ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-10071-24416
|
A Clinical and Demographic Profile of Elderly (>65 Years) in the Medical Intensive Care Units of a Tertiary Care Center
1–3Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
Corresponding Author: Kusugodlu Ramamoorthi, Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India, Phone: +91 9449615194, e-mail: ramamoorthi.k@manipal.edu
How to cite this article: Prabhudev P, Ramamoorthi K, Acharya RV. A Clinical and Demographic Profile of Elderly (>65 Years) in the Medical Intensive Care Units of a Tertiary Care Center. Indian J Crit Care Med 2023;27(3):166–175.
Source of support: Nil
Conflict of interest: None
Received on: 30 December 2022; Accepted on: 29 January 2023; Published on: 28 February 2023
ABSTRACT
Background: The elderly population in India is expected to increase to 319 million by 2050. Managing critically ill elderly patients in intensive care units (ICUs) is a difficult task. Proper planning and development of healthcare infrastructure are of prime importance to face this challenge.
Objectives: To study the clinical profile and outcomes of elderly patients admitted to the medical ICUs.
Materials and methods: A time-bound, prospective observational study on elderly patients admitted to medical ICUs for more than 48 hours was conducted from March 2019 to September 2020. The demographic, biochemical, hematologic, and microbiological data on antibiotic susceptibility patterns on various organisms and procalcitonin (PCT) reports were collected. Acute Physiology and Chronic Health Evaluation II (APACHE II) score was calculated. Various treatment modalities, such as mechanical ventilation, inotropes, hemodialysis, antibiotics, culture report in sepsis patients, and length of ICU stay were collected.
Results: The age of the patients and the length of their ICU stay were not significantly associated with outcomes. Sepsis and APACHE II scores are significantly associated with outcomes. Receipt of mechanical ventilation, vasopressor support, and hemodialysis are significantly associated with mortality (p < 0.001).
Conclusion: The patients’ ages were not significantly associated with outcomes. The most common cause of death among elderly patients was found to be sepsis, followed by pneumonia. In elderly ICU patients, gram-negative organisms are the most common causative agents in bloodstream infections. The APACHE II score, sepsis, receipt of mechanical ventilation, vasopressor support, and hemodialysis are significantly associated with mortality.
Keywords: Acute kidney injury, APACHE II, Blood culture, Elderly, Gram-negative infection, Hemodialysis, Intensive care units, Pneumonia, Procalcitonin, Sepsis.
HIGHLIGHTS
Gram-negative organisms were commonly isolated from the blood and endotracheal tube cultures of elderly patients admitted to intensive care units.
The risk factors significantly associated with mortality were sepsis, high APACHE II score, receipt of inotropic supports, and hemodialysis.
INTRODUCTION
In India, geriatric medicine is still an evolving field, and the elderly population is expected to increase to 319 million by 2050.1 However, addressing the healthcare needs of this growing number of vulnerable and heterogeneous populations is a big challenge. Most of the studies on the elderly population are from Western countries; however, data on the outcomes of elderly patients in Indian ICUs is lacking. This will help in resource management, designing a treatment protocol, and providing counseling to the patient’s family members regarding the outcomes.
Objectives of the Study
To study the system-wise disease spectrum and outcomes of elderly patients aged 65 years and above, and to assess disease severity using the APACHE II scoring system, admitted in medical ICUs of a tertiary care centre.
MATERIALS AND METHODS
After getting the institutional ethical committee approval (IEC no.744/2018) a time-bound, prospective observational study was conducted from March 2019 to September 2020. All the patients of age 65 years and above admitted to medical ICUs for a minimum duration of 48 hours were included in this study. We excluded the patients admitted under departments other than internal medicine in medical ICUs. The criteria for ICU admission were not defined, and individualized decisions were made by the admitting unit’s physician based on the clinical and physiological conditions of the patients. Informed written consent was taken from the patient’s relatives.
We collected all the demographic, biochemical, hematologic, and microbiological data. Age, sex, laboratory parameters, including complete blood counts, blood urea, serum creatinine, serum electrolytes, liver function tests, HbA1c, Glasgow Coma Scale (GCS), arterial blood gas reports, PCT, cultures from blood, endotracheal tube (ET), urine and catheter tip were collected whenever sepsis and infection were suspected. Data on treatment details including the requirement of mechanical ventilation, vasopressor therapy, and hemodialysis were collected. APACHE II score was calculated using the worst laboratory parameters in the first 24 hours of ICU admission.
