Vol.2, No.12, 1405-1412 (2010) Health
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Short-and long-term health implications of surgical
intensive care in the elderly
Stefan Utzolino*, Philipp A. Ober, Magnus Kaffarnik, Andreas Fischer, Ulrich T. Hopt, Peter K. Baier
Department of General Surgery, Surgical ICU, University of Freiburg, Freiburg im Breisgau, Germany
*Corresponding Author: stefan.utzolino@uniklinik-freiburg.de
Received 17 August 2010; revised 1 October 2010; accepted 8 October 2010
Background: Treatment of elderly patients on
intensive care units is an increasing challenge
all over the world. Objectives: To ev aluate short-
term survival and long-term quality of life im-
plications of intensive care for the elderly.
Methods: Retrospective analysis of 314 patients
75 years of age or more requiring over 48 hours
of intensive care. Results: In multivariate analy-
sis, significant risk factors for mortality were
chronic renal impairment (OR for survival 0.30,
p < 0.001) and chronic obstructive pulmonary
disease (OR 0.48, p = 0.003), pneumonia (OR for
non-surviving 3.01, p < 0.001), or thrombosis
(OR 1.89, p = 0.003); sepsis was not (OR 1.96, p
= 0.055). Therapeutic measures associated with
mort ality were ventilator therapy > 24 h (OR 4.5),
hemodialysis (O R 6.8), and vasopressor therapy
(OR 2.5, p < 0.001 for each). A health survey
questionnaire in an up to 60-month follow-up of
28 patients revealed considerably lower physi-
cal subscores of our patients compared to the
general elderly population. Conclu sions: Elderly
patients benefit from intensive care in terms of
survival. Complications are frequent, as are
severe consequences for long-term quality of
life. Short-term mortality in elderly intensive
care patients correlates most closely to pre-
existing disease, not age.
Keywords: Surgical Intensive Care; Aged;
Frail Elderly; Quality of Life; General Surgery;
Concomitant Disease
With the general population getting older and older,
physicians in general and intensivists in particular are
having to treat more elderly patients every year. Over
40% of the Germans will be older than 60 years in 2050
[1]. According to the National Hospital Discharge Sur-
vey in 1999, patients age 65 years and older constituted
12% of the population, yet used 48% of inpatient care
days and contributed to 40% of hospital discharges [2].
Intensive care is expensive, so there is continuous dis-
cussion about the allocation of resources, with health
care systems chronically short of funds all over the
world. There is thus concern about whether offering in-
tensive care to very old patients is a justifiable invest-
ment. Short-term survival is a priority, as are the long-
term health consequences and quality of life (QoL) after
treatment on an intensive care unit (ICU). To date, there
are no therapy restrictions at all in Germany. We aimed
to study mortality and survival in patients > 74 years
admitted to the surgical ICU of a university hospital.
Secondly, we aimed to determine the differences in QoL
by administering the Short Form 36 (SF-36) QoL ques-
tionnaire to a subgroup of survivors and comparing their
responses with standardized results from the general
population of Germany. We hypothezised that increasing
age correlates with a worse short-term outcome and
longer ICU-therapy, but that long-term QoL is compara-
ble with the general population.
From January 1, 2001 to December 31, 2004 we
treated 1, 346 patients of age 75 years or more on ad-
mission to our 20-bed surgical ICU. Most were admitted
for routine surveillance after elective surgery and usually
discharged within 24 hours. 314 patients whose stay was
over 48 hours in the ICU were defined as needing pro-
longed intensive care. They were eligible for this study.
We collected data from electronically-filed records for
this retrospective analysis. The study was approved at
the local IRB (University of Freiburg, Germany).
The Acute Physiology And Chronic Health Evaluation
2 (APACHE 2) score on admission was calculated as a
prognostic tool in all patients [3,4]. The Therapeutic
Intervention Scoring System (TISS) was used in its re-
duced form, with only 10 parameters measured daily.
This core-10-TISS is a component of the German reim-
S. Utzolino et al. / Health 2 (2010) 1405-1412
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bursement system of intensive care [5-7].
Patients still alive in December 2005 were contacted
and sent the German translation of the Short Form 36
(SF-36) QoL questionnaire. The SF-36 is a multi-
purpose, short-form health survey with only 36 ques-
tions. It yields an 8-scale profile of functional health
and well-being scores, as well as psychometrical-
ly-based physical and mental health summary meas-
ures and a preference-based health utility index. It is a
generic measure, as opposed to one that targets a spe-
cific age, disease, or treatment group. Accordingly, the
SF-36 has proven useful in surveys of general and
specific populations, comparing the relative burdens of
diseases, and in differentiating the health benefits
produced by a wide variety of treatments. A score be-
tween zero (poorest health) and 100 (optimum health)
can be achieved. Sub-scores according to functional
groups allow the differentiated estimation of health
impairment, as described elsewhere [8-10].
