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Josephine H Harris, Paul M Finucane, Denise C Healy and Anthony C Bakarich
Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details
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©MJA1997
Little is known about the characteristics of hospitalised
nonagenarians. Existing studies either have few subjects3 or include only medical4 or only surgical patients.5-7 To our knowledge, no study has
focused on hospitalised nonagenarians in Australia. Our lack of
knowledge about this group may hinder development of appropriate
clinical services to meet their needs and allow prejudices and
unfounded negative stereotypes to proliferate. For example, it has
been implied that some patients present to hospital with acute social
rather than medical crises,8
and that elderly patients become "bed blockers" who are difficult to
discharge from hospital.9
Elderly patients are satirised and derided in fiction,10 while their right to access
expensive medical technology is debated in scientific
publications.11
To learn more about the use of acute hospital services by very elderly
people, we reviewed the case notes of all people aged 90 years and over
who were admitted to our hospital in 1995. In particular, we focused on
the demographic characteristics of this group, the problems for
which they were hospitalised and the outcomes of hospitalisation.
The study group was identified from a computerised age and sex
register of all separations. This included day-only patients
(length of stay, 0-1 days), but excluded those attending the
emergency department who were subsequently not admitted.
Data were analysed with the Statview statistical package.12 Other data were derived from the
case notes. Differences between patient groups were assessed by chi-squared
tests for all
characteristics except length of hospital stay, which was assessed
by the Kruskal-Wallis one-way analysis of variance by ranks, a
non-parametric test. The association between patients' living
circumstances before and after hospitalisation was determined by
Cohen's k test.13 The study
received ethical approval from Flinders Medical Centre's Committee
on Clinical Invest igation.
Length of hospital stay is shown in Figure 1 (below).
Median stay was 5.0 days (range, 1-74 days) and the mean was 6.9 days
(SD, 8.3 days), compared with 3.7 days for the total inpatient
population. Seventy-eight separations (25%) were day-only; in 10%
of cases this was because of early death.
Hospital stay was shorter for patients who returned directly to their
previous living circumstances (mean [SD], 5.2 [5.7] days) than for
those who did not (mean [SD], 10.5 [11.2] days).
Hospital stay did not differ significantly between patients from
different living circumstances (mean in days [SD]: community, 7.4
[10.0]; hostels, 6.9 [6.1]; and nursing homes, 5.6 [5.4];
Kruskal-Wallis test statistic, T = 3.46; P =
0.18). However, mortality rose progressively in patients from the
community (6%), hostels (9%) and nursing homes (16%), in that order.
Patients admitted under the care of physicians other than
geriatricians were most likely to have day-only separations, to be
living in the community and to return directly to the community. In
contrast, admissions under geriatricians were almost all
emergencies and were least likely to be day-only. Hospital stay was
significantly longer for these patients (mean in days [SD]:
geriatricians, 8.9 [9.6]; surgeons, 5.9 [6.6]; other physicians 5.0
[8.2]; Kruskal-Wallis T = 28.98; P
< 0.001). However, when day-only separations were excluded, the
difference lost significance (mean in days: geriatricians, 10.0;
surgeons, 7.9; other physicians, 8.3; Kruskal-Wallis T
= 5.74; P = 0.06).
Mortality was highest for patients admitted under geriatricians
(12%) and lowest for those admitted under surgeons (5%), but this
difference was not statistically significant.
The limitations of this study need to be recognised. Its
retrospective nature and reliance on case notes mean that some
information, particularly about comorbidities and presence of
cognitive impairment, may be inaccurate and may underestimate their
true extent. However, validity was enhanced by the use of defined
objective measures, not subject to observer bias. The extent to which
our results may be generalised is uncertain. Although Flinders
Medical Centre is mostly typical of large university teaching
hospitals, it has a higher proportion of non-elective cases.
Differences in its clientele, range of services and service delivery
are also possible.
There are no data on nonagenarians admitted to other Australian
hospitals for comparison. Nor can we readily compare our study
results with those from other countries, as these have excluded
particular patient groups, such as medical6,7,14 or surgical4 patients or those living in
residential care.3
Nevertheless, others have found similarly that hospitalised
nonagenarians present with a wide range of medical and surgical
problems. The longer mean hospital stays in other studies may reflect
different patient profiles or management practices.
