Outcomes of trauma admission

The population demographic of the UK has changed significantly over the past 50 years. Average life expectancy has increased, and it is not uncommon for patients to live into their second century.¹ The last nationally recorded figures were in 2009, with over 11,000 centenarians living in the UK.² Box 1 compares the number of centenarians living in other countries.

There is relatively little published literature focusing on trauma surgery and outcomes in the extreme elderly. In the paper by Sieling et al³ reporting outcomes in trauma patients over 90 years of age, of the cohort of 137 patients, only five were over 100 years old.

The result of current demographic trends is that more patients over the age of 100 years will present to institutions with orthopaedic trauma. To our knowledge, this is the first study focusing on the outcome of trauma in this unique cohort.

Methods

Our institution is a level one trauma centre, with over 2,500 trauma admissions each year from an emergency department with more than 130,000 attendances per annum.

Patients admitted with a femoral neck fracture are cared for jointly by an orthopaedic consultant with a special interest in hip fractures and a consultant care of the elderly physician, along with a team of junior trainees and specialist nurses. Patients presenting with other injury patterns are cared for by the nominated on-call consultant and their team, with geriatric input on an as required basis.

From our local trauma database, we identified all patients aged 100 years or greater that were admitted to our institution between January 2007 and December 2011. For these patients, we recorded basic demographics, and identified usual place of residence, injury, treatment, duration of in patient stay, place of discharge, and date and cause of death.

Results

Eighteen patients (15 females and three males), with a mean age of 101 years (100-106) were admitted to our institution during the above time period. Of these, seven were from their own home and eleven were from institutional care.

Fractures of the proximal femur were the predominating injury, accounting for 67% of admissions. Box 2 reports the injuries sustained resulting in admission, and the surgical management utilised. Based on pre-existing medical comorbidities, sixteen patients had a pre-operative ASA grade of three or above, however two presented with an ASA of one. Fourteen patients underwent surgical intervention.

The in hospital mortality was 27.8% (5/18) with four of these patients having undergone surgery. The causes of death as recorded on the death certificate for the in patients deaths are shown in box 3. The one-year mortality was 66.7% (12/18), and the study period mortality was 83% (15/18).

Overall in patient stay averaged 18 days (2-60), which increased to an average of 20 days when in patient deaths were excluded. One patient returned home, whilst 12 were discharged to community care facilities-four returned to the care facility from which they were admitted, five were discharged to rehabilitation facilities with the aim of further improving mobility, one patient was discharged direct to a nursing home, and two were transferred to residential homes. Of the 13 patients who survived to discharge, 62% required increased support levels when compared to admission status.

Discussion

The mean age of the UK population is increasing¹ and therefore, inevitably, the frequency of patients requiring post traumatic orthopaedic attention in their second century will increase. This population group have been shown to have greater social care needs, greater comorbidity⁴ and a decreased life expectancy as compared to younger trauma patient populations. One study suggests that the post traumatic mortality rate in the over 90s to be almost double that of their younger study population (4.4% versus 2.5%).³ The mortality rate of the cohort in this study is significantly higher than the rate reported in the nonagenarian population, which is not unexpected.

Figures from the National Office of Statistics report that the life expectancy of an individual over 100 years is two years, with a predicted one year mortality of 40%. Therefore, our overall mortality of 66.7% following significant trauma is not unexpected.

The outcome of elective surgery in the extremely elderly has been shown to be comparable to their younger counterparts,⁵ however, this is undoubtedly influenced by a selection bias, contrasting the negative selection bias associated with trauma.

This unique cohort of patients present significant challenges to the orthopaedic trauma team, particularly in the management of pre-existing comorbidities and post-operative rehabilitation. It is clear that a multidisciplinary team approach is required, with routine geriatric input.⁶

There was no significant difference in the mortality rates of the patients treated operatively compared with those treated non-operatively.

Conclusions

To our knowledge, this is the first study focusing on trauma in centenarians. As might be expected, there is significant in hospital and one-year mortality. Patients have prolonged in patient stays, and frequently require increased social support on discharge. With current demographic trends, admission of patients over 100 years of age to trauma units will continue to increase.

Conflict of interest: none declared

References