SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Original Article
Comorbidities, clinical intercurrences, and factors associated with mortality in elderly patients
admitted for a hip fracture 夽
Stephanie Victoria Camargo Leão Edelmuth, Gabriella Nisimoto Sorio, Fabio Antonio Anversa Sprovieri, Julio Cesar Gali
∗, Sonia Ferrari Peron
FaculdadedeCiênciasMédicasedaSaúdedeSorocaba,PontifíciaUniversidadeCatólicadeSãoPaulo,Sorocaba,SP,Brazil
a r t i c l e i n f o
Articlehistory:
Received7June2017 Accepted26July2017 Availableonline2August2018
Keywords:
Elderly Hipfractures Orthopedicsurgery
a bs t r a c t
Objective:Toanalyzecomorbiditiesandclinicalcomplications,andtodeterminethefactors associatedwithmortalityratesofelderlypatientsadmittedwithahipfractureinatertiary publichospital.
Methods:Sixty-sevenmedicalrecordswerereviewedinaretrospectivecohortstudy,includ- ingpatientsequaltoorolderthan65yearsadmittedtothisinstitutionforhipfracture betweenJanuary2014andDecember2014.Theevaluateditemsconstitutedwerethefol- lowing:intervaloftimebetweenfractureandhospitaladmission,timebetweenadmission andsurgicalprocedure,comorbidities,clinicalcomplications,typeoforthopedicprocedure, surgicalrisk,cardiacrisk,andpatientoutcome.
Results:Theaveragepatients’ageinthesamplewas77.6years,withapredominanceof thefemalegender.Mostpatients(50.7%)hadtwoormorecomorbidities.Themainclinical complicationsduringhospitalizationincludedcognitivebehavioraldisorders,respiratory infectionandoftheurinarytract.Thetimesbetweenfractureandadmissionandbetween admissionandsurgeryweremorethansevendaysinmostofcases.Themortalityrate duringhospitalizationwas11.9%,andwasdirectlyconnectedtothepresenceofinfections duringhospitalstay(p=0.006),totimebetweenadmissionandsurgerylongerthanseven days(p=0.005),totheGoldmanCardiacRiskIndexclassIII(p=0.008),andtoageequaltoor greaterthan85years(p=0.031).
Conclusion: Patientswithhipfracturesgenerallypresentcomorbidities,aresusceptibleto clinicalcomplications,andhavean11.9%mortalityrate.
©2018SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
夽StudyconductedatFaculdadedeCiênciasMédicasedaSaúdedeSorocaba,PontifíciaUniversidadeCatólicadeSãoPaulo,Sorocaba, SP,Brazil.
∗ Correspondingauthor.
E-mail:jcgali@pucsp.br(J.C.Gali).
https://doi.org/10.1016/j.rboe.2018.07.014
2255-4971/©2018SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Thisisanopenaccessarticle undertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Comorbidades,intercorrênciasclínicasefatoresassociadosà mortalidadeempacientesidososinternadosporfraturadequadril
Palavras-chave:
Idosos
Fraturasdoquadril Cirurgiaortopédica
r e s u m o
Objetivo: Analisarascomorbidadeseasintercorrênciasclínicasedeterminarosfatores associadosà mortalidadedepacientesidososinternadosporfraturadequadrilem um hospitalpúblicodeatenc¸ãoterciária.
Métodos: Nesteestudocoorteretrospectivo,foramrevisados67 prontuáriosmédicosde pacientescomidadeigualoumaiorque65anos,admitidosemnossainstituic¸ãoporfratura dequadril,noperíodoentrejaneiroadezembrode2014.Foramavaliadososintervalosde tempoentrea fraturaeadmissãohospitalareentreessaeoprocedimentocirúrgico,o tempototaldeinternac¸ão,apresenc¸adecomorbidades,asintercorrênciasclínicas,otipo deprocedimentoortopédicoadotado,oriscocirúrgico,oriscocardíacoeodesfechodealta.
Resultados:Amédiadeidadefoide77,6anos,compredominânciadosexofeminino(64,1%).
