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Voga G, Kovačić D. The relativity of age or geriatric medicine at the crossroads. Wien Klin Wochenschr 2016; 128:430-432. [PMID: 27873025 DOI: 10.1007/s00508-016-1128-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 10/31/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Gorazd Voga
- Dpt. of Intensive Internal Medicine, General Hospital Celje, Oblakova 5, 3000, Celje, Slovenia.
| | - Dragan Kovačić
- Dpt. of Cardiology, General Hospital Celje, Oblakova 5, 3000, Celje, Slovenia
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52
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Reyes JCL, Alonso JV, Fonseca J, Santos ML, Jiménez MDLÁRC, Braniff J. Characteristics and mortality of elderly patients admitted to the Intensive Care Unit of a district hospital. Indian J Crit Care Med 2016; 20:391-7. [PMID: 27555692 PMCID: PMC4968060 DOI: 10.4103/0972-5229.186219] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AIM To study all the elderly patients (≥75 years) who were admitted in an Intensive Care Unit (ICU) of a Spanish hospital and identify factors associated with mortality. PATIENTS AND METHODS A retrospective, observational data collected prospectively in patients ≥75 years recruited from the ICU in the period of January 2004 to December 2010. RESULTS During the study period, 1661 patients were admitted to our unit, of whom 553 (33.3%) were older than 75 years. The mean age was 79.9 years, 317 (57.3%) were male, and the overall in-hospital mortality was 94 patients (17% confidence interval 14-20.3%). When comparing patients who survived to those who died, we found significant differences in mean age (P = 0.001), Acute Physiologic Assessment and Chronic Health Evaluation II and Simplified Acute Physiology Scoring II (SAPS II) on admission (P < 0.0001, postoperative patients (P = 0.001), and need for mechanical ventilation (P < 0.0001). Comparing age groups, we found statistically significant differences in SAPS II (P = 0.007), diagnosis of non-ST-segment elevation myocardial infarction (P = 0.014), complicated postoperative period (P = 0.001), and pacemaker (P = 0.034). Mortality between the groups was statistically significant (P = 0.004). The survival between the group of 65 and 74 years and patients >75 years was not significant (P = 0.1390). CONCLUSIONS The percentage of elderly patients in our unit is high, with low mortality rates. The age itself is not the sole determinant for admission to the ICU and other factors should be taken into account.
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Affiliation(s)
- José Carlos Llamas Reyes
- Department of Emergency and Critical Care Medicine, Hospital Comarcal Valle de los Pedroches de Pozoblanco, Cordoba, Spain
| | - Joaquín Valle Alonso
- Department of Accident and Emergency Medicine, Southport and Formby District General Hospital, Merseyside PR8 6PN, UK
| | - Javier Fonseca
- Department of Family Medicine, Centro de Salud Montoro, Cordoba, Spain
| | - Margarita Luque Santos
- Department of Emergency and Critical Care Medicine, Hospital Comarcal Valle de los Pedroches de Pozoblanco, Cordoba, Spain
| | | | - Jay Braniff
- Department of Accident and Emergency Medicine, Southport and Formby District General Hospital, Merseyside PR8 6PN, UK
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53
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Singer JP, Lederer DJ, Baldwin MR. Frailty in Pulmonary and Critical Care Medicine. Ann Am Thorac Soc 2016; 13:1394-404. [PMID: 27104873 PMCID: PMC5021078 DOI: 10.1513/annalsats.201512-833fr] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/22/2016] [Indexed: 02/07/2023] Open
Abstract
Conceptualized first in the field of geriatrics, frailty is a syndrome characterized by a generalized vulnerability to stressors resulting from an accumulation of physiologic deficits across multiple interrelated systems. This accumulation of deficits results in poorer functional status and disability. Frailty is a "state of risk" for subsequent disproportionate declines in health status following new exposure to a physiologic stressor. Two predominant models have emerged to operationalize the measurement of frailty. The phenotype model defines frailty as a distinct clinical syndrome that includes conceptual domains such as strength, activity, wasting, and mobility. The cumulative deficit model defines frailty by enumerating the number of age-related things wrong with a person. The biological pathways driving frailty include chronic systemic inflammation, sarcopenia, and neuroendocrine dysregulation, among others. In adults with chronic lung disease, frailty is independently associated with more frequent exacerbations of lung disease, all-cause hospitalization, declines in functional status, and all-cause mortality. In addition, frail adults who become critically ill are more likely develop chronic critical illness or severe disability and have higher in-hospital and long-term mortality rates. The evaluation of frailty appears to provide important prognostic information above and beyond routinely collected measures in adults with chronic lung disease and the critically ill. The study of frailty in these populations, however, requires multipronged efforts aimed at refining clinical assessments, understanding the mechanisms, and developing therapeutic interventions.
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Affiliation(s)
- Jonathan P. Singer
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - David J. Lederer
- Department of Medicine and
- Department of Epidemiology, Columbia University Medical Center, New York, New York; and
| | - Matthew R. Baldwin
- Department of Medicine, Columbia University Medical Center, New York, New York
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54
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Fassier T, Duclos A, Abbas-Chorfa F, Couray-Targe S, West TE, Argaud L, Colin C. Elderly patients hospitalized in the ICU in France: a population-based study using secondary data from the national hospital discharge database. J Eval Clin Pract 2016; 22:378-86. [PMID: 26711152 DOI: 10.1111/jep.12497] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 01/10/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES In the global context of population ageing, understanding and monitoring intensive care use by the elderly is a strategic issue. National-level data are needed to overcome sampling biases that often limit epidemiologic studies of the critically ill elderly. The objective of this study was to describe intensive care use for hospitalized elderly patients using secondary data from the French national hospital discharge database. METHOD Structured assessment of the national database coverage and accuracy; cross-sectional analysis of hospitalizations including at least one admission in an intensive care unit (ICU) for patients aged ≥ 80 years from 1 January to 31 December 2009. RESULTS In 2009, people aged ≥ 80 years accounted for 5.4% of the population but 15.3% of the 215 210 adult hospitalizations involving intensive care in France. In this elderly group, the mean age was 84.0 (± 3.56) years, and 51.6% were male. In-hospital mortality was 33.9%. The median time spent in the ICU was 3 [interquartile range (IQR), 2-8] days, the median time spent in hospital was 14 (IQR, 8-24) days and 9% of hospitalizations ended by the patient's death involved intensive care. A surgical procedure was included in 43% of hospitalizations. Medical and surgical diagnosis-related group hospitalizations were characterized by significant differences in volume, mortality, ICU days and costs. CONCLUSIONS There was marked clinical heterogeneity in the population of elderly patients hospitalized in the ICU. These data provide baseline information and prompt further studies comparing intensive care utilization across age groups, between countries and over time.
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Affiliation(s)
- Thomas Fassier
- EAM 4128 Santé - Individu - Société, Université de Lyon, France
| | - Antoine Duclos
- EAM 4128 Santé - Individu - Société, Université de Lyon, France.,Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, France
| | - Fatima Abbas-Chorfa
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, France
| | | | - T Eoin West
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA, 98104, USA
| | - Laurent Argaud
- Service de Réanimation Médicale, Hospices Civils de Lyon, France
| | - Cyrille Colin
- EAM 4128 Santé - Individu - Société, Université de Lyon, France.,Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, France
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55
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Piroddi IMG, Barlascini C, Esquinas A, Braido F, Banfi P, Nicolini A. Non-invasive mechanical ventilation in elderly patients: A narrative review. Geriatr Gerontol Int 2016; 17:689-696. [PMID: 27215767 DOI: 10.1111/ggi.12810] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/17/2016] [Accepted: 03/25/2016] [Indexed: 10/21/2022]
Abstract
The treatment of acute respiratory failure with non-invasive ventilation (NIV) as a first-line therapy is increasingly common in intensive care units. The reduced invasiveness of NIV leads to better outcomes than endotracheal intubation in carefully selected groups of patients. Furthermore, the use of NIV as a palliative treatment for respiratory failure and dyspnea has become increasingly common. NIV also has an impact on the use of "do not intubate" orders. In the present narrative review, we explore the use and outcome of NIV in elderly patients. To accomplish this, we reviewed the most recent available medical literature. Geriatr Gerontol Int 2017; 17: 689-696.
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Affiliation(s)
| | - Cornelius Barlascini
- Hygiene and Health Medicine Unit Hospital of Sestri Levante, Sestri Levante, Italy
| | | | - Fulvio Braido
- Allergy and Respiratory Diseases Unit Department IRCSS AOU San Martino- IST, Genova, Italy
| | - Paolo Banfi
- Pulmonary Rehabilitation Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Antonello Nicolini
- Respiratory Diseases Unit Hospital of Sestri Levante, Sestri Levante, Italy
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56
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Garrouste-Orgeas M, Ruckly S, Grégoire C, Dumesnil AS, Pommier C, Jamali S, Golgran-Toledano D, Schwebel C, Clec'h C, Soufir L, Fartoukh M, Marcotte G, Argaud L, Verdière B, Darmon M, Azoulay E, Timsit JF. Treatment intensity and outcome of nonagenarians selected for admission in ICUs: a multicenter study of the Outcomerea Research Group. Ann Intensive Care 2016; 6:31. [PMID: 27076186 PMCID: PMC4830777 DOI: 10.1186/s13613-016-0133-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 03/28/2016] [Indexed: 11/10/2022] Open
Abstract
Background Outcome of very elderly patients admitted in intensive care unit (ICU) was most often reported for octogenarians. ICU admission demands for nonagenarians are increasing. The primary objective was to compare outcome and intensity of treatment of octogenarians and nonagenarians. Methods We performed an observational study in 12 ICUs of the Outcomerea™ network which prospectively upload data into the Outcomerea™ database. Patients >90 years old (case patients) were matched with patients 80–90 years old (control patients). Matching criteria were severity of illness at admission, center, and year of admission. Results A total of 2419 patients aged 80 or older and admitted from September 1997 to September 2013 were included. Among them, 179 (7.9 %) were >90 years old. Matching was performed for 176 nonagenarian patients. Compared with control patients, case patients were more often hospitalized for unscheduled surgery [54 (30.7 %) vs. 42 (23.9 %), p < 0.01] and had less often arterial monitoring for blood pressure [37 (21 %) vs. 53 (30.1 %), p = 0.04] and renal replacement therapy [5 (2.8 %) vs. 14 (8 %), p = 0.05] than control patients. ICU [44 (25 %) vs. 36 (20.5 %), p = 0.28] or hospital mortality [70 (39.8 %) vs. 64 (36.4 %), p = 0.46] and limitation of life-sustaining therapies were not significantly different in case versus control patients, respectively. Only 16/176 (14 %) of case patients were transferred to a geriatric unit. Conclusion This multicenter study reported that nonagenarians represented a small fraction of ICU patients. When admitted, these highly selected patients received similar life-sustaining treatments, except RRT, than octogenarians. ICU and hospital mortality were similar between the two groups. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0133-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maité Garrouste-Orgeas
- Service de Réanimation et de médecine intensive, Medical-Surgical ICU, Saint Joseph Hospital Network, 185 rue Raymond Losserand, 75014, Paris, France. .,Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, INSERM and Paris Diderot University, Department of Biostatistics - HUPNVS. - AP-HP, UFR de Médecine, Bichat University Hospital, Paris, France.
