ICUs and the elderly

There is concern about the misuse of hospital resources by the elderly, assuming that in many circums-tances, the services received, apart from being disproportionate, may also be more harmful than beneficial. The last post analysed the syndrome of post-hospitalization, a pathology that contracted the vulnerable people by the fact of them having been admitted to a hospital. In the same vein, I would like to comment on a clinical trial carried out in 24 French hospitals, with more than 3,000 people over 75 years of age in a clinically critical situation, of which half entered a program that promoted ICU admission , while the other half simply followed the standard criteria of each centre, without any external pressure. In the observed results, the patients in the intervention group logically entered the critical units (61% versus 34%), but this did not lead them to live longer, since, despite the fact that the gross mortality at 6 months was higher in the group that had observed greater use of ICUs (45% versus 39%), after adjusting the numbers*, relative risk was reduced to 1.05 (not significant).

According to this study, the greater ease of entering the critical units by the 1,518 patients in the intervention group, in addition to not reducing their mortality, neither did it improve their functional status or their quality of life. The consistency of the methodology employed by the French researchers has been praised by JAMA editor Derek C. Angus in "Admitting Elderly Patients to the Intensive Care Unit." Is it the Right Decision?” which states that this is the first a clinical trial to analyse the medium-term results of admissions in critical units of older people.

Within the limitations of the study, it should be noted that randomization has been done on the basis of a hospital and not a person, so that the results can not be systematically reduced to clinical practice. By this, I mean that there are older or even very old people who can clearly benefit from admission to a critical unit, especially on the more complicated days of their acute processes, such as during pneumonia (there is another American study that demonstrates this), but that doesn’t mean that, on the whole, ICUs don’t seem to be a highly recommended place for vulnerable people and, therefore, all possible strategies should be deployed to reduce their admission to strictly justified cases.

Emergency doctors faced with a critically ill elderly person, often have a dilemma because many hospitals have no intermediate structures and sometimes the critical unit option seems overly aggressive, but the hospital is short on staff, especially nurses. Therefore, it must be admitted that the rigidity of the supply of beds for critical patients is a brake on being able to offer appropriate services to critically ill elderly people.

Chronic Care Model promotes the provision of services to suit the patient. According to this view, hospitals should be able to generate services tailored to each person, especially the most vulnerable, in the most appropriate place, either in a hospital facility, in a social residence or in the home. It’s time to change and learns to manage resources from needs, not the other way around.

-------------

*Adjustment factors: age, severity of the pathology, initial clinical diagnosis, level of experience of emergency department doctors, time between arrival to emergency room and admission to the critical unit, functional level of the patient, daily life and type of home support.

Jordi Varela

Editor