Intensive care in the very old. Hans Flaatten

Transcription

1 Intensive care in the very old Hans Flaatten

2 What is considered old and very old? WHO definition Old 60, suggested 65 in developed countries Very old No accepted definition 75 and 80 are often used as cut-off values in studies In my discussion 80 + will be used

3 Population pyramid: Malaysia vs Norway

4 CHINA NORWAY

5 Concerns about this development

6

7 Should we treat patients > 80 years at all? The answers of course depends on. What are the resources available? Developed versus developing countries may have different answers Is it ethical acceptable to withhold ICU treatment on age alone?? What is the outcome(s) after ICU in the elderly? What do the very old want?

8 Age and comorbidity Unfortunate After 40 years Unhealthy Healthy

9 Age and comorbidity Unfortunate Accidents Cancer Wrong genes Pollution War After 40 years Healthy Activity & training Non-smokers Avoid excesses Balanced diet Unhealthy Smokers Alcohol abuse Drug addicts Inactivity

10 Triage of the critical ill old patients Triage prior to admission Too well or to sick to profit from intensive care Triage during admission Give patients a proper treatment and observe the effect(s) The latter frequently used in the elderly ICU patients Chart Title SOFA adm SOFA 1 SOFA 2 SOFA 3 Improve Uncertain A Uncertain B Deteriorates

11 Triage prior to admission ICM 2016: Online first: DOI: /CCM

12 Survival- three groups

13 Time to death in the ICU Retrospectively analysis of ICU LOS of non-survivors A way to analyse ICU performance No gold standard One may argue that If you are going to die anyway a short LOS could be good Expressed as median time to death

14 Median LOS in non-survivors according to age Strand K et al. Variations in the length of stay of intensive care unit nonsurvivors in three Scandinavian countries. Crit Care. 2010;14(5):R175.

15 Mortality in very old critically ill

16 Long term mortality: age 80 years 15-55% 35-65%

17 Survival compared to a population of 80 Andersen FH, Flaatten H, Klepstad P, Romild U, Kvåle R. Long-term survival and quality of life after intensive care for patients 80 years of age or older. Ann Intensive Care Dec;5(1):53.

18 Impact of age in modern severity scores: SAPS II < 40 years (11% of max) APACHE II < (8.5% of max) SAPS III < (8.3% of max)

19 Non-mortality outcomes

20 Use of ICU resources

21 ICU LOS LOS median >90 LOS median

22 Ventilatory support

23 Quality of life In a small Norwegian study the following were found: Survivors (n= 58 > 80 years) were compared with a random sample from the population (n= 179 > 80 years) w/r to HRQOL (measured with EuroQual 5D) Mean age Mobility No significant differences Self-care No significant differences Usual activities No significant differences Pain/discomfort No significant differences Anxiety & depression No significant differences Andersen FH et al: Ann Intensive Care Dec;5(1):53.

24 Functional status

25 Recovery in the very old My One-quarter interpretation: of patients half of aged patients 80 years surviving or older one admitted year returned to ICU to survived baseline level. and Those returned dying to baseline from 3-12 levels months of physical all had function reduced Physical at one year. Function score

26 Outcome of elderly ICU patients in Finland 885 elderly patients and 1827 controls (< 65) Single centre study Outcomes Survival QOL Patient cohort divided in <65 ( controls ) Kaarlola A, et al. Crit Care Med. 2006;34:

27 What do the very old wants?

28 We do not know but other may help us Take home message from another part of medicine: Patients with malignant glioma Patients were randomised to ordinary information about possible otcomes, or see a video of Intensive care and CP resucitation, basic care and comfort care as possible options El-Jawahri A et al. J Clin Oncol Jan 10;28(2):

29 My mother knows She is 94 Living alone with some help from community nurses I have discussed with her about what she wants if she would be critically ill and need life sustaining therapy She is very clear: Then I want to die in peace