Proportion Of Octogenarians Research Articles

Clinical characteristics and outcomes of patients aged 80 years and over with heart failure: Need for better treatment.

Although the prevalence of heart failure (HF) increases markedly with advancing age, surprisingly little is known about HF in the very elderly. The aim of this study was to describe the clinical characteristics and outcomes of octogenarians with HF. Individual participant meta-analysis of patients with HF and reduced, mildly reduced, and preserved ejection fraction (HFrEF, HFmrEF, and HFpEF, respectively) enrolled in eight large randomized trials. Overall, the proportion of octogenarians was 1518 of 20 168 patients (7.5%) with HFrEF, 610 of 4609 (13.2%) with HFmrEF, and 3130 of 15 354 (20.4%) with HFpEF. Regardless of HF phenotype, octogenarian patients were more often female and had more comorbidities, more symptoms and signs of congestion, and worse health status (but not quality of life), in comparison to patients aged <80 years. The incidence (per 100 person-years) of the composite of cardiovascular death or HF hospitalization was 13.3 (95% confidence interval [CI] 12.7-14.0) in octogenarians versus 9.5 (95% CI 9.3-9.7) in non-octogenarians (adjusted hazard ratio [aHR] 1.40, 95% CI 1.32-1.48). Each component of the composite was more frequent in octogenarians with rates of cardiovascular mortality of 7.0 (95% CI 6.5-7.4) per 100 person-years versus 4.9 (95% CI 4.8-5.1) in non-octogenarians (aHR 1.60, 95% CI 1.48-1.72, p < 0.001). Octogenarians received less evidence-based therapy, especially mineralocorticoid receptor antagonists, than younger patients. Despite worse health status and higher hospitalization and mortality rates, octogenarians were undertreated compared to younger patients.

Editor's Choice – Sex Related Differences in Indication and Procedural Outcomes of Carotid interventions in VASCUNET

It has been suggested that peri-operative complications after carotid surgery may be higher in women than in men. This assumption may affect the treatment patterns, and it is thus possible that carotid endarterectomy (CEA) is provided to women less often. The aim of the current VASCUNET study was to determine sex related differences in operative risk in routine clinical practice among non-selected patients undergoing carotid revascularisation. Data on CEA and carotid artery stenting (CAS) from 14 vascular registries were collected and amalgamated. Comprehensive data were available for 223 626 carotid artery procedures; these were analysed overall and by country. The primary outcome was any stroke and or death within 30 days of carotid revascularisation. Secondary outcomes were stroke, death, or any major cardiac event or haemorrhage leading to re-operation. Of the procedures, 34.8% were done in women. The proportion of CEA for asymptomatic stenosis compared with symptomatic stenosis was significantly higher among women than men (38.4% vs. 36.9%, p < .001). The proportion of octogenarians was higher among women than men who underwent CEA in both asymptomatic (21.2% vs. 19.9%) and symptomatic patients (24.3% vs. 21.4%). In the unadjusted analysis of symptomatic and asymptomatic patients, there were no significant differences between men and women in the rate of post-operative combined stroke and or death, any major cardiac event, or combined death, stroke, and any major cardiac event after CEA. Also, after stenting for asymptomatic or symptomatic carotid stenosis, there were no significant differences between men and women in the rate of post-operative complications. In adjusted analyses, sex was not significantly associated with any of the end points. Higher age and CAS vs. CEA were independently associated with all four end points. This study confirmed that, in a large registry among non-selected patients, no significant sex related differences were found in peri-operative complication rates after interventions for carotid stenosis.