The data was analyzed using R i386.3.5.1 statistical software. Continuous data were shown as mean ± SD and the categorical variables were represented by the frequency table. Association between categorical variables was measured using the Chi-square test. Continuous data were compared using a one-way analysis of variance (ANOVA) test. P < 0.05 is considered significant.
RESULTS
Table 1 summarizes the clinical and demographic characteristics of patients. The majority of the participants (48.7%) belonged to the age-group of 70–79 years, followed by 65–69 years (32.5%). The mean ± SD APACHE II score was found to be 21.4 ± 5.33 with the lowest and highest score being 9 and 33, respectively. Table 2 shows the association of the types of organisms in different cultures of samples from elderly patients and patient outcomes.
Characteristics | Subcategory | Overall of patients (%) |
---|---|---|
Age-group | 65–69 | 52 (32.5) |
70–79 | 78 (48.75) | |
80–90 | 30 (18.75) | |
Gender | Male | 111 (69.38) |
Female | 49 (30.63) | |
Comorbidities | DM | 79 (49.38) |
HTN | 101 (63.13) | |
CKD | 10 (6.25) | |
CVA | 23 (14.38) | |
IHD | 24 (15) | |
CLD | 2 (1.25) | |
Bronchial asthma | 3 (1.88) | |
COPD | 35 (21.88) | |
Tuberculosis | 3 (1.88) | |
Total number of comorbidities | 0 | 36 (22.5) |
1 | 43 (26.88) | |
2 | 55 (34.38) | |
3 | 19 (11.88) | |
4 | 6 (3.75) | |
5 | 1 (0.63) |
Culture | Organism type | Overall | Improved | Succumbed | DAMA | p-value |
---|---|---|---|---|---|---|
N = 81 | N = 36 | N = 43 | ||||
Blood culture | None | 127 (79.38%) | 71 (55.91%) | 21 (16.54%) | 35 (27.56%) | 0.0150CS* |
Sensitive strain | 14 (8.75%) | 4 (28.57%) | 8 (57.14%) | 2 (14.29%) | ||
MDR | 13 (8.13%) | 4 (30.77%) | 5 (38.46%) | 4 (30.77%) | ||
PDR | 6 (3.75%) | 2 (33.33%) | 2 (33.33%) | 2 (33.33%) | ||
ET culture | None | 117 (73.13%) | 70 (59.83%) | 20 (17.09%) | 27 (23.08%) | 0.0050CS* |
Sensitive strain | 12 (7.5%) | 4 (33.33%) | 3 (25%) | 5 (41.67%) | ||
MDR | 26 (16.25%) | 6 (23.08%) | 10 (38.46%) | 10 (38.46%) | ||
PDR | 5 (3.13%) | 1 (20%) | 3 (60%) | 1 (20%) | ||
Urine culture | None | 143 (89.38%) | 73 (51.05%) | 30 (20.98%) | 40 (27.97%) | 0.3238CS |
Sensitive strain | 9 (5.63%) | 4 (44.44%) | 4 (44.44%) | 1 (11.11%) | ||
MDR | 7 (4.38%) | 4 (57.14%) | 1 (14.29%) | 2 (28.57%) | ||
PDR | 1 (0.63%) | 0 (0%) | 1 (100%) | 0 (0%) | ||
Catheter tip culture | None | 158 (98.75%) | 80 (50.63%) | 36 (22.78%) | 42 (26.58%) | 0.7201CS |
Sensitive strain | 1 (0.63%) | 0 (0%) | 0 (0%) | 1 (100%) | ||
MDR | 1 (0.63%) | 1 (100%) | 0 (0%) | 0 (0%) | ||
PDR | – | – | – | – |
Associations of the type of isolates from blood culture and ET culture and patient outcomes were found to be statistically significant (p < 0.05), whereas no significant association was found between the type of organism isolated from urine and catheter tip samples and patient outcomes (Table 2).
The resistance and susceptibility of various microbial isolates to different antibiotics obtained from the culture of blood, urine, ET aspirate are shown in Figures 1 to 3.
