| PART ONE A single-centre based analysis of hospitalised elderly surgical patients and the related perioperative mortalityObjective:As people grow older their demand for health services increases. Elderly people require surgery more often, and also in this group surgical risk is higher. The aim of this study is to describe the current situation of hospitalised elderly surgical patients and the associated perioperative mortality, in order to develop possible strategies to ensure a safe perioperative period for elderly patients.Method:From January2006to December2010, data on all surgical patients admitted to Huadong Hospital, a tertiary general hospital, in Shanghai were reviewed retrospectively. The patients were divided into two groups based upon age, the young and middle-aged group (18-59years) and the elderly group (≥60years). Statistical analysis of collected data (age, surgical department, and cause of death) was aimed at investigating the related perioperative mortality in both groups.Results:1) Elderly patients represented58.27%to60.52%of the total hospital admissions, and45.6%to52.0%of surgical admissions. Elderly surgical patients represented21.50%to24.54%of all admissions for the elderly. The indications for surgery were mostly due to abdominal, urological, and orthopaedic disorders.2) The perioperative mortality rate reported for hospitalised elderly surgical patients (1.15%) was significantly higher than that for young and middle-aged patients (0.26%),(p<0.001). While comparing the perioperative mortality among elderly patients gender difference had no significance,(p=0.22).3) With increasing age the perioperative mortality rate in elderly patients increased exponentially,(p<0.001).4) The perioperative mortality rate among the different surgical departments was significant, with the mortality rates in neurosurgery and thoracic surgery being relatively higher,(p<0.001).5) Chest infection, respiratory failure, multiple organ dysfunction syndrome (MODS), septic shock, heart failure and acute myocardial infarction were the main causes of perioperative death in elderly patients, and infection was the most important risk factor for these causes of death. In young and middle-aged patients, the progression of the primary disease was the leading cause of death during the perioperative period.Conclusion:Our study shows that elderly patients account for a major share of our hospital admissions and half of the admissions to our surgical units. We can only anticipate that with increased ageing of the population, more and more elderly patients will require surgical treatment and the number admissions will increase in the future. In elderly patients, the perioperative mortality rate is higher (four times more than in young and middle-aged patients), and it rises exponentially with increasing age. Therefore, in older patients perioperative risk is higher. In elderly patients, to reduce the perioperative risk to a minimum we propose that multidisciplinary preoperative assessment should be carried out. We should carefully weigh the need for surgery, estimate the surgical risks and benefits, perform optimum preoperative preparation, evaluate the need for intraoperative and postoperative intensive care, maintain high operation standards, adhere to strict fluid management, and lastly identify and handle abnormal conditions early. PART TWOHip fracture-a prototypical geriatric illness:perioperative and1year postoperative outcome assessment.Objective:Hip fracture is one of the most commonly seen fractures in the elderly. It is also one of the most frequently seen fragility fractures due to osteoporosis. Hip fracture not only leads to the loss of the lower limb functions but also predisposes the elderly to postfracture complications, significantly reduces their quality of life, and even endangers their lives by increasing the risk of mortality. In this study, multidimensional analysis of retrieved data on elderly patients who underwent surgery for hip fracture at Huadong Hospital for the year2010was performed. Postoperative follow-up through telephone interviews was carried out to learn more about the postoperative condition of elderly hip fracture patients after hospital discharge. Statistical analysis of all collected data was to assess the risk of surgery, to determine factors related to surgical outcome, and to explore measures to further reduce the risks of hip fracture surgery while also improving surgical efficacy.Method:1) First, a retrospective survey of elderly (age≥60years) hip fracture patients who underwent surgery at Huadong Hospital from January2010to December2010was carried out. The medical records of all elderly patients who were admitted for hip fracture (fracture of the neck of femur and intertrochanteric hip fracture) and then underwent surgical treatment were reviewed retrospectively and statistical analysis of the following data was performed:age, gender, type of fracture, prefracture general physical health status, prefracture cognitive function, prefracture Activities of Daily Living (ADL) function, preoperative comorbidities, prefracture cardiac function, preoperative nutritional status [Body Mass Index (BMI), serum albumin level, haemoglobin level etc.], type of surgery, type of anaesthesia, intraoperative blood transfusion, postoperative complications, and postoperative nutritional status (serum albumin level and haemoglobin level).2) Postoperative follow-up of patients, excluding those who passed away during the in-hospital postoperative period, was done prospectively through telephone interviews. The main points covered were:postoperative ADL function, postoperative cognitive function, survival outcome, and the exclusion of any morbidity that could have occurred after surgery and could have influenced our measure of surgical outcome. The end date for determining survival outcome was31st December2011. The methods used to assess postoperative ADL and cognitive