Amaioriadospacientes(50,7%)tinhaduasoumaiscomorbidades.Asprincipaisintercorrên- ciasclínicasduranteainternac¸ãoforamdistúrbioscognitivo-comportamentaiseinfecc¸ões respiratóriasedotratourinário.Osintervalosdetempoentrefraturaeinternac¸ãoeentre essaeacirurgiaforamsuperioresasetediasnamaioriadoscasos.Ataxademortalidade duranteainternac¸ãofoide11,9%eestevediretamentevinculadaàpresenc¸adeinfecc¸õesno períodohospitalar(p=0,006),aointervalodetempoentreainternac¸ãoeacirurgiasuperior asetedias(p=0,005),aoescoredeGoldmanigualaIII(p=0,008)eàidadeigualousuperior a85anos(p=0,031).
Conclusão: Pacientescomfraturasdoquadrilgeralmenteapresentamcomorbidades,estão predispostosaintercorrênciasclínicasetêmumataxademortalidadede11,9%.
©2018SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Asignificant increaseinthelifeexpectancy ofthepopula- tionhasbeenobservedbothinBrazilandworldwide;thishas triggeredahigherprevalenceofchronicanddegenerativedis- eases.AccordingtotheBrazilianInstituteofGeographyand Statistics(IBGE),thecurrentelderlypopulationinthecoun- tryreachesapproximately15million;estimatesforthenext 20yearsindicatethatitcouldexceed30millionwhenitwill representalmost13%ofthepopulation.1
Balanceandgaitdependonacomplexinteractionbetween nerve, musculoskeletal, cardiovascular, and sensory func- tions,aswellastheabilitytoquicklyadapttoenvironmental andposturalchanges.Balancecontrolchangeswithageand causesgaitinstability,which,togetherwiththeinteractionof variousenvironmentalandindividualfactors,mayresultin falls.2
The 2008 guidelines of the Brazilian Society of Geri- atricsandGerontologyindicatethatapproximately5%offall episodes triggerfractures,the most common ofwhich are vertebral fractures and those of the femur, humerus, dis- talradius, and ribcage. Femoralfractures can beobserved intheproximal,distal,orfemoraldiaphysis;inmostcases, thesefractures haveserious consequenceson the physical capacity and longevity of the patients. Since bone is able totransmitaloadduringmotion,fractures cause alossof bonestructuralintegrity,whichhinderstheeffectivenessof movement.2
It is estimated that one in three women and one in 12 men will experience this type of fracture (whether intertrochantericorofthefemoralneck),and86%ofthecases occur inpeople aged65 yearsorolder.A15–20%reduction in the lifeexpectancy of individuals withfractures can be expected, astherelativeriskofmortalityinthesepatients increasesby4%peryear.3,4
Osteoporosis,sensorydeficitscausedbyastroke,demen- tia, muscular hypotrophy, decreased visual acuity, altered balance and reflexes, muscleweakness,neurologicaldisor- ders,cardiovasculardisorders,andosteomyoarticulardefor- mitiesarepredisposingconditionstofallsand,consequently, fractures.Regardingmortalityduetohipfracture,otherpre- operative factors,identified atthe patient’s admission, are associatedwithanincreaseinthisindex,namely:beingnon- white,age,the presenceofdementia, malegender, clinical comorbidities,anddelirium.5
Clinicalcomorbidities,apartfrombeinganimportantrisk factorforhighermortality,arealsoassociatedwiththeonset ofimmediateorlatepostoperativecomplications.Immediate complicationsincludeshock,fatty embolism,compartment syndrome,venousthromboembolism,pulmonaryembolism, disseminatedintravascularcoagulation,andinfections.Late complicationsincludedelayedconsolidation,malunion,pseu- doarthrosis, avascular necrosis of the bone, reaction to internalfixationdevices,andreflexsympatheticdystrophy.6
Inadditiontocomplicationsinthepostoperativeperiod, the motordisability triggered byfalls and fractures in the elderly can lead to immobility, with several consequences
forthe patient’s health. Amongthe detrimental effects to themusculoskeletalsystem,muscularatrophy,osteoporosis worsening,andjointdegenerationarenoteworthy.Itisesti- matedthatafourtosix-weekbedrestmayleadtoa6–40%
decreaseinbonedensity,especiallyintrabecularbone.Other organic systemsare affected byrest,especiallythe cardio- vascularsystem;anincreaseinheartrateandadecreasein ejectionvolumemaybeobserved.7
Togetherwithcomorbiditiesandthecomplexityofortho- pedic operations, functional impairment highlights the importanceoftheclinicalfollow-upofthesepatients,aswell asanadequateevaluationoftheirsurgicalrisk.Theprimary scoresforthisanalysisaretheAmericanSocietyofAnesthe- siology(ASA)SurgicalRiskScoreandGoldman’sCardiacRisk Index.8
TheASAscore,describedinthe1960s,isuniversallyused foritsabilitytopredicttheoverallriskofmortalityaccord- ingtothepatient’s ageandfunctional status,regardlessof thetypeofproceduretobeperformed.9Goldman’sIndexwas thefirst multifactorialmodel specificallydesignedforperi- operativecardiaccomplicationstobewidelyadopted.Those authorsidentifiedninestatisticallysignificantandclinically relevantcardiacriskfactors,assigningvaluestoeachofthem.
