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Geriatric critical care
Ramesh Nagappan1, Geoffrey Parkin
1Intensive Care Unit, Monash Medical Centre, 246, Clayton Road, Melbourne, VIC-3168, Australia. ramesh@bigpond.net.au
Insights
Older age does not predict outcomes for critically ill elderly patients. Severity of illness, not age, is the primary factor influencing survival in intensive care units (ICUs).
Area of Science:
- Gerontology
- Critical Care Medicine
- Health Services Research
Background:
- Increasing life expectancy leads to a growing population of critically ill elderly patients.
- Elderly patients consume a disproportionate amount of intensive care unit (ICU) resources and hospital expenditures.
- Current outcome prediction models for the elderly critically ill are not widely validated, and research is insufficient to guide clinicians.
Purpose of the Study:
- To examine the role of age in predicting outcomes for critically ill elderly patients.
- To address the lack of evidence guiding clinical decisions for intensive care of the elderly.
- To explore factors influencing physician bias and decision-making in the critical care of older adults.
Main Methods:
- Review of existing literature and outcome prediction models for critically ill elderly patients.
- Analysis of factors influencing physician bias in ICU admission and treatment decisions.
- Discussion of the interplay between severity of illness, age, and patient/physician perceptions of quality of life.
Main Results:
- Age alone is not a predictor of short-term or long-term outcomes in critically ill older patients.
- Severity of illness is the most significant factor influencing outcomes in critical illness.
- Physician perceptions of quality of life differ from patient perceptions and influence treatment decisions.
Conclusions:
- Clinical decisions for critically ill elderly patients are complex and influenced by ethical, legal, socioeconomic, and personal factors.
- Age should not be the sole determinant in critical care decisions; severity of illness is paramount.
- Further research is needed to establish evidence-based guidelines for the critical care of the elderly.
Abstract:
Demographic compulsions are inescapable. There has been a 50% increase in life expectancy at birth for persons born in 1980 compared to those born in 1900. Not only do critical care units utilize up to a third of hospital expenditures and about 1% of GNP, the critically ill elderly consume a disproportionate amount of ICU resources. Outcome prediction models for very elderly critically ill patients have been proposed with age as one of numerous model variables; but such models have not been widely validated. Despite the burgeoning emphasis on evidence-based population approach to health care, there is insufficient research to guide the critical care clinician. There remains a modicum of subjectivity in crucial decisions that affect the elderly patient receiving intensive care. Older age is also one of the factors that lead to a physician bias in refusing ICU admission; this has recently been borne out in a multivariate analysis. Physicians generally consider their older patients' quality of life to be worse than do the patients, although other studies that have assessed the quality of live show no age-related differences among ICU survivors. Furthermore, physicians' estimations of patient quality of life significantly influence physicians' attitudes to futility of care issues, in contrast to patients' perceptions. Threshold for life-sustaining treatment in the elderly will continue to be different among the ICUs. In critical care of the elderly, geography may well be destiny. Clinical decisions will be subjected to many ethical, legal, and socioeconomic pressures. Personal and religious beliefs will inevitably influence societal expectations and clinician practices. Severity of illness has the biggest influence on outcome in a critical illness. Age alone is not a predictor of short-term or long-term outcome in the older patient who is critically ill. Critical illness in the elderly remains a fertile area for future research.