Fig. 1: Antibiotic susceptibility pattern of different isolates from blood samples of elderly patients
Fig. 2: Antibiotic susceptibility pattern of different isolates from urine samples of elderly patients
Fig. 3: Antibiotic susceptibility pattern of different isolates from ET samples of elderly patients
Table 3 shows the final diagnoses of elderly patients admitted to ICU. The most common diagnosis among the elderly was pneumonia in 94 (58.75%), followed by sepsis in 78 (48.7%) of patients. Among the 10 (6.3%) cases of acute febrile illness, 5 (3.13%) had leptospirosis, 4 (2.5%) had scrub typhus, and 1 (0.63%) was diagnosed with malaria. About 9 (5.67%) cases were admitted for intentional self-harm, with 7 (4.4%) due to poisoning by organophosphates, 1 (0.63%) due to phosphorus poisoning, and 1 (0.63%) due to other agents. Out of 54 other diagnoses, 17 (10.63 %) were due to encephalopathy, 11 (6.9%) were due to arrhythmias, 9 (5.63%) cases of malignancies, 7 (4.4%) cases of seizures, 3 (1.9%) cases of interstitial lung disease (ILD)/bronchiectasis, and remaining were due to snakebites, pulmonary thromboembolism (PTE), upper gastrointestinal bleed (UGI bleed) (1.25% each), and 1 (0.63%) case of infective endocarditis (IE) (Table 3).
Cause of death | No. of cases (%) |
---|---|
Pneumonia | 94 (58.75) |
Sepsis | 78 (48.75) |
Acute kidney injury | 67 (41.88) |
Others | 54 (33.75) |
Acute exacerbation of COPD | 41 (25.63) |
Stroke | 29 (18.13) |
Heart failure | 26 (16.25) |
Acute respiratory distress syndrome | 25 (15.63) |
Myocardial infarction | 25 (15.63) |
Urinary tract infection | 21 (13.13) |
Acute febrile illness | 10 (6.25) |
Intentional self-harm/poisoning | 9 (5.63) |
Acute gastroenteritis | 8 (5) |
Decompensated cirrhosis of the liver | 8 (5) |
The mean duration of ICU stay of elderly patients in this study was observed to be 11.8 ± 9.5 days with the shortest and longest duration being 2 days and 56 days, respectively. The median ICU stay was calculated to be 9 days. Of the 160 patients admitted during the study period, the condition of 81 (50.62%) patients improved after ICU stay. About 36 (22.5%) patients succumbed and 43 (26.87%) patients were discharged against medical advice (DAMA). In this study, the mortality rate among the elderly patients admitted to ICU was 22.5%. Table 4 shows the causes of death among elderly patients admitted to the ICU.
Sepsis | 31 |
Pneumonia | 25 |
Urinary tract infection | 8 |
Acute respiratory distress syndrome | 11 |
Stroke | 6 |
Acute exacerbation of COPD | 8 |
Heart failure | 6 |
Myocardial infarction | 5 |
Acute kidney injury | 23 |
Acute gastroenteritis | 2 |
Decompensated cirrhosis of liver | 3 |
Acute febrile illness | 2 |
Intentional self-harm/poisoning | 0 |
Others | 18 |
Sepsis was found to be the most common cause of death among the elderly (35 cases), followed by pneumonia (25 cases). Acute kidney injury (AKI) accounted for 23 deaths among the elderly patients. Other causes of deaths included encephalopathy, arrhythmias, malignancies, seizures, snakebites, PTE, UGI bleed, and IE. In this study, there were no deaths due to intentional self-harm.
The correlation between PCT and sepsis in elderly ICU patients in this study was found to be statistically significant (p < 0.001) as shown in Table 5. Table 6 depicts the association of patient outcomes with clinical and demographic characteristics of elderly ICU patients. Except in the case of cerebrovascular accident (CVA) and ischemic heart disease (IHD), there was no significant association between patient outcomes and comorbidities in this study. However, the rate of mortality was highest in patients with four comorbidities as compared to less number of comorbidities. A significant association was found between serum PCT and patient outcomes in this study (p < 0.001).
