Factors affecting mortality in nonagenarian population following surgery for fragility hip fractures: An experience from a tertiary level trauma center in India

Introduction: Fragility hip fractures in nonagenarian patients pose a great challenge in management. To the best of our knowledge, no study has previously evaluated the outcomes and risk factors for mortality after hip fractures in this subgroup of population from the Indian subcontinent. Materials and Methods: A retrospective observational study was performed on nonagenarian patients (aged ?90) who underwent surgery for hip fractures between March 2016 and March 2019. The patients were divided into two groups: “survivor group” (Group A) and “mortality group” (Group B). The demographic data, type of fracture, side of fractured limb, preinjury ambulatory status, American Society of Anesthesiologists (ASA) status, comorbidities, time interval from injury to surgery, operative time, length of hospital stay, and postoperative ambulatory status were recorded from hospital medical records and were studied between the two groups. The follow-up duration of the study was 1 year. Results: Thirty-four patients were included in the study. Both the groups had 17 patients each. Cardiac dysfunction was the most common cause of mortality. The time interval from injury to surgery (odds ratio [OR] = 11.2), gender (OR = 0.23) and postoperative mobility status (OR = 0.07) were found to be significantly different between the two groups. No significant difference in ASA grade, comorbidities, fracture type, preinjury ambulatory status, operative time, and length of hospital stay was seen between the two groups. Conclusions: Risk factors for mortality after hip fracture surgery in the nonagenarian population are male gender, delay in surgery (>3 days) and poor ambulatory status in the postoperative period. Hence, the aim for such patients with hip fractures should be to perform an early surgery and encourage an early ambulation.

Outcomes in Nonagenarians with Hip Fractures Treated Conservatively and Surgically

@#Introduction: We aimed to assess the clinical outcomes in nonagenarians following a hip fracture. We also further investigated the factors that influence these outcomes, such as method of treatment (operative versus conservative), comorbidities, and pre-morbid function. Materials and methods: We studied 65 nonagenarians that were identifiable from our hospital hip fracture database. We reviewed various parameters of these patients admitted after sustaining a hip fracture (neck of femur or intertrochanteric) and investigated how these parameters affected patient outcomes. The main outcomes studied were: inpatient morbidity, and mortality at one year. Results: Inpatient morbidity was more likely in patients with an ASA grade of 3 to 5. Urinary tract infection was the most common medical complication. The 1-year mortality was 15.4% and was significantly influenced by advancing age. Surgically managed patients had a 1-year mortality rate (14.3%) slightly less than non-operative patients (17.4%). Post injury mobility was significantly better in those who received operative treatment with 63% of surgical cases regaining ambulatory status versus 7% of conservatively managed patients. Conclusions: We presented the outcomes of hip fractures in an extreme age group in the population. In nonagenarians with hip fractures surgery was associated with a 1-year mortality rate of 14.3% which is comparable to the general hip fracture population and less than the mortality rate of conservatively managed patients (17.4%). The primary advantage of surgery would be that two-thirds of patients return to ambulatory status. This information is useful to counsel patients and their families especially since the elderly are often more fearful of surgical intervention.

Fractura de cadera en el paciente mayor de 90 años: nuestro nuevo desafío / Hip fracture in the extremely elderly: our new dilemma

INTRODUCCIÓN: El envejecimiento mundial de la población ha resultado en un aumento de las fracturas de cadera y sobre todo en pacientes cada vez más añosos. El objetivo es buscar la mortalidad al año y factores asociados en nuestra realidad nacional. MATERIALES Y MÉTODOS: Estudio retrospectivo observacional de fichas clínicas e imagenología de pacientes mayores de 90 años operados por fractura de cadera en la capital de nuestro país. Se presentan dos grupos según su sistema previsional, pacientes pertenecientes al sistema de salud público (SSPu) y pertenecientes a un sistema de salud privado (SSPr). Se realiza análisis estadístico univariado y multivariado con test de Chi2, Mann-Whitney y regresión logística. RESULTADOS: 129 pacientes mayores de 90 años operados por fractura de cadera (85 pertenecientes al SSPu y 44 en el SSPr), cumplieron con criterios de inclusión y exclusión en un período de 2 años. El promedio de edad general fue de 93,2 años (SD 2,9) sin diferencia entre grupos. El tiempo preoperatorio fue significativamente menor en el SSPr con mediana de 1 día (0­7) y de 6 días (1­40) para el SSPu (p < 0,001). La mortalidad general al año fue de 30,2% siendo de 38,8% para el SSPu y de 13,6% para el SSPr con diferencia significativa (p = 0,003). No se encontró asociación estadística en la mortalidad al año con las variables edad, género ni tipo de fractura. Se encontró asociación entre la mortalidad al año y menor tiempo preoperatorio (p < 0,001). En el análisis multivariado de mortalidad el único factor protector fue pertenecer al SSPr (p = 0,010). DISCUSIÓN: La mortalidad general de nuestros pacientes es similar a lo encontrado en la literatura internacional, siendo el menor tiempo preoperatorio y pertenecer al sistema de salud privado factores asociados a menor mortalidad al año, donde ese último es el único factor asociado en el estudio multivariable. Este estudio aporta a la contingencia nacional en describir cómo se comporta nuestra población tanto en el sistema de salud privado como en el público. Es necesario estudiar el efecto en la mortalidad de otros factores asociados que no fueron evaluados en el presente trabajo.

