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The primary objective of the present systematic review and meta-analysis was to determine the effect of differing exercise intensity on (areal) bone mineral density (BMD) at lumbar spine and hip in adults by a comparative meta-analysis.A systematic review of the literature according to the PRISMA statement included: (a) exercise trials, (b) with ≥two study arms that compared different exercise intensities, (c) intervention ≥6 months, (d) BMD assessments at lumbar spine (LS) or hip. Five electronic databases were scanned without language restrictions up to July 2021. The present analysis of exercise intensity was conducted as a mixed-effect meta-analysis and applied "type of exercise" and "study duration" as moderator in subgroup analyses. Outcome measures were standardized mean differences (SMD) for BMD changes at the LS, and hip.Eleven exercise studies with 26 study arms were included. Although the effect of high-intensity exercise was more pronounced on LS-BMD (SMD: 0.19, 95%-CI: 0.61 to -0.23) and hip-ROI (0.17, 0.38 to -0.04), we did not observe significant differences between the groups (LS-BMD: p=0.373 and hip-BMD: p=0.109). We observed a substantial level of heterogeneity between the trials for LS- but not for hip-BMD. Applying "type of exercise" and "study duration" as moderators did not significantly modify the differences between low and high exercise intensity on BMD at LS or hip.There is insufficient evidence for a superior effect of high-intensity exercise on areal BMD at lumbar spine and hip in people aged 50 years and older. Varying exercise intensity with periods of lower exercise intensity intermitted by higher intensity might be a promising option to address the issue of exercise intensities in intervention studies.

Chronic pain in older adults should be explained and treated on the basis of the biopsychosocial model. With its interdisciplinary and interprofessional approach, multimodal pain therapy is the method of choice. In old age freedom from pain is usually not the primary goal. It is more important to restore the quality of life of those affected and to maintain independence and autonomy with a versatile treatment offer. This article explains the basics of multimodal pain therapy and its special features in old age.Chronische Schmerzen des älteren Menschen sollten auf Basis des biopsychosozialen Modells erklärt und therapiert werden. Die multimodale Schmerztherapie stellt durch ihren interdisziplinären und interprofessionellen Ansatz die Methode der Wahl dar. Im Alter ist meist nicht die Schmerzfreiheit das vorrangige Ziel. Vielmehr gilt es, über ein vielseitiges Therapieangebot die Lebensqualität der Betroffenen wiederherzustellen bzw. die Selbstständigkeit und Autonomie zu erhalten. Der vorliegende Beitrag erklärt die Grundlagen der multimodalen Schmerztherapie sowie ihre Besonderheiten im Alter.

The current corona crisis affects older patients as well as the geriatric infrastructure in all sectors. This article provides an overview about the current state of knowledge on COVID-19 with special consideration of geriatric aspects and the consequences for the geriatric care system.

The clinical symptom dizziness encompasses a broad range of complaints. The prevalence among older adults is high. Over the course of 1 year 50% of people over 80 years old, 30% of those between 70-80 years old and 20% between 60-70 years old contact a physician as a result of dizziness. The diagnostic process has to be well organized. The medical history and clinical examination are frequently underestimated but in many cases are crucial. Extensive investigations should only be carried out in cases of a firmly suspected diagnosis. A good interdisciplinary cooperation can positively influence the diagnostic process. The awareness of red flags also helps to detect emergency patients with dizziness. This article discusses the differential diagnosis of dizziness in older adults and provides appropriate recommendations for the diagnostic process.

