Hip Fractures in People Older Than 95 Years: Are Patients Without Age-Associated Illnesses Different?

Hip Fractures in People Older Than 95 Years: Are Patients Without Age-Associated Illnesses... Abstract Background Patients older than 95 years of age can be categorized according to three morbidity profiles: escapers, delayers, and survivors. The aim of this study was to describe the baseline characteristics, in-hospital outcomes, and cumulative mortality of extremely elderly patients admitted with hip fractures and to examine whether there were differences between patients without age-related illnesses (escapers) and others in the same age group (survivors when age-associated illnesses were diagnosed before the age of 80, delayers when these illnesses appeared after the age of 80). Methods A retrospective review of clinical and outcome data of all patients older than 95 years of age admitted with hip fractures. Results Two hundred patients older than 95 years were admitted with hip fractures between December 2009 and September 2015. Eighty-six per cent of patients had at least one in-hospital complication. In-hospital mortality was 12.5 per cent; cumulative mortality rates at 30 days, 3 months, and 1 year were 20.3, 30.8, and 50.5 per cent, respectively. There were 15 (7.5%) escaper patients. Compared with other patients with age-related illnesses, they took fewer drugs, had lower Charlson scores, a higher Barthel index score, shorter length of hospital stay, less delay in surgery, and more often required discharge to an in-patient rehabilitation facility. No differences in cumulative mortality were noted. Conclusions Escaper patients had better baseline characteristics, shorter length of hospital stay, and delay in surgery. Nevertheless, their in-hospital and cumulative mortality rates were similar to those of other patients older than 95 years. Morbidity, Longevity, Bone aging The number of extremely elderly persons is increasing in Western societies. Although the percentage is still small compared with the general population, it is the fastest growing age group (1). A hip fracture, generally the result of a fall, is a serious injury commonly found among the elderly due to their increasing bone fragility. Fractures often lead to the loss of ability to perform basic and instrumental activities of daily living, and such patients may have to be admitted to institutional care (2). Mortality is also high and in patients older than 65 years of age it is around 20 per cent in the first year after the fracture (3). In the near future, more patients older than 95 years are expected to be admitted to hospital with hip fractures. There is little information in the literature about extremely elderly people with hip fractures. A few studies have compared these patients with those in the most frequent age range (75–83 years) and all of them found that older patients had poorer outcomes, with more in-hospital complications (40%) and higher mortality in the first year following discharge (35%–60%) (4–6). Nevertheless, the short- and long-term prognosis for individuals with exceptional longevity, as well as many other epidemiological aspects and outcomes, remains unknown. One study by Evert and colleagues of community-living people aged between 97 and 119 years found different morbidity profiles depending on the age when elderly individuals first developed age-related illnesses: hypertension, heart disease (congestive heart failure, ischemic heart disease, and arrhythmia), diabetes, stroke, nonskin cancer, skin cancer, osteoporosis, thyroid condition, Parkinson’s disease, dementia, chronic obstructive pulmonary disease (COPD), and cataracts. Three categories of patients were identified: survivors (age of onset of age-associated illnesses before 80 years old); delayers (after 80 years old); and escapers (those with no history of age-associated illness before age 100) (7). The aims of our study were first to describe the baseline characteristics of extremely elderly patients admitted to our center with hip fractures and their in-hospital outcomes and cumulative mortality in the first year after the fracture. Second, we wanted to examine whether patients who had not developed age-associated illnesses at very advanced ages (escapers) behaved differently from those who already had them (survivors and delayers). Methods Setting The study was conducted in the Orthopedic Surgery Ward at the Hospital de la Santa Creu i Sant Pau, a tertiary university hospital serving a population of about 425,000 people in Barcelona. Participants The clinical data of all patients admitted to the Orthopedic Surgery Ward with hip fractures between December 2009 and September 2015 were retrospectively reviewed. During admission, patients had been visited at least once by a doctor from the Geriatric Unit, in accordance with the framework of co-operation developed between the two services with respect to hip fractures. All patients older than 95 years with hip fracture were included. Only those patients with hip fractures due to accident or a neoplasm were excluded. It was decided to include only patients older than 95 years of age because that was the lower limit used by Holt and colleagues in their studies of hip fractures in the extreme elderly (6,8). In their paper about the decline of physical function in aging, Ayers and colleagues also considered 95 years to be the lower limit of exceptional longevity (9). A further reason was that our patients were similar in age to those included in the study by Evert and colleagues (7). The study was approved by the institutional ethics committee. Data Collection The following data were recorded as follows: age, sex, comorbidity measured by the Charlson index (10), the Barthel Index of Activities of Daily Living (ADL) (11), place of residence, number of drugs before admission, length of hospital stay, delay to surgery, type of fracture, and type of surgery. The Barthel Index was subdivided into the following: total dependence (<20 points), severe dependence (20–35 points), moderate dependence (40–55), mild dependence (60–95), and independence (100 points). Also noted were any of the following age-associated illnesses prior to admission: hypertension, heart disease (congestive heart failure, ischemic heart disease, and arrhythmia), diabetes, stroke, nonskin cancer, skin cancer, previous diagnosis of osteoporosis, thyroid condition, Parkinson’s disease, dementia, COPD, and cataracts. Diagnoses were established if they were recorded in the medical files or if the doctor from the Geriatric Unit considered that they were present before the current admission. A diagnosis of osteoporosis, which was the probable cause of hip fracture in all patients, was only regarded as a prior illness if the patient had a previous fragility fracture. We defined escapers as patients older than 95 years of age with no age-related illnesses prior to admission. Hemoglobin and albumin levels at admission were recorded. The number and type of complications, final discharge destination (home, nursing home, inpatient rehabilitation facility, or long-term care center) and in-hospital mortality were also noted. Cumulative mortality rates at 30 days, 3 months, and 1 year were obtained. Statistical Analysis Continuous variables were analyzed by calculating means and standard deviation (SD) and compared using Student’s t-test with Welch’s correction. For categorical variables, relative frequencies or proportions were calculated and compared using the Fisher’s exact test. Statistical analysis was performed using the IBM SPSS Statistical Package (version 22; SPSS Inc., Chicago, IL, USA). Statistical significance was p ≤ .05 in all cases. Results Between December 2009 and September 2015, 2,927 patients were admitted to hospital with a hip fracture. Two hundred (6.8%) of these were 95 years of age or older. Their baseline characteristics, in-hospital outcomes, and cumulative mortality are shown in Tables 1–3. With respect to age-associated illnesses, 150 (75%) patients had hypertension, 62 (31%) heart disease [30 (15%) congestive heart failure, 20 (10%) ischemic heart disease, 29 (14.5%) some type of arrhythmia, mainly atrial fibrillation], 27 (13.5%) diabetes, 29 (14.5%) stroke, 24 (12%) nonskin cancer, 6 (3%) skin cancer, 47 (23.5%) a previous fragility fracture, 13 (6.5%) a thyroid condition, 4 (2%) Parkinson’s disease, 60 (30%) dementia, 21 (10.5%) COPD, and 33 (16.5%) had cataracts. Fifteen (7.5%) patients had no prior age-related illnesses (escapers). Three patients (1.5%) died before they could be operated on. Table 1. Baseline Characteristics in Extremely Elderly Patients (Older Than 95 Years) Admitted With Hip Fractures   N = 200  Mean age, y (SD)  97.3 (2.4)  Female sex, n (%)  174 (87)  Charlson index (SD)  1.2 (1.2)  Barthel index (SD)  63.1 (23.9)   Total dependence, n (%)  11 (5.5)   Severe dependence, n (%)  23 (11.5)   Moderate dependence, n (%)  41 (20.5)   Mild dependence, n (%)  111 (55.5)   Independent, n (%)  14 (7)  Dementia, n (%)  60 (30)  Place of residence: n at home (%)  112 (56)  Number of drugs (SD)  5.1 (3)  Intracapsular fracture, n (%)  87 (43.5)  Hemoglobin at admission in g/L (SD)  119.1 (16.1)  Albumin at admission in g/L (SD)  28.1 (3.4)    N = 200  Mean age, y (SD)  97.3 (2.4)  Female sex, n (%)  174 (87)  Charlson index (SD)  1.2 (1.2)  Barthel index (SD)  63.1 (23.9)   Total dependence, n (%)  11 (5.5)   Severe dependence, n (%)  23 (11.5)   Moderate dependence, n (%)  41 (20.5)   Mild dependence, n (%)  111 (55.5)   Independent, n (%)  14 (7)  Dementia, n (%)  60 (30)  Place of residence: n at home (%)  112 (56)  Number of drugs (SD)  5.1 (3)  Intracapsular fracture, n (%)  87 (43.5)  Hemoglobin at admission in g/L (SD)  119.1 (16.1)  Albumin at admission in g/L (SD)  28.1 (3.4)  Note: SD = Standard deviation. View Large Table 1. Baseline Characteristics in Extremely Elderly Patients (Older Than 95 Years) Admitted With Hip Fractures   N = 200  Mean age, y (SD)  97.3 (2.4)  Female sex, n (%)  174 (87)  Charlson index (SD)  1.2 (1.2)  Barthel index (SD)  63.1 (23.9)   Total dependence, n (%)  11 (5.5)   Severe dependence, n (%)  23 (11.5)   Moderate dependence, n (%)  41 (20.5)   Mild dependence, n (%)  111 (55.5)   Independent, n (%)  14 (7)  Dementia, n (%)  60 (30)  Place of residence: n at home (%)  112 (56)  Number of drugs (SD)  5.1 (3)  Intracapsular fracture, n (%)  87 (43.5)  Hemoglobin at admission in g/L (SD)  119.1 (16.1)  Albumin at admission in g/L (SD)  28.1 (3.4)    N = 200  Mean age, y (SD)  97.3 (2.4)  Female sex, n (%)  174 (87)  Charlson index (SD)  1.2 (1.2)  Barthel index (SD)  63.1 (23.9)   Total dependence, n (%)  11 (5.5)   Severe dependence, n (%)  23 (11.5)   Moderate dependence, n (%)  41 (20.5)   Mild dependence, n (%)  111 (55.5)   Independent, n (%)  14 (7)  Dementia, n (%)  60 (30)  Place of residence: n at home (%)  112 (56)  Number of drugs (SD)  5.1 (3)  Intracapsular fracture, n (%)  87 (43.5)  Hemoglobin at admission in g/L (SD)  119.1 (16.1)  Albumin at admission in g/L (SD)  28.1 (3.4)  Note: SD = Standard deviation. View Large Table 2. In-hospital Outcomes in Patients Older Than 95 Years of Age   N = 200  Length of hospital stay in days (SD)  13.6 (10.4)  Delay to surgery in days (SD)  3.8 (2.9)  Prosthesis, n (%)  68 (34)  Patients with complications, n (%)  172 (86)  Mean complications, n (%)  1.8 (1.6)   Transfusion, n (%)  119 (59.5)   Delirium, n (%)  67 (33.5)   Respiratory infection, n (%)  50 (25)   Cardiovascular, n (%)  31 (15.5)   Urinary infection, n (%)  36 (18)   Acute renal failure, n (%)  46 (23)   Digestive, n (%)  8 (4)   Hip prosthesis luxation, n (%)  2 (1)   Wound infection, n (%)  1 (0.5)   Surgical technique problem, n (%)  2 (1)   Vascular section, n (%)  1 (0.5)  In-hospital mortality, n (%)  25 (12.5)  Discharge to a center, n (%)*  72 (41.1)   In-patient rehabilitation facility, n (%)  63 (36)   Long-term care center, n (%)  9 (5.1)    N = 200  Length of hospital stay in days (SD)  13.6 (10.4)  Delay to surgery in days (SD)  3.8 (2.9)  Prosthesis, n (%)  68 (34)  Patients with complications, n (%)  172 (86)  Mean complications, n (%)  1.8 (1.6)   Transfusion, n (%)  119 (59.5)   Delirium, n (%)  67 (33.5)   Respiratory infection, n (%)  50 (25)   Cardiovascular, n (%)  31 (15.5)   Urinary infection, n (%)  36 (18)   Acute renal failure, n (%)  46 (23)   Digestive, n (%)  8 (4)   Hip prosthesis luxation, n (%)  2 (1)   Wound infection, n (%)  1 (0.5)   Surgical technique problem, n (%)  2 (1)   Vascular section, n (%)  1 (0.5)  In-hospital mortality, n (%)  25 (12.5)  Discharge to a center, n (%)*  72 (41.1)   In-patient rehabilitation facility, n (%)  63 (36)   Long-term care center, n (%)  9 (5.1)  Notes: SD = Standard deviation. *These numbers refer to patients surviving after hospital admission (n = 175). View Large Table 2. In-hospital Outcomes in Patients Older Than 95 Years of Age   N = 200  Length of hospital stay in days (SD)  13.6 (10.4)  Delay to surgery in days (SD)  3.8 (2.9)  Prosthesis, n (%)  68 (34)  Patients with complications, n (%)  172 (86)  Mean complications, n (%)  1.8 (1.6)   Transfusion, n (%)  119 (59.5)   Delirium, n (%)  67 (33.5)   Respiratory infection, n (%)  50 (25)   Cardiovascular, n (%)  31 (15.5)   Urinary infection, n (%)  36 (18)   Acute renal failure, n (%)  46 (23)   Digestive, n (%)  8 (4)   Hip prosthesis luxation, n (%)  2 (1)   Wound infection, n (%)  1 (0.5)   Surgical technique problem, n (%)  2 (1)   Vascular section, n (%)  1 (0.5)  In-hospital mortality, n (%)  25 (12.5)  Discharge to a center, n (%)*  72 (41.1)   In-patient rehabilitation facility, n (%)  63 (36)   Long-term care center, n (%)  9 (5.1)    N = 200  Length of hospital stay in days (SD)  13.6 (10.4)  Delay to surgery in days (SD)  3.8 (2.9)  Prosthesis, n (%)  68 (34)  Patients with complications, n (%)  172 (86)  Mean complications, n (%)  1.8 (1.6)   Transfusion, n (%)  119 (59.5)   Delirium, n (%)  67 (33.5)   Respiratory infection, n (%)  50 (25)   Cardiovascular, n (%)  31 (15.5)   Urinary infection, n (%)  36 (18)   Acute renal failure, n (%)  46 (23)   Digestive, n (%)  8 (4)   Hip prosthesis luxation, n (%)  2 (1)   Wound infection, n (%)  1 (0.5)   Surgical technique problem, n (%)  2 (1)   Vascular section, n (%)  1 (0.5)  In-hospital mortality, n (%)  25 (12.5)  Discharge to a center, n (%)*  72 (41.1)   In-patient rehabilitation facility, n (%)  63 (36)   Long-term care center, n (%)  9 (5.1)  Notes: SD = Standard deviation. *These numbers refer to patients surviving after hospital admission (n = 175). View Large Table 3. Cumulative Mortality in Patients Older Than 95 Years   N = 182*  Mortality at 30 d, n (%)  37 (20.3)  Mortality at 3 mo, n (%)  56 (30.8)  Mortality at 1 y, n (%)  92 (50.5)    N = 182*  Mortality at 30 d, n (%)  37 (20.3)  Mortality at 3 mo, n (%)  56 (30.8)  Mortality at 1 y, n (%)  92 (50.5)  Note: *Only 182 patients were available at 1 year of follow-up. View Large Table 3. Cumulative Mortality in Patients Older Than 95 Years   N = 182*  Mortality at 30 d, n (%)  37 (20.3)  Mortality at 3 mo, n (%)  56 (30.8)  Mortality at 1 y, n (%)  92 (50.5)    N = 182*  Mortality at 30 d, n (%)  37 (20.3)  Mortality at 3 mo, n (%)  56 (30.8)  Mortality at 1 y, n (%)  92 (50.5)  Note: *Only 182 patients were available at 1 year of follow-up. View Large The most frequent complications were anemia requiring transfusion and delirium. One hundred eight patients (54%) had other complications (excluding anemia and transfusion). The escaper group of patients was compared with other patients older than 95 years. Comparison of their baseline characteristics at admission and in-hospital outcomes is shown in Tables 4 and 5. Statistically significant differences with respect to comorbidity were found, with escaper patients, as expected, having much lower Charlson scores. This group also scored higher on the Barthel ADL index, took fewer drugs before admission, and more often lived at home. When comparing in-hospital outcomes between the two groups, we found significant differences in length of hospital stay and delay in surgery, which were both shorter in the escaper group of patients. Also escaper patients more often required discharge to an inpatient rehabilitation facility. In the first year after the fracture, 182 patients (91%) were available for follow-up, whereas 18 patients (9%) could not be located. Table 6 shows cumulative mortality rates at 30 days, 3 months, and 1 year. There were no significant differences between the two groups. Table 4. Comparison of Escapers and Other Patients Older Than 95 Years of Age: Baseline Characteristics Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Age, y (SD)  97.87 (2.2)  97.23 (2.3)  .303  Female sex, n (%)  12 (80)  162 (87.6)  .420  Charlson index (SD)  0.20 (0.6)  1.27 (1.2)  <.001  Barthel index (SD)  76.67 (16.9)  62.05 (24.1)  .01   Total dependence, n (%)  0 (0)  11 (5.9)  1   Severe dependence, n (%)  0 (0)  23 (12.4)  .226   Moderate dependence, n (%)  2 (13.3)  39 (21.1)  .740   Mildly dependence, n (%)  11 (73.3)  101 (54.6)  .186   Independent, n (%)  2 (13.3)  11 (5.9)  .253  Place of residence: n at home (%)  13 (86.7)  99 (53.5)  .010  Number of drugs (SD)  2.13 (1.95)  5.33 (2.95)  <.001  Intracapsular fracture, n (%)  5 (33.3)  82 (44.3)  .293  Hemoglobin at admission in g/L (SD)  124.57 (19.8)  118.62 (15.7)  .291  Albumin at admission in g/L (SD)  27.98 (3.7)  28.15 (3.4)  .866  Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Age, y (SD)  97.87 (2.2)  97.23 (2.3)  .303  Female sex, n (%)  12 (80)  162 (87.6)  .420  Charlson index (SD)  0.20 (0.6)  1.27 (1.2)  <.001  Barthel index (SD)  76.67 (16.9)  62.05 (24.1)  .01   Total dependence, n (%)  0 (0)  11 (5.9)  1   Severe dependence, n (%)  0 (0)  23 (12.4)  .226   Moderate dependence, n (%)  2 (13.3)  39 (21.1)  .740   Mildly dependence, n (%)  11 (73.3)  101 (54.6)  .186   Independent, n (%)  2 (13.3)  11 (5.9)  .253  Place of residence: n at home (%)  13 (86.7)  99 (53.5)  .010  Number of drugs (SD)  2.13 (1.95)  5.33 (2.95)  <.001  Intracapsular fracture, n (%)  5 (33.3)  82 (44.3)  .293  Hemoglobin at admission in g/L (SD)  124.57 (19.8)  118.62 (15.7)  .291  Albumin at admission in g/L (SD)  27.98 (3.7)  28.15 (3.4)  .866  Note: SD = Standard deviation. View Large Table 4. Comparison of Escapers and Other Patients Older Than 95 Years of Age: Baseline Characteristics Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Age, y (SD)  97.87 (2.2)  97.23 (2.3)  .303  Female sex, n (%)  12 (80)  162 (87.6)  .420  Charlson index (SD)  0.20 (0.6)  1.27 (1.2)  <.001  Barthel index (SD)  76.67 (16.9)  62.05 (24.1)  .01   Total dependence, n (%)  0 (0)  11 (5.9)  1   Severe dependence, n (%)  0 (0)  23 (12.4)  .226   Moderate dependence, n (%)  2 (13.3)  39 (21.1)  .740   Mildly dependence, n (%)  11 (73.3)  101 (54.6)  .186   Independent, n (%)  2 (13.3)  11 (5.9)  .253  Place of residence: n at home (%)  13 (86.7)  99 (53.5)  .010  Number of drugs (SD)  2.13 (1.95)  5.33 (2.95)  <.001  Intracapsular fracture, n (%)  5 (33.3)  82 (44.3)  .293  Hemoglobin at admission in g/L (SD)  124.57 (19.8)  118.62 (15.7)  .291  Albumin at admission in g/L (SD)  27.98 (3.7)  28.15 (3.4)  .866  Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Age, y (SD)  97.87 (2.2)  97.23 (2.3)  .303  Female sex, n (%)  12 (80)  162 (87.6)  .420  Charlson index (SD)  0.20 (0.6)  1.27 (1.2)  <.001  Barthel index (SD)  76.67 (16.9)  62.05 (24.1)  .01   Total dependence, n (%)  0 (0)  11 (5.9)  1   Severe dependence, n (%)  0 (0)  23 (12.4)  .226   Moderate dependence, n (%)  2 (13.3)  39 (21.1)  .740   Mildly dependence, n (%)  11 (73.3)  101 (54.6)  .186   Independent, n (%)  2 (13.3)  11 (5.9)  .253  Place of residence: n at home (%)  13 (86.7)  99 (53.5)  .010  Number of drugs (SD)  2.13 (1.95)  5.33 (2.95)  <.001  Intracapsular fracture, n (%)  5 (33.3)  82 (44.3)  .293  Hemoglobin at admission in g/L (SD)  124.57 (19.8)  118.62 (15.7)  .291  Albumin at admission in g/L (SD)  27.98 (3.7)  28.15 (3.4)  .866  Note: SD = Standard deviation. View Large Table 5. Comparison of Escapers and Other Patients Older Than 95 Years: In-hospital Results Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Length of hospital stay in days (SD)  10.80 (3.8)  13.84 (10.7)  .022  