Increased age is not associated with higher incidence of complications, longer stay in acute care hospital and in hospital mortality in geriatric hip fracture patients

doi:10.1016/j.maturitas.2012.11.003

Maturitas

Volume 74, Issue 2, February 2013, Pages 185-189

https://doi.org/10.1016/j.maturitas.2012.11.003 Get rights and content

Abstract

The number of agile patients in the 10th decade with a strong need for postoperative mobility will increase in the following decades. The present prospective study sought to prove if very old patients with hip-related fractures are disadvantaged according to incidence of complications, length of ICU and in-hospital stay, and in-hospital mortality. We included 402 patients, age 60 years and older, with hip related fractures. Operative treatment consisted of osteosynthesis or endoprothesis. ASA score, body mass index, Charlson Comorbidity Index, Barthel Index and Mini-Mental-Status were documented. We noted length of in-hospital stay and ICU stay as well as readmission to ICU and complications, including their dispersal according to Clavien–Dindo Classification. After univariate analysis, a multivariate analysis was performed. The examined cohorts were 85 patients aged 60–74 years, 253 75–90 years old and 64 >90 year old patients. In-hospital periods (13–14 days) mean stay on ICU (2 days) and frequency of readmission on ICU did not significantly differ statistically. Most complications were grade II, with comparable frequency and modality, displaying no significant difference throughout age-related groups (p = 0.461). In-hospital mortality showing significance (p = 0.014) only between 75–89 (4.4%) and >90-year-old (12.5%) cohort. Nevertheless, according to multivariate analysis, including the common risk factors, increased age was not an independent risk factor for dying (p = 0.132). Patients at an advanced age with hip-related fractures showed neither a prolonged in-hospital nor ICU stay. There was no significant relation of advanced age to number and type of complications.

Introduction

The number of individuals at extreme old age is predicted to increase dramatically over the next decade [1]. Hip-related fractures are typical geriatric fractures. As shown in several studies, substantial femoral bone loss continues throughout the old age, followed by an exponential increase in the risk of hip fracture [2], [3]. Although osteoporosis plays a prominent role in the pathogenesis, there are many more factors of impact like atrophia of the musculoskeletal system, insecurity in coordination and walking and loss of sensorial skills [4].

In 2008, nearly 140,000 fractures (ICD 10 S.72.0–72.2) were registered in Germany [5]. These injuries display one of the most serious healthcare problems affecting the elderly, contributing to estimated costs of 2–4 billion euros per year in Germany [6]. Due to demographic transition, global incidence of hip related fracture is increasing [7], [8], [9].

Hip-related fractures are typically followed by a large number of peri- and postoperative complications. Specifically, the amount of outpatient care significantly rises after a femur fracture [10].

Most patients with fractures of the proximal femur are in the 8th decade. Until age 85, 11% of women and 5% of men are hospitalized because of femoral fractures [11]. Mortality in this cohort, compared to people the same age without fracture, is increased by 1.15–1.20 [4].

Considering that age-related mortality in patients >90 years is near 50%, the risk of suffering femoral fracture does not seem high. Literature addressing the outcomes of patients in the 10th decade is limited. The Scottish Hip Fracture Audit, a prospective, national, multicenter study, showed an age-related decrease of survival and favorable outcomes after surgery for the treatment of a hip fracture [12].

The present study was conducted to prove if patients in the 10th decade with hip-related fractures are disadvantaged according to incidence and type of complications, length of ICU stay, possible readmission to ICU, length of in-hospital stay, and short-term mortality.

Section snippets

Patients and methods

402 patients of at least 60 years old with proximal femoral fractures (ICD 10 S.72.0–72.2) were included in this prospective single center observational study. Criteria for exclusion were multiple traumas (injury severity score ≥16) and malignoma-associated fracture. All patients were surgically treated either with osteosynthesis or hip arthroplasty. The inclusion period lasted from the 1st of April 2009 to the 30th of September 2011. Approval from the University of Marburg's Ethics Committee

Results

In the observational period we were able to include 402 patients. 293 (73%) were females and 109 (27%) were males. The average age of patients was 81.4 years (range 60–99).

Examined cohorts showed 85 patients between 60 and 74 years, 253 patients from 75 to 90 years old, and 64 patients over 90 years with a ratio (f:m) of 2.7:1.

Further baseline data is shown in Table 1. Time from admission to operative treatment showed no statistically significant difference. The in-hospital period was similar,

Discussion

The aim of the present study was to prove if extremely old patients suffering hip-related fracture are severely endangered according to the incidence of complications, length of ICU and in-hospital stay, and short-term mortality.