Older hip fracture patients are still challenging in daily clinical practice. Due to the high prevalence of osteoporosis and atrial fibrillation in this age group, the number of fragility fracture patients under oral anticoagulation (OAC) increases. The outcome is still disappointing, short- and long-term mortality and morbidity is high. The impact of pre-existing OAC is not yet clear, especially regarding new OAC drugs like Factor Xa inhibitors (FXa). The purpose of our study was to compare the short-term outcome of older hip fracture patients, without OAC (controls), on Vitamin K antagonists (VKA) and on FXa.The study is a retrospective case-control study including patients older than 70 years who sustained hip fractures caused by an inadequate trauma and treated at a level 1 trauma center from February 2017 to June 2018. Patient's information was taken from patient's charts. 102 cases were analysed, 61 controls, 41 on OAC (15 on VKA and 26 on FXa). As outcome parameter we defined mortality, perioperative complications, bleeding, need of blood supplements, delay of surgery, length of stay, and a combined outcome parameter (mortality, myocardial infarction, stroke, thromboembolic events, blood preservations, re-vision surgery, major bleeding and decline of hemoglobin).Eight patients died during hospital stay, in-hospital mortality was 7.8%. The highest mortality rate was found in patients on VKA (20%), compared to patients on FXa (3.8%) and controls (6.6%). However, mortality rate did not differ significantly within the groups. The combined endpoint was significantly more frequently seen in patients on OAC compared to controls (p = 0.006). No difference was observed between patients on VKA or FXa. Mean time to surgery and LOS was significantly longer in patients on OAC compared to controls. No significant differences were seen between VKA and FXa.In our study OAC was significantly associated with worse outcome compared to controls. Marginal differences were observed between patients on FXa or VKA. Further studies involving a higher number of patients are necessary to confirm our results. At that time, some our results have to interpreted carefully and need confirmation.

Osteoporosis is a systemic bone disease with decreased bone strength and mass resulting in an increased predisposition to fracture risk. Especially older patients have a high risk for fragility fractures. In these patients an isolated view of osteoporosis without consideration of multimorbidity is insufficient. Various diseases are associated with osteoporosis because of shared pathophysiological mechanisms, risk factors or as a consequence of medication. Furthermore, geriatric syndromes, such as falls play an importance role. This article presents an overview about multimorbidity interactions based on selected frequent diseases in older age and shows the management in the clinical practice.

Background Fragility fractures are a major health care problem worldwide. Both hip and non-hip fractures are associated with excess mortality in the years following the fracture. Residents of long-term nursing homes represent a special high-risk group for poor outcomes. Orthogeriatric co-management models of care have shown in multiple studies to have medical as well as economic advantages, but their impact on this high-risk group has not been well studied. Objective We studied the outcome of long-term care residents with hip and non-hip fractures admitted to a geriatric fracture center. Methods The study design is a single center, prospective cohort study at a level-I trauma center in Austria running a geriatric fracture center. The cohort included all fragility fracture patients aged over 70 admitted from a long-term care residence from May 2009 to November 2011. The data set consisted of 265 patients; the mean age was 86.8 ± 6.7 years, and 80 % were female. The mean follow-up after the index fracture was 789 days, with a range from 1 to 1842 days. Basic clinical and demographic data were collected at hospital admission. Functional status and mobility were assessed during follow-up at 3, 6, and 12 months. Additional outcome data regarding readmissions for new fractures were obtained from the hospital information database; mortality was crosschecked with the death registry from the governmental institute of epidemiology. Results 187 (70.6 %) patients died during the follow-up period, with 78 patients (29.4 %) dying in the first year. The mean life expectancy after the index fracture was 527 (±431) days. Differences in mortality rates between hip and non-hip fracture patients were not statistically significant. Compared to reported mortality rates in the literature, hip fracture patients in this orthogeriatric-comanaged cohort had a significantly reduced one-year mortality [OR of 0.57 (95 % CI 0.31–0.85)]. After adjustment for confounders, only older age (OR 1.091; p = 0.013; CI 1.019–1.169) and a lower Parker Mobility Scale (PMS) (OR 0.737; p = 0.022; CI 0.568–0.957) remained as independent predictors. During follow-up, 62 patients (23.4 %) sustained at least one subsequent fracture, and 10 patients (3.4 %) experienced multiple fractures; 29 patients (10.9 %) experienced an additional fracture within the first year. Nearly, half (47.1 %) regained their pre-fracture mobility based on the PMS. Conclusion Despite the generally poor outcomes for fragility fracture patients residing in long-term care facilities, orthogeriatric co-management appears to improve the outcome of high-risk fragility fracture patients. One-year mortality was 29.4 % in this cohort, significantly lower than in comparable trials. Orthogeriatric co-management may also have positive impacts on both functional outcome and the risk of subsequent fractures.

