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Out-of-hospital cardiac arrests in the older age groups in Melbourne, Australia
Resuscitation 82 (2011) 398–403
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Clinical paper
Out-of-hospital cardiac arrests in the older age groups in Melbourne, Australia夽 C. Deasy a,b,∗ , J.E. Bray a , K. Smith a,b , L.R. Harriss a,b , S.A. Bernard a,b , P. Cameron b , on behalf of the VACAR Steering Committee a b
Ambulance Victoria, Australia Monash University, Department of Epidemiology and Preventive Medicine, Alfred Hospital, Level 3 Burnet Building, 89 Commercial Road, Melbourne 3004, Australia
a r t i c l e
i n f o
Article history: Received 7 September 2010 Received in revised form 2 November 2010 Accepted 15 December 2010
Keywords: Cardiac arrest Out-of-hospital Elderly Octogenarians Nonagenarians Centenarians Outcomes EMS Emergency Medical Services Emergency Resuscitation Cardiopulmonary resuscitation CPR
a b s t r a c t Background: Controversy exists around CPR in the elderly. The characteristics and outcomes of out-ofhospital cardiac arrest (OHCA) in this age group were studied in Melbourne, Australia. Methods: The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for all OHCAs not witnessed by Emergency Medical Services (EMS) occurring in those aged 65 years and older. Results: Between 2000 and 2009 there were 30,006 OHCAs of which 9703 (32%) were in people 65–79 years of age, 6430 (21%) in octogenarians, 1530 (5%) in nonagenarian and 40 (0.1%) in centenarians. Rates of attempted resuscitation decreased with advancing age: 48% for those aged 65–79 years, 39% for octogenarians, 31% for nonagenarians and 17% for centenarians. Similarly rates of survival to hospital discharge decreased with age: 8% for those aged 65–79 years, 4% for octogenarians, 2% for nonagenarians; for 65–79 year olds, octogenarians and nonagenarians survival if in VF/VT was – 17%, 10% and 4%; asystole – 1%, 1% and 0.5%; and PEA – 6%, 3% and 3%, respectively. Multivariable logistic regression shows that between 2000 and 2009 rates of transportation with return of spontaneous circulation have improved for both shockable and non-shockable rhythms [OR 95% CI 1.07(1.04–1.10) and 1.16(1.12–1.20), respectively] but survival to hospital discharge has improved in the shockable rhythm group only [OR 1.12(1.07–1.16)]. Conclusion: Outcomes for OHCA with shockable rhythm have improved over the last 10 years for people aged 65 years and over. Quality of life studies should be performed to help inform the community and EMS on appropriate resuscitative efforts. © 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Many investigators have studied outcomes after cardiac arrest in elders, with varying results.1–12 Some have suggested that resuscitation for elders with cardiac arrest is rarely effective4,13,14 and that cardiopulmonary resuscitation (CPR) in this age group may be a ‘curse’.13 Unfortunately, conclusions from these studies lack control for appropriate predictors, combine in-hospital and out-of-hospital arrests (study populations known to have very different outcomes), have small sample sizes, and use nonstandard definitions of outcome and “elderly.” Most studies are based on data from cardiac arrests occurring in the 1990s. These limitations make meaningful comparisons difficult. Attitudes toward resuscitation in elders have been shown to vary based on the perceived likelihood of a success-
夽 A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.12.016. ∗ Corresponding author at: Monash University, Department of Epidemiology and Preventive Medicine, Alfred Hospital, Level 3 Burnet Building, 89 Commercial Road, Melbourne 3004 Australia. Tel.: +61 41 6486887. E-mail address: [email protected] (C. Deasy). 0300-9572/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2010.12.016
