Introduction
Characterization of an old patient: lessons to be learnt from geriatricians
Aging
Comorbidities
Comorbidities
| |
Charlson comorbidity index [16] | Age (years old) |
50–59 (1 point) | |
60–69 (2 points) | |
70–79 (3 points) | |
≥ 80 (4 points) | |
Diabetes | |
Uncomplicated (1 point) | |
End-organ damage (2 points) | |
Liver disease | |
Mild (1 point) | |
Moderate to severe (3 points) | |
Malignancy | |
Any leukemia, lymphoma or localized solid tumor (2 points) | |
Metastatic solid tumor (6 points) | |
AIDS (6 points) | |
Moderate-to-severe renal disease (2 points) | |
Congestive heart failure (1 point) | |
Myocardial infarction (1 point) | |
Chronic pulmonary disease (1 point) | |
Peripheral vascular disease (1 point) | |
Cerebrovascular disease (1 point) | |
Dementia (1 point) | |
Hemiplegia (2 points) | |
Connective tissue disease (1 point) | |
Peptic ulcer disease (1 point) | |
Functional autonomy
| |
ADL scale [30] | Bathing (independent: 1 point; partially dependent: 0,5 point; totally dependent: 0 point) |
Dressing (independent: 1 point; partially dependent: 0,5 point; totally dependent: 0 point) | |
Toileting (independent: 1 point; partially dependent: 0,5 point; totally dependent: 0 point) | |
Transfer (independent: 1 point; partially dependent: 0,5 point; totally dependent: 0 point) | |
Continence (independent: 1 point; partially dependent: 0,5 point; totally dependent: 0 point) | |
Feeding (independent: 1 point; partially dependent: 0,5 point; totally dependent: 0 point) | |
Scale from 0 (totally dependent) to 6 (independent) | |
IADL scale [31] | Ability to use telephone |
Operates telephone on own initiative; looks up and dials numbers (1 point) | |
Dials a few well-known numbers (1 point) | |
Answers telephone, but does not dial (1 point) | |
Does not use telephone at all (0 point) | |
Shopping | |
Takes care of all shopping needs independently (1 point) | |
Shops independently for small purchases (0 point) | |
Needs to be accompanied on any shopping trip (0 point) | |
Completely unable to shop (0 point) | |
Food preparation | |
Plans, prepares and serves adequate meals independently (1 point) | |
Prepares adequate meals if supplied with ingredients (0 point) | |
Heats and serves prepared meals or prepares meals but does not maintain adequate diet (0 point) | |
Needs to have meals prepared and served (0 point) | |
Housekeeping | |
Maintains house alone with occasion assistance (heavy work) (1 point) | |
Performs light daily tasks such as dishwashing, bed making (1 point) | |
Performs light daily tasks, but cannot maintain acceptable level of cleanliness (1 point) | |
Needs help with all home maintenance tasks (1 point) | |
Does not participate in any housekeeping tasks (0 point) | |
Laundry | |
Does personal laundry completely (1 point) | |
Launders small items, rinses socks, stockings, etc. (1 point) | |
All laundry must be done by others (0 point) | |
Mode of transportation | |
Travels independently on public transportation or drives own car (1 point) | |
Arranges own travel via taxi, but does not otherwise use public transportation (1 point) | |
Travels on public transportation when assisted or accompanied by another (1 point) | |
Travel limited to taxi or automobile with assistance of another (0 point) | |
Does not travel at all (0 point) | |
Responsibility for own medications | |
Is responsible for taking medication in correct dosages at correct time (1 point) | |
Takes responsibility if medication is prepared in advance in separate dosages (0 point) | |
Is not capable of dispensing own medication (0 point) | |
Ability to handle finances | |
Manages financial matters independently (budgets, writes checks, pays rent and bills, goes to bank); collects and keeps track of income (1 point) | |
Manages day-to-day purchases, but needs help with banking, major purchases, etc. (1 point) | |
Incapable of handling money (0 point) | |
Scale from 0 (low function/dependent) to 8 (high function/independent) | |
Frailty
| |
Rockwood Clinical Frailty Scale [36] | 1. Very fit—People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age |
2. Well—People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g., seasonally | |
3. Managing well—People whose medical problems are well controlled, but are not regularly active beyond routine walking | |
4. Vulnerable—While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up,” and/or being tired during the day | |
5. Mildly frail—These people often have more evident slowing and need help in high-order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework | |
6. Moderately frail—People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing | |
7. Severely frail—Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~ 6 months) | |
8. Very severely frail—Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness | |
9. Terminally ill—Approaching the end of life. This category applies to people with a life expectancy |
Malnutrition
Cognitive impairment
Functional decline and frailty
Medications: a special concern in old patients
Triage: a multidisciplinary approach including the patient’s wishes
Patients triaged | Hospital mortality (%) | Long-term mortality (%) |
---|---|---|
Garrouste-Ortegas [67] | At 1 year | |
Admission (n = 48) | 62.5 | 70.8 |
Too sick (n = 79) | 70.8 | 87.3 |
Too well (n = 51) | 17.6 | 47 |
Boumendil [109] | At 6 months | |
Admission (n = 316) | 32.7 | 47.5 |
Too sick (n = 821) | 58 | 81.1 |
Too well (1339) | 10.1 | 33.1 |
Andersen [68] | At 1 year | |
Admission (n = 250) | 44 | 60 |
Too sick (n = 52) | 67.3 | 88.5 |
Too well (n = 46) | 34.8 | 50 |
Advanced directives should be available for older patients
-
The patient has a normal cognition and is able to consent to care. Usually such conversation should be undertaken in the presence of the family or caregivers.
