Predicting outcomes in very old ICU patients: time to focus on the past?

Differences in early, intermediate, and long-term mortality among elderly patients admitted to the ICU. Results of a retrospective observational study

BACKGROUND

Few studies have investigated both short- and long-term prognostic factors, and the differences between chronic and acute conditions in the very old critically-ill patient. Our study aims to shed light in this field and to provide useful prognostic factors that may support clinical decisions in the management of the elderly.

METHODS

Six ICUs collected data concerning patients 80 years old or more admitted in 2015 and 2016 and followed-up until may 2018. Three prognostic models were developed: an in-hospital mortality model, a model for patients discharged from the hospital and entering follow-up, and an intermediate model for those alive after three days from ICU admission.

RESULTS

Our centers admitted 1189 patients, 1071 (90.1%) had survived after three days from admission, 889 (74.8%) were discharged from the hospital, 701 (59.0%) survived six months after hospital discharge, 539 (45.3%) survived at the end of follow-up. Among survivors the median follow-up time was 810 days. Acute organ failures were the main causes of death in the hospital mortality multivariable model. These factors are modifiable and potentially a target for intervention to improve outcome. The model focused on mortality six months after hospital in patients that survived a three-day timelimited trial, showed a clear shift toward chronic diseases, unmodifiable factors crucial for prognostic assessment. This trend was even more evident at the end of follow-up.

CONCLUSIONS

Among very old ICU patients, prognostic factors shift from acute to chronic conditions in passing from in-hospital to post-hospital outcomes.

Age as Maestro or Solo Instrument in Opera of Death

How to cite this article: Zirpe KG, Nimavat BD, Gurav SK. Age as Maestro or Solo Instrument in Opera of Death. Indian J Crit Care Med 2021;25(6):606-607.

Elderly Patients in the Intensive Care Unit

Very old intensive care unit (ICU) patients, aged ≥ 80 years, are by no mean newcomers, but during the last decades their impact on ICU admissions has grown in parallel with the increase in the number of elderly persons in the community. Hence, from being a "rarity," they have now become common and constitute one of the largest subgroups within intensive care, and may easily be the largest group in 20 years and make up 30 to 40% of all ICU admissions. Obviously, they are not admitted because they are old but because they are with various diseases and problems like any other ICU patient. However, their age and the presence of common geriatric syndromes such as frailty, cognitive decline, reduced activity of daily life, and several comorbid conditions makes this group particularly challenging, with a high mortality rate. In this review, we will highlight aspects of current and future epidemiology and current knowledge on outcomes, and describe the effects of the aforementioned geriatric syndromes. The major challenge for the coming decades will be the question of whom to treat and the quest for better triage criteria not based on age alone. Challenges with the level of care during the ICU stay will also be discussed. A stronger relationship with geriatricians should be promoted to create a better and more holistic care and aftercare for survivors.

The contribution of frailty, cognition, activity of daily life and comorbidities on outcome in acutely admitted patients over 80 years in European ICUs: the VIP2 study

Purpose

Premorbid conditions affect prognosis of acutely-ill aged patients. Several lines of evidence suggest geriatric syndromes need to be assessed but little is known on their relative effect on the 30-day survival after ICU admission. The primary aim of this study was to describe the prevalence of frailty, cognition decline and activity of daily life in addition to the presence of comorbidity and polypharmacy and to assess their influence on 30-day survival.

Methods

Prospective cohort study with 242 ICUs from 22 countries. Patients 80 years or above acutely admitted over a six months period to an ICU between May 2018 and May 2019 were included. In addition to common patients’ characteristics and disease severity, we collected information on specific geriatric syndromes as potential predictive factors for 30-day survival, frailty (Clinical Frailty scale) with a CFS > 4 defining frail patients, cognitive impairment (informant questionnaire on cognitive decline in the elderly (IQCODE) with IQCODE ≥ 3.5 defining cognitive decline, and disability (measured the activity of daily life with the Katz index) with ADL ≤ 4 defining disability. A Principal Component Analysis to identify co-linearity between geriatric syndromes was performed and from this a multivariable model was built with all geriatric information or only one: CFS, IQCODE or ADL. Akaike’s information criterion across imputations was used to evaluate the goodness of fit of our models.

Results

We included 3920 patients with a median age of 84 years (IQR: 81–87), 53.3% males). 80% received at least one organ support. The median ICU length of stay was 3.88 days (IQR: 1.83–8). The ICU and 30-day survival were 72.5% and 61.2% respectively. The geriatric conditions were median (IQR): CFS: 4 (3–6); IQCODE: 3.19 (3–3.69); ADL: 6 (4–6); Comorbidity and Polypharmacy score (CPS): 10 (7–14). CFS, ADL and IQCODE were closely correlated. The multivariable analysis identified predictors of 1-month mortality (HR; 95% CI): Age (per 1 year increase): 1.02 (1.–1.03, p = 0.01), ICU admission diagnosis, sequential organ failure assessment score (SOFA) (per point): 1.15 (1.14–1.17, p < 0.0001) and CFS (per point): 1.1 (1.05–1.15, p < 0.001). CFS remained an independent factor after inclusion of life-sustaining treatment limitation in the model.

Conclusion

We confirm that frailty assessment using the CFS is able to predict short-term mortality in elderly patients admitted to ICU. Other geriatric syndromes do not add improvement to the prediction model. Since CFS is easy to measure, it should be routinely collected for all elderly ICU patients in particular in connection to advance care plans, and should be used in decision making.

Electronic supplementary material

The online version of this article (10.1007/s00134-019-05853-1) contains supplementary material, which is available to authorized users.

Cumulative Prognostic Score Predicting Mortality in Patients Older Than 80 Years Admitted to the ICU

OBJECTIVES

To develop a scoring system model that predicts mortality within 30 days of admission of patients older than 80 years admitted to intensive care units (ICUs).

DESIGN

Prospective cohort study.

SETTING

A total of 306 ICUs from 24 European countries.

PARTICIPANTS

Older adults admitted to European ICUs (N = 3730; median age = 84 years [interquartile range = 81‐87 y]; 51.8% male).

MEASUREMENTS

Overall, 24 variables available during ICU admission were included as potential predictive variables. Multivariable logistic regression was used to identify independent predictors of 30‐day mortality. Model sensitivity, specificity, and accuracy were evaluated with receiver operating characteristic curves.

RESULTS

The 30‐day‐mortality was 1562 (41.9%). In multivariable analysis, these variables were selected as independent predictors of mortality: age, sex, ICU admission diagnosis, Clinical Frailty Scale, Sequential Organ Failure Score, invasive mechanical ventilation, and renal replacement therapy. The discrimination, accuracy, and calibration of the model were good: the area under the curve for a score of 10 or higher was .80, and the Brier score was .18. At a cut point of 10 or higher (75% of all patients), the model predicts 30‐day mortality in 91.1% of all patients who die.

CONCLUSION

A predictive model of cumulative events predicts 30‐day mortality in patients older than 80 years admitted to ICUs. Future studies should include other potential predictor variables including functional status, presence of advance care plans, and assessment of each patient's decision‐making capacity.