ful outcome.15–19 To assist with the decisions regarding the end of life, it is important for physicians to provide patients and their families with accurate data that reflect the age-related potential of survival.20,21 The patient’s age may also affect paramedic and physician behaviour during resuscitative efforts and provision of immediate post resuscitative care. To allow an objective assessment by clinicians of likelihood of survival and appropriateness of resuscitation following out-of-hospital cardiac arrest (OHCA) in elderly patients, the characteristics and outcomes of OHCA were studied in Melbourne, Australia. 2. Methods The study setting was Melbourne, Australia which has an estimated population of 3.9 million. At last census 331,262 were aged 65–79 years, 110,429 were aged 80–89 years, 19,259 aged 90–99 years, and 573 were aged 100 years or older. Emergency call takers use the advanced Medical Priority Dispatch System©and Ambulance Victoria are the sole provider of ambulance services. Ambulance paramedics who have some advanced life support skills (laryngeal mask airway, intravenous epinephrine) and mobile
C. Deasy et al. / Resuscitation 82 (2011) 398–403
intensive care ambulance (MICA) paramedics who are authorized to perform endotracheal intubation and administer a wider range of cardiac drugs. MICA paramedics are dispatched to patients with critical illness, including patients with cardiac arrest. In addition, a fire-fighter first responder program operates for cardiac arrests in the inner two-thirds of Melbourne’s area.22 The pre-hospital cardiac arrest protocols follow the recommendations of the Australian Resuscitation Council.23,24 Since December 2007, all patients attended by paramedics have patient care data collected in an electronic patient record. Previous years involved a paper patient care record (PCR). Selected data from PCRs is collected from patients in cardiac arrest and stored on the Victorian Ambulance Cardiac Arrest Registry (VACAR). The VACAR also includes some data from the hospital record for those patients transferred to hospital, including outcome. Specific circumstances exist under which Ambulance Victoria paramedics are permitted not to attempt resuscitation or may cease resuscitation.24 Reasons for not resuscitating may include presence of rigor mortis and obvious signs of death; such patients are entered in the VACAR registry also. VACAR was searched for all OHCAs occurring in patients aged 65 years and over between the years 2000–2009, that were unwitnessed by Emergency Medical Services (EMS). 2.1. Ethics approval VACAR has been classified as a quality assurance project by the ethics committee at the Department of Health, Victoria. Ethical approval for outcome data was given by individual treating hospitals. This study was approved by the Research Committee of Ambulance Victoria and Monash University Human Research Ethics Committee. 2.2. Statistical analysis All data were entered into an Access software cardiac arrest registry database (Microsoft, Redmond, WA, USA). Statistical calculations were performed using STATA software (Version 10.0 Stata Corporation, College Station, TX, USA). Chi-square analyses were used for categorical variables. Continuous variables were compared using the t-test (normal distribution) or Mann–Whitney (skewed distribution). Factors effecting paramedic decision to attempt resuscitation, factors associated with return of spontaneous circulation and transport to hospital, and factors associated with patient survival to hospital discharge were examined in a multivariable logistic regression analysis in the presumed cardiac aetiology group. This logistic regression analysis was limited to those aged less than 100 years of age; numbers of patients in the age group greater than 100 years of age were small prohibiting meaningful analysis. An arrest was presumed to be of cardiac aetiology unless it was known or likely to have been caused by trauma, submersion, drug overdose, asphyxia, exsanguination, or any other non-cardiac cause as evident from the case record. Separate analyses were performed for cardiac arrests where the presenting rhythm was shockable (VF/VT) and non-shockable (asystole and PEA). Hospital survival data was unavailable for 1% of 65–79 year olds, 0.5% of octogenarians and 0.5% of nonagenarians; these cases were not included in survival and outcomes analysis. The Odds ratio for age group is given in reference to the 65–79 year old age group and for location of arrest to arrest in the home. 3. Results Between 2000 and 2009 there were 30,006 OHCAs attended by paramedics. Of these, 9703 (32%) were aged 65–79 years, 6430
