Volume 167 Issue 8

Hip fracture in elderly men: prognostic factors and outcomes Terrence H Diamond, Stephen W Thornley, Ronald Sekel and Peter Smerdely For editorial comment, see Seeman Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Statistical analysis - Results - Discussion - References - Authors' details - ©MJA1997 Abstract Objective: To examine prognostic factors and outcomes after hip fracture in men aged 60 years and older. Design and setting: Cohort study of all men presenting to St George Hospital (a 650-bed tertiary care centre) with hip fractures in 1995, recruited retrospectively from medical records and evaluated prospectively at six and 12 months after fracture. Patients: 51 men aged 60 years or more (and, for comparison, 51 age-matched women) who presented with hip fracture not caused by high impact injuries or local bone disease. Main outcome measures: Prognostic factors (such as pre-existing illness and osteoporotic risk factors) and outcome data (such as fracture-related complications, mortality, and level of function as measured by the Barthel index of activities of daily living at six and 12 months postfracture). Results: Median age of the 51 men was 80 years (interquartile range, 74-86 years); four were aged under 70 years. Outcome assessment was possible for 41 men (80%). Similar proportions of men and women came from institutions (32% v. 28%), and similar additional proportions required institutionalisation after discharge (18% v. 14%). Fracture-related complications affected similar proportions of men and women (30% v. 32%), and mean length of hospital stay was similar. Fourteen per cent of men died in hospital compared with only 6% of women (P = 0.06). Men had more risk factors for osteoporosis (P < 0.01). Physical functioning (measured by the Barthel index) deteriorated significantly in men from 14.9 at baseline to 13.4 at six months (P < 0.05) and 12.4 at 12 months (P < 0.05) after fracture. Conclusion: Compared with women, elderly men presenting with hip fracture have higher mortality and have more risk factors for osteoporosis. Like women with hip fracture, men are usually fragile, with pre-existing medical illness and fracture-related complications contributing to their overall poor outcomes. MJA 1997; 167: 412-415 Introduction The incidence of hip fracture in elderly men is approximately one-third of that reported in elderly women.1-5 In a recent Australian study, the incidence of hip fracture in men was calculated as 19.4 per 1000 population per year, with the highest incidence in those aged 80 years and older.3 The economic and social implications of hip fracture in the Australian community are enormous, with the overall cost approximating $420 million annually.6 Previous studies have shown an increased morbidity and mortality associated with hip fracture in elderly women, in whom outcomes are usually poor and partly related to age and medical conditions.7-12 Until recently, there have been comparatively few data on hip fracture in elderly men.12-19 Given the importance of hip fracture, we analysed the mortality and functional outcome of hip fracture in elderly men (aged 60 years and over) who presented to our hospital. Methods St George Hospital is a 650-bed tertiary care referral centre serving a population of 195 000 in the southern metropolitan area of Sydney. Patients admitted to this hospital with hip fractures are usually treated with internal fixation of the fractured hip within 24-48 hours of admission. We retrospectively audited the medical records of all men and women with hip fractures presenting to St George Hospital between 1 January and 31 December 1995. Men were eligible for the study if they were aged 60 years or over, and if their hip fracture was not the result of high impact injuries or local bone disease. The prognostic factors and outcomes following hip fracture of eligible men were compared with those of an equal number of age-matched women who presented with hip fractures during the same 12-month period. Ethical approval for this study was granted by the St George Hospital Ethics Committee. From the hospital medical records, we recorded: Patient's age; Prognostic factors, such as pre-existing illness, osteoporotic risk factors14,17-19 and type of fracture; and Outcome data, such as fracture-related complications, length of hospital stay, mortality, and level of function (as measured by the Barthel index of activities).20 These data are routinely recorded by the orthopaedic intern or registrar, appropriate consultative services, occupational therapist, and/or aged care and rehabilitative services. The Barthel index consists of a questionnaire