The overstretched intensive care unit (ICU) capacity during the 2019 coronavirus disease
(COVID-19) pandemic generated a debate about age being an important criterion for
triaging patients with COVID-19 for ICU admission [1, 2].
In Portugal, as of April 30, 2020, there have been 24,987 cases of severe acute respiratory
syndrome coronavirus 2 (SARS-CoV2) infection (6,136 [24.5%] patients aged ≥70 years)
and 1,007 individuals have died from COVID-19 (878 [87.2%] patients aged ≥70 years)
This was a multicenter retrospective cohort using data retrieved from the ICU databases.
For comparisons between variables, we used χ2 or Fisher exact tests (SPSS V20; IBM
Corp., North Castle, NY, USA).
As of April 30, in 6 hospitals in Lisbon (catchment area of 1.2 million people), 95
(4.8% of a total of 1,988 cases) patients with COVID-19 pneumonia (nasal/pharynx swab
or respiratory secretions with positive SARS-CoV2 by real-time polymerase chain reaction)
were admitted to the ICU, with 39 (41.1%) patients aged ≥70 years. Overall, 94 (98.9%)
patients required invasive mechanical ventilation (IMV). Among those aged ≥70 years,
38 (97.4%) patients required IMV and only 1 (2.6%) patient was managed solely with
a high-flow nasal cannula. Overall, the mean (±SD) sequential organ failure assessment
(SOFA) score on ICU admission was 7 (±3), and 16 (16.8%) patients did not survive
the ICU stay.
Four ICU (70.5% of the 95 patients included) were using the Clinical Frailty Scale
to help triage patients with COVID-19 for ICU admission, with those having >6 points
being generally declined for ICU care . In 5 (12.8%) patients aged ≥70 years, do-not-resuscitate
decisions were established during the ICU stay.
In this cohort, patients aged ≥70 years were twice more likely to be admitted to the
ICU than others (Table 1; RR = 2.14; 95% CI 1.44–3.18). Moreover, patients aged ≥70
years had access to IMV (RR = 0.97; 95% CI 0.93–1.03) and mean SOFA scores similar
to those of others (8 vs. 7; RR = 1.38; 95% CI 0.47–4.07). However, patients aged
≥70 years were 6 times more likely to die in the ICU than others (RR = 6.22; 95% CI
1.90–20.39). Alternatively, of every 4 patients aged ≥70 years admitted to the ICU,
1 derived a survival benefit from ICU care (number needed to treat: 4; 95% CI 2–8).
Our findings suggest that chronological age was not a limitative criterion for ICU
admission in patients with COVID-19. More likely, clinicians pondered factors such
as the number and severity of comorbidities, the presence and severity of frailty,
and the number and severity of acute organ dysfunctions .
The following limitations warrant consideration. First, the COVID-19 incidence decreased
a few weeks following the lockdown imposed by the Portuguese government on March 18
(from a peak of 1,516 cases on April 10 to 368 cases on April 30) . Second, the
peak ICU bed occupancy rate occurred on April 6 (60.1% of the total national capacity)
. Finally, data on comorbidities and patients declined for ICU admission were not
captured and thus we could not weigh for those potential confounders.
In conclusion, access to ICU care for elderly patients with COVID-19 may be preserved
during the pandemic, especially if there is no strained ICU capacity. While patients
aged ≥70 years may incur in a higher mortality, those selected by ICU clinicians may
benefit from ICU care.
Statement of Ethics
Informed consent was waived due to the observational nature of this study.
Conflicts of Interest Statement
The authors have no conflict of interests to declare.
The authors have no funding sources to declare.
F.S.C., A.B., I.B., A.R., G.D., A.C.A., and R.P. collected the data. F.S.C. analyzed
and interpreted the data. F.S.C. and A.B. drafted this paper. All of the authors read
and approved the final version of this work.