided into the intervention group(n=76)and the observation group(n=76)by random number table method.In addition to conventional treatment,the two groups were additionally supplemented with vitamin D.Both groups received vitamin D3 supplementation of 2000U(intervention group)or 400U(control group)daily for 12 weeks,respectively.The main outcome measures included the Geriatric Depression Scale(GDS-30)questionnaire and 25-hydroxyvitaminD[25-hydroxyvitamind,25(OH)D].Chi-square test was used for the comparison of classified variables,Mann Whitney U test and Wilcoxon signed rank sum test were used for the comparison of continuous variables.Multiple regression analysis was conducted for depression score as the dependent variable to evaluate the influencing factors of depressive symptoms.Results:A total of 148 subjects were enrolled,75 in the intervention group and 73 in the control group.There was no statistical significance in the shedding rate and elimination rate between the two groups(P>0.05).There were no significant differences in gender,age,education level,life style,concomitant diseases and depression between the two groups(P>0.05).The median baseline concentration of 25(OH)D was 12.4 ng/ml in the intervention group and 12.8 ng/ml in the control group(Z=0.232,P>0.05).The depression scores of the two groups before intervention were 15 and 14 respectively(Z=1.714,P>0.05).After 12 weeks,25(OH)D increased to 34.6 ng/ml in the intervention group(Z=7.558,P<0.05)and to 19.5 ng/ml in the control group(Z=7.434,P<0.05).Depression scores in the intervention group decreased from 15 points to 12 points(Z=7.340,P<0.05),and in the control group from 14 points to 13 points(Z=5.164,P<0.05).The increase of 25(OH)D level and the improvement of depression degree in the intervention group were significantly better than those in the control group(Z=7.397,P<0.05;Z=2.227,P<0.05).Multiple regression analysis showed that intervention grouping and pre-intervention depression score were the influential factors of post-intervention depression score(R2=0.727,F=62.459,P<0.05).Conclusions:Vitamin D supplementation may reduce depression scores in people 60 years of age and older and may help improve depressive symptoms in older adults with chronic musculoskeletal pain.