containing 10 questions pertaining to activities of daily living, such as mobility, bathing, dressing, and toilet use, and is scored out of a total of 20 points -- the lower the score, the worse the disability. Any additional data that were required were obtained by telephone interviews with the patients and/or their family members. Subsequently, patients were followed up prospectively six and 12 months after hip fracture by telephone interview. We obtained data pertaining to whether they were living at home or in an institution, and then used the original 10 questions on the Barthel index questionnaire again to assess activities of daily living, self-care ability and mobility. Statistical analysis Results were analysed with StatCalc21 statistics package. Data for men and women were compared by Student's t test or analysis of variance, where applicable. The main predictors of death and institutionalisation were determined by stepwise regression analysis; the variables entered into the equation included the patient's age, smoking history, alcohol intake, pre-existing medical illness, prefracture Barthel score, length of hospital stay, and fracture-related complications. Results One hundred and eighty-nine people had presented with hip fracture during 1995, comprising 57 men (30%) and 132 women (70%). Six of the men were excluded because their fractures were related to high impact injuries or local bone disease. Hence, we compared the prognostic factors and outcomes following hip fracture of the remaining 51 men with those of 51 age-matched women of the 132 who presented with hip fractures during the same period. Forty-one men (80%) were contactable for assessment of outcomes at six and 12 months. We were unable to contact 10 men, either by a mailed questionnaire or through the telephone directory services. Their names had not been recorded in the death registry of the New South Wales Bureau of Births, Deaths and Marriages. They were considered lost to follow-up. Box 1 (below) compares the clinical data of the men and women with hip fracture. The median age of the 51 eligible men was 80 years; four were aged less than 70 years. Their mean length of hospital stay was 13 days (range, 3-55 days). Sixteen men (32%) came from hostels or nursing homes before admission. Thirty men (58%) were classified radiologically as having trochanteric fractures and 21 (42%) as having cervical fractures; they did not differ with respect to clinical presentation or postfracture outcomes (data not shown). Compared with women, men had a higher prevalence of excessive alcohol consumption (chi-squared = 13.95; P = 0.004) and current smoking (chi-squared = 14.96; P = 0.0004). Forty-eight men (95%) had at least one medical problem before admission; the mean number of medical problems per patient was three (range, 0-4). Forty-seven women (92%) had at least one medical problem, with a mean number of medical problems per patient of two (range, 0-4) (Box 2). Forty men (78%) had at least one risk factor for osteoporosis; the mean number of risk factors per patient was one (range, 0-3). Similarly, 36 women (72%) had at least one risk factor for osteoporosis (not including menopausal status), with a mean number per patient of one (range, 0-4) (Box 2). Ten men (20%) with hip fractures died: seven during hospital admission and another three during the first six months after fracture. More men than women with hip fractures died during their acute hospital admission, but this difference was not significant (P = 0.06). Fifteen men (30%) developed fracture-related complications, five of whom died in hospital. Those who had complications developed an average of two complications each (range, 0-4). This was similar for women; 16 (32%) developed fracture-related complications, three of whom died in hospital, and the average number of complications was one (range, 1-4). The occurrence of individual fracture-related complications did not differ significantly between men and women with hip fracture. Fracture-related complications were the single most important predictor of death in men (odds ratio [OR], 13.5; 95% CI, 1.74-132; P = 0.06). By contrast, the most important predictor in women was the prefracture Barthel index score. In men, age, smoking history, alcohol intake, pre-existing medical illness, prefracture Barthel index score, and length of hospital stay did not contribute significantly to the fracture-related mortality. The Barthel index score (mean, 14.9 at baseline) deteriorated significantly by six months (mean, 13.4; P < 0.05) and 12 months (mean, 12.4; P < 0.05). The baseline Barthel score did not differ significantly between men and women. After