"Oldest old" patients in intensive care: prognosis and therapeutic activity

Intensive care of geriatric patients-a thin line between under- and overtreatment

Demographic developments are leading to an ever-increasing proportion of elderly and aged patients in hospitals at all levels of care, and even more patients from these age groups are to be expected in the future. Based on the projected population development, e.g., in Norway, an increase in intensive care beds of between 26 and 37% is expected by 2025. This poses special challenges for the treatment and management of geriatric intensive care patients. The acute illness is not the only decisive factor, but rather the existing multimorbidity and functional limitations of this vulnerable patient group must likewise be taken into account. Age per se is not the sole determinant of prognosis in critical patients, even though mortality increases with age.

Patient Information Items Needed to Guide the Allocation of Scarce Life-Sustaining Resources: A Delphi Study of Multidisciplinary Experts

OBJECTIVE

Plans for allocation of scarce life-sustaining resources during the coronavirus disease 2019 (COVID-19) pandemic often include triage teams, but operational details are lacking, including what patient information is needed to make triage decisions.

METHODS

A Delphi study among Washington state disaster preparedness experts was performed to develop a list of patient information items needed for triage team decision-making during the COVID-19 pandemic. Experts proposed and rated their agreement with candidate information items during asynchronous Delphi rounds. Consensus was defined as ≥80% agreement. Qualitative analysis was used to describe considerations arising in this deliberation. A timed simulation was performed to evaluate feasibility of data collection from the electronic health record.

RESULTS

Over 3 asynchronous Delphi rounds, 50 experts reached consensus on 24 patient information items, including patients' age, severe or end-stage comorbidities, the reason for and timing of admission, measures of acute respiratory failure, and clinical trajectory. Experts weighed complex considerations around how information items could support effective prognostication, consistency, accuracy, minimizing bias, and operationalizability of the triage process. Data collection took a median of 227 seconds (interquartile range = 205, 298) per patient.

CONCLUSIONS

Experts achieved consensus on patient information items that were necessary and appropriate for informing triage teams during the COVID-19 pandemic.

Determinants of prognosis in geriatric patients followed in respiratory ICU; either infection or malnutrition

Severity of illness, age, malnutrition, and infection are the important factors determining intensive care unit (ICU) survival.The aim of the study is to determine the relations between Geriatric Nutritional Risk Index (GNRI), C-reactive protein/albumin (CAR), and prognosis-mortality of geriatric patients (age of ≥65 years) admitted to intensive care unit.The study with 10/15/2020, 697 approval date, and number retrospectively registered. Between January 1, 2018 and December 31, 2019, 413 geriatric patients admitted to ICU. The patients were divided into three groups according to their age.The age group, gender, Charlson comorbidity index, intensive care scores (Acute Physiology And Chronic Health Evaluation II and Sequential Organ Failure Assessment), the infection markers (white blood cell, procalcitonin, CAR levels), malnutrition tools for each patient (body mass index, Nutrition Risk in Critically ill score, and GNRI scores) were analyzed retrospectively. Also length of stay (LOS) ICU, length of stay hospital, and 30-day mortality were recorded.Geriatric patients number of 403 was included in the study. Forty-nine (12.3%) patients had a history of malignancy, 272 (67.5%) patients had Chronic Obstructive Pulmonary Disease comorbidity. There was no difference in mortality between age groups.In patients with mortality, body mass index, had being Chronic Obstructive Pulmonary Disease history, GNRI, length of stay hospital, and albumin were significantly lower; malignancy comorbidity rate, inotrope use, modified Nutrition Risk in Critically ill score, mechanical ventilation duration, LOS ICU, Sequential Organ Failure Assessment, Acute Physiology And Chronic Health Evaluation II, Charlson comorbidity index, C-reactive protein, procalcitonin, and CAR were significantly higher.Both malnutrition and infection affect mortality in geriatric patients in intensive care. The GNRI is better than CAR at predicting mortality.