functions were the same as used in the retrospective survey. The prefracture and postoperative ADL function of each patient that could have been traced back was compared as follows:if the ADL function was similar it is "complete recovery"; if postoperative ADL function was "totally dependent" it is "no recovery"; and if postoperative ADL function was inferior to the prefracture level but was not "totally dependent" it is "partial recovery".3) A database for all study subjects (total population) was created and all collected perioperative data were subject to statistical analysis. For the purpose of our study, the subjects were further divided into two groups, the young-old elderly group (60-79years) and the oldest-old elderly group (≥80years). The perioperative data of the two groups were compared and univariate statistical analysis was performed to determine factors related to efficacy of surgical treatment.Results:1) In total,234patients met the inclusion criteria and could be followed up. Elderly people accounted for92.36%of hip fracture admissions. The female to male ratio was2.5:1.In our study population,59.83%of hip fracture occurred in the oldest-old elderly group, and52.85%of hip fractures were intertrochanteric fractures.2) The prefracture general physical health status of most patients belonged to American Society of Anethesiologists (ASA) class II and III. Their prefracture cognitive function was mostly "normal" or with "mild cognitive impairment", and cardiac function was mostly New York Heart Association (NYHA) class I or II. Prefracture general physical health status, cognitive and cardiac function of patients in the oldest-old elderly group were significantly lower than those in the young-old elderly group,(p<0.001).3) In elderly patients with hip fracture, the prefracture nutritional indicators like BMI, plasma albumin and haemoglobin were towards the lower limits of normal. The prefracture BMI, preoperative plasma albumin level, postoperative haemoglobin and plasma albumin levels in the oldest-old elderly group were significantly lower,(p<0.001). 4) The most commonly seen comorbidities in our study population were hypertension, cardiovascular disease, diabetes mellitus, neurological disease, COPD, and chest infection. The latter two were more common in the oldest-old elderly group,(p<0.05) by Fisher’s exact test result.5) In the young-old elderly group, both the surgical methods internal fixation and replacement arthroplasty, were used almost equally but in the oldest-old elderly group internal fixation was the main method used. Regional anaesthesia (epidural anaesthesia and spinal anaesthesia) was used in79.59%of all elderly patients, and in the oldest-old elderly it was used in89.29%of cases.6) The main postoperative complications were chest infection, delirium, heart failure, respiratory failure, serious cardiac arrhythmias, acute myocardial infarction, cerebrovascular accident, acute kidney injury, MODS and deep vein thrombosis. In the oldest-old elderly group, the rate at which postoperative complications occurred was30.71%, which is significantly higher than the13.83%reported in the young-old elderly group,(X2value=11.61, p<0.001).7) Chest infection complicated by respiratory failure, heart failure, MODS, malignant neoplasms, cerebrovascular accident, acute myocardial infarction, pulmonary embolism and liver cirrhosis were the main causes of death reported during the one year postoperative period. The in-hospital postoperative mortality rate was2.99%and one year postoperative mortality rate (including in-hospital postoperative deaths) was13.68%.While comparing the in-hospital postoperative and one year postoperative mortality rates between the young-old and oldest elderly groups they respectively were2.19%and3.57%,9.57%and16.43%,(p=0.0519).8) Approximately64%of our elderly patients had full recovery of their prefracture ability to maintain ADL function, about26%had partial recovery and about10%had no recovery. In both groups the ability to maintain ADL after surgery was significantly diminished (p<0.001), especially in the oldest-old elderly group where the average level fell from "partially independent" to "mainly needs assistance". One year after surgery the cognitive function in the young-old and oldest-old elderly groups were mostly "normal" to "mild cognitive impairment". Cognitive function was significantly diminished only in the oldest-old elderly group one year after surgery,(p<0.05). 9) By univariate analysis, the type of fracture, prefracture general physical health status determined by ASA classification, prefracture BMI, type of surgery, postoperative complications and postoperative cognitive function were closely related to efficacy of surgical treatment,(p<0.05).Conclusion:Hip fractures are more common in the oldest-old elderly females and intertrochanteric fractures are the most common type of hip fracture seen. In the elderly, especially the oldest-old the physiologic reserve of many organs of the body diminishes with increasing age, and multiple pathologies related the vital organs are not uncommon. Prefracture nutritional status (BMI) and general physical health status (determined by ASA classification) are relatively poor in older patients, which lead to poor tolerance of anaesthesia and surgery, and also increase surgical risk. However, as long as older patients are adequately prepared preoperatively through a multidisciplinary assessment, the right type of surgery and anaesthesia are choosen, and perioperative management is meticulous, about90%of elderly hip fracture patients achieve partial or complete recovery of ADL functions. Lastly, prefracture general physical health status, prefracture BMI, type of hip fracture, type of surgery, postoperative complications and postoperative cognitive function are the main factors that affect surgical outcome of hip fracture in the elderly. |
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