fracture, an additional nine men required hostel or nursing home accommodation. This correlated significantly with both the patient's age and the per cent decline in the Barthel index score (r = 0.41; P = 0.0002). Discussion Our findings support the limited published data on hip fracture in men.12-19 As in other studies,3-5 we found that men represented 30% of all hip fractures, and that men who sustained hip fractures were elderly, had pre-existing medical conditions5,13-16 and at least one risk factor for osteoporosis.14,18,19 Compared with the men in our study, women with hip fractures had fewer risk factors for osteoporosis (P < 0.01). Although our study has the major limitation of small sample size, it is the first Australian study to show a significant decline in physical functioning in men after hip fracture. A decline in physical functioning has been noted in both men and women after hip fracture, with many survivors requiring institutionalisation. Almost one-third (32%) of our men originated from institutionalised care, and an additional 18% were subsequently discharged to institutionalised care. Age and percent decline in Barthel index score were the most important criteria leading to their institutionalisation. While the use of the Barthel index may potentially identify individuals who will need long term institutionalisation, this is only a gross assessment of activities of daily living. Thirty per cent of the men in our study returned home to their previous level of function as measured by the Barthel index, but anecdotally many reported a decline in more subtle activities not measured by this index. In a study by Marotolli et al., 29% of all hip fracture patients were institutionalised at six months postfracture.13 Another study reported that 79% of the patients surviving at one year were residing in nursing homes or intermediate care facilities, while those who returned home had significant functional decline, with almost 60% limping or requiring a cane or walker.15 Reported rates of mortality and morbidity in men with hip fracture vary from 13%-44%,1,4,5,9,10,11,16,22 with the likelihood of a man dying after hip fracture increased by 83% and the likelihood of subsequent hospital admission after hip fracture increased by 231%.5 In our study, 20% of men with hip fractures died, either during the initial hospital admission or within the first six months after fracture. Although not statistically significant, we found that, compared with women, twice as many men with hip fractures died during the acute hospital admission (P = 0.06). These data are consistent with those of many other studies which have shown higher postfracture mortality rates in men.1,10,22 For example, Holt et al. recorded 17% mortality in men compared with 11.5% in women,22 while Jacobsen et al. reported mortality rates per 1000 person-months postfracture of 33.7 in white men compared with 17.2 in white women.10 In our study, death occurred predominantly within the first two months postfracture, and fracture-related complications was the strongest predictor of death. In a longitudinal study of ageing, Wolinsky and colleagues found a one-year postfracture mortality among 7527 members of approximately 24%, with the greatest risk of dying in the first six months after hip fracture (hazard-risk ratio, 57.4; 95% CI, 43.7-75.3); survival rates estimated at six months postfracture returned to a trend similar to that of control subjects.5 Despite the limitations of small sample size and a lack of control subjects who had not had hip fracture, this study shows men who present with hip fracture are usually elderly and fragile and have numerous risk factors for osteoporosis, pre-existing medical illnesses and fracture-related complications. In men, this results in higher postfracture mortality compared with age-matched women, as well as in significant functional decline. This study highlights the need to identify men with osteoporosis in the community, and the need to find effective strategies for preventing hip fracture. References Cummings SE, Kelsey JL, Nevitt MC, O'Dowd KJ. Epidemiology of osteoporosis and osteoporotic hip fractures. Epidemiol Rev 1985; 7: 178-208. Lord SR. Hip fractures: changing patterns in hospital bed use in NSW between 1979 and 1990. Aust N Z J Surg 1993; 63: 352-355. Jones G, Nguyen T, Sambrook PN, et al. Symptomatic fracture incidence in elderly men and women: the Dubbo Osteoporosis Epidemiology Study (DOES). Osteoporosis Int 1994; 4: 277-282. Cumming RG, Klineberg RJ. Case-control study of risk factors for hip fractures in the elderly. Am J Epidemiol 1994; 139: 493-503. Wolinsky FD, Fitzgerald JF, Stump