INTRODUCTION: The aging of world population has resulted in an increase of hip fractures and especially in extremely elderly patients. The objective is to describe 1-year mortality in these patients in our national reality. MATERIALS AND METHODS: Observational retrospective study of clinical records and imaging of patients over 90 years old who were operated for hip fracture in the capital of our country, belonging one group to private care health system (SSPr) and the other group to the public health system (SSPu). Statistical analysis was performed to type of implant and mortality. RESULTS: 129 patients over 90 years old were operated for hip fracture (85 in the SSPu and 44 in the SSPr) in a period of 2 years. The average age was of 93.2 years (SD 2.9) without statistical difference between groups. Preoperative time was significantly lower in SSPr group with mean of 1 day (0­7) for the SSPr and 6 days (1­40) for the SSPu (p < 0,001). The overall 1-year mortality was 30.2%; 38.8% in the SSPu and 13.6%%, which was statistically relevant (p = 0,003). No association was found between 1-year mortality and age, sex or fracture type. Statistical association was found between preoperative time and 1-year mortality where patients who have lower preoperative time have lower 1-year mortality (p < 0,001). Association was found between lower 1-year mortality and belonging to SSPr. This last association was the only one with statistical relevance in the multivariable analysis (p = 0,010) DISCUSSION: Surgery for hip fractures in extremely elderly patients is an increasing reality in our country. The overall mortality of our patients is similar to that published in the international literature, where belonging to private care health system and having a low preoperative time is associated with a lower 1-year mortality in our study. This study contributes to the national contingency in the sense of how our population develops in the private sphere as well as in the public care. It is necessary to study the effect on mortality of other associated factors that were not evaluated in the present study.

Prediction of Mortality in Nonagenarians Following the Surgical Repair of Hip Fractures

BACKGROUND: The purpose of this study is to report on the mortality of nonagenarians who underwent surgical treatment for a hip fracture, specifically in regards to preexisting comorbidities. Furthermore, we assessed the effectiveness of the Deyo score in predicting such mortality. METHODS: Thirty-nine patients over the age of 90 who underwent surgical repair of a hip fracture were retrospectively analyzed. Twenty-six patients (66.7%) suffered femoral neck fractures, while the remaining 13 (33.3%) presented with trochanteric type fractures. Patient charts were examined to determine previously diagnosed patient comorbidities as well as living arrangements and mobility before and after surgery. RESULTS: Deyo index scores did not demonstrate statistically significant correlations with postoperative mortality or functional outcomes. The hazard of in-hospital mortality was found to be 91% (p = 0.036) and 86% (p = 0.05) less in patients without a history of congestive heart failure (CHF) and chronic pulmonary disease (CPD), respectively. Additionally, the hazard of 90-day mortality was 88% (p = 0.01) and 81% (p = 0.024) less in patients without a history of dementia and CPD, respectively. The hazard of 1-year mortality was also found to be 75% (p = 0.01) and 80% (p = 0.01) less in patients without a history of dementia and CPD, respectively. Furthermore, dementia patients stayed in-hospital postoperatively an average of 5.3 days (p = 0.013) less than nondementia patients and only 38.5% returned to preoperative living conditions (p = 0.036). CONCLUSIONS: Nonagenarians with a history of CHF and CPD have a higher risk of in-hospital mortality following the operative repair of hip fractures. CPD and dementia patients over 90 years old have higher 90-day and 1-year mortality hazards postoperatively. Dementia patients are also discharged more quickly than nondementia patients.

Mortality after Hip Fractures in Nonagenarians

OBJECTIVES: Nonagenarians with hip fractures represent a special group of people because of their advanced age and co-morbidities. We evaluated mortality after hip fractures in nonagenarians. METHODS: Fifty-one patients were studied over a 2-year period. There were 39 female and 12 male patients. Twenty seven patients sustained an intertrochanteric fracture of the femur, 24 suffered from femoral neck fracture. The American Society of Anaesthetists (ASA) score of II was the most frequent among 51. Forty-one of them had one or more co-morbidities. Patient review was done 2 years after the fracture. RESULTS: The mortality rate at one year was 53.4% in men, and 15.7% in women. After multivariate analysis, the type of fracture (intertrochanteric fracture) was identified as a risk factor for one-year mortality (P = 0.025). CONCLUSION: The outcome in nonagenarians with hip fractures is poor due to the high rates of mortality, especially in men, and this could be informed to patients and their families before hip fracture surgery.