Outcomes After Major Surgical Procedures in Octogenarians: A Nationwide Cohort Study

IntroductionAging of the worldwide population has been observed, and postoperative outcomes could be worse in elderly patients. This nationwide study assessed trends in number of surgical resections in octogenarians regarding various major surgical procedures and associated postoperative outcomes.MethodsAll patients who underwent surgery between 2014 and 2018 were included from Dutch nationwide quality registries regarding esophageal, stomach, pancreas, colorectal liver metastases, colorectal cancer, lung cancer and abdominal aortic aneurysms (AAA). For each quality registry, the number of patients who were 80 years or older (octogenarians) was calculated per year. Postoperative outcomes were length of stay (LOS), 30 day major morbidity and 30 day mortality between octogenarians and younger patients.ResultsNo increase in absolute number and proportion of octogenarians that underwent surgery was observed. Median LOS was higher in octogenarians who underwent surgery for colorectal cancer, colorectal liver metastases, lung cancer, pancreatic disease and esophageal cancer. 30 day major morbidity was higher in octogenarians who underwent surgery for colon cancer, esophageal cancer and elective AAA-repair. 30 day mortality was higher in octogenarians who underwent surgery for colorectal cancer, lung cancer, stomach cancer, pancreatic disease, esophageal cancer and elective AAA-repair. Median LOS decreased between 2014 and 2018 in octogenarians who underwent surgery for stomach cancer and colorectal cancer. 30 day major morbidity decreased between 2014 and 2018 in octogenarians who underwent surgery for colon cancer. No trends were observed in octogenarians regarding 30 day mortality between 2014 and 2018.ConclusionNo increase over time in absolute number and proportion of octogenarians that underwent major surgery was observed in the Netherlands. Postoperative outcomes were worse in octogenarians.

Long-term Survival After Repair of Ruptured Abdominal Aortic Aneurysms Is Improving Over Time: Nationwide Analysis During Twenty-four Years in Sweden (1994-2017).

To investigate long-term survival after ruptured abdominal aortic aneurysms (rAAA) repair in Sweden during twenty-four years (1994-2017). Management of rAAA has seen significant changes in the past decades, with the shifting from open (OAR) to endovascular (EVAR) being the most striking, thereby enabling treatment of elderly patients with multiple comorbidities. A registry-based nationwide cohort study was performed, and three 8-year periods (1994-2001, 2002-2009, 2010-2017) were compared for crude long-term survival with Kaplan-Meier and multivariable Cox proportional hazards analyses. Relative survival compared to matched general population referents was estimated. Overall, 8928 rAAA repair subjects were identified (1994-2001 N = 3368; 2002-2009 N = 3405; 2010-2017 N = 2155). The proportion of octogenarians (20.6%; 27.5%; 34.0%; P < 0.001), women (14.3%; 18.5%; 20.6%; P < 0.001), and EVAR procedures (1.5%; 14.9%; 35.5%; P < 0.001) increased over time. The crude 5-year survival was 36%; 44%; 43% (P < 0.0001). Multivariable Cox proportional hazard analysis displayed a decreasing mortality hazard ratio (HR) over time (1.00; 0.80; 0.72; P < 0.001). Use of EVAR was associated with reduced hazards of crude long-term mortality (HR = 0.80, P < 0.001). Relative survival for patients surviving the perioperative period (ie, 90 days) was lower than matched general population referents, and was stable over time (relative 5-year survival: 86% vs 88%, vs 86% P < 0.001). Nationwide analysis of long-term outcomes after repair of rAAA in Sweden during 24 years (1994-2017) has revealed that, despite changes in the baseline population characteristics as well as in the treatment strategy, long-term survival improved over time.

The survival benefit of surgery for perihilar cholangiocarcinoma in octogenarians: Shinshu University experience.

In today's aging society, surgery is increasingly performed for older patients with perihilar cholangiocarcinoma (PHCC). This study aimed to examine survival and oncological outcomes in octogenarians with PHCC who underwent surgery. We retrospectively examined 480 consecutive PHCC patients treated for PHCC between 1991 and 2020. Two hundred forty-seven underwent resection. Patient and clinical characteristics, including postoperative complications, overall survival (OS), and disease-free survival (DFS) were analyzed. The proportion of octogenarians with PHCC undergoing surgery increased from 5.2% in 1991-2000to 13.4% in 2016-2020. R0 resection and postoperative complication rates were comparable between octogenarians and younger patients. Five-year OS (30.0% vs. 31.7%) and DFS (20.0% vs. 29.5%) did not significantly differ. One-year OS was significantly better in octogenarians who underwent resection than those who did not (95.0% vs. 17.6%; p < .001). Two octogenarians who developed Clavien-Dindo grade III complications had undergone right hemihepatectomy (RH). Posthepatectomy liver failure and biliary leakage (Grade B) were also observed in octogenarians who underwent RH. In well-selected octogenarians with PHCC, surgery offers short- and long-term outcomes comparable with those of their younger counterparts. RH may be considered in octogenarians on an individual basis.