Inthepreoperativeevaluation,eachfactorisadded;thehigher thesum,thegreatertheriskofdeathduetoacardiacrea- sonandoflife-threateningcardiacevents,suchasmyocardial infarction,pulmonaryedema,andventriculartachycardia.10
Duetothe relevanceoffallsandfractures intheelderly population,the authors aimedatanalyzingthe comorbidi- tiesandclinical complicationsofpatients aged65 yearsor olderhospitalizedforhipfracturesatthisinstitution,aswell astoidentifytheriskfactorsassociatedwithmortalityinthese patients.
Material and methods
ThisstudywasapprovedbytheResearchEthicsCommitteeof theinstitution.Thiswasaretrospectivecohortstudyofdata retrievedfromthemedicalrecordsofpatientsaged65years orolder,admittedforproximalfemoralfracturebetweenJan- uaryandDecember2014,whowerelongitudinallyfollowed-up duringhospitalization.
Themeanagewas77.6years(range:65–91years),and64.4%
were females.All patientsattended aninitial preoperative evaluationconsultation;casehistory,physicalexamination, and subsidiary examination were transcribed in the hos- pital’s Preoperative Record Form; the back of this form featurestheGoldman’scardiacriskindexandtheASAscore (AppendixA).
Inthe global clinical evaluation,the following variables were analyzed: gender;age; comorbidities,defined ascon- ditionsthatprecededthefracture;cardiacriskstratification according to the modified Goldman’s index, since arterial blood gasanalysis was onlymeasured when pulseoxime- try, atthe time ofthe clinical evaluation, was lower than 90%inambientair;clinicalcomplications,definedashealth problems that occurred during hospitalization; ASA score;
timebetweenfractureandhospitalization;timebetweenhos- pitalization and orthopedic procedure, whether surgical or
conservative;timebetweensurgeryand hospitaldischarge;
totaltimeofhospitalization;typeofsurgery,whenperformed;
needforintensivecareunit(ICU)duringhospitalstay; and dischargeoutcome.
Regarding the time between surgery and hospital dis- charge,patientswhodidnotundergosurgeryandthosewho diedduringhospitalizationwereexcluded.
Statisticalanalysis
Univariate analysis wasperformed. Thefrequencies ofthe studiedvariableswereobtainedandthetableswereassem- bledbyrelatingthedependentvariablewiththeindependent variables.Thechi-squaredtestwasusedtocomparethefac- torsconsidered;inalltests,thelevelofsignificancewassetat 0.05or5%.
Results
Regardingcomorbidities,11.9%ofthepatientshadnoasso- ciated disease, 37.3% had one comorbidity, 17.9% had two comorbidities,and22.3%hadthree.In10.4%ofthestudypop- ulation,morethanfourcomorbiditieswereobserved.
The main comorbidities found in this population were systemic arterial hypertension (SAH), witha prevalenceof 61.1%;diabetesmellitus,presentin28.3%ofthecases;and heart diseases, observed in 19.4% of the patients. Among the latter, the most frequent was coronary insufficiency, whichaccountedforhalfofthecases.Otherheartconditions includedarrhythmias(4.6%),aorticstenosis,heartfailure,and atrial fibrillation;the latterthree hadthe same prevalence (1.5%).Chronicobstructivepulmonarydiseasewasdetected in 10.4% of the population studied and hypothyroidism, in5.9%.