A catalogue of tools and variables from crisis and routine care to support decision-making about allocation of intensive care beds and ventilator treatment during pandemics: Scoping review

PURPOSE

This scoping review sought to identify objective factors to assist clinicians and policy-makers in making consistent, objective and ethically sound decisions about resource allocation when healthcare rationing is inevitable.

MATERIALS AND METHODS

Review of guidelines and tools used in ICUs, hospital wards and emergency departments on how to best allocate intensive care beds and ventilators either during routine care or developed during previous epidemics, and association with patient outcomes during and after hospitalisation.

RESULTS

Eighty publications from 20 countries reporting accuracy or validity of prognostic tools/algorithms, or significant correlation between prognostic variables and clinical outcomes met our eligibility criteria: twelve pandemic guidelines/triage protocols/consensus statements, twenty-two pandemic algorithms, and 46 prognostic tools/variables from non-crisis situations. Prognostic indicators presented here can be combined to create locally-relevant triage algorithms for clinicians and policy makers deciding about allocation of ICU beds and ventilators during a pandemic. No consensus was found on the ethical issues to incorporate in the decision to admit or triage out of intensive care.

CONCLUSIONS

This review provides a unique reference intended as a discussion starter for clinicians and policy makers to consider formalising an objective a locally-relevant triage consensus document that enhances confidence in decision-making during healthcare rationing of critical care and ventilator resources.

Utilization of tracheostomy among geriatric trauma patients and association with mortality

BACKGROUND

The purpose of this study was to investigate trends in tracheostomy (TR) utilization among trauma patients over the last decade and explore its impact on mortality among elderly trauma patients.

METHODS

Patients 18 years or older with at least 72 h on the ventilator were selected from the National Trauma Databank research datasets 2007 to 2015. Patients were divided into three groups based on age: 18-60, 61-80, and > 80 years and proportions of patients undergoing a TR were depicted. Elderly (> 80 years) were divided into two groups, based on whether they underwent a TR. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to account for survival bias.

RESULTS

Over the 9-year study period 284,774 patients met inclusion criteria. Of those, 21,465 (7.5%) were older than 80 years. Elderly patients were significantly less likely to undergo a TR (13.1% vs. 21.5% in the 18-60 years and 20.4% in the 61-80 years group, p < 0.01) and this trend continued throughout the study period. Among the elderly patients, those who underwent TR were more likely to have a severe (AIS ≥ 3) thoracic, abdominal, and/or spinal injury, but not head injury and were less likely to have a history of cerebrovascular accident (5.9% vs. 7.7%, p < 0.01). The overall mortality was significantly higher in elderly patients who did not undergo a TR (46.9% vs. 17.6%, p < 0.01). The adjusted hazard ratio for elderly patients undergoing a TR was 0.36 (adjusted p < 0.01).

CONCLUSION

In ventilated trauma patients, tracheostomy is less likely to be utilized in the elderly population compared to younger age groups. Amongst the elderly patients, performance of tracheostomy was associated with a significantly higher overall survival. Delaying or avoiding this procedure in the elderly trauma patient predominantly based on age might not be justified.

STUDY TYPE

Prognostic/epidemiological.

LEVEL OF EVIDENCE

III or IV.

The impact of intensive care admission criteria on elderly mortality

OBJECTIVE

To review systematically the influence of admission criteria on the mortality of elderly patients under intensive therapy.

METHODS

We performed a search on the PUBMED and BIREME databases by using the MeSH and DeCS terms "intensive care units", "patient admission", and "aged" in Portuguese, English, and Spanish. Only prospective and retrospective cohort studies were included. We analyzed the severity score, type of hospital admission, quality of life, co-morbidities, functionality, and elderly institutionalization.

RESULTS

Of the 1,276 articles found, thirteen were selected after evaluation of the inclusion and exclusion criteria. It was observed that the severity score, functionality, and co-morbidities had an impact on mortality. It was not possible to determine which severity score was more suitable.

CONCLUSION

We suggest that analysis of functionality, co-morbidities, and severity scores should be conducted to estimate the elderly mortality in relation to the admission to intensive care units.

