Changes in hospitalisation and surgical procedures among the oldest-old: a follow-up study of the entire Danish 1895 and 1905 cohorts from ages 85 to 99 years

Medication use among the oldest old in the Faroe Islands-A national cross-sectional study

Aging is often associated with an increasing number of comorbidities that warrant use of multiple drugs which increases the use of potentially inappropriate medications (PIMs), drug-drug interactions (DDIs) and drug-related problems (DRPs). The aim is to assess the prevalence of polypharmacy, PIMs, DDIs and DRPs among Faroese residents aged ≥90 years. In this population-based cross-sectional study, 494 individuals ≥90 years were invited and 298 (60%) participated. A pharmacist-led medication review was performed based on self-information, electronic patient journal and the Faroese Prescription Registry. The prevalence of polypharmacy was 74% with no sex-difference. Approximately 60% of participants used PIMs, primarily benzodiazepines and proton pump inhibitors, the latter being a frequently implicated medication in DRPs. Opioid use was low compared with other Nordic studies. DRPs were observed for 79% with discrepancies in the medication lists as the most common cause, and DDIs were identified for 47% of participants, mostly moderately clinically relevant DDIs. In conclusion, the medication use among the oldest old Faroese resembled that in other Nordic countries with a high prevalence of polypharmacy and use of PIMs, especially PPIs and benzodiazepines. However, no sex-difference was noted in medication use and the use of opioids was low.

Trends in Incidence of Hip Fracture and Hip Replacement in Denmark, 1996 to 2018

Importance

The past several decades have witnessed substantial changes in treatments that are particularly relevant for older patients.

Objectives

To assess changes in national-level incidence rates of fracture- and musculoskeletal-related (ie, arthritis-related) hip replacement procedures for individuals aged 40 to 104 years over a 23-year period in Denmark.

Design, Setting, and Participants

This cohort study used national Danish health registers to include the Danish population aged 40 to 104 years from January 1, 1996, to December 31, 2018. Data were analyzed from May 31, 2022, to February 14, 2024.

Main Outcomes and Measures

Age- and period-specific incidence rates of hip fracture and hip replacement stratified on fracture-related vs arthritis-related indication.

Results

From 1996 to 2018, a total of 3 664 979 individuals were followed up for a mean (SD) of 14.6 (7.7) years, resulting in a follow-up time of 53 517 861 person-years and 158 982 (first) hip fractures, of which 42 825 involved fracture-related hip replacement procedures. A further 104 422 individuals underwent arthritis-related hip replacement. During the first 2 decades of the 21st century, hip fracture rates declined by 35% to 40% for individuals aged 70 to 104 years, and the proportion of the population undergoing fracture-related hip replacement increased by 50% to 70%, with modest variation across those aged 75 to 99 years. Rates of arthritis-related hip replacements peaked for individuals aged 75 to 79 years, but with the largest relative rate increase (75%-100%) occurring for those aged 80 to 94 years, primarily from 2001 to 2015, whereafter it remained nearly unchanged. The decline in rates of arthritis-related hip replacement after 75 to 79 years of age was gradual and did not suggest an upper age limit for access to arthritis-related hip replacement.

Conclusions and Relevance

The findings of this cohort study suggest that during the past several decades in Denmark, the incidence of hip fractures declined by 35% to 40% among patients aged 80 to 104 years, while the proportion receiving fracture-related hip replacement remained relatively constant after 75 years of age. During the first decades of the 21st century, arthritis-related hip replacement incidence increased by 50% to 100% among older patients and stabilized hereafter, with no apparent cutoff age for this type of procedure. These patterns indicate a positive overall trend with declining hip fracture incidence over the last decades in Denmark, and the observed hip replacement incidence suggests that age is currently not a major determining factor guiding this type of surgery.

Use of prescription medication in the last years of life: a population-based comparison of two oldest old Danish birth cohorts born 10 years apart

INTRODUCTION

Age limits for diagnostics and treatments have been largely removed and replaced by an active diagnostic and treatment practice among the oldest old and has led to concerns about potential overtreatment during the last years of life.

