Premorbid functional status as a predictor of 1-year mortality and functional status in intensive care patients aged 80 years or older

Critical care beyond organ support: the importance of geriatric rehabilitation

Very old critically ill patients pose a growing challenge for intensive care. Critical illness and the burden of treatment in the intensive care unit (ICU) can lead to a long-lasting decline of functional and cognitive abilities, especially in very old patients. Multi-complexity and increased vulnerability to stress in these patients may lead to new and worsening disabilities, requiring careful assessment, prevention and rehabilitation. The potential for rehabilitation, which is crucial for optimal functional outcomes, requires a systematic, multi-disciplinary approach and careful long-term planning during and following ICU care. We describe this process and provide recommendations and checklists for comprehensive and timely assessments in the context of transitioning patients from ICU to post-ICU and acute hospital care, and review the barriers to the provision of good functional outcomes.

Clinical features and disease progression of elderly patients at the ICU setting

OBJECTIVE

To describe and characterize a cohort of octogenarian patients admitted to the ICU of the University Central Hospital of Asturias (HUCA).

DESIGN

Retrospective, observational and descriptive study of 14 months' duration.

SETTING

Cardiac and Medical intensive care units (ICU) of the HUCA (Oviedo).

PARTICIPANTS

Patients over 80 years old who were admitted to the ICU for more than 24 h.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Age, sex, comorbidity, functional dependence, treatment, complications, evolution, mortality.

RESULTS

The most frequent reasons for admission were cardiac surgery and pneumonia. The average admission stay was significantly longer in patients under 85 years of age (p = 0,037). 84,3% of the latter benefited from invasive mechanical ventilation compared to 46,2% of older patients (p = <0,001). Patients over 85 years of age presented greater fragility. Admission for cardiac surgery was associated with a lower risk of mortality (HR = 0,18; 95% CI (0,062-0,527; p = 0,002).

CONCLUSIONS

The results have shown an association between the reason for admission to the ICU and the risk of mortality in octogenarian patients. Cardiac surgery was associated with a better prognosis compared to medical pathology, where pneumonia was associated with a higher risk of mortality. Furthermore, a significant positive association was observed between age and frailty.

Evolution of Clinical Characteristics and Outcomes of Critically Ill Patients 90 Years Old or Older Over a 12-Year Period: A Retrospective Cohort Study

OBJECTIVES

The global population is aging, and the proportion of very elderly patients 90 years old or older in the ICU is expected to increase. The changes in the comorbidities and outcomes of very elderly patients hospitalized in the ICU that have occurred over time are unknown.

DESIGN

Retrospective observational cohort study.

SETTING

ICUs at a single academic hospital in Germany.

PATIENTS

Ninety years old or older and admitted to the ICU between January 1, 2008, and April 30, 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 92,958 critically ill patients, 1,108 were 90 years old or older. The study period was divided into two halves: January 1, 2008-August 30, 2013, and September 1, 2013-April 30, 2019. The number of patients 90 years old or older increased from the first period (n = 391; 0.90% of total admissions) to the second period (n = 717; 1.44%). The patients' demographic characteristics were similar between the both time periods. The median Charlson Comorbidity Index was higher during the first period (1 [interquartile range, 1-3]) than compared with the second time period (1 [0-2]; p = 0.052). The Simplified Acute Physiology Score (SAPS) II was higher during the first time period (38 [29-49]) than during the second period (35 [27-45]; p = 0.005). Vasopressor therapy was necessary in 40% (n = 158) and 43% (n = 310) of patients in each time period, respectively (p = 0.363). Invasive mechanical ventilation was administered in 37% (n = 146) and 34% (n = 243) of patients in each time period, respectively (p = 0.250). The median length of the ICU stay was significantly lower in the first time period than in the second time period (1.4 vs. 1.7 d; p = 0.002). The ICU (18% vs. 18%; p = 0.861) and hospital (31% vs. 29%; p = 0.395) mortality rates were comparable between the two groups. The 1-year mortality was significantly lower during the second time period than during the first time period (61% vs. 56%; p = 0.029). Cox regression analysis revealed that the SAPS II, medical cause of admission, mechanical ventilation requirement, and vasopressor use were associated with 1-year mortality.

CONCLUSIONS

The number of patients 90 years old or older who were treated in the ICU has increased in recent years. While the patients' clinical characteristics and short-term outcomes have not changed significantly, the long-term mortality of these patients has improved in recent years.

Association between Red Cell Distribution Width and Outcomes of Nonagenarians Admitted to the Intensive Care Unit-A Retrospective Cohort Study