| | | | - Charles Grégoire
- Service de Réanimation et de médecine intensive, Medical-Surgical ICU, Saint Joseph Hospital Network, 185 rue Raymond Losserand, 75014, Paris, France
| | - Anne-Sylvie Dumesnil
- Medical-Surgical ICU, AP-HP, Antoine Béclère University Hospital, Clamart, France
| | | | - Samir Jamali
- Medical-Surgical, General Hospital, Dourdan, France
| | | | - Carole Schwebel
- Medical ICU, Albert Michallon University Hospital, Grenoble, France
| | - Christophe Clec'h
- Medical-Surgical ICU, AP-HP, Avicennes University Hospital, Bobigny, France
| | - Lilia Soufir
- Service de Réanimation et de médecine intensive, Medical-Surgical ICU, Saint Joseph Hospital Network, 185 rue Raymond Losserand, 75014, Paris, France
| | - Muriel Fartoukh
- Medical ICU, AP-HP, Tenon University Hospital, Paris, France
| | - Guillaume Marcotte
- Medical-Surgical ICU, Hospices civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Laurent Argaud
- Medical ICU, Hospices civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Bruno Verdière
- Medical-Surgical ICU, Delafontaine University Hospital, Saint Denis, France
| | - Michael Darmon
- Medical-Surgical ICU, Saint Etienne University Hospital, Saint Priest en Jarez, France
| | - Elie Azoulay
- Medical ICU, AP-HP, Saint Louis University Hospital, Paris, France
| | - Jean-François Timsit
- Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, INSERM and Paris Diderot University, Department of Biostatistics - HUPNVS. - AP-HP, UFR de Médecine, Bichat University Hospital, Paris, France.,Department of Biostatistics, Outcomerea, Paris, France.,Medical ICU, AP-HP, Bichat University Hospital, Paris, France
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57
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Rowe T, Araujo KLB, Van Ness PH, Pisani MA, Juthani-Mehta M. Outcomes of Older Adults With Sepsis at Admission to an Intensive Care Unit. Open Forum Infect Dis 2016; 3:ofw010. [PMID: 26925430 PMCID: PMC4766385 DOI: 10.1093/ofid/ofw010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 01/18/2016] [Indexed: 12/29/2022] Open
Abstract
Background. Sepsis is a major cause of morbidity and mortality among older adults. The main goals of this study were to assess the association of sepsis at intensive care unit (ICU) admission with mortality and to identify predictors associated with increased mortality in older adults. Methods. We conducted a prospective cohort study of 309 participants ≥60 years admitted to an ICU. Sepsis was defined as 2 of 4 systemic inflammatory response syndrome criteria plus a documented infection within 2 calendar days before or after admission. The main outcome measure was time to death within 1 year of ICU admission. Sepsis was evaluated as a predictor for mortality in a Cox proportional hazards model. Results. Of 309 participants, 196 (63%) met the definition of sepsis. Among those admitted with and without sepsis, 75 (38%) vs 20 (18%) died within 1 month of ICU admission (P < .001) and 117 (60%) vs 48 (42%) died within 1 year (P < .001). When adjusting for baseline characteristics, sepsis had a significant impact on mortality (hazard ratio [HR] = 1.80; 95% confidence interval [CI], 1.28–2.52; P < .001); however, after adjusting for baseline characteristics and process covariates (antimicrobials and vasopressor use within 48 hours of admission), the impact of sepsis on mortality became nonsignificant (HR = 1.26; 95% CI, .87–1.84; P = .22). Conclusions. The diagnosis of sepsis in older adults upon ICU admission was associated with an increase in mortality compared with those admitted without sepsis. After controlling for early use of antimicrobials and vasopressors for treatment, the association of sepsis with mortality was reduced.
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Affiliation(s)
- Theresa Rowe
- Section of General Internal Medicine and Geriatrics , Northwestern University , Chicago, Illinois
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Peigne V, Somme D, Guérot E, Lenain E, Chatellier G, Fagon JY, Saint-Jean O. Treatment intensity, age and outcome in medical ICU patients: results of a French administrative database. Ann Intensive Care 2016; 6:7. [PMID: 26769605 PMCID: PMC4713395 DOI: 10.1186/s13613-016-0107-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/05/2016] [Indexed: 12/18/2022] Open
Abstract
Background Intensive care unit (ICU) patients are aging, and older age has been associated with higher mortality in ICU. As previous studies have reported that older age was also associated with less intensive treatment, we investigated the relationship between age, treatment intensity and mortality in medical ICU patients. Methods
Data were extracted from the administrative database of 18 medical ICUs. Patients with a unique medical ICU stay and a Simplified Acute Physiology Score II (without age-related points) >15 were included. Treatment intensity was described with a novel indicator, which is a four-group classification based upon the most frequent ICU procedures. The relationship between age, treatment intensity and hospital mortality was analyzed with the estimation of standardized mortality ratio in the four groups of treatment intensity. Results
A total of 23,578 patients, including 3203 patients aged ≥80 years, were analyzed. Hospital mortality increased from 13 % for the younger patients (age < 40 years) to 38 % for the older patients (age ≥ 80 years), while Simplified Acute Physiology Score II (without age-related points) increased only from 36 (age < 40 years) to 43 (age ≥ 80). Hospital mortality increased with age in the four groups of treatment intensity. Standardized mortality ratio increased with age among the patients with less intensive treatment but was not associated with age among the patients with the highest treatment intensity. Conclusion Our results support the fact that the increase in mortality with age among ICU patients is not related to an increase in severity. Using a new tool to estimate ICU treatment intensity, our study suggests that mortality of ICU patients increases with age whatever the treatment intensity is. Further investigations are required to determinate whether this increase in mortality among older ICU patients is related to undertreatment or to a lower efficiency of organ support treatment.
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Affiliation(s)
- Vincent Peigne
- Medical ICU, Hôpital Européen Georges Pompidou, Paris, France.,Université Paris Descartes, Paris, France
| | - Dominique Somme
- Geriatrics Department, CHU de Rennes, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, 35033, Rennes Cedex 9, France. .,Université de Rennes 1, Rennes, France.
| | - Emmanuel Guérot
- Medical ICU, Hôpital Européen Georges Pompidou, Paris, France.,Université Paris Descartes, Paris, France
| | - Emilie Lenain
- Université Paris Descartes, Paris, France.,Clinical Research Unit, Hôpital Européen Georges Pompidou, Paris, France
| | - Gilles Chatellier
- Université Paris Descartes, Paris, France.,Clinical Research Unit, Hôpital Européen Georges Pompidou, Paris, France
| | - Jean-Yves Fagon
- Medical ICU, Hôpital Européen Georges Pompidou, Paris, France.,Université Paris Descartes, Paris, France
| | - Olivier Saint-Jean
- Université Paris Descartes, Paris, France.,Geriatrics Department, Hôpital Européen Georges Pompidou, Paris, France
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Becker S, Müller J, de Heer G, Braune S, Fuhrmann V, Kluge S. Clinical characteristics and outcome of very elderly patients ≥90 years in intensive care: a retrospective observational study. Ann Intensive Care 2015; 5:53. [PMID: 26690798 PMCID: PMC4686461 DOI: 10.1186/s13613-015-0097-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 12/07/2015] [Indexed: 11/10/2022] Open
Abstract
Background Since the overall prognosis of very elderly patients is generally limited, admissions to intensive care in these patients are often restricted. Therefore, only very few information is available on the prognosis of nonagenarians after intensive care treatment. The aim of this study was to analyze the clinical characteristics and outcomes of very elderly patients (≥90 years) admitted to an intensive care unit (ICU). Methods Monocentric, retrospective observational study of all patients aged ≥90 years admitted to the Department of Intensive Care Medicine with a total capacity of 132 ICU beds at the University Medical Center Hamburg in Germany between January 2008 and June 2013. A multivariate Cox regression analysis was used to identify risk factors for 28-day outcome. Results A total of 372 patients ≥90 years of age were admitted to one of the departments ICUs. The majority of patients (66.7 %) were admitted as an emergency admission, of which half underwent unscheduled surgery. 39.8 % of patients required support by mechanical ventilation and vasoactive drugs, and 1.9 % of patients received renal replacement. ICU and hospital mortality rates were 18.3 and 30.9 %, respectively. Overall survival at 1 year after hospital discharge was 34.9 %. Multivariate Cox regression analysis revealed creatinine, bilirubin, age, and necessity of catecholamines as independent risk factors and scheduled surgery as protective factor for 28-day outcome. Conclusion Nearly 70 % of patients aged ≥90 years were discharged alive from hospital following treatment at the ICU, and more than half of them were still alive 1 year after their discharge. The results suggest that 1-year survival prognosis of very old ICU patients is not as poor as often perceived and that age per se should not be an exclusion criterion for ICU admission. Trial registration: WF-0561/13
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Affiliation(s)
- Sophie Becker
- Department of Intensive Care Medicine, University medical center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Jakob Müller
- Department of Intensive Care Medicine, University medical center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany. .,Department of Anesthesia, University medical center Hamburg-Eppendorf, Hamburg, Germany.