Safety and Feasibility of Thoracoscopic Lung Resection for Non-Small-Cell Lung Cancer in Octogenarians.

Octogenarians comprise an increasing proportion of patients presenting with non-small-cell lung cancer (NSCLC). This study examines postoperative morbidity and mortality, and long-term survival in octogenarians undergoing thoracoscopic anatomic lung resection for NSCLC, compared with younger cohorts. We conducted a retrospective review of our institutional Society of Thoracic Surgeons General Thoracic Surgery Database of all patients ≥60 years old undergoing elective lobectomy or segmentectomy for pathologic stage I, II, and IIIA NSCLC between 2009 and 2018. Results were compared between octogenarians (n = 71) to 2 younger cohorts of 60- to 69-year-olds (n = 359) and 70- to 79-year-olds (n = 308). Long-term survival among octogenarians was graphically summarized using the Kaplan-Meier method. Cox regression analysis was used to identify preoperative risk factors for mortality. A greater proportion of octogenarians required intensive care unit admission and discharge to extended-care facilities; however, postoperative length of stay was similar between groups. Among postoperative complications, arrhythmia and renal failure were more likely in the older cohort. Compared to the youngest cohort, in-hospital and 30-day mortality were highest among octogenarians. Overall survival among octogenarians at 1, 3, and 5 years was 87.3%, 61.8%, and 50.5%, respectively. On multivariable Cox regression analysis of baseline demographic variables, presence of stroke (hazard ratio [HR] = 28.5, 95% confidence interval [CI]: 6.1 to 132.7, P < 0.001) and coronary artery disease (HR = 2.5, 95% CI: 1.2 to 5.3, P = 0.02) were significant predictors of overall mortality among octogenarians. Thoracoscopic resection can be performed with favorable early postoperative outcomes among octogenarians. Long-term survival, although comparable to their healthy peers, is worse than those of younger cohorts. Further study into preoperative risk stratification and alternative therapies among octogenarians is needed.

Editor's Choice – International Variations and Sex Disparities in the Treatment of Peripheral Arterial Occlusive Disease: A Report from VASCUNET and the International Consortium of Vascular Registries

Objective:The aim of this study was to determine sex specific differences in the invasive treatment of symptomatic peripheral arterial occlusive disease (PAOD) between member states participating in the VASCUNET and International Consortium of Vascular Registries.Methods:Data on open surgical revascularisation and peripheral vascular intervention (PVI) of symptomatic PAOD from 2010 to 2017 were collected from population based administrative and registry data from 11 countries. Differences in age, sex, indication, and invasive treatment modality were analysed.Results:Data from 11 countries covering 671 million inhabitants and 1 164 497 hospitalisations (40% women, mean age 72 years, 49% with intermittent claudication, 54% treated with PVI) in Europe (including Russia), North America, Australia, and New Zealand were included. Patient selection and treatment modality varied widely for the proportion of female patients (23% in Portugal and 46% in Sweden), the proportion of patients with claudication (6% in Italy and 69% in Russia), patients’ mean age (70 years in the USA and 76 years in Italy), the proportion of octogenarians (8% in Russia and 33% in Sweden), and the proportion of PVI (24% in Russia and 88% in Italy). Numerous differences between females and males were observed in regard to patient age (72 vs. 70 years), the proportion of octogenarians (28% vs. 15%), proportion of patients with claudication (45% vs. 51%), proportion of PVI (57% vs. 51%), and length of hospital stay (7 days vs. 6 days).Conclusion:Remarkable differences regarding the proportion of peripheral vascular interventions, patients with claudication, and octogenarians were seen across countries and sexes. Future studies should address the underlying reasons for this, including the impact of national societal guidelines, reimbursement, and differences in health maintenance.