The red cell distribution width (RDW) measures the heterogeneity of the erythrocyte volume. Different clinical conditions are associated with increased RDW, and high levels (>14.5%) have been described as a predictive marker for unfavorable outcomes and mortality in critically ill patients. However, there is a lack of data on very elderly critically ill patients. Therefore, we aimed to investigate the association of RDW with outcomes in critically ill patients ≥ 90 years. A retrospective analysis was conducted for all consecutive critically ill patients ≥ 90 years who were admitted to the Department of Intensive Care Medicine of the Medical University Centre Hamburg-Eppendorf (Hamburg, Germany) with available RDW on admission. Clinical course and laboratory were analyzed for all patients with eligible RDW. High RDW was defined as (>14.5%). We clinically assessed factors associated with mortality. Univariable and multivariable Cox regression analysis was performed to determine the prognostic impact of RDW on 28-day mortality. During a 12-year period, we identified 863 critically ill patients ≥ 90 years old with valid RDW values and complete clinical data. In total, 32% (n = 275) died within 28 days, and 68% (n = 579) survived for 28 days. Median RDW levels on ICU admission were significantly higher in non-survivors compared with survivors (15.6% vs. 14.8%, p < 0.001). Overall, 38% (n = 327) had low, and 62% (n = 536) had high RDW. The proportion of high RDW (>14.5%) was significantly higher in non-survivors (73% vs. 57%, p < 0.001). Patients with low RDW presented with a lower Charlson Comorbidity Index (p = 0.014), and their severity of illness on admission was lower (SAPS II: 35 vs. 38 points, p < 0.001). In total, 32% (n = 104) in the low and 35% (n = 190) in the high RDW group were mechanically ventilated (p = 0.273). The use of vasopressors (35% vs. 49%, p < 0.001) and renal replacement therapy (1% vs. 5%, p = 0.007) was significantly higher in the high RDW group. Cox regression analysis demonstrated that high RDW was significantly associated with 28-day mortality [crude HR 1.768, 95% CI (1.355-2.305); p < 0.001]. This association remained significant after adjusting for multiple confounders [adjusted HR 1.372, 95% CI (1.045-1.802); p = 0.023]. High RDW was significantly associated with mortality in critically ill patients ≥ 90 years. RDW is a useful simple parameter for risk stratification and may aid guidance for the therapy in very elderly critically ill patients.

Management and outcomes of critically ill adult patients with convulsive status epilepticus and preadmission functional impairments

OBJECTIVE

Functional status is among the criteria relevant to decisions about intensive care unit (ICU) admission and level of care. Our main objective was to describe the characteristics and outcomes of adult patients requiring ICU admission for Convulsive Status Epilepticus (CSE) according to whether their functional status was previously impaired.

METHODS

We retrospectively analyzed data from consecutive adults who were admitted to two French ICUs for CSE between 2005 and 2018 and then included them retrospectively in the Ictal Registry. Pre-existing functional impairment was defined as a Glasgow Outcome Scale (GOS) score of 3 before admission. The primary outcome measure was a loss of ≥1 GOS score point at 1 year. Multivariate analysis was used to identify factors associated with this measure.

RESULTS

The 206 women and 293 men had a median age of 59 years [47-70 years]. The preadmission GOS score was 3 in 56 (11.2%) patients and 4 or 5 in 443 patients. Compared to the GOS-4/5 group, the GOS-3 group was characterized by a higher frequency of treatment-limitation decisions (35.7% vs. 12%, P < 0.0001), similar ICU mortality (19.6 vs. 13.1, P = 0.22), higher 1-year mortality (39.3% vs. 25.6%, P < 0.01), and a similar proportion of patients with no worsening of the GOS score at 1 year (42.9 vs. 44.1, P = 0.89). By multivariate analysis, not achieving a favorable 1-year outcome was associated with age above 59 years (OR, 2.36; 95%CI, 1.55-3.58, P < 0.0001), preexisting ultimately fatal comorbidity (OR, 2.92; 95%CI, 1.71-4.98, P = 0.0001), refractory CSE (OR, 2.19; 95%CI, 1.43-3.36, P = 0.0004), cerebral insult as the cause of CSE (OR, 2.75; 95%CI, 1.75-4.27, P < 0.0001), and Logistic Organ Dysfunction score ≥ 3 at ICU admission (OR, 2.08; 95%CI, 1.37-3.15, P = 0.0006). A preadmission GOS score of 3 was not associated with a functional decline during the first year (OR, 0.61; 95%CI, 0.31-1.22, P = 0.17).

SIGNIFICANCE

Preadmission functional status in adult patients with CSE is not independently associated with a functional decline during the first postadmission year. This finding may help physicians make ICU admission decisions and adult patients write advance directives.

STUDY REGISTRATION

#NCT03457831.

Optimizing an existing prediction model for quality of life one-year post-intensive care unit: An exploratory analysis

BACKGROUND

This study aimed to improve the PREPARE model, an existing linear regression prediction model for long-term quality of life (QoL) of intensive care unit (ICU) survivors by incorporating additional ICU data from patients' electronic health record (EHR) and bedside monitors.

METHODS

The 1308 adult ICU patients, aged ≥16, admitted between July 2016 and January 2019 were included. Several regression-based machine learning models were fitted on a combination of patient-reported data and expert-selected EHR variables and bedside monitor data to predict change in QoL 1 year after ICU admission. Predictive performance was compared to a five-feature linear regression prediction model using only 24-hour data (R²  = 0.54, mean square error (MSE) = 0.031, mean absolute error (MAE) = 0.128).

RESULTS

The 67.9% of the included ICU survivors was male and the median age was 65.0 [IQR: 57.0-71.0]. Median length of stay (LOS) was 1 day [IQR 1.0-2.0]. The incorporation of the additional data pertaining to the entire ICU stay did not improve the predictive performance of the original linear regression model. The best performing machine learning model used seven features (R²  = 0.52, MSE = 0.032, MAE = 0.125). Pre-ICU QoL, the presence of a cerebro vascular accident (CVA) upon admission and the highest temperature measured during the ICU stay were the most important contributors to predictive performance. Pre-ICU QoL's contribution to predictive performance far exceeded that of the other predictors.

CONCLUSION

Pre-ICU QoL was by far the most important predictor for change in QoL 1 year after ICU admission. The incorporation of the numerous additional features pertaining to the entire ICU stay did not improve predictive performance although the patients' LOS was relatively short.