The present review gives a summary of recent epidemiological data on osteoporosis and the state of the quality of care especially regarding older adults. The results show that three quarters of all patients with vertebral and peripheral fractures are older than 65 years. Regarding hip fractures three out of four patients are older than 70 years. The association between age and fractures results as a direct consequence of the practically invariably present underlying osteoporosis and frequent falls in older adults.In Germany the prevalence of osteoporosis among women aged over 50 years is given as 24% and among men as 6%. In contrast to men where the incidence continues to rise, there is a small decrease of the incidence of hip fractures among women. Despite this decrease an enormous increase in both sexes is expected caused by the ongoing demographic changes with substantial socioeconomic consequences.Despite this development, the treatment rates of patients with osteoporosis or fragility fractures have remained low for many years. In contrast, national and international studies have shown that the rate of subsequent fractures could be reduced by up to 50% by using various measures to improve osteoporosis care, such as a fracture liaison service, providing adherence is maintained by the patients.

In the original publication of this article, the members of the FORTA group were provided in such a way that they could not be indexed as collaborators on PubMed. The article should have included an Acknowledgement section as shown below.

Monoclonal antibodies are already used for many different clinical indications. Besides oncology and rheumatology, denosumab is the only antibody that is currently prescribed in older adults with osteoporosis; however, apart from osteoporosis there might be more possible indications for the use of antibodies in chronic diseases and geriatric syndromes. Particularly, with respect to sarcopenia the transition to "doping for older adults" seems to be fluent. The present review provides an overview on the newest developments and prospective options.

Osteoporosis is defined as a systemic bone disease with decreased bone strength and an increased susceptibility for fractures. Older people in particular face an increased risk of fractures. These kind of fractures are usually caused by an inadequate trauma and are the so-called fragility fractures. In older adults immediate fracture stabilization and early mobilization have become the standard procedure after a fragility fracture. Treatment of the underlying osteoporosis often plays a minor role in clinical practice. Only a small group of patients are already under osteoporosis medication and even after a fracture occurs only few patients receive osteoporosis drug treatment with the aim to reduce the progression of osteoporosis and to reduce subsequent fractures. In the literature this has been described as the osteoporosis care gap. The following article presents an overview of treatment options and answers many different questions from the clinical routine.

ZusammenfassungEine rasche chirurgische Versorgung der Frakturen und folglich eine möglichst rasche nachfolgende Mobilisierung sind mittlerweile zum Standard der Frakturversorgung im Alter geworden. Die Therapie der zugrunde liegenden Osteoporose tritt häufig in den Hintergrund der medizinischen Akutversorgung. Nur ein kleiner Anteil der Patienten ist vortherapiert, nur wenigen Patienten wird nach erlittener osteoporotischer Fraktur eine umfassende osteologische Medikation verschrieben, die die Progredienz der Osteoporose mindern und das Eintreten weiterer Frakturen reduzieren soll. Diese Minderversorgung ist in der Literatur als „osteoporosis care gap” bekannt. Der folgende Beitrag gibt einen Überblick über die Therapiemöglichkeiten und beantwortet zahlreiche Fragestellungen aus dem klinischen Alltag.

The number of osteoporotic fractures is still increasing and the overall management of these multimorbid patients is demanding. Surgical management of these fractures is challenging due to often comminuted fractures and poor purchase of implants. New implants and some with add-on possibilities such as standardized cement augmentation have been developed to address these problems. With these technical innovations the overall patient outcome can be improved. This review describes general considerations in operative treatment of osteoporotic fractures and gives recommendations for a selection of frequent fracture types.

Summary Background and purpose Osteoporotic fractures are an increasing problem in the world due to the ageing of the population. Different models of orthogeriatric co-management are currently in use worldwide. These models differ for instance by the health-care professional who has the responsibility for care in the acute and early rehabilitation phases. There is no international consensus regarding the best model of care and which outcome parameters should be used to evaluate these models. The goal of this project was to identify which outcome parameters and assessment tools should be used to measure and compare outcome changes that can be made by the implementation of orthogeriatric co-management models and to develop recommendations about how and when these outcome parameters should be measured. It was not the purpose of this study to describe items that might have an impact on the outcome but cannot be influenced such as age, co-morbidities and cognitive impairment at admission. Methods Based on a review of the literature on existing orthogeriatric co-management evaluation studies, 14 outcome parameters were evaluated and discussed in a 2-day meeting with panellists. These panellists were selected based on research and/or clinical expertise in hip fracture management and a common interest in measuring outcome in hip fracture care. Results We defined 12 objective and subjective outcome parameters and how they should be measured: mortality, length of stay, time to surgery, complications, re-admission rate, mobility, quality of life, pain, activities of daily living, medication use, place of residence and costs. We could not recommend an appropriate tool to measure patients’ satisfaction and falls. We defined the time points at which these outcome parameters should be collected to be at admission and discharge, 30 days, 90 days and 1 year after admission. Conclusion Twelve objective and patient-reported outcome parameters were selected to form a standard set for the measurement of influenceable outcome of patients treated in different models of orthogeriatric co-managed care.