Inaddition tothesediseases,psychiatricdisorderswere observed in 11.9% ofcases, half ofwhom had depression.
Alzheimer’sdiseaseandstrokehadanindividualprevalence of7.4%(Fig.1).
Themostcommonlyreportedclinicalcomplicationswere cognitive-behavioraldisorders,in28.3%ofthepatients.The most frequent was mental confusion, with a prevalence of 23.8%. Other behavioral and cognitive disorders were psychomotor agitation (8.9%) and lowering of the level of consciousness(2.9%).Intestinalconstipationwasobservedin 13.4% ofthepatients. Respiratoryinsufficiencyorinfection occurredin14.9%ofthecases.Furthermore,aconsiderable partofthepatients(8.9%)hadaurinarytractinfection(UTI) duringtheirhospitalstay(Fig.2).
WhentheGoldmanscorewasusedforcardiacriskassess- ment,50.7% (n=34)ofthe patientswere classified asclass I, 25.3% (n=17) as classII, and 13.4% (n=9) asclass III. In turn,thesurgicalriskassessmentindicatedthat56%(n=38) of the patients were classified as ASA II, 26.8% (n=18) as ASAIII,and4.4%(n=3)asASAIV.Theremainingindividuals notincludedinthesecategoriesofcardiacandsurgicalrisk werenotstratified:sevenpatientswerenotclassifiedbythe Goldmanscoreandeightpatientswerenotassessedbythe ASAscore.
HT Stroke AD COPD PD
DM SAH
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%
61.1% (n = 41) 28.3% (n = 19)
19.4% (n = 13) 11.9% (n = 8)
10.4% (n = 7) 7.4% (n = 5)
7.4% (n = 5) 5.9% (n = 4)
Cardiopatia
Principais comorbidities
Fig.1–Maincomorbiditiesobservedintheanalyzedpopulation.HT,hypothyroidism;AD,Alzheimer’sdisease;COPD, chronicobstructivepulmonarydisease;PD,psychiatricdisorders;DM,diabetesmellitus;SAH,systemicarterial hypertension.
Clinical intercorrences
UTI
IC
Resp. I.
CBD
0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%
28.3%
(n = 19) 14.9% (n =10)
13.4% (n =9) 8.9% (n =6)
Fig.2–Mostcommoncomplicationsobservedinthepostoperativeperiodofpatientswithfemoralfractures.UTI,urinary tractinfection;Resp.I.,respiratoryinsufficiencyorinfection;IC,intestinalconstipation;CBD,cognitive-behavioraldisorders.
The time between fracture and hospitalization was up toseven daysin 25.3% ofthe cases, sevento15 in 13.4%, 15–30in 19.4%, and over 30 days in7.4%. In 34.3% ofthe patients,thisperiodwasunknown,asthemedicalchartdid notfeaturetheexactdateofthefracture.Thetimebetween hospitalizationandsurgerywasuptosevendaysfor23.3%
ofthe patients, from sevento15 for43.3%,from 15 to30 for 30%, and more than 30 for 3.3%. Regarding the total hospitalizationduration,11.9%ofthepatientsremainedhos- pitalizedforuptosevendays;in31.3%,thetimewasfrom seven to 15; in 41.7%, from 15 to 30; and in 14.9%, over 30days(Table1).
Thetimebetweensurgeryandhospitaldischargewasup totwodaysin57.1%ofthecases,threetosevenin33.9%,and oversevendaysin7.1%.
Surgicaltreatmentpredominatedinmostcases,withprox- imalfemoralosteosynthesisin58.2%ofpatients(n=39)and total hip prosthesis in 31.3% of the analyzed population (n=21).Intheother10.4%ofcases(n=7),aconservativetreat- mentwaschosen,asthesepatientspresentedhighsurgical riskaccordingtothescoresapplied.PostoperativeICUadmis- sionwasnecessaryfor26.8%ofthepatients.Inthesepatients, thelengthofICUstayrangedfromoneto30days,withamean offivedays.
Table1–Descriptionofthetimeintervalsanalyzedin thepresentstudy.
