Geriatric intensive care--indication and contraindication.

Gerontology 23: 47-54 (1977)

Geriatric Intensive Care - Indication and Contraindication O. R. G sell

Key Words. Intensive care • Indication ■Contraindication • Statistics Abstract. The indications for intensive care are discussed on the basis of new statistics assembled by the Swiss Gerontological Society. From the analysis of all admissions to 40 intensive care units (ICU) in Switzerland in 1973, it follows that one third are in the age group 65 + , and 11 % are 75 + years of age. Nearly 50 % of these older patients in ICU had circulatory diseases, compared to 30% in the general population. The ICU of 3 clinics in Nuremberg admitted 38.5 % patients over 60and 18 % over 70years. The 4 main diseases were: myocardial infarction, dysrhythmia, cor pulmonale, and pulmonary embolism. Of 860 patients admitted to the ICU in Berne, 40% were over 64 years, and 17% over 73 years. These were followed for 6 months following discharge, with good results in 64%. It is concluded that old age is no contraindication to intensive care. Diagnosis and thera peutic possibilities, not calendar age, are the basic indication for intensive care. Contra indication is present in cases where after several days in the ICU no satisfactory life can be expected to follow. In acute intoxication only 9-12% were older than 60 years; here -ntensive care is always indicated.

Received: September 20, 1975.

Downloaded by: King's College London 137.73.144.138 - 1/16/2019 10:25:38 PM

The question how far intensive care can be used for older patients and where the limits in geriatric care are, is discussed very frequently today. It is a problem not only for physicians but also for nurses and the families. Ethical and human questions on the prolongation of life must also be considered. Four new statistical studies, proposed by the Swiss Society for Geronto logy, were carried out during 1973 and 1974. Their results can be summarized as follows:

48

G sell

Table I. Old age in intensive care units (Switzerland 1973) Patients

%

All ages 65 years or more 65-74 years

24,022 7,905 5,295

33 22.1

75 years or more

2,610

10.9

%

Age distribution

men women

22.5 21.4

men women

8.9 14.0

All ages, %

65 years or more, %

13.6 30.4 10.0 4.5 41.5

6.5 42.5 10.1 6.8 34.1

Disease groups Accidents Circulatory diseases Respiratory diseases Tumours Others

This study covered all intensive care units (ICU), whether medical, surgical, or combined. The main results are given in table I. One third of all ICU patients were 65 years or more, 11 % were over 75 years. In 40 ICU with 24,022 patients, 7,905 were 65 years or more. More than half of the elderly patients requiring intensive care were found to have heart and lung diseases, whereas accidents constituted only 6.5%. In smaller ICU many more older patients are found: large units (500 or more patients/year), 65-74 years 18%, over 75 years 9% . Middle size units (200-499 patients/year), 65-74 years 20%, over 75 years 12%. Small units (1-199 patients/year) 65-74 years 33%, over 75 years 15%. In 32 hos pitals with an ICU one patient in ten was admitted once to the ICU. Of the 6,316 beds in these hospitals, 240 (4%) were in the ICU. Of the 3,996 nurses employed, 421 (15%) worked in the ICU. The nurse/ patient index of these units were: surgery (accidents) 3.34, internal medicine 1.75, mixed units 2.78. These figures confirm the great need for nursing staff in the ICU.


Study on all Intensive Care Units in Switzerland [H orisblrger, 1974]

49

Geriatric Intensive Care

Table If. Acute diseases in old age treated in ICR (medical intensive care unit, Nuremberg 1973)

Coronary infarction Dysrhythmia Pulmonary heart disease Pulmonary embolism Neurological disease Other acute disease

All persons 30 years or more

Persons 60 years or more, %

776 230 35 75 26 224

354 178 33 47 4 131

69 77 94 63 15 58

Table III. Myocardial infarction Age

30-39 60-69 70-79 80 +

Males total cases

deaths n

%

198 202 137 15

26 39 47 7

13 20 34 47

552

Females total cases 39 83 91 11

deaths n

%

15 24 32 2

38 29 35 18

224

Study on Three Large Medical Clinics in Nuremberg [Schubert, 1974]


