Hip fractures in centenarians: a multicentre review of outcomes

Abstract

Introduction

Advances in healthcare have resulted in an increasing UK population, with the proportion of elderly individuals expanding significantly, including centenarians. Hospitals can expect to see growing numbers of so-called ‘super-elderly’ patients with trauma, a majority of whom will have hip fractures. We performed a multicentre review of hip fracture outcomes in centenarians to assess whether being an outlier in age correlates with poorer prognosis.

Methods

Centenarians admitted to Basingstoke, Southampton, Dorset, and Salisbury district hospitals with hip fractures between January 2014 and June 2019 were included. Electronic records were searched to obtain demographics, functional status, and admission details.

Results

A total of 60 centenarians were included, with a median age of 101 years (range 100–108 years), 85% of whom were female; 29 were admitted from their own home or sheltered housing and 31 from nursing or residential care; 33 had some outdoor mobility, 26 only mobilised indoors, and 1 had no mobility. Common comorbidities were renal and heart disease and dementia. Of the total, 56 underwent surgery, 51 within 36 hours. In terms of accommodation, 63.4% returned to their pre-injury level of independence. At 30 days, three months, and one year, mortality rates were 27% (n = 16), 40% (n = 24) and 55% (n = 33), respectively.

Conclusion

Trauma in the elderly population is an area of growing interest, yet few studies address centenarians with hip fractures. This work demonstrates that mortality rates within one year of injury were high, but almost half survived beyond a year. Two-thirds of patients regained their pre-injury level of independence, suggesting that functional recovery may not be as poor as previously reported.

Introduction

As a result of advances in healthcare and illness prevention, the UK population has been steadily increasing, with the proportion of elderly individuals expanding significantly. According to the Office for National Statistics, in 2018 there were 584,024 people aged 90 years and over living in the UK, of whom 13,170 were centenarians.¹ This group has increased by 85% in the past 15 years. As a result, NHS trusts can expect to see growing numbers of so-called ‘super-elderly’ patients being admitted with traumatic injuries, a majority of whom will have hip fractures.

Since the advent of the National Hip Fracture Database in 2007, there has been an increased focus on improving standards of care for patients with a fractured neck of femur.² This has been on a broad scale with less emphasis on particular patient groups or demographics. Outcomes when looking specifically at centenarians might be expected to be poor, in part due to worsening frailty with extreme age and reduction in physiological reserve. Equally, it could be argued that surviving to beyond 100 years makes centenarians a self-selecting group of individuals with perhaps a greater ability to overcome the physiological insult of a hip fracture and subsequent surgery, as compared with younger but more comorbid patients.

Our multicentre observational study aimed to evaluate the clinical outcomes of centenarians admitted with acute hip fractures and assess whether being an outlier in terms of age correlates with a poor prognosis.

Materials and methods

Patients admitted at 100 years of age or over with an acute traumatic hip fracture between January 2014 and June 2019 were retrospectively included. Patients were identified based on entry to the National Hip Fracture Database from the following NHS trusts: Basingstoke and North Hampshire Hospital, University Hospital Southampton, Dorset County Hospital, and Salisbury District Hospital. The following data were obtained from their electronic records:

• demographics

• comorbidities

• pre-injury functional status

• surgical management, time to surgery and operative procedure

• complications

• discharge location

• cumulative mortality rate.

Results

A total of 60 centenarians were admitted during the study period, with a median age of 101 years (range 100–108 years); 85% were female. Table 1 shows the patients’ preoperative baseline characteristics. Some 29 (48.3%) patients were admitted from their own homes or sheltered housing, compared with 31 (51.7%) from either nursing or residential care. In the majority of cases, patients had some outdoor mobility (n = 33), the remainder only mobilising indoors (n = 26) and one patient having no functional mobility. The most frequently seen comorbidities were heart disease, chronic kidney disease and dementia. Comorbidity data were not available for 17 patients. Of the total, 23 patients had an admission Abbreviated Mental Test score of 8 or more, 11 had scores of 5–7 and 25 had scores less than 5 (1 patient refused). Table 2 shows fracture types and management and Table 3 shows discharge location, postoperative complications, transfusions and readmissions.