We compared our patients’ test results with standar-
dized results of the general population aged over 70
years, as evaluated by Bullinger et al. in 4,741 persons
living in Germany [11].
Complications: “Sepsis” means severe sepsis (organ
dysfunction and/or septic shock) according to the surviving
sepsis campaign definitions. We diagnosed “pneumonia”
if the clinical pulmonary infection score (CPIS) [12]
yielded > 6 points. This score was applied regardless of
mechanical ventilation. “Acute renal failure” is defined
as oliguria (< 400 ml/24 h) or increase in serum
creatinine of 50% in 24 h. “Urinary tract infection”
means symptomatic infection with bacteriological con-
firmation. “Surgical complications” include wound in-
fection, bleeding from the surgical site, fascia disruption,
and anastomotic leakage.
2.1. Statistical Analysis
Statistical Package for the Social Sciences (Version
15.0 SPSS Inc., Chicago, IL, USA) software was used
for statistical analysis. Data are presented as mean ±
standard deviation (SD). Survival was analyzed by the
Kaplan-Meier method. Probability of survival was com-
pared by using the log-rank test. We used the Cox logis-
tic regression method for multivariate analysis. To com-
pare independent parameters, we used the Spearman
correlation test. Differences between groups were calcu-
lated by the Mann-Whitney U-test and the Wilcoxon test
as appropriate.
Mean age was 80.9 ± 5.1 years, median age was 80
(75-96). 54/314 (17.2%) of the patients died on the ICU.
27/314 (8.6%) died later on the general ward. 233 pa-
tients (74.2%) were discharged home or to a nursing
facility. Of these, 114 (36.3%) were alive at the end of
our data collection period (60 months). The overall sur-
vival dropped strongly during the first year, but re-
mained constant after 40 months (Figure 1). The mean
duration of follow-up was 15.9 ± 17 months.
Figure 1. Cumulative survival in 314 patients over 74 years admitted to the intensive care unit.
Months after ICU admission
S. Utzolino et al. / Health 2 (2010) 1405-1412
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All 114 patients alive in December 2005 could be
contacted. They were sent the SF36 QoL questionnaire.
We received 73 questionnaires back. In another 9 cases,
relatives telephoned, informing us that the former patient
could not complete the questionnaire because of demen-
tia. 13 returned with no identification, and 32 were in-
complete. Thus only 28 forms remained for analysis.
The 28 patients eligible for analysis did not differ
from the rest of the survivors in any category: not in age,
nor in length of hospital stay, ICU length of stay,
APACHE 2 score, or core-10-TISS score (p > 0.15 for
all parameters). None of the diagnoses, no complication
and no procedure demonstrated an influence on the re-
turn of our questionnaire.
The questionnaire revealed profound impairment in
our patients’ physical scores (Ta ble 1) compared to the
general aged population. Less pronounced, but also
present were lower estimations of general health and
mental scores.
Suffering from any complication was correlated with
a significantly lower score in emotional role (75 vs. 31
points, p = 0.009), but in no other SF-36 sub-score.
Seven out of eight SF-36 sub-scores were significantly
higher in those patients who had had an arterial line.
Former vasopressor therapy was associated with slightly
lower physical sub-scores, but better self-assessment in
mental sub-scores and the general health score (data not
shown). Pre-existing cardiac disease was significantly
associated with lower scores for physical functioning (29
vs. 40, p = 0.017), and the physical role (15 vs. 54, p =
The main indications for admission in all 314 patients
were surgery for gastrointestinal malignancies, or emer-
gencies (Table 2). 16% were trauma patients.
Ta b le 1 . Results of the short-form 36 questionnaire of the evaluable study patients (n = 28) compared with data from the
general population over 70 years of age [10]. maximum value is 100 for each parameter. percentiles: e.g. 25% of the study
patients had a physical functioning value under 5, 50% under 30, 75% under 50, and so on.