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(21%) were octogenarians, 1530 (5%) were nonagenarian and 40 (0.1%) were centenarians. Resuscitation was attempted in 48% of 65–79 year olds (10 year range 44–55%), 39% (10 year range 38–42%) of octogenarians, 31.6% (10 year range 23–39%) of nonagenarians and 17% of centenarians. Table 1 describes the Utstein data elements characterizing OHCA for all adults and those in elderly age groups. Asystole was more common as the presenting rhythm for octogenarians, nonagenarians and centenarians than for those aged 65–79 years and shockable rhythm less common. Pulseless electrical activity (PEA) was seen in similar proportions in those aged over 65 years. Fewer cardiac arrests occurred in the home or in public places in octogenarians and nonagenarians compared with those aged 65–79 years while significantly more occurred in nursing homes. However, less cardiac arrests in octogenarians and nonagenarians were witnessed and less received bystander CPR compared with those aged 65–79 years. Where resuscitation was attempted octogenarians achieved a return of spontaneous circulation (ROSC) in 31% of cases and nonagenarians in 20%, compared with ROSC rates of 36% achieved in those aged 65–79 years. Octogenarians and nonagenarians were less likely to be transported to hospital with ROSC compared with those aged 65–79 years (Table 1). Where EMS attempted resuscitation, overall survival to hospital discharge was significantly lower for octogenarians (4%) and nonagenarians (2%) compared with those aged 65–79 years (8%). Of the 40 centenarians attended, 7 (17%) had an attempted resuscitation and only one person survived to hospital discharge. When survival was examined by initial monitored rhythm (Table 1), differences were seen in survival rates for shockable rhythms and PEA. Significantly higher survival rates were seen in those aged 65–79 years with a shockable rhythm (VF/pulseless VT) (17%) compared with octogenarians (10%, p = 0.005) and nonagenarians (4%, p = 0.002). Survival was also greater in the younger age group for PEA (6%) when compared with octogenarians (3%, p = 0.004). The number of bed days for those who survived to hospital discharge was available for 73% of those aged 65–79 years, 76% for octogenarians and 90% for nonagenarians. The median (IQR) length of stay was 16 (10–27) days for those aged 65–79 years, 17 (9–24) days for octogenarians and 9 (7–11) days for nonagenarians. Discharge direction of survivors is shown in Table 2. Most survivors were discharged to the level of care from which they originated with the majority of cases discharged home. One octogenarian and two nonagenarians who sustained the OHCA in a nursing home and were discharged from hospital back to the same nursing home. The paramedic decision to commence resuscitation for OHCAs with cardiac aetiology and a non-shockable rhythm was analyzed; age was divided into five year age groups with the 65–69 year old age group as the reference age and known Utstein elements as predictors (Table 3). The decision to resuscitate was most strongly associated with the arrest being witnessed, the patient having bystander CPR and the arrest occurring in a public place. ‘Transported with return of spontaneous circulation’ was analyzed separately for shockable and non-shockable rhythms, using known Utstein elements as predictors. More recent year of arrest was a positive predictor of transportation with return of spontaneous circulation in both non-shockable and shockable OHCA. Having a witnessed OHCA was the strongest predictor of being transported with ROSC in the non-shockable group (Table 4). Survival to hospital discharge was analyzed separately for shockable and non-shockable rhythms, using known Utstein elements as predictors (Table 5). Survival to hospital discharge was associated with more recent year of arrest, bystander CPR and faster EMS response times for shockable OHCA only.
