Changes in health-related quality of life and factors predicting long-term outcomes in older adults admitted to intensive care units*:

A scoping review of older patients' health-related quality of life, recovery and well-being after intensive care

AIMS

In the present study, we aimed to determine how Health-Related Quality of Life (HRQoL), recovery (function and capacity in daily life) and well-being are followed up and characterised in persons ≥65 years of age who were being cared for in an intensive care unit (ICU).

DESIGN

A scoping review.

METHODS

CINAHL, MEDLINE (Ovid) and PsycINFO databases were searched in October 2021. 20 studies met the inclusion criteria. The scoping review followed the principles outlined by Arksey and O'Malley, and the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) checklist and Joanna Briggs Institute (JBI) framework were used.

RESULTS

Results are presented under five subheadings: Study characteristics, Type of studies, Methods for follow-up, health-related quality of life, and Recovery. Time seems to be an important factor regarding HRQoL among older patients being cared for in an ICU, with most elderly survivors perceiving their HRQoL as acceptable after 1 year. Nevertheless, several studies showed patients' willingness to be readmitted to the ICU if necessary, indicating that life is worth fighting for.

PATIENT OR PUBLIC CONTRIBUTION

Due to the design of the study, this study involves no patient or public contribution.

Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data

Introduction

In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, and is rarely included in EHRs.

Objectives

The aim of the study was to describe the prevalence and trend of NDs in a hospital surgical setting by also analyzing the relationship between NDs and hospital outcomes.

Methods

A retrospective study was conducted. All adult inpatients consecutively admitted to one of the 15 surgical inpatient units of an Italian university hospital across 1 year were included. Data, including the Professional Assessment Instrument and the Hospital Discharge Register, were collected retrospectively from the hospital's EHRs.

Results

The sample included 5,027 surgical inpatients. There was a mean of 6.3 ± 4.3 NDs per patient. The average distribution of NDs showed a stable trend throughout the year. The most representative NANDA-I ND domain was safety/protection. The total number of NDs on admission was significantly higher for patient whose length of stay was longer. A statistically significant correlation was observed between the number of NDs on admission and the number of intra-hospital patient transfers. Additionally, the mean number of NDs on admission was higher for patients who were later transferred to an intensive care unit compared to those who were not transferred.

Conclusion

NDs represent the key to understanding the contribution of nurses in the surgical setting. NDs collected upon admission can represent a prognostic factor related to the hospital's key outcomes.

Impact on 6-month outcomes of hospital trajectory in critically ill older patients: analysis of the ICE-CUB2 clinical trial

Background

Little is known about the impact of hospital trajectory on survival and functional decline of older critically ill patients. We evaluate 6-month outcomes after admission to: intensive care units (ICU), intermediate care units (IMCU) or acute medical wards (AMW).

Methods

Data from the randomised prospective multicentre clinical trial ICE-CUB2 was secondarily analysed. Inclusion criteria were: presenting at emergency departments in critical condition; age ≥ 75 years; activity of daily living (ADL) ≥ 4; preserved nutritional status; and no active cancer. A Cox model was fitted to compare survival according to admission destination adjusting for patient characteristics. Sensitivity analysis using multiple imputation for missing data and propensity score matching were performed.

Results

Among 3036 patients, 1675 (55%) were women; median age was 85 [81–99] years; simplified acute physiology score (SAPS-3) 62 [55–69]; 1448 (47%) were hospitalised in an ICU, 504 in IMCU (17%), and 1084 (36%) in AMW. Six-month mortality was 629 (44%), 155 (31%) and 489 (45%) after admission in an ICU, IMCU and AMW (p < 0.001), respectively. In multivariate analysis, AMW admission was associated with worse 6-month survival (HR 1.31, 95% CI 1.04–1.63) in comparison with IMCU admission, after adjusting for age, gender, comorbidities, ADL, SAPS-3 and diagnosis. Survival was not significantly different between patients admitted in an ICU and an IMCU (HR 1.17, 95% CI 0.95–1.46). Sensitivity analysis using multiple imputation for missing data and propensity score matching found similar results. Hospital destination was not significantly associated with the composite criterion loss of 1-point ADL or mortality. Physical and mental components of the 12-Item Short-Form Health Survey were significantly lower in the acute medical ward group (34.3 [27.5–41.7], p = 0.037 and 44.3 [38.6–48.6], p = 0.028, respectively) than in the ICU group (34.7 [28.4–45.3] and 45.5 [40.0–50.0], respectively) and IMCU group (35.7 [29.7–43.8] and 44.5 [39.7–48.4], respectively).

Conclusions

Admission in an AMW was associated with worse 6-month survival in older critically ill patients in comparison with IMCU admission, with no difference of survival between ICU and IMCU admission. There were no clinically relevant differences in quality of life in each group. These results should be confirmed in specific studies and raise the question of dedicated geriatric IMCUs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01042-4.

Prognosis of Very Elderly Patients after Intensive Care

Elderly patients (over age 85) are increasingly treated in Intensive Care Units (ICU), despite doctors’ reluctance to accept these frail patients. There are only few studies describing the relevance of treatments for this group of patients in ICU. One of these studies defined an age of 85 or over as the essential admittance criterion. Exclusion criteriwere low autonomy before admittance or an inability to answer the phone. Epidemiological data, history, lifestyle, and autonomy (ADL score of six items) were recorded during admission to the ICU and by phone interviews six months later. Eight French ICUs included 239 patients aged over 85. The most common diagnostics were non-cardiogenic lung disease (36%), severe sepsis/septic shock (29%), and acute pulmonary oedem (28%). Twenty-three percent of patients were dependent at the time of their admission. Seventy-one percent of patients were still alive when released from ICU, and 52% were still alive after 6 months. Among the patients which were non-dependent before hospitalization, 17% became dependent. The only prognostic criterifound were the SAPS II score on admission and the place of residence before admission (nursing home or family environment had poor prognosis). Although the prognosis of these elderly patients was good after hospitalization in ICU, it should be noted that the population was carefully selected as having few comorbidities or dependence. No triage critericould be suggested.

Longitudinal validation of an electronic health record delirium prediction model applied at admission in COVID-19 patients

OBJECTIVE

To validate a previously published machine learning model of delirium risk in hospitalized patients with coronavirus disease 2019 (COVID-19).

METHOD

Using data from six hospitals across two academic medical networks covering care occurring after initial model development, we calculated the predicted risk of delirium using a previously developed risk model applied to diagnostic, medication, laboratory, and other clinical features available in the electronic health record (EHR) at time of hospital admission. We evaluated the accuracy of these predictions against subsequent delirium diagnoses during that admission.

RESULTS

Of the 5102 patients in this cohort, 716 (14%) developed delirium. The model's risk predictions produced a c-index of 0.75 (95% CI, 0.73-0.77) with 27.7% of cases occurring in the top decile of predicted risk scores. Model calibration was diminished compared to the initial COVID-19 wave.

CONCLUSION

This EHR delirium risk prediction model, developed during the initial surge of COVID-19 patients, produced consistent discrimination over subsequent larger waves; however, with changing cohort composition and delirium occurrence rates, model calibration decreased. These results underscore the importance of calibration, and the challenge of developing risk models for clinical contexts where standard of care and clinical populations may shift.

Lean mass as a risk factor for intensive care unit admission: an observational study

PURPOSE

Intensive care unit (ICU) survivors have reduced physical function likely due to skeletal muscle wasting and weakness acquired during critical illness. However, the contribution of pre-morbid muscle mass has not been elucidated. We aimed to examine the association between pre-ICU muscle mass and ICU admission risk. Secondary outcomes include the relationship between muscle mass and ICU outcomes.