Study patients
Physical func-
Physical role
Bodily pain
General health
Social function-
Emotional role
Mental health
Mean 33.03 25.89 45.00 43.75 43.21 66.96 51.19 64.00
25 5 .00 14 25 26 37 .00 48
50 30 .00 41 45 40 68 50 70
75 50 25 71 65 58 100 100 83
General population
Physical role
Bodily pain
Social func-
Mental health
Mean 58.59 62.16 64.2 55.3 53.91 83.94 83.04 71.41
25 35 25 41 35 35 75 100 56
50 55 75 62 52 50 87.5 100 72
75 80 100 100 72 70 100 100 84
Table 2. Indication for admission to the ICU in 314 patients.
n %
Gastrointestinal malignancy 92 29
Ileus or bowel ischaemia 31 10
Visceral perforation 28 9
Gastrointestinal bleeding 26 8
Visceral inflammation 21 7
Surgical complication 16 5
Hip fracture 27 9
Polytrauma 22 7
Other 25 8
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These patients presented numerous comorbidities; the
most frequent were cardiac, respiratory, neurological
(mostly dementia), and diabetes (Tab le 3). Therapeutic
measures included 24% needing mechanical ventilation
(mean duration 5.7 +/3.6 days), 35% were on vaso-
pressors for more than one hour (mean duration 5.4 +/–
4.2 days), and 57% underwent a transfusion of blood
components (at least 2 units of packed red cells or 2
units of fresh-frozen plasma). Only one of 11 attempted
resuscitations after cardiac arrest was successful.
Many patients developed complications in the ICU
(Tab le 4), infections leading by far in 142/314 patients
(45%), 70 of which were pneumonia (22%). A surgical
complication occurred in 65 patients (75% were post-
operative patients).
Of the pre-existing diseases, only two turned out to be
statistically significant risk factors for mortality in mul-
tivariate analysis; namely chronic renal impairment (OR
3.35, p < 0.001), and chronic obstructive pulmonary
disease (OR 3.04, p = 0.003).
Of the complications suffered in the ICU, acute kid-
ney failure correlated strongly with mortality, as did
pneumonia and sepsis in univariate analysis of the entire
follow-up period. (Table 4). Nevertheless, only pneu-
monia (OR 3.01, p < 0.0001) and thromboembolism (OR
1.89, p = 0.003) remained independent predictors of
mortality in multivariate analysis. Sepsis narrowly missed
significance (OR 1.96, p = 0.055).
The need for the following therapeutic measures cor-
related closely with mortality: hemodialysis, vasopres-
sors, mechanical ventilation, and having an arterial line
(Table 5). Multivariate analysis left only mechanical
ventilation as an independent factor (OR for survival
0.27, p < 0.001).
Mean length of ICU stay was 8.53 ± 8.63 days (range,
2-78). 25% of patients had an ICU length of stay of less
than 4 days, and 25% one of over 9 days.
Mean APACHE 2 score (admission time) was 15.5 ±
5.1 (range, 6-38). Because we enrolled only patients 75
Tab le 3 . Pre-existing disease in 314 patients on admission to
the ICU.
n %
Coronary heart disease 109 35
Cardiac insufficiency NYHA 2 93 30
Arterial occlusive disease 28 9
Any malignancy 137 44
Renal insufficiency 61 19
Chronic respiratory disease 109 35
Diabetes 93 30
Neurological / psychiatric disorder 122 39
Alcoholism 10 3
Other 69 22
Tabl e 4 . Odds ratios (OR) for mortality for complications suf-
fered during ICU stay, univariate analysis. n = 314.
n OR
95% confidence
interval p
Pneumonia 704.1 2.1-8.2 <0.001
Sepsis 285.5 1.6-18.5 <0.001
Acute renal failure 424.2 1.7-10.3 <0.001
Urinary tract infection 290.5 0.2-1.3 1.0
Surgical complication 650.9 0.5-1.5 0.48
Decubitus 132.1 0.5-18.3 0.06
Venous thromboembolism6 0.6 0.1-1.5 0.48
Delirium 360.7 0.4-1.9 0.54
Any complication 1.3 0.8-2.1 0.57
Table 5. Odds ratios (OR) for hospital mortality associated
with therapeutic measures during ICU stay, univariate analysis.
n = 314.
n OR
Ventilator therapy (> 24 h)75 4.5 3.1-6.7 <0.001
Haemodialysis 17 6.8 2.5-18.8 <0.001
Vasopressor therapy 109 2.5 1.9-3.3 <0.001
Arterial line 200 1.3 1.1-2.5 0.003
Transfusion 177 1.4 1.2-1.7 0.001
Any surgery 236 1.1 0.9-1.2 0.3
years or older, 6 age points are always present. Mean
APACHE 2 score was significantly higher in
non-survivors than in survivors (Figur e 2).