TE. The effect of hip fracture on mortality, hospitalization and functional status: a prospective study. Am J Public Health 1997; 87: 398-403. Wark JD. Osteoporosis: the emerging epidemic. Med J Aust 1996; 164: 327-328. Aitken JM. Relevance of osteoporosis in women with fracture of the femoral neck. BMJ 1984; 288: 597-601. Pettiti DB, Sidney S. Hip fracture in women. Clin Orthop 1989; 246: 150-155. Myers AM, Robinson EG, Van Natta ML, et al. Hip fractures among the elderly: factors associated with in-hospital mortality. Am J Epidemiol 1991; 134: 1128-1137. Jacobsen SJ, Goldberg J, Miles TP, et al. Race and sex differences in mortality following fracture of the hip. Am J Public Health 1992; 82: 1147-1150. Cooper C, Atkinson EJ, Jacobsen SJ, et al. Population-based study of survival after osteoporotic fractures. Am J Epidemiol 1993; 137: 1001-1005. Marotolli RA, Berkman LF, Cooney LM. Decline in physical function following hip fracture. J Am Geriatr Soc 1992; 40: 861-866. Marotolli RA, Berkman LF, Leo-Summers L, Cooney LM. Predictors of mortality and institutionalisation after hip fracture: The New Haven EPESE Cohort. Am J Public Health 1994; 84: 1807-1812. Seeman E. Osteoporosis in men: epidemiology, pathophysiology and treatment possibilities. Am J Med 1993; 95 (Suppl 5A): 23S-28S. Poor G, Atkinson EJ, Lewallen DJ, et al. Age-related hip fractures in men: clinical spectrum and short-term outcomes. Osteoporosis Int 1995; 5: 419-426. Poor G, Atkinson EJ, O'Fallon WM, Melton LJ. Determinants of reduced survival following hip fractures in men. Clin Orthop 1995; 319: 260-265. Ringe JD. Hip fractures in men. Osteoporosis Int 1996; 6 (Suppl 3): 48-51. Looker AC, Mussolino ME, Madans JH, Orwoll ES. Risk factors for hip fractures in white men: The NHANES I Epidemiologic Follow up Study [abstract]. J Bone Miner Res 1996; 11: 233. Smerdely P, Thornley S, Sekel R, Diamond T. Subclinical vitamin D deficiency is the major biochemical risk factor associated with hip fracture in elderly men [abstract]. J Bone Miner Res 1996; 11: 233. Mahoney F, Barthel D. The Barthel index. Maryland State Med J 1965; 14: 61-65. StatCalc (Epi Info) [computer program]. Version 6.046. Geneva: WHO, 1997. Holt EM, Evans RA, Hindley CJ, Metcalfe JW. 1000 femoral neck fractures: the effect of pre-injury mobility and surgical experience on outcome. Injury 1994; 25: 91-95. (Received 25 Mar, accepted 10 Jul, 1997) Authors' details St George Hospital, Sydney, NSW. Terrence H Diamond, FRACP, Senior Endocrinologist, Department of Endocrinology; Stephen W Thornley, FRACP, Endocrine Registrar, Department of Endocrinology; Ronald Sekel, FRCS, Senior Orthopaedic Surgeon, Department of Orthopaedic Surgery; Peter Smerdely, PhD, FRACP, Endocrinologist, Department of Aged Care. Reprints: Dr T Diamond, Department of Endocrinology, St George Hospital, 32 Belgrave Street, Kogarah, NSW 2217. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Terrence H Diamond · Stephen W Thornley · Ronald Sekel · Peter Smerdely

Use of inpatient hospital services by people aged 90-99 years Josephine H Harris, Paul M Finucane, Denise C Healy and Anthony C Bakarich Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - ©MJA1997 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. MJA 1997; 167: 417-420 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). 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. 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. 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 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. 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. 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%). 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. 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). 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). 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. 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. 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. 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. 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. 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. 