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      Factors that predict outcome of intensive care treatment in very elderly patients: a review

      research-article
      Author(s): 1 , , 2 , 3 , 4
      Publication date (Electronic):
      Journal: Critical Care
      Publisher: BioMed Central

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          Abstract

          Introduction

          Advanced age is thought to be associated with increased mortality in critically ill patients. This report reviews available data on factors that determine outcome, on the value of prognostic models, and on preferences regarding life-sustaining treatments in (very) elderly intensive care unit (ICU) patients.

          Methods

          We searched the Medline database (January 1966 to January 2005) for English language articles. Selected articles were cross-checked for other relevant publications.

          Results

          Mortality rates are higher in elderly ICU patients than in younger patients. However, it is not age per se but associated factors, such as severity of illness and premorbid functional status, that appear to be responsible for the poorer prognosis. Patients' preferences regarding life-sustaining treatments are importantly influenced by the likelihood of a beneficial outcome. Commonly used prognostic models have not been calibrated for use in the very elderly. Furthermore, they do not address long-term survival and functional outcome.

          Conclusion

          We advocate the development of new prognostic models, validated in elderly ICU patients, that predict not only survival but also functional and cognitive status after discharge. Such a model may support informed decision making with respect to patients' preferences.

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          Most cited references61

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          The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults.

          W A Knaus, D P Wagner, E A Draper … (1991)
          The objective of this study was to refine the APACHE (Acute Physiology, Age, Chronic Health Evaluation) methodology in order to more accurately predict hospital mortality risk for critically ill hospitalized adults. We prospectively collected data on 17,440 unselected adult medical/surgical intensive care unit (ICU) admissions at 40 US hospitals (14 volunteer tertiary-care institutions and 26 hospitals randomly chosen to represent intensive care services nationwide). We analyzed the relationship between the patient's likelihood of surviving to hospital discharge and the following predictive variables: major medical and surgical disease categories, acute physiologic abnormalities, age, preexisting functional limitations, major comorbidities, and treatment location immediately prior to ICU admission. The APACHE III prognostic system consists of two options: (1) an APACHE III score, which can provide initial risk stratification for severely ill hospitalized patients within independently defined patient groups; and (2) an APACHE III predictive equation, which uses APACHE III score and reference data on major disease categories and treatment location immediately prior to ICU admission to provide risk estimates for hospital mortality for individual ICU patients. A five-point increase in APACHE III score (range, 0 to 299) is independently associated with a statistically significant increase in the relative risk of hospital death (odds ratio, 1.10 to 1.78) within each of 78 major medical and surgical disease categories. The overall predictive accuracy of the first-day APACHE III equation was such that, within 24 h of ICU admission, 95 percent of ICU admissions could be given a risk estimate for hospital death that was within 3 percent of that actually observed (r2 = 0.41; receiver operating characteristic = 0.90). Recording changes in the APACHE III score on each subsequent day of ICU therapy provided daily updates in these risk estimates. When applied across the individual ICUs, the first-day APACHE III equation accounted for the majority of variation in observed death rates (r2 = 0.90, p less than 0.0001).
          Article 0 comments Cited 455 times – based on 0 reviews     Review now
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            The impact of delirium in the intensive care unit on hospital length of stay

            E. ELY, S Gautam, R. Margolin … (2001)
            Abstract. Study objective: To determine the relationship between delirium in the intensive care unit (ICU) and outcomes including length of stay in the hospital. Design: A prospective cohort study. Setting: The adult medical ICU of a tertiary care, university-based medical center. Participants: The study population consisted of 48 patients admitted to the ICU, 24 of whom received mechanical ventilation. Measurements: All patients were evaluated for the development and persistence of delirium on a daily basis by a geriatric or psychiatric specialist with expertise in delirium assessment using the Diagnostic Statistical Manual IV (DSM-IV) criteria of the American Psychiatric Association, the reference standard for delirium ratings. Primary outcomes measured were length of stay in the ICU and hospital. Results: The mean onset of delirium was 2.6 days (S.D.±1.7), and the mean duration was 3.4±1.9 days. Of the 48 patients, 39 (81.3%) developed delirium, and of these 29 (60.4%) developed the complication while still in the ICU. The duration of delirium was associated with length of stay in the ICU (r=0.65, P=0.0001) and in the hospital (r=0.68, P<0.0001). Using multivariate analysis, delirium was the strongest predictor of length of stay in the hospital (P=0.006) even after adjusting for severity of illness, age, gender, race, and days of benzodiazepine and narcotic drug administration. Conclusions: In this patient cohort, the majority of patients developed delirium in the ICU, and delirium was the strongest independent determinant of length of stay in the hospital. Further study and monitoring of delirium in the ICU and the risk factors for its development are warranted.
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              A simplified acute physiology score for ICU patients.

              P. Le Mercier, Stefan Glaser, D Mathieu … (1984)
              We used 14 easily measured biologic and clinical variables to develop a simple scoring system reflecting the risk of death in ICU patients. The simplified acute physiology score (SAPS) was evaluated in 679 consecutive patients admitted to eight multidisciplinary referral ICUs in France. Surgery accounted for 40% of admissions. Data were collected during the first 24 h after ICU admission. SAPS correctly classified patients in groups of increasing probability of death, irrespective of diagnosis, and compared favorably with the acute physiology score (APS), a more complex scoring system which has also been applied to ICU patients. SAPS was a simpler and less time-consuming method for comparative studies and management evaluation between different ICUs.
              Article 0 comments Cited 157 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Crit Care
                Title: Critical Care
                Publisher: BioMed Central (London )
                ISSN (Print): 1364-8535
                ISSN (Electronic): 1466-609X
                Publication date (Print): 2005
                Publication date (Electronic): 17 May 2005
                Volume: 9
                Issue: 4
                Pages: R307-R314
                Affiliations
                [1 ]Head, Department of Geriatrics, Academic Medical Center, University of Amsterdam, Amsterdam
                [2 ]Adjunct Head, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam
                [3 ]Professor and Head, Department of Internal Medicine, Cardiology and Pulmonary Disease, Academic Medical Center, University of Amsterdam, Amsterdam
                [4 ]Adjunct Head Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam
                Article
                Publisher ID: cc3536
                DOI: 10.1186/cc3536
                PMC ID: 1269437
                PubMed ID: 16137342
                SO-VID: 2319792a-2131-4584-9155-84b1e709ecb0
                Copyright © Copyright © 2005 de Rooij et al.; licensee BioMed Central Ltd.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 13 January 2005
                Date revision requested : 11 March 2005
                Date revision received : 6 April 2005
                Date accepted : 8 April 2005
                Categories
                Subject: Research

                ScienceOpen disciplines: Emergency medicine & Trauma
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma

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