METHODS

ICU admissions between June 1, 1998, and February 1, 2019, were identified among participants of Geelong Osteoporosis Study (GOS), a population-based cohort study. Cox proportional hazard regression models estimated hazard ratios (HR) for ICU admission across T-score strata and continuous values of DXA-derived lean mass measures of skeletal mass index (SMI, lean mass/body mass %) and appendicular lean mass corrected for height (ALM/h2, kg/m2). Multivariable regression was used to determine the relationship between lean mass and ICU outcomes.

RESULTS

One hundred and eighty-six of 3126 participants enrolled in GOS were admitted to the ICU during the follow-up period. In adjusted models, lean mass was not predictive of ICU admission (SMI: HR 0.99 95%CI 0.97-1.01, p = 0.32; ALM/h2: HR 1.11 95%CI 0.94-1.31, p = 0.23), while greater appendicular lean mass was related to reduced 28-day mortality (ALM/h2 adjOR: 0.25, 95%CI 0.10-0.63, p = 0.003, SMI adjOR: 0.91, 95%CI 0.82-1.02, p = 0.09).

CONCLUSION

Lean mass was not associated with ICU admission in this population-based cohort study; however, greater appendicular lean mass was associated with reduced mortality. This suggests pre-ICU muscle status may not predict development of critical illness but is associated with better survival after critical illness occurs.

[Early Pulmonary Rehabilitation after Long Term Mechanical Ventilation]

Einleitung  Unter Frührehabilitation versteht man eine frühzeitig bei- oder nach akuter Erkrankung einsetzende, rehabilitationsmedizinische Behandlung die im § 39SGB V verankert ist. Ziel dieser Untersuchung ist es, die Ergebnisqualität der pneumologischen Frührehabilitation zu untersuchen und darzustellen.

Methoden  Prospektive Erhebung von funktionellen Parametern, Beatmungsstatus und Entlass-Disposition in einer spezialisierten Abteilung für pneumologische Frührehabilitation über den Zeitraum von einem Jahr.

Ergebnisse  Von den 190 Patienten waren 179 (94,2 %) zuvor invasiv beatmet. Während einer Behandlungsdauer von 39 ± 17 Tagen stieg der FAM-Index von 84,4 ± 19,8 auf 118,5 ± 23,3 (Ci 30,9 – 37,3, Cohen’s d 1,58; p < 0,001), der Barthel-Index von 30,5 ± 13,8 auf 58,3 ± 16,2 (Ci 25,4 – 33,8, Cohen’s d 1,4; p < 0,001) und die Wegstrecke von 12,9 ± 40,1 m auf 131,4 ± 85,2 m (Ci 105,6 – 131,4 m, Cohen’s d 1,78; p < 0,001). Die Patienten wurden weniger häufig in eine weitere Anschlussheilbehandlung verlegt, wenn sie beatmet waren.

Diskussion  Patienten in der pneumologischen Frührehabilitation sind bei Aufnahme schwer kompromittiert, es lässt sich aber eine sehr gute Ergebnisqualität erzielen, die unabhängig davon zu sein scheint, ob der Patient eigenständig atmet oder mittels nicht-invasiver oder invasiver Beatmung versorgt wird. Die weitere Disposition dieser Patienten ist vor allem dann schwierig, wenn eine Beatmung vorliegt.

Non-sedation-Does it improve health-related quality of life after critical illness? A 3-month follow-up sub-study of the NONSEDA trial

BACKGROUND

Critical illness is associated with severely impaired health-related quality of life (HRQoL) for years following discharge. The NONSEDA trial was a multicenter randomized trial on non-sedation versus sedation with a daily wake-up trial in critically ill, mechanically ventilated patients in Scandinavia. The aim of this sub-study was to assess the effect of non-sedation on HRQoL and degree of independence in activities in daily living (ADL) 3 months post-ICU.

METHODS

All survivors were asked to complete the Medical Outcomes Study Short-Form 36 questionnaire (SF-36) and the Barthel Index 3 months post-ICU. To limit missing data, reminders were sent. If unsuccessful, telephone interviews could be used. Outcomes were the level of HRQoL and ADL-function in each group. All outcomes were assessed blinded.

RESULTS

Of the 700 patients included 412 survived to follow-up. A total of 344 survivors participated (82%). Baseline data were equal between the two groups. Mean SF-36 scores for the non-sedated vs sedated patients were as follows: Physical Function 45 vs 40, P = .69, Bodily Pain: 61 vs 52, P = .81, General Health: 50 vs 50, P = .84, Vitality: 42 vs 44, P = .85, Social Function: 75 vs 63, P = .85, Role Emotional: 58 vs 50, P = .82, Mental Health: 70 vs 70, P = .89, Role Physical: 25 vs 28, P = .32, Physical Component Score: 38 vs 37, P = .81, Mental Component Score: 48 vs 46, P = .94, Barthel Index: 20 vs 20, P = .74.

CONCLUSION

Randomization to non-sedation neither improved nor impaired health-related quality of life or degree of independence in activities in daily living 3 months post-ICU discharge.

A comparison of standard occupational therapy versus early enhanced occupation-based therapy in a medical/surgical intensive care unit: study protocol for a single site feasibility trial (EFFORT-ICU)

BACKGROUND

Admissions to intensive care units (ICUs) are increasing due to an ageing population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care.

METHODS

This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60-min sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed.

DISCUSSION

This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268 ; prospectively registered on 13 March 2018/ https://www.anzctr.org.au Trial funding: Metro South Health Research Support Scheme Postgraduate Scholarship.

Familism, Self-Esteem, and Weight-Specific Quality of Life Among Latinx Adolescents With Obesity

OBJECTIVE

Obesity is a critical public health condition affecting Latinx adolescents and contributes to health disparities across the lifespan. Childhood and adolescent obesity is associated with reduced quality of life (QoL) and decreased self-esteem. The purpose of this study is to examine the role of cultural (e.g., familism) and psychosocial (e.g., self-esteem) factors as predictors of weight-specific QoL among Latinx adolescents with obesity.

METHODS

Baseline data from 160 Latinx adolescents (ages 14-16 years) with obesity (BMI > 95th percentile for age and sex) who were recruited for a diabetes prevention intervention were used. Structural equation modeling tested the relationships between four latent constructs (familism, positive self-esteem, self-deprecation, and weight-specific QoL).

RESULTS

The model tested paths from familism to positive self-esteem, self-deprecation, and weight-specific QoL, and paths from positive self-esteem and self-deprecation to weight-specific QoL. Higher familism was positively associated with positive self-esteem but not self-deprecation. In turn, positive self-esteem was positively associated with higher weight-specific QoL, whereas self-deprecation was negatively associated. Furthermore, there was an indirect effect of familism on QoL via positive self-esteem.

CONCLUSIONS

These data shed light into specific cultural and psychosocial constructs that influence QoL among Latinx adolescents with obesity. This study suggests that familism and positive self-esteem can operate as protective factors associated with higher weight-specific QoL in Latinx adolescents with obesity; whereas self-deprecation may operate as a risk factor for lower weight-specific QoL.

Stratified delirium risk using prescription medication data in a state-wide cohort

OBJECTIVE

Delirium is a common condition associated with increased morbidity and mortality. Medication side effects are a possible source of modifiable delirium risk and provide an opportunity to improve delirium predictive models. This study characterized the risk for delirium diagnosis by applying a previously validated algorithm for calculating central nervous system adverse effect burden arising from a full medication list.

