key: cord-308677-dr9a3ug0
authors: Hall, William J.
title: Benefits of Intensive Care Unit Hospitalization for Patients Older than 90 Years
date: 2020-06-27
journal: J Am Geriatr Soc
DOI: 10.1111/jgs.16626
sha: 
doc_id: 308677
cord_uid: dr9a3ug0

This editorial comments on the article by Haas et al.

G eriatricians realize that the decision to admit our oldest patients to an intensive care unit (ICU) is never easy. The potential medical benefits are less clear, especially in the case of individuals aged 90 years and older. Those potential benefits have to be weighed against well-known downsides, including isolation from family. Complications are almost inevitable, including delirium, infection, and adverse reaction to medications. Often, these decisions have to be made by surrogates and may infringe on patient autonomy. Somewhat surprisingly, there is scant literature regarding the outcomes of ICU care for patients older than 90 years in the pre-coronavirus disease 2019 (COVID-19) era. Recently, during the early days of the COVID-19 pandemic, ICUs were full of patients and in some instances critically short of ventilators. A new ethical debate quickly emerged, namely, how should the oldest patients be regarded when it might become necessary or preferable to develop a triage system to decide which patients receive ventilators? What value set would be most fair and rational? Who decides to remove an older patient from a ventilator, so that someone judged to have a better prognosis could benefit? Could these decisions be made when even such basic data, such as ICU mortality in the pre-COVID-19 era, are not readily available? Some of these ICU admitting recommendations would have had the decision made by third parties, independent of family considerations. 1 Fortunately, stocks of ventilators became available and the benefits of ventilator therapy in all cases have become called into question. But the reality is, fundamental data on what benefit ICU care might have for older adults were not a paramount decision tool. Where are the data in in the pre-COVID-19 universe to address even crude end points, such as mortality in the patients older than 90 years? Therefore, it is timely that in this current issue of the Journal of the American Geriatrics Society, Hass and colleagues report on a large-scale clinical review comparing short-term mortality after ICU admission (i.e., ICU and hospital mortality) in the population aged 80 to 90 years versus a cohort in the older than 90 years group. 2 The study found that mortality statistics were similar in both cohorts. ICU mortality of the patients aged 90 years and older was actually lower (13.8% vs 16.1%; P < .001) and hospital mortality was similar (26.1% vs 25.7%; P < .41) compared with octogenarians. After 3 months, mortality was higher for the patients aged 90 years and older (43.1% vs 33.7%; P < .001), and after 1 year, mortality was 55.0% versus 42.7% (P < .001). Thus, long-term mortality was higher in the nonagenarians, yet 75% of nonagenarians were living 1 year following hospital stay. Nonagenarians and octogenarians had relatively similar prognoses. This study has several outstanding aspects. First, the investigators were able to identify every ICU admission in the Netherlands (82 ICUs) from January 2018 through December 2018. In aggregate, 103,754 patients, including 9,493 nonagenarians, were included. This study may have included the largest cohort of ICU patients reported in the medical literature. Second, access to advance health care is universally available in the Netherlands. The data reported were unlikely to be confounded by access issues due to class differences, such as potential differences in mortality due to socioeconomic variables. Third, some attempt was made to factor in key postadmission clinical characteristics of illness severity, such as Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) scores.

There have been previous studies with perhaps lower statistical power that have documented mortality rates among older adults hospitalized in ICUs similar to those reported here, but Hass and colleagues 2 have added a decade of hospital experience for the entire country. Hass and colleagues 2 acknowledge they were not able to characterize key differentiating risk factors. Chief among these would have been prehospitalization measures of frailty, which at present are recognized as being central predictive factors for morbidity and mortality. 3 APACHE scores, which the authors factored into their analysis, are recognized as a valuable tool to measure acute illness severity, but do not provide data on prehospitalization functional status.

As acknowledged by the authors, the study did not have sufficient granularity to assess how frailty measures might have predictive value in both the 80 and 90 years cohorts. Some studies not focused on nonagenarians have reported that the use of relatively simple screening tools, such as the Clinical Frailty Scale, may be highly predictive of the impact of frailty on acute hospital stays and ICU mortality. 4 Future prospective studies incorporating frailty scores in nonagenarians admitted to the ICU will be of great interest, especially when one considers the well-known demographic projections of the oldest populations worldwide. For example, by the year 2050, the U.S. population aged 65 years is projected to be 83.7 million, almost double the estimated 43.1 million in 2012. Of these, 3.7 million will be older than 85 years. 5 In addition to the challenge of caring for these oldest, there may be an additional unanticipated change in the physician workforce. In my community, as is true throughout the nation, the bulk of hands-on care for older adults with COVID-19 respiratory involvement requiring ICU care is being shouldered by selfless young physicians, nurses, and other care providers. They are witnessing the extraordinary respiratory-related mortality in COVID-19 patients in this subset of old adults. Might these impressionable experiences influence the attitudes of this next generation of caregivers even to the point that it adversely contravenes the somewhat optimistic data presented by Hass and colleagues about prognosis of older adults in the ICU environment? The evolutionary biologist Richard Dawkins in his 1976 book, The Selfish Gene, introduced the concept of a "meme" that he characterized as units of cultural transfer that catch on and pass between people and cultures. 6 His analogy was that a meme was the cultural equivalent of a gene. A wellrecognized example of a medical meme from prior generations might be the description of pneumonia in older adults as "the old man's friend," first attributed to the influential William Osler in the first edition of his textbook on medicine. 7,8 "(Pneumonia) in the debilitated, in drunkards, and in the aged, the chances are against recovery. So fatal is it in the latter class that it has been termed the natural end of the old man." The meme may have resurfaced in the late 1970s. Few physicians trained 30 or 40 years ago will not recognize a variation in the use of the meme, "Gomers go to ground" in the book, House of God. 9 Fast forwarding to the present time, the meme may reappear when the popular press describes the phenomenon of fatal respiratory complications of COVID-19 infection as "only in the elderly." 10 Is it possible that the stark experiences of this new generation of frontline healthcare providers will be imbedded with a skewed pessimistic view of the oldest? Historically, it has been the responsibility and mission of each successive generation of geriatricians to counter the many memes that still creep into the cultural response of healthcare providers when they encounter older adults. That is perhaps why evidence-based studies, such as that presented by Hass and colleagues, 2 are so important to our work. Evidence can still trump prejudice.

William J. Hall, MD Highland Hospital, Division of Geriatrics, Department of Internal Medicine, University of Rochester School of Medicine and Dentistry, 1000 South Avenue, Rochester, New York, 14520

Fair allocation of scarce medical resources in the time of Covid-19

Outcomes of intensive care patients over 90 years old, a 11-year national observational study

VIP1 Study Group. The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients≥ 80 years

Clinical frailty scale in acute medicine unit: a simple tool that predicts length of stay

An Aging Nation: The Older Population in the United States: Current Population Reports

The old man's friend. Pneumonia

The Principles and Practice of Medicine

COVID-19 Kills Only Old People: Only?

Sponsor's Role: There is no sponsor.