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.

Predictors of treatment limitations in Finnish intensive care units

BACKGROUND

Few studies have examined the factors that predict the limitations of life-sustaining treatment (LST) to patients in intensive care units (ICUs). We aimed to identify variables associated with the decision of withholding of life support (WHLS) at admission, WHLS during ICU stay and the withdrawal of ongoing life support (WDLS).

METHODS

This retrospective observational study comprised 17,772 adult ICU patients who were included in the nationwide Finnish ICU Registry in 2016. Factors associated with LST limitations were identified using hierarchical logistic regression.

RESULTS

The decision of WHLS at admission was made for 822 (4.6%) patients, WHLS during ICU stay for 949 (5.3%) patients, and WDLS for 669 (3.8%) patients. Factors strongly predicting WHLS at admission included old age (adjusted odds ratio [OR] for patients aged 90 years or older in reference to those younger than 40 years was 95.6; 95% confidence interval [CI], 47.2-193.5), dependence on help for activities of daily living (OR, 3.55; 95% CI, 3.01-4.2), and metastatic cancer (OR, 4.34; 95% CI, 3.16-5.95). A high severity of illness predicted later decisions to limit LST. Diagnoses strongly associated with WHLS at admission were cardiac arrest, hepatic failure and chronic obstructive pulmonary disease. Later decisions were strongly associated with cardiac arrest, hepatic failure, non-traumatic intracranial hemorrhage, head trauma and stroke.

CONCLUSION

Early decisions to limit LST were typically associated with old age and chronic poor health whereas later decisions were related to the severity of illness. Limitations are common for certain diagnoses, particularly cardiac arrest and hepatic failure.

Nutritional and Functional Status as a Predictor of Short-Term Mortality in Hospitalized Elderly Patients in a Tertiary Care Hospital

Context

Elderly people are at a high risk of malnutrition leading to poor outcomes and quality of life.

Aims

We aimed to find an association between the nutritional and functional status of hospitalized elderly patients and the three-month all-cause mortality among them.

Settings and design

A cross-sectional study was carried out at a tertiary care hospital in North India from July 2018 to December 2019.

Methods and material

A total of 177 patients were recruited for the study, and their demographic and clinical data were collected on a preformed questionnaire. Comorbidity, nutritional status, functional status, and depression were calculated using the Charlson Comorbidity Index (CCI), Mini Nutritional Assessment (MNA) form, Katz Index of Independence in Activities of Daily Living (Katz ADL), and Geriatric Depression Scale (GDS), respectively.

Statistical analysis

A Chi-square test was used to find the association between different qualitative variables. A regression model was used to find out the odds for mortality. Statistical significance was set at p<0.05.

Results

According to the MNA score, 49.7% (88) were at risk of malnutrition, and 22.6%(40) were malnourished. Malnutrition, Charlson Comorbidity Index, and the functional status of the patients were found to be associated with three-month mortality, with a p value of 0.005, 0.017, and 0.021, respectively. On regression analysis, malnutrition (odds ratio (OR): 3.796; 95% confidence interval (CI): 1.178-12.234; p=0.025) and the functional status (OR: 3.160; 95% CI: 1.256-7.952; p=0.015) of the study participants were found to have higher odds for three-month all-cause mortality.

Conclusions

Nutritional status and ADL assessed at the time of discharge are good prognostic markers of health outcomes in the elderly population.

Key message

ADL and nutritional assessment at admission and discharge should be routinely incorporated in the geriatric assessment of hospitalized patients to triage and prognosticate.

Premorbid Clinical Frailty Score and 30‐day mortality among older adults in the emergency department

Objectives

The association between frailty and short‐term prognosis has not been established in critically ill older adults presenting to the emergency department. We sought to examine the association between premorbid frailty and 30‐day mortality in this patient population.

Methods

This is a retrospective observational study on older adults aged over 75 who were triaged as Level 1 resuscitation with subsequent admissions to intermediate units or intensive care units (ICUs) in a single critical care center, from January to December 2019. We excluded patients with out‐of‐hospital cardiac arrest or those transferred from other hospitals. Frailty was evaluated by the Clinical Frailty Scale (CFS) from the patients’ chart reviews. The primary outcome was 30‐day mortality, and we examined the association between frailty scored on the CFS and 30‐day mortality using a multivariable logistic regression model with CFS 1–4 as a reference.

Results

A total of 544 patients, median age: 82 years (interquartile rang 78 to 87), were included in the study. Of these, 29% were in shock and 33% were in respiratory failure. The overall 30‐day mortality was 15.1%. The adjusted risk difference (95% confidence interval [CI]) in mortality for CFS 5, CFS 6, and CFS 7–9 was 6.3% (‐3.4 to 15.9), 11.2% (0.4 to 22.0), and 17.7% (5.3 to 30.1), respectively; and the adjusted risk ratio (95% CI) was 1.45 (0.87 to 2.41), 1.85 (1.13 to 3.03), and 2.44 (1.50 to 3.96), respectively.

Conclusion

The risk of 30‐day mortality increased as frailty advanced in critically ill older adults. Given this high risk of short‐term outcomes, ED clinicians should consider goals of care conversations carefully to avoid unwanted medical care for these patients.

Premorbid functional status as an outcome predictor in intensive care patients aged over 85 years

BACKGROUND

Poor premorbid functional status (PFS) is associated with mortality after intensive care unit (ICU) admission in patients aged 80 years or older. In the subgroup of very old ICU patients, the ability to recover from critical illness varies irrespective of age. To assess the predictive ability of PFS also among the patients aged 85 or older we set out the current study.