Outcome and survival following tracheostomy in patients ≥ 85 years old

PURPOSE

To evaluate percutaneous dilatational tracheostomy in patients ≥ 85 years old: its complication rate and possible risk factors. In addition, to assess prognostic factors for short, intermediate and long term survival following the procedure.

METHODS

A retrospective case-control study of 72 patients ≥ 85 years who received percutaneous dilatation tracheotomy (PTD), compared to a control group of younger patients (n = 182). Demographics, clinical and laboratory data were collected. Survival and risk for complications were analyzed.

RESULTS

The study group's mean age was 89 ± 4. Twelve patients had complications, three (4.2%) were major. No significant difference was found in overall complication rates between the groups. Cerebrovascular disease with neurologic deficits and pre-procedure albumin levels were significantly associated with complications. Survival rates did not differ in 1 week and 1 month following procedure between study and control group. There was a significant difference in the 1-year survival rates between the patients ≥ 85 years and the control groups (18.1% vs. 34.4%, p = 0.01, respectively). Congestive heart failure, a frailty score > 0.27 and failure to wean from a cannula were associated with reduced 1-year survival.

CONCLUSION

PTD is safe for patients ≥ 85 years. Complication risk factors and reduced survival should be discussed with patients and families before conducting tracheostomies.

LEVEL OF EVIDENCE

3b.

Are we ever too old?: Characteristics and outcome of octogenarians admitted to a medical intensive care unit

The aging population increases the demand of intensive care unit (ICU) treatments. However, the availability of ICU beds is limited. Thus, ICU admission of octogenarians is considered controversial. The population above 80 years is a very heterogeneous group though, and age alone might not be the best predictor. Aim of this study was to analyze resource consumption and outcome of octogenarians admitted to a medical ICU to identify reliable survival predictors in a senescent society.This retrospective observational study analyzes 930 octogenarians and 5732 younger patients admitted to a medical ICU. Admission diagnosis, APACHE II and SAPS II scores, use of ICU resources, and mortality were recorded. Long-term mortality was analyzed using Kaplan-Meier survival curves and multivariate cox regression analysis.Patients ≥80 years old had higher SAPS II (43 vs 38, P < .001) and APACHE II (23 vs 21, P = .001) scores. Consumption of ICU resources by octogenarians was lower in terms of length of stay, mechanical ventilation, and renal replacement therapy. Among octogenarians, ICU survivors got less mechanical ventilation or renal replacement therapy than nonsurvivors. Intra-ICU mortality in the very old was higher (19% vs 12%, P < .001) and long-term survival was lower (HR 1.76, P < .001). Multivariate cox regression analysis of octogenarians revealed that admission diagnosis of myocardial infarction (HR 1.713, P = .023), age (1.08, P = .002), and SAPS II score (HR 1.02, 95%, P = .01) were independent risk factors, whereas admission diagnoses monitoring post coronary intervention (HR .253, P = .002) and cardiac arrhythmia (HR .534, P = .032) had a substantially reduced mortality risk.Octogenarians show a higher intra-ICU and long-term mortality than younger patients. Still, they show a considerable life expectancy after ICU admission even though they get less invasive care than younger patients. Furthermore, some admission diagnoses like myocardial infarction, cardiac arrhythmia and monitoring post cardiac intervention are much stronger predictors for long-term survival than age or SAPS II score in the very old.

[Intensive care medicine in old age : The individual status is the determining factor]

The increasing aging of the population in highly developed countries poses a profound impact on intensive care services. This is illustrated by a finding from a large Austrian database showing that 20% of all intensive care patients are aged ≥80 years. Age per se is not an exclusion criteria for admission to the intensive care unit, but older patients are frequently affected by multiple comorbidities and experience a decreased physiologic reserve. Due to the very heterogeneous population of aged patients and since no generally accepted criteria for admission and treatment of these patients exist, any treatment decision must be made taking into consideration the individual situation. The perspective after possible survival from a critical illness is considered as the most important outcome and goes far beyond the question of survival alone. Many old patients have the chance to return to an acceptable quality of life even after a life-threatening illness. However, with respect to the limitations of human life, it is not justified to start or prolong intensive care in elderly patients without a reasonable possibility of a benefit, which is not soley defined in terms of survival.