Timebetweenfractureandhospitalization n=67(100%)
0–7days 17(25.3%)
7–15days 9(13.4%)
15–30days 13(19.4%)
Over30days 5(7.4%)
Unknown 23(34.3%)
Timebetweenhospitaladmissionandsurgery n=60(100%)
0–7days 14(23.3%)
7–15days 26(43.3%)
15–30days 18(30%)
Over30days 2(3.3%)
Lengthofhospitalstay n=67(100%)
0–7days 8(11.9%)
7–15days 21(31.3%)
15–30days 28(41.7%)
Over30days 10(14.9%)
Table2–Characterizationoftheeightpatientswhose outcomewasdeath.
Gender Female50%(n=4)
No.ofcomorbidities 1comorbidity50%(n=4) 3comorbidities37.5%(n=3) Morethan3comorbidities 12.5%(n=1)
Age≥85years 50%(n=4)
Infectionsduring hospitalization
67.5%(n=5) Goldmanscore ClassI:12.5%(n=1)
ClassII:37.5%(n=3) ClassIII:50%(n=4) Timebetweenhospitalization
andsurgery>7days
37.5%(n=3)
Treatment Conservative50%(n=4)
Femoralosteosynthesis 37.5%(n=3)
Hipprosthesis12.5%(n=1)
Finally,duringthehospitalizationperiod,amortalityrate of11.9%(n=8)wasobserved.Table2showsthemainchar- acteristics of patients who died, including variables with statisticalsignificance.
Theunivariatestatisticalanalysisindicatedthatthepres- ence of infections in the hospitalization period (p=0.006), the time between hospitalization and surgery for more than seven days (p=0.005), a Goldman score equal to III (p=0.008), or age equal to or greater than 85 years (p=0.031)wereassociatedwithdeathduringhospitalization.
Otherfactors,withoutstatistical significance,are described inTable3.
Discussion
Themainfindingofthepresentstudywasthatthemortalityof hospitalizedpatientswithhipfracturewasrelatedtothetime betweenhospitalizationandsurgeryofmorethansevendays,
Table3–Univariateanalysiswiththechi-squaredtestto determinethep-valuebetweentheindependent variablesanddeathoutcome.
Independentvariable(inrelationtothe dependentvariable“death”)
p-Value
Gender 0.373
Age≥85years 0.031
No.ofcomorbidities 0.397
Diabetesmellitus 0.541
Systemicarterialhypertension 0.991
Heartconditions 0.670
Psychiatricdisorders 0.959
Cardiacrisk(Goldman) 0.008
Surgicalrisk(ASA) 0.653
Infectionduringhospitalstay 0.006
Cognitive-behavioraldisordersduring hospitalization
0.148 Timebetweenfractureandadmission 0.980 Timebetweenadmissionandsurgery 0.005
PostoperativeICUadmission 0.401
theoccurrenceofinfections,Goldman’sscoreequaltoIII,and ageequaltoorgreaterthan85years.Post-hipfracturemor- talityiselevatednotonlyinthemonthsfollowingtheevent, butforyearsafterthetrauma.Themultiplecohortdataanal- ysisperformedbyHaentjensetal.11showedthepersistence ofexcessivemortalitytenyearsafterthefracture,whichhigh- lightstheimpactofthispathologyonpublichealth.Although BelmontJr.etal.12havementionedseveralrisksituationsfor deathandcomplicationsinelderlyfracturedpatients,such asobesity,dialysis,shock,andcomorbidities,inthepresent studytheauthorsattemptedtoaddressthemostrelevantfac- tors.
Inthepresentstudy,themortalityrateduringhospitaliza- tionwas11.9%,higherthanthatobservedintheliterature.A reviewofmortalityincasesoffemoralfracturesintheelderly gathereddatafrom25studiesandconcludedthatthemean mortalityduringhospitalstaywas5.5%.13
In turn,the study by Roche et al., which included2448 patients assessedover aperiodfouryears,presenteda30- daypostoperativemortalityof9.6%,lowerthanthatobserved inthepresentpopulation.14Thepatientsinthatstudywere olderthan60yearsandpresentedcardiovascularandrespi- ratorydisordersastheirmaincomorbidities,whileinfections andheartfailurewerethemostprevalentcomplications.14
Timeuntilsurgerywasafactorstatisticallyassociatedwith the mortality rate. In the present study, the waiting time betweenhospitaladmissionandtheprocedurerangedfrom sevento15daysin43.3%ofthepatients;in30%ofthecases, from15to30days;andin3.3%,over30days.Asystematic review and meta-analysis of35 studies retrieved from the MEDLINE,Embase,andCochranedatabasesdemonstrateda significantincreaseintheriskofdeathinpatientswhounder- went surgeryover48hafterhospitaladmission(p<0.0001).
