OUTCOME ASSESSMENT IN ELDERLY PATIENTS WITH CRITICAL ILLNESS AND RESPIRATORY FAILURE

Trends in hospital and intensive care admissions in the Netherlands attributable to the very elderly in an ageing population

Introduction

The Dutch population is ageing and it is unknown how this is affecting trends in the percentage of hospital and intensive care unit (ICU) admissions attributable to patients aged 80 years or older, the very elderly.

Methods

We present data on the percentage of the very elderly in the general population and the percentage of hospital admissions attributable to the very elderly. We subsequently performed a longitudinal cross-sectional study on ICU admissions from hospitals participating in the National Intensive Care Evaluation registry for the period 2005 to 2014. We modeled the percentage of adult ICU admissions and treatment days attributable to the very elderly separately for ICU admissions following cardiac surgery and other reasons.

Results

The percentage of Dutch adults aged 80 years and older, increased from 4.5 % in 2005 to 5.4 % in 2014 (p-value < 0.0001) and with this ageing of the population, the percentage of hospital admissions attributable to very elderly increased from 9.0 % in 2005 to 10.6 % in 2014 (p-value < 0.0001). The percentage of ICU admissions following cardiac surgery attributable to the very elderly increased from 6.7 % in 2005 to 11.0 % in 2014 in nine hospitals (p-value < 0.0001), while the percentage of treatment days attributable to this group rose from 8.6 % in 2005 to 11.7 % in 2014 (p-value = 0.0157). In contrast, the percentage of very elderly patients admitted to the ICU for other reasons than following cardiac surgery remained stable at 13.8 % between 2005 and 2014 in 33 hospitals (p-value = 0.1315). The number of treatment days attributable to the very elderly rose from 11,810 in 2005 to 15,234 in 2014 (p-value = 0.0002), but the percentage of ICU treatment days attributable to this group remained stable at 12.0 % (p-value = 0.1429).

Conclusions

As in many European countries the Dutch population is ageing and the percentage of hospital admissions attributable to the very elderly rose between 2005 and 2014. However, the percentage of ICU admissions and treatment days attributable to very elderly remained stable. The percentage of ICU admissions following cardiac surgery attributable to this group increased between 2005 and 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1061-z) contains supplementary material, which is available to authorized users.

Unique Aspects of the Elderly Surgical Population: An Anesthesiologist's Perspective

Increasing life expectancies paired with age-related comorbidities have resulted in the continued growth of the elderly surgical population. In this group, age-associated changes and decreased physiological reserve impede the body's ability to maintain homeostasis during times of physiological stress, with a subsequent decrease in physiological reserve. This can lead to age-related physiological and cognitive dysfunction resulting in perioperative complications. Changes in the cardiovascular, pulmonary, nervous, hepatorenal, endocrine, skin, and soft tissue systems are discussed as they are connected to the perioperative experience. Alterations affect both the pharmacodynamics and pharmacokinetics of administered drugs. Elderly patients with coexisting diseases are at a greater risk for polypharmacy that can further complicate anesthetic management. Consequently, the importance of conducting a focused preoperative evaluation and identifying potential risk factors is strongly emphasized. Efforts to maintain intraoperative normothermia have been shown to be of great importance. Procedures to maintain stable body temperature throughout the perioperative period are presented. The choice of anesthetic technique, in regard to a regional versus general anesthetic approach, is debated widely in the literature. The type of anesthesia to be administered should be assessed on a case-by-case basis, with special consideration given to the health status of the patient, the type of operation being conducted, and the expertise of the anesthesiologist. Specifically addressed in this article are age-related cognitive issues such as postoperative cognitive dysfunction and postoperative delirium. Strategies are suggested for avoiding these pitfalls.

Trauma in the elderly: considerations for anesthetic management

The volume of geriatric trauma patients is expected to increase significantly in coming years. Recognition of severe injuries may be delayed because they are less likely to mount classic symptoms of hemodynamic instability. Head injuries of any severity may place geriatric patients at increased risk of mortality, but there are currently no geriatric-specific treatment recommendations that differ from usual adult guidelines. Our understanding of best practices in geriatric trauma and anesthesia care continues to expand, as it does in all other areas of medicine.

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

OBJECTIVE

In view of ethical considerations and the limited resources in intensive care medicine, the present investigation aims to give a descriptive overview of the prognosis and therapeutic activity for the oldest age group of elderly patients admitted to an intensive care unit (ICU) in comparison with younger ICU patients.