Cognitive impairment increased with age, and >90 year old patients had significant lower BMI levels compared to the middle-aged cohort. Patients in very advanced age showed neither significantly higher percentage of diagnosed osteoporosis (p = 0.171), nor significantly

Contributors

All authors declare that they participated in the collection of data, analysis and interpretation, and writing of the manuscript and that they have approved the final version.

Competing interest

All authors declare that they have no competing interests.

Funding

There was no funding for this study.

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Cited by (38)

A predictive model for increased hospital length of stay following geriatric hip fracture
2019, Journal of Clinical Orthopaedics and Trauma
The purpose of this study was to identify the risk factors that are significantly associated with hospital length of stay (LOS) following geriatric hip fracture and to use these significant variables to develop a LOS calculator.
This was a retrospective study examining 614 patients treated for geriatric hip fracture between January 2000 and December 2009 at an urban, Level 1 trauma center. A negative binomial regression analysis was used to identify perioperative variables associated with hospital LOS.
614 patients met the inclusion criteria, presenting with a mean age of 78 (±10) years. The most common pre-operative comorbidity was hypertension, followed by diabetes and COPD. After controlling for all collected comorbidities as well as demographics and operative variables, hypertension (IRR: 1.10, p = 0.029) and disseminated cancer (IRR: 1.24, p = 0.007) were found to be significantly associated with LOS. In addition, two demographic/presenting variables, admission to the medicine service (IRR: 1.48, p < 0.001) and male sex (IRR: 1.09, p = 0.034), were shown to be independent risk factors for prolonged LOS. These variables were synthesized into a LOS formula, which estimated LOS to within 3 days of the true length of stay for 0.758 of the series (95% confidence interval: 0.661 to 0.855).
This study identified several comorbidity and perioperative variables that were significantly associated with LOS following geriatric hip fracture surgery. The resulting LOS model may have utility in the risk stratification of orthopaedic trauma patients presenting with hip fracture.
Usefulness of simple biomarkers at admission as independent indicators and predictors of in-hospital mortality in older hip fracture patients
2018, Injury
Citation Excerpt :
Associations between 5 other on-admission clinical parameters and in-hospital mortality found by the univariate analysis, however, disappeared, indicating that these factors are incorporated in the underlying chronic diseases. It appears that age [5,104,105] and male gender [5,106], traditional mortality indicators in HF patients, are confounding factors affecting survival, rather than independent prognostic factors. The final multivariate model based on 14 candidate laboratory variables and 8 clinical characteristics (each with p ≤ 0.10 on univariate analyses) identified the following seven factors as independent statistically significant on-admission indicators of in-hospital mortality: albumin <33 g/L, 25(OH)D <25 nmol/L, PTH >6.8 pmol/L, GGT/ALT >2.5, CKD, history of MI, and COPD.
The data on predictive value of the routinely obtained preoperative biochemical parameters in hip fracture (HF) patients are limited. The aims of this study were to examine in older HF patients (1) the relationships between a broad set of routine laboratory parameters at admission and in-hospital mortality, and (2) evaluate the prognostic value the biomarkers and clinical characteristics (alone or in combination) provide to predict a fatal outcome.
In 1820 consecutive patients with low-trauma osteoporotic HF aged >60 years (mean age 82.8 ± 8.1 years; 76.4% women; 65% community-dwelling) 35 laboratory variables along with 20 clinical and socio-demographic characteristics at admission were analysed. The validation cohort included data on 455 older (≥60 years of age) HF patients (mean age 82.1 ± 8.0 years, 72.1% women).
The mortality rate was 6% (n = 109). On univariate analysis 14 laboratory and 8 clinical parameters have been associated with in-hospital mortality. Multiple regression analyses determined 7 variables at admission as independent indicators of a fatal outcome: 4 biomarkers (albumin <33 g/L; alanine aminotransferase/gamma-glutamyl transferase ratio [GGT/ALT] >2.5; parathyroid hormone [PTH] >6.8 pmol/L; 25(OH)vitamin D < 25 nmol/L) and 3 pre-fracture clinical conditions (history of myocardial infarction, chronic kidney disease [GFR <60 ml/min/1.73 m²] and chronic obstructive pulmonary disease); the area under the receiver operating characteristic curve (AUC) was 0.75 (95%CI 0.70–0.80). The risk of in-hospital death was 1.6–2.6 times higher in subjects with any of these risk factors (RFs), and increased by 2.6–6.0-fold in patients with any two RFs (versus no RFs). The mortality rate increased stepwise as the number of RFs increased (from 0.43% –none RF to 16.8%- ≥4RF). The prognostic value of a single RF was low (AUC ≤0.635) but combination of 2 or more RFs improved the prediction significantly; AUC reached 0.84(95%CI 0.77–0.90) when ≥4 RFs (versus 0–1RF) were present. In the validated and main cohorts the number of predicted by 1, 2, 3 or ≥4 RFs and observed deaths were practically similar.