Procalcitonin | Subcategory | Sepsis | p-value | |
---|---|---|---|---|
Positive | Negative | |||
Positive | 43 (71.67%) | 17 (28.33%) | <0.0001* | |
Negative | 35 (35%) | 65 (65%) |
Factor | Sub-category | Improved | Succumbed | DAMA | p-value |
---|---|---|---|---|---|
N = 81 | N = 36 | N = 43 | |||
Age-group | 65–69 | 26 (50%) | 12 (23.08%) | 14 (26.92%) | 0.6431 |
70–79 | 43 (55.13%) | 17 (21.79%) | 18 (23.08%) | ||
80–90 | 12 (40%) | 7 (23.33%) | 11 (36.67%) | ||
Gender | Male | 50 (45.05%) | 27 (24.32%) | 34 (30.63%) | 0.0969 |
Female | 31 (63.27%) | 9 (18.37%) | 9 (18.37%) | ||
Comorbidities | DM | 43 (54.43%) | 14 (17.72%) | 22 (27.85%) | 0.3526 |
Hypertension | 52 (51.49%) | 20 (19.8%) | 29 (28.71%) | 0.5298 | |
CKD | 4 (40%) | 4 (40%) | 2 (20%) | 0.4018cs | |
CVA | 9 (39.13%) | 3 (13.04%) | 11 (47.83%) | 0.0461* | |
IHD | 11 (45.83%) | 2 (8.33%) | 11 (45.83%) | 0.0403* | |
CLD | 1 (50%) | 0 (0%) | 1 (50%) | >0.99cs | |
BA | 0 (00.00%) | 1 (33.33%) | 2 (66.67%) | 0.194 | |
COPD | 17 (48.57%) | 6 (17.14%) | 12 (34.29%) | 0.554 | |
TB | 2 (66.67%) | 1 (33.33%) | 0 (00.00%) | 0.548 | |
Total number of comorbidities | 0 | 17 (47.22%) | 12 (33.33%) | 7 (19.44%) | 0.2704cs |
1 | 25 (58.14%) | 7 (16.28%) | 11 (25.58%) | ||
2 | 27 (49.09%) | 14 (25.45%) | 14 (25.45%) | ||
3 | 10 (52.63%) | 1 (5.26%) | 8 (42.11%) | ||
4 | 1 (16.67%) | 2 (33.33%) | 3 (50%) | ||
5 | 1 (100%) | 0 (0%) | 0 (0%) |
Table 7 shows the correlation between various factors and patient outcomes. The APACHE II score was significantly higher (25 ± 5.09) in non-survivors compared to survivors (19.11 ± 4.45) and DAMA (22.53 ± 5.02) in this study, and this correlation was statistically significant (p < 0.0001) as analyzed by one-way ANOVA test. Using Tukey HSD as a post hoc analysis, it has been found that the mean of APACHE II scores for succumbed and DAMA patients were significantly different from improved subjects (p < 0.0001), whereas there was no significant difference between succumbed and DAMA cases (p = 0.0594). Non-survivors had a longer ICU stay than those who recovered or were DAMA (Table 7). The association between the recovery rates, mortality, DAMA, intubation, and the use of inotropes was found to be statistically significant (p < 0.0001). The number of survivors was more in patients who were not intubated, whereas the number of non-survivors was higher in patients who received inotropes (Table 7). In this study, there was a significant association between hemodialysis and patient outcome (p < 0.001). About 56.4% of non-survivors were on hemodialysis, indicating that the mortality rate was higher in elderly patients receiving hemodialysis.
Factors | Improved | Succumbed | DAMA | p-value |
---|---|---|---|---|
N = 81 | N = 36 | N = 43 | ||
APACHE II | 19.11 ± 4.45 | 25 ± 5.09 | 22.53 ± 5.02 | <0.0001* |
Duration of ICU stay | 10.74 ± 7.57 | 14.4 ± 12.84 | 11.42 ± 9.11 | 0.1621 |
Inotropes | ||||
Yes | 21 (28%) | 32 (42.67%) | 22 (29.33%) | <0.0001* |
No | 60 (70.59%) | 4 (4.71%) | 21 (24.71%) | |
Intubated | ||||
Yes | 42 (38.89%) | 31 (28.7%) | 35 (32.41%) | <0.0001* |
No | 39 (75%) | 5 (9.62%) | 8 (15.38%) | |
Hemodialysis | ||||
Present | 10 (25.64%) | 22 (56.41%) | 7 (17.95%) | <0.0001* |
Not present | 71 (58.68%) | 14 (11.57%) | 36 (29.75%) |
Table 8 shows that the patient outcomes were significantly associated with sepsis (p < 0.0001), whereas it was not significantly associated with pneumonia. The association of diabetes mellitus with patient outcomes has been given in Table 9. The association of diabetes mellitus with patient outcomes was not found to be statistically significant.