METHODS

In this nationwide observational registry study based on the Finnish Intensive Care Consortium database, we analysed data of patients aged 85 years or over treated in ICUs between May 2012 and December 2015. We defined PFS as good for patients who had been independent in activities of daily living (ADL) and able to climb stairs and as poor for those who were dependent on help or unable to climb stairs. To assess patients' functional outcome one year after ICU admission, we created a functional status score (FSS) based on how many out of five physical activities (getting out of bed, moving indoors, dressing, climbing stairs, and walking 400 m) the patient could manage. We also assessed the patients' ability to return to their previous type of accommodation.

RESULTS

Overall, 2037 (3.3% of all adult ICU patients) patients were 85 years old or older. The average age of the study population was 87 years. Data on PFS were available for 1446 (71.0%) patients (good for 48.8% and poor for 51.2%). The one-year mortalities of patients with good and those with poor PFS were 29.2% and 50.1%, respectively, p < 0.001. Poor PFS increased the probability of death within 12 months, adjusted odds ratio (OR), 2.15; 95% confidence interval (CI) 1.68-2.76, p < 0.001. For 69.5% of survivors, the FSS one year after ICU admission was unchanged or higher than their premorbid FSS and 84.2% of patients living at home before ICU admission still lived at home.

CONCLUSIONS

Poor PFS doubled the odds of death within one year. For most survivors, functional status was comparable to the premorbid status.

Emergency Department Referral for Hospice and Palliative Care Differs among Patients with Different End-of-Life Trajectories: A Retrospective Cohort Study

Emergency units have been gradually recognized as important settings for palliative care initiation, but require precise palliative care assessments. Patients with different illness trajectories are found to differ in palliative care referrals outside emergency unit settings. Understanding how illness trajectories associate with patient traits in the emergency department may aid assessment of palliative care needs. This study aims to investigate the timing and acceptance of palliative referral in the emergency department among patients with different end-of-life trajectories. Participants were classified into three end-of-life trajectories (terminal, frailty, organ failure). Timing of referral was determined by the interval between the date of referral and the date of death, and acceptance of palliative care was recorded among participants eligible for palliative care. Terminal patients had the highest acceptance of palliative care (61.4%), followed by those with organ failure (53.4%) and patients with frailty (50.1%) (p = 0.003). Terminal patients were more susceptible to late and very late referrals (47.4% and 27.1%, respectively) than those with frailty (34.0%, 21.2%) and with organ failure (30.1%, 18.8%) (p < 0.001, p = 0.022). In summary, patients with different end-of-life trajectories display different palliative care referral and acceptance patterns. Acknowledgement of these characteristics may improve palliative care practice in the emergency department.

Development of a practically usable prediction model for quality of life of ICU survivors: A sub-analysis of the MONITOR-IC prospective cohort study

PURPOSE

As the goal of ICU treatment is survival in good health, we aimed to develop a prediction model for ICU survivors' change in quality of life (QoL) one year after ICU admission.

MATERIALS & METHODS

This is a sub-study of the prospective cohort MONITOR-IC study. Adults admitted ≥12 h to the ICU of a university hospital between July 2016-January 2019 were included. Moribund patients were excluded. Change in QoL one year after ICU admission was quantified using the EuroQol five-dimensional (EQ-5D-5L) questionnaire, and Short-Form 36 (SF-36). Multivariable linear regression analysis and best subsets regression analysis (SRA) were used. Models were internally validated by bootstrapping.

RESULTS

The PREdicting PAtients' long-term outcome for Recovery (PREPARE) model was developed (n = 1308 ICU survivors). The EQ-5D-models had better predictive performance than the SF-36-models. Explained variance (adjusted R²) of the best model (33 predictors) was 58.0%. SRA reduced the number of predictors to 5 (adjusted R² = 55.3%, SE = 0.3), including QoL, diagnosis of a Cardiovascular Incident and frailty before admission, sex, and ICU-admission following planned surgery.

CONCLUSIONS

Though more long-term data are needed to ascertain model accuracy, in future, the PREPARE model may be used to better inform and prepare patients and their families for ICU recovery.

Physical, Mental, and Cognitive Health Status of ICU Survivors Before ICU Admission: A Cohort Study

OBJECTIVES

Although patient's health status before ICU admission is the most important predictor for long-term outcomes, it is often not taken into account, potentially overestimating the attributable effects of critical illness. Studies that did assess the pre-ICU health status often included specific patient groups or assessed one specific health domain. Our aim was to explore patient's physical, mental, and cognitive functioning, as well as their quality of life before ICU admission.

DESIGN

Baseline data were used from the longitudinal prospective MONITOR-IC cohort study.

SETTING

ICUs of four Dutch hospitals.

PATIENTS

Adult ICU survivors (n = 2,467) admitted between July 2016 and December 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients, or their proxy, rated their level of frailty (Clinical Frailty Scale), fatigue (Checklist Individual Strength-8), anxiety and depression (Hospital Anxiety and Depression Scale), cognitive functioning (Cognitive Failure Questionnaire-14), and quality of life (Short Form-36) before ICU admission. Unplanned patients rated their pre-ICU health status retrospectively after ICU admission. Before ICU admission, 13% of all patients was frail, 65% suffered from fatigue, 28% and 26% from symptoms of anxiety and depression, respectively, and 6% from cognitive problems. Unplanned patients were significantly more frail and depressed. Patients with a poor pre-ICU health status were more often likely to be female, older, lower educated, divorced or widowed, living in a healthcare facility, and suffering from a chronic condition.

