NO COUNTRY FOR OLD MEN

ElderyWhat does ICU do to old patients? How does the elderly popuplation do after critical illness? One thing is that we can often get them through the initial surgery/treatment and even through ICU, but the total burden of illness can be too much in the end. Even after discharge, a critical illness event will continue to take its toll. The latest number is a 1-year mortality of 97% for patients 85 years and older.

1 year mortality 97%
Even short term survival data after an ICU stay are pretty tough numbers for the elderly, there’s a high mortality. But then again, patients in ICU are critically ill, and have fairly high mortality rates even for young and previously healthy patients. Looking at the ‘very old’ as defined by >85 years of age in the Biton study in the table below, they have an ICU-discharge survival of 33%. On the low side, but still seems worth it. When following these patients through to hospital discharge, survival was 24%. Still maybe worth it. But check in on these patients after 6 months, and there are only 8% left. At one year, there are only 3% still alive. A one year mortality of 97% for patients over 85 years with circulatory failure after an ICU stay! Still worth it? And how was their quality of life during these last months?

Mortality elderly ICU

Quality of life after critical illness
This article, not on ICU treatment per se, but on functional outcomes for elderly after severe sepsis concludes:

“Severe sepsis in this older population was independently associated with substantial and persistent new cognitive impairment and functional disability among survivors. The magnitude of these new deficits was large, likely resulting in a pivotal downturn in patients’ ability to live independently.”

Is it about age? Or frailty?
Several studies find an association between old age and mortality, even after trying to correct for other factors. But is it just age, or could it be just as much about frailty? Many try to sum up the meaning of the buzz word frailty. A good overview article on frailty and its impact on outcome losely defines it as “a multidimensional syndrome characterized by loss of physiologic and cognitive reserves that confers vulnerability to adverse outcomes”. It can be hard to describe, but I think we all know it when we see it.

Mortality elderly graphFrom available studies, like the Danish retrospective cohort study on 49.000 ICU patients from the Danish National patients registry that included at over 6000 patients over 80 years. Mortality started rising sharply around 75 years.

Old new world
Both the total and the relative number of people over 80 will increase dramatically over the next decades. Predictions say the relative number will double from around 5% in 2010 to around 10% in 2050. This will surely have implications for the health system. And even today, evaluating the very old for intensive care treatment is something we do daily.

In my opinion, frailty can describe much of this added morbidity and mortality we see in the very old. But it’s harder to quantify than a birth date. In some ways it’s the same as debating over chronological vs biological age. So, it’s just important to remember among the dismal survival rates in the very old that an individual assessment is always warranted when admitting to the ICU. It can swing both ways.

Still, what these studies do show is that age must be taken into account when evaluating patients for level of treatment and admittance to an ICU. And remember, getting the patient through ICU doesn’t mean the patient benefited, nor that the patient will survive. Choose wisely.

References
1-year mortality of 97% for patients 85 years or older after circulatory failure:
Outcome of elderly patients with circulatory failure, Intensive Care Med, 2014.

Danish cohort study on 49.000 ICU patients:
Mortality in elderly ICU patients: a cohort study, Acta Anaesthesiol Scand, 2014.

Quality of life after critical illness:
Long-term cognitive impairment and functional disability among survivors of severe sepsis, JAMA, 2010.

Editorial on the elderly and ICU:
Are You Sure it’s about Age?, editorial, Intensive Care Med, 2014.

Good overview article on the elderly, ICU and future predictions:
The challenge of admitting the very elderly to intensive care, Ann of Intensive Care, 2011.

A bit on frailty:
Association between frailty and short- and long-term outcomes among critically ill patients: a multicentre prospective cohort study, CMAJ, 2013.

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