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Newsletter April 2022: The age handicap

Gabriel M. Gurman, MD
Chief Editor

The idea to approach the subject of the old patient and our professional attitude toward advanced age came to me after I read a paper recently published in the New England Journal of Medicine (1) by authors Bertagnolli from Brigham and Women’s Hospital, Boston and Singh from the US Food and Drug Administration (FDA).

It dealt with the treatment of older adults with cancer and included the following sentence: “as compared with the average patient, older or frail adults may tolerate certain treatments less well, may derive less benefit from treatments, or may have different treatment goals-for example they may value quality of life more than duration of survival”.

The above sentence raises a question related to our daily activity in the intensive care units (ICU): could our approach to the very old patient admitted to ICU be similar to that expressed in the above sentence?

Let’s start with facts.

First of all, what is a definition of a very old patient? A good answer to this question is the following one: age nearing or surpassing the life expectancy of human beings, and is thus the end of the human life cycle. If so, old age in Israel is above 82.5 years, which was the life expectancy in this country in 2017, but in the USA a person aged 80 should be already considered an old one, since the life expectancy there is only 79 years.

Today advanced age is not an impediment to even performing an urgent surgical procedure. Oliver in 2000 (2) reported a patient, 113-year-old, who passed a repair for a femur fracture under general surgery, discharged later home on the 23rd postoperative day, lived an additional nine months and celebrated her 114th birthday!

But what about the situation of the critically ill very old patient requiring  ICU admittance?

The number of very elderly patients admitted to the ICU with acute illness is increasing (3). The ICU cost of treatment is high and the availability of beds is limited.

At the same time, life expectancy is growing all over the world, with a direct impact on the demand for ICU beds. Muessig et al, citing UN sources, reported some years ago (4) that while only 4% of the developed countries’ population entered the category of “very old”, they represented 10% of all ICU admittances.

So one could question if old age is a risk factor in ICU.

In general, most of the published studies show a direct and significant impact of old age on ICU mortality.

For instance, Muessing et al (4) compared 930 octogenarians with 5732 younger patients admitted to a medical ICU. They found out that patients older than 80 had a higher SAPS II, a higher APACHE II, significantly higher mortality, and a significantly lower long-term survival, but also a lower consumption of ICU resources (length of stay, length of mechanical ventilation, etc.).

Sim et al (5) defined the eight factors which could be related to higher mortality in the ICU, among them age higher than 90, together with poor nutrition, pneumonia, mechanical ventilation or use of vasopressors. The ICU mortality rate in their study was 32% for this category of patients.

Chin-Yee (6) reported similar data. In his study of patients, older than 80 mortality was 35% (585/1671) in hospital and 41% (253/610) at 12 months.

Farfel et al (7) reported that age was strongly correlated with mortality among an invasively ventilated subgroup of patients, and the multivariate-adjusted odds ratios increased progressively with every age increment (OR = 1.60, 95% CI = 1.01-2.54 for 65-74 years old and OR = 2.68, 95% CI = 1.58-4.56 for > or =75 years).

It seems that the bad prognosis of very old patients treated in an ICU characterises also the period after discharge. Guillon et al. (8)  compared two groups of patients: the first one- patients older than 80, discharged alive from an ICU after acute respiratory infection; the second one: a matched-age control group after cataract surgery. The results showed that the patients included in the first group had a ten-time higher risk of death at six months after discharge and 3.6 times higher risk of death after two years.

The only study presenting a different result is that of Kir et al (9), who studied ICU patients older than 65 and found out that old age by itself was not accompanied by higher mortality, and that only malignity had a significant effect on the survival percentage, but one cannot ignore the fact that this report referred to patients older than 65, a category which could be defined as “young old”.

This point seems to be very important since a good part of the so-called old people are actually old but still healthy. They might have some physiological changes produced by ageing (delayed gastric emptying, bone fragility, hypothyroidism, etc), but they have a pretty normal life.

Some others could be old and sick, but their co-morbidity (hypertension, ischemic heart disease, diabetes, etc), would be kept stable and within acceptable limits due to proper medication and regular control.  True, today we live longer, and a greater proportion of our life is spent in ill health, but most of the diseases which accompany old age can be well treated which would assure a decent standard of daily life and activity.