Only patients with acute diseases (acute heart failure or circulatory break down, new coronary infarction or dysrhythmia, thromboembolic pulmonary processes) were accepted in these units, but no patients with chronic diseases or cerebral insults. The age distribution of the 1,401 patients in these ICU in 1973 showed two thirds aged 60 years or more, and one third 70 years or more: 933 (549 men, 384 women) 60+ years, 479 (256 men, 223 women) 70+ years. The age distribution of the most frequent diseases treated in the ICU (with the exception of 23 cases under 30 years of age) are given in table II. The detailed analysis by sex and age group for the 5 major diseases gave the following results: Myocardial infarction. 69 % of these cases were 60 years or over. There

G seix

50

Table IV. Dysrhythmia Age

Males total cases

30-59 60-69 70-79 80 +

34 30 37 8

deaths n

%

2 2 2 1

6 6 5 12


deaths n

i

%

6 3 2

6 17 7 8

deaths n

%

0 1 2 2

33 40 50

HI

1Ö9

Table V. Cor pulmonale Age

30-59 60-69 70-79 80-89

Males total cases 2 11 10 -

23

deaths n

%

0 4 2 -

36 20 -

-


-

12


were more than twice as many men than women with myocardial infarction and the mortality of the men was found to increase with age (table III). Women under 60 with myocardial infarction were less frequently seen than men (who were more often heavy smokers). The prognosis was more unfavourable and the diseases were more severe in the women. Dysrhythmia. 77 % of all patients with disturbance of heart rhythm in ICU were found to be over 60 years of age in both sexes. 41 % of the men and 53 % of the women in this group were over 70. Mortality was low in all age groups (table IV). Pulmonary heart disease (cor pulmonale). Nearly all patients are over 60. 43% of the men and 75% of the women are over 70 years of age (table V). Pulmonary embolism. 34 % of the men and 40 % of the women are over 60. 19% of the men and 28% of the women are over 70 years of age (table VI). Other acute diseases. Here, too, more than 50 % of all patients were 60 years or older (table VII).

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Geriatric Intensive Care Table VI. Pulmonary embolism Age

30-59 60-69 70-79 80 +

Females

Males total cases

deaths n

%

total cases

deaths n

ii 15 5 I

3 7 3 1

27 47 60 100

17 14 10 2

4 4 1 0

% 23 30 10

—

43

32

Table VII. Other acute disease Age

30-59 60-69 70-79 80 +

Males total cases

deaths n

61 35 34 8

19 10 9 1

%

Females total cases

deaths n

%

30 30 26 12

41 25 28 5

ii 15 20 1

27 60 71 20

680 patients who had been treated at the ICU in the course of 2 years were followed up for 6 months after discharge from the hospital. After 6 months, one third of the total had died, but 40 % were in good general condi tion, 24% were in a satisfactory, and only 2.5% were in an unsatisfactory state. 40 % were over 64, and 17 % over 73 years of age. The death rate after hospital discharge increased from 5.3 % in persons under age 20 to 25 % in those aged 73, but decreased to less than 20% in persons above age 74. In this aged group, mostly people with a heart block in need of a pacemaker, there was found to be a more favourable course after admission to an ICU. The patients in the ICU were usually older than those in other clinical units. Cardiac diseases were responsible for nearly one half of all admissions to the ICU, and respiratory insufficiency for 12.5 %. This experience speaks against a fixed age limit for acceptance to the ICU.


Study o f the ICU o f the Medical Clinic o f Berne University Medical School [Iff et al„ 1974]

52

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Table VIII. Intensive care unit for acute intoxication (Nuremberg 1973)

Age of the most frequent intoxications All ages 60-69 years 70-79 years 80 years or more Age

Soporifics, %

CO, %

92 85 78.7 68.9

5.9 11.4 16.9 24.1

Cases

Severe soporific intoxication (unconsciousness 36 h or more) 126 Under 60 years 60-69 years 18 70-79 years 15 80-90 years 4

Deaths, %

7 22 20 50

Medical Department, Basel University Medical School [Ritz, 1974] Of 100 patients transferred to the ICU following hemodynamically suc cessful resuscitation, 17 were aged 60 or more (29 under 60 years, 39 between 61 and 70, 32, 71 years or more).