Differences in clinical outcomes and health care utilization between octogenarians and nonagenarians following decompression for lumbar spinal stenosis. A market scan analysis

ObjectiveLumbar spinal stenosis (LSS) in octogenarians and beyond has a significant impact on quality of life requiring surgical decompression and hence impact on health care utilization. Risk of surgical failure and impact on health care resources is always a concern in this patient population (more so in nonagenarians). The aim of our study was to compare clinical outcomes and healthcare utilization in patients (80–89 vs.90+) undergoing decompression for LSS. Patients and methodsData was extracted using ICD9/10 and CPT codes from MarketScan (2001–2015) in this retrospective study. We defined the comparative groups based on the age groups (80–89 and 90+), in patients with LSS. Outcomes of interest were: length of hospital stay, discharge disposition and utilization in the index hospitalization, 6- months, 12 months following index procedure as well as the associated health care utilization. Patient characteristics and outcomes among cohorts were compared using univariate tests. Outcomes were further compared using adjusted multivariable regression models. Statistical analysis was performed with SAS 9.4. ResultsA cohort of 5387 was identified from the database, 96.38% were in the 80–89 age group and 3.62%were in the 90+ age group. The proportion of patients undergoing surgery for LSS among 80–89 (95.7–98.5%) and 90+ age group (1.5–4.3%) remained constant through the years. Interestingly, 13.83% and 16.92% of patients had Elixhauser comorbidity index of 3+ in 80–89 age group and 90+ age groups respectively. Decompression with fusion was performed in 19.4% of patients in 80–89 age group, compared to 9.74% of patients in 90+ age group. There was no difference in median length of hospital stay (3 days, p = 0.19) and complications across the cohorts (80–89: 16.7%; 90+: 18.46% p = 0.51). 70.6% of patients in 80–89 age groups were discharged to home compared to 60.5% in 90+ age group (p = 0.0023). At 6 months follow-up, overall rate of new decompression, new fusion, re-fusion at index level were 2.38%, 0.59% and 0.33% only, with no differences across the cohorts. Interestingly, patients in 80–89 age group incurred higher outpatient services, number of medication refills and related payments at 6-months and 12-months follow-up, compared to patients in 90+ age group. Overall, combined median post-discharge payments at 12 months were similar across the groups [80–89 (median $ 40,257) and 90+ (median$ 36,161), p = 0.14]. ConclusionUsing MarketScan database, there has been a gradual decline in the number of decompressions being performed for LSS in elderly patients (>80 years of age), however there is no change in the proportion of octogenarians and nonagenarians undergoing decompression for LSS. There was no difference in rate of reoperations and overall health care utilization among the groups. Surgery for LSS can be offered to nonagenarians (in appropriately selected patients) with no difference in clinical outcomes and health care utilization, compared to octogenarians.

23 Burns in Octogenarians: 80 is the New 60

Geriatric trauma patients (age≥65 years) with burn injuries have a 5x higher mortality rate compared to younger adults. Although the LD50 for children and younger adults has improved significantly over the past decade, it remains at 35% total-body surface area (TBSA) for geriatric patients. Due to an aging population, the proportion of octogenarians (80–89 years) suffering burns are increasing. An analysis from over a decade ago using the National Burn Repository demonstrated a linear increase in mortality for patients older than 65-years. We hypothesized that octogenarians with burn injuries would have a higher rate of in-hospital complications as well as mortality, compared to patients aged 65–79 years. The Trauma Quality Improvement Program (2010–2016) was queried for patients with any burn injuries. Two groups were compared: age 65–79 vs 80–89. A multivariable logistic regression model was used to determine risk for mortality. From 282 patients, 209 (74.1%) were aged 65–79 and 73 (25.9%) were 80–89. Both groups had a similar median injury severity score (ISS) (p=0.81), TBSA (p=0.30) and rate of comorbidities except for higher rate of smoking (12.9% vs. 4.1%, p=0.04) and lower rate of hypertension (52.2% vs. 65.8%, p=0.04) in the age 65–79 group. Octogenarians had a similar rate of complications (acute kidney injury, acute respiratory distress syndrome, deep vein thrombosis, pneumonia) (p>0.05) as well as mortality (15.1% vs. 10.5%, p=0.88), compared to those aged 65–79. On multivariable logistic regression, octogenarians were not associated with increased risk of mortality (p=0.67). Compared to patients aged 65–79 with burn injuries, octogenarians have a similar rate of complications and risk of mortality. This differs from a previous national database analysis. Octogenarians are making up a larger proportion of patients admitted for burn injuries than ever before. Among patients ≥65 years, age in of itself is not a significant predictor of mortality. Future research on alternative methods to prognosticate mortality in elderly burn patients, such as development of a burn-related frailty index appears warranted.