We found that more nonagenarians were admitted under the care of
surgeons than under geriatricians or other physicians. Those
admitted under surgeons had the lowest mortality, with 95% surviving
to leave hospital, even though almost 70% were admitted as
emergencies. It is recognised that surgical patients in general have
lower mortality rates than medical patients,15 and our study suggests that this
holds true for the very old. We did not determine the number who
actually underwent a surgical procedure, so cannot estimate
perioperative mortality. Others have estimated it to be 10%-30%,5-7,14 with a higher
mortality rate for emergency compared with elective procedures.15 However, recent advances
in anaesthetic and surgical techniques17 have probably improved survival
prospects for very elderly surgical patients.
Our finding that nonagenarians admitted under the care of
geriatricians were most likely to be admitted as emergencies, to have
documented cognitive impairment and to come from residential care,
probably reflects the hospital's policy of assigning this type of
specialist to very elderly patients with complex medical
conditions. This may also explain why patients admitted under
geriatricians were less likely to return directly to the community
and had longer hospital stays. Alternatively, the longer hospital
stays after admission under geriatricians can be explained by
casemix factors as, for example, the difference was not
statistically significant when day-only patients were excluded.
It was notable that 25% of all separ ations were day only, suggesting
that strategies to minimise hospital stay with day surgery and other
day procedures are being applied successfully to the very old as well
as to younger age groups. Further, hospital stay was twice as long in
people who needed transfer to a rehabilitation facility or more
supportive level of residential care. While it is widely recognised
that inability to readily access rehabilitation and residential
care facilities prolongs stay in acute hospitals, our study provides
quantitative evidence for this.
We believe that many people can be reassured by this study. Firstly,
hospital administrators and health planners can be reassured that
very elderly people seem to make appropriate use of acute hospital
services. Secondly, health professionals can take a positive
approach to treating acute illness in their elderly patients.
Finally, and perhaps most importantly, very elderly people needing
acute hospitalisation can be optimistic in the knowledge that most
will survive and return home after a short hospital stay.
Flinders Medical Centre, Adelaide, SA.
Reprints will not be available from the authors. Correspondence: Dr J
H Harris, Flinders Medical Centre, Bedford Park, SA 5042.
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©MJA 1997
<URL: http://www.mja.com.au/>
© 1997 Medical Journal of Australia.
Abstract
Objective: To examine the use of inpatient hospital
services by people aged 90-99 years.
Design: Retrospective case note review.
Setting: Flinders Medical Centre, a 516-bed
university teaching hospital in Adelaide, South Australia.
Patients: All patients aged 90-99 years on the
separation register for 1995.
Main outcome measures: Patient demographic
characteristics, principal diagnosis, length of hospital stay and
outcome, including destination at discharge.
Results: In 1995, 317 separations involved 214
patients aged 90-99 years; 148 patients (69%) were admitted to
hospital once, 43 (20%) twice and 23 (11%) three times or more. In 54% of
separations, patients came from the community, and these were less
likely to be emergency admissions (72%) than were admissions from
hostels (87%) and nursing homes (93%). Patients had a wide
range of acute medical and surgical problems and a median of five
documented comorbidities. Patients survived to leave hospital in
290 separations (91%) and returned directly to their previous living
circumstances in 212 (67%). Median hospital stay was 5.0 days, and in
25% of separations stay was one day or less. Patients admitted under
the care of geriatricians had more emergency admissions (98%) and
longer mean hospital stays (8.9 days) than those admitted under
surgeons (69%; 5.9 days) or other physicians (66%; 5.0 days).
Conclusion: Despite the acute nature of their
illnesses and their multiple medical problems, most hospitalised
nonagenarians in this study returned directly to their previous
living circumstances after short hospital stays.
Introduction
Australia's rapidly ageing population and changing patterns of
health care delivery are combining to increase the number of old
people using acute hospital services.1 The greatest proportional
population increase is among the very old; between 1990 and 1995 the
estimated number of people aged 85 years and over in Adelaide grew by
27.3%, while the general population grew by only 3%.2 The impact on hospital services is
substantial. For example, inpatient separations for people aged 90
years and over at Flinders Medical Centre, Adelaide, increased by 66%
between the 1989-90 and 1994-95 financial years, from 274 to 454
separations annually (unpublished data).