Digitalis und Theophyllin gehoren zu den altesten Medikamenten in der Behandlung von Herz-Lungen-Erkrankungen. Trotz der langen Tradition ist die Evidenz widerspruchlich, teils eher negativ. Besonders gros ist das Spannungsfeld in der Geriatrie. Einerseits haben beide Substanzen noch einen Stellenwert, insbesondere in fortgeschrittenen Stadien der Erkrankungen bzw. als symptomatische Therapie, andererseits werden sie auf Listen als potenziell ungeeignete Medikamente fur den alteren Patienten gefuhrt. Der vorliegende Beitrag beleuchtet die aktuelle Datenlage zu beiden Substanzen auf Basis der aktuellen Literatur.

The treatment of geriatric patients in the field of trauma surgery is increasingly gaining importance. To provide optimized treatment to these mostly multimorbid patients, interdisciplinary treatment concepts between trauma surgeons and geriatricians have been designed and implemented successfully.The aim of this survey was to evaluate the current state of interdisciplinary management in the treatment of geriatric patients on trauma surgery wards throughout Austria.The directors of 64 Austrian trauma surgery wards were surveyed using an online-questionnaire regarding the current interdisciplinary treatment of geriatric patients.A total of 39 (61 %) questionnaires were analyzed. Of the participating wards, 20 % distinguished between geriatric and non-geriatric patients. There were various criteria to classify the patients. The average percentage of patients older than 70 years was 43 %. Of the participating wards, 26 % had established a periodical cooperation between trauma surgeons and geriatricians and 8 % of the participants stated that there is no interdisciplinary cooperation. The establishment of an interdisciplinary treatment concept in the near future was planned in 28 %. The most commonly mentioned obstacle that prevented trauma surgery wards from establishing an interdisciplinary management model was the lack of personnel resources (59 %) - especially the lack of geriatricians (62 %).The survey's results underline the geriatric trauma surgery's great importance especially regarding the high percentage of geriatric patients, as well as the fact that the significance of the interdisciplinary cooperation between trauma surgeons and geriatricians is not yet perceived by the majority of Austrian trauma surgery wards.

Background Fragility fractures are a major health care problem worldwide. Due to the ageing population an increase of distal femoral fractures is to be expected. We studied the long-term functional outcome and their influencing factors in geriatric patients with LISS-plated distal femoral fractures. Patients and methods A cohort study with functional long-term follow up examination was carried out in a level one trauma centre on distal femoral fracture patients 65 years and older. Of 53 consecutive patients who were treated in our hospital, 43 patients with a mean age of 80 years met our inclusion criteria. 48.8% died within the study period of 5.3 years. On the remaining patients the residential status, the Barthel index and the Parker score were assessed. Results The mean Barthel index was 47.7 and the mean Parker score was 3.5. 23% were found to be totally housebound and 26% were not able to perform any social activity. Only 18% were able to walk unaided. Patients with any medical complication had significantly higher mortality rates. Patients with extraarticular fractures had better mobility scores. Nursing home residents showed higher mortality rates but compared to patients coming from their own home the difference regarding Barthel and Parker scores remained non-significant. Conclusion This study documents the poor functional long-term outcome of geriatric patients with distal femoral fractures. In comparison to other fragility fracture patients it seems that this population is at higher risk to die in-hospital during their perioperative course. Medical complications have to be avoided as they were found to be associated with worse functional outcome and higher mortality rates. An osteoporosis therapy may be associated with reduced mortality rates also in these patients.