METHOD

Using a cohort of hospitalized adult (age 18-65) patients from the Massachusetts All-Payers Claims Database, we calculated medication burden following hospital discharge and characterized risk of new coded delirium diagnosis over the following 90 days. We applied the resulting model to a held-out test cohort.

RESULTS

The cohort included 62,180 individuals of whom 1.6% (1019) went on to have a coded delirium diagnosis. In the training cohort (43,527 individuals), the medication burden feature was positively associated with delirium diagnosis (OR = 5.75, 95% CI 4.34-7.63) and this association persisted (aOR = 1.95; 1.31-2.92) after adjusting for demographics, clinical features, prescribed medications, and anticholinergic risk score. In the test cohort, the trained model produced an area under the curve of 0.80 (0.78-0.82). This performance was similar across subgroups of age and gender.

CONCLUSION

Aggregating brain-related medication adverse effects facilitates identification of individuals at high risk of subsequent delirium diagnosis.

Health-related Quality of Life Evaluated by MOS SF-36 in the Elderly Patients 1 Month before ICU Admission and 3 Months after ICU Discharge

Objectives

The aims of this study were to evaluate changes in health-related quality of life (HRQoL) before ICU admission and after ICU discharge in elderly patients and to determine predictors of this HRQoL.

Materials and methods

This prospective study has been realized in the medical ICU (August 2012-March 2013). All patients 65 years of age or older who were hospitalized for ≥48 hours in our medical ICU have been included. The HRQoL was assessed 1 month prior to ICU admission in all the patients at admission and 3 months after ICU discharge for survivors using the Arabic version of MOS SF-36 questionnaire.

Results

We enrolled 118 patients (66 M: 55.9% and 52 F: 44.1%). The mean age was 72 ± 6 years. ICU mortality rate was 47.5% and three-month mortality rate was 55.1%. The reliability and validity of MOS SF-36 were satisfactory. Among the 53 survivors at follow-up, the subscales of MOS SF-36 decreased significantly at 3 months after ICU stay except the “Bodily Pain”. The physical component score (PCS) and mental component score (MCS) decreased also significantly. The independent factors strongly associated with PCS and its variations were: age (β = −1.56, p = 0.001), prior functional status (β = −22.10, p = 0.002) and SAPSII (β = −0.16, p = 0.04). For MCS, these factors were: live alone (β = 16.50, p = 0.006), previous functional status (β = −9.09, p = 0.008) and existence of education level (β = 2.98, p = 0.037).

Conclusion

We demonstrated a fall in the physical and psychical aspects of HRQoL 3 months after ICU discharge in the elderly patients. In addition to factors such as age, prior functional status and severity of illness, family status and educational level seem decisive in the post-ICU HRQoL.

How to cite this article

Zeggwagh Z, Abidi K, Kettani MNZ, Iraqi A, Dendane T, Zeggwagh AA. Health-related Quality of Life Evaluated by MOS SF-36 in the Elderly Patients 1 Month before ICU Admission and 3 Months after ICU Discharge. Indian J Crit Care Med 2020;24(7):531–538.

Demographic Shifts, Case Mix, Activity, and Outcome for Elderly Patients Admitted to Adult General ICUs in England, Wales, and Northern Ireland

OBJECTIVES

Major increases in the proportion of elderly people in the population are predicted worldwide. These population increases, along with improving therapeutic options and more aggressive treatment of elderly patients, will have major impact on the future need for healthcare resources, including critical care. Our objectives were to explore the trends in admissions, resource use, and risk-adjusted hospital mortality for older patients, admitted over a 20-year period between 1997 and 2016 to adult general ICUs in England, Wales, and Northern Ireland.

DESIGN

RETROSPECTIVE ANALYSIS OF NATIONAL CLINICAL AUDIT DATABASE.

SETTING

The Intensive Care National Audit & Research Centre Case Mix Programme Database, the national clinical audit for adult general ICUs in England, Wales, and Northern Ireland.

PATIENTS

All adult patients 16 years old or older admitted to adult general ICUs contributing data to the Case Mix Programme Database between January 1, 1997, and December 31, 2016.

MEASUREMENTS AND MAIN RESULTS

The annual number, trends, and outcomes for patients across four age bands (16-64, 65-74, 75-84, and 85+ yr) admitted to ICUs contributing to the Case Mix Programme Database from 1997 to 2016 were examined. Case mix, activity, and outcome were described in detail for the most recent cohort of patients admitted in 2015-2016. Between 1997 to 2016, the annual number of admissions to ICU of patients in the older age bands increased disproportionately, with increases that could not be explained solely by general U.K. demographic shifts. The risk-adjusted acute hospital mortality decreased significantly within each age band over the 20-year period of the study. Although acute severity at ICU admission was comparable with that of the younger age group, apart from cardiovascular and renal dysfunction, older patients received less organ support. Older patients stayed longer in hospital post-ICU discharge, and hospital mortality increased with age, but the majority of patients surviving to hospital discharge returned home.

CONCLUSIONS

Over the past two decades, elderly patients have been more commonly admitted to ICU than can be explained solely by the demographic shift. Importantly, as with the wider population, outcomes in elderly patients admitted to ICU are improving over time, with most patients returning home.

Concordance in advance care preferences among high-risk surgical patients and surrogate health care decision makers in the perioperative setting

BACKGROUND

Earlier studies have demonstrated poor concordance between patients' advance care preferences and those endorsed by their surrogate health care decision makers in a medical setting. This study aimed to determine concordance in the perioperative setting among high-risk patients and to identify areas for improvement.

METHODS

This was a prospective cohort study set in a preoperative clinic for high-risk patients. Patients (>55 y) and their surrogates (dyads) were eligible for participation. Dyads were surveyed on the patient's desire for advance care preferences (cardiopulmonary resuscitation, mechanical ventilation, hemodialysis, artificial nutrition) and tolerance for physical disability, cognitive disability, and chronic pain. Concordance was defined as the surrogate correctly predicting patient preferences. Patients and surrogates were resurveyed for concordance 30 to 60 d after the index procedure.

RESULTS

A total of 100 dyads (200 subjects) completed the survey. Median patient age was 68 y. Most patients were white (87%) and had an American Society of Anesthesiologists score of III (88%). The majority of dyads (59%) reported prior conversations about advance care preferences. Concordance specifically for cardiopulmonary resuscitation was 84%. In all other domains, <60% of dyads achieved concordance. Prior conversations regarding advance care preferences did not improve concordance in univariable or multivariable analysis. In postoperative surveys, substantial improvement was found in all domains except mechanical ventilation and cardiopulmonary resuscitation.

CONCLUSION

In all domains except cardiopulmonary resuscitation, concordance was <60% in the preoperative setting and was not improved among dyads who reported prior conversations regarding advance care preferences. Discordance may limit patient autonomy by prolonging undesired interventions or terminating desired interventions prematurely.

Caring for the critically ill patients over 80: a narrative review

Background

There is currently no international recommendation for the admission or treatment of the critically ill older patients over 80 years of age in the intensive care unit (ICU), and there is no valid prognostic severity score that includes specific geriatric assessments.

Main body

In this review, we report recent literature focusing on older critically ill patients in order to help physicians in the multiple-step decision-making process. It is unclear under what conditions older patients may benefit from ICU admission. Consequently, there is a wide variation in triage practices, treatment intensity levels, end-of-life practices, discharge practices and frequency of geriatrician’s involvement among institutions and clinicians. In this review, we discuss important steps in caring for critically ill older patients, from the triage to long-term outcome, with a focus on specific conditions in the very old patients.