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 Lipski P. Optimum care of the elderly in an acute general hospital. Med J Aust 1996; 164: 5-6. Australian Bureau of Statistics. Estimated resident population by age and sex in statistical local areas of South Australia. Canberra: ABS, 1991 and 1996. (Catalogue no. 3204.4). Patterson C, Crescenzi C, Steel K. Hospital use by the extremely elderly (nonagenarians): a two-year study. J Am Geriatr Soc 1984; 32: 350-352. Saint Jean O, Thibert JB, Holstein J, et al. Hospitalisation en medecine interne des nonagenaires. Etude de 150 sejours. Rev Med Interne 1993; 14: 825-831. Ackermann RJ, Vogel RL, Johnson LA, et al. Surgery in nonagenarians: morbidity, mortality and functional outcome. J Fam Pract 1995; 40: 129-135. Hosking MP, Warner MA, Lobdell CM, et al. Outcomes of surgery in patients 90 years of age and older. JAMA 1989; 261: 1909-1915. Cohen JR, Johnson H, Eaton S, et al. Surgical procedures in patients during the tenth decade of life. Surgery 1988; 104: 646-651. Hobbs R. Rising emergency admissions. BMJ 1995; 310: 207-209. Lewis H, Purdie G. The blocked bed: a prospective study. N Z Med J 1988; 101: 575-577. Shem S. The house of God. London: Bodley Head, 1978. Callahan D. Controlling the costs of health care for the elderly -- fair means and foul. N Engl J Med 1996; 335: 744-746. Apple Macintosh statview statistical package. Version 512+. Calabasas, Cal: Brain Power Inc, 1986. Cohen JA. A coefficient of agreement of nominal scales. Educ Psychol Meas 1960; 20: 37-46. Denney JL, Denson JS. Risk of surgery in patients over 90. Geriatrics 1972; 27: 115-118. Green J, Passman LJ, Wintfeld N. Analysing hospital mortality: the consequences of diversity in patient mix. JAMA 1991; 265: 1849-1853. Adkins RB, Scott HW. Surgical procedures in patients aged 90 years and older. South Med J 1984; 77: 1357-1364. Finucane P, Phillips G. Preoperative assessment and postoperative management of the elderly surgical patient. Med J Aust 1995; 163: 328-330. (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. Flinders Medical Centre, Adelaide, SA. Anthony C Bakarich, RN, BN, Assistant Director of Nursing. Reprints will not be available from the authors. Correspondence: Dr J H Harris, Flinders Medical Centre, Bedford Park, SA 5042. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Josephine H Harris · Paul M Finucane · Denise C Healy · Anthony C Bakarich

Driving and dementia: a cause for concern Peter S Lipski Until we have better evidence about what is safe, we should not allow people with dementia to drive motor vehicles MJA 1997; 167: 453-454 For editorial comment, see Fox & Bashford Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Introduction - Road safety and dementia - Identifying impaired drivers - Identifying dementia - Implications - Conclusion - References - Author's details - - ©MJA1997 Introduction With the ageing of the Australian population, an increasing proportion of elderly drivers may not be medically fit to drive motor vehicles, particularly people with dementia of the Alzheimer's type. Many people with dementia, particularly men, refuse to give up driving, and families frequently have great difficulty convincing them to stop.1,2 Also, in my experience, drivers with dementia -- particularly those who live alone -- frequently continue to drive even when they have been advised not to and their driving licences have been cancelled. Road safety and dementia There is now strong evidence that the risk of motor vehicle accidents for drivers with dementia is significantly greater than that for aged-matched, cognitively normal drivers.1,2 This is not surprising, as important cognitive functions such as switching of visual selective attention, visuospatial orientation and judgement are impaired even in the early stages of Alzheimer's disease. Risks for car accidents are related to speed of information processing and efficient switching of selective attention, both of which are impaired in the early stages of Alzheimer's disease.2 When traffic conditions become complex and stressful (e.g., at intersections and roundabouts), demands on drivers with dementia may exceed their driving capabilities.3 Visuospatial orientation is important for selecting the correct side of the road and for making appropriate and safe turns. Impaired judgement would reduce a driver's ability to make appropriate decisions in traffic and to interpret traffic signs. Drivers with dementia would also have difficulty with aspects of driving that rely heavily on recent memory (such as remembering warnings about changed traffic conditions), and may not cope with sudden changes or new environments. Further, a recent postmortem study of the brains of drivers aged 65 years and older who were killed in car accidents found that over 50% had the neuropathological changes of Alzheimer's disease.4 Despite such evidence, and the increased risk of crashes among drivers with Alzheimer's disease (4.7 times that of control subjects),1 there is still great controversy in the medical literature about the safety of driving for people with the early stages of the disease. Some studies suggest that it would be acceptable to