PATIENTS AND METHODS

3069 patients admitted to the ICU during a seven-year period were categorized into four age groups: under 65 years (48%), 65 to 74 years (26%), 75 to 85 years (22%) and 85 years or older (5%). Type and reason for ICU admission, length of ICU stay, severity of illness as measured by the simplified acute physiology score (SAPS)-II, level of provided care as measured by the simplified therapeutic intervention scoring system (TISS)-28, and vital status at the date of ICU discharge were recorded.

RESULTS

The ICU mortality rate of patients aged 85 years or older was significantly higher than in patients under 65 (OR of mortality: 1.8, p < 0.001). Non-survivors had higher SAPS II levels (even when excluding age points) in all age groups, but higher daily average TISS points only in patients under 85. The daily average TISS score was negatively correlated to age (r = -0.03; p < 0.001) and was significantly lower in the oldest group when compared with all the younger groups (p < 0.001). The oldest patients had a significantly shorter length of stay (median: 2; interquartile range [IQR] 1-3, p < 0.001) than the younger patient groups.

CONCLUSIONS

Within the very elderly population, age is an important and independent predictor of mortality, but acute severity of illness is even more strongly associated with mortality. Consequently, age alone may be an inappropriate criterion for allocation of ICU resources.

Critically ill old and the oldest-old patients in intensive care: short- and long-term outcomes

OBJECTIVE

The purpose of this study was to examine characteristics and outcome of the old, very old and oldest-old ICU patients DESIGN. This is a cohort study.

SETTING

The study was set in a ten-bed medical ICU in a university hospital. PARTICIPANTS. There were 410 patients classified in three subgroups: old, 75-79 years ( n=184; 44.4%), very old, 80-84 ( n=137, 33.4%) and the oldest-old, >or=85 ( n=91; 22.2%).

MEASUREMENTS

Underlying medical conditions, organ dysfunction, severity of illness, length of stay, use of mechanical ventilation, therapeutic activity and nosocomial infections were recorded. Multivariate analysis was conducted to identify risk factors for ICU and long-term mortality.

RESULTS

Characteristics at ICU admission did not differ among the three groups. ICU length of stay, therapeutic activity, mechanical ventilation and nosocomial infection(s) decreased with age. ICU survival rates for those below 75, 75-79, 80-84 and over 85 years were 80, 68, 75 and 69%, respectively; survival rates at 3 months were 54, 56 and 51%, respectively. APACHE II score [odds ratio (OR): 1.11] was identified as the only factor associated with ICU mortality, and age (OR: 2.17, for patients >or=85 years old and 1.82, for patients 80-84 years old) and limitation of activity before admission (OR: 1.74) as factors associated with long-term mortality.

CONCLUSION

In a population of patients >or=75 years old, very old age is not directly associated with ICU mortality. After ICU discharge, deaths occurred predominantly during the first 3 months: age and prior limitation of activity were associated with the risk of dying.

[Mortality and quality of life of patients beyond 65 years one year after ICU discharge]

BACKGROUND

Intensive care in elderly patients is a subject of controversy, because they generally present a high rate of mortality and short expectation of life. Due to the increasing life expectancy, more elderly patients will be treated in Intensive Care Unit (ICU) with an increasing consume of resources. The present study considers the mortality and quality of life (QOL) of patients beyond 65 years after ICU, and theirs predictors.

PATIENTS AND METHOD

Retrospective study of patients >= 65 years admitted in multidisciplinaire ICU. Mortality and QOL (with modified EuroQOL Instrument) one year after discharge were studied. To determine mortality and QOL one year independent predicting factors, multiple logistic regression models were used.

RESULTS

Of 313 patients studied, 95 (30%) died in ICU, 32 (10%) in hospital and 34 (11%) died after discharge. The independent predicting factors of mortality one year after ICU discharge were: organ failure (p < 0.000; odds ratio [OR], 2.9), cardiac surgery (p < 0.0000; OR, 0.15) and respiratory disease (p < 0.01; OR, 2.8). Of the 152 surviving patients, 21% got worse their previous QOL and only 17% were severely discapitated. The independent predicting factors of QOL one year after ICU discharge were: prior QOL (p < 0.0002; OR, 10.2) and age (p < 0.002; OR, 0.09).

