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EFFECT OF TYPE OF ADMISSION ON SHORT‐ AND LONG‐TERM OUTCOME OF NONAGENARIANS ADMITTED TO AN INTENSIVE CARE UNIT

2009; Wiley; Volume: 57; Issue: 6 Linguagem: Inglês

10.1111/j.1532-5415.2009.02297.x

1532-5415

André Miguel Japiassú, Bruno Assis de Oliveira, Carlos Roberto Naegeli Gondim, Pedro Kurtz, Gustavo Fonseca de Almeida, Márcia Pinto, Leonam C. Martins, Marcelo Kalichsztein, Gustavo Freitas Nobre,

Geriatric Care and Nursing Homes

To the Editor: Patients aged 90 and older have increasingly been admitted to intensive care units (ICUs),1 but their baseline characteristics and prognosis may differ from those of elderly people younger than 90 and are poorly understood. An analysis of type of admission (medical or surgical), length of stay (LOS), and mortality was conducted in nonagenarians admitted to a Brazilian ICU. Elderly patients' admissions to a private ICU of a community hospital with 30 bed, from July 2005 to October 2007 were retrospectively evaluated. Demographic data, primary reason for ICU admission, medical or surgical type of admission, and incidence of nosocomial infections were analyzed. ICU LOS and mortality were compared with those of younger patients: younger than 65 (n=1,259), 65 to 75 (n=742), 76 to 89 (n=636), and 90 and older (n=85). Severity of acute illness was calculated according to simplified acute physiology score (SAPS II) within 24 hours of admission. ICU and hospital mortality were analyzed, and 6-month survival was checked by telephone interview. Nonagenarians represented almost 3% of all admissions. ICU LOS was longer for patients aged 90 and older than for any other age group (<65, 2.8 ± 5.9 days; 65–75, 3.5 ± 7.8 days; 76–89, 5.3 ± 15.4 days; ≥90, 10.0 ± 19.1 days, P<.01). Mortality was also significantly higher in nonagenarian patients (0.8%, 1.1%, 2.8%, and 14.1%, respectively, P<.001). Nonagenarians were predominantly female (66%), and mean hospital LOS was prolonged (31.0 ± 54.5 days). Two-thirds of patients had at least one comorbidity (mean 1.6 comorbidity per patient). The most prevalent diseases were systemic arterial hypertension (37 patients), diabetes mellitus (16 patients), coronary artery disease (16 patients), active neoplasia (10 patients), peripheral atherosclerotic artery disease (4 patients), chronic obstructive pulmonary disease (3 patients), stroke (2 patients), and dementia (2 patients). Invasive mechanical ventilation was necessary in 20 patients, and nosocomial infections occurred in 22 patients during ICU stay. SAPS II score was 41.7 ± 11.4 points, with 30% predicted mortality, although hospital mortality was 21% for all nonagenarian patients. Follow-up survival after 6 months was 64%, revealing an excess mortality of 13 patients. The analysis of subgroups showed different survival rates depending on type of admission (Table 1). Forty-seven patients were admitted for medical causes: acute respiratory insufficiency (11 patients), pneumonia (10 patients), and nonpulmonary sepsis (6 patients). In surgical nonagenarians (n=38), hip fracture correction was the commonest diagnosis (12 patients), followed by stomach, lung, or kidney cancer resections, gastrointestinal perforation, and acute cholecystitis. Twenty-two (55%) surgeries were performed on an urgent basis, mainly for hip fracture. Other studies with very elderly patients presenting to the emergency department showed that medical reasons and hip fracture were the most common admission diagnosis as well.2,3 Medical patients were older than surgical patients (1.4 years older, P=.02) and had higher SAPS II score at ICU admission. Nosocomial infections were more common in medical than surgical admitted patients, although there was no significant difference (73 vs 49% ly, P=.08). Any order for withholding of therapy was given to six patients (5 medical vs 1 surgical, P=.12). Surgical nonagenarians had shorter ICU and hospital LOS and mortality, as well as lower 6-month mortality. Odds ratios for ICU, hospital, and 6-month mortality for surgical nonagenarians compared with medical patients were 0.04 (95% confidence interval (CI)=0.00–0.65), 0.14 (95% CI=0.04–0.51), and 0.35 (95% CI=0.14–0.90), respectively. A recent prospective analysis of 60 nonagenarian patients admitted to the ICU also confirms that the main reasons for admission are for medical causes or orthopedic or abdominal procedures.4 Mean ICU and hospital LOS were also longer, and hospital mortality was higher (40%). Nevertheless, there was no difference in ICU mortality according to type of admission. Clinical outcomes have been shown to be fairly good in previous studies, with a wide range of admission diagnosis, from medical to cardiovascular and orthopedic surgery.5–7 The moderately good outcomes observed in the current study must be cautiously interpreted, because elderly patients have long rehabilitation after hospital discharge, mainly because of poor previous functional status.8 Furthermore, mortality after 6 months was 36%, adding an extra 15% mortality after discharge. A French study of patients aged 85 and older reported similar results, with mortality after 3 months of 29%.9 Nonagenarians will become increasingly common in the intensive care setting, and their prognosis must be studied. In this preliminary analysis, surgical type of admission is associated with good outcomes, despite older age and high prevalence of urgent surgeries. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: André M. Japiassú: manuscript concept, data analysis and preparation of manuscript. Bruno A. Oliveira: manuscript concept, data acquisition (clinical characteristics and short-term outcome) and analysis. Carlos Roberto N. Gondim: data acquisition (clinical characteristics and short-term outcome). Pedro Kurtz: data analysis and preparation of manuscript. Gustavo F. Almeida: data acquisition (long-term outcome) and analysis. Leonam C. Martins: data analysis, geriatrics expertise, and preparation of manuscript. Marcia Pinto: data acquisition (nosocomial infection information) and infection control expertise. Marcelo Kalichsztein: data analysis and intensive care expertise. Gustavo F. Nobre: manuscript concept and final version of manuscript. Sponser's Role: None.