Introduction
The world’s population is aging, and the rate of aging is much faster in developing countries like India when compared to the developed nations.[1 2 3 4 5 6 7 8
Methods
Ethics
The study protocol was submitted to the institutional ethics committee who approved the study vide (IEC 365/2019). A consent waiver was sort as the study was retrospective in nature.
Study design and eligibility criteria
This was a retrospective medical record analysis involving all patients aged 60 years and above visiting the ED of a tertiary care teaching hospital during the 6-month period August 2018–January 2019. The hospital serves a catchment area exceeding 1.5 million people in Southern India. There were no exclusion criteria.
Study procedures
After obtaining permission from the medical records department (MRD) of the hospital, a retrospective chart analysis was performed. The personal information and identity of the participants were masked to maintain confidentiality. A structured case record form was used to capture information such as the demographic details, presenting complaints, clinical profile, the treatment offered at ED, and their outcomes.
Data management
Data entry was done in Microsoft Excel (Publisher: Microsoft Corporation, Redmond, Washington, USA, 2016). Statistical analyses were performed using Statistical Package for Social Sciences (SPSS) Statistics for Windows, Version 20.0 (Publisher: IBM Corp., USA, 2011).
Statistical analysis plan
Demographic characteristics and clinical profile were summarized using descriptive statistics such as mean and standard deviation for continuous data, and frequency and percentages for discrete data. The hypothesized risk factors for mortality were subjected to univariate analysis using binary logistic regression. Those factors whose significance was <0.2 in univariate analysis were subjected to the multivariate analysis again using a binary logistic regression model. The statistical significance was set at P < 0.05.
Results
The total number of elderly patients registered with the MRD during the 6-month time period (Aug 2018–Jan 2019) was 503. The mean (SD) age of the study participants was 70.23 (7.182), and 62% of them were men. Tobacco smoking history was present 23/503 (4.57%) patients and consumption of alcohol in 34/503 (6.75%) patients. The baseline demographic characteristics, medical history, and outcomes are summarized in Table 1 . The duration of ICU stay for the majority (n = 405/503; 80.52%) of the patients was less than a week, and mortality was seen in 106/503 (21.07%). Table 2 summarizes the details of the chief presenting complaints. The three most common complaints were breathing difficulty (n = 148/503; 29.42%), fever (n = 108/503; 21.47%), and altered sensorium (n = 79/503; 15.70%).
Table 1: Demographic characteristics, medical history, and outcomes
Table 2: Details of chief presenting complaints
The details of the diagnosis and the cause of death of patients are summarized in Table 3 . Respiratory conditions such as pneumonia and exacerbations of chronic obstructive pulmonary disease (COPD), bronchial asthma, and obstructive sleep apnoea (OSA) were the most common diagnosis. The commonest cause of death was pneumonia seen in41/106 (38.67%) fatalities. This was followed by sepsis (nonrespiratory illness related) and cardiac ailments. The posthoc power calculation of the study to determine the proportion of mortality was >99%.
Table 3: Diagnosis and cause of death
The analysis to identify the risk factors for mortality was performed only in 432/503 patients (excluding patients who received DAMA) whose outcome was known. The significant predictors of mortality [adjusted odds ratio (aOR); 95% confidence intervals (CI); P value] as assessed by the multivariate binary logistic regression analysis were hypertension (2.195; 1.255, 3.840; 0.006), chronic liver disease (CLD) (4.324; 1.170, 15.979; 0.028), malignancy (2.854; 1.045, 7.796; 0.041), requiring noninvasive ventilation (NIV) (2.618; 1.449, 4.730; 0.001), requiring intubation (6.638; 3.705, 11.894; <0.001), and requiring vasopressors (3.583; 1.985, 6.465; <0.001). The details of univariate and multivariate analysis are listed in Table 4 .
Table 4: Predictors of mortality (n=432)
Discussion
We report that the mortality rate seen among elderly reporting to the ED-ICU was 21.07% (n = 106/503). The proportion of patients who were discharged against medical advice (DAMA) was 14.11% (n = 71/503). The three most common causes of mortality were pneumonia, sepsis (nonrespiratory illness related), and cardiac ailments. The significant predictors of mortality based on our study were those who had a medical history of hypertension, CLD, or malignancy and those requiring NIV, intubation, or vasopressors during the course of illness in ED-ICU.
