Older age is associated with higher prevalence of chronic illness and functional impairment, contributing to an increased rate of hospitalization and admission to intensive care. The primary objective was to evaluate the rate, characteristics and outcomes of very old (age ≥ 80 years) patients admitted to intensive care units (ICUs). Retrospective analysis of prospectively collected data from the Australian New Zealand Intensive Care Society Adult Patient Database. Data were obtained for 120,123 adult admissions for ≥ 24 hours across 57 ICUs from 1 January 2000 to 31 December 2005. A total of 15,640 very old patients (13.0%) were admitted during the study. These patients were more likely to be from a chronic care facility, had greater co-morbid illness, greater illness severity, and were less likely to receive mechanical ventilation. Crude ICU and hospital mortalities were higher (ICU: 12% vs. 8.2%, P < 0.001; hospital: 24.0% vs. 13%, P < 0.001). By multivariable analysis, age ≥ 80 years was associated with higher ICU and hospital death compared with younger age strata (ICU: odds ratio (OR) = 2.7, 95% confidence interval (CI) = 2.4 to 3.0; hospital: OR = 5.4, 95% CI = 4.9 to 5.9). Factors associated with lower survival included admission from a chronic care facility, co-morbid illness, nonsurgical admission, greater illness severity, mechanical ventilation, and longer stay in the ICU. Those aged ≥ 80 years were more likely to be discharged to rehabilitation/long-term care (12.3% vs. 4.9%, OR = 2.7, 95% CI = 2.6 to 2.9). The admission rates of very old patients increased by 5.6% per year. This potentially translates to a 72.4% increase in demand for ICU bed-days by 2015. The proportion of patients aged ≥ 80 years admitted to intensive care in Australia and New Zealand is rapidly increasing. Although these patients have more co-morbid illness, are less likely to be discharged home, and have a greater mortality than younger patients, approximately 80% survive to hospital discharge. These data also imply a potential major increase in demand for ICU bed-days for very old patients within a decade.

https://link.springer.com/content/pdf/10.1186%2Fcc7768.pdf

Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis

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.

/pdf/icu-admission-characteristics-and-mortality-rates-among-2cuxm66omh.pdf

ICU admission characteristics and mortality rates among elderly and very elderly patients

Frailty is a recent concept used for evaluating elderly individuals. Our study determined the prevalence of frailty in intensive care unit (ICU) patients and its impact on the rate of mortality. A multicenter, prospective, observational study performed in four ICUs in France included 196 patients aged ≥65 years hospitalized for >24 h during a 6-month study period. Frailty was determined using the frailty phenotype (FP) and the clinical frailty score (CFS). The patients were separated as follows: FP score <3 or ≥3 and CFS <5 or ≥5. Frailty was observed in 41 and 23 % of patients on the basis of an FP score ≥3 and a CFS ≥5, respectively. At admission to the ICU, the Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) scores did not differ between the frail and nonfrail patients. In the multivariate analysis, the risk factors for ICU mortality were FP score ≥3 [hazard ratio (HR), 3.3; 95 % confidence interval (CI), 1.6–6.6; p < 0.001], male gender (HR, 2.4; 95 % CI, 1.1–5.3; p = 0.026), cardiac arrest before admission (HR, 2.8; 95 % CI, 1.1–7.4; p = 0.036), SAPS II score ≥46 (HR, 2.6; 95 % CI, 1.2–5.3; p = 0.011), and brain injury before admission (HR, 3.5; 95 % CI, 1.6–7.7; p = 0.002). The risk factors for 6-month mortality were a CFS ≥5 (HR, 2.4; 95 % CI, 1.49–3.87; p < 0.001) and a SOFA score ≥7 (HR, 2.2; 95 % CI, 1.35–3.64; p = 0.002). An increased CFS was associated with significant incremental hospital and 6-month mortalities. Frailty is a frequent occurrence and is independently associated with increased ICU and 6-month mortalities. Notably, the CFS predicts outcomes more effectively than the commonly used ICU illness scores.

/pdf/prevalence-and-impact-of-frailty-on-mortality-in-elderly-icu-3jxxwcksnm.pdf

Prevalence and impact of frailty on mortality in elderly ICU patients: a prospective, multicenter, observational study.