Vorhofflimmern ist die haufigste Herzrhythmusstorung bei geriatrischen Patienten, die Pravalenz bei uber 80-Jahrigen betragt etwa 10%. Patienten mit Vorhofflimmern haben ein doppelt so hohes Mortalitatsrisiko, das Risiko fur einen Schlaganfall ist um den Faktor 5 erhoht. Im Gegensatz dazu stehen die aktuellen Leitlinien der Europaischen Kardiologischen Gesellschaft (ESC), die diese Patientengruppe kaum berucksichtigen. Insbesondere mangelt es an Empfehlungen zu alltaglichen Fragen in der klinischen Betreuung dieser Patientengruppe. Ziel der vorliegenden Arbeit ist, fur geriatrisch tatige Kolleg(inn)en unter Aufarbeitung der spezifischen Fachliteratur die vorliegende europaische Leitlinie fur dieses Patientenkollektiv zu erganzen. Diskutiert werden die Themenbereiche Rhythmus- versus Frequenzkontrolle, Antikoagulation, Outcome und Pravention, Sturze, Compliance/Adharenz, Polypharmazie, geriatrisches Assessment, Demenz, Pflegeheimpatienten und Frailty nach Literaturrecherche in PubMed in Hinblick auf den geriatrischen Patienten. Individuelle Aspekte sollten in die Therapiegestaltung einfliesen, allerdings darf die Komplexitat dieser Patienten nicht zu einer bedingungslosen Individualisierung der Therapie abseits der Leitlinien fuhren. Denn es gibt zahlreiche Literaturstellen, mit denen sich viele offene Fragen im Zusammenhang mit Vorhofflimmern bei geriatrischen Patienten beantworten lassen.

The democratic shift poses new challenges in emergency medicine and intensive care. Old patients call for special needs that have to be taken into consideration during treatment. Due to the heterogeneity in this patient group biological age plays an important role. Mortality among old patients is high, but functionality and comorbidity have a great effect on patient outcome. Structural and functional organ changes have an additional impact on the treatment of geriatric patients in emergency medicine and intensive care. Therefore, basic geriatric knowledge should be part of the curricula of both, intensive care and emergency medicine.

Clostridium difficile is the main cause of nosocomial antibiotic-associated diarrhea in adults in Europe and North America. Infections with C. difficile typically occur in elderly patients with comorbidities and prior antibiotic therapy. Other risk factors are proton pump inhibitors, which are taken by many elderly patients. The main virulence factors are toxins A and B. The clinical spectrum ranges from asymptomatic colonization to severe disease with abdominal complications and sepsis. The current diagnostic gold standard is anaerobic culture but is impractical in routine use due to the long duration. Proven techniques involve glutamate dehydrogenase, toxins A and B immunoassays and PCR. First infections and recurrences can be treated with 400-500 mg metronidazole 3 times a day for 10 days. Further recurrences, serious infections or patients with more than two positive pred ictors should be treated orally with 125 mg vancomycin 4 times a day for at least 10 days. Fidaxomicin, rifaximin, stool transplantation and monoclonal antibodies are promising alternative therapies.

Proximal femoral fractures represent an increasing major healthcare problem due to the demographic changes in this aging population and are associated with the highest mortality among fractures in elderly patients after suffering insufficiency injuries (so-called fragility fractures). The main aim in the treatment of orthogeriatric patients who suffered from a proximal femoral fracture is the preservation of function and independency. Given the high prevalence of comorbidities in these patients, interdisciplinary and interprofessional approaches are required. The use of modern osteosynthesis procedures can provide an improved, individualized surgical treatment with early full weight bearing of the affected extremity. Another aspect is the accompanying geriatric treatment which is associated with a significant reduction of perioperative and postoperative complications. In addition to acute treatment, the organization of secondary fracture prevention is a crucial pillar of treatment. This article provides an overview of the essential elements of orthogeriatric trauma surgery in elderly patients following proximal femoral fractures.

Due to the demographic change fractures of the proximal femur are an increasing major healthcare problem and are associated with the highest mortality among frailty fractures.These mainly osteoporosis-associated fractures of the hip often represent a surgical challenge and the outcome has a decisive influence on the preservation of function and independency of orthogeriatric patients. Augmentation techniques could improve the stability of osteosynthesis in proximal femoral fractures.Cement augmentation of proximal femoral nailing (PFNA) for the treatment of pertrochanteric femoral fractures is the most commonly used and standardized method of augmentation for these fractures by which a safer condition for immediate full weight bearing and mobilization can be achieved.In biomechanical and clinical studies good fracture healing was shown and there was no evidence of cement-associated complications in augmented PFNA nailing. In the majority of patients the mobility level prior to trauma could be achieved.In addition to the optimal surgical treatment, secondary prevention such as osteoporosis management to avoid further fractures is crucial in the treatment of these patients. This article is based on the current literature and provides an overview of the possible applications of cement augmentation for the treatment of proximal femoral fractures. In addition the surgical approach as well as previous scientific data on an established osteosynthesis using cement-augmented PFNA for the treatment of pertrochanteric frailty fractures are presented.