Early hemodynamic assessment and treatment of elderly patients in the medical ICU

BACKGROUND AND OBJECTIVES

The aim of this retrospective study was to analyze differences in the initial hemodynamic assessment and its impact on the treatment in patients aged 80 years or older compared to younger patients during the first 6 h after admission to the medical intensive care unit (ICU).

RESULTS

We analyzed 615 consecutive patients admitted to the medical ICU of which 124 (20%) were aged 80 years or more. The older group had a significantly higher acute physiology and chronic health evaluation (APACHE II) score, an overall mortality in the ICU and a presence of pre-existing cardiac disease. Both groups did not differ in the presence of shock and shock types on admission. In 57% of older and in 56% of younger patients, transthoracic echocardiography was performed with a higher therapeutic impact in the older patients. Transesophageal echocardiography was performed in 3% of the patients in both groups for specific diagnostic problems. Early reassessment with transthoracic echocardiography was necessary in 5% of the older and in 6% of the younger patients and resulted in a change of the treatment in one third of the patients. Continuous invasive hemodynamic monitoring was used in 11% of the older and in 10% of the younger patients and resulted in a therapeutic change in 71% of the older and in 64% of the younger patients.

CONCLUSION

Patients aged 80 years or older represent 20% of all admissions to the medical ICU. Once admitted the older patients were similarly hemodynamically assessed as the younger ones with a similar impact on the treatment.

Clinical characteristics and outcome of very elderly patients ≥90 years in intensive care: a retrospective observational study

Background

Since the overall prognosis of very elderly patients is generally limited, admissions to intensive care in these patients are often restricted. Therefore, only very few information is available on the prognosis of nonagenarians after intensive care treatment. The aim of this study was to analyze the clinical characteristics and outcomes of very elderly patients (≥90 years) admitted to an intensive care unit (ICU).

Methods

Monocentric, retrospective observational study of all patients aged ≥90 years admitted to the Department of Intensive Care Medicine with a total capacity of 132 ICU beds at the University Medical Center Hamburg in Germany between January 2008 and June 2013. A multivariate Cox regression analysis was used to identify risk factors for 28-day outcome.

Results

A total of 372 patients ≥90 years of age were admitted to one of the departments ICUs. The majority of patients (66.7 %) were admitted as an emergency admission, of which half underwent unscheduled surgery. 39.8 % of patients required support by mechanical ventilation and vasoactive drugs, and 1.9 % of patients received renal replacement. ICU and hospital mortality rates were 18.3 and 30.9 %, respectively. Overall survival at 1 year after hospital discharge was 34.9 %. Multivariate Cox regression analysis revealed creatinine, bilirubin, age, and necessity of catecholamines as independent risk factors and scheduled surgery as protective factor for 28-day outcome.

Conclusion

Nearly 70 % of patients aged ≥90 years were discharged alive from hospital following treatment at the ICU, and more than half of them were still alive 1 year after their discharge. The results suggest that 1-year survival prognosis of very old ICU patients is not as poor as often perceived and that age per se should not be an exclusion criterion for ICU admission.

Trial registration: WF-0561/13

What is the importance of age on treatment of the elderly in the intensive care unit?

BACKGROUND

By 2050, the percentage of the population older than 80 years will double, and some data suggest that elderly patients receive less advanced treatment. Information of outcome in elderly (≥ 65 year), representing roughly half the intensive care unit (ICU) admissions, in Sweden is scarce.

METHODS

Retrospective cohort study. We included all critically ill patients aged 65 or older (n = 605), admitted to the ICU during the years 2010-2011. Patients were categorized into two age groups: 65-79 (64%) and above 80 (36%). Demographic and epidemiology data were registered, as well as primary diagnosis, Simplified Acute Physiology Score III (SAPS III) mortality (ICU and hospital), withhold/withdraw life-sustaining treatment, the ICU workload, length of stay (ICU and hospital) and discharge location.