Condition | Sub-category | Improved | Succumbed | DAMA | p-value |
---|---|---|---|---|---|
Sepsis | Present | 19 (24.36%) | 32 (41.03%) | 27 (34.62%) | <0.0001* |
Absent | 62 (75.61%) | 4 (4.88%) | 16 (19.51%) | ||
Pneumonia | Present | 45 (47.87%) | 26 (27.66%) | 23 (24.47%) | 0.1713 |
Absent | 36 (54.55%) | 10 (15.15%) | 20 (30.3%) |
Diabetic mellitus | Outcomes | p-value | ||
---|---|---|---|---|
Improved | Succumbed | DAMA | ||
Present | 43 (54.43%) | 14 (17.72%) | 22 (27.85%) | 0.3526 |
Absent | 38 (46.91%) | 22 (27.16%) | 21 (25.93%) |
DISCUSSION
Aging is an inevitable and natural process which leads to a decline in immunity and physiological reserves. This, in turn, leads to a rapid deterioration in health in the case of an illness, as the disease remains untreated it progresses rapidly, causing further complications and admission to ICU.
The majority of the participants in this study were in the age-group of 70–79 years (48.7%) and the mean age of the admitted elderly patients was 72.7 ± 6.4 years. This is comparable with other studies.2,3 The ICU admission rate for patients aged 80 years and above was about 18%, which was 13% in the earlier report.4 Previous studies have found no significant relationship between the patient’s age and outcomes.2,3,5,6 These studies have consistently established that age by itself cannot be considered a factor for patient outcome, and that other factors, such as severe illness, comorbidities, and the individual’s physiological status play an equally significant role in the outcomes of elderly patients.2,3,4,7 Similarly, male patients’ predominance was observed in our study.2–8
Of the 160 elderly patients studied, 124 had one or more comorbidities. Comorbidities are common in elderly patients since chronic illnesses are a natural part of the aging process.4,8 Incidences of stroke and heart diseases are often associated with poor outcomes in elderly patients,9 as confirmed by this study. APACHE II score is a disease severity score widely used to assess the severity of illness in an ICU.3,4,6,10 The non-survivors had a significantly higher APACHE II score as compared to survivors, and there was a significant association between APACHE II scores of elderly patients with their outcomes.4,6,10,11
The duration of ICU stay, which is one of the main determinants of ICU expenses and resource utilization, and the mean ICU stay of elderly patients in this study was observed to be 11.8 ± 9.5 days. The mean ICU stay in non-survivors was 14.4 ± 12. 84 days, while it was 10.74 ± 7.57 days in survivors and and 11.42 ± 9.11 days in DAMA. The duration of ICU stay in this study was higher than in earlier reported studies.3,4,8,12 Probably this variation in the length of ICU stay may be due to differences in the severity of disease patterns, infections, and other complications.12 In this study, the association between APACHE II scores of the patients and the duration of ICU stay was insignificant, as observed in previous studies.10
Comorbidities, reduced immune status, and chronic illnesses all contribute to different microbiological flora in geriatric patients as compared to younger patients. The literature is devoid of information on the microbiological aspects of elderly patients admitted to ICU in India. Among the gram-negative bacteria, 65.63% were susceptible to piperacillin and tazobactam and the majority of the gram-positive bacteria were susceptible to vancomycin, teicoplanin, and linezolid. In this study, multidrug-resistant (MDR) strains of Acinetobacter followed by Pseudomonas were the major isolates in blood samples and ET tube samples. In the previous report, the most common organisms isolated were Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii.13 In elderly patients, gram-negative organisms are the most common causative agents in bloodstream infections.13–15 Associations of the type of isolates from blood culture and ET tube culture and patients’ outcomes were found to be statistically significant (p < 0.05).