Mean core-TISS-10 score was 46.2 ± 77.9. Median
was 20 (range, 0-582) over the entire ICU stay. The me-
dian daily score per patient was 3.9 ± 4.7. Mean core-
TISS-10 score also was significantly higher in
non-survivors than in survivors (Figur e 3).
Of our cohort’s patients 17.2% died on the ICU and
8.6% during the same hospital stay on a general ward.
One year after admission, 48% were still alive. After 24,
36, and 48 months survival rates were 40%, 35%, and
32%, respectively. These results correlate well with data
published elsewhere [13-15].
Generally speaking, the probability of surviving ICU
admission diminishes with age, but this is no longer true
beyond a certain age. Pocard et al. [16] reported a mor-
tality rate of 8.5% in 182 surgical ICU patients under 75
years of age, compared with a 20% mortality rate in pa-
tients over 75 years. As in other collectives, an age over
75 years alone no longer affected survival rates [17-19].
In our patients, complications were associated with sev-
S. Utzolino et al. / Health 2 (2010) 1405-1412
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Figure 2. Mean APACHE 2-scores whether discharged
alive or not, n = 313.
Figure 3. Mean core TISS-10 counts whether discharged alive
or not, n = 313.
eral ICU indicators, such as core TISS-10, vasopressors,
haemodialysis, and mechanical ventilation, but not with
age (Table 5). Very old patients demonstrate survival
similar to the younger “oldies”. Here, survival is deter-
mined by biological rather than calendaric age, as de-
termined by coexisting disease and APACHE score. In
more than 13,000 patients over age 70, Wilson et al. [20]
demonstrated that the severity of disease and health sta-
tus are nearly independent of age.
It has been repeatedly shown that one-third of all
those over 65 years suffer from 3 to 4 chronic diseases,
and almost all of those over 80 have at least one chronic
disease [21]. In Pocard’s study, 93% had documented
chronic disease, and so did 99% of the patients in our
As evident from our data, Perdue et al. [22] found that
pre-existing heart, lung, or kidney disease had a pro-
nounced impact on mortality in more than 5,000 patients.
They also observed that gastrointestinal and infectious
complications influence outcomes, something not ap-
parent in our patients. In a study of Torres et al., co-
morbidity was the strongest predictor of long-term mor-
tality in patients 65 years or over treated on an interme-
diate care unit [23]. In an attempt to develop quality in-
dicators for perioperative care in elderly surgical patients,
McGory et al. [24] found a high impact of comorbidity.
The high mortality rate of trauma patients is striking in
our study (40.7% for hip fracture, 35.3% for other frac-
tures). The Scottish Hip Fracture Audit database re-
vealed outcomes in elderly patients being dependent on
co-morbidity, but not on management [25]. Evidently,
elderly trauma patients requiring prolonged intensive
care present a group at very high risk, especially when
very old. The usual elderly patient with a hip fracture
stays in the ICU for only one night postoperatively.
Those patients that require a prolonged stay due to
co-morbidity have a high mortality rate in our cohort.
Neurological disease, predominantly dementia and to
a certain degree transient delirium, significantly reduced
long-term survival in our patients. There was no influ-
ence on ICU or hospital mortality. Pisani [26] also stated
that dementia did not reduce ICU survival in elderly
patients, but Hamrick [27] found that it did so in patients
with delirium. As described in numerous publications
[28-30], sepsis and multiple organ failure are the most
important determinants of mortality in geriatric trauma
patients. In our study, patients with pneumonia had a
significantly elevated risk of death (OR 4.11) and had a
longer ICU length of stay. Due to our study’s retrospec-
tive character, we cannot differentiate between compli-
cations as a reason for or a sequel to prolonged ICU stay.
Surgical complications, wound infections, and colo-
nization with multiple drug-resistant rods had no impact
on mortality in our predominantly (75%) surgical pa-
tients. Although often observed elsewhere [31], coloni-
zation with multiple drug-resistant rods had neither an
influence on hospital nor ICU length of stays, nor on
long-term survival.
The aforementioned incidence of complications did
not correlate with age in our patients, but it did so with
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Table 6. Mean values of intensive care parameters whether suffering from a distinct complication or not.