METHODS

Use of prescription medication in the last years of life was assessed from 1995 to 2012 for the entire 1905 and 1915 Danish birth cohorts using nationwide register data. Medication use was quantified as the number different pharmacy-redeemed drugs during 120 days up to a given date.

RESULTS

For both cohorts, prescription medication use increased with proximity to death and calendar year, while age at death had little impact; use in the 1915 cohort was markedly higher than in the 1905 cohort. Average number of prescription medications varied from below 3 to above 9 depending on age, calendar year and proximity to death. From 1995 to 2005, average number of prescription medications for a 90-year-old person in the last month of life increased from 6.0 to 8.7. Out of 90-year-old persons dying in 2005, 82% were exposed to polypharmacy, up from 63% in 1995.

CONCLUSIONS

Prescription medication use accelerates throughout the last of years life among two Danish oldest old cohorts born 10 years apart, with substantially larger use in the most recent cohort. This pattern suggests an increase in drug prescribing regimens in the period 1995-2012, reinforcing the need for evidence-based guidelines on medications in the particularly vulnerable population of the oldest old patients in their last years of life.

Preparing for the future: The changing demographic composition of hospital patients in Denmark between 2013 and 2050

BACKGROUND

Population aging will pose huge challenges for healthcare systems and will require a promotion of positive attitudes towards older people and the encouragement of careers in geriatrics to attract young professionals into the field and to meet the needs of a rapidly growing number of old-aged patients. We describe the current demographic profile of hospital care use in Denmark and make projections for changes in the patient profile up to 2050.

METHODS

The Danish population in 2013 (N = 5.63 million) was followed up for inpatient and emergency admissions recorded in Danish hospitals in 2013 using population-based registers. We combined age- and sex-specific hospital care use in 2013 with official population estimates to forecast the profile of hospital days up to 2050 with respect to age and sex.

RESULTS

The total number of hospital days per year is projected to increase by 42% between 2013 and 2050, from 4.66 to 6.72 million days. While small changes are projected for the population aged 0-69, the largest change is projected to occur for the population aged 70+. The 2013 levels were 0.82 and 0.93 million days for men and women aged 70+, respectively. By 2050, these levels are projected to have reached 1.94 and 1.84 million days. While the population aged 70+ accounted for 37.5% of all days in 2013, its contribution is projected to increase to 56.2% by 2050.

CONCLUSION

Our study shows one possible scenario for changes in the hospital days due to population aging by 2050: Assuming no changes in hospital care use over the forecast period, the absolute contribution of individuals aged 70+ to the total hospital days will more than double, and the relative contribution of persons aged 70+ will account for nearly 60% of all hospital days by 2050, being largest among men.

Trends in Hospital Deaths in Denmark from 1980 to 2014, at Ages 50 and Older

OBJECTIVES

To explore temporal trends and individual-level determinants of hospital deaths at ages 50 and older in Denmark from 1980 to 2014.

DESIGN

Individual-level register-based retrospective study.

SETTING

Denmark, 1980 to 2014.

PARTICIPANTS

All deaths that occurred in Denmark from 1980 to 2014 among individuals 50 years or older (N = 1 834 437), extracted from population registers.

MEASUREMENTS

A death was defined as a hospital death if the individual was admitted to the hospital as an inpatient and the date of discharge from the hospital is equal to the date of death.

RESULTS

The percentage of hospital deaths decreased in both sexes (all ages combined, men: 56% to 44%; women: 49% to 39%) and at ages 50 to 79, remained almost unchanged at ages 80 to 89, and increased in the oldest age group (90+ men: 27% to 32%; women: 18% to 24%). We observed increasing trends of hospital deaths for three groups, people 90 years and older, dying from respiratory diseases, and who had terminal hospitalizations lasting 1 to 3 days. Subanalysis of all hospital deaths according to length of the terminal hospitalizations suggests that the overall reduction of hospital deaths might be driven by a reduction in hospitalizations that were longer than 1 week. Persons who are married, have middle or high income, have a history of hospitalizations in the year before death, or die because of respiratory diseases have higher odds of dying in a hospital.