In the current study, only 50% of MDR Acinetobacter strains were sensitive to minocycline and resistant to all other antibiotics. A similar finding was observed in previous studies, where the Acinetobacter strains showed high resistance to carbapenems and other cephalosporins.15 Among the Escherichia coli strains from blood, the majority were sensitive to aminoglycosides, meropenem and piperacillin-tazobactam antibiotics, and the majority of the strains of E. coli from urine were sensitive to amikacin, cefoperazone-sulbactam, and nitrofurantoin antibiotics in our study. Among the E. coli from the ET aspirate culture majority of strains were sensitive to tigecycline, meropenem, and amikacin antibiotics. However, the majority of E. coli strains were sensitive to carbapenems and third and fourth-generation cephalosporins in previous reports.15 Among Pseudomonas strains from blood, the majority of strains were sensitive to aminoglycosides, meropenem, and cephalosporins, and among Pseudomonas strains from urine only 40–50% were sensitive to aminoglycosides, meropenem, and piperacillin–tazobactam antibiotics in our study. However, in previous studies, the majority of Pseudomonas strains were resistant to cephalosporins and carbapenems.15 30–50% and 30–45% of Klebsiella strains were sensitive to cephalosporins and amoxicillin/clavulanic acid, respectively. Among Klebsiella strains, 50–60% and 40–70% were sensitive to aminoglycosides and carbapenems, respectively. This sensitivity pattern was comparable to previous studies.15 The correlation between the microbial isolates and patient outcomes further strengthens the need of including microbiological analysis as a criterion to predict the outcome of elderly patients admitted to the ICU and deciding on the treatment strategy accordingly.
In this study, the most important cause of hospital admissions among the elderly was pneumonia (58.75%), followed by sepsis (48.7%). It has been reported in previous studies that elderly patients in ICU were more prone to develop pneumonia,3,16,17 which is compounded by the presence of a significant number of MDR and pan drug-resistant (PDR) strains in this study’s elderly patients.13–16 Leptospirosis was the most common cause of acute febrile illnesses diagnosed in elderly ICU patients in this study. Leptospirosis is prevalent in warm humid regions and has high fatality rates if not treated early.18
Nine of the 160 elders admitted were due to intentional self-harm, with 7 cases due to poisoning by organophosphates, which are easily accessible to in India. This brings the focus onto the need for regular assessment of the mental health of the elderly along with their physical health. Death from intentional self-harm has been reported in older patients, and it is a major risk factor for suicide in older adults.19,20 Poisoning oneself in the elderly population may be a result of depression, which is very common among the elderly. Other factors, such as dementia and confusion, inappropriate use of medicines, inappropriate storage, or incorrect identities, can also lead to self-harm by poisoning in the elderly.19,20
Mortality rates among elderly ICU patients in this study were 22.5%. The mortality rate in various studies on elderly patients varies from 17 to 73%.2,3,5,6,8 The reason for this variation in the mortality of elderly patients may be due to disease severity, the expertise of the staff, and the availability of types of equipment and infrastructures of the ICUs in various countries. The main cause of death of elderly patients admitted to ICUs was sepsis followed by pneumonia and AKI. Invasive procedures and instrumentations constitute a considerable risk factor for bloodstream infections in the elderly because they provides direct access to the bloodstream by breaking the body’s natural barriers.17,21,22
We observed a significant association between sepsis and patient outcome.2,14,21,22 In the elderly, several factors including decreased physiological reserves and reduced immunity make sepsis an important cause of mortality.21 There was a significant association between sepsis (p < 0.0001) and patient outcomes.2,17,21,22
Procalcitonin, a glycoprotein, has emerged as an ideal biomarker for sepsis and early detection of bacteremia. In this study, 71.7% of the sepsis cases were found to be positive for PCT, which is in accordance with the previous reports23 and can also be used to identify severely ill elderly patients who may need intensive care.23
The requirement of vasopressors in elderly ICU patients is significantly associated with poor outcomes in this study, which is in agreement with earlier reports.2,6,24,26–28 The mortality rate for intubated patients was 28.7%, whereas previous published reports reported mortality rates ranging from 20.3 to 51%.25 Previous research has shown that the intubation and receipt of mechanical ventilation were associated with increased mortality in elderly ICU patients.2,5,13,26–28
AKI was one of the most common diagnoses on admission in the current study. Most commonly, AKI mandates the need for hemodialysis (renal replacement therapy). A significant correlation between the need for hemodialysis and patient outcomes was established in this study (p < 0.0001). AKI patients have a high mortality rate than non-AKI patients.25 In previous reports, the incidence of AKI ranged from 45 to 80%.25 Sepsis, shock, inotropes, mechanical ventilation, length of hospital stay, and advanced age are the important independent predictors of AKI.25,27
A significant correlation between the need for hemodialysis and patient outcome was established in this study (p < 0.0001). Both short- and long-term mortality rates were increased in more elderly patients compared to relatively young elderly patients who require hemodialysis.24,29
CONCLUSION
The age of the patients was not significantly associated with outcomes. The most common cause of death among elderly patients was found to be sepsis followed by pneumonia. In elderly patients admitted to ICU, gram-negative organisms are the most common causative agents in bloodstream infections. Sepsis was significantly associated with poor outcomes. Pneumonia was the most common diagnosis in elderly patients admitted to ICU. Procalcitonin was significantly associated with sepsis. Duration of ICU stay was not significantly associated with outcome. There was a significant association between the APACHE II score and outcomes. Receipt of mechanical ventilation, vasopressor support, and hemodialysis are significantly associated with mortality.