Delay in surgery in days (SD)  2.60 (1.2)  3.95 (3)  .022  Prosthesis, n (%)  3 (20)  65 (35.7)  .269  Patients with any complication, n (%)  13 (86.7)  159 (85.9)  1  Mean complications, n (%)  1.47 (0.9)  1.91 (1.6)  .11   Transfusion, n (%)  8 (53.3)  111 (60)  .785   Delirium, n (%)  4 (26.7)  63 (34.1)  .777   Respiratory infection, n (%)  1 (6.7)  49 (26.5)  .122   Cardiovascular, n (%)  2 (13.3)  29 (15.7)  1   Urinary infection, n (%)  3 (20)  33 (17.8)  .736   Acute renal failure, n (%)  3 (20)  43 (23.2)  1   Digestive, n (%)  0 (0)  8 (4.3)  1   Prosthesis luxation, n (%)  1 (6.7)  1 (0.5)  .145   Wound infection, n (%)  0 (0)  1 (0.5)  1   Surgical technique problem, n (%)  0 (0)  2 (1.1)  1   Vascular section, n (%)  0 (0)  1 (0.5)  1  In-hospital mortality, n (%)  1 (6.7)  24 (13)  .699  Discharge to a center n (%)*  11 (78.6)  61 (37.9)  .004   Inpatient rehabilitation facility, n (%)  10 (71.4)  53 (32.9)  .007   Long-term care center, n (%)  1 (7.1)  8 (5)  .537  Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Length of hospital stay in days (SD)  10.80 (3.8)  13.84 (10.7)  .022  Delay in surgery in days (SD)  2.60 (1.2)  3.95 (3)  .022  Prosthesis, n (%)  3 (20)  65 (35.7)  .269  Patients with any complication, n (%)  13 (86.7)  159 (85.9)  1  Mean complications, n (%)  1.47 (0.9)  1.91 (1.6)  .11   Transfusion, n (%)  8 (53.3)  111 (60)  .785   Delirium, n (%)  4 (26.7)  63 (34.1)  .777   Respiratory infection, n (%)  1 (6.7)  49 (26.5)  .122   Cardiovascular, n (%)  2 (13.3)  29 (15.7)  1   Urinary infection, n (%)  3 (20)  33 (17.8)  .736   Acute renal failure, n (%)  3 (20)  43 (23.2)  1   Digestive, n (%)  0 (0)  8 (4.3)  1   Prosthesis luxation, n (%)  1 (6.7)  1 (0.5)  .145   Wound infection, n (%)  0 (0)  1 (0.5)  1   Surgical technique problem, n (%)  0 (0)  2 (1.1)  1   Vascular section, n (%)  0 (0)  1 (0.5)  1  In-hospital mortality, n (%)  1 (6.7)  24 (13)  .699  Discharge to a center n (%)*  11 (78.6)  61 (37.9)  .004   Inpatient rehabilitation facility, n (%)  10 (71.4)  53 (32.9)  .007   Long-term care center, n (%)  1 (7.1)  8 (5)  .537  Notes: SD = Standard deviation. *These numbers refer to patients surviving after hospital admission (n = 175). View Large Table 5. Comparison of Escapers and Other Patients Older Than 95 Years: In-hospital Results Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Length of hospital stay in days (SD)  10.80 (3.8)  13.84 (10.7)  .022  Delay in surgery in days (SD)  2.60 (1.2)  3.95 (3)  .022  Prosthesis, n (%)  3 (20)  65 (35.7)  .269  Patients with any complication, n (%)  13 (86.7)  159 (85.9)  1  Mean complications, n (%)  1.47 (0.9)  1.91 (1.6)  .11   Transfusion, n (%)  8 (53.3)  111 (60)  .785   Delirium, n (%)  4 (26.7)  63 (34.1)  .777   Respiratory infection, n (%)  1 (6.7)  49 (26.5)  .122   Cardiovascular, n (%)  2 (13.3)  29 (15.7)  1   Urinary infection, n (%)  3 (20)  33 (17.8)  .736   Acute renal failure, n (%)  3 (20)  43 (23.2)  1   Digestive, n (%)  0 (0)  8 (4.3)  1   Prosthesis luxation, n (%)  1 (6.7)  1 (0.5)  .145   Wound infection, n (%)  0 (0)  1 (0.5)  1   Surgical technique problem, n (%)  0 (0)  2 (1.1)  1   Vascular section, n (%)  0 (0)  1 (0.5)  1  In-hospital mortality, n (%)  1 (6.7)  24 (13)  .699  Discharge to a center n (%)*  11 (78.6)  61 (37.9)  .004   Inpatient rehabilitation facility, n (%)  10 (71.4)  53 (32.9)  .007   Long-term care center, n (%)  1 (7.1)  8 (5)  .537  Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Length of hospital stay in days (SD)  10.80 (3.8)  13.84 (10.7)  .022  Delay in surgery in days (SD)  2.60 (1.2)  3.95 (3)  .022  Prosthesis, n (%)  3 (20)  65 (35.7)  .269  Patients with any complication, n (%)  13 (86.7)  159 (85.9)  1  Mean complications, n (%)  1.47 (0.9)  1.91 (1.6)  .11   Transfusion, n (%)  8 (53.3)  111 (60)  .785   Delirium, n (%)  4 (26.7)  63 (34.1)  .777   Respiratory infection, n (%)  1 (6.7)  49 (26.5)  .122   Cardiovascular, n (%)  2 (13.3)  29 (15.7)  1   Urinary infection, n (%)  3 (20)  33 (17.8)  .736   Acute renal failure, n (%)  3 (20)  43 (23.2)  1   Digestive, n (%)  0 (0)  8 (4.3)  1   Prosthesis luxation, n (%)  1 (6.7)  1 (0.5)  .145   Wound infection, n (%)  0 (0)  1 (0.5)  1   Surgical technique problem, n (%)  0 (0)  2 (1.1)  1   Vascular section, n (%)  0 (0)  1 (0.5)  1  In-hospital mortality, n (%)  1 (6.7)  24 (13)  .699  Discharge to a center n (%)*  11 (78.6)  61 (37.9)  .004   Inpatient rehabilitation facility, n (%)  10 (71.4)  53 (32.9)  .007   Long-term care center, n (%)  1 (7.1)  8 (5)  .537  Notes: SD = Standard deviation. *These numbers refer to patients surviving after hospital admission (n = 175). View Large Table 6. Cumulative Mortality: Escaper Patients Compared With Patients With Previous Age-Related Illnesses Patients = 182*  Escapers, n = 14  Other patients, n = 168  p value  Mortality at 30 d, n (%)  2 (14.3)  35 (20.8)  0.738  Mortality at 3 mo, n (%)  3 (21.4)  53 (31.5)  0.555  Mortality at 1 y, n (%)  5 (35.7)  87 (51.8)  0.278  Patients = 182*  Escapers, n = 14  Other patients, n = 168  p value  Mortality at 30 d, n (%)  2 (14.3)  35 (20.8)  0.738  Mortality at 3 mo, n (%)  3 (21.4)  53 (31.5)  0.555  Mortality at 1 y, n (%)  5 (35.7)  87 (51.8)  0.278  Note: *Only 182 patients were available at 1 year of follow-up. View Large Table 6. Cumulative Mortality: Escaper Patients Compared With Patients With Previous Age-Related Illnesses Patients = 182*  Escapers, n = 14  Other patients, n = 168  p value  Mortality at 30 d, n (%)  2 (14.3)  35 (20.8)  0.738  Mortality at 3 mo, n (%)  3 (21.4)  53 (31.5)  0.555  Mortality at 1 y, n (%)  5 (35.7)  87 (51.8)  0.278  Patients = 182*  Escapers, n = 14  Other patients, n = 168  p value  Mortality at 30 d, n (%)  2 (14.3)  35 (20.8)  0.738  Mortality at 3 mo, n (%)  3 (21.4)  53 (31.5)  0.555  Mortality at 1 y, n (%)  5 (35.7)  87 (51.8)  0.278  Note: *Only 182 patients were available at 1 year of follow-up. View Large Discussion This study showed that, in general, extremely elderly patients admitted for hip fractures had good overall baseline characteristics before admission, although rates of in-hospital complications and cumulative mortality during the first year were very high. Although escaper patients had better baseline characteristics, their in-hospital complications and cumulative mortality rates were similar to those of patients with age-associated illnesses. The mean Barthel index score of patients older than 95 years was over 60, indicating that most were mildly dependent for activities of daily living. Most of them were able to live at home. The number of patients with dementia could be considered low, given that about 50 per cent of the extremely elderly have dementia (12). Complications are very frequent in extremely elderly patients as expected. Our study showed that 86 per cent of patients had at least one complication (54% excluding transfusions and delirium). These results are consistent with those described by other authors. In a retrospective study of centenarians with hip fractures carried out by Tarity and colleagues, 43 per cent of patients experienced complications, excluding transfusions and delirium (13). In a retrospective study performed in Barcelona, Pelavski and colleagues found that 76.5 per cent of centenarian patients required a transfusion and post-operative delirium was 41.1 per cent (5). In-hospital mortality was 12.5 per cent, similar to the study by Tarity and colleagues, which was 15 per cent (13). Post-discharge outcomes also showed high cumulative mortality at 30 days, 3 months, and 1 year: 20.3, 30.8 and 50.5 per cent, respectively. These results are comparable to other studies carried out among extremely elderly patients. Forster and colleagues found 31 per cent mortality at 30 days and 56 per cent at 12 months (14), whereas Verma and colleagues found 30.4 per cent mortality at 30 days (15). Both papers were carried out on centenarian patients. The largest study of the extremely elderly was a prospective study by Holt and colleagues who compared 919 patients of 95 years of age or older with another group aged between 75 and 89 years. Their 30 day mortality rate was lower (16.8%) than in our study, but the 3 month mortality rate was higher (38.1%) (6). There are few studies focused on hip fractures in extremely elderly patients. Most of these are retrospectives reviews (13–19). A limited number compared patients older than 95 years with those in the most frequent age range for hip fractures (75–83 years) (4–6,8). There is one prospective study of nonagenarians and centenarians, although it evaluates only outcomes related to anesthesia 48 hours after surgery (20). Retrospective papers describe basal characteristics, in-hospital outcomes, and cumulative mortality. The number of patients is low, between 10 and 50 patients. Our study has a larger number of patients (200) and confirms the findings of these studies with respect to the high number of complications and cumulative mortality. Additionally, our study provides details of different types of in-hospital complications and includes other results such as mean number of complications, delay to surgery, and whether patients required discharge to a center. Studies comparing the extremely elderly with patients in the most frequent age range show that most outcomes (in-hospital complications and cumulative mortality at 4 months) are worse in the first group. Our study provides a comparison that has not yet been made: to examine whether there were differences between extremely elderly patients with and without age-related illnesses. No studies have so far been found analyzing whether people with an “escaper” morbidity profile show different behaviors in clinical practice. A recently published study carried out in China analyzed the prevalence of disability in the 3 years immediately prior to death and found that a quarter of the oldest old remained independent until death. These findings support previous studies showing that there is a subset of individuals who escape common age-associated diseases (21). In our study, escaper patients had better baseline characteristics than other patients in the