Japanese Surveillance of Neuroendovascular Therapy in JR-NET - Part II. Japanese Registry of NeuroEndovascular Treatment 3. Main Report

This study, following Japanese Registry of NeuroEndovascular Treatment 1 and 2 (JR-NET 1 & 2), shows an annual trend of cases including adverse events and clinical outcomes at 30 days after NET. JR-NET3 was registered by 749 cumulative total number of physicians, certified by the Japanese Society of Neuroendovascular Therapy in 166 centers, between 2010 and 2014. Medical information about the patients was anonymized and retrospectively registered through a website. A total of 40,177 patients were recruited, 632 patients were excluded because data of preprocedural status were not available. So we analyzed 39,545 patients retrospectively. The proportion of octogenarians is increasing year-by-year and 14.7% in 2014 compared with 10.4% in 2010. Most frequent target disease is intracranial aneurysm. For the proportion of the treatment of intracranial aneurysm, 50.0% in 2010, but that has decreased to 44.8% in 2014. However, number of procedures were increased from 3150 in 2010 to 3419 in 2014. Although before the positive clinical evidence of mechanical thrombectomy for acute ischemic stroke (AIS) was established, the proportion of endovascular treatment for AIS increased 13.8% in 2014 compared with 6.3% in 2010. The number of patients requiring neuroendovascular treatment in Japan is increasing since 2010–2013, but that declined a little in 2014 caused by study operation suspended at the end of 2013. The outcomes of such therapy are clinically acceptable. Details of each type of treatment will be investigated in sub-analyses of the database.

Is pancreaticoduodenectomy justified for octogenarians even in the low-volume center? Single community-based center opinion

Introduction: Establishment of the Japanese Society of Hepato-Biliary-Pancreatic Surgery board certification system has decreased mortality subsequent to pancreaticoduodenectomy (PD) in Japan. However, not all patients, especially octogenarians, live in proximity to board-certified centers. The aim of this study is to evaluate clinical outcomes of PD in octogenarians from a community-based low-volume center. Method: Between 2006 and 2017, a total of 54 PD were performed. We analyzed clinicopathological data and short-term outcomes in octogenarians (Group O: n = 15) compared with patients <80 years (Group Y: n = 39). Results: In our center, the proportion of octogenarians who underwent PD reached 27.8%. There were no statistical differences between two groups in preoperative morbidity; however, preoperative median prognostic nutritional index (PNI) in Group O was 37.7 (26.3–51.9) and significantly lower than Group Y (p = 0.0036). There were no significant differences in operative time and blood transfusion between two groups. In terms of postoperative complications, Clavien-Dindo IIIa≧ was 26.7% in Group O and 12.8% in Group Y, which was not significantly different (p = 0.415). The rate of postoperative fistula, delayed gastric empting, and severe infection were almost same between two groups. The median length of hospital stay were 25 days in Group O and 17 days in Group Y, which was not significantly different (p=0.067). The rate of hospital mortality was 0% in Group O and 2.6% in Group Y. Conclusions: Fortunately, our outcomes of PD were equivalent of high-volume centers; however, if there is a system that board-certified surgeons relocate to low-volume centers, further developments may be expected.

Coronary revascularisation in the elderly

### Leaning objectives To date, there remains no universal definition for ‘elderly’, and indeed for some, biological age does not correspond with chronological age. However, most now consider elderly as...