CONCLUSION

Results provide evidence that Danes 50 years and older are increasingly dying outside the hospital context. We find three age-specific patterns in the proportion of hospital deaths. Changes in healthcare and social systems implemented in Denmark during the observation period may underlie the broader reduction in hospital deaths in the country. J Am Geriatr Soc 67:471-476, 2019.

Aging process, adherence to Mediterranean diet and nutritional status in a large cohort of nonagenarians: Effects on endothelial progenitor cells

BACKGROUND AND AIM

Adherence to the Mediterranean Diet (MD) has been associated with a longer and better life. The aim of this study was to examine the effects of adherence to the MD, and of nutritional habits on endothelial progenitor (EPCs) and circulating progenitor (CPCs) cells in a cohort of nonagenarians enrolled within the Mugello Study, an epidemiological study aimed at investigating both clinically relevant geriatric items and various health issues, including those related to nutritional status.

METHODS AND RESULTS

Four hundred twenty-one nonagenarians (306 F, 115 M, mean age: 93.1 ± 3.2 years) were evaluated. Adherence to MD was assessed through the Mediterranean Diet Score. Elderly subjects who were in the fourth quartile of the Mediterranean diet score showed significantly higher EPCs than subjects grouped into the other three quartiles. After adjustment for confounders, elderly subjects who were in the highest quartile of adherence to the MD score reported to have EPCs' levels significantly higher than those who reported lower values of adherence to the MD. Furthermore, by analyzing different food categories, it was reported that daily consumption of olive oil and a higher consumption of fruit and vegetables showed higher CPCs CD34⁺ and EPCs CD34⁺/KDR⁺ than subjects with not daily or lower consumption.

CONCLUSION

Our results support the hypothesis that the adherence to MD, as well as a daily consumption of olive oil and fruit and vegetables, characteristics of MD, may protect against the development of endothelial dysfunction through increasing EPCs and CPCs in older age.

Postoperative Morbidity and Discharge Destinations After Fast-Track Hip and Knee Arthroplasty in Patients Older Than 85 Years

BACKGROUND

Elderly patients are at risk of increased length of hospital stay (LOS), postoperative complications, readmission, and discharge to destinations other than home after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). Recent studies have found that enhanced recovery protocols or fast-track surgery can be safe for elderly patients undergoing these procedures and may result in reduced LOS. However, detailed studies on preoperative comorbidity and differentiation between medical and surgical postoperative morbidity in elderly patients are scarce. The aim of this study was to provide detailed information on postoperative morbidity resulting in LOS >4 days or readmissions <90 days after fast-track THA and TKA in patients ≥85 years.

METHODS

This is a descriptive, observational study in consecutive unselected patients ≥85 years undergoing fast-track THA/TKA. The primary outcome was the causes of postoperative morbidity leading to an LOS of >4 days. Secondary outcomes were 90-day surgically related readmissions, discharge destination, 90-day mortality, and role of disposing factors for LOS >4 days and 90-day readmissions. Data on preoperative characteristics were prospectively gathered using patient-reported questionnaires. Data on all admissions were collected using the Danish National Health Registry, ensuring complete follow-up. Any cases of LOS >4 days or readmissions were investigated through review of discharge forms or medical records. Backward stepwise logistic regression was used for analysis of association between disposing factors and LOS >4 days and 90-day readmission.

RESULTS

Of 13,775 procedures, 549 were performed in 522 patients ≥85 years. Median age was 87 years (interquartile range, 85-88) and median LOS of 3 days (interquartile range, 2-5). In 27.3% procedures, LOS was >4 days, with 82.7% due to medical causes, most often related to anemia requiring blood transfusion and mobilization issues. Use of walking aids was associated with LOS >4 days (odds ratio [OR], 1.99; 95% confidence interval [CI], 1.26-3.15; P = 0.003), whereas preoperative anemia showed borderline significance (OR, 1.52; 95% CI, 0.99-2.32; P = 0.057). Thirty-eight patients (6.9%) were not discharged directly home, of which 68.4% had LOS >4 days. Readmission rates were 14.2% and 17.9% within 30 and 90 days, respectively, and 75.5% of readmissions within 90 days were medical, mainly due to falls and suspected but disproved venous thromboembolic events. Preoperative anemia was associated with increased (OR, 1.81; 95% CI, 1.13-2.91; P = 0.014) and living alone with decreased (OR, 0.50; 95% CI, 0.31-0.80; P = 0.004) risk of 90-day readmissions. Ninety-day mortality was 2.0%, with 1.0% occurring during primary admission.