LIMITATIONS
Due to the prevailing Covid-19 pandemic, an adequate sample size could not be collected. As the study was done in medical ICUs, cases of acute coronary syndrome and chronic kidney disease may have been missed as they get admitted under the cardiology and nephrology departments, respectively. Social, economic, and psychiatric factors of the subjects were not considered in the study.
ORCID
Pruthvi Prabhudev https://orcid.org/0000-0002-3022-3219
Kusugodlu Ramamoorthi https://orcid.org/0000-0002-4264-0079
Raviraja V Acharya https://orcid.org/0000-0002-3849-8356
REFERENCES
1. Perianayagam A, Bloom D, Lee J, et al. Cohort profile: The Longitudinal Ageing Study in India (LASI). Int J Epidemiol 2022;51(4):e167–e176. DOI: 10.1093/ije/dyab266.
2. Owojuyigbe AM, Adenekan AT, Babalola RN, et al. Pattern and outcome of elderly admissions into the Intensive Care Unit (ICU) of a low resource tertiary hospital. East Cent Afr J Surg 2016;21(2):40–46. DOI: 10.4314/ecajs.v21i2.6.
3. Belayachi J, El Khayari M, Dendane T, et al. Factors predicting mortality in elderly patients admitted to a Moroccan medical intensive care unit. South Afr J Crit Care 2012;28(1):22–27. DOI: 10.7196/sajcc.122.
4. Bagshaw SM, Webb SA, Delaney A, et al. Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis. Crit Care 2009;13(2):R45. DOI: 10.1186/cc7768.
5. Reyes JC, Alonso JV, Fonseca J, et al. Characteristics and mortality of elderly patients admitted to the Intensive Care Unit of a district hospital. Indian J Crit Care Med 2016;20(7):391–397. DOI: 10.4103/0972-5229.186219.
6. Sodhi K, Singla MK, Shrivastava A, et al. Do Intensive Care Unit treatment modalities predict mortality in geriatric patients: an observational study from an Indian Intensive Care Unit. Indian J Crit Care Med 2014;18(12):789–795. DOI: 10.4103/0972-5229.146312.
7. de Rooij SE, Abu-Hanna A, Levi M, et al. Factors that predict outcome of intensive care treatment in very elderly patients: a review. Crit Care 2005;9(4): R307–314. DOI: 10.1186/cc3536.
8. Lankoandé M, Bonkoungou P, Simporé A, et al. Inhospital outcome of elderly patients in an intensive care unit in a Sub-Saharan hospital. BMC Anesthesiol 2018;18(1):118. DOI: 10.1186/s12871-018-0581-x.
9. Rodgers JL, Jones J, Bolleddu SI, et al. Cardiovascular risks associated with gender and aging. J Cardiovasc Dev Dis 2019;6(2):19. DOI: 10.3390/jcdd6020019.
10. Naved SA, Siddiqui S, Khan FH. APACHE-II score correlation with mortality and length of stay in an intensive care unit. J Coll Physicians Surg Pak 2011;21(1):4–8. PMID: 21276376.
11. Edipoglu IS, Dogruel B, Dizi S, et al. The association between the APACHE-II scores and age groups for predicting mortality in an intensive care unit: a retrospective study. Rom J Anaesth Intensive Care 2019;26(1):53–58. DOI: 10.2478/rjaic-2019-0008.
12. Upparakadiyala R, Singapati S, Sarkar MK, et al. Clinical profile and factors affecting outcomes in elderly patients admitted to the medical Intensive Care Unit of a Tertiary Care Hospital. Cureus 2022;14(2): e22136. DOI: 10.7759/cureus.22136.