| | - Geraldine de Heer
- Department of Intensive Care Medicine, University medical center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Stephan Braune
- Department of Intensive Care Medicine, University medical center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University medical center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Stefan Kluge
- Department of Intensive Care Medicine, University medical center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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60
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The very old ICU patient: a never-ending story. Intensive Care Med 2015; 41:1996-8. [PMID: 26359170 DOI: 10.1007/s00134-015-4052-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 09/01/2015] [Indexed: 10/23/2022]
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Palomba H, Corrêa TD, Silva E, Pardini A, Assuncao MSCD. Comparative analysis of survival between elderly and non-elderly severe sepsis and septic shock resuscitated patients. ACTA ACUST UNITED AC 2015; 13:357-63. [PMID: 26313436 PMCID: PMC4943779 DOI: 10.1590/s1679-45082015ao3313] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 05/21/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To compare outcomes between elderly (≥65 years old) and non-elderly (<65 years old) resuscitated severe sepsis and septic shock patients and determine predictors of death among elderly patients. METHODS Retrospective cohort study including 848 severe sepsis and septic shock patients admitted to the intensive care unit between January 2006 and March 2012. RESULTS Elderly patients accounted for 62.6% (531/848) and non-elderly patients for 37.4% (317/848). Elderly patients had a higher APACHE II score [22 (18-28)versus 19 (15-24); p<0.001], compared to non-elderly patients, although the number of organ dysfunctions did not differ between the groups. No significant differences were found in 28-day and in-hospital mortality rates between elderly and non-elderly patients. The length of hospital stay was higher in elderly compared to non-elderly patients admitted with severe sepsis and septic shock [18 (10-41)versus 14 (8-29) days, respectively; p=0.0001]. Predictors of death among elderly patients included age, site of diagnosis, APACHE II score, need for mechanical ventilation and vasopressors. CONCLUSION In this study population early resuscitation of elderly patients was not associated with increased in-hospital mortality. Prospective studies addressing the long-term impact on functional status and quality of life are necessary.
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Affiliation(s)
| | | | - Eliézer Silva
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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62
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Andersen FH, Flaatten H, Klepstad P, Romild U, Kvåle R. Long-term survival and quality of life after intensive care for patients 80 years of age or older. Ann Intensive Care 2015; 5:53. [PMID: 26055187 PMCID: PMC4456598 DOI: 10.1186/s13613-015-0053-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 05/19/2015] [Indexed: 01/20/2023] Open
Abstract
Background Comparison of survival and quality of life in a mixed ICU population of patients 80 years of age or older with a matched segment of the general population. Methods We retrospectively analyzed survival of ICU patients ≥80 years admitted to the Haukeland University Hospital in 2000–2012. We prospectively used the EuroQol-5D to compare the health-related quality of life (HRQOL) between survivors at follow-up and an age- and gender-matched general population. Follow-up was 1–13.8 years. Results The included 395 patients (mean age 83.8 years, 61.0 % males) showed an overall survival of 75.9 (ICU), 59.5 (hospital), and 42.0 % 1 year after the ICU. High ICU mortality was predicted by age, mechanical ventilator support, SAPS II, maximum SOFA, and multitrauma with head injury. High hospital mortality was predicted by an unplanned surgical admission. One-year mortality was predicted by respiratory failure and isolated head injury. We found no differences in HRQOL at follow-up between survivors (n = 58) and control subjects (n = 179) or between admission categories. Of the ICU non-survivors, 63.2 % died within 2 days after ICU admission (n = 60), and 68.3 % of these had life-sustaining treatment (LST) limitations. LST limitations were applied for 71.3 % (n = 114) of the hospital non-survivors (ICU 70.5 % (n = 67); post-ICU 72.3 % (n = 47)). Conclusions Overall 1-year survival was 42.0 %. Survival rates beyond that were comparable to those of the general octogenarian population. Among survivors at follow-up, HRQOL was comparable to that of the age- and sex-matched general population. Patients admitted for planned surgery had better short- and long-term survival rates than those admitted for medical reasons or unplanned surgery for 3 years after ICU admittance. The majority of the ICU non-survivors died within 2 days, and most of these had LST limitation decisions. Electronic supplementary material The online version of this article (doi:10.1186/s13613-015-0053-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Finn H Andersen
- Department of Anesthesia and Intensive Care, Møre and Romsdal Health Trust, Ålesund Hospital, 6026, Ålesund, Norway,
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Ferrão C, Quintaneiro C, Camila C, Aragão I, Cardoso T. Evaluation of long-term outcomes of very old patients admitted to intensive care: Survival, functional status, quality of life, and quality-adjusted life-years. J Crit Care 2015; 30:1150.e7-11. [PMID: 26143283 DOI: 10.1016/j.jcrc.2015.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 03/19/2015] [Accepted: 05/12/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate long-term outcomes among a population of very old patients (≥80years) after nonelective intensive care unit (ICU) admission. METHODS A retrospective study of very old patients admitted to a mixed ICU between 2006 and 2012 was conducted. A detailed description was made; functional status was assessed through the modified Rankin Scale and quality of life through EQ-5D-3L. Follow-up results are compared between 3 groups: very old with "old" (66-79 years) and "non-old" (≤65years) patients. RESULTS A total of 278 very old patients were admitted into the ICU representing 10.3% of admissions. The mean (SD) Simplified Acute Physiology Score II was 61 (16) predicting a hospital mortality of 70%, and the observed hospital mortality was 53%. Two-year survival rate was 38%. Of the 158 patients who survived in the ICU, 51 were evaluated in the outpatient clinic, and of those, 25 (51%) had already resumed previous functional activity. Evaluation through the modified Rankin Scale showed that 29 (60%) remained independent in their daily activities. When comparing the 3 groups, several differences were observed between theme, with the oldest groups (>80years) reporting more problems in motility, self-care, and usual activities. The respondent's self-rated health through the median visual analog scale score on the day of the outpatient clinic appointment decreased with age. CONCLUSIONS For those who survive, return to previous functional activity was likely. Long-term survival and quality of life achieved afterward were translated in more than a year of perfect health status gained.
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Affiliation(s)
- Cláudia Ferrão
- Hospital de Santo António-Centro Hospitalar do Porto, Internal Medicine, Oporto Medical Center, University of Porto, Largo Prof. Abel Salazar, Porto, Portugal; Hospital de Santo António-Centro Hospitalar do Porto, Unidade de Cuidados Intensivos Polivalentes, Oporto Medical Center, University of Porto, Largo Prof. Abel Salazar, Porto, Portugal.
| | - Cláudio Quintaneiro
- Hospital de Santo António-Centro Hospitalar do Porto, Unidade de Cuidados Intensivos Polivalentes, Oporto Medical Center, University of Porto, Largo Prof. Abel Salazar, Porto, Portugal; Internal Medicine, Hospital Distrital da Figueira da Foz, Gala, Figueira da Foz, Portugal.
| | - Cláudia Camila
- Department of Health Information and Decision Sciences, Center for Research and Health Technology and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal.
| | - Irene Aragão
- Hospital de Santo António-Centro Hospitalar do Porto, Unidade de Cuidados Intensivos Polivalentes, Oporto Medical Center, University of Porto, Largo Prof. Abel Salazar, Porto, Portugal.
| | - Teresa Cardoso
- Hospital de Santo António-Centro Hospitalar do Porto, Unidade de Cuidados Intensivos Polivalentes, Oporto Medical Center, University of Porto, Largo Prof. Abel Salazar, Porto, Portugal.
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Orsini J, Butala A, Salomon S, Studer S, Gadhia S, Shamian B, Prajapati R, Blaak C. Prognostic factors associated with adverse outcome among critically ill elderly patients admitted to the intensive care unit. Geriatr Gerontol Int 2014; 15:889-94. [PMID: 25255733 DOI: 10.1111/ggi.12363] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite concerns over the appropriateness and quality of care provided in the intensive care unit (ICU) at the end of life, the number of elderly patients who receive critical care is increasing. Despite this, many physicians have doubts as to whether elderly patients are good candidates for ICU care because of the apparently poor outcome during and after critical care in this population. The objective of the present study was to describe the clinical characteristics and outcome of a geriatric population admitted to the ICU. MATERIALS AND METHODS A single-center, prospective, observational study was carried out among geriatric patients, aged 75 years or older, admitted to ICU. RESULTS A total of 71 patients were admitted to ICU during the study period. Their mean age was 83 years (range 75-98 years), with a mean Acute Physiology and Chronic Health Evaluation-II score of 21.8 (range 8-39) on admission to ICU. A total of 48 patients (68%) required mechanical ventilation, and 39 (55%) received at least one vasoactive drug. The mean ICU length of stay was 4.6 days (range 1-18 days), and it was similar for ICU survivors and non-survivors (4.7 vs 4.5). A total of 14 patients (19.7%) were admitted after cardiac arrest, and eight (57.1%) of them died in ICU. A total of 28 patients (39.4%) died in the hospital, and 18 (25.4%) died in ICU. CONCLUSION Advanced age, critical illness, cardiopulmonary resuscitation, and needs for mechanical ventilation and/or vasopressor therapy are independent risk factors associated with adverse outcome in elderly patients admitted to ICU. Alternatives for ICU admission should be considered in geriatric patients with severe critical illnesses.
