Long-term outcome of elderly patients requiring intensive care admission for abdominal pathologies: survival and quality of life

Self-perceived recovery and quality of life in elderly patients surviving ICU-admission for abdominal sepsis

Introduction

Concern for loss of physical performance and Health-Related Quality of Life (HRQoL) may raise doubts regarding the meaningfulness of an Intensive Care (ICU) admission in elderly patients. We evaluated self-perceived long-term recovery and satisfaction in elderly surviving an abdominal sepsis related ICU-admission and related this to objective measures of HRQoL.

Methods

A cross-sectional survey study was performed in all ICU-survivors with age ≥70 admitted with abdominal sepsis. HRQoL, frailty and self-perceived long-term recovery were measured using the EQ-5D-3L, Groningen Frailty Indicator, and a self-developed questionnaire, respectively.

Results

Of 144 patients admitted, 48 were alive at follow up (2.42 [0.92; 3.83] years), and 29 (60%) returned the survey. Eleven patients out of 29 (38%) recovered to baseline functioning, and reported higher HRQoL compared to unrecovered patients (0.861 [0.807; 1.000] and 0.753 [0.499; 0.779] respectively, p=0.005). Of the unrecovered patients, 53% were satisfied with their functioning, and 94% were willing to return to ICU.

Conclusions

Mortality in elderly patients with abdominal sepsis is high and ICU-admission should be weighed carefully. However, despite substantial functional decline in survivors, it does not necessarily cause self-perceived unsatisfactory functioning, poor HRQoL and unwillingness to receive life-sustaining therapy again. Caution is advised to use an anticipated loss of functioning as an argument to deny an ICU-admission.

Caregiver Out-of-Pocket Costs for Octogenarian Intensive Care Unit Patients in Canada

ABSTRACTMedical issues facing the aging population are of growing concern with consequences for patients and their caregivers. This study determined the indirect and out-of-pocket costs incurred by the caregivers of elderly patients in Canadian Intensive Care Units (ICUs). Primary family caregivers were surveyed capturing out-of-pocket costs, hours of work, and hours of leisure forgone in providing patient care while the patient was in the ICU. Total costs of care per month were reported across caregiver sex, age, and geographic region. Average out-of-pocket costs were $791 (2016 Canadian dollars) in the first month of ICU care. The mean total cost to family caregivers per patient was $162 per day. Male primary caregivers had higher mean out-of-pocket costs than female caregivers. Subsidization programs covering expenses such as travel, meals, accommodation, and parking are needed to support family caregivers of elderly ICU patients who are incurring considerable out-of-pocket costs.

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.

Functional Status and Quality of Life in Elderly Intensive Care Unit Survivors

OBJECTIVES

To evaluate functional status and quality of life in elderly intensive care unit (ICU) survivors at 1-year follow-up.

DESIGN

Prospective 18-month observational study.

SETTING

University medical-surgical ICU.

PARTICIPANTS

ICU survivors aged 75 and older.

MEASUREMENTS

Functional status at baseline (Barthel Index (BI)) was compared with that at hospital discharge and 1-year follow-up. Health-related quality of life (HRQL Spanish version of the Medical Outcomes Study 36-item Short-From Survey) was measured at 1-year follow-up and compared with that of the Spanish population of same age.

RESULTS

Of 176 individuals admitted to the ICU, 110 (62.1%) were discharged alive from the hospital, and 94 (53.1%) were alive at 1-year follow-up. ICU admission was associated with significant clinical deterioration (median BI 100 points (interquartile range (IQR) 85-100) at baseline vs 85 (IQR 60-100) at hospital discharge, P < .001). Three months after discharge, there was a significant although modest improvement in functional status (BI 95 (IQR 80-100) P = .03). Baseline functional status was not recovered at 1-year follow-up (BI 95 (IQR 80-100) P < .001). More ICU survivors had moderate to severe dependence at the end of follow-up (20.3%) than at ICU admission (6.6%) (P < .001). Factors independently associated with poor functional recovery were low baseline BI and ICU stay longer than 4 days. At 1-year follow-up, 76.8% of participants who survived were living in their own homes. HRQL was similar to that of the Spanish population of the same age.

CONCLUSION

Elderly ICU survivors experienced significant deterioration in functional status, and although they recovered modestly during the following year, they never regained their baseline status. Good recovery was associated with short ICU stay and better baseline functional status.

A systematic review of instruments for measuring outcomes in economic evaluation within aged care

BACKGROUND

This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector.

METHODS

Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000.

RESULTS

The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care.

CONCLUSION

In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.

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.