13. Osman M, Manosuthi W, Kaewkungwal J, et al. Etiology, clinical course, and outcomes of pneumonia in the elderly: a retrospective and prospective cohort study in Thailand. Am J Trop Med Hyg 2021;104(6):2009–2016. DOI: 10.4269/ajtmh.20-1393.
14. Yahav D, Eliakim-Raz N, Leibovici L, et al. Bloodstream infections in older patients. Virulence 2016;7(3):341–352. DOI: 10.1080/21505594.2015.1132142.
15. Golli AL, Nitu FM, Balasoiu M, et al. Antibiotic resistance pattern of bacterial pathogens in elderly patients admitted in the intensive care unit. Rev Chem 2018;69(12):3433–3438. DOI: 10.37358/RC.18.12.6764.
16. Li W, Ding C, Yin S. Severe pneumonia in the elderly: a multivariate analysis of risk factors. Int J Clin Exp Med 2015;8(8):12463–12475. PMID: 26550157.
17. Sousa AL, de Souza LM, Santana Filho OV, et al. Incidence, predictors and prognosis of acute kidney injury in nonagenarians: an in-hospital cohort study. BMC Nephrology 2020;21(1):1–9. DOI: 10.1186/s12882-020-1698-y.
18. Gancheva GI. Leptospirosis in elderly patients. Braz J Infect Dis 2013;17(5):592–595. DOI: 10.1016/j.bjid.2013.01.012.
19. Morgan C, Webb RT, Carr MJ, et al. Self-harm in a primary care cohort of older people: incidence, clinical management, and risk of suicide and other causes of death. Lancet Psychiatry 2018;5(11):905–912. DOI: 10.1016/S2215-0366(18)30348-1.
20. Afzali S, Seifrabiei MA, Taheri SK, et al. Acute poisoning in elderly; a five-year study (2008-2013) in Hamadan, Iran. Asia Pac J Med Toxicol 2015;4(4):143–146. Available from: http://apjmt.mums.ac.ir.
21. Nasa P, Juneja D, Singh O, et al. Severe sepsis and its impact on outcome in elderly and very elderly patients admitted in intensive care unit. J Intensive Care Med 2012;27(3):179–183. DOI: 10.1177/0885066610397116.
22. Martin-Loeches I, Guia MC, Vallecoccia MS, et al. Risk factors for mortality in elderly and very elderly critically ill patients with sepsis: a prospective, observational, multicenter cohort study. Ann Intensive Care 2019;9(1):26. DOI: 10.1186/s13613-019-0495-x.
23. Malik M, Nair AS, Illango J, et al. The advancement in detecting sepsis and its outcome: usefulness of procalcitonin in diagnosing sepsis and predicting fatal outcomes in patients admitted to intensive care unit. Cureus 2021;13(4): e14439. DOI: 10.7759/cureus.14439.
24. Paškevičius Ž, Skarupskienė I, Balčiuvienė V, et al. Mortality prediction in patients with severe acute kidney injury requiring renal replacement therapy. Medicina 2021;57(10):1076. DOI: 10.3390/medicina57101076.
25. Liang J, Li Z, Dong H, et al. Prognostic factors associated with mortality in mechanically ventilated patients in the intensive care unit: a single-center, retrospective cohort study of 905 patients. Medicine 2019;98(42): e17592. DOI: 10.1097/MD.0000000000017592.
26. Lim KY, Nik Ab Rahman NH. Predictive factors for special care units admission and in-hospital mortality among geriatric patients that presented to the emergency department of a teaching hospital. Hong Kong J Emerg Med 2019;26(6):336–342. Available from: https://doi.org/10.1177/1024907918802069.
27. Teles F, Santos RO, Lima HM, et al. The impact of dialysis on critically ill elderly patients with acute kidney injury: an analysis by propensity score matching. J Bras Nephrol 2019;41:14–21. DOI: 10.1590/2175-8239-jbn-2018-0058.
28. Miniksar ÖH, Özdemir M. Clinical features and outcomes of very elderly patients admitted to the intensive care unit: a retrospective and observational study. Indian J Crit Care Med 2021;25(6):629–634. DOI: 10.5005/jp-journals-10071-23846.
29. Rhee H, Jang KS, Park JM, et al. Short-and long-term mortality rates of elderly acute kidney injury patients who underwent continuous renal replacement therapy. PLoS One 2016;11(11):e0167067. DOI: 10.1371/journal.pone.0167067.
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