The mortality rate seen in our study is comparable to other such studies conducted across the world. Mukhopadhyaye et al . from Singapore have reported that 20.9% (n = 148/709) of all elderly ≥65 years of age died in the ICU following an ED admission.[9 8 10
We report that the most common presenting complaint was breathing difficulty, and pneumonia was the main cause of mortality. These findings were similar to those reported by Abhilash et al . from India who reported that the most common presenting complaints among elderly ≥65 years of age visiting the ED were breathing difficulty (28%) and fever (21.6%).[11 et al .[12 13 14 15
Studies have identified that elderly patients with hypertension, malignancy, and CLD had approximately two, three, and four times the increased odds of mortality, respectively. Comorbidities among the elderly are a known risk for mortality, and the literature is replete in various indications of ED or ICU admissions among the elderly.[16 17
We further report that those requiring NIV, intubation, and vasopressor had approximately 2.6, 6.6, and 3.6 times the increased odds of mortality, respectively. Mechanical or non-invasive ventilation and vasopressors which are considered as “life-support” are usually used in patients who are severely ill with a poor prognosis. These findings are once again in line with the findings reported by Mukhopadhyay et al . wherein those requiring mechanical ventilation and vasopressor therapy were at increased odds of mortality by 2.74 (95% CI: 2.00, 3.76; P < 0.001) and 2.56 (95% CI: 2.00–3.26; P < 0.001) times, respectively.[9 et al .[18
Our study showed increased odds of mortality with NIV. Other studies have also reported that, apart from reduced expenditure, there is no mortality benefit with NIV when compared with mechanical ventilation.[19 20
The elderly in India face a multitude of socioeconomic challenges. Nearly 75% of the elderly population resides in rural areas. (1) This highlights the importance of primary care physicians to be vigilant of the unique problems faced by them. Clinical presentations of the elderly population are different from other populations and require due attention. Breathlessness, fever, and altered sensorium were the most common presentations noted by us for ICU admissions. These presentations in the rural setting should alert the primary care physicians about possible sinister etiology and necessitate investigations and aggressive therapy and even referral if required. With an ICU mortality rate of close to 20%, community health camps with an emphasis on screening and early identification of symptoms should be conducted to help prevent untimely deterioration. Primary physicians and peripheral health care workers should also raise awareness about comorbidity control as well. Comorbidities such as hypertension, cancer, and liver disease have been shown to be associated with poorer outcomes. The elderly need to be oriented towards regular follow ups and routine screening to recognize the acute factors linked to these chronic diseases.
Our study highlights the need for training peripheral health care workers in geriatric medicine. As the population of the elderly increases, so will the disease burden on our rural infrastructure. They need specialized training to learn the nuances of geriatric physiology and disease presentation to mitigate morbidity and mortality. To the best of our knowledge, there are very few studies aimed at geriatric intensive care profile and outcome. This invaluable data can be extrapolated by primary care physicians in their practice to help reduce the disease burden of this special population group. Our study has a few limitations. The patients with ST-Elevation myocardial infarction, requiring urgent cardiac catheterization, were directly shifted to the cath lab and later to cardiac ICU. Hence, there may be an underestimation of cardiac ailments requiring ICU care. As it was a retrospective record–based study, we were unable to follow up on the outcome of those patients who went DAMA. Further, it was a single center study, and hence the results are reflective only of the population that the hospital catered to. The strengths of our study include adequate power to estimate the proportion of ICU-ED deaths among the elderly although a formal sample size calculation was not done. Further, it is the first of a kind study in our setting to the best of the knowledge of the authors.
Conclusion
Clinical profiling of elderly patients admitted in ED-ICU enables primary care physicians to understand the geriatric emergencies they are likely to encounter and to take swift action when these conditions present early in the disease course. We noted that approximately one in every five patients died in the hospital, and the most common causes were respiratory illnesses such as pneumonia, sepsis (nonrespiratory illness related), and cardiac ailments such as acute coronary syndrome or heart failure. The predictors of mortality as assessed by our study were comorbidities such as hypertension, CLD, or malignancy and those requiring NIV, intubation, or vasopressors. We hope that by understanding the symptomology and red flag signs, primary care physicians can identify these early and plan treatment strategies. This would also help in early referral, thereby helping in reducing morbidity and mortality.
Informed consent
Written informed consent was obtained from the patients for their anonymized information to be published in this article. All the data were kept confidential and were coded.
Ethical approval
The Kasturba Medical College Institutional Ethics Committee consent was taken. (Ref. IEC 365/2019).
Author contributions
WW and PR researched literature and conceived the study and wrote the first draft.
JPR and UK were involved in protocol development, gaining ethical approval.
VJ BB SK – data acquisition and data analysis.