same age group. Escaper patients took fewer drugs, attributed to the lack of age-related diseases, and had a higher Barthel index score, which probably allowed them to live at home more often. It should also be emphasized that the Charlson comorbidity index was not previously zero in escaper patients, since this index takes into account other comorbidities not related to age, such as ulcers, liver disease, and connective tissue diseases. Delay in surgery and length of hospital stay were shorter in the escaper group of patients. They may have been operated on at an earlier date, because they had lower comorbidity scores, which may partly explain their shorter length of stay, since complications and in-hospital mortality were very similar to those of other patients of the same age. Another significant difference between the two groups was that escaper patients had to be discharged more frequently to an in-patient rehabilitation facility. This seemingly paradoxical result may be due to the fact that they more often lived at home before being admitted to hospital and were unable to return there following discharge. Our hypothesis was that escaper patients should have fewer complications and lower mortality than other patients older than 95 years of age, although this was not in fact the case. One possible reason is that these patients had not yet developed age-related diseases, or at least the first symptoms did not appear until the hip fracture. However, once symptoms begin (and hip fracture is a clinical manifestation of osteoporosis), the period until death is the same for all the extremely elderly. This explanation may be related to the compression of morbidity hypothesis proposed by James Fries in 1980, according to which, in some extremely elderly people, the onset of illness and associated disability are compressed into the last months of life. This would be the most favorable situation, although it is also possible to reach an advanced age with a history of chronic illness (22). It is clear that further studies will be necessary to find out more about the extremely elderly with hip fractures. In addition to age-related diseases, aspects such as sarcopenia and frailty may have an influence on short and long term prognosis and mortality. In a recent paper, Kramer and colleagues found extensive type-II muscle fiber atrophy in elderly females with hip fractures (23). Due to the characteristics of our study, we do not know the previous degree of frailty of these patients, although it has been shown that frailty is prevalent in other surgeries, such as aortic valve replacement, and is associated with poor outcomes (24). Patients without age-related diseases were easy to identify. For many patients though, it was difficult to determine the exact, or even approximate, date of onset of the disease after many years of evolution. Because of this, we decided to divide the patients into two groups: escapers and the rest of the population older than 95 years of age, since it was often difficult to determine with any certainty whether patients were survivors or delayers. We considered that all patients had osteoporosis and that this caused the hip fracture. This raises the question therefore of whether the escaper patients were true escapers if they probably had the disease.We decided nevertheless to consider them escapers on the grounds that the osteoporosis had not yet manifested clinically. The main limitation of our study is that the number of patients was small, particularly in the escaper group, even though we considered escapers to be those patients older than 95 years of age, rather than centenarians as in the original article (7). However, a greater number of patients could eventually disclose differences not revealed in our study. Another limitation is that we were unable to track down all patients after discharge. The main strength is that this is, to the best of our knowledge, the first time that morbidity profiles of extremely elderly patients have been applied to clinical studies of patients with hip fractures. Conclusions Extremely elderly patients with hip fractures had a high number of complications while admitted to hospital. Mortality within the first year of the fracture was very high, regardless of whether the patient had previous age-related diseases. Escaper patients had better baseline characteristics, shorter length of hospital stay, and delay in surgery, although their in-hospital and cumulative mortality were similar to those of other patients older than 95 years. Funding No sources of funding were used to assist in the performance of this study or the preparation of the article. Conflict of interest statement None declared. References 1. Alarcón T, González-Montalvo JI, Bárcena A, Saez P. Further experience of nonagenarians with hip fractures. Injury . 2001; 32: 555– 558. doi: 10.1016/S0020-1383(00)00244-8 Google Scholar CrossRef Search ADS PubMed  2. Braithwaite RS, Col NF, Wong JB. Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc . 2003; 51: 364– 370. doi: 10.1046/j.1532-5415.2003.51110.x Google Scholar CrossRef Search ADS PubMed  3. Schnell S, Friedman SM, Mendelson DA, Bingham KW, Kates SL. The 1-year mortality of patients treated in a hip fracture program for elders. Geriatr Orthop Surg Rehabil . 2010; 1: 6– 14. doi: 10.1177/2151458510378105 Google Scholar CrossRef Search ADS PubMed  4. Oliver CW, Burke C. Hip fractures in centenarians. Injury . 2004; 35: 1025– 1030. doi: 10.1016/j.injury.2003.10.004 Google Scholar CrossRef Search ADS PubMed  5. Pelavski Atlas AD, Colomina MJ, De Miguel M, Roigé J. Centenarians versus patients within the most frequent age range for hip fractures: transfusion practice. Arch Orthop Trauma Surg . 2009; 129: 685– 689. doi: 10.1007/s00402-009-0842-8 Google Scholar CrossRef Search ADS PubMed  6. Holt G, Smith R, Duncan K, Hutchinson JD, Gregori A. Outcome after surgery for treatment of hip fracture in the extremely elderly. J Bone Joint Surg Am  2008; 90: 1899– 1905. doi: 10.2106/JBJS.G.00883 Google Scholar CrossRef Search ADS PubMed  7. Evert J, Lawler E, Bogan H, Perls T. Morbidity profiles of centenarians: survivors, delayers, and escapers. J Gerontol A Biol Sci Med Sci . 2003; 58: 232– 237. Google Scholar CrossRef Search ADS PubMed  8. Holt G, Macdonald D, Fraser M, Reece AT. Outcome after surgery for fracture of the hip in patients aged over 95 years. J Bone Joint Surg Br . 2006; 88: 1060– 1064. doi: 10.1302/0301-620X.88B8.17398 Google Scholar CrossRef Search ADS PubMed  9. Ayers E, Barzilai N, Crandall JP, Milman S, Verghese J. Association of family history of exceptional longevity with decline in physical function in aging. J Gerontol A Biol Sci Med Sci  2017; 72: 1649– 1655. doi: 10.1093/gerona/glx053 Google Scholar CrossRef Search ADS PubMed  10. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis  1987; 40: 373– 383. doi: 10.1016/0021-9681(87)90171–8 Google Scholar CrossRef Search ADS PubMed  11. Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J . 1965; 14: 61– 65. Google Scholar PubMed  12. Poon LW, Woodard JL, Stephen Miller L, et al.   Understanding dementia prevalence among centenarians. J Gerontol A Biol Sci Med Sci . 2012; 67: 358– 365. doi: 10.1093/gerona/glr250 Google Scholar CrossRef Search ADS PubMed  13. Tarity TD, Smith EB, Dolan K, Rasouli MR, Maltenfort MG. Mortality in centenarians with hip fractures. Orthopedics . 2013; 36: e282– e287. doi: 10.3928/01477447-20130222-15 Google Scholar CrossRef Search ADS PubMed  14. Forster MC, Calthorpe D. Mortality following surgery for proximal femoral fractures in centenarians. Injury . 2000; 31: 537– 539. doi: 10.1016/S0020-1383(00)00049-8 Google Scholar CrossRef Search ADS PubMed  15. Verma R, Rigby AS, Shaw CJ, Mohsen A. Acute care of hip fractures in centenarians–do we need more resources? Injury . 2009; 40: 368– 370. doi: 10.1016/j.injury.2008.09.008 Google Scholar CrossRef Search ADS PubMed  16. Patil S, Parcells B, Blasted A, Chamberlain RS. Surgical outcome following hip fracture in patients > 100 years old: will they ever walk again. Surg Sci  2012; 3: 554– 559. doi: org/10.4236/ss.311109 Google Scholar CrossRef Search ADS   17. Mazzola P, Perego S, Picone D, et al.   Hip fracture in centenarans: retrospective analysis of an orthogeriatric unit reveals the limitations of the current research. Glob Anaesth Perioper Med  2015; 1: 68– 72. doi: 10.15761/GAPM.1000118 Google Scholar CrossRef Search ADS   18. Shabat S, Mann G, Gepstein R, Fredman B, Folman Y, Nyska M. Operative treatment for hip fractures in patients 100 years of age and older: is it justified? J Orthop Trauma . 2004; 18: 431– 435. Google Scholar CrossRef Search ADS PubMed  19. Kapicioglu M, Ersen A, Saglam Y, Akgul T, Kizilkurt T, Yazicioglu O. Hip fractures in extremely old patients. J Orthop . 2014; 11: 136– 141. doi: 10.1016/j.jor.2014.06.009 Google Scholar CrossRef Search ADS PubMed  20. Imbelloni LE, Gouveia MA, Borges de Morais G, da Silva A. Outcome after anesthesia and orthopedic surgery in patients nonagenarians and centenarians. J Anesth Clin Res . 2014; 5: 411. doi: org/10.4172/2155–6148.1000411 Google Scholar CrossRef Search ADS   21. Liu Z, Han L, Wang X, Feng Q, Gill TM. Disability prior to death among the oldest old in China. J Gerontol . 2018; 2: 1– 7. doi: 10.10937gerona/gly010 Google Scholar CrossRef Search ADS   22. Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med . 1980; 303: 130– 135. doi: 10.1056/NEJM198007173030304 Google Scholar CrossRef Search ADS PubMed  23. Kramer IF, Snijders T, Smeets JSJ, et al.   Extensive type II muscle fiber atrophy in elderly female hip fracture patients. J Gerontol A Biol Sci Med Sci . 2017; 72: 1369– 1375. doi: 10.1093/gerona/glw253 Google Scholar CrossRef Search ADS PubMed  24. Kotajarvi BR, Schafer MJ, Atkinson EJ, et al.   The impact of frailty on patient-centered outcomes following aortic valve replacement. J Gerontol A Biol Sci Med Sci . 2017; 72: 917– 921. doi: 10.1093/gerona/glx038 Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences Oxford University Press

Hip Fractures in People Older Than 95 Years: Are Patients Without Age-Associated Illnesses Different?