In HF patients, seven easily identifiable at admission characteristics, including 4 biomarkers, are strong and independent indicators of in-hospital mortality and can be used for risk stratification and individualised management.
One‐year mortality of elderly patients with hip fracture surgically treated at a hospital in Southern Brazil
2017, Revista Brasileira de Ortopedia
Analisar a mortalidade, em um ano de seguimento, de pacientes com fratura da extremidade proximal do fêmur submetidos a procedimento cirúrgico no hospital universitário da nossa instituição.
Foram revisados 213 prontuários de pacientes internados com 65 anos ou mais, conforme a ordem de admissão no Serviço de Ortopedia e Traumatologia de janeiro de 2012 a agosto de 2013.
A taxa de mortalidade em um ano foi de 23,6%. A mortalidade foi maior em mulheres, numa proporção 3:1. Anemia (p = 0,000) e demência (p = 0,041) estiveram significativamente associadas ao grupo óbito. Pacientes que permaneceram internados por até 15 dias e os que tiveram alta hospitalar em até sete dias após a cirurgia apresentaram um aumento na sobrevida.
Em nossa amostra de pacientes com fratura de fêmur submetidos a procedimento cirúrgico, a taxa de mortalidade foi de 23,6%; as principais comorbidades associadas a esse desfecho foram anemia e demência.
To analyze the mortality rate at one‐year follow‐up of patients with hip fracture who underwent surgery at the university hospital of this institution.
The authors reviewed 213 medical records of hospitalized patients aged 65 years or older, following to the order they were admitted to the orthopedics and traumatology service from January 2012 to August 2013.
One‐year mortality rate was 23.6%. Mortality was higher among women, with a 3:1 ratio. Anemia (p = 0.000) and dementia (p = 0.041) were significantly associated with the death group. Patients who remained hospitalized for less than 15 days and who were discharged within seven days after surgery showed increased survival.
In the present sample of patients with hip fracture who underwent surgery, one‐year mortality rate was 23.6%, and the main comorbidities associated with this outcome were anemia and dementia.
Predictors of mortality in hip fracture patients
2016, European Geriatric Medicine
To examine the potential risk factors for in-hospital and 1-year mortality in elderly patients with hip fracture.
Included were elderly patients aged 65 years and older admitted to the orthopedic department with hip fractures. Clinical and laboratory data were obtained from electronic medical records.
Among the significant risk factors for in-hospital and or 1-year mortality were male gender, age, higher Charlson comorbidity index (CCI), chronic renal failure (CRF) and cholesterol lower level. In a number of risk factors, there were gender differences, e.g., the survival of females and not of men treated with statins was significantly higher than for those not treated with the drug.
It is important to make efforts to identify risk factors for mortality after hip fracture to be able to devise course of action to reduce mortality rate after hip fracture.
Surgical delay as a risk factor for wound infection after a hip fracture
2016, Injury
Citation Excerpt :
The problem with multicenter and national/regional studies [2–4,8,11–17] is that the reporting of complications may vary widely according to the different locations [9], so some data may be under or over reported. A large number of papers [2–4,7,8,11,14,16–22] explore the risk factors for mortality after a hip fracture (age, gender, surgical delay, previous comorbidity, anti-platelet therapy, dialysis, cardiac disease), many of them contributing contradictory results. An impressively higher number of publications [1–4,7,8,10–12,14–26] try to identify risk factors for medical complications (age, gender, ASA status, previous comorbidity, cognitive impairment, frailty, diabetes, stroke, nicotine abuse, bleeding, depression, surgical delay, analytical abnormalities, anti-platelet therapy, dialysis, obesity, cardiac disease, dehydration, hyperthyroidism).
Analysis of significant risk factors for mortality and for medical and orthopaedic complications.
Observational study of a prospective consecutive cohort of 697 patients diagnosed of hip fracture from December 2012 to December 2014. Average age was 85 ± 9 years and 520 were female (75%). Intracapsular fractures (308, 44%) were treated non-operatively, (19 patients), with cannulated screws (58) or with hip arthroplasty (228 bipolar, 3 total hip atrhoplasty). Extracapsular fractures (389, 56%) were reduced and fixed with 375 trochanteric nails and 14 sliding-hip-screw-plates. Patients were controlled clinically and radiographically in outpatient clinic after 1, 3, 6 and 12 months. Bivariate analysis (Pearson, Mann-Whitney, Wilcoxon) was applied to study statistically significant relations, and Odds Ratio were calculated.
