Date Published: June 1, 2018
Publisher: Public Library of Science
Author(s): Pierrick Le Borgne, Quentin Maestraggi, Sophie Couraud, François Lefebvre, Jean-Etienne Herbrecht, Alexandra Boivin, Baptiste Michard, Vincent Castelain, Georges Kaltenbach, Pascal Bilbault, Francis Schneider, Chiara Lazzeri.
Patients aged over 90 are being admitted to intensive care units (ICUs) with increasing frequency. The appropriateness of such decisions still remains controversial due to questionable outcome, limited resources and costs. Our objective was to determine the clinical characteristics and outcome in elderly patients (≥ 90 years) admitted in a medical ICU, with an additional focus on medico-economic implications.
We reviewed the charts of all patients (≥ 90 years) admitted to our ICU. We compared them with all other ICU patients (< 90 years), sought to identify ICU mortality predictors and also performed a long-term survival follow-up. In the study group of 317 stays: median age was 92 years (IQR: 91–94 years); most patients were female (71.3%.). Acute respiratory failure (52.4%) was the main admission diagnosis; mean SAPS II was 55.6±21.3; half the stays (49.2%) required mechanical ventilation (duration: 7.2±8.8 days); withholding and withdrawing decisions were made for 33.4% of all stays. ICU and hospital mortality rates were 35.7% and 42.6% respectively. Mechanical ventilation (OR = 4.83, CI95%: 1.59–15.82) was an independent predictor of ICU mortality whereas age was not (OR = 0.88, CI95%: 0.72–1.08). Social security reimbursement was significantly lower in the study group compared with all other ICU stays, both per stay (13,160 vs 22,092 Euros, p< 0.01) and per day of stay (p = 0.03). Among critically ill elderly patients (≥ 90 years), chronological age was not an independent factor of ICU mortality. ICU care-related costs in this population should not be considered as a limiting factor for ICU admission.
According to the US Census Bureau, more than 1.87 million adults are 90 years or older (29% increase from 2000) . As the population ages, intensive care units (ICUs) are confronted with increasing demand, with elderly patients now representing up to 20–30% of all admissions [2–3].
Most countries are now faced with the growing challenge related to global population ageing. In our region with good bed availability, ICU physicians have been admitting very old patients for a long time. Poor availability of ICU beds will require unbiased triage guidelines and it should ideally use different tools than in younger patients [22,23]. In this context, our data underscore two significant points: firstly, life expectancy of patients over 90 years old admitted to the ICU is limited to 3 years and secondly, the financial burden of critical care for these elderly patients is—on average—not on the increase compared with younger patients.
Critically ill elderly patients (≥ 90 years) constitute a fast-expanding subgroup proposed for ICU admission. Until now, some physicians have been reluctant to admit them, mostly because of high in-hospital mortality; however prognosis is not as poor as often perceived. Our data suggests that chronological age is not a viable exclusion criterion for ICU admission, but rather that elderly patients should benefit of equitable access to ICUs. The present study adds to our understanding that there is no real financing issue regarding ICU care in patients over 90 years old.