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Abstract

Abstract Background Patients older than 95 years of age can be categorized according to three morbidity profiles: escapers, delayers, and survivors. The aim of this study was to describe the baseline characteristics, in-hospital outcomes, and cumulative mortality of extremely elderly patients admitted with hip fractures and to examine whether there were differences between patients without age-related illnesses (escapers) and others in the same age group (survivors when age-associated illnesses were diagnosed before the age of 80, delayers when these illnesses appeared after the age of 80). Methods A retrospective review of clinical and outcome data of all patients older than 95 years of age admitted with hip fractures. Results Two hundred patients older than 95 years were admitted with hip fractures between December 2009 and September 2015. Eighty-six per cent of patients had at least one in-hospital complication. In-hospital mortality was 12.5 per cent; cumulative mortality rates at 30 days, 3 months, and 1 year were 20.3, 30.8, and 50.5 per cent, respectively. There were 15 (7.5%) escaper patients. Compared with other patients with age-related illnesses, they took fewer drugs, had lower Charlson scores, a higher Barthel index score, shorter length of hospital stay, less delay in surgery, and more often required discharge to an in-patient rehabilitation facility. No differences in cumulative mortality were noted. Conclusions Escaper patients had better baseline characteristics, shorter length of hospital stay, and delay in surgery. Nevertheless, their in-hospital and cumulative mortality rates were similar to those of other patients older than 95 years. Morbidity, Longevity, Bone aging The number of extremely elderly persons is increasing in Western societies. Although the percentage is still small compared with the general population, it is the fastest growing age group (1). A hip fracture, generally the result of a fall, is a serious injury commonly found among the elderly due to their increasing bone fragility. Fractures often lead to the loss of ability to perform basic and instrumental activities of daily living, and such patients may have to be admitted to institutional care (2). Mortality is also high and in patients older than 65 years of age it is around 20 per cent in the first year after the fracture (3). In the near future, more patients older than 95 years are expected to be admitted to hospital with hip fractures. There is little information in the literature about extremely elderly people with hip fractures. A few studies have compared these patients with those in the most frequent age range (75–83 years) and all of them found that older patients had poorer outcomes, with more in-hospital complications (40%) and higher mortality in the first year following discharge (35%–60%) (4–6). Nevertheless, the short- and long-term prognosis for individuals with exceptional longevity, as well as many other epidemiological aspects and outcomes, remains unknown. One study by Evert and colleagues of community-living people aged between 97 and 119 years found different morbidity profiles depending on the age when elderly individuals first developed age-related illnesses: hypertension, heart disease (congestive heart failure, ischemic heart disease, and arrhythmia), diabetes, stroke, nonskin cancer, skin cancer, osteoporosis, thyroid condition, Parkinson’s disease, dementia, chronic obstructive pulmonary disease (COPD), and cataracts. Three categories of patients were identified: survivors (age of onset of age-associated illnesses before 80 years old); delayers (after 80 years old); and escapers (those with no history of age-associated illness before age 100) (7). The aims of our study were first to describe the baseline characteristics of extremely elderly patients admitted to our center with hip fractures and their in-hospital outcomes and cumulative mortality in the first year after the fracture. Second, we wanted to examine whether patients who had not developed age-associated illnesses at very advanced ages (escapers) behaved differently from those who already had them (survivors and delayers). Methods Setting The study was conducted in the Orthopedic Surgery Ward at the Hospital de la Santa Creu i Sant Pau, a tertiary university hospital serving a population of about 425,000 people in Barcelona. Participants The clinical data of all patients admitted to the Orthopedic Surgery Ward with hip fractures between December 2009 and September 2015 were retrospectively reviewed. During admission, patients had been visited at least once by a doctor from the Geriatric Unit, in accordance with the framework of co-operation developed between the two services with respect to hip fractures. All patients older than 95 years with hip fracture were included. Only those patients with hip fractures due to accident or a neoplasm were excluded. It was decided to include only patients older than 95 years of age because that was the lower limit used by Holt and colleagues in their studies of hip fractures in the extreme elderly (6,8). In their paper about the decline of physical function in aging, Ayers and colleagues also considered 95 years to be the lower limit of exceptional longevity (9). A further reason was that our patients were similar in age to those included in the study by Evert and colleagues (7). The study was approved by the institutional ethics committee. Data Collection The following data were recorded as follows: age, sex, comorbidity measured by the Charlson index (10), the Barthel Index of Activities of Daily Living (ADL) (11), place of residence, number of drugs before admission, length of hospital stay, delay to surgery, type of fracture, and type of surgery. The Barthel Index was subdivided into the following: total dependence (<20 points), severe dependence (20–35 points), moderate dependence (40–55), mild dependence (60–95), and independence (100 points). Also noted were any of the following age-associated illnesses prior to admission: hypertension, heart disease (congestive heart failure, ischemic heart disease, and arrhythmia), diabetes, stroke, nonskin cancer, skin cancer, previous diagnosis of osteoporosis, thyroid condition, Parkinson’s disease, dementia, COPD, and cataracts. Diagnoses were established if they were recorded in the medical files or if the doctor from the Geriatric Unit considered that they were present before the current admission. A diagnosis of osteoporosis, which was the probable cause of hip fracture in all patients, was only regarded as a prior illness if the patient had a previous fragility fracture. We defined escapers as patients older than 95 years of age with no age-related illnesses prior to admission. Hemoglobin and albumin levels at admission were recorded. The number and type of complications, final discharge destination (home, nursing home, inpatient rehabilitation facility, or long-term care center) and in-hospital mortality were also noted. Cumulative mortality rates at 30 days, 3 months, and 1 year were obtained. Statistical Analysis Continuous variables were analyzed by calculating means and standard deviation (SD) and compared using Student’s t-test with Welch’s correction. For categorical variables, relative frequencies or proportions were calculated and compared using the Fisher’s exact test. Statistical analysis was performed using the IBM SPSS Statistical Package (version 22; SPSS Inc., Chicago, IL, USA). Statistical significance was p ≤ .05 in all cases. Results Between December 2009 and September 2015, 2,927 patients were admitted to hospital with a hip fracture. Two hundred (6.8%) of these were 95 years of age or older. Their baseline characteristics, in-hospital outcomes, and cumulative mortality are shown in Tables 1–3. With respect to age-associated illnesses, 150 (75%) patients had hypertension, 62 (31%) heart disease [30 (15%) congestive heart failure, 20 (10%) ischemic heart disease, 29 (14.5%) some type of arrhythmia, mainly atrial fibrillation], 27 (13.5%) diabetes, 29 (14.5%) stroke, 24 (12%) nonskin cancer, 6 (3%) skin cancer, 47 (23.5%) a previous fragility fracture, 13 (6.5%) a thyroid condition, 4 (2%) Parkinson’s disease, 60 (30%) dementia, 21 (10.5%) COPD, and 33 (16.5%) had cataracts. Fifteen (7.5%) patients had no prior age-related illnesses (escapers). Three patients (1.5%) died before they could be operated on. Table 1. Baseline Characteristics in Extremely Elderly Patients (Older Than 95 Years) Admitted With Hip Fractures   N = 200  Mean age, y (SD)  97.3 (2.4)  Female sex, n (%)  174 (87)  Charlson index (SD)  1.2 (1.2)  Barthel index (SD)  63.1 (23.9)   Total dependence, n (%)  11 (5.5)   Severe dependence, n (%)  23 (11.5)   Moderate dependence, n (%)  41 (20.5)   Mild dependence, n (%)  111 (55.5)   Independent, n (%)  14 (7)  Dementia, n (%)  60 (30)  Place of residence: n at home (%)  112 (56)  Number of drugs (SD)  5.1 (3)  Intracapsular fracture, n (%)  87 (43.5)  Hemoglobin at admission in g/L (SD)  119.1 (16.1)  Albumin at admission in g/L (SD)  28.1 (3.4)    N = 200  Mean age, y (SD)  97.3 (2.4)  Female sex, n (%)  174 (87)  Charlson index (SD)  1.2 (1.2)  Barthel index (SD)  63.1 (23.9)   Total dependence, n (%)  11 (5.5)   Severe dependence, n (%)  23 (11.5)   Moderate dependence, n (%)  41 (20.5)   Mild dependence, n (%)  111 (55.5)   Independent, n (%)  14 (7)  Dementia, n (%)  60 (30)  Place of residence: n at home (%)  112 (56)  Number of drugs (SD)  5.1 (3)  Intracapsular fracture, n (%)  87 (43.5)  Hemoglobin at admission in g/L (SD)  119.1 (16.1)  Albumin at admission in g/L (SD)  28.1 (3.4)  Note: SD = Standard