Thisassociationremainedtrueafteradjustingforage,gen- der,location,andyear.Inconclusion,thoseauthorssuggest thatorthopedicservicesshouldadvocatethatfemoralfrac- turepatientsoughttoundergosurgerywithinthefirst 48h afteradmission.15
Mesquitaetal.,16inasurveyextractedfromtheMEDLINE, LILACS,andSciELOdatabasesfromJanuary2003toDecember 2007,reportedthatthemeanwaitingtimebetweenfracture andsurgerywas6.8days,andthat theincreaseofoneday waitingincreasedthepossibility ofdeathbyapproximately 4%.16Consideringthatinthepresentstudythevastmajority ofpatientshadawaitingtimebetweenhospitalizationand surgerylonger thansevendays,and thatthetimebetween fractureandhospitalizationwasalsolongerthansevendays, thestrongnegativeimpactonthemortalityratecanbewell understood.
The presence of infections during hospitalization was anothervariableassociatedwiththedeathoutcome.Respi- ratoryandurinarytractinfectionswerethemostcommonly observedinthepresentsample;together,theywerepresent in23.8%ofthepatients.AliteratureresearchintheLILACS, SciELO,andBDENFdatabasesbetweenJanuary2003andJune 2008retrieved38articlesonhospitalizedelderlypatients.In thesecases,thepresenceofinfectiousdiseaseswasafactor associatedwithmortalityrates,andthemostprevalentsites were therespiratory systemand urinarytract.17 That find- ingissimilartothoseobservedinastudybyCunhaetal., inwhichafrequencyof28.5%wasobserved;themostpreva- lentinfections werepneumonia,urinarytract,and surgical site.18 Itisknown thatelderlyindividualswho aresubmit- tedtolonghospitalizationsaremoresusceptibletoinfections due to physiological alterations caused by the aging pro- cess,adeclineintheimmuneresponse,andthepresenceof comorbidities,withaconsequentincreaseinmorbidityand mortality.19
Barba et al.,20 in a study that included elderly patients admitted to an internal medicine unit in Spain between 2005and2007,observedthatpneumoniawasthemostfre- quentfatalinfectioninthispopulation,whichreinforcesthe importance and severity of this infectious process in hos- pitalized elderly patients, not onlyin the orthopedic area.
RegardingUTIs,Nymanetal.observedaprevalencerateof 52.3%ofthisinfection inelderlypatientshospitalizedfora hipfractureatauniversityhospitalinSwitzerland.21These authors emphasized the needto prevent sucha prevalent complicationinthehospitalizedpopulationinordertoavoid the unnecessary clinical picture of urinary symptoms and fever.21
Althoughcardiacdiseases,asanisolatedvariable,werenot significantlyassociatedwiththeriskofdeath,Goldman’scar- diacriskindexshowedapositivecorrelationinthosepatients classifiedasclassIII.Thisscoreincludesvariablesrelatedto theclinicalevaluation,electrocardiogram,andtypeofsurgery, stratifyingpatientsintoclassesItoIVastotheriskofpre- sentingcardiovascularcomplicationsorevolvingtodeath.22 Infact, cardiac conditions havebeen described as afactor intheprognosisofpatientswithfemoralfractures;theyare essentialintheevaluationoftheanestheticriskoftheseindi- viduals.Theseverityofheartdiseaseisassociatedwithan increasedanestheticriskand,consequently,withanunfavor- ableoutcome.13
Age equal toor higher than 85 years was alsostatisti- callyassociatedwiththemortalityrateinthepresentstudy.
Patientsfromthisagegroupaccountedfor50%ofthedeaths.