Conclusion

According to previous considerations, we provide an algorithm presented as a guide to aid in the decision-making process for the caring of the critically ill older patients.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0458-7) contains supplementary material, which is available to authorized users.

Postprandial hypotension in older survivors of critical illness

PURPOSE

In older people postprandial hypotension occurs frequently; and is an independent risk factor for falls, cardiovascular events, stroke and death. The primary aim of this pilot study was to estimate the frequency of postprandial hypotension and evaluate the mechanisms underlying this condition in older survivors of an Intensive Care Unit (ICU).

MATERIALS AND METHODS

Thirty-five older (>65 years) survivors were studied 3 months after discharge. After an overnight fast, participants consumed a 300 mL drink containing 75 g glucose, labelled with 20 MBq ^99mTc-calcium phytate. Patients had concurrent measurements of blood pressure, heart rate, blood glucose and gastric emptying following drink ingestion. Proportion of participants is presented as percent (95% CI) and continuous variables as mean (SD).

RESULTS

Postprandial hypotension was evident in 10 (29%; 95% CI 14-44), orthostatic hypotension in 2 (6%; 95% CI 0-13) and cardiovascular autonomic dysfunction in 2 (6%; 95% CI 0-13) participants. The maximal postprandial nadir for systolic blood pressure and diastolic blood pressures were -29 (14) mmHg and -18 (7) mmHg.

CONCLUSIONS

In this cohort of older survivors of ICU postprandial hypotension occurred frequently . This suggests that postprandial hypotension is an unrecognised issue in older ICU survivors.

How does prior health status (age, comorbidities and frailty) determine critical illness and outcome?

PURPOSE OF REVIEW

Critical illness has a significant impact on an individual's physical and mental health. However, it is less clear to what degree outcomes after critical illness are due to patients' preexisting characteristics, rather than the critical illness itself. In this review, we summarize recent findings regarding the role of age, comorbidity and frailty on long-term outcomes after critical illness.

RECENT FINDINGS

Age, comorbidity and frailty are all associated with an increased risk of critical illness. Although severity of illness drives the risk of acute mortality, recent data suggest that longer term outcomes are much more closely aligned with prior health status. There are growing data regarding the important role of noncardiovascular comorbidity, including psychiatric illness and obesity, in determining long-term outcomes. Finally, preadmission frailty is associated with poor long-term outcomes after critical illness; further data are needed to evaluate the attributable impact of critical illness on the health trajectories of frail individuals.

SUMMARY

Age, comorbidity and frailty play a critical role in determining the long-term outcomes of patients requiring intensive care.

Factors associated with non-response at health-related quality of life follow-up in a septic shock trial

BACKGROUND

Follow-up of intensive care unit (ICU) patients often includes health-related quality of life (HRQoL) surveying, but non-responders hamper the interpretation. Our aim was to assess factors for non-response to HRQoL survey in ICU patients with septic shock at follow-up in a clinical trial.

METHODS

In a post hoc follow-up registry study, we assessed all the Danish survivors in the Transfusion-Requirements in Septic Shock trial patients, who were mailed the Short Form 36-item Survey (SF-36) 1-year after randomization. We used covariates from the trial database merged with covariates from nation-wide registries using the unique national identification number to explore possible factors for not responding. Five covariates were pre-specified to be included in the primary multivariate analysis: age, number of days in hospital from randomization to follow-up, level of education, cohabitation and employment status at follow-up. We compared the mortality from 1-year survival (2012-2014) till end of final follow-up (January 2016) between non-responders and responders.

RESULTS

We assessed 308 survivors of whom 108 (35%) were non-responders. In the primary analysis lower age (odds ratio 1.03, 95% CI [1.01-1.05]), more admission days in hospital (1.006 [1.001-1.011]) and living alone (4.33 [2.46-7.63]) were associated with non-responding, whereas the level of education and employment status were not. Non-responders had a hazard ratio of 1.63 [0.97-2.72] for mortality from 1-year follow-up to final follow-up as compared to the responders.

CONCLUSION

Being younger, spending more days in hospital and living alone were all associated with non-response at 1-year HRQoL follow-up among ICU patients with septic shock.

Home return following invasive mechanical ventilation for the oldest-old patients in medical intensive care units from two US hospitals

Background:

The aging of the US population has been associated with an increase in intensive care unit (ICU) utilization and correspondingly, invasive mechanical ventilation (IMV) among the oldest-old (age ≥80 years). While previous studies have examined ICU and IMV outcomes in the elderly, very few have focused on patient-centered outcomes, specifically home return, in the oldest-old. We investigated the rate of immediate home return following IMV in the medical ICU in previously home-dwelling oldest-old patients relative to that of a comparison group of 50–70-year olds.

Methods:

Data were extracted retrospectively from patient records at Elmhurst Hospital Center in Elmhurst, NY, USA, encompassing the period from January 2009 to May 2014 and Jacobi Medical Center in the Bronx, NY, USA, from January 2010 to March 2014. Medical ICU admissions within those date ranges were screened for possible inclusion into one of two study groups based on age: ≥80 years old and 50–70 years old. The primary end point was hospital discharge: home return versus no home return (death or nonhome discharge). Cox proportional hazards’ regression models were used to estimate crude and multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for failure to return home.

Results:

A total of 375 patients were included in the analysis: 279 (74%) patients aged 50–70 years and 96 (26%) patients aged ≥80 years. Compared to 50–70-year olds, being ≥80 years old was associated with a nearly two-fold greater risk of no home return: adjusted HR: 1.96; 95% CI 1.43–2.67. The oldest-old was at significantly increased risk of both being discharged to a skilled nursing facility or subacute rehabilitation (adjusted HR: 2.19; 95% CI 1.33–3.59) as well as of dying in the hospital (adjusted HR: 1.81; 95% CI 1.21–2.71).

Conclusion:

Previously home-dwelling oldest-old are at significantly increased risk of failing to return home immediately following medical ICU admission with IMV as compared to patients aged 50–70 years. These results can help medical ICU staff establish appropriate expectations when addressing the families of their oldest patients. Further studies are needed to evaluate the potential for delayed home return among the oldest old and to assess the ability of frailty indices to predict home return within this ICU population.

Risk factors for death in septic shock: A retrospective cohort study comparing trauma and non-trauma patients

The aim of this study was to compare septic shock directly associated-mortality between severe trauma patients and nontrauma patients to assess the role of comorbidities and age. We conducted a retrospective study in an intensive care unit (ICU) (15 beds) of a university hospital (928 beds). From January 2009 to May 2015, we reviewed 2 anonymized databases including severe trauma patients and nontrauma patients. We selected the patients with a septic shock episode. Among 385 patients (318 nontrauma patients and 67 severe trauma patients), the ICU death rate was 43%. Septic shock was directly responsible for death among 35% of our cohort, representing 123 (39%) nontrauma patients and 10 (15%) trauma patients (P < 0.0). A sequential organ failure assessment score above 12 (odds ratio [OR]: 6.8; 95% confident interval (CI) [1.3-37], P = 0.025) was independently associated with septic shock associated-mortality, whereas severe trauma was a protective factor (OR: 0.26; 95% CI [0.08-0.78], P = 0.01). From these independent risk factors, we determined the probability of septic shock associated-mortality. The receiver-operating characteristics curve has an area under the curve at 0.76 with sensitivity of 55% and specificity of 86%. Trauma appears as a protective factor, whereas the severity of organ failure has a major role in the mortality of septic shock. However, because of the study's design, unmeasured confounding factors should be taken into account in our findings.