CONCLUSIONS

In an era with increasing attention for health problems after ICU admission, the results of this study indicate that a part of the ICU survivors already experience serious impairments in their physical, mental, and cognitive functioning before ICU admission. Substantial differences were seen between patient subgroups. These findings underline the importance of accounting for pre-ICU health status when studying long-term outcomes.

Costs and Cost-Utility of Critical Care and Subsequent Health Care: A Multicenter Prospective Study

OBJECTIVES

The number of critical care survivors is growing, but their long-term outcomes and resource use are poorly characterized. Estimating the cost-utility of critical care is necessary to ensure reasonable use of resources. The objective of this study was to analyze the long-term resource use and costs, and to estimate the cost-utility, of critical care.

DESIGN

Prospective observational study.

SETTING

Seventeen ICUs providing critical care to 85% of the Finnish adult population.

PATIENTS

Adult patients admitted to any of 17 Finnish ICUs from September 2011 to February 2012, enrolled in the Finnish Acute Kidney Injury (FINNAKI) study, and matched hospitalized controls from the same time period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We primarily assessed total 3-year healthcare costs per quality-adjusted life-years at 3 years. We also estimated predicted life-time quality-adjusted life-years and described resource use and costs. The costing year was 2016. Of 2,869 patients, 1,839 (64.1%) survived the 3-year follow-up period. During the first year, 1,290 of 2,212 (58.3%) index episode survivors were rehospitalized. Median (interquartile range) 3-year cumulative costs per patient were $49,200 ($30,000-$85,700). ICU costs constituted 21.4% of the total costs during the 3-year follow-up. Compared with matched hospital controls, costs of the critically ill remained higher throughout the follow-up. Estimated total mean (95% CI) 3-year costs per 3-year quality-adjusted life-years were $46,000 ($44,700-$48,500) and per predicted life-time quality-adjusted life-years $8,460 ($8,060-8,870). Three-year costs per 3-year quality-adjusted life-years were $61,100 ($57,900-$64,400) for those with an estimated risk of in-hospital death exceeding 15% (based on the Simplified Acute Physiology Score II).

CONCLUSIONS

Healthcare resource use was substantial after critical care and remained higher compared with matched hospital controls. Estimated cost-utility of critical care in Finland was of high value.

Age, Frailty, Resuscitation and Intensive Care: With Reference to COVID-19

Discussion regarding cardiopulmonary resuscitation and admission to an intensive care unit is frequently fraught in the context of older age. It is complicated by the fact that the presence of multiple comorbidities and frailty adversely impact on prognosis. Cardiopulmonary resuscitation and mechanical ventilation are not appropriate for all. Who decides and how? This paper discusses the issues, biases, and potential harms involved in decision-making. The basis of decision making requires fairness in the distribution of resources/healthcare (distributive justice), yet much of the printed guidance has taken a utilitarian approach (getting the most from the resource provided). The challenge is to provide a balance between justice for the individual and population justice.

Short-term and long-term survival in critical patients treated by helicopter emergency medical services in Finland: a registry study of 36 715 patients

OBJECTIVES

This study aimed to describe the short-term and long-term mortality of patients treated by prehospital critical care teams in Finland.

DESIGN AND SETTING

We performed a registry-based retrospective study that included all helicopter emergency medical service (HEMS) dispatches in Finland from 1 January 2012 to 8 September 2019. Mortality data were acquired from the national Population Register Centre to calculate the standardised mortality ratio (SMR).

PARTICIPANTS

All patients encountered by Finnish HEMS crews during the study period were included.

MAIN OUTCOMES

Mortalities presented at 0 to 1 day, 2 to 30 days, 31 days to 1 year and 1 to 3 years for different medical reasons following the prehospital care. Patients were divided into four groups by age and categorised by gender. The SMR at 2 to 30 days, 31 days to 1 year and 1 to 3 years was calculated for the same groups.

RESULTS

Prehospital critical care teams participated in the treatment of 36 715 patients, 34 370 of whom were included in the study. The cumulative all-cause mortality at 30 days was 27.5% and at 3 years was 36.5%. The SMR in different medical categories and periods ranged from 23.2 to 72.2, 18.1 to 22.4, 7.7 to 9.2 and 2.1 to 2.6 in the age groups of 0 to 17 years, 18 to 64 years, 65 to 79 years and ≥80 years, respectively.

CONCLUSIONS

We found that the rate of mortality after a HEMS team provides critical care is high and remains significantly elevated compared with the normal population for years after the incident. The mortality is dependent on the medical reason for care and the age of the patient. The long-term overmortality should be considered when evaluating the benefit of prehospital critical care in the different patient groups.

Determinants of hospital and one-year mortality among older patients admitted to intensive care units: results from the multicentric SENIOREA cohort

BACKGROUND

Improving outcomes of older patients admitted into intensive care units (ICU) is a raising concern. This study aimed at determining which geriatric and ICU parameters were associated with in-hospital and long-term mortality in this population.

METHODS

We conducted a prospective multicentric observational cohort study, including patients aged 75 years and older requiring mechanical ventilation, admitted between September 2012 and December 2013 into ICU of 13 French hospitals. Comprehensive geriatric assessment at ICU admission and ICU usual parameters were registered in a standardized manner. Survival was recorded and comprehensive geriatric assessment was updated after 1 year during a dedicated home visit.