Age (y)
Va so -
Pneumonia no 80.9 6.4 14.5 28.0 3.4 0.6 0.1 0.9
yes 80.8 16.3* 18.9* 110.3* 5.8* 4.2* 1.0* 5.3*
Decubitus no 80.9 8.1 15.3 43.0 3.9 1.3 0.2 1.6
yes 80.3 18.0 19.5* 110.2* 3.8 2.8 2.4* 7.9*
Surgical complication no 81.0 7.3 15.5 39.2 3.9 1.2 0.2 1.5
yes 80.2 13.4* 15.4 74.3* 4.0 2.1 0.7* 3.4*
Delirium no 80.9 8.6 15.4 46.9 4.1 1.4 0.3 1.9
yes 80.8 8.6 16.3 44.8 3.1 1.2 0.2 1.8
Sepsis no 81.0 7.2 14.9 34.8 3.4 0.9 0.1 1.2
yes 79.2 22.3* 21.8* 165.4* 9.2* 5.9* 1.7* 8.8*
Acute renal failure no 81.0 7.0 14.7 30.7 3.2 0.8 0.0 1.0
yes 77.6 19.0* 20.2* 148.1* 8.7* 5.3* 1.7* 7.6*
Any complication no 80.9 5.7 14.3 23.3 3.2 0.5 0.1 0.7
yes 80.8 11.0* 16.6* 66.4* 4.6 2.2* 0.4 2.9*
* denotes p < .05 for the difference as calculated by the Mann-Whitney U-test; APACHE = Acute Physiology and Chronic Health Evaluation 2 score; TISS =
Therapeutic Intervention and Scoring System; LOS = Length of Stay (days).
the APACHE 2 score on admission and with pre-existing
disease. We found a significant correlation between
COPD and wound infection, and between COPD and
sepsis. These observations accommodate easily the hy-
pothesis of co-morbidities as important determinants of
outcome. Hospital discharge alive correlated with the
APACHE 2 score, core-TISS-10 score, ventilator days,
vasopressor days and days with haemodialysis (Table 6),
but not with age.
The results of our questionnaire show a remarkably
reduced quality of life in our post-ICU elderly patients
compared with an average matched population. This is
true above all for the physical or bodily items of the
SF36. 75% of our patients have a physical functioning
score below 50 points, whereas the mean score in the
general population in elderly patients is 58. Only 25% of
the general population has a score under 35, compared
with our patients’ average score of 33. We obtained sim-
ilar results for physical role and bodily pain. Indeed, our
patients’ results lie consistently within the range of the
25-percentile in the general elderly population. Other
investigators, however, reported fair to good cognitive
and physical functioning in survivors of surgical ICU
treatment at the age of 80 or more [32]. Kaarlola et al.
observed high mortality and substantially worse out-
comes as measured in quality-adjusted life-years
(QALYs) in ICU patients over 65 compared to younger
ICU patients [33]. On the other hand, the higher scores
for mental health and emotional role may indicate that
our patients adapt well to physical disabilities. Merlani
et al. reported a decrease in quality of life in their study
including 141 elderly surgical ICU patients, and 81% of
the survivors lived at home 2 years after discharge [34].
The phenomenon of subjectively-reported better health
than measured by objective criteria in the elderly was
described in 1993 by Rockwood et al. [35].
There are conflicting results about long-term inten-
sive-care outcomes in the elderly [36-40], and the deli-
very of ICU treatment in these patients is under intense
debate [41-44]. The main drawbacks of our study are its
retrospective character, which only permits hypotheses
about causality, and the disappointingly low number of
returned questionnaires. The latter, however, is certainly
due to the numerous deceased or disabled patients, re-
flecting the burden of the post-ICU course in the elderly.
Baldwin et al. [45] assessed the quality of life of general
adult ICU survivors using the SF-36 at only 4 months
post ICU. After this short period in a non-geriatric cohort
only 65 of 175 questionnaires had sufficient data for
analysis. It is possible that those able or willing to send
back the questionnaire present a positive selection, so
that overall outcome results might be even worse. Fur-
ther, most of our patients were intermediate care patients,
as reflected by the low APACHE 2 scores. Our results
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may not apply to critically ill older patients. Our study
includes patients of 75 years or more. By contrast com-
parable groups in other studies are typically aged 70
years or more. This mismatch, although small, can be
expected to cause a bias towards worse scores in our
Age alone does not imply a worse outcome in surgical
ICU patients over 74 years of age. The development of
pneumonia is an independent predictor of mortality. The
main determinant of mortality is pre-existing disease.
Quality of life after discharge may be dramatically im-
paired, even in a mixed intermediate care or critically ill
older population. Further research is needed to address
the long-term health implications of ICU treatment in the
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