As the general population ages, an increasing number of patients over 80 years are being admitted to the intensive care unit (ICU) Selection of older patients for ICU admission results in lower rates of co-morbidities and underlying fatal diseases After adjustment for disease severity, ICU and post-ICU mortality rates are higher in elderly patients than in younger populations Age itself explains only a small part of the increased hospital mortality, suggesting that specific information such as functional, cognitive, and nutritional status, as well as co-morbidities, should be collected to predict mortality in elderly ICU patients The long-term prognosis depends chiefly on functional status, whereas initial disease severity no longer influences mortality According to our review, it is impossible to define evidence-based recommendations for ICU admission of the elderly This justifies further studies that encompass several aspects, such as the initial triage process and the long-term prognosis (mortality, autonomy and quality of life)

Should elderly patients be admitted to the intensive care unit

People who are older than 65 years of age are the fastest growing segment of the US population.1 By 2030 the population older than 65 years will double to approximately 70 million, and the fastest growing segment of the population, those older than 84 years, will triple.1–3 Age is associated with an increasing prevalence of multiple diseases and disabilities. Age is also associated with a decline of the functional reserve of multiple organ systems and a progressive restriction in personal and social resources. It is, therefore, not surprising that elderly patients will utilize a disproportionate share of health care resources. It is estimated that by the year 2030, 55% of all health care expenses in the USA will be spent on caring for the elderly.4 By virtue of having lived longer, increasing numbers of elderly patients (age >65 years) are being admitted to intensive care units (ICUs), with diagnoses ranging from exacerbations of chronic illnesses and new onset of catastrophic health problems to trauma caused by home-related incidents and injury-resultant accidents that have occurred outside of the home. Elderly patients currently account for 42–52% of ICU admissions and for almost 60% of all ICU days.3,5–7 A disproportionate number of these ICU days is spent by elderly patients before their death. Forty percent of Medicare dependants are admitted to an ICU during their terminal illness, accounting for a quarter of all Medicare expenditure.8,9 Clearly ICU utilization by the elderly will increase exponentially over the next three decades. With the current unitization patterns, a severe shortage of intensivists and ICU beds has therefore been predicted.3 The reality of our aging society dictates that we must focus on how to best care for the elderly who develop critical illness.

Management of the Critically Ill Geriatric Patient

To report short-term and long-term mortality of very elderly ICU patients and to determine independent risk factors for short-term and long-term mortality Retrospective cohort study in the medical/surgical ICU of a tertiary university teaching hospital. 578 consecutive ICU patients aged 80 years or older. Demographic, physiological, and laboratory values derived from the first 24 h after ICU admission. ICU mortality of unplanned surgical (34.0%) and medical patients (37.7%) was higher than that of planned surgical patients (10.6%), as was post-ICU hospital mortality (26.5% and 29.7% vs. 4.4%). Mortality 12 months after hospital discharge, including ICU and hospital mortality, was 62.1% in unplanned surgical and 69.2% in medical patients vs. 21.6% in planned patients. Only median survival of planned surgical patients did not differ from survival in the age- and gender-matched general population. Independent risk factors for ICU mortality were lower Glasgow Coma Scale score, higher SAPS II score, the lowest urine output over 8 h, abnormal body temperature, low plasma bicarbonate levels, and higher oxygen fraction of inspired air. High urea concentrations and admission type were risk factors for hospital mortality, and high creatinine concentration was an independent risk factor for 12-month mortality. Mortality in very elderly patients after unplanned surgical or medical ICU admission is higher than after planned admission. The most important factors independently associated with ICU mortality were related to the severity of illness at admission. Long-term mortality was associated with renal function.

Short-term and long-term mortality in very elderly patients admitted to an intensive care unit

Plasma substitutes, such as crystalloid or colloid solutions are frequently used in bleeding patients or in situations with a high risk of bleeding such as trauma or during surgery. There is ample evidence that these agents may affect blood coagulation and platelet function [1], although some authors, referring to thromboelastography studies, have suggested that hemodilution per se results in a hypercoagulable state [2]. These findings, however, have been disputed. In particular, all three distinct classes of artificial colloids (i.e., dextrans, hydroxyethyl starches [HES], and gelatins) have been associated with derangements of the hemostatic system, although the clinical significance of these derangements is a matter of debate [3]. In this chapter, we will focus on the anti-hemostatic effects of various volume replacement fluids on platelet function and blood coagulation.

Effects of Plasma Substitutes on Coagulation

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Short-term and long-term mortality in very elderly patients admitted to an intensive care unit

Effects of Plasma Substitutes on Coagulation