Abstract W P221: Temporal Trends in Door-to-needle Time and Patient Characteristics in Patients Treated With Intravenous Thrombolysis: Analysis of the Sits-east Registry

Introduction: Shorter door-to-needle time (DNT) improves treatment efficacy in acute ischemic stroke (AIS) patients. Still, there are groups of patients at increased risk of longer DNT. The goal of our study was to determine temporal trends of DNT. The second goal was to identify if baseline characteristics of patients treated with intravenous thrombolysis changed throughout the years and if such change (e.g. treating older patients) could have affected DNT. Methods: Prospectively collected data from the Safe Implementation of Treatments in Stroke - EAST (12 Central/Eastern European countries) registry between January 2005 and August 2013 were analyzed. Baseline patient characteristics over period 2005-2013 were analyzed descriptively and using ANOVA. DNT and association between DNT and the patient characteristics were analyzed using linear logistic regression. Obtained regression coefficients and descriptive statistics were used to simulate average DNT values in individual years during 2005-2013. Several simulations were performed (e.g. for patients above 80 years). Results: Altogether, all 13401 patients treated with thrombolysis within 4.5 hours of symptom onset between January 2005 and August 2013 with available DNT were analyzed. Mean DNT during 2005-2013 was 74.4min with slightly improving trend over time. We found almost 6-fold increased proportion of octogenarians in 2013 compared to 2005. Patients with lower and higher NIHSS, prestroke mRS 0-2, arriving sooner to hospital, and treated in a center with less experience (&lt;50 pts per year/center) had longer DNT between 2005 and 2013. In patients arriving within 60min to hospital DNT was longest 88min in 2007 and shortest 75min in 2013. Change in baseline characteristics during 2005-2013 can explain only small proportion of DNT (R-squared decreased from 50% in 2005 to 17% in 2013). Conclusions: Although DNT is improving, it remains long especially for some subgroups of patients, e.g. those arriving early to hospital after symptom onset. Every AIS patient should be treated as fast as possible.

Outcome of 1051 octogenarians after primary percutaneous coronary intervention for ST elevation myocardial infarction: observational cohort from the London Heart Attack Group

Purpose: Octogenarians with STEMI are less commonly treated by primary PCI than other age groups. We present long-term survival data of a large cohort of elderly patients following primary PCI in London. Methods: This was an observational study of 10,249 patients undergoing primary PCI for STEMI at 8 London heart attack centres between January 2005 and November 2011. The primary end-point was all-cause mortality at a median follow-up of 3.0 years (IQR range: 1.2-4.6 years). Results: A total of 1051 octogenarians (10.3%) with an average age of 84.2 years (IQR 80-101) were treated with primary PCI. Over time, the annual proportion of octogenarians increased from 9.1% in 2005 to 10.5% in 2010. Compared to patients <80, they included a higher proportion of women, and more hypertension, hypercholesterolaemia, multi-vessel disease, previous infarction and previous CABG. They were less likely to undergo radial access, receive GPIIb/IIIa inhibitors or DES. When compared with younger patients, primary PCI in octogenarians was less likely to achieve TIMI flow grade 3 (84.7% vs 88.3%, p=0.003). However, between 2005 and 2011 the rates of post-procedural TIMI flow grade 3 increased significantly from 80.5% in 2005 to 90% in 2011 (p for trend 0.05). The cumulative incidence of all-cause mortality during follow-up was significantly higher in the octogenarian group (51.6% vs 12.8%, p<0.0001). As expected, the hazard of death during follow-up increased with age (unadjusted HR 1.069 per year increase [95% CI 1.064-1.074], p<0.0001), which persisted after adjustment for other predictors of mortality (HR of 1.059 [95% CI 1.048-1.071], p<0.0001). ![Figure][1] Figure 1 Conclusion: London's experience suggests that primary PCI is increasing in this group and that despite the high long term mortality, acute survival rates are encouraging. [1]: pending:yes

Reperfusion therapy and mortality in octogenarian STEMI patients: results from the Belgian STEMI registry