The Impact of Mitral Annular Calcification on Left Ventricular Function in Nonagenarians

BACKGROUND AND OBJECTIVES: Mitral annular calcification (MAC) is known to be associated with degenerative processes of the cardiac fibrous skeleton and cardiovascular disease mortality. However, MAC has not been evaluated in an extreme age group (patients > or =90 years of age). In this study, the clinical significance of MAC associated with aging was examined in this age group and compared with MAC associated with aging in a younger (20 to 50 years of age) group of patients. SUBJECTS AND METHODS: We assessed echocardiographic parameters in 43 nonagenarians and 51 young patients. In the nonagenarian group, patient's age was 92+/-2 years and 27% were male; in the young control group, patient's age was 36+/-9 years and 51% were male. Comprehensive M-mode and Doppler echocardiography, including tissue Doppler imaging, were performed. The frequency and severity of MAC was assessed from the leading anterior to the trailing posterior edge at its largest width for least 3 cardiac cycles. RESULTS: Echocardiography showed that the left ventricular (LV) end-diastolic dimension was larger in the young controls (p=0.007); however, the ejection fraction (EF) was lower in the nonagenarian group (p=0.001). The frequency of MAC was greater in nonagenarians {42/43 (97%)} than in controls {9/51 (17%), p<0.0001}. The maximal width of MAC was larger in nonagenarians (0.52+/-0.17 mm and 0.05+/-0.13 mm, p<0.0001). MAC was correlated with LV mass index (g/m2) (r=0.280, p=0.014) and EF (%) (r=-0.340, p=0.001). More importantly, early mitral inflow velocity/early diastolic mitral annulus velocity (E/E') was strongly correlated with MAC in non-agenarians (r= 0.683, p<0.0001). CONCLUSION: MAC may be associated with extreme age and increased LV filling pressure in nonagenarians. Further study is necessary to assess the cardiovascular mortality and structural changes related to mitral annulus calcification associated with aging.

Preoperative transthoracic echocardiography in patients older than 90 years undergoing noncardiac surgery / 대한내과학회지

BACKGROUND/AIMS: Adverse cardiac events pose a significant perioperative risk to patients undergoing noncardiac surgery, especially geriatric patients. This study presents resting echocardiography data for a population older than 90 years. METHODS: We performed transthoracic echocardiography in 108 patients who were older than 90 years and scheduled to undergo noncardiac surgery between November 1, 2004, and September 22, 2008, and evaluated their medical histories and electrocardiograms. RESULTS: The 108 patients included 73 (67.3%) women and 35 (32.7%) men with a mean age of 92.0+/-2.77 years (range 90-104). Their medical histories included hypertension in 38.9% and diabetes mellitus in 15.7%. The average left ventricular end diastolic dimension and ejection fraction were 49.0+/-6.3 mm and 62.9+/-11.1%, respectively. Six (5.6%) patients had clinically significant aortic regurgitation and seven (6.5%) had mitral regurgitation as pathologic changes of aging. Six patients had mild to moderate aortic stenosis, found incidentally, that did not affect the clinical decision regarding the scheduled operation. The diastolic parameters showed that most of the patients (87%) had grade I relaxation abnormalities. The average mitral inflow E/A, deceleration time, and E/E's were 0.69+/-0.33, 266+/-82 msec, and 11.15+/-3.88, respectively. CONCLUSIONS: Echocardiography cannot predict all of the postoperative cardiovascular complications and risks, but it is useful for screening for significant left ventricular dysfunction, valvular abnormalities, and as a guide for managing extremely old patients in the perioperative period.

Heart failure in very elderly population- a profile of heart failure in patients over the age of eighty / 老年心脏病学杂志（英文版）

Objective Heart failure is an epidemic in the elderly, but there is a striking lack of data in this clinically important patient population. We investigated the demographics, cardiac performance, and medication management of a segment of the hospital population in at least their eighth decade of life. Methods We retrospectively reviewed 75 records of heart failure patients who were 80 years of age or older. Records were reviewed for demographic information, presence or absence of diastolic dysfunction, evaluation of ejection fraction, and medication usage including angiotensin-concerting enzyme (ACE) inhibitors, angiotensin receptor antagonists (ARBs),beta-adrenergic blockers, digoxin, and aldosterone antagonists. Assessment for contra-indications to ACE inhibitor or ARBs use was also performed to assess co-morbidities that limit treatment of heart failure. Results The population of very elderly with heart failure is heterogeneous. We found a higher proportion of females as well as higher rates of diastolic dysfunction in patients aged ≥ 90 years compared to patients between the ages of 80-89 years. Usage of ACE inhibitors, ARBs and beta-adrenergic blockers was strikingly low throughout the very elderly population. While co-morbid conditions limited use of agents in many cases, there was a lack of explicit contra-indication in most patients not on an ACE inhibitor or an ARB. Conclusions Heart failure is not a single disease processes, but a continuum of disease processes that vary with age. The elderly with heart failure are an undertreated population, in part due to the multitude of co-morbidities that affect them. Further prospective studies are needed to better understand the physiology and ideal treatment regiment in this growing population.