Predicting Health Care Utilization for Children With Respiratory Insufficiency Using Parent-Proxy Ratings of Children's Health-Related Quality of Life

INTRODUCTION

Children with chronic respiratory insufficiency and mechanical ventilation often experience acute illnesses requiring unscheduled hospitalizations. Health-related quality of life (HRQL) may predict future health care utilization.

METHODS

Participants were 30 days to 22 years old with chronic respiratory insufficiency (N = 120). Parent-proxies completed global HRQL and general health measures. Outcomes were total health care (emergency department, outpatient, inpatient) and inpatient days over 6 months. Adjusted negative binomial regression estimated the effects of global HRQL and general health on utilization.

RESULTS

Three quarters of children had any utilization; 32% had hospitalizations. Children with poor/fair global HRQL had 3.7 times more health care days than those with very good/excellent global HRQL. Children with poor/fair global HRQL had 6.3 times more inpatient days than those with very good/excellent global HRQL. Similar relationships existed between general health and utilization.

DISCUSSION

HRQL was associated with health care and inpatient days. Clinical teams can use HRQL as a marker for utilization risk, enabling potentially earlier intervention, better outcomes, and lower costs.

Haemato-oncology patients' perceptions of health-related quality of life after critical illness: A qualitative phenomenological study

INTRODUCTION

Haemato-oncology patients often require critical care support due to side-effects of treatment. Discharge can mark the start of an uncertain journey due to the impact of critical illness on health-related quality of life. Qualitatively establishing needs is a priority as current evidence is limited.

AIMS

To qualitatively explore perceptions of haemato-oncology patients' health-related quality of life after critical illness and explore how healthcare professionals can provide long-term support.

METHODS

Nine in-depth interviews were conducted three to eighteen months post-discharge from critical care. Phenomenology was used to gain deeper understanding of the patients' lived experience.

SETTING

A 19-bedded Intensive Care Unit in a specialist cancer centre.

FINDINGS

Five major themes emerged: Intensive care as a means to an end; Rollercoaster of illness; Reliance on hospital; Having a realistic/sanguine approach; Living in the moment. Haemato-oncology patients who experience critical illness may view it as a small part of a larger treatment pathway, thus health-related quality of life is impacted by this rather than the acute episode.

CONCLUSIONS

Discharge from the intensive care unit can be seen as a positive end-point, allowing personal growth in areas such as relationships and living life to the full. The contribution of health-care professionals and support of significant others is regarded as critical to the recovery experience.

Goals of Care and End of Life in the ICU

Despite advances in surgical critical care, critical illness remains traumatic and has long-term adverse sequelae. Unrealistic expectations and erroneous assumptions about outcomes acceptable to patients have been identified as drivers of goal-discordant treatment. Goal setting in the ICU begins with compassionately delivered, accurate, and honest prognostic information. Through skilled communication and shared decision making, clinicians forge a mutual understanding of patient values and priorities and the role of therapeutic options in achieving patient goals. Ensuring that treatment is goal-concordant and meets physical, psychosocial, existential, and spiritual needs is crucial for attaining optimal patient and caregiver outcomes, independent of survival.

An Exploratory Study of Long-Term Outcome Measures in Critical Illness Survivors: Construct Validity of Physical Activity, Frailty, and Health-Related Quality of Life Measures

OBJECTIVE

Functional capacity is commonly impaired after critical illness. We sought to clarify the relationship between objective measures of physical activity, self-reported measures of health-related quality of life, and clinician reported global functioning capacity (frailty) in such patients, as well as the impact of prior chronic disease status on these functional outcomes.

DESIGN

Prospective outcome study of critical illness survivors.

SETTING

Community-based follow-up.

PATIENTS

Participants of the Musculoskeletal Ultrasound Study in Critical Care: Longitudinal Evaluation Study (NCT01106300), invasively ventilated for more than 48 hours and on the ICU greater than 7 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Physical activity levels (health-related quality of life [36-item short-form health survey] and daily step counts [accelerometry]) were compared to norm-based or healthy control scores, respectively. Controls for frailty (Clinical Frailty Score) were non-morbid, age- and gender-matched to survivors. Ninety-one patients were recruited on ICU admission: 41 were contacted for post-discharge assessment, and data were collected from 30 (14 female; mean age, 55.3 yr [95% CI, 48.3-62.3]; mean post-discharge, 576 d [95% CI, 539-614]). Patients' mean daily step count (5,803; 95% CI, 4,792-6,813) was lower than that in controls (11,735; 95% CI, 10,928-12,542; p < 0.001), and lower in those with preexisting chronic disease than without (2,989 [95% CI, 776-5,201] vs 7,737 [95% CI, 4,907-10,567]; p = 0.013). Physical activity measures (accelerometry, health-related quality of life, and frailty) demonstrated good construct validity across all three tools. Step variability (from SD) was highly correlated with daily steps (r = 0.67; p < 0.01) demonstrating a potential boundary constraint.

CONCLUSIONS

Subjective and objective measures of physical activity are all informative in ICU survivors. They are all reduced 18 months post-discharge in ICU survivors, and worse in those with pre-admission chronic disease states. Investigating interventions to improve functional capacity in ICU survivors will require stratification based on the presence of premorbidity.

Predicting Performance Status 1 Year After Critical Illness in Patients 80 Years or Older: Development of a Multivariable Clinical Prediction Model

OBJECTIVE

We sought to develop and internally validate a clinical prediction model to estimate the outcome of very elderly patients 12 months after being admitted to the ICU.

DESIGN

Prospective, longitudinal cohort study.

SETTING

Twenty-two Canadian ICUs.

PATIENTS

We recruited 527 patients 80 years or older who had a medical or urgent surgical diagnosis and were admitted to an ICU for at least 24 hours.

MEASUREMENTS AND MAIN RESULTS

At baseline, we completed a comprehensive geriatric assessment of enrolled patients; survival and functional status was determined 12 months later. We defined recovery from critical illness as Palliative Performance Scale score of greater than or equal to 60. We used logistic regression analysis to examine factors associated with this outcome. Of the 434 patients (82%) whose Palliative Performance Scale was known at 12 months, 50% had died and 29% (126/434) had a score of greater than or equal to 60. In the multivariable model, we found that being married, having a primary diagnosis of emergency coronary artery bypass grafting or valve replacement, and higher baseline Palliative Performance Scale were independently predictive of a 12-month Palliative Performance Scale score of greater than or equal to 60. Male sex, primary diagnosis of stroke, and higher Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity index, or clinical frailty scale were independently predictive of Palliative Performance Scale score of less than 60.

CONCLUSION

Approximately one-quarter of very old ICU patients achieve a reasonable level of function 1 year after admission. This prediction model applied to individual patients may be helpful in decision making about the utility of life support for very elderly patients who are admitted to the ICU.

PReventing early unplanned hOspital readmission aFter critical ILlnEss (PROFILE): protocol and analysis framework for a mixed methods study

INTRODUCTION

Survivors of critical illness experience multidimensional disabilities that reduce quality of life, and 25-30% require unplanned hospital readmission within 3 months following index hospitalisation. We aim to understand factors associated with unplanned readmission; develop a risk model to identify intensive care unit (ICU) survivors at highest readmission risk; understand the modifiable and non-modifiable readmission drivers; and develop a risk assessment tool for identifying patients and areas for early intervention.