CONCLUSIONS

Fast-track THA and TKA with an LOS of median 3 days and discharge to home are feasible in most patients ≥85 years. However, further attention to pre- and postoperative anemia and the pathogenesis of medical complications is needed to improve postoperative outcomes and reduce readmissions.

Trend study on the association between hospital admissions and the health of Dutch older adults (1995-2009)

OBJECTIVES

An increase in hospital admission rates in older people may reflect improved access to healthcare, but also declining health trends in the older population. Owing to a lack of individual-level data, the latter possibility has received little attention. The current study examines associations between health status and hospitalisation rates of older adults in the Netherlands.

DESIGN

Observational individual-level data linked to hospital register data.

SETTING

Data from 1995 to 2009 from the nationally representative Longitudinal Aging Study Amsterdam were linked to the Dutch Hospital Discharge Register.

PARTICIPANTS

A total of 5681 observations of 2520 respondents across 4 measurement points (each with a follow-up of 36 months; ages 65-88 years).

OUTCOME MEASURES

The contribution of health, demographic, psychosocial and lifestyle characteristics to time trends in hospitalisation was assessed in multivariate models.

RESULTS

Between 1995 and 2009, the percentage with 1 or more overnight admissions (planned or acute) increased slightly from 38.1% to 39.7%. This was due to an increase in acute admission only (22.2-27.0%). Increased prevalences of chronic diseases, functional limitations and polypharmacy accounted for part of the observed increase in acute admissions. In addition, a more than doubled prevalence of day admissions over time was observed (12.3-28.3%), a trend that was unrelated to changes in individual characteristics.

CONCLUSIONS

This trend study showed a contribution of declines in population health to increases in acute hospital admissions. Since these declines did not provide a full explanation, healthcare reforms and increases in treatment possibilities in this period are likely to have contributed as well.

Cancer and aging: Epidemiology and methodological challenges

Epidemiological cancer data shed light on key questions within basic science, clinical medicine and public health. For decades, Denmark has had linkable health registers that contain individual level data on the entire population with virtually complete follow-up. This has enabled high quality studies of cancer epidemiology and minimized the challenges often faced in many countries, such as uncertain identification of the study base, age misreporting, and low validity of the cancer diagnoses. However, methodological challenges still remain to be addressed, especially in cancer epidemiology studies among the elderly and the oldest-old. For example, a characteristic pattern for many cancer types is that the incidence increases up to a maximum at about ages 75-90 years and is then followed by a decline or a leveling off at the oldest ages. It has been suggested that the oldest individuals may be asymptomatic, or even insusceptible to cancer. An alternative interpretation is that this pattern is an artifact due to lower diagnostic intensity among the elderly and oldest-old caused by higher levels of co-morbidities in this age group. Currently, the available cancer epidemiology data are not able to provide clear evidence for any of these hypotheses.

Do surgical trainees believe they are adequately trained to manage the ageing population? A UK survey of knowledge and beliefs in surgical trainees

OBJECTIVE

Increasing numbers of older patients are undergoing surgery. Older surgical patients are at a higher risk of perioperative complications and mortality. Multimorbidity, frailty, and physiological changes of ageing contribute to adverse outcomes. These complications are predominantly medical, rather than directly surgical. Guidelines recommend preoperative assessment of comorbidity, disability, and frailty in older patients undergoing surgery and closer perioperative collaboration between surgeons and geriatricians. We conducted a survey to assess knowledge and beliefs of surgical trainees toward common perioperative problems encountered in older surgical patients.

DESIGN

Paper-based survey.

SETTING

Unselected UK surgical training-grade physicians (CT1-ST8) attending the 2013 Congress of The Association of Surgeons of Great Britain and Ireland, Glasgow, UK, May 1-3, 2013.