Treatment strategies and outcome of ST-elevation myocardial infarction (STEMI) have been mainly studied in middle-aged patients. With increasing lifetime expectancy, the proportion of octogenarians will substantially increase. We aimed to evaluate whether the benefit of currently recommended reperfusion strategies is maintained in octogenarians. Reperfusion therapy and in-hospital mortality were evaluated in 1,092 octogenarians and compared with 7,984 STEMI patients <80 years old based on data from the prospective Belgian STEMI registry. The octogenarian STEMI group had more cardiovascular comorbidities, contained more female patients and presented more frequently with cardiac failure (Killip class >1, 40 vs. 20 %) compared with their younger counterparts (all p < 0.05). Although the rate of thrombolysis was similar (9.2 vs. 9.9 %) between both groups, a conservative approach was chosen more frequently (13.8 vs. 4.7 %), while PCI was performed less frequently (76.9 vs. 85.4 %) in octogenarians (p < 0.001). Moreover, ischemic time and door-to-needle/balloon time were longer for octogenarians. In-hospital mortality for octogenarians was 17.8 vs. 5.5 % in the younger group [adjusted OR 2.43(1.92-3.08)]. In haemodynamically stable octogenarians, PCI seemed to improve outcome compared with thrombolysis or conservative treatment (5.7 vs. 12.7 vs. 8.5 %, p = 0.09). In octogenarians with cardiac failure, in-hospital mortality was extremely high independent of the chosen reperfusion therapy (34.6 vs. 31.6 vs. 36.3 %, p = 0.88). In-hospital mortality in octogenarian STEMI patients was high and related to a high prevalence of cardiac failure. Less PCI was performed in the octogenarian group compared with the younger patients, although mortality benefit of PCI was maintained in haemodynamically stable octogenarians.

Pancreatic Surgery in the Very Old: Face to Face With a Challenge of the Near Future

The proportion of octogenarians requiring surgery for pancreatic disease is rapidly growing. This trend will be continued during the next decades, posing a challenge to surgeons and the health care system worldwide. This study aimed to analyze the results of pancreatic surgery in octogenarians in terms of safety and survival based on a cohort of patients at a European high-volume center. During a 7-year period, 1,705 operations were performed, 76 in patients ≥ 80 years of age. Data on the octogenarians were retrospectively reviewed and compared to those of the whole collective and to contemporary data from the literature. Primary endpoints were mortality, morbidity, and survival. Overall, 80 % had a malignant disease, and resections were performed in 50 % of all cases. Mortality was 11.8 % and morbidity 72.4 %. There were significantly more medical than surgical complications: 56.6 versus 34.2 %. Pancreatic fistula occurred in 5.3 %, postoperative bleeding in 3.9 %, and delayed gastric emptying in 19.7 %. The median hospital stay was 15 days and the intensive care unit stay 2 days. Mean survival was 28.2 months and in patients with cancer 22.6 months. The 1-, 3-, and 5-year survival rates were 61.4, 31.3, and 18.8 %, respectively. Despite high mortality and morbidity rates, surgery remains the only chance for cure in most octogenarians with pancreatic disease. Careful patient selection is the key to success and improved long-term survival in this group, which will represent a substantial fraction of the population in the near future.

Filter-Protected versus Unprotected Carotid Artery Stenting: A Randomised Trial

Background: Our aim was to determine whether filter protection reduces embolisation to the brain during carotid artery stenting (CAS). Methods: Thirty patients with symptomatic carotid artery stenosis ≧70% (North American Symptomatic Carotid Endarterectomy Trial) were randomly assigned to filter-protected or unprotected CAS. Diffusion-weighted magnetic resonance imaging (DWI) of the brain was performed before and at 3 time points after CAS. In a subset of patients, high-intensity transient signals on transcranial Doppler (TCD) were recorded with categorisation of emboli. Data were independently reviewed off-site. Results: There were no significant differences in mean age, proportion of octogenarians or presenting symptoms between the groups. On procedural DWI (1–3 and 24 h after stenting), there were 7/24 (29%) and 4/22 (18%) new lesions in protected and unprotected patients respectively (p = 0.38). At 30 days there were 9/33 (26%) and 4/33 (12%) lesions in protected and unprotected patients, respectively (p = 0.1). On TCD there were significantly more signals in total as well as particulate emboli during filter-protected CAS (426.5 and 251.3) than during unprotected CAS (165.2 and 92) – p = 0.01 and 0.03, respectively. Conclusions: Filter-protected CAS is associated with an increase in new lesions on DWI and significantly higher rates of total and particulate microembolisation on TCD than unprotected CAS. The clinical significance of these findings requires further study.