Table 1.

Patients’ preoperative baseline characteristics

Characteristic	Patients
	(value)	(%/range)
Median age (years)a	101
Sex (n):
male	9	15
female	51	85
Admission location (n):
own home or sheltered housing	29	48.3
residential care	17	28.4
nursing care	14	23.3
Mobility (n):
freely mobile	7	11.7
mobile outdoors with aids	26	43.3
mobile indoors with or without aids	26	43.3
no functional mobility	1	1.7
AMTS (n):
< 5	25	4.1.7
5–7	11	18.3
8–10	23	38.3
patient refused	1	1.7
Preoperative blood tests (median values):
haemoglobin level (g/l)	119.5	83–151
estimated GFR (ml/minute/1.73m2)	52.4	14 to > 90
lymphocyte count (10x9 cells/litre)	1.1	0.3–14.1
Comorbidities:
heart diseaseb	16	26.7
respiratory disease (COPD, asthma)	4	6.7
chronic kidney disease	23	38.3
dementia	16	26.7

^a Range 100–108 years

^b Atrial fibrillation, heart failure, ischaemic heart disease

AMTS, Abbreviated Mental Test score; COPD, chronic obstructive pulmonary disease; GFR, glomerular filtration rate

Table 2.

Fracture types and management

Characteristic	Patients
	(n)	(%)
Fracture side:
right	28	47
left	32	53
Fracture location:
intracapsular	29	48
intertrochanteric	27	45
subtrochanteric	4	7
Time to surgery:
up to 12 hours	8	13.3
12–24 hours	29	48.3
24–36 hours	14	23.3
over 36 hours	5	8.3
Non-operative management	4	6.7
Surgical procedure:
cemented hemiarthroplasty	22	36.7
uncemented hemiarthroplasty	2	3.3
total hip arthroplasty	1	1.7
short intramedullary nail	14	23.3
long intramedullary nail	3	5
dynamic hip screw	12	20
cannulated screws	2	3.3

Table 3.

Discharge location, postoperative complications, transfusions and readmissions

Characteristic	Patients
	(n)	(% or range)
Median length of stay (days)	14.5	1–113
Discharge location:
own home or sheltered housing	15	25
rehabilitation unit	7	11.7
residential care	14	23.3
nursing care	16	26.7
died in hospital	8	13.3
Mortality:
30 days	16	27
3 months	24	40
1 year	33	55
Median time to mortality (days)	77.5	2–1326
Postoperative complications (n = 43):	20	46.6
acute kidney injury	3
anaemia	2
respiratory infection	7
intraoperative cardiac arrhythmia	1
gastrointestinal bleed	1
pulmonary oedema	1
surgical site infection	1
transient ischaemic attack	1
urinary tract infection	3
Readmission within 30 days (n = 43)	2	4.7
Post-operative transfusion (n = 43)	13	30.2
1 unit	6
2 units	6
3 units	1

In terms of their living accommodation, 63.4% of patients returned to their pre-fracture level of independence and of those admitted from their own homes, sheltered housing or residential care and 60.9% were discharged back to the same accommodation. There were no reoperations recorded. Data on readmissions and postoperative complications were not complete for 17 patients. For those with available data, the readmission rate within 30 days was 4.7% (n = 2); 20/43 had some form of postoperative complication and 13/43 received a postoperative transfusion. At 30 days, three months and one year, the cumulative mortality rates were 27% (n = 16), 40% (n = 24) and 55% (n = 33), respectively. The median time from injury to mortality was 77.5 days.

Discussion

A number of papers published over the past two decades have reported on the minority of hip fracture patients that present as centenarians.^3–11 The majority of these series are single-centre studies and have fewer than 30 patients. To our knowledge, this is the first UK multicentre review of hip fracture outcomes in centenarians with more than 50 cases.