For treatment of acute intoxications a special intensive care institution exists in Nuremberg. S c h u b er t [1974] remarks that in the 10 years before 1972, 10,510 intoxications were treated, 7,810 being inpatients and 2,700 outpatients. Only 9.1 % were older than 60 years (table VIII). In 1973, 1,736 acute intoxications were admitted, with a death rate of 1.3 %. The age distri bution was: 15-29 years 44%, 30-59 years 44%, 60-69 years 7%, 70-79 years 3%, 80+ years 2% . Even aged people with acute intoxications were admitted to this ICU. 92% of all intoxications were due to drugs, 5.9% were caused by CO, 1 % by pesticides, 0.5 % by severe alcoholism and 0.6 % by a variety of causes. The age group 70+ shows a decrease in soporific intoxications, but an increase in CO intoxications (IX). Among 807 soporific intoxications (2% deaths) 163 were severe (unconciousness over 36 h) with the following age distribution and death rates (X).


Treatment o f Acute Intoxications [Sc h u b e r t , 1974]

Geriatric Intensive Care

53

Table IX. Increase of CO intoxications in old age Age

Soporifics, %

CO, %

60-69 70-79 80 +

85 78.7 68.9

11.4 16.9 24.1

Table X. Severe soporic intoxication Age

Cases

Deaths

%

Under 60 60-69 70-79 80-90

126 18 15 4

9 4 3 2

7 22 20 50

Suicidal intoxications are found in old persons as well as in young. Inten sive care is always indicated in intoxications. Schubert [1974] states: ‘Every poisoned person is for me, as a doctor, a patient who - in the acute stage which often is essential - needs help under all circumstances and with all possible methods, without regard for high age.’ Social and psychiatric help has to start immediately when the patient awakes. For suicides, no primary passive euthanasia exists. The limits to survival are drawn by the failure of intensive care, of elementary assistance, of removal of the toxin and of ad ministration of the antidote. Only when, in spite of all treatment, irreversible damage from progressive decerebralisation and complications (e.g. pneu monia) occur does the problem of discontinuing therapeutic measures arise

From these statistical enquiries we can conclude that advanced age per se is no reason for rejecting a patient from an ICU. Today one third of all pa tients in ICU are over 65 years of age, and 11 % are over 75. In the ICU for internal diseases one third of the patients are over 70 years old. Even in very aged persons restitution and happy continuation of life can be expected, but we have to separate acute from chronic illnesses. Removal of acute symptoms in internal medicine as well as in surgery is possible even in pa


Discussion and Conclusions

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G sell

tients over 80. A diagnosis such as myocardial infarction, dysrhythmia, pneumonia, cancer or an accident, as well as the individual’s overall state of health and the therapeutic possibilities are the indicating criteria for the use of intensive care, rather than calendar age. In chronic diseases, especially in those with acute deterioration or further complications, decision-making is often difficult. Here, clinical observation over several days is indicated before a decision is made whether to start intensive care, or if recently start ed, whether to continue. If the psychological state of the aged patient is severely damaged, if dementia or paralysis are present in addition, and if no enjoyable subjective life can be expected, then there is a contraindication to start or to continue intensive therapy. The decision of the physician to discontinue intensive care should be made only after talking to members of the patient’s family, often also with the advice of a consultant physician, and if possible according to the expressed desire of the patient. A humane attitude has to guide the doctor, after analysis of all aspects of disease in old age has been considered, as to which course to take, whether to start, or when started whether to discontinue intensive care. Old age is no contraindication to intensive care. Diagnosis and thera peutic possibilities, not calendar age are the criteria to be used. A fixed upper age limit for admission to an ICU is not reasonable. Contraindication is present in cases where after several days of treatment in the ICU no satis factory future life can be expected to follow.

References G sell, O .: Gedanken über Lebensverlängerung und Ethik im hohen Alter. Akt. Geront.

4: 421 (1974). H orisberger, B .: Medizinische und pflegerische Probleme der Intensivmedizin. Schweiz,

med. Wschr. 104: 1854 (1974). I ff, W. H .; Stäubli, R., and Schlup , M. M .: Age and clinical course of patients treated

in a intensive care unit. Schweiz, med. Wschr. 104: 1859 (1974). R itz , R.: Follow-up of 100 patients following hemodynamically successful resuscitation.

Schweiz, med. Wschr. 104: 1861 (1974). Schubert, R .: Potentials and limits of intensive care in geriatrics. Schweiz, med. Wschr.

104: 1847 (1974).

Prof. Dr. med. O tto R. G sell, Zwinglistrasse 21, CH-9000 St. Gallen (Switzerland)


Summa, J. D .: Success of intensive therapy in geriatrics, Acta geront. 5: 655 (1975).

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