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Frequently, the old patients are unable to consent to care. In that case, physicians must discuss the intensity of care with the surrogate decision makers (family or caregivers). The main question is not what the surrogate decision maker think about and ICU admission, but what they know about the patient’s wishes and how the patient would have responded to being admitted to intensive care.
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In emergency situations, there is no time for information retrieval from the surrogate decision makers and treatments are usually started without informed consent. In most countries, it is then possible to withdraw life-sustaining therapies (LSTs) when more information is available [70] (see small case story in Additional file 2).
Level of treatment during the intensive care unit stay
Severity of the disease
Withholding and withdrawing treatment
Situations with specificities related to age
Timing and location of ICU discharge are keys elements for the outcome
Long-term outcomes are the best criteria to judge appropriateness of decision (admission, LST during the ICU stay)
References | Tool | Design | Age-group | Patient followed | Main results | Comparison with baseline data (ICU admission) |
---|---|---|---|---|---|---|
Kass [123] | ADL | Prospective and retrospective | > 80 years | 38/105 (36.1%) | Nonsignificant decline of ADL score at 1 year | Yes |
Chelluri [124] | ADL | Prospective | > 75 years, 65–74 years) | 96 18/54 (33%) 20/43 (46.5%) | No difference between two age-groups at 1, 6, 12 months | Yes Method? |
Broslawski [125] | ADL, IADL, GDS | Prospective | > 70 years | 27/45 (60%) | Changes at 6 months related to ICU LOS and severity but not to age | Yes Method? |
Montuclard [126] | ADL | Retrospective | > 70 years with 30 days of MV | 30/75 (40%) | Decrease in all domains except feeding at 6 months | Retrospective estimation by the patient |
Udekwu [127] | ADL | Retrospective | > 70 years | 342/672 (50.8%) | At 21 months, significant decrease in ADL with more dependent patients | Yes Method? |
Garrouste-Orgeas [37] | ADL | Prospective | ≥ 80 years | 9/48 (18%) | No change | Retrospective estimation by the patient |
Kaarlola [119] | EQ-5D SF-36 | Retrospective (in survivors) | 65–69 years 70–74 years 75–79 years 80–94 years | 114 117 91 50 | More than 50% assessed their overall health status as satisfactory. Largest % in those ≥ 80 | No |
Tabah [128] | ADL | Prospective | ≥ 80 years | 23/106 (21%) | No change 74% of patients were fully independent | Prospective estimation by the patient or relatives |
Boumendil [109] | ADL | Prospective | ≥ 80 years | 162/329 | At 6 months 16.2% were unable to perform at least one activity that they had been able to perform at the time of the ED visit | Prospective estimation by the patient or relatives |
Andersen [129] | EQ-5D | Retrospective | ≥ 80 | 58/395 | HRQOL comparable with a comparison group (1 year) | |
Andersen 2017 [68] | EQ-5D | Prospective | ≥ 80 | 62/250 | Lower HRQOL than a comparison group (1 year) | Compared with a age and gender reference population n = 179 |
Heyland [104] | SF-36 (physical function) | Prospective | ≥ 80 | 505/610 | 50% dead and 26% achieved physical recovery at 12 months | PF compared with baseline values at admission |
Level 2017 [130] | ADL, Barthel index | Prospective | ≥ 75 | 65/188 | 83% of 1-year survivors lived in their own home | ADL compared with baseline at admission |
Guidet [110] | ADL | Prospective | ≥ 75 years | 1528/3036 | Selection criteria: preserved baseline ADL (median 6) At 6 months, decrease in ADL of 0.5 points | Prospective estimation by the patient or relatives |
Quality-adjusted life years
House caregivers
Conclusions and algorithm
Triage
| |
Seek for advance directives—How promoting diffusion? | |
Every time it is possible, ask the patient about his/her wishes | |
If the patient is unable to communicate, seek for relatives/family wishes | |
Try to estimate the immediate and long-term risk of death considering | |
Patient baseline characteristics: | |
Age | |
Functional status (Clinical Frailty Scale, frailty phenotype, Performance status) | |
Comorbidities including cancer | |
Nutritional status and protein–energy balance | |
Cognitive and psychiatric disorders | |
Type of admission: scheduled versus urgent | |
Reason for admission | |
Acute severity—a specific score tailored to old patient should be available | |
Mobilize geriatric expertise if possible—impact should be proved by interventional studies | |
Define a goal of care anticipating second evaluation after few ICU days—Impact on triage, mortality, LOS, LST limitation? | |
If the patient is denied ICU admission consider palliative care | |
During the ICU stay
| |
Organ support guidelines might not be appropriate for old patients—Interventional studies focusing on older adults | |
Fluid loading | |
Ventilator settings | |
Weaning strategy | |
Special attention to medication with high risk of | |
Overdose | |
Interaction | |
Consider LST limitation in case of poor response to initial treatment—Harmonize practice within and between countries | |
ICU discharge—Intervention that should be tested in prospective trials | |
Patients are seen by a geriatrician after ICU discharge | |
They are discharged to specialized geriatric unit | |
Discuss timing | |
Long-term outcomes
| |
Test the impact of early rehabilitation on mortality, HRQOL and functional status | |
Consider the burden for the house caregivers |