Fragility fractures are becoming more common and are leading to significantly increased morbidity and mortality rates.In order to improve the outcome of these patients, they are increasingly being treated from the beginning interdisciplinarily and interprofessionally as part of co-management models. The main contents of these systems are rapid surgical stabilization for rapid remobilization, treatment with standardized paths and regular communication within the team and a well-functioning discharge management. Furthermore, the organization is a key ingredient in secondary prevention of geriatric traumatology.If this system can be implemented as a whole, this will lead to an improvement of the functional outcomes for the patient as well as to cost savings.

Sowohl bei der Entstehung als auch bei der Therapie der weiblichen Harninkontinenz spielen die Anatomie und die Funktion des Beckenbodens eine wichtige Rolle. Das Ziel dieser Fallkontrollstudie war es, festzustellen wie der Kenntnisstand geriatrischer Frauen mit Harninkontinenzsymptomen bezuglich ihres Beckenbodens, ist und wieweit sie imstande sind die Beckenbodenmuskulatur willkurlich willkurlich und reflektorisch zu kontrahieren. 377 geriatrische Frauen mit Harninkontinenzsymptomen wurden im Rahmen eines Harninkontinenz-Basis-Assessments untersucht. Die Fahigkeit zur Kontraktion der Beckenbodenmuskulatur wurde mittels einer digitalen vaginalen Palpation gepruft. Das Ausmas der festgestellten Muskelkraft wurde eingeteilt mit der sechsteiligen Oxford Grading Scale nach Laycock 1994. 65,5% der Patientinnen wussten nicht, was der Beckenboden ist und waren zu keiner Beckenbodenmuskelkontraktion fahig (Grad 0 bis 1 nach Laycock), 22% hatten eine vage Ahnung von der Lage ihres Beckenbodens—konnten aber nur eine insuffiziente Muskelkontraktion erreichen (Grad 2 nach Laycock). Nur bei 12,5% der Patientinnen konnte eine sichere, masige bis starke Muskelkontraktion festgestellt werden (Grad 3 bis 4 nach Laycock). Eine Untergruppe bestehend aus 83 Patientinnen hatte in der Vergangenheit bereits Bekkenbodenubungen durchgefuhrt, 80 davon mit konventionellen Unterweisungen, 3 mit digitaler vaginaler Kontrolle. In dieser Untergruppe konnten 54,2% der Patientinnen den Beckenboden nicht (Grad 0 bis 1 nach Laycock), 25,3% nur insuffizient (Grad 2 nach Laycock) kontrahieren. 20,5% waren zu einer sicheren Beckenbodenkontraktion fahig (Grad 3 bis 4 nach Laycock). Die 3 Patientinnen, deren Beckenbodenubungen mittels einer digitalen vaginalen Palpation kontrolliert worden waren, befanden sich in dieser Gruppe und erreichten eine Beckenbodenmuskelkraft Grad 4 nach Laycock. Ein groser Prozentsatz geriatrischer Patientinnen mit Harninkontinenzsymptomen hat keine oder eine eingeschrankte Kenntnis uber die Lage und die Funktion des Beckenbodens. Der Einsatz konventioneller Beckenbodenubungen ohne zielgerichtete Kontrolle scheint bei geriatrischen Patientinnen die Fahigkeit zu einer Beckenbodenmuskelkontraktion als Schutz vor einem unfreiwilligen Harnverlust nicht zu verbessern.

Osteoporosis is characterized by low bone mineral density and associated with low impact skeletal fractures most often involving the spine, hip, pelvis, proximal humerus and forearm. It is predominantly a disease of ageing, affecting primarily postmenopausal women, but also older men. Both hip and non-hip fractures are associated with excess mortality post-fracture. Fragility fractures can be acutely and subacutely life threatening for many older patients. Postmenopausal osteoporosis has a big impact on health care expenses, with associated spending expected to double for osteoporosis by the year 2050. Despite the severe medical and socioeconomic consequences of fragility fractures, treatment and prevention efforts remain inadequate, particularly in the oldest and highest-risk patients. Osteoporosis is still viewed as an inevitable consequence of aging, rather than an opportunity for treatment and prevention. Multiple factors contribute to the failure of initiating appropriate treatment for osteoporosis, even in patients with fragility fractures. Our review offers an overview of the current literature and offers answers common issues in the management of osteoporosis in older adults.

