Short-and long-term health implications of surgical intensive care in the elderly

doi:10.4236/health.2010.212209

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Vol.2, No.12, 1405-1412 (2010) Health

doi:10.4236/health.2010.212209

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

ABSTRACT

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

1. INTRODUCTION

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.

2. MATERIALS AND METHODOLOGY

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

1406

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.

3. RESULTS

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.

605040302010

Months after ICU admission

1.0

0.8

0.6

0.4

0.2

0.0

S. Utzolino et al. / Health 2 (2010) 1405-1412

1407

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 =

0.041).

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-

tioning

Physical role

Bodily pain

General health

Vitality

Social function-

ing

Emotional role

Mental health

Mean 33.03 25.89 45.00 43.75 43.21 66.96 51.19 64.00

Percentiles

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

functioning

Physical role

Bodily pain

General

health

Vitality

Social func-

tioning

Emotional

role

Mental health

Mean 58.59 62.16 64.2 55.3 53.91 83.94 83.04 71.41

Percentiles

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

S. Utzolino et al. / Health 2 (2010) 1405-1412

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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

95%

confidence

interval

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).

4. DISCUSSION

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

cohort.

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

S. Utzolino et al. / Health 2 (2010) 1405-1412

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Table 6. Mean values of intensive care parameters whether suffering from a distinct complication or not.

Age (y)

Hospital

LOS

APACHE

TISS 10

total

TISS

median

Ventilator

days

Dialysis

days

Va so -

presssor

days

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

S. Utzolino et al. / Health 2 (2010) 1405-1412

1411

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

patients.

5. CONCLUSION

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

elderly.

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