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Affiliation(s)
- Jose Orsini
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, New York, New York, USA
| | - Ashvin Butala
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, New York, New York, USA
| | - Say Salomon
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, New York, New York, USA
| | - Sean Studer
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, New York, New York, USA
| | - Shardul Gadhia
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, New York, New York, USA
| | - Ben Shamian
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, New York, New York, USA
| | - Ramesh Prajapati
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, New York, New York, USA
| | - Christa Blaak
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, New York, New York, USA
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Comparison of intensive-care-unit-acquired infections and their outcomes among patients over and under 80 years of age. J Hosp Infect 2014; 87:152-8. [DOI: 10.1016/j.jhin.2014.03.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 03/27/2014] [Indexed: 11/21/2022]
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Gibson AA, Hay AW, Ray DC. Patients with hip fracture admitted to critical care: epidemiology, interventions and outcome. Injury 2014; 45:1066-70. [PMID: 24680801 DOI: 10.1016/j.injury.2014.02.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 02/07/2014] [Accepted: 02/25/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Although there is much current debate about the use of critical care to enhance peri-operative care of patients with hip fracture there are limited supporting data. We investigated the epidemiology, critical care interventions and outcomes of patients with hip fracture admitted to a large UK critical care unit. PATIENTS AND METHODS We reviewed all patients with hip fracture (excluding those with multiple trauma, and those with femoral shaft or peri-prosthetic fracture) who were admitted to our critical care unit during a four year period. We recorded patient characteristics, reason for admission to critical care, interventions and organ support performed, and patient outcome. RESULTS We identified 99 patients with a mean age of 81 years; this represented 1% of patients admitted to critical care, and 2.4% of patients with hip fracture admitted to hospital during the study period. Fifty-two patients required no organ support; 19 received only respiratory support, 13 only cardiovascular support, 12 received both respiratory and cardiovascular support, and 3 received respiratory, cardiovascular and renal support. Outcome worsened as the level of organ support increased (p=0.01). Fifteen patients died in critical care, acute hospital mortality was 33% and 1-year mortality was 54%. No patient for whom admission was planned before surgery died in critical care and the 30-day mortality for this group was 13%. Outcome was related to the time between surgery and critical care admission: patients admitted before surgery or longer than 2 days after surgery had worse outcomes (p=0.001). The reason for admission to critical care also influenced outcome: patients with sepsis had poor outcome with one-third dying in critical care and a further one-third not surviving to hospital discharge. CONCLUSIONS The major determinants of outcome in this population were reason for admission, and timing of admission to critical care. One year survival was better than that for unselected patients aged >80 years admitted to critical care. Admission to critical care and use of enhanced peri-operative care for selected hip fracture patients is entirely appropriate and beneficial.
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Affiliation(s)
- Alistair A Gibson
- Department of Anaesthesia & Critical Care, Royal Infirmary of Edinburgh, United Kingdom
| | - Alasdair W Hay
- Department of Critical Care, Royal Infirmary of Edinburgh, United Kingdom
| | - David C Ray
- Department of Anaesthesia & Critical Care, Royal Infirmary of Edinburgh, United Kingdom.
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High burden of palliative needs among older intensive care unit survivors transferred to post-acute care facilities. a single-center study. Ann Am Thorac Soc 2014; 10:458-65. [PMID: 23987743 DOI: 10.1513/annalsats.201303-039oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
RATIONALE Adults with chronic critical illness (tracheostomy after ≥ 10 d of mechanical ventilation) have a high burden of palliative needs, but little is known about the actual use and potential need of palliative care services for the larger population of older intensive care unit (ICU) survivors discharged to post-acute care facilities. OBJECTIVES To determine whether older ICU survivors discharged to post-acute care facilities have potentially unmet palliative care needs. METHODS We examined electronic records from a 1-year cohort of 228 consecutive adults ≥ 65 years of age who had their first medical-ICU admission in 2009 at a single tertiary-care medical center and survived to discharge to a post-acute care facility (excluding hospice). Use of palliative care services was defined as having received a palliative care consultation. Potential palliative care needs were defined as patient characteristics suggestive of physical or psychological symptom distress or anticipated poor prognosis. We examined the prevalence of potential palliative needs and 6-month mortality. MEASUREMENTS AND MAIN RESULTS The median age was 78 years (interquartile range, 71-84 yr), and 54% received mechanical ventilation for a median of 7 days (interquartile range, 3-16 d). Six subjects (2.6%) received a palliative care consultation during the hospitalization. However, 88% had at least one potential palliative care need; 22% had chronic wounds, 37% were discharged on supplemental oxygen, 17% received chaplaincy services, 23% preferred to not be resuscitated, and 8% were designated "comfort care." The 6-month mortality was 40%. CONCLUSIONS Older ICU survivors from a single center who required postacute facility care had a high burden of palliative care needs and a high 6-month mortality. The in-hospital postcritical acute care period should be targeted for palliative care assessment and intervention.
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Lagu T, Zilberberg MD, Tjia J, Pekow PS, Lindenauer PK. Use of mechanical ventilation by patients with and without dementia, 2001 through 2011. JAMA Intern Med 2014; 174:999-1001. [PMID: 24781856 PMCID: PMC4532282 DOI: 10.1001/jamainternmed.2014.1179] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Increasing demand for US critical care resources, including beds, intensivists, and invasive mechanical ventilation (IMV),, has placed substantial strain on the critical care system. Since 2000, elderly patients treated in the intensive care unit have received higher intensity care (and have experienced lower mortality rates) than historical cohorts. Yet certain populations of elderly patients exposed to intensive care experience substantial long-term adverse effects, including functional decline and excess mortality. Patients with dementia receiving IMV, for example, are at high risk for delirium, which confers a 3.2-fold increased risk of 6-month mortality. The increasing use of aggressive therapies suggests that demand for IMV in elderly populations will increase in the future, both among patients that are likely to benefit and among those with terminal illness. We examined temporal trends in IMV use by older patients with and without dementia and projected future use.
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Affiliation(s)
- Tara Lagu
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts2Division of General Medicine, Baystate Medical Center, Springfield, Massachusetts3Tufts University School of Medicine, Boston, Massachusetts
| | - Marya D Zilberberg
- EviMed Research Group, LLC, Goshen, Massachusetts5School of Public Health and Health Sciences, University of Massachusetts-Amherst, Amherst
| | - Jennifer Tjia
- Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Penelope S Pekow
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts5School of Public Health and Health Sciences, University of Massachusetts-Amherst, Amherst
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts3Tufts University School of Medicine, Boston, Massachusetts
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Khouri T, Kabeshova A, Annweiler C, Mercat A, Beauchet O, Lerolle N. Amount of care per survivor in young and older patients hospitalized in intensive care unit: a retrospective study. J Gerontol A Biol Sci Med Sci 2014; 69:1291-8. [PMID: 24721724 DOI: 10.1093/gerona/glu051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND It is unknown whether the amount of care deployed in the intensive care unit population divided by the number of survivors, that is, amount of care per survivor including the care performed for nonsurvivors, differs between patients older and younger than 75 years of age. METHODS Data were extracted from the computerized files of all 2,220 patients admitted in a medical intensive care unit between January 2009 and December 2010. Patients ≥75 and <75 years old were compared. The Omega score per survivor (OMEGA/S) was calculated in both age groups by dividing the total amount of Omega points, a score of cumulated care load calculated over intensive care unit stay, by the number of survivors in each group. RESULTS OMEGA/S was 26% higher in elderly versus younger patients when considering intensive care unit mortality and 40% higher when considering hospital mortality. The absence of difference in raw Omega values between the two groups implies that OMEGA/S differences were related to differences in mortality rate. Simplified Acute Physiology Score II (without age-related points) strata analysis (<20, 20-39, 40-59, 60-79, and ≥80) showed that OMEGA/S in the elderly patients was significantly higher in the first three Simplified Acute Physiology Score II strata only. When calculating by main diagnosis categories, a major increase in the difference of OMEGA/S between elderly and younger patients was observed in cardiac arrest patients due to a major difference in mortality rate. CONCLUSIONS Elderly patients required a significantly higher care load per survivor in comparison to younger patients. This excess was mainly due to patients with low initial severity.
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Affiliation(s)
- Tarik Khouri
- Department of Medical Intensive Care and Hyperbaric Medicine, Angers University Hospital, France
| | - Anastasia Kabeshova
- UPRES EA 4638, LUNAM, Angers University, France. Department of Neuroscience, Division of Geriatric Medicine, Angers University Hospital, France. Angers University Memory Clinic, France
| | - Cedric Annweiler
- UPRES EA 4638, LUNAM, Angers University, France. Department of Neuroscience, Division of Geriatric Medicine, Angers University Hospital, France. Angers University Memory Clinic, France. Robarts Research Institute, London, Ontario, Canada. Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Alain Mercat
- Department of Medical Intensive Care and Hyperbaric Medicine, Angers University Hospital, France
| | - Olivier Beauchet
- UPRES EA 4638, LUNAM, Angers University, France. Department of Neuroscience, Division of Geriatric Medicine, Angers University Hospital, France. Angers University Memory Clinic, France
| | - Nicolas Lerolle
- Department of Medical Intensive Care and Hyperbaric Medicine, Angers University Hospital, France.