METHODS AND ANALYSIS

We will use mixed methods with concurrent data collection. Quantitative data will comprise linked healthcare records for adult Scottish residents requiring ICU admission (1 January 2000-31 December 2013) who survived to hospital discharge. The outcome will be unplanned emergency readmission within 90 days of index hospital discharge. Exposures will include pre-ICU demographic data, comorbidities and health status, and critical illness variables representing illness severity. Regression analyses will be used to identify factors associated with increased readmission risk, and to develop and validate a risk prediction model. Qualitative data will comprise recorded/transcribed interviews with up to 60 patients and carers recently experiencing unplanned readmissions in three health board regions. A deductive and inductive thematic analysis will be used to identify factors contributing to readmissions and how they may interact. Through iterative triangulation of quantitative and qualitative data, we will develop a construct/taxonomy that captures reasons and drivers for unplanned readmission. We will validate and further refine this in focus groups with patients/carers who experienced readmissions in six Scottish health board regions, and in consultation with an independent expert group. A tool will be developed to screen for ICU survivors at risk of readmission and inform anticipatory interventions.

ETHICS AND DISSEMINATION

Data linkage has approval but does not require ethical approval. The qualitative study has ethical approval. Dissemination with key healthcare stakeholders and policymakers is planned.

TRIAL REGISTRATION NUMBER

UKCRN18023.

Changes in health-related quality of life in older patients one year after an intensive care unit stay

AIMS AND OBJECTIVES

This study investigates health-related quality of life in older patients, over one year following an intensive care unit stay.

BACKGROUND

Health-related quality of life is an important outcome when assessing long-term effectiveness of intensive care treatment, and to assist patients, their relatives and healthcare professionals in making treatment decisions.

DESIGN

Prospective non-randomised longitudinal study.

METHODS

The Short Form Health Survey 36 was administered 1 week after an intensive care stay (retrospective baseline), and after six months and 12 months to the study population and to an age-matched comparison group at recruitment (baseline), and after six months and 12 months. Demographic data, admission diagnosis, length of stay, severity of illness, pain, anxiety, agitation, and intratracheal suctioning, turning and intubation were recorded. Recruitment period: December 2008 to April 2011.

RESULTS

Health-related quality of life of the older patients was significantly lower than the comparison group, both before and after the intensive care unit stay, and showed great individual variability. Within group scores, however, were stable over the year. Both physical and mental health scores were lower for the older patients. Renal failure, cardiac surgery and illness severity were associated with lower physical health scores. Cardiovascular illness, intratracheal suctioning and turning were associated with lower mental health scores.

CONCLUSIONS

Health-related quality of life was lower in older patients than in the age-matched group but remained stable over one year.

RELEVANCE TO CLINICAL PRACTICE

Older patients with severe illnesses, acute renal failure or who have had cardiac surgery, need additional support after hospital discharge due to functional restrictions. Discharge planning should ensure that this support would be provided. Special attention should be given to develop and use methods to reduce distress during routine intensive care interventions such as intratracheal suctioning or turning.

Quality of life after mild to moderate trauma

INTRODUCTION

To evaluate potential reduction in health-related quality of life (HRQOL) after a mild to moderate trauma.

MATERIALS AND METHODS

Follow-up study of a cohort of 153 trauma patients admitted to the High Dependency Unit of the Emergency Department of the University-Hospital of Florence from July 2008 to February 2012. After 6 months from the event, a telephone interview using the Physical (PCS) and Mental (MCS) Health Composite Score (SF12) was conducted. Patients reported their HRQOL both at present and before trauma. Scores ≥ 50 represent no disability; 40-49, mild disability; 30-39, moderate disability; and below 30, severe disability.

RESULTS

Before the event 143 (93%) subjects reported a normal PCS and MCS. After the events, a significantly lower proportion of patients maintained a normal PCS and MCS values (52 and 68%, all p<0.01). One, two, three and four PCS items worsened in 14%, 15%, 18% and 38% of the study population, while one, two, three or four MCS dimensions worsened in 12%, 19%, 19% and 24%. We identified 109 subjects (N+), which showed normal PCS and MCS values before trauma, in the absence of any pre-existing medical condition. After the event, we observed a significant PCS (before: 54, standard deviation, SD 6; after 43, SD 11, p<0.0001) and MCS (before: 55, SD 7; after 47, SD 11, p<0.0001) worsening among N+ subjects. Distribution across the four disability categories was 52, 24, 17 and 6% for MCS score and 38, 25, 27 and 11% for PCS score: overall 8 (7%) patients reported a moderate disability and 5 (5%) reported a severe disability in both dimensions. Compared with subjects with preserved values, patients with an abnormal (<39) HRQOL were older, showed a higher prevalence of female gender and pre-existing medical conditions and a worst Sequential Organ Failure Assessment score. An advanced age (OR 1.033, 95% CI 1.010-1.057, p=0.005) and a higher SOFA T1 score (OR 1.500, 95% CI 1.027-2.190, p=0.036) were independently associated with a worsening PCS.

CONCLUSIONS

After a mild trauma, we evidenced a relevant reduction in HRQOL; an advanced age and a higher degree of organ dysfunction were independently associated with HRQOL deterioration.

Functional trajectories among older persons before and after critical illness

IMPORTANCE

Little is known about functional trajectories of older persons in the year before and after admission to the intensive care unit (ICU) or how pre-ICU functional trajectories affect post-ICU functional trajectories and death.

OBJECTIVES

To characterize functional trajectories in the year before and after ICU admission and to evaluate the associations among pre-ICU functional trajectories and post-ICU functional trajectories, short-term mortality, and long-term mortality.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of 754 community-dwelling persons 70 years or older, conducted between March 23, 1998, and December 31, 2012, in greater New Haven, Connecticut. The analytic sample included 291 participants who had at least 1 admission to an ICU through December 2011.

MAIN OUTCOMES AND MEASURES

Functional trajectories in the year before and after an ICU admission based on 13 basic, instrumental, and mobility activities. Additional outcomes included short-term (30 day) and long-term (1 year) mortality.

RESULTS

The mean (SD) age of participants was 83.7 (5.5) years. Three distinct pre-ICU functional trajectories identified were minimal disability (29.6%), mild to moderate disability (44.0%), and severe disability (26.5%). Seventy participants (24.1%) experienced early death, defined as death in the hospital (50 participants [17.2%]) or death after hospital discharge but within 30 days of admission (20 participants [6.9%]). Among the remaining 221 participants, 3 distinct post-ICU functional trajectories identified were minimal disability (20.8%), mild to moderate disability (28.1%), and severe disability (51.1%). More than half of the participants (53.4%) experienced functional decline or early death after critical illness. The pre-ICU functional trajectories of mild to moderate disability and severe disability were associated with more than double (adjusted hazard ratio [HR], 2.41; 95% CI, 1.29-4.50) and triple (adjusted HR, 3.84; 95% CI, 1.84-8.03) the risk of death within 1 year of ICU admission, respectively. Other factors associated with 1-year mortality included ICU length of stay (adjusted HR, 1.03; 95% CI, 1.00-1.05), mechanical ventilation (adjusted HR, 2.89; 95% CI, 1.91-4.37), and shock (adjusted HR, 2.68; 95% CI, 1.63-4.38).

CONCLUSIONS AND RELEVANCE

Among older persons with critical illness, more than half died within 1 month or experienced significant functional decline over the following year, with particularly poor outcomes in those who had high levels of premorbid disability. These results may help to inform discussions about prognosis and goals of care before and during critical illness.