Topical issues in old age psychiatry.

With advancements in medical science over past decades, our aging population has increased substantially. Census studies in 2001 showed that 429,100 of the population of the Republic of Ireland were aged 65yrs and older, making up 11.2% of the overall population. While the overall population of the Republic is expected to remain stable over the next ten years, the demographic projections for the elderly population is for significant growth: numbers of over 65yrs are expected to increase by nearly 108,000 people between 1996 - 2011, comprising over 14.1% of the overall population. In particular, our communities will contain a much higher proportion of octogenarians and nonagenarians: at present 21% of our over 65's are 80 yrs or older; by 2011, it is projected that this number will increase to 25%. In tandem, the prevalence of dementia will increase. In 2000, it was estimated that 31,000 people suffered with dementia in the Republic of Ireland, and this figure is expected to increase by 5000 cases per year between 2001-2011. The ultimate outcome of this demographic shift, will be higher demands on medical services for older people, especially geriatric medicine and old age psychiatry. This paper will focus on two particular aspects of management which will increasingly impact on the work of old age psychiatrists - medicolegal issues and management issues in dementia.

Renal replacement therapy in the over-80s

The incidence of chronic renal failure rises dramatically with age, which is no longer seen as a contraindication to treatment. To characterise Scottish dialysis patients aged 80 years and over at the time of their first treatment and to compare their outcomes with those of patients with other serious illnesses. Retrospective survey of all older patients starting dialysis in Dumfries and Galloway between 1 January 1994 and 31 December 2003, and of all older chronic renal failure patients starting dialysis in Scotland between 1 January 1994 and 31 December 2001. Comparison with 4,565 Scottish Lung Cancer and 14,398 myocardial infarction (MI) patients of similar age. 213/3,944 Scottish dialysis patients were aged 80 years or over at the time of their first treatment, representing 5.4% of all new patients and 9.2% of all new starts in 2001. Ninety per cent of older patients received haemodialysis as their first mode of renal replacement therapy. The most common diagnosis was chronic renal failure of unknown cause in 41% of cases. Quality of life, measured in a subset of Dumfries patients, suggested similar social functioning and mental health, but poorer physical health than their younger dialysis counterparts. Early mortality was high in all three diagnostic groups. Median survival from 90 days after the start of treatment, registration or hospital admission was 459 days (95% CI, 375, 543) for the older Scottish CRF patients, compared to 141 days (128, 154) for lung cancer and 1242 days (1192, 1292) for MI patients. Dialysis can be an effective treatment modality for at least a proportion of octogenarians with end-stage renal failure.

Population-based study of carotid endarterectomy in Western Australia.

Previous studies reported an increase in the rates of operation following the publication of major trials that demonstrated the benefit of carotid endarterectomy in reducing stroke. The aim of this study was to determine whether carotid endarterectomy rates have continued to rise despite the reducing trend in most manifestations of atherosclerotic cardiovascular disease. Record linkage was used to select patients who had a carotid endarterectomy during the interval from 1988 to 2001. Incidence rates were age-standardized and trends were examined with Poisson regression. The rate increased by 13.8 per cent per year between 1988 and 1998; however, from 1999 onwards the rate of carotid surgery fell by 15.8 per cent per year. In octogenarians, the rate increased steadily from 0.9 to 5.1 per 100,000 person-years between 1992 and 2000. The proportion of octogenarians also increased significantly from 0.9 per cent in 1988-1990 to 19.5 per cent in 2000-2001 (chi2=60.11, 4 d.f., P<0.001). For the first time a recent decline has been observed in the rate of carotid endarterectomy, most likely owing to a combination of the deceasing incidence of atherosclerosis and more widespread use of effective drugs in the treatment of cardiovascular disease. The rate and proportion of operations in patients aged 80 years or older has increased steadily.