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Fuchs L, Novack V, McLennan S, Celi LA, Baumfeld Y, Park S, Howell MD, Talmor DS. Trends in severity of illness on ICU admission and mortality among the elderly. PLoS One 2014; 9:e93234. [PMID: 24699251 PMCID: PMC3974713 DOI: 10.1371/journal.pone.0093234] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 03/03/2014] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND There is an increase in admission rate for elderly patients to the ICU. Mortality rates are lower when more liberal ICU admission threshold are compared to more restrictive threshold. We sought to describe the temporal trends in elderly admissions and outcomes in a tertiary hospital before and after the addition of an 8-bed medical ICU. METHODS We conducted a retrospective analysis of a comprehensive longitudinal ICU database, from a large tertiary medical center, examining trends in patients' characteristics, severity of illness, intensity of care and mortality rates over the years 2001-2008. The study population consisted of elderly patients and the primary endpoints were 28 day and one year mortality from ICU admission. RESULTS Between the years 2001 and 2008, 7,265 elderly patients had 8,916 admissions to ICU. The rate of admission to the ICU increased by 5.6% per year. After an eight bed MICU was added, the severity of disease on ICU admission dropped significantly and crude mortality rates decreased thereafter. Adjusting for severity of disease on presentation, there was a decreased mortality at 28- days but no improvement in one- year survival rates for elderly patient admitted to the ICU over the years of observation. Hospital mortality rates have been unchanged from 2001 through 2008. CONCLUSION In a high capacity ICU bed hospital, there was a temporal decrease in severity of disease on ICU admission, more so after the addition of additional medical ICU beds. While crude mortality rates decreased over the study period, adjusted one-year survival in ICU survivors did not change with the addition of ICU beds. These findings suggest that outcome in critically ill elderly patients may not be influenced by ICU admission. Adding additional ICU beds to deal with the increasing age of the population may therefore not be effective.
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Affiliation(s)
- Lior Fuchs
- Intensive Care Unit, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Science, Ben Gurion University of the Negev, Beer-Sheba, Israel
- * E-mail:
| | - Victor Novack
- Intensive Care Unit, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Science, Ben Gurion University of the Negev, Beer-Sheba, Israel
| | - Stuart McLennan
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Leo Anthony Celi
- Intensive Care Unit, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard-MIT Division of Health Science and Technology, Boston, Massachusetts, United States of America
| | - Yael Baumfeld
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Science, Ben Gurion University of the Negev, Beer-Sheba, Israel
| | - Shinhyuk Park
- Harvard-MIT Division of Health Science and Technology, Boston, Massachusetts, United States of America
| | - Michael D. Howell
- Intensive Care Unit, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Daniel S. Talmor
- Intensive Care Unit, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
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Commereuc M, Rondeau E, Ridel C. [Acute kidney injury in elderly patient: Diagnostic and therapeutic aspects]. Presse Med 2014; 43:341-7. [PMID: 24560978 DOI: 10.1016/j.lpm.2013.07.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 06/08/2013] [Accepted: 07/08/2013] [Indexed: 10/25/2022] Open
Abstract
Acute renal failure in elderly patient is a public health problem. It is worsen by physiological status and anatomical changes associated with age, polymedication and chronic diseases. The etiologies of acute renal failure in the elderly are the same as in adults. Their distribution is specific with a large proportion of obstructive acute renal failure. The diagnostic and therapeutic strategies are the same as for young adults; the injection of iodinated-contrast should be avoided. Therapeutic strategies are discussed in terms of quality of life pre-morbid. Age is not considered a determinant of intensive treatment decisions. Renal replacement therapy in the elderly is not associated with excess mortality. Prevention of acute renal failure should be a permanent concern.
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Affiliation(s)
- Morgane Commereuc
- Hôpital Tenon, service d'urgences néphrologiques et transplantation rénale, 75020 Paris, France.
| | - Eric Rondeau
- Hôpital Tenon, service d'urgences néphrologiques et transplantation rénale, 75020 Paris, France
| | - Christophe Ridel
- Hôpital Tenon, service d'urgences néphrologiques et transplantation rénale, 75020 Paris, France
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Shigemura K, Osawa K, Jikimoto T, Yoshida H, Hayama B, Ohji G, Iwata K, Fujisawa M, Arakawa S. Comparison of the clinical risk factors between Candida albicans and Candida non-albicans species for bloodstream infection. J Antibiot (Tokyo) 2014; 67:311-4. [DOI: 10.1038/ja.2013.141] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 11/17/2013] [Accepted: 12/02/2013] [Indexed: 11/09/2022]
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The feasibility of measuring frailty to predict disability and mortality in older medical intensive care unit survivors. J Crit Care 2014; 29:401-8. [PMID: 24559575 DOI: 10.1016/j.jcrc.2013.12.019] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 12/30/2013] [Accepted: 12/30/2013] [Indexed: 12/18/2022]
Abstract
PURPOSE To determine whether frailty can be measured within 4 days prior to hospital discharge in older intensive care unit (ICU) survivors of respiratory failure and whether it is associated with post-discharge disability and mortality. MATERIALS AND METHODS We performed a single-center prospective cohort study of 22 medical ICU survivors age 65 years or older who had received noninvasive or invasive mechanical ventilation for at least 24 hours. Frailty was defined as a score of ≥3 using Fried's 5-point scale. We measured disability with the Katz Activities of Daily Living. We estimated unadjusted associations between Fried's frailty score and incident disability at 1-month and 6-month mortality using Cox proportional hazard models. RESULTS The mean (SD) age was 77 (9) years, mean Acute Physiology and Chronic Health Evaluation II score was 27 (9.7), mean frailty score was 3.4 (1.3), and 18 (82%) were frail. Nine subjects (41%) died within 6 months, and all were frail. Each 1-point increase in frailty score was associated with a 90% increased rate of incident disability at 1-month (rate ratio: 1.9, 95% CI 0.7-4.9) and a threefold increase in 6-month mortality (rate ratio: 3.0, 95% CI 1.4-6.3). CONCLUSIONS Frailty can be measured in older ICU survivors near hospital discharge and is associated with 6-month mortality in unadjusted analysis. Larger studies to determine if frailty independently predicts outcomes are warranted.
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Guidet B, Thomas C, Pateron D, Pichereau C, Bigé N, Boumendil A, Garrouste-Orgeas M, N’guyen YL. Personnes âgées et réanimation. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-013-0814-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Biston P, Aldecoa C, Devriendt J, Madl C, Chochrad D, Vincent JL, De Backer D. Outcome of elderly patients with circulatory failure. Intensive Care Med 2013; 40:50-6. [PMID: 24132383 DOI: 10.1007/s00134-013-3121-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Accepted: 09/17/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE The proportion of elderly patients admitted to the ICU is increasing. Mortality rates are known to increase with age but the impact of age on outcomes after circulatory shock has not been well defined. METHODS We performed a secondary analysis of data from a large randomized trial comparing the effects of dopamine and norepinephrine on outcome in the ICU. Patients were separated into not old (<75 years), old (75-84 years), and very old (≥85 years). RESULTS Of the 1,679 patients included in the initial trial, 1,651 had sufficient age data available: 1,157 (70%) were not old, 410 (25%) were old, and 84 (5%) were very old. There were minor differences among the age groups in the APACHE II score calculated without the age component (not old, 17 ± 9; old, 18 ± 9; very old, 19 ± 9; p = 0.047), but SOFA scores were similar (not old, 9 ± 4; old, 9 ± 3; very old, 9 ± 3; p = 0.76). Mortality rates were higher in old and very old patients at 28 days, at hospital discharge, and after 6 and 12 months. Most very old patients were dead at 6 (92%) and 12 months (97%). Mortality rates increased with age in all types of shock. Using multivariable analysis, the risk of death was higher in very old patients as compared to not old (adjusted OR 0.33, 95% CI 0.2-0.56, p < 0.001). CONCLUSIONS Ageing is independently associated with higher mortality rates in patients with circulatory failure, whatever the etiology. By 1 year after admission, most patients 85 years of age and older were dead.
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Affiliation(s)
- Patrick Biston
- Department of Intensive Care, CHU Charleroi, Université Libre de Bruxelles, Charleroi, Belgium
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Mudumbai SC, Cronkite R, Hu KU, Heidenreich PA, Gonzalez C, Bertaccini E, Stafford RS, Cason BA, Mariano ER, Wagner T. Association of age and packed red blood cell transfusion to 1-year survival--an observational study of ICU patients. Transfus Med 2013; 23:231-7. [PMID: 23480030 PMCID: PMC4012294 DOI: 10.1111/tme.12010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 12/31/2012] [Accepted: 01/09/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the 1-year survival for different age strata of intensive care unit (ICU) patients after receipt of packed red blood cell (PRBC) transfusions. BACKGROUND Despite guidelines documenting risks of PRBC transfusion and data showing that increasing age is associated with ICU mortality, little data exist on whether age alters the transfusion-related risk of decreased survival. METHODS We retrospectively examined data on 2393 consecutive male ICU patients admitted to a tertiary-care hospital from 2003 to 2009 in age strata: 21-50, 51-60, 61-70, 71-80 and >80 years. We calculated Cox regression models to determine the modifying effect of age on the impact of PRBC transfusion on 1-year survival by using interaction terms between receipt of transfusion and age strata, controlling for type of admission and Charlson co-morbidity indices. We also examined the distribution of admission haematocrit and whether transfusion rates differed by age strata. RESULTS All age strata experienced statistically similar risks of decreased 1-year survival after receipt of PRBC transfusions. However, patients age >80 were more likely than younger cohorts to have haematocrits of 25-30% at admission and were transfused at approximately twice the rate of each of the younger age strata. DISCUSSION We found no significant interaction between receipt of red cell transfusion and age, as variables, and survival at 1 year as an outcome.
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Affiliation(s)
- S C Mudumbai
- Anesthesiology and Perioperative Care Service; Center for Health Care Evaluation, VA Palo Alto Health Care System, Palo Alto, CA 94304, USA.
