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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 1990&#44; the population 90 years of age or older in Spain was approximately 114&#44;000 individuals&#44; i&#46;e&#46; 0&#46;3&#37; of the total population&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> Back then&#44; it was unusual to treat a hospitalized nonagenarian patient and even more exceptional to propose&#44; for patients older than 80 years&#44; complex or invasive treatments or hospitalization in critical care units&#46; In 2015&#44; the number of nonagenarians in Spain has grown to 450&#44;000 &#40;0&#46;8&#37; of the total population&#41;&#44; which represents an increase of approximately 300&#37;&#44; a much higher growth rate than the other age ranges&#46; An individual who reaches the age of 90 is therefore no longer exceptional&#46; The increase in longevity is the result of advances&#44; in recent decades&#44; in the prevention&#44; diagnosis and treatment of diseases&#44; which have significantly reduced &#8220;early&#8221; morbidity and mortality related to cardiovascular disease and malignancies&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> For these patients&#44; it is also ethically acceptable to implement invasive techniques that improve their morbidity and mortality with an acceptable risk&#44; such as coronary angioplasty and percutaneous aortic valve replacement&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">This new healthcare situation is undoubtedly a positive fact&#46; However&#44; once a patient has reached the 9th decade of life&#44; the risk of hospitalization and the annual mortality rate are high &#40;between 15&#37; and 20&#37;&#41;&#46;<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&#44; especially&#44; frailty&#44; the result of the exhaustion of the physiological reserve by the comorbidity burden and the physiological processes of senescence&#44; which are especially aggravated after hospitalization&#46;<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&#44; these patients are usually admitted to departments of geriatric medicine or internal medicine &#40;IM&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> According to the minimum basic data set &#40;MBDS&#41;&#44; there has been an increase during the past decade &#40;2005&#8211;2015&#41; in hospitalizations of nonagenarians in IM departments &#40;approximately 200&#37;&#41;&#46; The increase has been almost exponential in recent years and much higher than that observed in younger elderly patients&#46; Moreover&#44; approximately 20&#37; of nonagenarians who require hospitalization in IM departments die during the hospitalization&#44; without the rate having changed appreciably from 2005 to 2015&#46;<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 Cl&#237;nica Espa&#241;ola</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> Singer et al&#46; retrospectively analyzed the hospital mortality of a cohort of 421 nonagenarian patients&#44; most of whom were not institutionalized and who were hospitalized for any cause in a department of IM&#46; The observed mortality rate of 22&#46;8&#37; confirms the abovementioned data&#46; The predictors of mortality were hospitalization for respiratory failure&#44; sepsis&#44; pneumonia &#40;odds ratio&#44; 3&#46;66&#8211;4&#46;88&#41; and&#44; with a lower degree of association&#44; age&#44; disability and comorbidity &#40;Charlson index&#41; &#40;odds ratio&#44; 1&#46;19&#8211;1&#46;54&#41;&#46; One of the strengths and innovations of the study was the incorporation of data from the comprehensive geriatric assessment &#40;CGA&#41;&#44; which were missing from the majority of similar studies&#46; Unfortunately&#44; the studied omitted other CGA variables &#40;cognition&#44; nutritional risk&#41; and some adverse events prior to admission &#40;hospitalizations for surgical reasons&#41; or occurring during hospitalization &#40;delirium&#44; nosocomial infections&#44; falls&#44; adverse drug reactions&#41;&#44; which could negatively affect the clinical progression&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Few studies have analyzed the risk factors of hospital mortality in nonagenarians hospitalized in IM departments&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;8&#8211;11</span></a> The most important predictors that have been detected are age&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8&#44;9</span></a> some disease antecedents and acute diseases that result in hospitalization&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8&#44;9</span></a> abnormal laboratory results&#44;<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 &#40;NaURSE&#41; based on clinical and laboratory data&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In community-dwelling octogenarians and nonagenarians&#44; the risk of mortality conferred by a number of elements identifiable through the CGA &#40;comorbidity&#44; cognitive impairment&#44; frailty&#44; geriatric syndromes&#41;<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&#46; However&#44; the information available on the influence of the CGA on the hospital mortality of nonagenarians hospitalized in IM departments is very limited&#46;<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&#44; such as the medical team&#39;s experience and training&#44; the patient&#39;s advance directives&#44; the family&#39;s opinion concerning the therapeutic effort and the availability of healthcare&#47;palliative devices&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">When faced with this state of uncertainty&#44; how does one act appropriately&#63; First&#44; we avoid hospitalization&#44; which involves having health professionals with sufficient training to provide &#40;in the outpatient setting&#41; comprehensive geriatric care&#44; as well as specialized care devices that help optimize this process&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> Second&#44; we need to ensure that hospitalized patients are treated by expert practitioners&#44; not only in the treatment of the acute disease but also in the care of the comorbidity characteristic of elderly patients&#44; the geriatric syndromes and the complications associated with the hospitalization of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> Lastly&#44; new studies should accurately identify patients with poor prognoses&#44; who are candidates for palliative care in settings other than acute care hospitals&#46; The nonagenarian population is predicted to continue growing&#44; around 400&#37; in the next 30 years&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> This new situation requires patients&#44; their families&#44; practitioners and the healthcare system to be better prepared to offer ethical and quality care&#46;</p></span>"
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March 2018 Nonagenarians in Internal Medicine: Another 21st century epidemic
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Vol. 218. Issue 2.
Pages 70-71 (March 2018)
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Vol. 218. Issue 2.
Pages 70-71 (March 2018)
Editorial
DOI: 10.1016/j.rceng.2018.01.001
Nonagenarians in Internal Medicine: Another 21st century epidemic
Nonagenarios en Medicina Interna: otra epidemia del siglo XXI
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D. Chivite
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dchivite@bellvitgehospital.cat

Corresponding author.
, F. Formiga
Programa de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
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