deviation. View Large Table 1. Baseline Characteristics in Extremely Elderly Patients (Older Than 95 Years) Admitted With Hip Fractures   N = 200  Mean age, y (SD)  97.3 (2.4)  Female sex, n (%)  174 (87)  Charlson index (SD)  1.2 (1.2)  Barthel index (SD)  63.1 (23.9)   Total dependence, n (%)  11 (5.5)   Severe dependence, n (%)  23 (11.5)   Moderate dependence, n (%)  41 (20.5)   Mild dependence, n (%)  111 (55.5)   Independent, n (%)  14 (7)  Dementia, n (%)  60 (30)  Place of residence: n at home (%)  112 (56)  Number of drugs (SD)  5.1 (3)  Intracapsular fracture, n (%)  87 (43.5)  Hemoglobin at admission in g/L (SD)  119.1 (16.1)  Albumin at admission in g/L (SD)  28.1 (3.4)    N = 200  Mean age, y (SD)  97.3 (2.4)  Female sex, n (%)  174 (87)  Charlson index (SD)  1.2 (1.2)  Barthel index (SD)  63.1 (23.9)   Total dependence, n (%)  11 (5.5)   Severe dependence, n (%)  23 (11.5)   Moderate dependence, n (%)  41 (20.5)   Mild dependence, n (%)  111 (55.5)   Independent, n (%)  14 (7)  Dementia, n (%)  60 (30)  Place of residence: n at home (%)  112 (56)  Number of drugs (SD)  5.1 (3)  Intracapsular fracture, n (%)  87 (43.5)  Hemoglobin at admission in g/L (SD)  119.1 (16.1)  Albumin at admission in g/L (SD)  28.1 (3.4)  Note: SD = Standard deviation. View Large Table 2. In-hospital Outcomes in Patients Older Than 95 Years of Age   N = 200  Length of hospital stay in days (SD)  13.6 (10.4)  Delay to surgery in days (SD)  3.8 (2.9)  Prosthesis, n (%)  68 (34)  Patients with complications, n (%)  172 (86)  Mean complications, n (%)  1.8 (1.6)   Transfusion, n (%)  119 (59.5)   Delirium, n (%)  67 (33.5)   Respiratory infection, n (%)  50 (25)   Cardiovascular, n (%)  31 (15.5)   Urinary infection, n (%)  36 (18)   Acute renal failure, n (%)  46 (23)   Digestive, n (%)  8 (4)   Hip prosthesis luxation, n (%)  2 (1)   Wound infection, n (%)  1 (0.5)   Surgical technique problem, n (%)  2 (1)   Vascular section, n (%)  1 (0.5)  In-hospital mortality, n (%)  25 (12.5)  Discharge to a center, n (%)*  72 (41.1)   In-patient rehabilitation facility, n (%)  63 (36)   Long-term care center, n (%)  9 (5.1)    N = 200  Length of hospital stay in days (SD)  13.6 (10.4)  Delay to surgery in days (SD)  3.8 (2.9)  Prosthesis, n (%)  68 (34)  Patients with complications, n (%)  172 (86)  Mean complications, n (%)  1.8 (1.6)   Transfusion, n (%)  119 (59.5)   Delirium, n (%)  67 (33.5)   Respiratory infection, n (%)  50 (25)   Cardiovascular, n (%)  31 (15.5)   Urinary infection, n (%)  36 (18)   Acute renal failure, n (%)  46 (23)   Digestive, n (%)  8 (4)   Hip prosthesis luxation, n (%)  2 (1)   Wound infection, n (%)  1 (0.5)   Surgical technique problem, n (%)  2 (1)   Vascular section, n (%)  1 (0.5)  In-hospital mortality, n (%)  25 (12.5)  Discharge to a center, n (%)*  72 (41.1)   In-patient rehabilitation facility, n (%)  63 (36)   Long-term care center, n (%)  9 (5.1)  Notes: SD = Standard deviation. *These numbers refer to patients surviving after hospital admission (n = 175). View Large Table 2. In-hospital Outcomes in Patients Older Than 95 Years of Age   N = 200  Length of hospital stay in days (SD)  13.6 (10.4)  Delay to surgery in days (SD)  3.8 (2.9)  Prosthesis, n (%)  68 (34)  Patients with complications, n (%)  172 (86)  Mean complications, n (%)  1.8 (1.6)   Transfusion, n (%)  119 (59.5)   Delirium, n (%)  67 (33.5)   Respiratory infection, n (%)  50 (25)   Cardiovascular, n (%)  31 (15.5)   Urinary infection, n (%)  36 (18)   Acute renal failure, n (%)  46 (23)   Digestive, n (%)  8 (4)   Hip prosthesis luxation, n (%)  2 (1)   Wound infection, n (%)  1 (0.5)   Surgical technique problem, n (%)  2 (1)   Vascular section, n (%)  1 (0.5)  In-hospital mortality, n (%)  25 (12.5)  Discharge to a center, n (%)*  72 (41.1)   In-patient rehabilitation facility, n (%)  63 (36)   Long-term care center, n (%)  9 (5.1)    N = 200  Length of hospital stay in days (SD)  13.6 (10.4)  Delay to surgery in days (SD)  3.8 (2.9)  Prosthesis, n (%)  68 (34)  Patients with complications, n (%)  172 (86)  Mean complications, n (%)  1.8 (1.6)   Transfusion, n (%)  119 (59.5)   Delirium, n (%)  67 (33.5)   Respiratory infection, n (%)  50 (25)   Cardiovascular, n (%)  31 (15.5)   Urinary infection, n (%)  36 (18)   Acute renal failure, n (%)  46 (23)   Digestive, n (%)  8 (4)   Hip prosthesis luxation, n (%)  2 (1)   Wound infection, n (%)  1 (0.5)   Surgical technique problem, n (%)  2 (1)   Vascular section, n (%)  1 (0.5)  In-hospital mortality, n (%)  25 (12.5)  Discharge to a center, n (%)*  72 (41.1)   In-patient rehabilitation facility, n (%)  63 (36)   Long-term care center, n (%)  9 (5.1)  Notes: SD = Standard deviation. *These numbers refer to patients surviving after hospital admission (n = 175). View Large Table 3. Cumulative Mortality in Patients Older Than 95 Years   N = 182*  Mortality at 30 d, n (%)  37 (20.3)  Mortality at 3 mo, n (%)  56 (30.8)  Mortality at 1 y, n (%)  92 (50.5)    N = 182*  Mortality at 30 d, n (%)  37 (20.3)  Mortality at 3 mo, n (%)  56 (30.8)  Mortality at 1 y, n (%)  92 (50.5)  Note: *Only 182 patients were available at 1 year of follow-up. View Large Table 3. Cumulative Mortality in Patients Older Than 95 Years   N = 182*  Mortality at 30 d, n (%)  37 (20.3)  Mortality at 3 mo, n (%)  56 (30.8)  Mortality at 1 y, n (%)  92 (50.5)    N = 182*  Mortality at 30 d, n (%)  37 (20.3)  Mortality at 3 mo, n (%)  56 (30.8)  Mortality at 1 y, n (%)  92 (50.5)  Note: *Only 182 patients were available at 1 year of follow-up. View Large The most frequent complications were anemia requiring transfusion and delirium. One hundred eight patients (54%) had other complications (excluding anemia and transfusion). The escaper group of patients was compared with other patients older than 95 years. Comparison of their baseline characteristics at admission and in-hospital outcomes is shown in Tables 4 and 5. Statistically significant differences with respect to comorbidity were found, with escaper patients, as expected, having much lower Charlson scores. This group also scored higher on the Barthel ADL index, took fewer drugs before admission, and more often lived at home. When comparing in-hospital outcomes between the two groups, we found significant differences in length of hospital stay and delay in surgery, which were both shorter in the escaper group of patients. Also escaper patients more often required discharge to an inpatient rehabilitation facility. In the first year after the fracture, 182 patients (91%) were available for follow-up, whereas 18 patients (9%) could not be located. Table 6 shows cumulative mortality rates at 30 days, 3 months, and 1 year. There were no significant differences between the two groups. Table 4. Comparison of Escapers and Other Patients Older Than 95 Years of Age: Baseline Characteristics Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Age, y (SD)  97.87 (2.2)  97.23 (2.3)  .303  Female sex, n (%)  12 (80)  162 (87.6)  .420  Charlson index (SD)  0.20 (0.6)  1.27 (1.2)  <.001  Barthel index (SD)  76.67 (16.9)  62.05 (24.1)  .01   Total dependence, n (%)  0 (0)  11 (5.9)  1   Severe dependence, n (%)  0 (0)  23 (12.4)  .226   Moderate dependence, n (%)  2 (13.3)  39 (21.1)  .740   Mildly dependence, n (%)  11 (73.3)  101 (54.6)  .186   Independent, n (%)  2 (13.3)  11 (5.9)  .253  Place of residence: n at home (%)  13 (86.7)  99 (53.5)  .010  Number of drugs (SD)  2.13 (1.95)  5.33 (2.95)  <.001  Intracapsular fracture, n (%)  5 (33.3)  82 (44.3)  .293  Hemoglobin at admission in g/L (SD)  124.57 (19.8)  118.62 (15.7)  .291  Albumin at admission in g/L (SD)  27.98 (3.7)  28.15 (3.4)  .866  Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Age, y (SD)  97.87 (2.2)  97.23 (2.3)  .303  Female sex, n (%)  12 (80)  162 (87.6)  .420  Charlson index (SD)  0.20 (0.6)  1.27 (1.2)  <.001  Barthel index (SD)  76.67 (16.9)  62.05 (24.1)  .01   Total dependence, n (%)  0 (0)  11 (5.9)  1   Severe dependence, n (%)  0 (0)  23 (12.4)  .226   Moderate dependence, n (%)  2 (13.3)  39 (21.1)  .740   Mildly dependence, n (%)  11 (73.3)  101 (54.6)  .186   Independent, n (%)  2 (13.3)  11 (5.9)  .253  Place of residence: n at home (%)  13 (86.7)  99 (53.5)  .010  Number of drugs (SD)  2.13 (1.95)  5.33 (2.95)  <.001  Intracapsular fracture, n (%)  5 (33.3)  82 (44.3)  .293  Hemoglobin at admission in g/L (SD)  124.57 (19.8)  118.62 (15.7)  .291  Albumin at admission in g/L (SD)  27.98 (3.7)  28.15 (3.4)  .866  Note: SD = Standard deviation. View Large Table 4. Comparison of Escapers and Other Patients Older Than 95 Years of Age: Baseline Characteristics Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Age, y (SD)  97.87 (2.2)  97.23 (2.3)  .303  Female sex, n (%)  12 (80)  162 (87.6)  .420  Charlson index (SD)  0.20 (0.6)  1.27 (1.2)  <.001  Barthel index (SD)  76.67 (16.9)  62.05 (24.1)  .01   Total dependence, n (%)  0 (0)  11 (5.9)  1   Severe dependence, n (%)  0 (0)  23 (12.4)  .226   Moderate dependence, n (%)  2 (13.3)  39 (21.1)  .740   Mildly dependence, n (%)  11 (73.3)  101 (54.6)  .186   Independent, n (%)  2 (13.3)  11 (5.9)  .253  Place of residence: n at home (%)  13 (86.7)  99 (53.5)  .010  Number of drugs (SD)  2.13 (1.95)  5.33 (2.95)  <.001  Intracapsular fracture, n (%)  5 (33.3)  82 (44.3)  .293  Hemoglobin at admission in g/L (SD)  124.57 (19.8)  118.62 (15.7)  .291  Albumin at admission in g/L (SD)  27.98 (3.7)  28.15 (3.4)  .866  Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Age, y (SD)  97.87 (2.2)  97.23 (2.3)  .303  Female sex, n (%)  12 (80)  162 (87.6)  .420  Charlson index (SD)  0.20 (0.6)  1.27 (1.2)  <.001  Barthel index (SD)  76.67 (16.9)  62.05 (24.1)  .01   Total dependence, n (%)  0 (0)  11 (5.9)  1   Severe dependence, n (%)  0 (0)  23 (12.4)  .226   Moderate dependence, n (%)  2 (13.3)  39 (21.1)  .740   Mildly dependence, n (%)  11 (73.3)  101 (54.6)  .186   Independent, n (%)  2 (13.3)  11 (5.9)  .253  Place of residence: n at home (%)  13 (86.7)  99 (53.5)  .010  Number of drugs (SD)  2.13 (1.95)  5.33 (2.95)  <.001  Intracapsular fracture, n (%)  5 (33.3)  82 (44.3)  .293  Hemoglobin at admission in g/L (SD)  124.57 (19.8)  118.62 (15.7)  .291  Albumin at admission in g/L (SD)  27.98 (3.7)  28.15 (3.4)  .866  Note: SD = Standard deviation. View Large Table 5. Comparison of Escapers and Other Patients Older Than 95 Years: In-hospital Results Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Length of hospital stay in days (SD)  10.80 (3.8)  13.84 (10.7)  .022  Delay in surgery in days (SD)  2.60 (1.2)  3.95 (3)  .022  Prosthesis, n (%)  3 (20)  65 (35.7)  .269  Patients with any complication, n (%)  13 (86.7)  159 (85.9)  1  Mean complications, n (%)  1.47 (0.9)  1.91 (1.6)  .11   Transfusion, n (%)  8 (53.3)  111 (60)  .785   Delirium, n (%)  4 (26.7)  63 (34.1)  .777   Respiratory infection, n (%)  1 (6.7)  49 (26.5)  .122   Cardiovascular, n (%)  2 (13.3)  29 (15.7)  1   Urinary infection, n (%)  3 (20)  33 (17.8)  .736   Acute renal failure, n (%)  3 (20)  43 (23.2)  1   Digestive, n (%)  0 (0)  8 (4.3)  1   Prosthesis luxation, n (%)  1 (6.7)  1 (0.5)  .145   Wound infection, n (%)  0 (0)  1 (0.5)  1   Surgical technique problem, n (%)  0 (0)  2 (1.1)  1   Vascular section, n (%)  0 (0)  1 (0.5)  1  In-hospital mortality, n (%)  1 (6.7)  24 (13)  .699  Discharge to a center n (%)*  11 (78.6)  61 (37.9)  .004   Inpatient rehabilitation facility, n (%)  10 (71.4)  53 (32.9)  .007   Long-term care center, n (%)  1 (7.1)  8 (5)  .537  Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Length of hospital stay in days (SD)  10.80 (3.8)  13.84 (10.7)  .022  Delay in surgery in days (SD)  2.60 (1.2)  3.95 (3)  .022  Prosthesis, n (%)  3 (20)  65 (35.7)  .269  Patients with any complication, n (%)  13 (86.7)  159 (85.9)  1  Mean complications, n (%)  1.47 (0.9)  1.91 (1.6)  .11   Transfusion, n (%)  8 (53.3)  111 (60)  .785   Delirium, n (%)  4 (26.7)  63 (34.1)  .777   Respiratory infection, n (%)  1 (6.7)  49 (26.5)  .122   Cardiovascular, n (%)  2 (13.3)  29 (15.7)  1   Urinary infection, n (%)  3 (20)  33 (17.8)  .736   Acute renal failure, n (%)  3 (20)  43 (23.2)  1   Digestive, n (%)  0 (0)  8 (4.3)  1   Prosthesis luxation, n (%)  1 (6.7)  1 (0.5)  .145   Wound infection, n (%)  0 (0)  1 (0.5)  1   Surgical technique problem, n (%)  0 (0)  2 (1.1)  1   Vascular section, n (%)  0 (0)  1 (0.5)  1  In-hospital mortality, n (%)  1 (6.7)  24 (13)  .699  Discharge to a center n (%)*  11 (78.6)  61 (37.9)  .004   Inpatient rehabilitation facility, n (%)  10 (71.4)  53 (32.9)  .007   Long-term care center, n (%)  1 (7.1)  8 (5)  .537  Notes: SD = Standard deviation. *These numbers refer to patients surviving after hospital admission (n = 175). View Large Table 5. Comparison of Escapers and Other Patients Older Than 95 Years: In-hospital Results Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Length of hospital stay in days (SD)  10.80 (3.8)  13.84 (10.7)  .022  Delay in surgery in days (SD)  2.60 (1.2)  3.95 (3)  .022  Prosthesis, n (%)  3 (20)  65 (35.7)  .269  Patients with any complication, n (%)  13 (86.7)  159 (85.9)  1  Mean complications, n (%)  1.47 (0.9)  1.91 (1.6)  .11   Transfusion, n (%)  8 (53.3)  111 (60)  .785   Delirium, n (%)  4 (26.7)  63 (34.1)  .777   Respiratory infection, n (%)  1 (6.7)  49 (26.5)  .122   Cardiovascular, n (%)  2 (13.3)  29 (15.7)  1   Urinary infection, n (%)  3 (20)  33 (17.8)  .736   Acute renal failure, n (%)  3 (20)  43 (23.2)  1   Digestive, n (%)  0 (0)  8 (4.3)  1   Prosthesis luxation, n (%)  1 (6.7)  1 (0.5)  .145   Wound infection, n (%)  0 (0)  1 (0.5)  1   Surgical technique problem, n (%)  0 (0)  2 (1.1)  1   Vascular section, n (%)  0 (0)  1 (0.5)  1  In-hospital mortality, n (%)  1 (6.7)  24 (13)  .699  Discharge to a center n (%)*  11 (78.6)  61 (37.9)  .004   Inpatient rehabilitation facility, n (%)  10 (71.4)  53 (32.9)  .007   Long-term care center, n (%)  1 (7.1)  8 (5)  .537  Patients = 200  Escapers, n = 15  Other patients, n = 185  p value  Length of hospital stay in days (SD)  10.80 (3.8)  13.84 (10.7)  .022  Delay in surgery in days (SD)  2.60 (1.2)  3.95 (3)  .022  Prosthesis, n (%)  3 (20)  65 (35.7)  .269  Patients with any complication, n (%)  13 (86.7)  159 (85.9)  1  Mean complications, n (%)  1.47 (0.9)  1.91 (1.6)  .11   Transfusion, n (%)  8 (53.3)  111 (60)  .785   Delirium, n (%)  4 (26.7)  63 (34.1)  .777   Respiratory infection, n (%)  1 (6.7)  49 (26.5)  .122   Cardiovascular, n (%)  2 (13.3)  29 (15.7)  1   Urinary infection, n (%)  3 (20)  33 (17.8)  .736   Acute renal failure, n (%)  3 (20)  43 (23.2)  1   Digestive, n (%)  0 (0)  8 (4.3)  1   Prosthesis luxation, n (%)  1 (6.7)  1 (0.5)  .145   Wound infection, n (%)  0 (0)  1 (0.5)  1   Surgical technique problem, n (%)  0 (0)  2 (1.1)  1   Vascular section, n (%)  0 (0)  1 (0.5)  1  In-hospital mortality, n (%)  1 (6.7)  24 (13)  .699  Discharge to a center n (%)*  11 (78.6)  61 (37.9)  .004   Inpatient rehabilitation facility, n (%)  10 (71.4)  53 (32.9)  .007   Long-term care center, n (%)  1 (7.1)  8 (5)  .537  Notes: SD = Standard deviation. *These numbers refer to patients surviving after hospital admission (n = 175). View Large Table 6. Cumulative Mortality: Escaper Patients Compared With Patients With Previous Age-Related Illnesses Patients = 182*  Escapers, n = 14  Other patients, n = 168  p value  Mortality at 30 d, n (%)  2 (14.3)  35 (20.8)  0.738  Mortality at 3 mo, n (%)  3 (21.4)  53 (31.5)  0.555  Mortality at 1 y, n (%)  5 (35.7)  87 (51.8)  0.278  Patients = 182*  Escapers, n = 14  Other patients, n = 168  p value  Mortality at 30 d, n (%)  2 (14.3)  35 (20.8)  0.738  Mortality at 3 mo, n (%)  3 (21.4)  53 (31.5)  0.555  Mortality at 1 y, n (%)  5 (35.7)  87 (51.8)  0.278  Note: *Only 182 patients were available at 1 year of follow-up. View Large Table 6. Cumulative Mortality: Escaper Patients Compared With Patients With Previous Age-Related Illnesses Patients = 182*  Escapers, n = 14  Other patients, n = 168  p value  Mortality at 30 d, n (%)  2 (14.3)  35 (20.8)  0.738  Mortality at 3 mo, n (%)  3 (21.4)  53 (31.5)  0.555  Mortality at 1 y, n (%)  5 (35.7)  87 (51.8)  0.278  Patients = 182*  Escapers, n = 14  Other patients, n = 168  p value  Mortality at 30 d, n (%)  2 (14.3)  35 (20.8)  0.738  Mortality at 3 mo, n (%)  3 (21.4)  53 (31.5)  0.555  Mortality at 1 y, n (%)  5 (35.7)  87 (51.8)  0.278  Note: *Only 182 patients were available at 1 year of follow-up. View Large Discussion This study showed that, in general, extremely elderly patients admitted for hip fractures had good overall baseline characteristics before admission, although rates of in-hospital complications and cumulative mortality during the first year were very high. Although escaper patients had better baseline characteristics, their in-hospital complications and cumulative mortality rates were similar to those of patients with age-associated illnesses. The mean Barthel index score of patients older than 95 years was over 60, indicating that most were mildly dependent for activities of daily living. Most of them were able to live at home. The number of patients with dementia could be considered low, given that about 50 per cent of the extremely elderly have dementia (12). Complications are very frequent in extremely elderly patients as expected. Our study showed that 86 per cent of patients had at least one complication (54% excluding transfusions and delirium). These results are consistent with those described by other authors. In a retrospective study of centenarians with hip fractures carried out by Tarity and colleagues, 43 per cent of patients experienced complications, excluding transfusions and delirium (13). In a retrospective study performed in Barcelona, Pelavski and colleagues found that 76.5 per cent of centenarian patients required a transfusion and post-operative delirium was 41.1 per cent (5). In-hospital mortality was 12.5 per cent, similar to the study by Tarity and colleagues, which was 15 per cent (13). Post-discharge outcomes also showed high cumulative mortality at 30 days, 3 months, and 1 year: 20.3, 30.8 and 50.5 per cent, respectively. These results are comparable to other studies carried out among extremely elderly patients. Forster and colleagues found 31 per cent mortality at 30 days and 56 per cent at 12 months (14), whereas Verma and colleagues found 30.4 per cent mortality at 30 days (15). Both papers were carried out on centenarian patients. The largest study of the extremely elderly was a prospective study by Holt and colleagues who compared 919 patients of 95 years of age or older with another group aged between 75 and 89 years. Their 30 day mortality rate was lower (16.8%) than in our study, but the 3 month mortality rate was higher (38.1%) (6). There are few studies focused on hip fractures in extremely elderly patients. Most of these are retrospectives reviews (13–19). A limited number compared patients older than 95 years with those in the most frequent age range for hip fractures (75–83 years) (4–6,8). There is one prospective study of nonagenarians and centenarians, although it evaluates only outcomes related to anesthesia 48 hours after surgery (20). Retrospective papers describe basal characteristics, in-hospital outcomes, and cumulative mortality. The number of patients is low, between 10 and 50 patients. Our study has a larger number of patients (200) and confirms the findings of these