RESULTS

501 patients were analyzed. 108 patients (21.6%) died during the hospital stay. One-year survival rate was 53.8% (IC 95% [49.2%; 58.2%]). Factors associated with increased in-hospital mortality were higher acute illness severity score, resuscitated cardiac arrest as primary ICU diagnosis, perception of anxiety and low quality of life by the proxy, and living in a chronic care facility before ICU admission. Among patients alive at hospital discharge, factors associated with increased 1-year mortality in multivariate analysis were longer duration of mechanical ventilation, all primary ICU diagnoses other than septic shock, a Katz-activities of daily living (ADL) score below 5 and living in a chronic care facility before ICU admission. Among the 163 survivors at 1 year who received a second comprehensive geriatric assessment, the ADL score (functional abilities) showed a significant but moderate decline over time, whereas the Mini-Zarit score (family burden) improved. No significant change in patients' place of life was observed after 1 year, and quality of life was reported as happy-to-very-happy in 88% of survivors.

CONCLUSIONS

The mortality rate remains high among older ICU patients requiring mechanical ventilation. Factors associated with short- and long-term mortality combined geriatric and ICU criteria, which should be jointly evaluated in routine care. Clinical trial registration NCT01679171.

The FRAIL-FIT 30 Study – Factors influencing 30-day mortality in frail patients admitted to ICU: A retrospective observational cohort study

Background

Frailty is a multi-dimensional syndrome of reduced reserve, resulting from overlapping physiological decrements across multiple systems. The contributing factors, temporality and magnitude of frailty’s effect on mortality after ICU admission are unclear. This study assessed frailty’s impact on mortality and life sustaining therapy (LST) use, following ICU admission.

Methods

This single-centre retrospective observational cohort study analysed data collected prospectively in Glasgow Royal Infirmary ICU. Of 684 eligible patients, 171 were frail and 513 were non-frail. Frailty was quantified using the Rockwood Clinical Frailty Scale (CFS). All patients were followed up 1-year after ICU admission. The primary outcome was all-cause mortality at 30-days post-ICU admission. Key secondary outcomes included mortality at 1-year and LST use.

Results

Frail patients were significantly less likely to survive 30-days post-ICU admission (61.4% vs 81.1%, p < 0.001). This continued to 1-year (48.5% vs 68.2%, p < 0.001). Frailty significantly increased mortality hazards in covariate-adjusted analyses at 30-days (HR 1.56; 95%CI 1.14–2.15; p = 0.006), and 1-year (HR 1.35; 95%CI 1.03–1.76; p = 0.028). Single-point CFS increases were associated with a 30-day mortality hazard of 1.23 (95%CI 1.13–1.34; p < 0.001) in unadjusted analyses, and 1.11 (95%CI 1.01–1.22; p = 0.026) after covariate adjustment. Frail patients received significantly more days of LST (median[IQR]: 5[3,11] vs 4[2,9], p = 0.008).

Conclusion

Frailty was significantly associated with greater mortality at all time points studied, but most notably in the first 30-days post-ICU admission. This was despite greater LST use. The accrual effect of frailty increased adverse outcomes. Point-by-point use of frailty scoring could allow for more informed decision making in ICU.

Long term outcomes for elderly patients after emergency intensive care admission: A cohort study

Background

Elderly patients (≥ 80 years of age) surviving an episode of critical illness suffer long-term morbidity and risk of mortality. Identifying high risk groups could assist in informing discussions with patients and families.

Aim

To determine factors associated with long-term survival following ICU admission.

Design

A cohort study of patients aged ≥ 80 years of age admitted to the ICU as an emergency.

Methods

Patients admitted from January 2010 to December 2018 were included in the study. Primary outcome was five year survival. Mortality was assessed using a multivariable flexible parametric survival analysis adjusted for demographics, and clinically relevant covariates.

Results

There were 828 patients. Mean age was 84 years (SD 3.2) and 419 (51%) were male. Patients were categorised into medical (423 (51%)) and surgical (405 (49%)) admissions. Adjusted hazard ratios (aHR) for mortality were highest for serum lactate (>8 mmol/l aHR 2.56 (C.I. 1.79–3.67)), lowest systolic blood pressure (< 70 mmHg aHR 2.04 (C.I. 1.36–3.05)) and pH (< 7.05 aHR 4.70 (C.I 2.67–8.21)). There were no survivors beyond one year with severe abnormalities of pH and lactate (< 7.05 and > 8 mmol/l respectively). Relative survival for medical patients was below that expected for the general population for the duration of the study.

Conclusion

Overall five-year survival was 27%. For medical and surgical patients it was 19% and 35% respectively. Survival at 30 days and one year was 61% and 46%. The presence of features of circulatory shock predicted poor short and long term survival.

Intensive care patient survival after limiting life-sustaining treatment-The FINNEOL* national cohort study

BACKGROUND

Few studies have examined survival in intensive care unit (ICU) patients after the restriction of life-sustaining treatment (LST). We aimed to analyse independent factors associated with hospital and 12-month survival rates in ICU patients after treatment restrictions.

METHODS

This retrospective observational study examined all patients treated in adult ICUs from 1 January 2016 until 31 December 2016 included in the Finnish ICU Registry. Multivariable logistic regression analysis was performed to explain the effect on survival.