Clinical and psychosocial factors predicting health-related quality of life in hemodialysis patients

Many patients with end-stage renal disease have significant impairment in health-related quality of life (HRQoL). Most previous studies have focused on clinical factors; however, quality of life can also be affected by psychosocial factors. The aim of this study was to identify the possible predictors of HRQoL among clinical and psychosocial factors in hemodialysis (HD) patients. The study included 101 patients who were undergoing HD. Psychosocial factors were evaluated using the Hospital Anxiety and Depression Scale, Multidimensional Scale of Perceived Social Support, Montreal Cognitive Assessment, and Pittsburgh Sleep Quality Index. We also assessed laboratory and clinical factors, including albumin, Kt/V as a marker of dialysis adequacy, normalized protein catabolic rate, and duration of HD. The Euro Quality of Life Questionnaire 5-Dimensional Classification (EQ-5D) was used to evaluate HRQoL. The mean EQ-5D index score was 0.704 ± 0.199. The following variables showed a significant association with the EQ-5D index: age (P < 0.001), depression (P < 0.001), anxiety (P < 0.001), support from friends (P < 0.001), cognitive function (P < 0.001), duration of HD (P = 0.034), triglyceride (P = 0.031), total iron-binding capacity (P = 0.036), and phosphorus (P = 0.037). Multiple regression analysis showed that age (95% confidence interval [CI] -0.008 to -0.002), anxiety (95% CI -0.025 to -0.009), and support from friends (95% CI 0.004 to 0.018) were independent predictors of impaired HRQoL. This study explored determinants of impaired HRQoL in HD patients. We found that impaired HRQoL was independently associated with age, anxiety, and support from friends. We should consider psychosocial as well as clinical factors when evaluating ways to improve HRQoL in HD patients.

Sarcopenia and critical illness: a deadly combination in the elderly

Sarcopenia is the age-associated loss of lean skeletal muscle mass. It is the result of multiple physiologic derangements, ultimately resulting in an insidious functional decline. Frailty, the clinical manifestation of sarcopenia and physical infirmity, is associated with significant morbidity and mortality in the elderly population. The underlying pathology results in a disruption of the individual's ability to tolerate internal and external stressors such as injury or illness. This infirmity results in a markedly increased risk of falls and subsequent morbidity and mortality from the resulting traumatic injury, as well as an inability to recover from medical insults, resulting in critical illness. The increasing prevalence of sarcopenia and critical illness in the elderly has resulted in a deadly intersection of disease processes. The lethality of this combination appears to be the result of altered muscle metabolism, decreased mitochondrial energetics needed to survive critical illness, and a chronically activated catabolic state likely mediated by tumor necrosis factor-α. Furthermore, these underlying derangements are independently associated with an increased incidence of critical illness, resulting in a progressive downward spiral. Considerable evidence has been gathered supporting the role of aggressive nutrition support and physical therapy in improving outcomes. Critical care practitioners must consider sarcopenia and the resulting frailty phenotype a comorbid condition so that the targeted interventions can be instituted and research efforts focused.

The Cost of Inappropriate Care at the End of life: Implications for an Aging Population

Elderly patients patients (older than 65 years) account for only 11% of the US population yet they account for 34% of health care expenditure. The disproportionate usage of health care costs by elderly patients is in striking contrast with that of other Western Nations. It is likely that these differences are largely due to variances in hospitalization and the use of high technology health care resources at the end of life. The United States has 8 times as many intensive care unit (ICU) beds per capita when compared to other Western Nations. In the United States, elderly patients currently account for 42% to 52% of ICU admissions and for almost 60% of all ICU days. A disproportionate number of these ICU days are spent by elderly patients before their death. In many instances, aggressive life supportive measures serve only to prolong the patient's death. Such treatment inflicts pain and suffering on the patient (with little prospects of gain) and incurs enormous financial costs to the health care system. We present the case of an 86-year-old female who spent almost 3 months in our ICU prior to her death. The fully allocated hospital costs for this patient were estimated to be US$254 945 (US$5100/d). With the increasing age of the population and the projected increased demand for ICU beds, we review the benefits and burdens of admitting elderly patients to the ICU.

Measuring functional recovery in older patients discharged from intensive care units: is advanced technology an option?

The purpose of this descriptive study was to determine if older patients discharged from intensive care units (ICU) would be willing to use mobile phone and sensor technology (aka "mobile monitoring") to measure their functional recovery in the posthospitalization period. Semistructured interviews were conducted with 22 older ICU patients and/or their surrogates 24 to 48 hr prior to hospital discharge. While 11 respondents reported they would agree to participate in a future study involving mobile monitoring, an equal number reported they would not participate. Numerous contextual factors were found to affect older adults' willingness to participate including the belief the research would ultimately benefit themselves or other older adults, concerns about loss of privacy, perception that the research is feasible and valuable, and lack of skills using the technology. Future studies using the mobile monitoring technique with older survivors of a serious illness will require substantial recruitment and educational efforts.

Defining quality outcomes for complex-care patients transitioning across the continuum using a structured panel process

BACKGROUND

No standardised set of quality measures associated with transitioning complex-care patients across the various healthcare settings and home exists. In this context, a structured panel process was used to define quality measures for care transitions involving complex-care patients across healthcare settings.

METHODS

A modified Delphi consensus technique based on the RAND method was used to develop measures of quality care transitions across the continuum of care. Specific stages included a literature review, individual rating of each measure by each of the panelists (n=11), a face-to-face consensus meeting, and final ranking by the panelists.

RESULTS

The literature review produced an initial set of 119 measures. To advance to rounds 1 and 2, an aggregate rating of >75% of the measure was required. This analysis yielded 30/119 measures in round 1 and 11/30 measures in round 2. The final round of scoring yielded the following top five measures: (1) readmission rates within 30 days, (2) primary care visit within 7 days postdischarge for high-risk patients, (3) medication reconciliation completed at admission and prior to discharge, (4) readmission rates within 72 h and (5) time from discharge to homecare nursing visit for high-risk patients.

CONCLUSIONS

The five measures identified through this research may be useful as indicators of overall care quality related to care transitions involving complex-care patients across different healthcare settings. Further research efforts are called for to explore the applicability and feasibility of using the quality measures to drive quality improvement across the healthcare system.

Joint models for predicting transplant-related mortality from quality of life data

PURPOSE

To test whether longitudinally measured health-related quality of life (HRQL) predicts transplant-related mortality (TRM) in pediatric hematopoietic stem cell transplant (HSCT).

METHODS

The predictors of interest were emotional functioning, physical functioning, role functioning, and global HRQL, as rated by the parent about the child up to 6 times over 12 months of follow-up and measured by the Child Health Ratings Inventories. We used joint models, specifically shared parameter models, with time to TRM as the outcome of interest and other causes of mortality as a competing risk, via the JM software package in R. Choosing shared parameter models instead of standard survival models, such as Cox models with time-dependent covariates, enabled us to address measurement error in the HRQL trajectories and appropriately handle missing data. The nonlinear trajectories for each HRQL domain were modeled by random spline functions. The survival submodels were adjusted for baseline patient, family, and transplant characteristics.

RESULTS

Hazard ratios per one-half standard deviation difference in emotional, physical, and role functioning, and global HRQL were 0.61 (95 % CI 0.46-0.81; p < 0.001), 0.70 (0.51-0.96; p = 0.03), 0.54 (0.34-0.85; p = 0.007), and 0.57 (0.41-0.79; p < 0.001), respectively.

CONCLUSIONS

HRQL trajectories were predictive of TRM in pediatric HSCT, even after adjusting the survival outcome for baseline characteristics.