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Ma CF, Li FQ, Shi LN, Hu YA, Wang Y, Huang M, Kong QQ. Surveillance study of species distribution, antifungal susceptibility and mortality of nosocomial candidemia in a tertiary care hospital in China. BMC Infect Dis 2013; 13:337. [PMID: 23875950 PMCID: PMC3723814 DOI: 10.1186/1471-2334-13-337] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 07/18/2013] [Indexed: 12/02/2022] Open
Abstract
Background Bloodstream infections due to Candida species cause significant morbidity and mortality, and the epidemiology of Candida infection is changing. Surveillance for candidemia is necessary to detect trends in species distribution and antifungal resistance. Methods The medical and electronic records of all patients who had candidemia at the authors’ hospital from 2009 to 2011 were reviewed for demographic data and clinical information, including the infecting Candida species, resistance to antifungals and survival, and the presence of risk factors associated with candidemia. Results A total of 133 distinct episodes of candidemia were identified over the study period. The annual incidence of candidemia ranged between 0.71 and 0.85 cases/1000 hospital discharges. The most frequent Candida species were C. tropicalis (28.6%), followed by C. albicans (23.3%) and C. parapsilosis (19.5%). The rates of susceptibility to antifungal agents were as followed: voriconazole (97.8%), itraconazole (69.5%), fluconazole (46.1%), ketoconazole (38.9%). Out of 131 evaluable patients, 34 (26.0%) died within 30 days from the onset of candidemia. C. tropicalis candidemia was associated with the highest mortality rate (44.7%). Regarding the crude mortality in the different units, patients in Hemato-Oncology ward had the highest mortality rate (66.7%), followed by patients in cardiovascular wards and ICU (57.1% and 25.6%, respectively). Predictors of 30-day mortality were identified by uni- and multivariate analyses. Complicated abdominal surgery, presence of central venous catheter (CVC), neutropenia, candidemia due to C. tropicalis and poor treatment with fluconazole were significantly associated with the 30-day mortality. Presence of CVC (odds ratio[OR] = 4.177; 95% confidence interval [CI] = 1.698 to 10.278; P = 0.002) was the only independent predictor for mortality in the multivariate analysis. Conclusion This report provides baseline data for future epidemiological and susceptibility studies and for the mortality rates associated with candidemia in our hospital. The knowledge of the local epidemiological trends in Candida species isolated in blood cultures is important to guide therapeutic choices.
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Affiliation(s)
- Chun-fang Ma
- Laboratory of Molecular Biology, Institute of Medical Laboratory Sciences, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, PR China
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Baldwin MR, Narain WR, Wunsch H, Schluger NW, Cooke JT, Maurer MS, Rowe JW, Lederer DJ, Bach PB. A prognostic model for 6-month mortality in elderly survivors of critical illness. Chest 2013; 143:910-919. [PMID: 23632902 DOI: 10.1378/chest.12-1668] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Although 1.4 million elderly Americans survive hospitalization involving intensive care annually, many are at risk for early mortality following discharge. No models that predict the likelihood of death after discharge exist explicitly for this population. Therefore, we derived and externally validated a 6-month postdischarge mortality prediction model for elderly ICU survivors. METHODS We derived the model from medical record and claims data for 1,526 consecutive patients aged ≥ 65 years who had their first medical ICU admission in 2006 to 2009 at a tertiary-care hospital and survived to discharge (excluding those patients discharged to hospice). We then validated the model in 1,010 patients from a different tertiary-care hospital. RESULTS Six-month mortality was 27.3% and 30.2% in the derivation and validation cohorts, respectively. Independent predictors of mortality (in descending order of contribution to the model's predictive power) were a do-not-resuscitate order, older age, burden of comorbidity, admission from or discharge to a skilled-care facility, hospital length of stay, principal diagnoses of sepsis and hematologic malignancy, and male sex. For the derivation and external validation cohorts, the area under the receiver operating characteristic curve was 0.80 (SE, 0.01) and 0.71 (SE, 0.02), respectively, with good calibration for both (P = 0.31 and 0.43). CONCLUSIONS Clinical variables available at hospital discharge can help predict 6-month mortality for elderly ICU survivors. Variables that capture elements of frailty, disability, the burden of comorbidity, and patient preferences regarding resuscitation during the hospitalization contribute most to this model's predictive power. The model could aid providers in counseling elderly ICU survivors at high risk of death and their families.
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Affiliation(s)
- Matthew R Baldwin
- Division of Pulmonary, Allergy, and Critical Care, Columbia University, New York, NY.
| | - Wazim R Narain
- Data Analytics Group, New York-Presbyterian Hospital, New York, NY
| | - Hannah Wunsch
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, New York, NY
| | - Neil W Schluger
- Division of Pulmonary, Allergy, and Critical Care, Columbia University, New York, NY; Department of Epidemiology, New York, NY
| | - Joseph T Cooke
- Division of Pulmonary and Critical Care, Weill Cornell Medical College, New York, NY
| | - Mathew S Maurer
- Division of Cardiology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - John W Rowe
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY
| | - David J Lederer
- Division of Pulmonary, Allergy, and Critical Care, Columbia University, New York, NY; Department of Epidemiology, New York, NY
| | - Peter B Bach
- Center for Health Policy and Outcomes, Memorial Sloan-Kettering Cancer Center, New York, NY
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Abstract
SummaryAs the proportion of elderly people in the general population increases, so does the number admitted to critical care. In caring for an older patient, the intensivist has to balance the complexities of an acute illness, pre-existing co-morbidities and patient preference for life-sustaining treatment with the chances of survival, quality of life after critical illness and rationing of expensive, limited resources. This remains one of the most challenging areas of critical care practice.
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Eliott S, Chaboyer W, Ernest D, Doric A, Endacott R. A national survey of Australian Intensive Care Unit (ICU) Liaison Nurse (LN) services. Aust Crit Care 2012; 25:253-62. [DOI: 10.1016/j.aucc.2012.03.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 02/24/2012] [Accepted: 03/13/2012] [Indexed: 10/28/2022] Open
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Blancas R, Martínez-González Ó, Vigil D, López-Matamala B, Algaba Á, Martín-Parra C, Ballesteros D, Estébanez B, Chana M, Serrano-Castañeda J, Martín-Delgado C. Influence of age and intensity of treatment on intra-ICU mortality of patients older than 65 years admitted to the intensive care unit. Eur Geriatr Med 2012. [DOI: 10.1016/j.eurger.2012.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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83
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Morrow DA, Fang JC, Fintel DJ, Granger CB, Katz JN, Kushner FG, Kuvin JT, Lopez-Sendon J, McAreavey D, Nallamothu B, Page RL, Parrillo JE, Peterson PN, Winkelman C. Evolution of Critical Care Cardiology: Transformation of the Cardiovascular Intensive Care Unit and the Emerging Need for New Medical Staffing and Training Models. Circulation 2012; 126:1408-28. [DOI: 10.1161/cir.0b013e31826890b0] [Citation(s) in RCA: 199] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Cleveland AA, Farley MM, Harrison LH, Stein B, Hollick R, Lockhart SR, Magill SS, Derado G, Park BJ, Chiller TM. Changes in incidence and antifungal drug resistance in candidemia: results from population-based laboratory surveillance in Atlanta and Baltimore, 2008-2011. Clin Infect Dis 2012; 55:1352-61. [PMID: 22893576 DOI: 10.1093/cid/cis697] [Citation(s) in RCA: 280] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Candidemia is common and associated with high morbidity and mortality; changes in population-based incidence rates have not been reported. METHODS We conducted active, population-based surveillance in metropolitan Atlanta, Georgia, and Baltimore City/County, Maryland (combined population 5.2 million), during 2008-2011. We calculated candidemia incidence and antifungal drug resistance compared with prior surveillance (Atlanta, 1992-1993; Baltimore, 1998-2000). RESULTS We identified 2675 cases of candidemia with 2329 isolates during 3 years of surveillance. Mean annual crude incidence per 100 000 person-years was 13.3 in Atlanta and 26.2 in Baltimore. Rates were highest among adults aged ≥65 years (Atlanta, 59.1; Baltimore, 72.4) and infants (aged <1 year; Atlanta, 34.3; Baltimore, 46.2). In both locations compared with prior surveillance, adjusted incidence significantly declined for infants of both black and white race (Atlanta: black risk ratio [RR], 0.26 [95% confidence interval {CI}, .17-.38]; white RR: 0.19 [95% CI, .12-.29]; Baltimore: black RR, 0.38 [95% CI, .22-.64]; white RR: 0.51 [95% CI: .29-.90]). Prevalence of fluconazole resistance (7%) was unchanged compared with prior surveillance; 32 (1%) isolates were echinocandin-resistant, and 9 (8 Candida glabrata) were multidrug resistant to both fluconazole and an echinocandin. CONCLUSIONS We describe marked shifts in candidemia epidemiology over the past 2 decades. Adults aged ≥65 years replaced infants as the highest incidence group; adjusted incidence has declined significantly in infants. Use of antifungal prophylaxis, improvements in infection control, or changes in catheter insertion practices may be contributing to these declines. Further surveillance for antifungal resistance and efforts to determine effective prevention strategies are needed.