RESULTS

Decisions to limit LST were made for 2444 patients (13.7%; 95% CI 13.2-14.2). ICU, hospital, and 12-month survival rates were 71% (95% CI 69-73), 49% (95% CI 47-51), and 24% (95% CI 22-26), respectively. In patients for whom life support was withheld, increased 12-month survival rates were associated with admission from the operating theatre (OR 1.9, 95% CI 1.1-3.4), good pre-hospital physical fitness (OR 4.7, 95% Cl 1.2-16.8) and being housed at home (OR 2.0, 95% Cl 1.4-2.8). Decreased survival rates were associated with admission from a hospital ward (OR 0.67, 95% Cl 0.5-0.9), higher comorbidity (OR 0.6, 95% Cl 0.4-0.9), cancer (OR 0.4, 95%CI 0.2-0.9), greater illness severity (SAPS II; OR 0.98, 95% Cl 0.98-0.99), and higher care intensity (TISS-76; OR 0.93, 95% Cl 0.92-0.95).

CONCLUSION

Survival among ICU patients with limited treatment was higher than expected. Advanced age was not associated with higher mortality, potentially because treatment restrictions may be set more easily for older patients.

Elderly patients with cancer admitted to intensive care unit: A multicenter study in a middle-income country

BACKGROUND

Very elderly critically ill patients (ie, those older than 75 or 80 years) are an increasing population in intensive care units. However, patients with cancer have encompassed only a minority in epidemiological studies of very old critically-ill patients. We aimed to describe clinical characteristics and identify factors associated with hospital mortality in a cohort of patients aged 80 or older with cancer admitted to intensive care units (ICUs).

METHODS

This was a retrospective cohort study in 94 ICUs in Brazil. We included patients aged 80 years or older with active cancer who had an unplanned admission. We performed a mixed effect logistic regression model to identify variables independently associated with hospital mortality.

RESULTS

Of 4604 included patients, 1807 (39.2%) died in hospital. Solid metastatic (OR = 2.46; CI 95%, 2.01-3.00), hematological cancer (OR = 2.32; CI 95%, 1.75-3.09), moderate/severe performance status impairment (OR = 1.59; CI 95%, 1.33-1.90) and use of vasopressors (OR = 4.74; CI 95%, 3.88-5.79), mechanical ventilation (OR = 1.54; CI 95%, 1.25-1.89) and renal replacement (OR = 1.81; CI 95%, 1.29-2.55) therapy were independently associated with increased hospital mortality. Emergency surgical admissions were associated with lower mortality compared to medical admissions (OR = 0.71; CI 95%, 0.52-0.96).

CONCLUSIONS

Hospital mortality rate in very elderly critically ill patients with cancer with unplanned ICU admissions are lower than expected a priori. Cancer characteristics, performance status impairment and acute organ dysfunctions are associated with increased mortality.

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.

Outcomes of Intensive Care Patients Older Than 90 Years: An 11-Year National Observational Study

BACKGROUND/OBJECTIVES

Many intensive care unit (ICU) physicians are reluctant to admit patients aged 90 years and older, although evidence to support these decisions is scarce. Although the body of evidence on outcomes of patients aged 80 years and older is growing, it does not include patients aged 90 years and older. The aim of this study was to compare the short- and long-term mortality of ICU patients aged 90 years and older in the Netherlands with ICU patients aged 80 to 90 years, that is, octogenarians.

DESIGN

Multicenter national cohort study over an 11-year period (2008-2018), using data of the National Intensive Care Evaluation (NICE) registry and the Dutch insurance claims registry.

SETTING

All 82 ICUs in the Netherlands.

PARTICIPANTS

All patients aged 80 years and older at the time of ICU admission.

MEASUREMENTS

A total of 104,754 patients aged 80 years and older, of whom 9,495 (9%) were 90 years and older, were admitted to Dutch ICUs during the study period.

RESULTS

ICU mortality of the patients aged 90 years and older was lower (13.8% vs 16.1%; P < .001) and hospital mortality was similar (26.1% vs 25.7%; P = .41) compared with octogenarians. After 3 months, mortality was higher for the patients aged 90 years and older (43.1% vs 33.7%; P < .001) and after 1-year mortality was 55.0% vs 42.7%; P < .001.

CONCLUSION

In the Netherlands, mortality rates of patients aged 90 years and older admitted to the ICU are not as disappointing as often assumed. They have a lower ICU mortality and a similar hospital mortality compared with octogenarians. Nevertheless, their longer term mortality is higher compared with octogenarians. However, almost 3 of 4 patients leave the hospital alive, and almost half of the patients aged 90 years and older are still alive 1 year after their ICU admission. J Am Geriatr Soc 68:1842-1846, 2020.

Performance of the quick SOFA in very old ICU patients admitted with sepsis

BACKGROUND

The number of very elderly ICU patients (abbreviated to VOPs; ≥80 years) with sepsis increases. Sepsis was redefined in 2016 (sepsis 3.0) using the quick SOFA (qSOFA) score. Since then, multiple studies have validated qSOFA for prognostication in different patient categories, but the prognostic value in VOPs with sepsis is still unknown.

METHODS

Retrospective cohort study including patients admitted to Dutch ICUs with sepsis, in the period 2012 to 2016, evaluating the outcome and the performance of qSOFA, an extended qSOFA model, SOFA, SAPS II, and APACHE IV for hospital mortality.