In the UK, the approach to managing trauma in older and more frail patients has changed significantly in recent years, both at the individual level and across the country. In particular, there has been greater recognition of the importance of multidisciplinary care and early restoration of mobility to prevent functional decline. The aforementioned National Hip Fracture Database and the Best Practice Tariff initiatives brought about a change in focus by incentivising hospitals to meet certain key targets, including surgery within 36 hours, early involvement of orthogeriatricians, physiotherapists and occupational therapists, and mandatory assessments for falls risk, dementia and delirium, and bone health. In their attempts to meet these targets, many trusts have implemented additional strategies to improve patient care and outcomes.

It is now commonplace for patients with hip fractures to be placed first on trauma operating lists and to have a preoperative anaesthetic review the night before surgery. To prevent delays to surgery, orthopaedic and anaesthetic teams have worked together to produce specific guidelines on medical optimisation of patients with hip fractures, reversal of anticoagulation, and when not to postpone surgery to perform additional investigations (eg obtaining echocardiograms for new murmurs). Although the Best Practice Tariff states that patients should have an orthogeriatric review within 72 hours of admission, often they are reviewed prior to undergoing surgery and in many centres, there are dedicated hip fracture bays or wards, staffed by nurses and other healthcare professionals with specific training and experience in hip fracture management. These changes represent a shift in the culture around trauma management in the ageing population and move toward greater collaboration between specialties to improve standards of care.

Functional status

The ability to regain pre-fracture functional status, such as usual place of residence and mobility, has been shown to decline in patients with advancing age, which in turn has a significant bearing on other outcomes, such as mortality. In line with this, we might expect the pre- and post-injury functional status of centenarians to be the poorest of all those sustaining hip fractures. In 2004 in one of the first published series, Oliver and Burke compared a series of 18 centenarians with hip fractures to a control group of patients aged 75–83 years.³ They found that 22.2% of the centenarians regained their pre-fracture walking ability and 28.6% returned to independent living, which was significantly lower than that of the younger group. This is similar to rates reported in more recent research, suggesting that few centenarians can be expected to return to their baseline following hip fracture. By contrast, a high number of patients from our cohort were admitted from either their own homes, sheltered housing, or residential care and, of those, almost two-thirds were discharged back to the same accommodation (Table 4). This points to whether the functional prognosis for the more elderly hip fracture patients has in fact improved in recent years. Still, a large proportion of all hip fracture patients will see a decline in function following their injury and thus it remains important to promptly assess the expected levels of care required to facilitate discharge planning.

Table 4.

Location of admission and discharge

Study	Patients (n)	Admitted from own home or sheltered housing, n (%)	Patients returning to previous level of independence (%)	Mortality at 30 days, n (%)	Mortality at 1 year, n (%)
Oliver and Burke3	18	7 (39)	28.6	6 (33)	–
Verma et al4	26	6 (26)	–	7 (30.4)	–
Tarity et al6	21	–	–	5 (20)	16 (70)
Forster and Calthorpe8	13	5 (38)	–	4 (31)	7 (56)
Shabat et al9	19	4 (17)	–	5 (20)	–
Dick et al10	22	18 (81.8)	–	6 (30)	11 (50)
Morice et al11	39	15 (38.5)	48.7	–	28 (71.8)
Our study	60	29 (48.3)	63.4	16 (27)	33 (55)