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Affiliation(s)
- Angela Ahlquist Cleveland
- Mycotic Diseases Branch, Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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85
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Fuchs L, Chronaki CE, Park S, Novack V, Baumfeld Y, Scott D, McLennan S, Talmor D, Celi L. ICU admission characteristics and mortality rates among elderly and very elderly patients. Intensive Care Med 2012; 38:1654-61. [PMID: 22797350 DOI: 10.1007/s00134-012-2629-6] [Citation(s) in RCA: 161] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 06/13/2012] [Indexed: 12/14/2022]
Abstract
PURPOSE The effect of advanced age per se versus severity of chronic and acute diseases on the short- and long-term survival of older patients admitted to the intensive care unit (ICU) remains unclear. METHODS Intensive care unit admissions to the surgical ICU and medical ICU of patients older than 65 years were analyzed. Patients were divided into three age groups: 65-74, 75-84, and 85 and above. The primary endpoints were 28-day and 1-year mortality. RESULTS The analysis focused on 7,265 patients above the age of 65, representing 45.7 % of the total ICU population. From the first to third age group there was increased prevalence of heart failure (25.9-40.3 %), cardiac arrhythmia (24.6-43.5 %), and valvular heart disease (7.5-15.8 %). There was reduced prevalence of diabetes complications (7.5-2.4 %), alcohol abuse (4.1-0.6 %), chronic obstructive pulmonary disease (COPD) (24.4-17.4 %), and liver failure (5.0-1.0 %). Logistic regression analysis adjusted for gender, sequential organ failure assessment, do not resuscitate, and Elixhauser score found that patients from the second and third age group had odds ratios of 1.38 [95 % confidence interval (CI) 1.19-1.59] and 1.53 (95 % CI 1.29-1.81) for 28-day mortality as compared with the first age group. Cox regression analysis for 1-year mortality in all populations and in 28-day survivors showed the same trend. CONCLUSIONS The proportion of elderly patients from the total ICU population is high. With advancing age, the proportion of various preexisting comorbidities and the primary reason for ICU admission change. Advanced age should be regarded as a significant independent risk factor for mortality, especially for ICU patients older than 75.
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Affiliation(s)
- Lior Fuchs
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 1 Deaconess Rd. CC-470, Boston, MA 02215, USA.
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Nasa P, Juneja D, Singh O, Dang R, Arora V. Severe sepsis and its impact on outcome in elderly and very elderly patients admitted in intensive care unit. J Intensive Care Med 2012; 27:179-183. [PMID: 21436163 DOI: 10.1177/0885066610397116] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Elderly patients comprise an increasing proportion of intensive care unit (ICU) admissions. Advanced age and multiple comorbidities compromise their immunity and hence they may be more prone to succumbing to severe infection and have poorer outcome. We undertook this study to review impact of severe sepsis on mortality in the elderly patients. METHODS All patients admitted to a medical ICU of a tertiary care institute with severe sepsis or septic shock were prospectively included. Patients were divided into young (age below 60 years), old (age between 60 and 80 years), and very old (age above 80 years) groups. Data regarding baseline patient characteristics, admission APACHE II score, and ICU course including need for organ support and ICU length of stay were noted. Categorical data were analyzed using χ(2) or Fisher Exact test as appropriate and continuous data were analyzed using Student t test. Primary outcome measure was the ICU mortality. RESULTS Of 387 patients with sepsis, 132 patients who fulfilled the criteria for severe sepsis/septic shock were included in the analysis. The most common suspected site of infection was lungs (45.5%), followed by urinary tract (21.2%) and abdomen (16.7%). Intensive care unit mortality in younger patients was 45.6% as compared to 60.7% in old and 78.9% in very old patients (P = .035). The relative risk (RR) for dying in the old age was 1.125 and RR for dying in the very old age group was 1.487 as compared to the young patients. There was an increased need for organ support in the elderly and very elderly population as compared to the younger population. On multivariate analysis, only age of the patient was found to be independently predicting ICU mortality (P = .002, OR: 1.038, 95% CI: 1.014-1.062). CONCLUSIONS The risk of dying from severe sepsis is considerably higher in the elderly and very elderly subgroup of patients with age as an independent risk factor for mortality. Hence, early aggressive care to recognize and manage severe sepsis is required to improve outcome.
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Affiliation(s)
- Prashant Nasa
- Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi, India.
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87
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Nasa P, Juneja D, Singh O, Dang R, Arora V. Severe Sepsis and its Impact on Outcome in Elderly and Very Elderly Patients Admitted in Intensive Care Unit. J Intensive Care Med 2012; 27:179-183. [DOI: https:/doi.org/10.1177/0885066610397116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2025]
Abstract
Received October 7, 2010, and in revised form November 10, 2010. Accepted for publication December 7, 2010. Background: Elderly patients comprise an increasing proportion of intensive care unit (ICU) admissions. Advanced age and multiple comorbidities compromise their immunity and hence they may be more prone to succumbing to severe infection and have poorer outcome. We undertook this study to review impact of severe sepsis on mortality in the elderly patients. Methods: All patients admitted to a medical ICU of a tertiary care institute with severe sepsis or septic shock were prospectively included. Patients were divided into young (age below 60 years), old (age between 60 and 80 years), and very old (age above 80 years) groups. Data regarding baseline patient characteristics, admission APACHE II score, and ICU course including need for organ support and ICU length of stay were noted. Categorical data were analyzed using χ 2 or Fisher Exact test as appropriate and continuous data were analyzed using Student t test. Primary outcome measure was the ICU mortality. Results: Of 387 patients with sepsis, 132 patients who fulfilled the criteria for severe sepsis/septic shock were included in the analysis. The most common suspected site of infection was lungs (45.5%), followed by urinary tract (21.2%) and abdomen (16.7%). Intensive care unit mortality in younger patients was 45.6% as compared to 60.7% in old and 78.9% in very old patients ( P = .035). The relative risk (RR) for dying in the old age was 1.125 and RR for dying in the very old age group was 1.487 as compared to the young patients. There was an increased need for organ support in the elderly and very elderly population as compared to the younger population. On multivariate analysis, only age of the patient was found to be independently predicting ICU mortality ( P = .002, OR: 1.038, 95% CI: 1.014-1.062). Conclusions: The risk of dying from severe sepsis is considerably higher in the elderly and very elderly subgroup of patients with age as an independent risk factor for mortality. Hence, early aggressive care to recognize and manage severe sepsis is required to improve outcome.
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Affiliation(s)
- Prashant Nasa
- Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi, India
| | - Deven Juneja
- Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi, India
| | - Omender Singh
- Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi, India
| | - Rohit Dang
- Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi, India
| | - Vikas Arora
- Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi, India
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Ihra GC, Lehberger J, Hochrieser H, Bauer P, Schmutz R, Metnitz B, Metnitz PGH. Development of demographics and outcome of very old critically ill patients admitted to intensive care units. Intensive Care Med 2012; 38:620-6. [DOI: 10.1007/s00134-012-2474-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 12/30/2011] [Indexed: 12/21/2022]
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Schortgen F, Follin A, Piccari L, Roche-Campo F, Carteaux G, Taillandier-Heriche E, Krypciak S, Thille AW, Paillaud E, Brochard L. Results of noninvasive ventilation in very old patients. Ann Intensive Care 2012; 2:5. [PMID: 22353636 PMCID: PMC3306189 DOI: 10.1186/2110-5820-2-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 02/21/2012] [Indexed: 02/01/2023] Open
Abstract
Background Noninvasive ventilation (NIV) is frequently used for the management of acute respiratory failure (ARF) in very old patients (≥ 80 years), often in the context of a do-not-intubate order (DNI). We aimed to determine its efficacy and long-term outcome. Methods Prospective cohort of all patients admitted to the medical ICU of a tertiary hospital during a 2-year period and managed using NIV. Characteristics of patients, context of NIV, and treatment intensity were compared for very old and younger patients. Six-month survival and functional status were assessed in very old patients. Results During the study period, 1,019 patients needed ventilatory support and 376 (37%) received NIV. Among them, 163 (16%) very old patients received ventilatory support with 60% of them managed using NIV compared with 32% of younger patients (p < 0.0001). Very old patients received NIV more frequently with DNI than in younger patients (40% vs. 8%). Such cases were associated with high mortality for both very old and younger patients. Hospital mortality was higher in very old than in younger patients but did not differ when NIV was used for cardiogenic pulmonary edema or acute-on-chronic respiratory failure (20% vs. 15%) and in postextubation (15% vs. 17%) out of a context of DNI. Six-month mortality was 51% in very old patients, 67% for DNI patients, and 77% in case of NIV failure and endotracheal intubation. Of the 30 hospital survivors, 22 lived at home and 13 remained independent for activities of daily living. Conclusions Very old patients managed using NIV have an overall satisfactory 6-month survival and functional status, except for endotracheal intubation after NIV failure.
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Affiliation(s)
- Frederique Schortgen
- AP-HP, Groupe Hospitalier Albert Chenevier-Henri Mondor, Réanimation Médicale, Créteil, France.
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90
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Nasa P, Juneja D, Singh O. Severe sepsis and septic shock in the elderly: An overview. World J Crit Care Med 2012; 1:23-30. [PMID: 24701398 PMCID: PMC3956061 DOI: 10.5492/wjccm.v1.i1.23] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/20/2011] [Accepted: 12/30/2011] [Indexed: 02/06/2023] Open
Abstract
The incidence of severe sepsis and septic shock is increasing in the older population leading to increased admissions to the intensive care units (ICUs). The elderly are predisposed to sepsis due to co-existing co-morbidities, repeated and prolonged hospitalizations, reduced immunity, functional limitations and above all due to the effects of aging itself. A lower threshold and a higher index of suspicion is required to diagnose sepsis in this patient population because the initial clinical picture may be ambiguous, and aging increases the risk of a sudden deterioration in sepsis to severe sepsis and septic shock. Management is largely based on standard international guidelines with a few modifications. Age itself is an independent risk factor for death in patients with severe sepsis, however, many patients respond well to timely and appropriate interventions. The treatment should not be limited or deferred in elderly patients with severe sepsis only on the grounds of physician prejudice, but patient and family preferences should also be taken into account as the outcomes are not dismal. Future investigations in the management of sepsis should not only target good functional recovery but also ensure social independence and quality of life after ICU discharge.