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Table 1 Modified Utstein template describing OHCA characteristics among 30,006 people in Melbourne, Australia (2000–2009). Utstein element
All OHCA
65–79 years
Octogenarians
Nonagenarians
Centenarians
Absence of signs of circulation and/or considered for resuscitation Age median (IQR) years Female sex (%) Resuscitation not attempted n (%) First monitored rhythm n (%) Shockable (VF/pulseless VT) Non-shockable Asystole PEA Location of arrest n (%) Home Public place Nursing home Other Arrest not witnessed CPR before EMS arrival n (%) EMS response time Median (IQR) min Aetiology n (%) Presumed cardiac Trauma Overdose Other Where resuscitation attempted n (%) Outcome Any ROSC Survived event Discharged alive Survival based on initial rhythm n (%) VF/pulseless VT Asystole PEA
30,006
9,609 (32%)
6,430 (21.4%)
1,530 (5.1%)
40 (0.1%)
70 (52–80) 34.5 16,943 (56)
73 (69–76) 34 5,016 (52)
84 (81–86) 44 3,888 (60)*
92 (91–94) 59 1,047 (68)*
100 (100–101) 67 33 (82)
4,485 (15)
1,711 (18)
722 (11)*
90 (6)*
2 (5)
*
*
21,984 (73) 3,533 (12)
6,638 (69) 1,260 (13)
4,798 (75) 910 (14)
1,214 (79) 226 (15)
36 (90)* 2 (5)
23,035 (77) 2,372 (8) 2,350 (8) 2,249 (7) 20,514 (68) 7,080 (24)
7,931 (82) 562 (6) 561 (6) 555 (6) 6,241 (65) 2,315 (24)
4,998 (78)* 216 (3)* 1,016 (16)* 200 (3) 4,450 (69)* 1,232 (17)*
1,024 (67)* 34 (2)* 452 (29)* 20 (1) 1,105 (72)* 259 (4)*
27 (67) 0 11 (27) 2 (5) 33 (82) 6 (15)
7 (6–9)
7 (6–9)
7 (6–9)
7 (6–10)
7 (5–10)
22,564 (75) 1,376 (5) 1,926 (6) 4,140 (13)
8,312 (86) 150 (2) 48 (0.5) 1,099 (11)
5,764 (90)* 63 (1)* 19 (0.3)* 564 (9)
1,440 (94)* 6 (0.4)* 6 (0.4) 78 (5)
35 (87) 0 1 (2.5) 4 (10)
4,416 (34) 3,713 (28) 1,105 (8)
1,640 (36) 1357 (29) 389 (8)
797 (31)* 649 (25)* 111 (4)*
98 (20)* 80 (17)* 10 (2)*
3 (42) 2 (29) 1 (14)
830 (19) 78 (1.5) 197 (6)
290 (17) 26 (1.5) 73 (6)
74 (10)* 10 (1) 27 (3)*
3 (4)* 1 (0.5) 6 (3)
1 (100)
Chi-square test comparing octogenarian and nonagenarians to the 65–79 year old age group. * p < 0.05.
4. Discussion Previous studies looking specifically at OHCA in older age groups age groups have been based on data from OHCAs occurring during the 1980s and 1990s however treatments, EMS systems as well as elderly population demographics have evolved since then. We report increasing survival in those aged 65–79 years and octogenarians who experienced shockable rhythm OHCA throughout the last 10 years, while there have been a handful of survivors in the nonagenarians and a single survivor in the centenarian age group. Australia has the fourth highest life expectancy for men and women in the world, behind Japan, France and Italy, but ahead of Sweden, Switzerland, Spain, Canada, Singapore, New Zealand, Norway, the United Kingdom and the US.25,26 Projections based on a series of assumptions that take into account recent trends in fertility, mortality and migration predict that one in four Australians will be 65 years or older by 2056 and that those aged 85 years or over will make up 5–7% of Australia’s population, compared with only 1.6% currently.27 Centenarians are the fastest growing age segment of the Australian population. Their numbers have increased by 8.5% per year over the past 25 years.28
As the number of elderly persons increase, the dilemmas of whom to resuscitate and when increase. The decision can be highly complex, made even more difficult by the lack of reliable outcome data and in particular quality of life outcome data. Ideally, it should be an informed consensual plan made by the patient with the physician in collaboration with family members well in advance of the event. However this is rarely the reality with EMS and emergency department personnel often confronting difficult late-night decisions to initiate or withhold resuscitation. The American Heart Association (AHA) has long maintained that “except in narrowly defined circumstances . . . professional first responders are expected to always attempt BLS [basic life support] and ACLS”.29 The AHA’s most recent ethical guidelines reiterate this imperative: You must start CPR.30 The imperative to “always resuscitate” offers clarity but can have substantial emotional, moral, and financial costs. Currently our outcome measures of success for treatment of the elderly in OHCA are based on ROSC rates and survival, metrics for measuring the quality of death, the dignity offered to the dying elderly patient and the quality of acute bereavement support for their families are lacking. Scott and Guyatt state that because of the greater risk of harm and the lesser potential for benefit in older patients and
Table 2 Discharge direction of OHCA survivors for elderly age groups in Melbourne, Australia (2000–2009). Discharge direction
65–79 years (n = 389) n (%)
Octogenarians (n = 111) n (%)
Nonagenarians (n = 10) n (%)
Normal residence Rehabilitation Nursing home Unknown
268 (72.4) 77 (20.8) 20 (5.4) 24 (5)
71(67) 23 (21.9) 7 (6.7)a 10 (9)
3(30) 3(30) 3(30)a 1 (10)
a
One octogenarian and two nonagenarians had sustained the OHCA in a nursing home.