CONCLUSION

Despite the high one year after ICU discharge mortality rate (51%), 83% of the survivors were able to live independently. Due to dependence between mortality and multiorganic failure during ICU stay and not age, this latter cannot be the determining factor of the care level.

Outcomes of critically ill elderly patients: is high-dependency care for geriatric patients worthwhile?

OBJECTIVES

To study the outcomes of elderly patients in a high-dependency care unit and to evaluate the costs and benefits of a geriatric high-dependency unit (GHDU).

DESIGN

Prospective data collection and analysis.

SETTING

Geriatric high-dependency unit.

PATIENTS

One hundred fifty patients > or =70 yrs of age who had been admitted to the GHDU over a 10-month period were investigated during their treatment and rehabilitation.

MEASUREMENT AND MAIN RESULTS

The patients' Acute Physiology and Chronic Health Evaluation (APACHE) II scores and Simplified Acute Physiology Scores (SAPS) were recorded. The APACHE II scores and SAPSs provided a close correlation with the patients' mortality (correlation coefficients were 0.97 and 0.92, respectively). The SAPS proved to have a better linear relationship with the elderly patients' mortality in comparison with APACHE II scores. Most of the elderly patients included in the study were suffering from multiple premorbid medical problems. Overall, the mortality rate up to 1 month after discharge from the hospital was 48%. For patients ranging in age from 70 to 84 yrs, the 1-month mortality was 39.6%; however, for patients > or =85 yrs of age, the 1-month mortality was 68.1%. The mortality ratio was 0.96 (for all patients), 0.88 (for those ages 70-84 yrs), and 1.05 (for those age 85 yrs and above). For patients with nil organ system failure, the mortality rate was 32%. For patients with one organ system failure, the mortality increased to 48%. For patients with two organ system failures, the mortality rate was 86%. Survival for patients with three or more organ system failures was unprecedented. Survivors and nonsurvivors were compared. Three poor-prognosis groups were identified: group 1, patients who had received preadmission cardiopulmonary resuscitation; group 2, patients with a recent history of malignant diseases; and group 3, patients who had been mechanically ventilated. All three groups had a significantly higher mortality than those without these factors (p<.05). Patients in the 85 yrs and above group had a significantly higher mortality rate than those in the 70- to 84-yr age group (p<.05). Patients with SAPS and APACHE II scores >20 and >30, respectively, had a poor prognosis. The geriatric outcome scoring system (GOSS) was used as the functional outcome test for the survivors. The GOSS has three components: activities of daily living, mobility status, and social condition. At 1 month after discharge, 66.7% of the survivors returned to their premorbid activities of daily living abilities, 79.5% maintained their mobility status, and 91.7% remained at the same social environment. No survivors deteriorated more than one grade in any of the three components measured by the GOSS. The severity-of-illness scores, percentage of mechanical ventilation utilization, mortality rate, length of GHDU stay, and total hospital stay were comparable with those of other intensive care units (ICUs). The cost of 1 GHDU bed-day was equivalent to 24% of 1 ICU bed-day.

CONCLUSION

The prognostic information that we gathered from an unselected group of critically ill elderly patients is useful. The GHDU achieved treatment results similar to those achieved by an ICU and is therefore seen as an innovative way of treating critically ill elderly patients. High-dependency care for the elderly patient is worthwhile.

Limitation of therapeutic activity in elderly critically ill patients. Project for the Epidemiological Analysis of Critical Care Patients

OBJECTIVE

To establish whether the age of patients admitted into the intensive care unit (ICU) influences the amount of therapy received.

DESIGN

Observational, prospective, multicenter study.

SETTING

Eighty-six multidisciplinary ICUs in Spain, including coronary patients.

PATIENTS

The patients (n = 8,838) were studied during a 6-month period between 1992 and 1993. Patients < 16 yrs of age and patients dying within the first 6 hrs were excluded from the study.