I doubt if all those studies cited above, which report a bad prognosis for old patients admitted to an ICU refer also to this kind of ageing.

This is why I am of an opinion that it would be incorrect to draw a general conclusion about the futility of ICU admission of the old patient since every single patient is a different entity, and because we are taught and teach that we treat patients and not diseases, and surely not numbers.

The reality of these days is more complicated than, let’s say, two years ago. The COVID pandemic affects our daily activity and poses serious problems to the teams in charge of the treatment of patients who suffer from that viral disease and are in need of intensive care. Old patients with COVID are in an increased danger of complications and even death. Alharthy et al (10) published a list of risk factors that could affect negatively the COVID patient prognosis, among them: old age, active smoking and pulmonary embolism.

There is no question that the paucity of ICU beds obliges the people involved in the triage process for admitting a patient in a critical care area to take into consideration all of the above.

But using rigid protocols and guidelines could sometimes lead to a serious mistakes. We are supposed to use clinical judgment in addition to objective facts, such as comorbidity and regular daily activity before the illness, in order to reach a correct decision regarding every single case. Age by itself cannot be a contraindication to accepting a patient in an intensive care unit.

 

References

  1. Bertagnolli MM and Singh H. New Engl J Med 2021;385:1062
  2. Oliver Cd, White Sa. Brit J Anaesth 2000;84:260
  3. Bagshaw SM et al. Crit Care 2009;13: R45
  4. Muessig JM et al. Medicine 2017;96:37
  5. Sim YS et al. Resp Care 2015;60:347
  6. Chin-Yee N. Crit Care 2017;21:109
  7. Farfel JM et al. Age Aging 2009;38:515
  8. Guillon A et al. Crit Care 2020;24:384
  9. Kir S et al. Ir J Med Sci 2021;190:317
  10. Alharthy A et al. J Epidemiol Global Health 2021;11:98

 

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3 replies

Alexandre Tarnopolsky
Dear Prof. Gurman, I want to thank you for your answer and proposal but I don't work in an academic environment and would be very pretentious of mine to suggest any kind of anesthetic classification. I'm sure we have qualified colleagues in Europe and Israel ready to develop, discuss, test and validate any approach.  What I can report here is my own practice borrowing many of the Geriatric criteria and ideas to evaluate frailty. During my pre-anesthetic visit, beyond ASA Classification, I try to evaluate and understand the mental activities as regards to cognitive abilities such as talking about his/her medical problems and any other subject, care and taking their own medicines, reading newspapers, books, use of smartphones, internet , social medias and maybe cooking with receipts all provides information. Also the physical capacities regarding autonomy to daily living activities at home and out. Talking to family and caregivers is important. All this information provides me with a " frailty picture" , not a classical score evaluation, of the patient and helps me to understand and discuss the case with the patient, the surgeon, the family and plan my anesthetic approach and post operative support care. It Would be better to receive a qualified Geriatric assessment instead of the classical Clinical/cardiologic preoperative evaluation as is usual in Brazil.   To finish my answer I copied the two sentences below from the British Geriatric Society Recognising frailty (https://www.bgs.org.uk/resources/recognising-frailty) that synthesize my worries : 'Frailty is an independent risk factor for post-operative major morbidity, mortality, protracted length of stay and institutional discharge.' 'It is important to identify preoperative frailty in order to manage risk, inform shared decision making and highlight areas for potential modification. 'Best Regards.
4 months ago
gabriel gurman, Chief editor
Thanks, Dr Tarnopolsky, for your interesting comment. We would like to host in our Newsletter a paper signed by you in which you would try to configurate this kind of classification you wrote about.
4 months ago
Alexandre Tarnopolsky
Dear Prof. Gurman and colleagues, The elderly population is growing all over the world and the very old group becoming a common patient nowadays. The last paragraph of the text resume the reality: we have healthy elderly in full activity and the frail ones limited and sick. Two populations completely different in their life quality, expectancy and probabilities to return to pre-acute illness state. That said, I think it´s time to anesthesiologists to create a kind of ASA Physical Status Classification System specifically dedicated to this population older than 65/70 year old to help to identify, understand and improve the anesthetic approach to this group as regard surgeon and family expectations about interventions and care.
4 months ago

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