Comorbidities

It stands to reason that as we age the probability of developing chronic diseases increases. However, as previously postulated, it may be that surviving to greater than 100 years of age suggests that a person has led a healthy life, free from chronic comorbidities that they would otherwise have succumbed to. The evidence on the concurrent disease in centenarians presenting following trauma is conflicting. Verma et al compared a series of 26 centenarians with hip fractures to a control group aged 75–85 years.⁴ They found that there were lower American Society of Anesthesiology (ASA) grades and rates of heart disease among the younger patients but greater numbers with a history of previous stroke and pneumonia. Oliver and Burke’s study assessed whether ASA grade was associated with mortality among two similar cohorts of hip fracture patients. They found that higher ASA grade was not significantly associated with mortality in both the centenarians and those aged 75–83 years, although comorbidities were present among many patients in each group. They note that this is an unusual finding, given that frailer patients would be expected to have a higher mortality risk. Their study is, however, limited by small sample sizes. Kent et al presented a series of 24 centenarians admitted with various traumatic injuries.⁵ Within their series, there were eight (33.3%) patients reporting no comorbidities at all.⁵ While this finding may be surprising, it raises the question of whether age alone should be used a surrogate marker for the presence of chronic conditions such as heart disease or diabetes. Instead, patients’ pre-injury functional, physical and psychological status may be of more use in predicting likely outcome. The most common comorbidity they identified was dementia. Cognitive impairment is a well-established risk factor for poorer outcomes and mortality rates following hip fracture, and in many ways one of the more difficult comorbid conditions to manage. Despite this, knowledge of the impact of dementia on recovery and mortality after hip fracture can help clinicians in planning rehabilitation and setting realistic treatment goals.

Management

The British Orthopaedic Association guidelines on fragility hip fracture management state that patients should be operatively managed to allow restriction-free mobilisation in the immediate postoperative period.¹² It also suggests that all patients should have their surgery on the day of or following admission. Within our cohort, the majority of patients underwent surgical management, leaving approximately 7% who were treated conservatively. This non-operative treatment rate is higher than that found by the National Hip Fracture Database.² When looking at all age groups across the country, the proportion of non-operatively managed fractures has not risen beyond 2.5% since 2012; 85% of our cohort underwent surgery within the 36-hour Best Practice Tariff target, compared with a national average of between 66% and 76% over the past five years. This finding is interesting, suggesting that, while centenarians were more likely to be deemed unfit for surgery, those who were fit were not delayed in reaching theatre.

Complications

Complications following hip fracture are common events in elderly individuals and often the cause of significant morbidity and mortality. Readmissions are also frequently seen. In our series, over one-third of patients had some form of postoperative complication and there was a high rate of postoperative transfusion, which has not universally been demonstrated elsewhere. In 2009, Pelavski Atlas et al investigated complication and transfusion rates in centenarians with hip fractures and found that, while the centenarians had significantly more complications, the numbers requiring transfusion were similar to younger hip fracture patients.¹³

Mortality

The mortality rates presented here mirror those seen in other studies published throughout the past 10 years, showing that only around 70% of patients will survive beyond one month and fewer than 50% will survive to one year. This prognosis is worsened when considering those treated non-operatively, signifying that the principle of early surgery to restore mobility is well-founded, even in ‘super-elderly’ individuals. However, a caveat to interpreting the overall mortality rate – addressed by Mazzola et al – is that many studies, including this one, report cumulative mortality crudely without incorporating the increased risk of mortality for any centenarian, regardless of hip fracture.¹⁴ In fact, they found that among a group of centenarians without a hip fracture the survival probability over a two-year period dropped to less than 40%. Nevertheless, it is well-known that for many patients a hip fracture represents a pre-terminal event and therefore it is sensible to initiate discussions regarding end of life care and resuscitation with all very elderly patients.

Conclusion

Management of trauma in the ageing population is an area of growing interest, yet at present, there are few studies that specifically address those at the very extreme of old age. To our knowledge, we present the largest and only multicentre UK series of centenarians with hip fractures. This work demonstrates that, while mortality rates within one year of injury were high, almost half survived beyond one year post-injury. In addition, a higher proportion than reported elsewhere were able to return to their pre-fracture level of independence, with many patients returning to their own homes or residential care, rather than to 24-hour nursing care. This suggests that the prognosis for very elderly patients with hip fractures may not be as poor as previously thought. This could be due in part to improvements in health care provision as a whole but may also be a testament to the culture change and greater focus on holistic care brought about by the implementation of national initiatives such as the National Hip Fracture Database and the Best Practice Tariff, as well as British Orthopaedic Association Standards for Trauma guidelines. At the individual level, our work emphasises the importance of prompt surgical management to restore function in those fit for surgery, with the aim of improving the quality of patients’ remaining weeks and months, regardless of their age.