Long-term consequences of pain, anxiety and agitation for critically ill older patients after an intensive care unit stay

AIMS AND OBJECTIVES

This study investigated whether an intensive care unit (ICU) stay is associated with persistent pain, anxiety and agitation in critically ill older patients.

BACKGROUND

Patients hospitalised in the ICU are at risk for experiencing pain, anxiety and agitation, but long-term consequences for older patients have rarely been investigated.

DESIGN

Prospective nonrandomised longitudinal study.

METHODS

Pain, anxiety and agitation, measured with a numeric rating scale (0-10), were assessed in older patients (≥65 years) hospitalised in the medical-surgical ICU of a university hospital. Agitation during the ICU was assessed with the Richmond Agitation-Sedation Scale. Data collection occurred during the ICU, one week after the stay and six and 12 months after hospital discharge. Data were collected from an age-matched community-based comparison group at recruitment and after six and 12 months. Study recruitment took place from December 2008-April 2011.

RESULTS

This study included 145 older patients (ICU group) and 146 comparison group participants. Pain was higher in the ICU group one week after discharge, although pain levels in general were low. Both groups reported no or low levels of pain after six and 12 months. Anxiety levels in general were low, although higher in the ICU group one week after ICU discharge. After six and 12 months, anxiety in both groups was comparable. Throughout the study, levels of agitation were similar in both groups.

CONCLUSIONS

Critically ill older patients did not experience increased pain, anxiety or agitation 12 months after an ICU stay.

RELEVANCE TO CLINICAL PRACTICE

This study positively shows that an ICU stay is not associated with persistent pain, anxiety and agitation thus providing additional information to older patients and their families when making intensive care treatment decisions. Adequate management of pain during and after an ICU stay may minimise the suffering of older patients.

Healthcare resource utilisation by critically ill older patients following an intensive care unit stay

AIMS AND OBJECTIVES

This study examines the utilisation of healthcare resources by critically ill older patients over one year following an intensive care unit stay.

BACKGROUND

Information on healthcare resource utilisation following intensive care unit treatment is essential during times of limited financial resources.

DESIGN

Prospective longitudinal nonrandomised study.

METHODS

Healthcare resource utilisation by critically ill older patients (≥65 years) was recorded during one year following treatment in a medical-surgical intensive care unit. Age-matched community-based participants served as comparison group. Data were collected at one-week following intensive care unit discharge/study recruitment and after 6 and 12 months. Recorded were length of stay, (re)admission to hospital or intensive care unit, general practitioner and medical specialist visits, rehabilitation program participation, medication use, discharge destination, home health care service use and level of dependence for activities of daily living.

RESULTS

One hundred and forty-five critically ill older patients and 146 age-matched participants were recruited into the study. Overall, critically ill older patients utilised more healthcare resources. After 6 and 12 months, they visited general practitioners six times more frequently, twice as many older patients took medications and only the intensive care unit group patients participated in rehabilitation programs (n = 99, 76%). The older patients were less likely to be hospitalised, very few transferred to nursing homes (n = 3, 2%), and only 7 (6%) continued to use home healthcare services 12 months following the intensive care unit stay.

CONCLUSIONS

Critically ill older patients utilise more healthcare resources following an intensive care unit stay, however, most are able to live at home with no or minimal assistance after one year.

RELEVANCE TO CLINICAL PRACTICE

Adequate healthcare resources, such as facilitated access to medical follow-up care, rehabilitation programs and home healthcare services, must be easily accessible for older patients following hospital discharge. Nurses need to be aware of the healthcare services available and advise patients accordingly.

Prediction of chronic critical illness in a general intensive care unit

OBJECTIVE

To assess the incidence, costs, and mortality associated with chronic critical illness (CCI), and to identify clinical predictors of CCI in a general intensive care unit.

METHODS

This was a prospective observational cohort study. All patients receiving supportive treatment for over 20 days were considered chronically critically ill and eligible for the study. After applying the exclusion criteria, 453 patients were analyzed.

RESULTS

There was an 11% incidence of CCI. Total length of hospital stay, costs, and mortality were significantly higher among patients with CCI. Mechanical ventilation, sepsis, Glasgow score <15, inadequate calorie intake, and higher body mass index were independent predictors for CCI in the multivariate logistic regression model.

CONCLUSIONS

CCI affects a distinctive population in intensive care units with higher mortality, costs, and prolonged hospitalization. Factors identifiable at the time of admission or during the first week in the intensive care unit can be used to predict CCI.

[Post-Intensive Care Unit mortality and related prognostic factors in a cohort of critically ill patients with multi-organ dysfunction]

BACKGROUND AND OBJECTIVE

To assess the post-Intensive Care Unit (ICU) mortality (in-hospital and one year after hospital discharge) and the associated factors.