RESULTS

Hospital mortality was significantly higher in patients above 80 years compared with patients 65-79 years of age (33.7% vs. 22.8%). These patients received less treatment and obtained more limitations in care (withhold/withdraw life-sustaining treatments). Patients above 80 years received less invasive ventilatory support (28.3% vs. 37.8%) and shorter length of invasive ventilatory support (1.1 ± 3.9 vs. 2.9 ± 7.4) compared with patients aged 65-79. In multivariate analysis, patients ≥ 80 years received less mechanical ventilation and more limitations in care even after adjustment for SAPS III and comorbidity.

CONCLUSIONS

Patients above 80 years received less treatment and obtained more limitations in life-sustaining treatments compared with patients aged 65-79, even after adjustment for severity of illness and comorbidity.

[Medical geriatric aspects in intensive care therapy of elderly patients]

For elderly patients specific medical problems, such as the consequences of aging organs, comorbidities or geriatric syndromes must be considered in the intensive care treatment of acute diseases. Under these circumstances special instruments for geriatric assessment are particularly useful. Up to now geriatrics and intensive care medicine have made complementary contributions in the treatment of severely ill elderly patients. A closer interdisciplinary cooperation of the two disciplines could be of substantial beneficial value in the care of the sick and elderly to overcome the many open questions and pressing problems.

[Geriatric patients in intensive care medicine. Ethical aspects]

Due to demographic change and progress in medicine, the percentage of geriatric patients treated in intensive care is continuously increasing. In addition to the acute disease, many of these patients may also have chronic illnesses, multimorbidity, and cognitive limitations. In view of these conditions, it might become questionable whether intensive care treatment is medically and economically justifiable and really in the interest of the patient. From an ethical perspective, age might indeed be a factor to consider when making a decision about initiating or continuing intensive care treatment in an individual case. The denial of access to intensive care, however, cannot be justified by the advanced age of the patient alone. This would display an ethically problematic form of discrimination (ageism).

Does gender impact intensity of care provided to older medical intensive care unit patients?

Introduction. Women receive less aggressive critical care than men based on prior studies. No documented studies evaluate whether men and women are treated equally in the medical intensive care unit (MICU). The Therapeutic Intervention Scoring System-28 (TISS-28) has been used to examine gender differences in mixed ICU studies. However, it has not been used to evaluate equivalence of care in older MICU patients. We hypothesize that given nonsignificant, baseline health differences between genders at MICU admission, the level of care provided would be equivalent. Methods. Prospective cohort of 309 patients ≥60 years old in the MICU of an urban university teaching hospital. Explanatory variables were demographic data and baseline measures. Primary outcomes were TISS-28 scores and MICU interventions. We compare TISS-28 scores by gender using a statistical test of equivalence. Results. Women were older and had more chronic respiratory failure at MICU admission. Using equivalence limits of ±15% on gender-based scores of TISS-28, MICU interventions were equivalent. Supplementary analysis showed no statistically significant association between gender and mortality. Conclusions. In contrast with other reports from the cardiac critical care literature, as measured by the TISS-28, gender-based care delivered to older MICU patients in this cohort was equivalent.

[Specific aspects in septic patients: initial phase in the emergency department, age, sex and post-ICU-care]

This article deals with specific aspects of the patient with sepsis and his treatment. With adequate therapy (antibiotics started within the first hour, early goal-directed therapy) initiated as early as possible, the patient with community-aquired severe sepsis in the emergency department has a considerable better chance to survive than the patient with prolonged severe sepsis in the ICU. The average age of patients with severe sepsis and septic shock treated at the ICU is rising, with consequences like oligosymptomatic presentation, altered pharmakokinetics according to older-age-induced reduced organ functions and prolonged stay at the ICU due to comorbidity. Due to sexual dimorphisms of the immune system, women have a better prognosis in sepsis than men. In an animal sepsis model activation of the estrogen receptor beta improves prognosis. Within six months after having survived severe sepsis, morbidity and mortality is still increased. Taking care for the patient in a post-ICU outpatient department during this time will help to recognize these problems and to effectively treat the patient as soon as possible.