allow a person with early Alzheimer's disease to continue to drive rather that subvert their autonomy and "right" to drive a motor vehicle.3,5 Medical practitioners in Australia are not obliged by law to report drivers with dementia (there are much more specific guidelines for conditions such as epilepsy or stroke). The current New South Wales Roads and Traffic Authority guidelines for medical practitioners do not specifically exclude all people with dementia from driving (rather, recommending that drivers with dementia should be referred for on-road assessment if their ability to drive is in doubt),6 and do not give specific direction about how to assess cognitive function and behaviour in relation to driving skills. The Federal Office of Road Safety does exclude any person with dementia from driving a commercial vehicle.7 Restricted licences are commonly issued for impaired drivers in Australia. The use of these licences to allow drivers with dementia to drive only short distances from home has not been proved effective or safe, and may give a false sense of security to drivers with dementia and their doctors based on the erroneous expectation that people with dementia will not have problems if they remain in familiar surroundings. The increased crash risk for drivers with dementia remains even though they may restrict their driving.2,3 In one study nearly 50% of drivers with dementia incurred at least one crash, compared with only 10% of control subjects, within a five-year period.1 Having someone act as a "copilot" to assist drivers with dementia has not yet been proved a safe practice and should not be encouraged.8 Identifying impaired drivers Routine medical examinations frequently fail to identify elderly drivers with poor driving habits or those at higher crash risk.9 Increased crash risk may be associated with a lower Mini-Mental State Examination score, but this is not always the case.10,11 Also, a spouse or other family mem ber cannot be relied upon to predict the safety of continued driving.12 A multidisciplinary team approach involving an occupational therapist and neuropsychologist can help identify unsafe drivers when there is still doubt after a medical assessment.2,13 The occupational therapist and neuropsychologist are skilled in assessing cognitive impairments such as attentional deficits, impaired concentration, visuospatial impairments, slowed reaction times and distractibility which correlate with impaired driving. The current criterion standard in assessing driving safety is probably the on-road driving assessment, with specific testing protocols for drivers with cognitive impairments.9,13 Unfortunately such programs are costly, often geographically difficult to access, can entail lengthy delays and are impractical in view of the enormous number of elderly drivers who require such assessments. Identifying dementia Over 18 months in my department of geriatric medicine, of 1129 patients referred by general practitioners or medical specialists for routine geriatric medicine consultations we identified at least 38 drivers who had moderately or very advanced Alzheimer's disease who were not only continuing to drive, but whose dementia had not even been diagnosed by their referring practitioners. I believe that medical practitioners are failing to detect drivers with dementia because they are not routinely carrying out cognitive screening tests. Together, the short version of the informant questionnaire on cognitive decline in the elderly and the abbreviated mental test are a sensitive tool for detecting dementia.14 The simple clock drawing test (in which patients are asked to draw the numbers on a round clock face, requiring visuospatial orientation, concentration and planning ability) may also prove to be a very simple and sensitive, but non-specific, screening test for dementia.15,16 Compulsory screening of all drivers over 70 years old would be the only way to ensure compliance in screening. Implications There are currently 799 443 licensed drivers in Australia over the age of 70 years (Roads and Traffic Authority, unpublished data). Epidemiological figures tell us that about 10% of the population at 70 years may have dementia. Even if we make the generous assumption that 50% of all licence holders aged over 70 years no longer drive because of disability or for other reasons, then there would still be at least 40 000 drivers with dementia on Australian roads. Driving a car is a privilege and not a right. The evidence is not yet available to support allowing people with dementia to continue to drive. Further, there are no guidelines as to when people with early dementia who have been