PATIENTS AND METHOD

Cohort design in medical-surgical patients with multi-organ dysfunction syndrome (MODS) during the first 24h of admission to ICU. We recorded the following data: personal background, functional general situation, general information about admission to ICU, hospital stay and contact by phone after one year of hospital discharge. We registered mortality at the follow-up at anytime. Cox regression was performed to evaluate mortality factors.

RESULTS

Five hundred and forty five patients were recruited. During the study period 256 patients (52.9%) died; out of them 29.5% in ICU; 14.8% of 384 patients transferred to the ward died. Of 327 discharged patients, 266 (81.3%) were contacted; 14.3% of those had died. In-hospital death-related factors were age (odds ratio [OR] 1.04; 95% confidence interval [95% CI] 1.02-1.06; P<.01) and a decreased functional general status (OR 1.7; 95% CI 1.1-2.9; P<.05). Post-hospitalisation mortality-related variables were: diminished functional general status (OR 2.42; 95% CI 1.23-4.75; P<.01) and readmission after discharge from hospital (1.45 OR; 95% CI 1.19-1.76; P<.001).

CONCLUSIONS

Patients admitted for a medical-surgical MODS presented a mortality of 52.9% within one year. The factors influencing hospital mortality are age and a generally diminished functional status, both being not modifiable factors. After discharge, the decreased general functional status remained central along with the re-hospitalisation.

Trends in intensive care in patients over 90 years of age

BACKGROUND

Average life expectancy has increased over the past century, leading to a larger proportion of elderly in the population. Comorbidity and dependence increases with age, and recent data have shown that the number of elderly patients admitted to intensive care is increasing. This has implications for the availability of health care for these patients, as health care is a finite resource.

OBJECTIVE

This study examines the demographics of patients aged over 90 years who were admitted into the medical intensive care unit, in order to verify the results of previous research.

METHODS

From 2007 to 2011, a retrospective study was conducted in very elderly patients (over 90 years of age) and elderly patients (between 80 and 89 years of age) admitted into intensive care in Vinzentius Hospital, a medium-size, acute-care, general hospital in Landau, Germany.

RESULTS

A total of 8554 intensive care treatments were carried out in the study period. The number of intensive care treatments performed on patients aged over 90 years and those aged 80 to 89 years was 212 (2.48%) and 1715 (20.05%), respectively. No increase in the number of medical intensive care treatments was observed in very elderly patients over this period.

CONCLUSION

Compared to the results of previous studies, an increase in the number of medical treatments in the intensive care units of patients aged over 90 years over the study period could not be found.

Outcome in patients with long-term treatment in a surgical intensive care unit

BACKGROUND

This study aimed to evaluate the outcome of patients with abdominal, thoracic or vascular operations and long-term intensive care unit (ICU) treatment.

PATIENTS AND METHODS

The present retrospective observational cohort study was performed at the authors' surgical ICU at the Marburg University Medical Centre. All patients who stayed at the ICU longer than 48 h and underwent visceral, thoracic or vascular surgery between January 2005 and December 2006 were retrospectively analysed. Patients with an ICU stay of 20 or more days were defined as the long-term study group. Clinical variables were tested for prognostic value.

RESULTS

In 2 years, 852 patients were treated at the intensive care unit. Follow-up was available in 502 patients, with 219 patients treated for two and more days and a median of 16.4 days. Sixty-seven long-term patients were compared to 152 (69.4 %) patients treated between 2 and 20 days. Overall survival after 12 months was 50.2 % (110/219), while 65.8 % (144/219) were discharged from ICU. Older age, longer treatment at the ICU and increased simplified acute physiology score (SAPS) at admission were associated with decreased 12-month survival, while no statistical differences were observed for the underlying and malignant disease by univariate analysis. The risk of death was 29, 56 and 61 % for patients treated 2-4, 5-19 and ≥20 days at the ICU. Decreased survival of patients treated for 5-19 and ≥20 days were confirmed by logrank test (p = 0.001).

CONCLUSIONS

Patients with long-term ICU stay showed decreased survival than patients who are treated less than 5 days but similar survival as patients which stayed between 5 and 19 days. Malignant disease is not associated with an unfavourable 12-month survival while older age, higher SAPS index at discharge and longer stay at ICU are. Long-term ICU survivors have no increased risk to succumb after discharge from ICU.

Prognosis of elderly patients subjected to mechanical ventilation in the ICU

OBJECTIVE

To analyze the prognosis of mechanically ventilated elderly patients in the Intensive Care Unit (ICU).