studies with respect to the high number of complications and cumulative mortality. Additionally, our study provides details of different types of in-hospital complications and includes other results such as mean number of complications, delay to surgery, and whether patients required discharge to a center. Studies comparing the extremely elderly with patients in the most frequent age range show that most outcomes (in-hospital complications and cumulative mortality at 4 months) are worse in the first group. Our study provides a comparison that has not yet been made: to examine whether there were differences between extremely elderly patients with and without age-related illnesses. No studies have so far been found analyzing whether people with an “escaper” morbidity profile show different behaviors in clinical practice. A recently published study carried out in China analyzed the prevalence of disability in the 3 years immediately prior to death and found that a quarter of the oldest old remained independent until death. These findings support previous studies showing that there is a subset of individuals who escape common age-associated diseases (21). In our study, escaper patients had better baseline characteristics than other patients in the same age group. Escaper patients took fewer drugs, attributed to the lack of age-related diseases, and had a higher Barthel index score, which probably allowed them to live at home more often. It should also be emphasized that the Charlson comorbidity index was not previously zero in escaper patients, since this index takes into account other comorbidities not related to age, such as ulcers, liver disease, and connective tissue diseases. Delay in surgery and length of hospital stay were shorter in the escaper group of patients. They may have been operated on at an earlier date, because they had lower comorbidity scores, which may partly explain their shorter length of stay, since complications and in-hospital mortality were very similar to those of other patients of the same age. Another significant difference between the two groups was that escaper patients had to be discharged more frequently to an in-patient rehabilitation facility. This seemingly paradoxical result may be due to the fact that they more often lived at home before being admitted to hospital and were unable to return there following discharge. Our hypothesis was that escaper patients should have fewer complications and lower mortality than other patients older than 95 years of age, although this was not in fact the case. One possible reason is that these patients had not yet developed age-related diseases, or at least the first symptoms did not appear until the hip fracture. However, once symptoms begin (and hip fracture is a clinical manifestation of osteoporosis), the period until death is the same for all the extremely elderly. This explanation may be related to the compression of morbidity hypothesis proposed by James Fries in 1980, according to which, in some extremely elderly people, the onset of illness and associated disability are compressed into the last months of life. This would be the most favorable situation, although it is also possible to reach an advanced age with a history of chronic illness (22). It is clear that further studies will be necessary to find out more about the extremely elderly with hip fractures. In addition to age-related diseases, aspects such as sarcopenia and frailty may have an influence on short and long term prognosis and mortality. In a recent paper, Kramer and colleagues found extensive type-II muscle fiber atrophy in elderly females with hip fractures (23). Due to the characteristics of our study, we do not know the previous degree of frailty of these patients, although it has been shown that frailty is prevalent in other surgeries, such as aortic valve replacement, and is associated with poor outcomes (24). Patients without age-related diseases were easy to identify. For many patients though, it was difficult to determine the exact, or even approximate, date of onset of the disease after many years of evolution. Because of this, we decided to divide the patients into two groups: escapers and the rest of the population older than 95 years of age, since it was often difficult to determine with any certainty whether patients were survivors or delayers. We considered that all patients had osteoporosis and that this caused the hip fracture. This raises the question therefore of whether the escaper patients were true escapers if they probably had the disease.We decided nevertheless to consider them escapers on the grounds that the osteoporosis had not yet manifested clinically. The main limitation of our study is that the number of patients was small, particularly in the escaper group, even though we considered escapers to be those patients older than 95 years of age, rather than centenarians as in the original article (7). However, a greater number of patients could eventually disclose differences not revealed in our study. Another limitation is that we were unable to track down all patients after discharge. The main strength is that this is, to the best of our knowledge, the first time that morbidity profiles of extremely elderly patients have been applied to clinical studies of patients with hip fractures. Conclusions Extremely elderly patients with hip fractures had a high number of complications while admitted to hospital. Mortality within the first year of the fracture was very high, regardless of whether the patient had previous age-related diseases. Escaper patients had better baseline characteristics, shorter length of hospital stay, and delay in surgery, although their in-hospital and cumulative mortality were similar to those of other patients older than 95 years. Funding No sources of funding were used to assist in the performance of this study or the preparation of the article. Conflict of interest statement None declared. References 1. Alarcón T, González-Montalvo JI, Bárcena A, Saez P. Further experience of nonagenarians with hip fractures. Injury . 2001; 32: 555– 558. doi: 10.1016/S0020-1383(00)00244-8 Google Scholar CrossRef Search ADS PubMed  2. Braithwaite RS, Col NF, Wong JB. Estimating hip fracture morbidity, mortality and costs. 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J Chronic Dis  1987; 40: 373– 383. doi: 10.1016/0021-9681(87)90171–8 Google Scholar CrossRef Search ADS PubMed  11. Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J . 1965; 14: 61– 65. Google Scholar PubMed  12. Poon LW, Woodard JL, Stephen Miller L, et al.   Understanding dementia prevalence among centenarians. J Gerontol A Biol Sci Med Sci . 2012; 67: 358– 365. doi: 10.1093/gerona/glr250 Google Scholar CrossRef Search ADS PubMed  13. Tarity TD, Smith EB, Dolan K, Rasouli MR, Maltenfort MG. Mortality in centenarians with hip fractures. Orthopedics . 2013; 36: e282– e287. doi: 10.3928/01477447-20130222-15 Google Scholar CrossRef Search ADS PubMed  14. Forster MC, Calthorpe D. Mortality following surgery for proximal femoral fractures in centenarians. Injury . 2000; 31: 537– 539. doi: 10.1016/S0020-1383(00)00049-8 Google Scholar CrossRef Search ADS PubMed  15. Verma R, Rigby AS, Shaw CJ, Mohsen A. Acute care of hip fractures in centenarians–do we need more resources? Injury . 2009; 40: 368– 370. doi: 10.1016/j.injury.2008.09.008 Google Scholar CrossRef Search ADS PubMed  16. Patil S, Parcells B, Blasted A, Chamberlain RS. Surgical outcome following hip fracture in patients > 100 years old: will they ever walk again. Surg Sci  2012; 3: 554– 559. doi: org/10.4236/ss.311109 Google Scholar CrossRef Search ADS   17. Mazzola P, Perego S, Picone D, et al.   Hip fracture in centenarans: retrospective analysis of an orthogeriatric unit reveals the limitations of the current research. Glob Anaesth Perioper Med  2015; 1: 68– 72. doi: 10.15761/GAPM.1000118 Google Scholar CrossRef Search ADS   18. Shabat S, Mann G, Gepstein R, Fredman B, Folman Y, Nyska M. Operative treatment for hip fractures in patients 100 years of age and older: is it justified? J Orthop Trauma . 2004; 18: 431– 435. Google Scholar CrossRef Search ADS PubMed  19. Kapicioglu M, Ersen A, Saglam Y, Akgul T, Kizilkurt T, Yazicioglu O. Hip fractures in extremely old patients. J Orthop . 2014; 11: 136– 141. doi: 10.1016/j.jor.2014.06.009 Google Scholar CrossRef Search ADS PubMed  20. Imbelloni LE, Gouveia MA, Borges de Morais G, da Silva A. Outcome after anesthesia and orthopedic surgery in patients nonagenarians and centenarians. J Anesth Clin Res . 2014; 5: 411. doi: org/10.4172/2155–6148.1000411 Google Scholar CrossRef Search ADS   21. Liu Z, Han L, Wang X, Feng Q, Gill TM. Disability prior to death among the oldest old in China. J Gerontol . 2018; 2: 1– 7. doi: 10.10937gerona/gly010 Google Scholar CrossRef Search ADS   22. Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med . 1980; 303: 130– 135. doi: 10.1056/NEJM198007173030304 Google Scholar CrossRef Search ADS PubMed  23. Kramer IF, Snijders T, Smeets JSJ, et al.   Extensive type II muscle fiber atrophy in elderly female hip fracture patients. J Gerontol A Biol Sci Med Sci . 2017; 72: 1369– 1375. doi: 10.1093/gerona/glw253 Google Scholar CrossRef Search ADS PubMed  24. Kotajarvi BR, Schafer MJ, Atkinson EJ, et al.   The impact of frailty on patient-centered outcomes following aortic valve replacement. J Gerontol A Biol Sci Med Sci . 2017; 72: 917– 921. doi: 10.1093/gerona/glx038 Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

The Journals of Gerontology Series A: Biomedical Sciences and Medical SciencesOxford University Press

Published: Mar 26, 2018

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