RESULTS

5969 patients were included, of which 935 VOPs. Crude hospital mortality rates were 19%, 28%, and 39% for patients aged 18-65, 65-80, and ≥80 years respectively. Discriminative performance of qSOFA for in-hospital mortality in VOPs was poor (AUC 0.596) and lower than that of SOFA, APACHE IV, and SAPS II (0.704, 0.722, and 0.780 respectively). A qSOFA model extended with several other characteristics (AUC 0.643) was non-inferior to the full SOFA, but still inferior to APACHE IV and SAPS II, for all age groups. The Hosmer-Lemeshow goodness-of-fit test showed non-significant p-values for all models. Accuracy for both qSOFA and the extended qSOFA was lower compared to APACHE IV and SAPS II (Brier scores 0.227, 0.223, 0.184, and 0.183 respectively).

CONCLUSION

The qSOFA showed worse discriminative performance to predict mortality than SOFA, APACHE IV, and SAPS II in both VOPs and younger patients admitted with sepsis.

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

OBJECTIVES

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

DESIGN

RETROSPECTIVE ANALYSIS OF NATIONAL CLINICAL AUDIT DATABASE.

SETTING

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

PATIENTS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Management of prolonged epileptic seizures and status epilepticus in palliative care patients

Prolonged seizures and status epilepticus (SE) are relevant problems in palliative care. Timely recognition and effective early treatment with first- and second-line antiepileptic drugs (AEDs) may prevent unnecessary hospitalizations. Seizures should be recognized and addressed like any other symptom that causes discomfort or reduces quality of life. Use of alternative AED administration routes (buccal, intranasal, or subcutaneous) may offer possibilities for effective and individualized AED therapy, even during the last days of life. In hospice or home care, however, also intravenous treatment is possible via vascular access devices for long-term use. Aggressive unlimited intensive care unit (ICU) treatment of refractory SE in palliative patients is mostly not indicated. At worst, intensive care can be futile and possibly harmful: death in the ICU is often preceded by long and aggressive treatments. Metastatic cancer, old age, high severity of acute illness, overall frailty, poor functional status before hospital admission, and the presence of severe comorbidities all increase the probability of poor outcome of intensive care. When several of these factors are present, consideration of withholding intensive care may be in the patient's best interests. Anticipated outcomes influence patients' preferences. A majority of patients with a limited life expectancy because of an incurable disease would not want aggressive treatment, if the anticipated outcome was survival but with severe functional impairment. Doctors' perceptions about their patients' wishes are often incorrect, and therefore, advance care planning including seizure management should be done early in the course of the disease. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".

Relationship between community walking ability and in-hospital mortality in elderly patients with sepsis: a single-center retrospective cohort study

Purpose

To examine the association of a simple frailty assessment, Life Space (LS), with in-hospital mortality in elderly patients with sepsis.

Methods

We used data from a single hospital between 2014 and 2017. We included elderly patients (age ≥ 65 years) admitted to the intensive care unit (ICU) with sepsis, as defined by sepsis-3 criteria. Frailty assessment was based on a patient's ability to independently go out of the house before the ICU admission. We termed this dichotomous score as Life Space. The primary outcome was in-hospital mortality. Logistic regression was used to investigate the association of LS with each outcome after adjusting for age, sex, and Sequential Organ Failure Assessment score.

Results

Of the 335 participants included in the final analysis, 121 (36%) were classified as frail. LS-positive patients had a higher in-hospital mortality (adjusted odds ratio (aOR) 2.32; 95% confidence interval (CI) 1.36-3.96; P = 0.002) than did LS-negative patients. We observed similar patterns in six sets of sensitivity analyses after accounting for different confounders. In subgroup analyses, significant interactions were observed in participants with versus those without treatment limitations (aOR 1.02 vs. 2.66, P for interaction = 0.042).

Conclusions

In this single-center study, frailty assessed by LS was independently associated with a higher in-hospital mortality.

Red-flag sepsis and SOFA identifies different patient population at risk of sepsis-related deaths on the general ward

Controversy exists regarding the best diagnostic and screening tool for sepsis outside the intensive care unit (ICU). Sequential organ failure assessment (SOFA) score has been shown to be superior to systemic inflammatory response syndrome (SIRS) criteria, however, the performance of "Red Flag sepsis criteria" has not been tested formally.The aim of the study was to investigate the ability of Red Flag sepsis criteria to identify the patients at high risk of sepsis-related death in comparison to SOFA based sepsis criteria. We also investigated the comparison of Red Flag sepsis to quick SOFA (qSOFA), SIRS, and national early warning score (NEWS) scores and factors influencing patient mortality.Patients were recruited into a 24-hour point-prevalence study on the general wards and emergency departments across all Welsh acute hospitals. Inclusion criteria were: clinical suspicion of infection and NEWS 3 or above in-line with established escalation criteria in Wales. Data on Red Flag sepsis and SOFA criteria was collected together with qSOFA and SIRS scores and 90-day mortality.459 patients were recruited over a 24-hour period. 246 were positive for Red Flag sepsis, mortality 33.7% (83/246); 241 for SOFA based sepsis criteria, mortality 39.4% (95/241); 54 for qSOFA, mortality 57.4% (31/54), and 268 for SIRS, mortality 33.6% (90/268). 55 patients were not picked up by any criteria. We found that older age was associated with death with OR (95% CI) of 1.03 (1.02-1.04); higher frailty score 1.24 (1.11-1.40); DNA-CPR order 1.74 (1.14-2.65); ceiling of care 1.55 (1.02-2.33); and SOFA score of 2 and above 1.69 (1.16-2.47).The different clinical tools captured different subsets of the at-risk population, with similar sensitivity. SOFA score 2 or above was independently associated with increased risk of death at 90 days. The sequalae of infection-related organ dysfunction cannot be reliably captured based on routine clinical and physiological parameters alone.