Surgical delay reached 2.1 ± 2.2 days, 1.7 ± 1.9 in medically stable patients. Main reason for delay was anticoagulant/anti-platelet therapy. Immediate weight-bearing was begun for 72% of patients. Average time in-hospital was 12 ± 8 days and 63% returned to previous environment. Lost-to-follow-up reached 4% after 1 month and 8% after 6 months. After 1 year, 6% of previously-walking patients were unable to walk. Mortality reached 4% while in-hospital and 14% after 1 year, with older age as only significant risk factor (p = 0.004), OR = 1.9. Wound infection developed in 2.3% of the series, and surgical delay longer than 24 hours was a significant risk factor (p = 0.023), with an OR = 3.48 (1.1–10.8). Fixation failed in 7.9% of cannulated screws and 1.9% of trochanteric nails (1.1% cut-out, 0.8% nail fracture), while 2.7% of arthroplasty patients suffered a prosthesis dislocation and 1.3% a periprosthetic fracture. Pyelonephritis appeared in 6.7%, pneumonia in 6.3% and cardiac failure in 2.2% of patients; significant risk factors were previous comorbidity for pneumonia (p = 0.007) (OR = 2.7) and cardiac failure (p = 0.007) (OR = 9.7), as well as older age (p = 0.006) (OR = 2.2) for pneumonia.
Surgical delay longer than 24 hours has been an important risk factor for wound infection, a finding not previously described in literature. Older age is a significant risk factor for mortality and pneumonia, and previous comorbidity for cardiac failure and pneumonia.
Factors associated to institutionalization and mortality over three years, in elderly people with a hip fracture - An observational study
2016, Maturitas
Citation Excerpt :
Several studies showed that age is a factor influencing mortality [6,7] and new institutionalization [4]. In our study, age did not predict intra-hospital mortality, contrary to the observations of Eschbach el al. [8], or institutionalization, with a low association to long term mortality. As has been previously demonstrated [9], our results may be due to the fact that we took other correction factors other than age which may influence mortality into account (comorbidity, complications, cognitive impairment and functional status).
To identify the factors associated to institutionalization and mortality in elderly patients with hip fractures (HF).
Thirty-six months observational study.
A post-acute rehabilitation ward.
subjects living in the community or in nursing-home, above the age of 65, with HF.
The following were registered: comorbidity, intra-hospital complications, Barthel index, walking ability and Mini Mental State Examination, as well as blood samples upon admission and discharge. Destination upon discharge was recorded as well as mortality during hospital stay and over the three-year follow up.
a total of 430 subjects were included in the study. Twenty-three patients (5.3%) died during their stay in hospital and 152 (35.3%) during follow up after discharge. Forty-five patients (10.5%) were institutionalized upon discharge. In adjusted analysis, the factors that predict intra-hospital mortality are higher comorbidity (OR, 1.46; 95%CI, 1.06–2.01), and the number of complications (OR, 1.71; 95%CI, 1.16–2.64).
Factors that predict mortality in the long term are age (HR 1.04; 95%CI, 1.01–1.06), comorbidity (HR 1.19, 95% CI, 1.09–1.30), the number of complications (HR 1.17, 95%CI, 1.05–1.31).
The factors that predicted new institutionalization were age (OR 1.04, 95%CI, 0.98–1.09), living alone (OR 3.95, 95%CI, 1.38–11.3), and length of hospital stay (OR 1.02 95%CI, 1.00–1.03).
Mortality 3 years after a hip fracture and institutionalization are associated to age, the loss of autonomy in walking, a worse cognitive status and living alone before the fracture. Identification of and, when possible, intervention upon these factors can improve care of elderly people with hip fractures.

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Increased age is not associated with higher incidence of complications, longer stay in acute care hospital and in hospital mortality in geriatric hip fracture patients

Abstract

Introduction

Section snippets

Patients and methods

Results

Discussion

Contributors

Competing interest

Funding

Injury

Injury

Clinics in Geriatric Medicine

Incidence rates of fragility hip fracture in middle-aged and elderly men and women in southern Norway

Age and Ageing

Prevention of hip fractures by correcting calcium and vitamin D insufficiencies in elderly people

Scandinavian Journal of Rheumatology. Supplement

Can we stop bone loss and prevent hip fractures in the elderly?

Osteoporosis International

Fall severity and bone mineral density as risk factors for hip fracture in ambulatory elderly

Journal of the American Medical Association

Proximal femoral fractures in the elderly Analysis of data from health insurance providers on more than 23 million insured persons––part 1

Unfallchirurg

Trend of hip fracture incidence in Germany 1995–2004: a population-based study