PARTICIPANTS

A total of 160 eligible UK surgical trainees attending the conference were invited to participate in the survey. Of them, 157 participated.

RESULTS

Of the trainees, 68% (n = 107) reported inadequate training and 89.2% (n = 140) supported the inclusion of geriatric medicine issues in surgical curricula. Of the respondents, 77.2% (n = 122) were unable to correctly identify the key features required to demonstrate mental capacity, and only 3 of 157 respondents were familiar with the diagnostic criteria for delirium. Support from geriatric medicine was deemed necessary (84.7%, n = 133) but often inadequate (68.2%, n = 107). Surgical trainees support closer collaboration with geriatric medicine and shared care of complex, older patients (93.6%, n = 147).

CONCLUSIONS

UK surgical trainees believe that they receive inadequate training in the perioperative management of complex, older surgical patients and are inadequately supported by geriatric medicine physicians. In this survey sample, trainee knowledge of geriatric issues such as delirium and mental capacity was poor. Surgical trainees support the concept of closer liaison and shared care of complex, older patients with geriatric medicine physicians. Changes to surgical training and service development are needed.

Comprehension deficits among older patients in a quick diagnostic unit

Background

Higher prevalence of multiple illnesses and cognitive impairment among older patients pose a risk of comprehension difficulties, potentially leading to medication errors. Therefore, the objective of this study was to investigate comprehension of discharge instructions among older patients admitted to a Quick Diagnostic Unit (QDU).

Methods

One hundred and two patients discharged from the QDU answered a questionnaire covering understanding of their hospitalization and discharge plan. Patients’ ability to recall discharge instructions and awareness of comprehension deficits, ie, ability to identify the misconceived information, were evaluated by comparing the questionnaires with the discharge letters. The population was divided into an older group (age ≥65 years) and a younger group.

Results

The older group (n=40) was less able to recall correct medication instructions when compared to the younger group (54% versus 78%, respectively; P=0.02). In multiple logistic regression analysis, correct recall of medication instructions was 4.2 times higher for the younger group compared to the older group (odds ratio 4.2, 95% confidence interval 1.5–11.9, P=0.007) when adjusted for sex and education. The older patients were less aware of their own comprehension deficits, and in respect to medication instructions awareness decreased 6.1% for each additional year of age (odds ratio 0.939, 95% confidence interval 0.904–0.98, P=0.001) when adjusted for sex and education.

Conclusion

Older patients were less able to recall correct medication instructions and less aware of their comprehension deficits after discharge from a QDU. The findings of the present study emphasize the importance of thorough communication and follow-up when treating older patients.

Trends in age at first hospital admission in relation to trends in life expectancy in Swedish men and women above the age of 60

OBJECTIVES

To examine whether the first admission to hospital after the age of 60 has been postponed to higher ages for men and women in Sweden, in line with the shift in mortality.

DESIGN

This nationwide observational study was based on data obtained from national registries in Sweden. The study cohort was created by linking the Register of the Total Population in Sweden with the National Patient Register and the Swedish Cause of Death Register.

SETTING

The entire Swedish population born between 1895 and 1950 was followed up between 1987 and 2010 with respect to hospital admissions and deaths using the national registry data.

PRIMARY OUTCOME MEASURES

The time from age 60 until the first admission to the hospital, regardless of the diagnosis, and the time from age 60 until death (remaining life expectancy, LE) were estimated for the years 1995-2010. The difference between these two measures was also estimated for the same period.

RESULTS

Between 1995 and 2010 mortality as well as first hospital admission shifted to higher ages. The average time from age 60, 70, 80 and 90 until the first hospital admission increased at all ages. The remaining LE at age 60, 70 and 80 increased for men and women. For the 90-year-olds it was stable.

CONCLUSIONS

In Sweden, the first hospital admission after the age of 60 has been pushed to higher ages in line with mortality for the ages 60 and above. First admission to the hospital could indicate the onset of first severe morbidity; however, the reorganisation of healthcare may also have influenced the observed trends.