MEASUREMENTS AND MAIN RESULTS

We collected data on age, gender, type of diagnosis at the time of admission, severity level by Acute Physiology and Chronic Health Evaluation (APACHE) II and III, quality of life survey score, therapeutic activity during the first 24 hrs by Therapeutic Intervention Scoring System, and ICU and hospital mortality rates. In the sample of patients, 12.5% were > 75 yrs of age. Compared with younger patients, these patients had higher APACHE II (18.41 +/- 0.23 vs. 15.14 +/- 0.09 points, p < .001) and APACHE III (65.8 +/- 0.81 vs. 53.32 +/- 0.33 points, p < .001) scores, a higher quality of life survey score (i.e., worse quality of life, 7.19 +/- 0.19 vs. 3.86 +/- 0.05 points, p < .001), and a greater ICU mortality rate (21.9% vs. 15.3%, p < .00001) and hospital mortality rate (30.8% vs. 19.3%, p < .00001). However, patients > 75 yrs had a lower Therapeutic Intervention Scoring System score (19.83 +/- 0.28 vs. 21.17 +/- 0.12 points, p < .001). Multivariate analysis showed that once severity, need for mechanical ventilation, diagnostic group, and mortality rate were taken into account, there was less therapeutic activity in patients > 75 yrs of age.

CONCLUSIONS

Patients > 75 yrs of age represent a large proportion of patients in Spanish ICUs. Although their mortality rate and severity scores were higher than those values in younger patients, patients > 75 yrs of age received less therapy.

Energy Needs Are Poorly Predicted in Critically Ill Elderly

Changes in energy expenditure with age have been described, but this physiology is not routinely considered when managing critically ill elderly patients. To allow us to avoid the potential problems associated with underfeeding or overfeeding the critically ill elderly population, with approval of the human studies committee and appropriate consent from legal guardians, 25 critically ill patients over 65 years of age requiring mechanical ventilation underwent expired gas indirect calorimetry. If they had a pulmonary artery catheter in place for clinical reasons, reverse-Fick indirect calorimetry was also performed. Data obtained by indirect calorimetry was compared with commonly applied equations for predicting energy expenditure by statistical methods of correlation and limits of agreement. These 25 patients had an average age of 74 ± 1.23 (standard error of the mean) and an average APACHE II score of 15. Predictive equations correlated poorly with measured resting energy expenditure, and although they showed reasonable bias, they were imprecise in their estimation of resting energy expenditure. These data suggest that energy expenditure in critically ill, mechanically ventilated elderly patients is highly variable. Although generally overestimating energy needs, currently available equations for predicting energy expenditure in this population are associated with significant bias and imprecision, which may lead to both overfeeding and underfeeding. Although these equations may be suitable as a basis of initiating nutritional support, energy provisions should ideally be guided by indirect calorimetry.

Aging and the respiratory system

All the components of the respiratory system are affected by aging, though at different rates: i) the lung elastic recoil decreases; ii) PaO2 decreases and the D(A-a)O2 increases; iii) the chest wall becomes stiffer; iv) the inspiratory muscles loose strength; and v) the respiratory centres are less sensitive. Residual volume, closing volume and function residual capacity increase, whereas vital capacity and FEV1 progressively decrease. The flow volume curve becomes more convex to the volume axis at low lung volume. Whether these changes are due to aging or associated with aging is a matter of debate. However, the aging lung is more fragile in the face of respiratory and systemic diseases than the respiratory system of young adults. Nutrition, smoking habits and sleep-related disorders also affect the respiratory system. Although bronchial asthma may also appear in the elderly, chronic obstructive pulmonary disease is one of the most common respiratory diseases in advanced life and is a major cause of respiratory failure and ICU admission. Age in itself is not a risk factor of respiratory failure, but elderly patients have an increased risk of mortality for both acute respiratory failure (the failing lung), and exacerbated chronic ventilatory failure (the failing pump). Although advanced age can influence the final outcome of elderly patients from the intensive care unit (ICU), admission to the ICU as well as the institution of mechanical ventilation should not be denied on the basis of age alone, since the severity of illness, prior health status and admitting diagnosis have more weight than age in the final outcome.

Resuscitation of the geriatric patient

The elderly represent the fastest-growing segment of the population. As the country ages, the number of elderly patients who present in extremis will undoubtedly increase. Emergency physicians must be cognizant of the fact that age alone is a poor predictor of outcome in the critically ill elderly patient. Premorbid status, including previous level of functioning and pre-existing disease, is more important than chronologic age in predicting outcome, guiding assessment, and deciding on therapy. Knowledge and consideration of the geriatric ABCs includes a fundamental understanding that loss of protective airway reflexes, occult respiratory insufficiency, and clinically unrecognized shock are especially prevalent in the sickest geriatric patients. Early recognition and treatment can minimize morbidity and mortality rates in the ED.