Health-related quality of life and long-term survival and graft failure in kidney transplantation: a 12-year follow-up study

BACKGROUND

Although the prognosis of kidney transplantation is generally good, long-term survival varies substantially between patients. This study examined whether health-related quality of life (HRQOL) predicts long-term mortality in kidney transplantation after adjustment for known risk factors.

METHODS

A cohort of 347 (46.77 ± 13.96 years) kidney transplant recipients was followed up for 12 years after enrolment (1999-2001). Patients completed measures of HRQOL and medical records were reviewed to document clinical and cardiovascular risk factors and comorbidities at study entry (mean [SD], 8.57 [6.55] years after transplantation). The primary outcomes were ensuing all-cause mortality and all-cause graft failure (a composite endpoint consisting of return to dialysis therapy, preemptive retransplantation, or death with function). Cox proportional hazards multivariate models were developed to identify predictors of long-term patient and graft survival.

RESULTS

During the 12-year follow-up, 86 (24.8%) patients died, 64 (18.3%) died with a functioning graft, and 35 (11.1%) were placed back to dialysis. Physical QOL impairment increased the risk of mortality and graft failure during the follow-up period. The risk remained significant after adjusting for sociodemographic and clinical risk factors (adjusted hazard ratio, 1.89; 95% confidence interval, 1.09-2.95; P=0.022 and adjusted hazard ratio, 1.68; 95% confidence interval, 1.12-2.52; P=0.012 for patient and graft survival, respectively). Other significant risk factors were older age, time elapsed since transplantation, and Charlson comorbidity index. Risk of graft failure was also associated with glomerular filtration rate.

CONCLUSIONS

Physical HRQOL predicts long-term mortality and graft failure independently of sociodemographic and clinical risk factors in renal transplant patients. Future research should identify the determinants of HRQOL and refine interventions to improve it.

What follows survival of critical illness? Physical therapists' management of patients with post-intensive care syndrome

Historically, the management of patients in the intensive care unit (ICU) has involved immobilization and sedation, with care focused on physiological impairments and survival. Because more ICU patients are now surviving their hospital stay, it is imperative that their ICU care be managed with the goal of long-term health, wellness, and functioning. The evidence confirms that mobilization and exercise are feasible in the ICU and demonstrates that the benefits of early mobilization include reduced length of stay in the ICU and hospital. In 2010, the Society of Critical Care Medicine (SCCM) invited key stakeholder groups, including the American Physical Therapy Association (APTA), to identify strategies to improve long-term consequences following ICU discharge, including early mobilization in the ICU and integration of the physical therapist as a member of the ICU team. This model appears to be successful in some institutions, but there is variation among institutions. The SCCM Task Force developed major areas of focus that require multidisciplinary action to improve long-term outcomes after discharge from an ICU. This article describes physical therapist practice in the management of ICU survivors, the importance of long-term follow-up after ICU discharge, and how APTA is taking steps to address the major areas of focus identified by the SCCM Task Force to improve long-term outcomes after ICU discharge.

Prediction of outcome in critically ill elderly patients using APACHE II and SOFA scores

OBJECTIVE

Performances of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the Sequential Organ Failure Assessment (SOFA) score were assessed in predicting mortality outcome in critically ill elderly patients.

METHODS

Mean APACHE II and SOFA scores were compared in 106 intensive care unit patients aged > 65 years classified as survivors or deaths. The discriminatory ability of the scores was evaluated using the area under the receiver operating characteristic (ROC) curve. Calibration was assessed using the Hosmer-Lemeshow test.

RESULTS

Mean APACHE II and SOFA scores in survivors were lower than in those who died. There was a positive correlation between the APACHE II and SOFA scores. The area under the ROC curve was 0.76 for the APACHE II score and ranged from 0.74 for the initial SOFA score to 0.98 for the maximum SOFA score. Hosmer-Lemeshow values for the APACHE II score and various SOFA scores indicated that predictions based on these scores closely fit the observed outcomes.

CONCLUSIONS

APACHE II and SOFA scores can accurately predict mortality outcome in critically ill elderly patients, especially the maximum SOFA score and the difference between the maximum and initial SOFA scores.

Intensive care unit-acquired weakness: clinical phenotypes and molecular mechanisms

Intensive care unit-acquired weakness (ICUAW) begins within hours of mechanical ventilation and may not be completely reversible over time. It represents a major functional morbidity of critical illness and is an important patient-centered outcome with clear implications for quality of life and resumption of prior work and lifestyle. There is heterogeneity in functional outcome related to ICUAW across various patient populations after an episode of critical illness. This state-of-the art review argues that this observed heterogeneity may represent a clinical spectrum of disability in which there are recognizable clinical phenotypes for outcome according to age, burden of comorbid illness, and ICU length of stay. It further argues that these functional outcomes are modified by mood, cognition, and caregiver physical and mental health. This proposed construct of clinical phenotypes will be used as a framework for a review of the current literature on the molecular biology of muscle and nerve injury. This translational approach for the development of models pairing clinical phenotypes for different functional outcomes after critical illness with molecular mechanism of injury may offer unique insights into the diagnosis and treatment of muscle and nerve lesions.

Relationships among advance directives, principal diagnoses, and discharge outcomes in critically ill older adults

OBJECTIVE

The purpose of this study was to determine the relationships among advance directive status, principal diagnoses, and the discharge outcomes in community-dwelling, critically ill older adults.

METHOD

Using administrative and clinical data (n = 1673), multinomial logit regressions were used to examine the relationships among advance directive status, principal diagnoses, and discharge outcomes (in-hospital deaths, hospice discharges, and transition to institutions).

RESULTS

In the overall sample, the adjusted probability of in-hospital deaths with advance directives (12%) was lower than that without advance directives (17%; odds ratio [OR] = 0.56; p = 0.007) and the adjusted probability of hospice discharges with advance directives (11%) was higher than that without advance directives (7%; OR = 1.96; p = 0.03). Subgroup analysis showed that the magnitude of the abovementioned changes was aggregated when their principal diagnoses were a group of diseases with more difficult prognostication (circulatory and respiratory diseases) and more potential for reversibility (infectious diseases). By contrast, the magnitude of the abovementioned findings was diminished with other principal diagnoses. On the other hand, the presence of advance directives did not make a contribution to transition from communities to institutions.

SIGNIFICANCE OF RESULTS

Significantly fewer in-hospital deaths in addition to higher hospice discharges were observed with any advance directives in community-dwelling, critically ill older adults. The magnitude of these findings was aggregated when their principal diagnoses were a group of diseases with more difficult prognostication (circulatory and respiratory diseases) and more potential for reversibility (infectious diseases). By contrast, the magnitude of these findings was diminished with other principal diagnoses.

Transitions experienced by older survivors of critical care

The transition from hospital to home is complicated for older adults who experience a serious or life-threatening illness. The specific aims of this prospective, observational cohort study were to determine the number of older adults who experience a change in their functional ability and residence after an intensive care unit (ICU) stay and to explore risk factors for functional decline and new institutionalization at hospital discharge. We found high rates of unrecognized preexisting cognitive impairment, delirium, complications, functional decline, and new institutionalization in this sample (N = 43). A number of variables were associated with functional decline or new institutionalization, including narcotic agent use (p = 0.03), ICU complications (p = 0.05), comorbidities (p = 0.01), depression (p = 0.05), and severity of illness (p = 0.05). We identified device self-removal, admission type, and ICU delirium as also potentially associated with these outcomes (p ≤ 0.25). There are a number of important and potentially modifiable factors that influence an older adult's ability to recover after a critical illness.