DESIGN AND SCOPE

Sub-analysis of a prospective multicenter observational cohort study conducted over a period of two years in 13 medical-surgical ICUs in Spain.

PATIENTS

Adult patients who required mechanical ventilation (MV) for longer than 24 hours.

INTERVENTIONS

None.

STUDY VARIABLES

Demographic data, APACHE II, SOFA, reason for MV, comorbidity, functional condition, reintubation, duration of MV, tracheotomy, ICU mortality, in-hospital mortality.

RESULTS

A total of 1661 patients were recruited. Males accounted for 67.9% (n=1127), with a mean age of 62.1 ± 16.2 years. APACHE II: 20.3 ± 7.5. Total SOFA: 8.4 ± 3.5. Four hundred and twenty-three patients (25.4%) were ≥ 75 years of age. Comorbidity and functional condition rates were poorer in these patients (p<0.001 for both variables). Mortality in the ICU was higher in the elderly patients (33.6%) than in the younger subjects (25.9%) (p=0.002). Also, in-hospital mortality was higher in those ≥ 75 years of age. No differences in duration of MV, prevalence of tracheostomy or reintubation incidence were found. Regarding the indication for MV, only the patient ≥ 75 years of age with pneumonia, sepsis or trauma had a higher in-ICU mortality than the younger patients (46.3% vs 33.1%, p=0.006; 55% vs 25.8%, p=0.002; 63.6% vs 4.5%, p<0,001, respectively). No differences were found referred to other reasons for MV.

CONCLUSION

Older patients (≥ 75 years) have significantly higher in-ICU and in-hospital mortality than younger patients without differences in the duration of mechanical ventilation. Differences in mortality were at the expense of pneumonia, sepsis and trauma.

Predictors of mortality and short-term physical and cognitive dependence in critically ill persons 75 years and older: a prospective cohort study

BACKGROUND

The purpose of this study was to identify predictors of 3-month mortality in critically ill older persons under medical care and to assess the clinical impact of an ICU stay on physical and cognitive dependence and subjective health status in survivors.

METHODS

We conducted a prospective observational cohort study including all older persons 75 years and older consecutively admitted into ICU during a one-year period, except those admitted after cardiac arrest, All patients were followed for 3 months or until death. Comorbidities were assessed using the Charlson index and physical dependence was evaluated using the Katz index of Activity of Daily Living (ADL). Cognitive dependence was determined by a score based on the individual components of the Lawton index of Daily Living and subjective health status was evaluated using the Nottingham Health Profile (NHP) score.

RESULTS

One hundred patients were included in the analysis. The mean age was 79.3 ± 3.4 years. The median Charlson index was 6 [IQR, 4 to 7] and the mean ADL and cognitive scores were 5.4 ± 1.1 and 1.2 ± 1.4, respectively, corresponding to a population with a high level of comorbidities but low physical and cognitive dependence. Mortality was 61/100 (61%) at 3 months. In multivariate analysis only comorbidities assessed by the Charlson index [Adjusted Odds Ratio, 1.6; 95% CI, 1.2-2.2; p < 0.003] and the number of organ failures assessed by the SOFA score [Adjusted Odds Ratio, 2.5; 95% CI, 1.1-5.2; p < 0.02] were independently associated with 3-month mortality. All 22 patients needing renal support after Day 3 died. Compared with pre-admission, physical (p = 0.04), and cognitive (p = 0.62) dependence in survivors had changed very little at 3 months. In addition, the mean NHP score was 213.1 ± 132.8 at 3 months, suggesting an acceptable perception of their quality of life.

CONCLUSIONS

In a selected population of non surgical patients 75 years and older, admission into the ICU is associated with a 3-month survival rate of 38% with little impact on physical and cognitive dependence and subjective health status. Nevertheless, a high comorbidity level (ie, Charlson index), multi-organ failure, and the need for extra-renal support at the early phase of intensive care could be considered as predictors of death.

Quality of life after intensive care: a systematic review of the literature

OBJECTIVES

To evaluate quality of life at least 12 months after discharge from the intensive care unit of adult critically ill patients, to evaluate the methodology used to assess long-term quality of life, and to give an overview of factors influencing quality of life.

DATA SOURCES

EMBASE-PubMed, MEDLINE (OVID), SCI/Web of Science, the Cochrane Library, Google Scholar, and personal files.

DATA EXTRACTION

Data extraction was performed independently and cross-checked by two reviewers using a predefined data extraction form. Eligible studies were published between 1999 and 2009 and assessed quality of life ≥12 months after intensive care unit discharge by means of the Medical Outcomes Study 36-Item Short Form Health Survey, the RAND 36-Item Health Survey, EuroQol-5D, and/or the Nottingham Health Profile in adult intensive care unit patients.

