Buggy, D. J.

Exadaktylos, A. K.

Sclabas, G.

Zimmermann, H.

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Age and Ageing 2006; 35: 204–207 © The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society.All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org204Letters to the EditorSix month outcome of extremely old (³95 years) trauma patientsSIR—Trauma in the elderly is an issue of escalating import-ance in health care. The proportion of the 6 billion individu-als born in the twentieth century surviving to age 65 in thetwenty-first century will continue to increase because ofimprovements in public health, medicine and economicconditions in developed as well as emerging developingcountries.In extremely old (≥95 years) trauma patients, clinicalmanagement must strike a balance between potentially det-rimental aggressive treatment and an inappropriately con-servative approach [1–3]. The cost of trauma care forelderly patients will continue to increase due to the propor-tional increase in the ageing population. The NationalTrauma Database in the US has stated that elderly traumapatients account for 25% of all trauma and use about one-third of the total trauma health care resources [4]. Althoughtrauma in elderly patients has been studied previously, thereare no such reports detailing outcome in patients aged 95years or older [5, 6].Our emergency department in Bern, Switzerland, is alevel 1 trauma referral centre serving a population of about1.5 million people. All cases were collected from a computerdatabase using defined key words (trauma, age ≥95 years). Atotal of 57,248 case histories of patients presenting to thedepartment of emergency medicine between January 2002and December 2003 were reviewed using the ‘Qualicare’database. This yielded 50 consecutive patients meeting theentry criteria of incurring a trauma injury and being ≥95years. Their six-months outcome after the injury wasassessed by phoning the patients themselves and by contact-ing their relatives or general practitioners. Patients werequestioned about their general health and their ability toundertake activities of daily living compared with their pre-morbid state, including dressing, self-hygiene and preparingmeals.Fifty consecutive patients (42 females) 95 yearspresented with trauma during the study period. Their meanage was 97 years (range 95–103). The presence of pre-existingcardiovascular disease was noted in 64% and diabetesmellitus in 28% (Table 1). Forty-two (84%) of injuriesoccurred indoors, the remainder outdoors. Twenty weretreated on an out-patient basis, eight of them had isolatedfractures of the distal arm (e.g., Colles fracture). All traumawas blunt and consisted largely of lower limb fractures(n = 32, 64%). Among admitted patients, the median hos-pital stay was 6 days (range 1–27 days). In n = 22 (44%)patients, surgery was necessary. No intraoperative deathhad been noted. Four patients died due to pre-existingco-morbidity between 8 and 16 days after hospitalisation.Two patients died within 24 h of admission due to severehead injury. All 44 patients who were discharged after treat-ment returned to their pre-morbid home environment. Nodischarged patient died within the first 6 months aftertrauma (Table 1).Our results could imply that once the elderly have sur-vived the initial injury, their prognosis for a good outcomeis similar to that of younger patients concerning their func-tional status. Comparisons between the studies of traumacan be difficult, because of differences in the severity of theinjuries observed.Ours is a sizeable patient cohort of extremely oldtrauma patients, with injuries ranging from minor Collesfracture, managed on an out-patient basis, to fracturedneck of femur, which is associated with significant mor-bidity. Despite this, 88% of our patients had not onlysurvived but also recovered to their pre-injury standardof living.In summary, this retrospective review of over 57,000emergency department attendances identified 50 patients 95years or older presenting with trauma. Notwithstandingtheir advanced years and pre-existing co-morbidity, 88%had resumed their pre-injury state at 6 months, sug-gesting that extremely old trauma patients merit con-sideration of definitive treatment as for youngerpatients.Table 1. Details of patients, trauma and treatment [datashown is n (%) unless stated]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Patient characteristics. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .n (%)Age in years [median (range)] 97 (95–103)Females 42 (84)Pre-existing morbidityCoronary heart disease 20 (40)Diabetes 14 (28)Hypertension 12 (24)Cerebrovascular episodes 2 (4)Asthma 2 (4)Antiplatelet agents/Warfarin dependent 44 (96)Anatomical site of injuryLower limb 32 (64)Upper limb 8 (16)Head injury 4 (8)Pelvis 6 (12)TreatmentConservative non-surgical 28 (56)Surgical 36 (44)Letters to the Editor205A. K. EXADAKTYLOS1,2*, D. J. BUGGY1,G. SCLABAS3, H. ZIMMERMANN31University Department of Anaesthesia, Mater MisericordiaeUniversity Hospital, Eccles Street, Dublin 7, Ireland2Departments of Anaesthesia, Intensive Care Medicine,University Hospital, Inselspital, Bern, Switzerland3Department of Emergency Medicine, University Hospital,Inselspital, Bern, Switzerland*To whom correspondence should be addressedTel: (+353) 1 803 2281Email: aristomenis@exadaktylos.ch1. Kohn RK. Cause of death in very old people. JAMA 1982;247: 2793–7.2. Fazeny-Dorner B, Wenzel C, Berzlanovich A et al. Unex-pected out-of-hospital deaths in persons aged 85 years orolder: an autopsy study of 1886 patients. Am J Med 2003;114: 365–9.3. van der Sluis CK, Klasen HJ, Eisma WH, ten Duis HJ. Majortrauma in young and old: what is the difference? J Trauma 1996;40: 78–82.4. The Major Trauma Outcome Study. Establishing nationalnorms for trauma care. J Trauma 1990; 30: 1356–65.5. Baker SP, O’Neill B, Haddon W et al. The injury severity score:a method for describing patients with multiple injuries andevaluating emergency care. J Trauma 1974; 14: 187.6. van Aalst JA, Morris JA, Yates HK et al. Severely injuredgeriatric patients return to independent living: a study offactors influencing function and independence. J Trauma1991; 31: 1096.doi:10.1093/ageing/afj022Published electronically 16 January 2006Another case of missing denturesSIR—I read with interest ‘Mystery of the missing denture:an unusual cause of respiratory arrest in a nonagenarian’published on 19 June 2005 [1] and have a similar case toreport.Having recently commenced employment as a physicalcare practitioner working in mental health for older peopleon continuing care wards, I was asked to see a lady who hadsuffered a recent choking event. Following the incident, thepatient was generally unwell, but the main concern was thatshe was unable to eat or drink despite being both hungryand thirsty. A local general practitioner saw the patient butcould find no reason for her difficulty in eating or drinkingand confirmed that she did not appear to have aspirated.Nursing staff had noticed that the patient’s top set of den-tures were missing and had enquired if she could have swal-lowed them, but this was not considered to be possible.On examination, I found that the patient had recentlydeveloped a very hoarse voice. Whilst the patient had theability to swallow, she then had to expel any food or fluidfrom her mouth. There was only very mild tenderness inher throat on examination. No foreign body could be seenin the mouth or throat. I discussed the case with an ENTcolleague and escorted the patient to the local ENTdepartment. The patient was seen and examined under localanaesthetic, and the initial diagnosis was either a residualfood bolus or a tumour. On further examination, theconsultant confirmed that he could see teeth and that thiswas only the second time he had ever seen this. Theoffending denture was removed under local anaesthetic.The patient developed no complications and was eating anddrinking within a couple of hours.I agree with the author that asking about loose-fittingdentures should be part of comprehensive assessment of allolder people and, following this incident, I now include adental assessment as part of my routine physical assessment.Many older people in long-term care receive suboptimaldental care. Locally, I am leading a working group toimprove all aspects of oral care for older people in mentalhealth wards, and I have little doubt that this work shouldbe replicated by all long-term care providers.LESLEY CHAPMANPhysical Care Practitioner, Auckland Park Hospital,Bishop Auckland, County Durham, UKTel: (+044) 7785304067Email: lesley.chapman@cddps.northy.nhs.ukNote: This work was carried out for Mental Health Services for OlderPeople, County Durham, and Darlington Priority Services NHS Trust.1. Arora A, Arora M and Roffe C. Mystery of the missing den-ture: an unusual cause of respiratory arrest in a nonagenarian.Age Ageing 2005; 34: 519–20.doi:10.1093/ageing/afj034Published electronically 16 January 2006Post-fall syndrome: a matter to study in patients with hip fractures admitted to orthopaedic wardsSIR—We have read with pleasure Dr Martín et al.’s [1] veryinteresting paper about fear of falling limiting activity inyoung-old women being associated with reduced functionalmobility. We would like to contribute our experience.A prospective study was carried out for 2 years (2003and 2004). All patients with hip fractures admitted to ortho-paedic wards of a teaching hospital and referred to the geri-atrician were included. The geriatrician makes a daily wardround taking medical control of the patients, and a studyrecord was completed for each of the patients. In this study,all the independent predictive variables of functional recov-ery after hip fracture in the elderly were collected [2]. Oneof them was the presence of post-fall syndrome detected bythe geriatrician during in-hospital stay. Follow-up outcomedata were collected by telephone, 3 and 6 months afterinjury.A total of 196 patients were recruited. The mean age was84 years and post-fall syndrome was identified in 5.1% ofpatients. These patients were older (86.1 versus 82.7) andhad a greater number of past medical diagnoses (5.6 versus

Six month outcome of extremely old (≥95 years) trauma patients

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