Hypertension has a high prevalence among elderly patients. Randomised trials have already demonstrated that treating healthy older persons with hypertension is highly efficacious. Nevertheless some questions have arisen. On the one hand the generalizability of these trial results, particularly for older persons with serious medical comorbidities and poor functional status, is not clear. On the other hand different antihypertensive drugs have shown to be effective. Which drug for which patient? Even data from randomised intervention trials showing that the treatment affects cardiovascular morbidity and mortality, were missing, ACE inhibitors have been used for more than a decade to treat high blood pressure. For a younger population the captopril prevention project showed no differences between ACE inhibitors and conventional antihypertensive treatment (diuretics, beta-blocker) concerning the primary endpoints (myocardial infarction, stroke and other cardiovascular death). The STOP-2 study also confirmed these results for elderly patients. When treating elderly patients one must be aware of physiological changes with age and the comorbidities. Of significance among this patient group is declining renal function. Admissions for uraemia that are related to the use of ACE inhibitors are still commonplace, although many cases are preventable by monitoring renal function, but guidelines are still missing. Concerning the comorbidities ACE inhibitors have benefits compared to other antihypertensive drugs, especially in cases of heart failure, diabetes and coronary heart disease.

Delirium is common in older adults in the perioperative period, being a complication in up to 60 % of major surgical procedures. Delirium has a significant impact on the medical, functional, and cognitive outcomes of older patients. Treatment of delirium can be quite complex and requires individualized patient assessment, plan of care, and empirical treatment. In light of the difficulties associated with delirium treatment and the complexity and frequent inadequacy of nonpharmacologic preventive measures, several drugs have been evaluated for efficacy in delirium prevention. We performed a literature review using Medline and the Cochrane Database for Systematic Reviews for randomized controlled trials, observational studies, and case reports evaluating pharmacologic treatments for prevention of delirium in older adults. Trials focused on patients with alcohol abuse were excluded. There is some preliminary evidence that haloperidol, newer neuroleptics (e.g., risperidone or olanzapine), and melatonin may be effective in reducing the incidence of postoperative delirium, but the data are not robust. Health care teams should still focus on traditional delirium prevention efforts, and reserve specific pharmacologic prevention to individual high-risk patients for whom the risks and benefits have been carefully considered.

Digitalis and theophylline are some of the oldest drugs used to treat cardiopulmonary diseases. Despite a long history, the evidence for both drugs is still inconsistent, in parts negative. In this context, geriatric medicine represents a special area of conflict. On the one hand, both drugs may play a role in the treatment of advanced heart failure and chronic obstructive pulmonary disease, particularly in the treatment of symptoms. On the other hand, both drugs are often listed as potentially inappropriate medications for the elderly. This paper discusses the evidence for both drugs based on the current literature.

Osteoporosis is very common in elderly patients. Despite the severe health-related consequences for individual patients and the socioeconomic costs caused by osteoporotic fractures, treatment rates are still low. Due to drug interactions and patient compliance, polypharmacy is often mentioned as a reason for undertreatment. Several drugs have a direct or indirect effect on bone metabolism. The present paper discusses the risk of interactions of anti-osteoporotic drugs (oral and parenteral bisphosphonates, raloxifene, strontium ranelate, teriparatide, and denosumab) with other common medications in elderly patients and their impact on bone metabolism and fracture risk. In summary, the number and risk of drug interactions of all common anti-osteoporotic drugs are small and clinically rather irrelevant. However, patients with a polypharmacy are at a higher risk of fractures and should receive osteoporosis treatment, if indicated.

Due to the demographic changes of the last few decades, there has been a significant increase in the number of osteoporotic fractures. After a fracture, geriatric patients are at particularly high risk for an increase of their functional impairments as well as a loss of independence and quality of life. In spite of the severe medical and socioeconomic consequences of fragility fractures, osteoporotic treatment and prevention are still insufficient. Based on the current literature, the pharmacological and nonpharmacological treatment options as well as new surgical techniques for geriatric patients are reviewed.