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Affiliation(s)
- Prashant Nasa
- Prashant Nasa, Deven Juneja, Omender Singh, Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Deven Juneja
- Prashant Nasa, Deven Juneja, Omender Singh, Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Omender Singh
- Prashant Nasa, Deven Juneja, Omender Singh, Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
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91
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Nasa P, Juneja D, Singh O. Severe sepsis and septic shock in the elderly: An overview. World J Crit Care Med 2012. [PMID: 24701398 DOI: 10.5492/wjccm.v1.i1.23.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The incidence of severe sepsis and septic shock is increasing in the older population leading to increased admissions to the intensive care units (ICUs). The elderly are predisposed to sepsis due to co-existing co-morbidities, repeated and prolonged hospitalizations, reduced immunity, functional limitations and above all due to the effects of aging itself. A lower threshold and a higher index of suspicion is required to diagnose sepsis in this patient population because the initial clinical picture may be ambiguous, and aging increases the risk of a sudden deterioration in sepsis to severe sepsis and septic shock. Management is largely based on standard international guidelines with a few modifications. Age itself is an independent risk factor for death in patients with severe sepsis, however, many patients respond well to timely and appropriate interventions. The treatment should not be limited or deferred in elderly patients with severe sepsis only on the grounds of physician prejudice, but patient and family preferences should also be taken into account as the outcomes are not dismal. Future investigations in the management of sepsis should not only target good functional recovery but also ensure social independence and quality of life after ICU discharge.
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Affiliation(s)
- Prashant Nasa
- Prashant Nasa, Deven Juneja, Omender Singh, Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Deven Juneja
- Prashant Nasa, Deven Juneja, Omender Singh, Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Omender Singh
- Prashant Nasa, Deven Juneja, Omender Singh, Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
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92
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Abstract
The democratic shift poses new challenges in emergency medicine and intensive care. Old patients call for special needs that have to be taken into consideration during treatment. Due to the heterogeneity in this patient group biological age plays an important role. Mortality among old patients is high, but functionality and comorbidity have a great effect on patient outcome. Structural and functional organ changes have an additional impact on the treatment of geriatric patients in emergency medicine and intensive care. Therefore, basic geriatric knowledge should be part of the curricula of both, intensive care and emergency medicine.
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93
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Personnes âgées. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-011-0359-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Balas MC, Chaperon C, Sisson JH, Bonasera S, Hertzog M, Potter J, Peterson D, McVay W, Gorman J, Burke WJ. Transitions experienced by older survivors of critical care. J Gerontol Nurs 2011. [PMID: 22084959 DOI: 10.3928/00989134-20111102-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Michele C Balas
- College of Nursing, University of Nebraska Medical Center, Omaha, NE, USA.
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95
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Abstract
A retrospective audit of length of hospital inpatient stay of all patients admitted to the Royal Adelaide Hospital Burns Unit over a 5-year period was performed. Data gathered from the Burns Unit database and records allowed patient division into two comparison groups: those younger than 70 years and those aged 70 years or older. Further comparison based on discharge destination was made in the ≥70 years group. Outcomes included length of stay, burn size, and discharge destination. A total of 1641 patients were included. The median length of stay was 5.0 days for patients younger than 70 years and 10.0 days for those aged 70 years or older (P < .0001). The mean percentage of TBSA burned was similar. A greater proportion of those aged 70 years or older were discharged to supported care facilities, such as nursing homes, and a greater proportion needed assessment for placement (P < .001) when compared with those younger than 70 years. The median length of stay of those aged 70 years or older who did not need assessment for placement was 9.0 days compared with 38.0 days for those who needed assessment (P < .0001). Elderly patients have, generally, nearly twice the length of stay of younger patients; when further subdivided according to discharge destination, the effect of placement delay (a social issue) becomes apparent and disturbing. This has significant implications, given the limited capacity and high cost of burn unit admission. A geriatrician will be appointed to the Burn Service over the next 12 months to assess whether earlier geriatric assessment can decrease the length of inpatient admission by facilitating a more efficient placement process.
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96
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Nguyen YL, Angus DC, Boumendil A, Guidet B. The challenge of admitting the very elderly to intensive care. Ann Intensive Care 2011; 1:29. [PMID: 21906383 PMCID: PMC3224497 DOI: 10.1186/2110-5820-1-29] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 08/01/2011] [Indexed: 12/01/2022] Open
Abstract
The aging of the population has increased the demand for healthcare resources. The number of patients aged 80 years and older admitted to the intensive care unit (ICU) increased during the past decade, as has the intensity of care for such patients. Yet, many physicians remain reluctant to admit the oldest, arguing a "squandering" of societal resources, that ICU care could be deleterious, or that ICU care may not actually be what the patient or family wants in this instance. Other ICU physicians are strong advocates for admission of a selected elderly population. These discrepant opinions may partly be explained by the current lack of validated criteria to select accurately the patients (of any age) who will benefit most from ICU hospitalization. This review describes the epidemiology of the elderly aged 80 years and older admitted in the ICU, their long-term outcomes, and to discuss some of the solutions to cope with the burden of an aging population receiving acute care hospitalization.
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Affiliation(s)
- Yên-Lan Nguyen
- Centre d'Epidémiologie Clinique, Hôpital Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France.
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97
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Current world literature. Curr Opin Anaesthesiol 2011; 24:224-33. [PMID: 21386670 DOI: 10.1097/aco.0b013e32834585d6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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98
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Fassier T, Duclos A. Older patients in the ICU: a cautious analysis of epidemiologic data is required. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:421. [PMID: 21542891 PMCID: PMC3219391 DOI: 10.1186/cc10134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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99
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Sacanella E, Pérez-Castejón JM, Nicolás JM, Masanés F, Navarro M, Castro P, López-Soto A. Functional status and quality of life 12 months after discharge from a medical ICU in healthy elderly patients: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R105. [PMID: 21443796 PMCID: PMC3219378 DOI: 10.1186/cc10121] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 12/23/2010] [Accepted: 03/28/2011] [Indexed: 01/20/2023]
Abstract
Introduction Long-term outcomes of elderly patients after medical ICU care are little known. The aim of the study was to evaluate functional status and quality of life of elderly patients 12 months after discharge from a medical ICU. Methods We prospectively studied 112/230 healthy elderly patients (≥65 years surviving at least 12 months after ICU discharge) with full functional autonomy without cognitive impairment prior to ICU entry. The main diagnoses at admission using the Acute Physiology and Chronic Health Evaluation III (APACHE III) classification diagnosis and length of ICU stay and ICU scores (APACHE II, Sepsis-related Organ Failure Assessment (SOFA) and OMEGA) at admission and discharge were collected. Comprehensive geriatric assessment included the presence of the main geriatric syndromes and the application of Lawton, Barthel, and Charlson Indexes and Informant Questionnaire on Cognitive Decline to evaluate functionality, comorbidity and cognitive status, respectively. The EuroQol-5D assessed quality of life. Data were collected at baseline, during ICU and ward stay and 3, 6 and 12 months after hospital discharge. Paired or unpaired T-tests compared differences between groups (continuous variables), whereas the chi-square and Fisher exact tests were used for comparing dichotomous variables. For variables significant (P ≤ 0.1) on univariate analysis, a forward multiple regression analysis was performed. Results Only 48.9% of patients (mean age: 73.4 ± 5.5 years) were alive 12 months after discharge showing a significant decrease in functional autonomy (Lawton and Barthel Indexes) and quality of life (EuroQol-5D) compared to baseline status (P < 0.001, all). Multivariate analysis showed a higher Barthel Index and EQ-5D vas at hospital discharge to be associated factors of full functional recovery (P < 0.01, both). Thus, in patients with a Barthel Index ≥ 60 or EQ-5D vas ≥40 at discharge the hazard ratio for full functional recovery was 4.04 (95% CI: 1.58 to 10.33; P = 0.005) and 6.1 (95% CI: 1.9 to 19.9; P < 0.01), respectively. Geriatric syndromes increased after ICU stay and remained significantly increased during follow-up (P < 0.001). Conclusions The survival rate of elderly medical patients 12 months after discharge from the ICU is low (49%), although functional status and quality of life remained similar to baseline in most of the survivors. However, there was a two-fold increase in the prevalence of geriatric syndromes.
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Affiliation(s)
- Emilio Sacanella
- Geriatric Unit, Department of Internal Medicine Hospital Clínic of Barcelona, Villarroel, 170, Barcelona 08036, Spain.
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Theodosiou CA, Loeffler RE, Oglesby AJ, McKeown DW, Ray DC. Rapid sequence induction of anaesthesia in elderly patients in the emergency department. Resuscitation 2011; 82:881-5. [PMID: 21440977 DOI: 10.1016/j.resuscitation.2011.02.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 02/02/2011] [Accepted: 02/14/2011] [Indexed: 11/25/2022]
Abstract
AIM Our primary objective was to evaluate the characteristics and outcomes of elderly (≥ 80 years) patients undergoing rapid sequence induction of anaesthesia and intubation (RSI) in our emergency department (ED). METHODS We retrospectively analysed data collected prospectively between January 1999 and December 2007. We retrieved age; gender; presenting diagnosis; indication and urgency for RSI; complications related to RSI; hospital destination; and outcome. RESULTS 1686 patients underwent RSI in the ED during the study period; 107 (6%) were aged ≥ 80 years. The mean age (range) was 84 (80-91) years. 94 patients (88%) were living in a private residence before presentation to the ED. Intracerebral haemorrhage, ischaemic stroke and head injury were the commonest presenting diagnoses. Forty-one patients were admitted to intensive care, 55 were admitted to a ward (31 for palliative care) and 11 died in the ED. Seventy-two patients (67%) died; of the 35 survivors, 21 (60%) made a good recovery with no requirement for increased social care. Outcome was worse after neurological diagnoses, sepsis and trauma than after cardiac or respiratory failure, seizures or drug overdose. Presenting diagnosis predicted outcome on univariable analysis (p<0.001), but it was not possible to calculate risk for individual diagnoses. RSI-related complications, of which hypotension was commonest, occurred in 15% of patients. CONCLUSION A small number of patients who undergo RSI in our ED are aged ≥ 80 years. They generally have high mortality with only 20% surviving to hospital discharge with no increase in dependency; however 60% of survivors make a good recovery. In this highly selected elderly population age is not the main determinant of outcome which is influenced more by presenting diagnosis.
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