Clinical decision making for oldest old

In India, as in the rest of the world, the elderly population is getting older. In India, around 10% of older people are 80 or older. The oldest old are the fastest growing segment of the population. Presently, nonagenarians (90 years or above) are reported to be over 1.59 million in India.[1] Oldest old people have more underlying chronic diseases, unique clinical presentation, and higher hospitalization rates, and only a small proportion of their problems are solvable. Their issues are multiple; the response to treatment is slow and subtle and treating doctors are not trained in geriatric care. These issues reduce the satisfaction and enthusiasm of treating clinicians. The common consensus among clinicians is that there was little survival to gain with poor long-term mortality rates despite treatment in the oldest old patients. Lack of knowledge and available pieces of evidence have promoted a fatalistic ageist attitude among health care professionals. The dilemma in the care of the oldest old is the question of the futility of treatment and uncertainty of the treatment outcome. Older people, especially nonagenarians, are often not included in clinical trials and are underrepresented in clinical registries. Therefore, evidence that informs treatment decisions for the oldest old population is lacking. Various studies have looked for prognostic factors for this segment of the population. Zafrir et al., in their research, inferred that the main predictors for in-hospital death of nonagenarians were pressure sores, older age, atrial fibrillation, malignant disease, and admission due to an acute infection, especially Clostridium difficile-associated diseases.[2] In addition, mental decline, permanent urinary catheter, leukocytosis, renal failure, and hypoalbuminemia predicted post-discharge mortality.[2] Darvall et al. reported that frailty is common in very old critically ill patients and is associated with considerably poorer health outcomes. Therefore older ICU patients must be screened for frailty to improve outcome prediction and inform intensive care and community health care planning.[3] Yust-Katz et al. found that the main prognostic factors for mortality and functional outcome in nonagenarian patients admitted to a non-acute geriatric hospital are incontinence and functional state before admission and not age per se.[4] Fragility hip fracture is a serious complication of osteoporosis, particularly in the oldest old. The hip fractures in nonagenarians are associated with a significant increase in postoperative complications, a high mortality rate, and poor functional prognosis. Urgent management of these fractures, particularly with early surgery, mobilization, optimal nursing care, and rehabilitation, leads to better functional outcomes, shorter duration of hospital stay, and decreased mortality. The timing of the surgery is crucial; early surgical fixation is associated with better results and less mortality. Bolton et al. reported that oncologic fracture, dementia, and CHF were significant risk factors for 1-year mortality, while the type of fracture and length of stay in hospital was associated with perioperative complications, including anaemia and pneumonia.[5] Mayordomo-Cava et al. identified several variables influencing 30-day mortality in nonagenarian hip fracture patients, such as respiratory infection, electrolyte disorders, polypharmacy, cardiac arrhythmia, and spinal anaesthesia.[6] With the ageing of society, it is increasingly common to deal with ethical dilemmas involving decision-making in elderly patients with hip fractures. Herrera-Pérez et al. emphasized that ageism due to ignorance can lead to surgical delay and, therefore, the mortality of these patients.[7] In this issue, Jain et al. have studied factors affecting mortality in the nonagenarian population following surgery for fragility hip fractures, adding to sparse literature available from India. The study highlighted that the male gender, delay in surgery (>3 days), and poor ambulatory status in the postoperative period are risk factors for mortality. However, being a small study, it did not find a correlation between mortality and the American Society of Anesthesiologists (ASA) grade, comorbidities, fracture type, preinjury ambulatory status, operative time, and length of hospital stay. Early ambulation after surgery provided a beneficial outcome and enhanced the survival rate significantly.[8] Besides hip fractures, the experience of managing several other medical conditions in nonagenarians has been mixed. Advanced age is considered one of the factors but making a decision based on age alone is not justifiable. Studies on cancer management in nonagenarians concluded that the treatment should be considered based on stage and patient preferences in a multidisciplinary setting and should not be denied based on age.[9,10] In nonagenarians, percutaneous coronary intervention (PCI) is associated with an increased risk for adverse cardiovascular events that reduce long-term survival. In older people, trans-radial intervention for PCI might contribute to risk reduction for periprocedural complications.[11,12] Mechanical thrombectomy (MT) is a proven treatment for acute ischemic stroke (AIS) for ≥90-year-old patients with favourable functional outcomes at discharge, in-hospital death, successful recanalization, and complications. Therefore clinicians should not exclude it based on age alone.[13] The diagnostic colonoscopy, in patients 90 years or older, though it picks up more cancers, is associated with an increased risk of the incomplete procedure, inadequate bowel preparation, and adverse events.[14] In patients presenting to the emergency department, Woitok et al. reported that age above 90 years and high comorbidity burden were identified as independent risk factors for death. Polypharmacy, hyponatremia and high comorbidity burden were independent risk factors for more prolonged hospitalizations. Advanced age and high comorbidity burden were independent risk factors for placement in a nursing facility.[15] Clinical research usually exclude older people, especially nonagenarians. As a result, clinical care for these very elderly lacks evidence and scientific recommendations; thus is mainly based on expert opinion. For the physician, choosing to treat or not treat very elderly patients (for fear of side effects) is difficult. More studies are needed to identify higher-risk oldest old patients and develop appropriate triage (resource limitation enforced decisions), guidelines and prediction models for proper clinical decisions. We should also strive to change the ageistic attitude of health professionals.