Methods
Setting and subjects
We examined retrospectively the case notes of all people aged 90-99
years on the separation register for Flinders Medical Centre during
1995. The Centre, with 516 beds, is the largest hospital in the
southern metropolitan region of Adelaide and the principal teaching
hospital of Flinders University. Relative to other Australian
public hospitals of a similar size, a large proportion of its caseload
is non-elective (Dr C Baggoley, Director of Emergency Department,
Flinders Medical Centre, personal communication). The emphasis is
on acute care; hospitalised patients needing rehabilitation are
generally transferred to other public and private facilities in the
region. Some acute surgical specialties (e.g., urology and vascular
surgery) are largely provided at a sister institution. Flinders
Medical Centre has an age-related admission policy whereby elderly
patients with complex medical problems are admitted under the care of
a geriatrician, while those with more specific problems are admitted
under the appropriate specialist physician or surgeon.
Data collection and analysis
The principal diagnosis for each separ ation was obtained from the
hospital's Australian national diagnosis-related group (AN-DRG)
coding system and verified by review of all case notes. The diagnosis
was further classified according to the major body system affected.
Comorbidities and cognitive impairment were identified from the
discharge letter.
Results
During 1995, 317 of the hospital's 27 833 inpatient separations
(1.1%) involved 214 patients aged 90-99 years.
Patient characteristics
Of the 214 patients, 157 (73%) were women and 57 (27%) were men, with
median age, 92 years. Age distribution was 57%, 90-93 years; 27%,
94-95; and 16%, over 95. Before initial hospitalisation, 111
subjects (52%) lived in the community, 58 (27%) in hostels and 45 (21%)
in nursing homes. Most subjects (148; 69%) were admitted to hospital
once during 1995, 43 (20%) twice and 23 (11%) three times or more. The
maximum number of separations per patient in the year was six.
Separation characteristics
The major reason for each hospitalisation (identified as the
principal diagnosis at separation) is shown in Box 1. Orthopaedic
problems (especially fractured neck of femur) and cardiovascular
disorders (especially myocardial ischaemic syndromes and
congestive cardiac failure) were most common. Most separations
(80%) had been classed as emergency admissions. Median number of
comorbidities was five (range, 0-14), with fewer than four
comorbidities recorded for 31% of separations, and eight or more for
14%. Cognitive impairment, either acute or chronic was documented
for 94 separ ations (30%). 
Outcomes
Destinations at separation are shown in Figure 2.
Overall, patients returned directly to their previous living
circumstances in 212 separations (67%), were transferred to other
hospitals for continuing rehabilitation or "step down" care in 56
(18%) or to a more supportive residential environment in 22 (7%), and
died in 27 (9%). The percentage who returned directly to their
previous living circumstances rose to 91% when deaths and hospital
transfers were excluded, and the trend for this return was
statistically significant (Cohen's k = 0.85, P <
0.001).
Comparison of patients from the community and from residential care
Characteristics of patients admitted from different living
circumstances are compared in Box 2. Women predomin ated in all
categories, but the proportion of women was higher among those
admitted from residential care, especially nursing homes, than
among those from the community. Patients from residential care were
more likely to have emergency admissions and be under the care of
surgeons than those from the community, but less likely to be under the
care of physicians (other than a geriatrician). The proportions
under the care of geriatricians were similar in each category.
Comparison of surgical and medical patients
Patients admitted under the care of different specialists are
compared in Box 3. Most patients were admitted under the care of
surgeons (133, 42%), while 126 (40%) were admitted under the care of
geriatricians and 58 (18%) under the care of other physicians.
Discussion
This study challenges some negative stereotypes about use of acute
hospital services by very elderly people. We found that people aged
90-99 years accounted for 1.1% of all separations, with most (54%)
coming from the community. Over 90% survived to leave hospital and
most returned to their previous living circumstances after a median
hospital stay of just under a week. They presented with a wide range of
acute problems, predominantly orthopaedic and cardiovascular
problems. Only a small proportion were frequent users of inpatient
beds.
Acknowledgements
We gratefully acknowledge Dr Michael Clark (Department of
Rehabilitation and Aged Care) for his assistance with
statistical analyses. This survey was supported by a research grant
from Flinders 2000, a research foundation based at Flinders Medical
Centre.
References
(Received 2 Jun, accepted 27 Aug 1997)
Authors' details
Department of Rehabilitation and Aged Care, Flinders University of
South Australia, Adelaide, SA.
Josephine H Harris, BM BS(Hons), Medical Registrar;
Paul
M Finucane, FRACP, FRCPI, Professor;
Denise C Healy, RN,
RM, Research Assistant.
Anthony C Bakarich, RN, BN, Assistant Director of Nursing.