DATA SYNTHESIS

Fifty-three articles (10 multicenters) were included, with the majority of studies performed in Europe (68%). The Medical Outcomes Study 36-Item Short Form Health Survey was used in 55%, and the EuroQol-5D, the Nottingham Health Profile, the RAND 36-Item Health Survey, or a combination was used in 21%, 9%, 8%, or 8%, respectively. A response rate of ≥80% was attained in 26 studies (49%). Critically ill patients had a lower quality of life than an age- and gender-matched population, but quality of life tended to improve over years. The worst reductions in quality of life were seen in cases of severe acute respiratory distress syndrome, prolonged mechanical ventilation, severe trauma, and severe sepsis. Study quality criteria, defined as a baseline quality of life assessment, the absence of major exclusion criteria, a description of nonresponders, and a comparison with a reference population were met in only four studies (8%). Results concerning the influence of severity of illness, comorbidity, preadmission quality of life, age, gender, or acquired complications were conflicting.

CONCLUSIONS

Quality of life differed on diagnostic category but, overall, critically ill patients had a lower quality of life than an age- and gender-matched population. A minority of studies met the predefined methodologic quality criteria. Results concerning the influence of the patients' characteristics and illnesses on long-term quality of life were conflicting.

Albumin administration in patients with severe sepsis due to secondary peritonitis

BACKGROUND

To determine whether or not intravenous administration of human albumin can reduce mortality in patients with severe sepsis due to secondary peritonitis.

METHODS

Adult patients who were admitted to the surgical intensive care unit (SICU) who fulfilled the criteria of severe sepsis due to secondary peritonitis were consecutively included in this retrospective study. Patients who received and those who did not receive at least a daily minimum of 25 g intravenous human albumin for 3 days during their first 7 days of SICU admission were classified as the study group and control group, respectively.

RESULTS

A total of 133 patients were included in this study. For patients with baseline serum albumin < or = 20 g/L, 28-day mortality was significantly lower in the study group. For patients with baseline serum albumin > 20 g/L, albumin administration had no significant effects on 28-day mortality.

CONCLUSION

For patients with severe sepsis due to secondary peritonitis, albumin administration may reduce 28-day mortality in patients whose baseline serum albumin is < or = 20 g/L, but no such effect was found in patients whose baseline serum albumin was > 20 g/L.

Health-related quality of life in patients treated for enterocutaneous fistula

BACKGROUND

Patients with enterocutaneous fistulas undergo long intensive treatment. The aim of this study was to investigate the long-term health-related quality of life (HRQL) of these patients.

METHODS

Consecutive patients treated for enterocutaneous fistula between 1990 and 2005 were eligible for this retrospective study. The Karnofsky Performance Scale (KPS), Short Form 36 (SF-36) and the Inflammatory Bowel Disease Questionnaire were used to measure HRQL. The SF-36 was matched with results from healthy controls. Patients also gave information on concurrent medical illnesses.

RESULTS

Of 135 patients, 44 died, 14 were lost to follow-up and 12 refused to participate; of the remaining 65, 62 participated (response rate 81 per cent). HRQL was independent of patient characteristics during treatment. Scores for SF-36 domains were lower than in their matched controls (P < 0.050). Concurrent medical illness (cancer, depression and gastrointestinal disease) significantly reduced HRQL (for example with a 40 per cent reduction in vitality). The median KPS score was 80, indicating that activities could be performed with effort and patients had some signs of disease.

CONCLUSION

HRQL is lower in patients treated for enterocutaneous fistula than in matched controls, particularly in those with concurrent medical illnesses. Patients treated successfully have normal independence in daily functioning.

What limits for acute care in the elderly?

PURPOSE OF REVIEW

This review aims to address the important question of the increasing life expectancy and the aging population in the healthcare system today. We try to give some elements that will help the reflection about the ethical stakes balancing the necessity of care in the increasing number of elderly patients and the limited resources available, in the special context of acute care.

RECENT FINDINGS

There is growing evidence that the chronological age itself is not a reliable marker of bad prognosis or of mortality. The new concept of frailty may better correlate with the aging process of the elderly. The frailty index is an integrative approach considering the multiple factors impacting on the aging individual. Applied in the practical arena, it might become a useful tool for clinicians.

SUMMARY

Aging implies many biological modifications at molecular, cellular, organic levels as well as of the behavior. Some aspects of these processes and their consequences on health are described. The frailty concept is detailed, and its potential interest explained. We conclude that the measurement of aging phenomenon, including the frailty index, may help us to better assess the true health and the required therapeutics of elderly patients.