In thestudy byGarcia et al.,23 71% ofthedeaths occurred in individuals over 80 years of age; in their sample, the variable of age over 80 years was associated with mortal- ity.Turrentineetal.24statedthattheelderlypresentunique healthchallenges;theyhaveaspecialphysiological,pharma- cological,andpsychologicalstate,aswellassocialattributes notobservedinyoungerpatients.Thesepeculiaritiesrequire specialattention and understanding bysurgeonsand their teams. Intheirstudy,agewas significantlyassociatedwith morbidity.24
Instresssituations,suchassurgery,elderlypatientsmay notmeettheincreasedfunctionaldemand.Thisreserveloss is an important factor inthe reduced tolerance of elderly patientstoinvasiveprocedures.25AccordingtoSouzaetal.,26 each year of a patient’s life represents an increase in the chanceofdeathofapproximately6%. Alongitudinalstudy in a large hospital in Australia followed-up 410 men and 1094womenwithfemoralfracturesandobservedan8.7-fold increase inthe risk ofdeath in patients aged 90 years or over.27Guerraetal.28foundasignificantassociationbetween age greater than 86 years and the mortality rate (38.3%).
Theseauthorsassociatedthefactthatfemoralfracturespre- dominantlyoccurinveryoldpatientswithrelevantprevious diseases and high surgical risk, which increases mortality whencomparedwithothertypesoffractures.
Females accounted for64.1% ofthe studied population, a finding similar tothat observedbyAriyoshi29 and Arndt etal.,30whoreportedfemalesas62.6%and76.2%ofpatients hospitalized due to femoral fractures and/or falls, respec- tively.Oneofthehypothesestojustifythispredominanceis thedeclineinbonemineraldensity,whichisobservedear- lieramongfemales,asthetwocomponentsresponsiblefor bone strength,density and bonequality, beginto decrease in females after menopause due tothe decrease in estro- genproduction.Somewomenlosebonemassatarateabove 1% per year;some may lose up to 5%and, at the end of five years,the totalloss isabove25%, characterizingpost- menopausal osteoporosis.30Moreover,womenachievepeak muscular strength earlierthan menand suffer thedecline earlier.31
Thehighpercentage(61.1%)ofpatientswithSAHfound in the present study can be understood as aconsequence oftheincreasedprevalenceofthisconditionobservedwith increasedage.Astudy conductedattheStateUniversityof Campinasestimatedthat50.4%ofthepatientsagedbetween 60 and 69 years suffered from hypertension; this percent- age reached 54.1% in the age range between 70 and 79 years.32PresenceofSAHhasalsobeenconsideredariskfac- tor forthe occurrence offallsand fractures in the elderly.
A possible explanation would be the type of antihyper- tensive medication used by these patients. A case series in Ontario,Canada indicatedthat elderly patientson anti- hypertensive therapy had a 43% increase in the risk of hip fractures within the first 45 days of treatment onset, which was significant for beta-blockers and angiotensin- converting enzyme inhibitors.33 In contrast, the use of calcium-channel blockerswould cause urinary loss of this mineral,thus alsocontributingtobonefragilityandconse- quentfractures.34
Diabetesmellituswasthesecondmostprevalentdisease inthe studied population, observed in 28.3% ofthe cases, similarlytothestudybyAriyoshi,29inwhichthemostpreva- lentchronicdiseasesinthepopulationwithfemurfracture treatedinahospitalinRibeirãoPreto(SãoPauloState,Brazil) were,respectively,SAHanddiabetes.Thispathologycanalso beunderstoodasanamplifyingfactoroffracturerisk.Ithas been observedthat patients olderthan 65 years with type II diabetes have, on average, glycated hemoglobin greater than 9%, which would increase the chance of fracture by upto31%.35Ameta-analysisthatincluded21studiesfrom the PubMed and Embase databases also demonstrated a strongassociationofthiseventwithtypeIdiabetes.Possible explanations for this excessive risk increase are diabetic complications, such as polyneuropathy and retinopathy, vestibular dysfunction, cognitive deficit, and episodes of hypoglycemiaduetotheuseofinsulin.36
