Age bias in clinical trials in sepsis: how relevant are guidelines to older people?

Sepsis and Other Infectious Disease Emergencies in the Elderly

Waning immunity and declining anatomic and physiologic defenses render the elder vulnerable to a wide range of infectious diseases. Clinical presentations are often atypical and muted, favoring global changes in mental status and function over febrile responses or localizing symptoms. This review encompasses early recognition, evaluation, and appropriate management of these common infections specifically in the context of elders presenting to the emergency department. With enhanced understanding and appreciation of the unique aspects of infections in the elderly, emergency physicians can play an integral part in reducing the morbidity and mortality associated with these often debilitating and life-threatening diseases.

Outcomes of Older Adults With Sepsis at Admission to an Intensive Care Unit

Background. Sepsis is a major cause of morbidity and mortality among older adults. The main goals of this study were to assess the association of sepsis at intensive care unit (ICU) admission with mortality and to identify predictors associated with increased mortality in older adults.

Methods. We conducted a prospective cohort study of 309 participants ≥60 years admitted to an ICU. Sepsis was defined as 2 of 4 systemic inflammatory response syndrome criteria plus a documented infection within 2 calendar days before or after admission. The main outcome measure was time to death within 1 year of ICU admission. Sepsis was evaluated as a predictor for mortality in a Cox proportional hazards model.

Results. Of 309 participants, 196 (63%) met the definition of sepsis. Among those admitted with and without sepsis, 75 (38%) vs 20 (18%) died within 1 month of ICU admission (P < .001) and 117 (60%) vs 48 (42%) died within 1 year (P < .001). When adjusting for baseline characteristics, sepsis had a significant impact on mortality (hazard ratio [HR] = 1.80; 95% confidence interval [CI], 1.28–2.52; P < .001); however, after adjusting for baseline characteristics and process covariates (antimicrobials and vasopressor use within 48 hours of admission), the impact of sepsis on mortality became nonsignificant (HR = 1.26; 95% CI, .87–1.84; P = .22).

Conclusions. The diagnosis of sepsis in older adults upon ICU admission was associated with an increase in mortality compared with those admitted without sepsis. After controlling for early use of antimicrobials and vasopressors for treatment, the association of sepsis with mortality was reduced.

Impact of older age and nursing home residence on clinical outcomes of US emergency department visits for severe sepsis

PURPOSE

The purpose of this study is to compare the impact of older age and nursing home residence on the incidence and morbidity of severe sepsis.

MATERIALS AND METHODS

This was a retrospective analysis of 19460 emergency department visits from the 2005 to 2009 National Ambulatory Medical Care Surveys with diagnosis of infection with or without severe sepsis (acute organ dysfunction). Clinical outcomes included intensive care unit (ICU) admission, hospital length of stay (LOS), and in-hospital mortality.

RESULTS

Older adults (age≥65 years) were 5-fold more likely to have infections classified as severe sepsis than younger adults (6.5% vs 1.3%), and nursing home residents were 7-fold more likely to have a severe sepsis diagnosis compared with nonnursing home residents (14% vs 1.9%). Among visits for severe sepsis, older adults, compared with younger adults, had modestly higher rates of ICU admission (27% vs 21%), hospital LOS (median, 6 vs 5 days), and in-hospital mortality (24% vs 16%). Nursing home residents with severe sepsis, compared with nonnursing home residents, had significantly higher rates of ICU admission (40% vs 21%), hospital LOS (median, 7 vs 5 days), and in-hospital mortality (37% vs 15%).

CONCLUSIONS

Older adults and particularly nursing home residents have a disproportionately high incidence of and morbidity from severe sepsis.