Editorial
Nonagenarians in Internal Medicine: Another 21st century epidemic
Nonagenarios en Medicina Interna: otra epidemia del siglo XXI
Programa de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
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Chivite, F. Formiga" "autores" => array:2 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Chivite" "email" => array:1 [ 0 => "dchivite@bellvitgehospital.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Formiga" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Programa de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nonagenarios en Medicina Interna: otra epidemia del siglo XXI" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 1990, the population 90 years of age or older in Spain was approximately 114,000 individuals, i.e. 0.3% of the total population.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> Back then, it was unusual to treat a hospitalized nonagenarian patient and even more exceptional to propose, for patients older than 80 years, complex or invasive treatments or hospitalization in critical care units. In 2015, the number of nonagenarians in Spain has grown to 450,000 (0.8% of the total population), which represents an increase of approximately 300%, a much higher growth rate than the other age ranges. An individual who reaches the age of 90 is therefore no longer exceptional. The increase in longevity is the result of advances, in recent decades, in the prevention, diagnosis and treatment of diseases, which have significantly reduced “early” morbidity and mortality related to cardiovascular disease and malignancies.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> For these patients, it is also ethically acceptable to implement invasive techniques that improve their morbidity and mortality with an acceptable risk, such as coronary angioplasty and percutaneous aortic valve replacement.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This new healthcare situation is undoubtedly a positive fact. However, once a patient has reached the 9th decade of life, the risk of hospitalization and the annual mortality rate are high (between 15% and 20%).<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> This poor progression does not depend solely on the presence of severe acute disease but rather on other factors such as disability and, especially, frailty, the result of the exhaustion of the physiological reserve by the comorbidity burden and the physiological processes of senescence, which are especially aggravated after hospitalization.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Except in cases of specific diseases that can be addressed with specific treatment and controllable mild exacerbations in short-stay units, these patients are usually admitted to departments of geriatric medicine or internal medicine (IM).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> According to the minimum basic data set (MBDS), there has been an increase during the past decade (2005–2015) in hospitalizations of nonagenarians in IM departments (approximately 200%). The increase has been almost exponential in recent years and much higher than that observed in younger elderly patients. Moreover, approximately 20% of nonagenarians who require hospitalization in IM departments die during the hospitalization, without the rate having changed appreciably from 2005 to 2015.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In an article published in this issue of <span class="elsevierStyleSmallCaps">Revista Clínica Española</span>,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> Singer et al. retrospectively analyzed the hospital mortality of a cohort of 421 nonagenarian patients, most of whom were not institutionalized and who were hospitalized for any cause in a department of IM. The observed mortality rate of 22.8% confirms the abovementioned data. The predictors of mortality were hospitalization for respiratory failure, sepsis, pneumonia (odds ratio, 3.66–4.88) and, with a lower degree of association, age, disability and comorbidity (Charlson index) (odds ratio, 1.19–1.54). One of the strengths and innovations of the study was the incorporation of data from the comprehensive geriatric assessment (CGA), which were missing from the majority of similar studies. Unfortunately, the studied omitted other CGA variables (cognition, nutritional risk) and some adverse events prior to admission (hospitalizations for surgical reasons) or occurring during hospitalization (delirium, nosocomial infections, falls, adverse drug reactions), which could negatively affect the clinical progression.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Few studies have analyzed the risk factors of hospital mortality in nonagenarians hospitalized in IM departments.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5,8–11</span></a> The most important predictors that have been detected are age,<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8,9</span></a> some disease antecedents and acute diseases that result in hospitalization,<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8,9</span></a> abnormal laboratory results,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> in-hospital complications<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> and a prognostic score (NaURSE) based on clinical and laboratory data.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In community-dwelling octogenarians and nonagenarians, the risk of mortality conferred by a number of elements identifiable through the CGA (comorbidity, cognitive impairment, frailty, geriatric syndromes)<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> and by hospitalization<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> has been consistently demonstrated. However, the information available on the influence of the CGA on the hospital mortality of nonagenarians hospitalized in IM departments is very limited.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> There are also other unevaluated predictors whose influence on the hospital mortality of nonagenarians could be significant, such as the medical team's experience and training, the patient's advance directives, the family's opinion concerning the therapeutic effort and the availability of healthcare/palliative devices.</p><p id="par0030" class="elsevierStylePara elsevierViewall">When faced with this state of uncertainty, how does one act appropriately? First, we avoid hospitalization, which involves having health professionals with sufficient training to provide (in the outpatient setting) comprehensive geriatric care, as well as specialized care devices that help optimize this process.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> Second, we need to ensure that hospitalized patients are treated by expert practitioners, not only in the treatment of the acute disease but also in the care of the comorbidity characteristic of elderly patients, the geriatric syndromes and the complications associated with the hospitalization of these patients.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> Lastly, new studies should accurately identify patients with poor prognoses, who are candidates for palliative care in settings other than acute care hospitals. The nonagenarian population is predicted to continue growing, around 400% in the next 30 years.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> This new situation requires patients, their families, practitioners and the healthcare system to be better prepared to offer ethical and quality care.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Chivite D, Formiga F. Nonagenarios en Medicina Interna: otra epidemia del siglo XXI. 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