Psychiatricdisorders– especiallydepression–were also reportedbypatients,withaprevalenceof11.9%.Jahanaand Diogo37 believethatpsychiatricdisorderscanactbothasa causeandaconsequenceoffracturesintheelderly.Ahigh riskoffallsamongdepressedelderlypatientscanbeexplained bytheuseofantidepressantandsedativemedications,poor health,physicaldecline,decreasedself-confidence,indiffer- encetotheenvironment,seclusion,andinactivity,whichmay contributetotheoccurrenceoftrauma.38 Inturn,fractures, thefearoffallingagain,andthelossofpost-fallindependence mayfavortheonsetofdepressionintheaffectedpopulation.26 Furthermore,previousdiagnosisofdepressionhasbeenasso- ciatedwithdifficultiesintherehabilitationprocess,greater susceptibilitytoinfectiousdiseases,andareducedsurvivalof patientswithfemoralfractures.39
Inthepresentstudy,anotherprevalentclinicalcomplica- tionwascognitivebehavioraldisorders,presentin28.3%of thepatientsanalyzed.Ofthese,themostcommonlyobserved alterationwasmentalconfusion,in23.8%.Often,mentalcon- fusionmaybepartofadeliriumstate,acommoncomplication inthe hospitalization of elderly patients afterhip surgery, especiallyinthosewithcognitiveimpairment,advancedage, multiplecomorbidities,and low body massindex.40 Inthe study byCunhaet al.,18 a waitingtime forsurgerygreater than48hwasassociatedwithagreaternumberofdelirium cases.Thisfindingcouldexplainthehighprevalenceofdisor- derssuchasmentalconfusionobservedinthepostoperative periodinthepresentstudy,asthetimebetweensurgeryand hospitalizationwasoversevendaysinmostcases.
Intestinalconstipationwasobservedin14%ofinpatients.
Based on data that indicates a prevalence of constipa- tion between 62.3% and 71.7% in post-fractured geriatric patients,41,42theauthorsbelievethatthisconditionmayhave been underreported in medical records. Immobilization is known to cause alterations, such as lack of appetite and constipation.Thelattermaybetheresultofadrenergicinhibi- tion,mobilityimpairment,lowfluidandfiberintake,andthe adverseeffectsofanticholinergicandopioidmedications.42,43 Thepresent study haslimitations,suchasthe factthat itdid notincludepatients withproximalfemoralfractures youngerthan65years,asthisinstitution’sprotocolrequires clinicalfollow-uponlyforpatientsolderthan65years.The inclusionofpatientsyoungerthan65yearscouldreducethe
mortalityrate, astheytheoreticallypresent alower riskof death.Moreover,insomecases,thedataobtainedinthemed- icalchartsdidnotallowGoldmanandASAscoring,northe inclusionofsmokingasariskfactorforcomplicationsand death.
Thepresentfindingsrevealedanimportantpost-fracture mortalityrateinthepopulationevaluatedincomparisonwith other studies,which indicatestheneedtointerveneinthe factors associatedwith this unfavorable outcome. Surgical treatmentofpatientswithfemoralfracturesinthefirst48h afteradmissionmaybeduetothelackofsufficientoperating roomsandthehighdemandofpatientsintheBrazilianUni- fiedHealthSystem,buteffortsmustbemadetochangethis reality.
Thepreventionandappropriatetreatmentofcomorbidities andclinicalcomplicationsareimportantmeasurestoimprove the short-termprognosisoftheseindividuals,especiallyas theyarepatientswithadvancedageandhighcardiovascular risk.Inturn,inthosewhoremainhospitalized,clinicalatten- tiontotheemergenceofpneumonia,urinarytractinfection, andotherinfectionsthatmaydestabilizetheelderlypatient isparamount.
Conclusions
Patientswithhipfracturesusuallypresentcomorbidities,are predisposed toclinical complications,andhaveamortality rateof11.9%,mainlyrelatedtoinfectionsduringhospitaliza- tion,thetimebetweenhospitalizationandsurgerylongerthan sevendays,GoldmanscoreequaltoIII,andageequaltoor greaterthan85years.
Conflicts of interest
Theauthorsdeclarenoconflictsofinterest.
Appendix A. Supplementary data
Supplementarydataassociatedwiththisarticlecanbefound, intheonlineversion,atdoi:10.1016/j.rboe.2018.07.014.
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