permitted to continue driving should be reassessed and what sort of end-points should be used in deciding when to terminate their licences. There are many reasons why a medical practitioner may allow a person with dementia to continue to drive. These include a perceived breach of personal liberty if a licence is cancelled, restriction in lifestyle for the older patient, demands by the older patient to continue to drive, and threats to the doctor-patient relationship. However, failure to advise a patient with dementia not to drive, failure to document that advice and failure to notify the relevant driver licensing authority may result in injury or death of the patient or of other innocent people. Such failure of patient care and social duty may breach professional ethics and may expose the doctor to legal action. Conclusion Doctors should use a recognised form of cognitive screening to assess all their patients over 70 years who drive. Doctors also need better training in medical driving assessments and diagnosis of early Alzheimer's disease. More funding is needed for on-road assessment of cognitively impaired drivers. We need more research into the reliability of medical driver assessments, crash risks and cognitive screening measures, particularly for the very early stages of Alzheimer's disease. Future research may also involve interactive computer-based simulations to evaluate on-road driving skills. To encourage drivers with dementia to surrender their licences, alternative forms of transport need to be arranged, including "community transport schemes" and better public transport.2,13 Rural drivers with dementia who are forced to give up their licences may be particularly at risk of becoming socially isolated, disadvantaged and perhaps stranded. Still, this is still no excuse for allowing an impaired driver to continue driving. References Freidland RP, Kos E, Kumar A, et al. Motor vehicle crashes in dementia of the Alzheimer's type. Ann Neurol 1988; 24: 782-786. Parasuraman R, Nestor PG. Attention and driving skills in ageing and Alzheimer's disease. Human Factors 1991; 33: 539-557. Hunt L, Morris JC, Edwards D, et al. Driving performance in persons with mild senile dementia of the Alzheimer's type. J Am Geriatric Soc 1993; 41: 747-753. Johansson K, Bojdanovic N, Kalimo H, et al. Alzheimer's disease and apolipoprotein E 4 allele in older drivers who died in automobile accidents. Lancet 1997; 349: 1143-1144. Drachman DA, Swearer JM. Driving and Alzheimer's disease: the risk of crashes. Neurology 1993; 43: 2448-2456. Roads and Traffic Authority. Drivers and riders. Guidelines for medical practitioners. 3rd ed. Sydney: NSW Roads and Traffic Authority, 1993. Dementia and other cognitive impairments. In: Medical examination of commercial vehicle drivers. Melbourne: National Road Transport Commission, and Federal Office of Road Safety, 1994. Shua-Haim JR, Gross JS. The "co-pilot" driver syndrome. J Am Geriatric Soc 1996; 44: 815-817. Johansson K, Bronge L, Lundberg C, et al. Can a physician recognise an older driver with increased crash risk potential? J Am Geriatric Soc 1996; 44: 1198-1204. Odenheimer GL, Beaudet M, Jette AM, et al. Performance-based driving evaluation of the elderly driver: safety, reliability and validity. J Gerontol 1994; 49: M153-M159. Fitten LJ, Perryman KM, Wilkinson CJ, et al. Alzheimer and vascular dementias and driving. A prospective road and laboratory study. JAMA 1995; 273: 1360-1365. Kapust LR, Weintraub S. To drive or not to drive: preliminary results from road testing of patients with dementia. J Geriatr Psychiatry Neurol 1992; 5: 210-216. Fox GK, Withaar F, Bashford GM. Dementia and driving: a survey of clinical practice in aged care assessment teams. Aust J Ageing 1996; 15: 111-114. Harwood DMJ, Hope T, Jacoby R. Cognitive impairment in medical inpatients. 1: Screening for dementia -- is history better than mental-state? Age Ageing 1997; 26: 31-35. Watson YI, Arfken CL, Birge SJ. Clock completion: an objective screening test for dementia. J Am Geriatric Soc 1993; 41: 1235-1240. Death J, Douglas A, Kenny RA. Comparison of clock drawing with Mini-Mental State examination as a screening test in elderly acute hospital admissions. Postgrad Med J 1993; 69: 696-700. Author's details Central Coast Area Health Service, Gosford, NSW. Peter S Lipski, MD, FRACP, Staff Specialist Geriatrician. Reprints will not be available from the author. Correspondence: Dr P S Lipski, Department of Geriatric Medicine, Central Coast Area Health Service, Health Services Building Level 2, Gosford Hospital, Stephen Street, Gosford, NSW 2250. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Peter S Lipski