All authors reviewed and edited the manuscript and approved the final version of the manuscript.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
We acknowledge the support of the hospital technical and nontechnical staff for the study.
References
1. United Nations. World Population Ageing - Highlights. 2017Last accessed on 2020 Apr 05 Available from:
https://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2017_Highlights.pdf 2. United Nation. Concise Report on the World Population Situation in 2014. Dep Econ Soc Aff Popul Div. 2014;30 Available from:
https://www.un.org/en/development/desa/population/publications/pdf/trends/ConciseReportontheWorldPopulationSituation2014/en.pdf 3. Das SK. Situation Analysis of the Elderly in India. Cent Stat Off Minist Stat Program Implement Gov India 2011:1–63 Available from:
http://mospi.nic.in/mospi_new/upload/elderly_in_india.pdf 4. Samaras N, Chevalley T, Samaras D, Gold G. Older patients in the emergency department: A review Ann Emerg Med. 2010;56:261–9
5. Shah MN, Bazarian JJ, Lerner EB, Fairbanks RJ, Barker WH, Auinger P, et al The epidemiology of emergency medical services use by older adults: An analysis of the national hospital ambulatory medical care survey Acad Emerg Med. 2007;14:441–7
6. Aminzadeh F, Dalziel WB. Older adults in the emergency department: A systematic review of patterns of use, adverse outcomes, and effectiveness of interventions Ann Emerg Med. 2002;39:238–47
7. McCusker J, Ionescu-Ittu R, Ciampi A, Vadeboncoeur A, Roberge D, Larouche D, et al Hospital characteristics and emergency department care of older patients are associated with return visits Acad Emerg Med. 2007;14:426–33
8. Keskinolu P, Inan F. Analysis of emergency department visits by elderly patients in an urban public hospital in Turkey J Clin Gerontol Geriatr. 2014;5:127–31
9. Mukhopadhyay A, Tai BC, See KC, Ng WY, Lim TK, Onsiong S, et al Risk factors for hospital and long-Term mortality of critically ill elderly patients admitted to an intensive care unit Biomed Res Int 2014. 2014 doi: 10.1155/2014/960575
10. Demiselle J, Duval G, Hamel JF, Renault A, Bodet-Contentin L, Martin-Lefèvre L, et al Determinants of hospital and one-year mortality among older patients admitted to intensive care units: Results from the multicentric SENIOREA cohort Ann Intensive Care. 2021;11:35
11. Abhilash KP, Kirubairaj M, Sahare S. Profile of geriatric patients presenting to the emergency department Curr Med Issues. 2017;15:227
12. Lim KH, Yap KB. The presentation of elderly people at an emergency department in Singapore Singapore Med J. 1999;40:742–4
13. Ittisanyakorn M, Ruchichanantakul S, Vanichkulbodee A, Sri-On J. Prevalence and factors associated with one-year mortality of infectious diseases among elderly emergency department patients in a middle-income country BMC Infect Dis. 2019;19:1–10
14. Troeger C, Blacker B, Khalil IA, Rao PC, Cao J, Zimsen SR, et al Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016 Lancet Infect Dis. 2018;18:1191–210
15. Institute of Health Metrics and Evaluation. Global Burden of Diseases Compare |IHME Viz Hub - India, Both sexes, 70+years, deaths per 100,000. 2017Last accessed on 2020 Apr 15 Available from:
https://vizhub.healthdata.org/gbd-compare/ 16. Hentzien M, Dramé M, Allavena C, Jacomet C, Valantin MA, Cabié A, et al Impact of age-related comorbidities on five-year overall mortality among elderly HIV-infected patients in the late HAART era —Role of chronic renal disease J Nutr Heal Aging. 2016;20:408–14
17. Camilloni L, Farchi S, Giorgi Rossi P, Chini F, Borgia P. Mortality in elderly injured patients: The role of comorbidities Int J Inj Contr Saf Promot. 2008;15:25–31
18. Cirik MO, Yenibertiz D. What are the prognostic factors affecting 30-day mortality in geriatric patients with respiratory failure in the intensive care unit? Pakistan J Med Sci. 2021;37:15–20
19. Urkmez S, Dikmen Y. Noninvasive ventilation in acute respiratory distress syndrome. Noninvasive Mechanical Ventilation: Theory, Equipment, and Clinical Applications 20162nd ed Switzerland Springer International Publishing:413–8
20. Valley TS, Walkey AJ, Lindenauer PK, Wiener RS, Cooke CR. Association between noninvasive ventilation and mortality among older patients with pneumonia Crit Care Med. 2017;45:e246–54