C. Deasy et al. / Resuscitation 82 (2011) 398–403 Table 3 Odds ratios [OR(95% CI)] for the associations between selected characteristics and paramedic attempted resuscitation for non-shockable OHCA, among 15,084 people in Melbourne, Australia, aged 65–105 years (2000–2009)a . Characteristic Age group, years 65–69 70–74 75–79 80–84 85–89 90–94 95–99 100–105 Year of arrest Female sex Witnessed arrest Bystander CPR given EMS response time Location of arrest Home Nursing home Public place Other
Model 1b OR(95% CI)
Model 2c OR(95% CI)
1.00 0.87(0.76–0.99) 0.80(0.71–0.91) 0.71(0.63–0.81) 0.59(0.52–0.66) 0.57(0.48–0.67) 0.46(0.34–0.63) 0.20(0.07–0.56)
1.00 0.90(0.77–1.05) 0.82(0.70–0.95) 0.77(0.66–0.89) 0.59(0.50–0.70) 0.58(0.47–0.70) 0.44(0.31–0.62) 0.23(0.07–0.72) 0.99(0.98–1.00) 0.88(0.81–0.96) 8.12(7.36–8.96) 4.76(4.25–5.34) 0.98(0.97–0.99) 1.00 0.84(0.74–0.96) 2.51(1.95–3.21) 2.04(1.29–3.25)
a Odds ratios calculated using logistic regression and those aged 65–69 years as reference. b Univariate analysis. c Multivariate analysis adjusted for year in which arrest took place, sex of patient, patient having a witnessed arrest, patient receiving bystander CPR, EMS response time and location of arrest.
the greater variability in treatment effects, the quality of evidence supporting substantial benefit and limited harm ideally should be more stringent in older versus younger populations.31 Nowhere is this more relevant than in the area of out-of-hospital cardiac arrest. Our study shows that although octogenarians were less likely to survive than their 65–79 year old counterparts they had a 10.5% survival rate when the initial rhythm was shockable and a 4% survival overall when resuscitation was attempted. Survival for nonagenarians who were found in a shockable rhythm was significantly less at 4%. There was one centenarian found in ventricular fibrillation who
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represents the one survivor in the centenarian age group having been successfully defibrillated. We report an increasing rate of transportation with ROSC for both shockable and non-shockable rhythm OHCA and an increased survival to hospital discharge for shockable OHCA over the period 2000–2009. This corresponds to changes that have occurred through the decade in the demographics of the older population and their health status, EMS resuscitation provision, CPR guideline changes and introducing compression-focused dispatcher CPR instructions.30,32 An increasing number of OHCAs occur in nursing homes as age increases; 6% of OHCAs in the 65–79 year old age group occurred in a nursing home, while 16% of OHCAs in octogenarians and 29% of nonagenarians OHCAs occurred in a nursing home. In keeping with this is the decrease seen in OHCAs occurring in the home as age increases (Table 1). Given that patients who enter nursing homes usually do so due to increased infirmity and frailty it stands to reason that paramedics are less likely to attempt resuscitation in those over 65 years who sustain their OHCA in a nursing home (Table 3). The extent of the difference in survival between OHCA occurring in the home and those occurring in a nursing home is noteworthy; survival to hospital discharge for non-shockable rhythm cardiac arrests occurring in nursing homes was 74% worse than when the arrest occurred in the home (Table 5). Informing patients, their families and caregivers on issues around end of life and allowing an informed and appropriate decision be made regarding whether they would want an attempted resuscitation is a challenge for nursing homes and the General Practitioners and all Health Professionals that serve them. A community-wide approach to expected natural deaths occurring outside of a hospital when carried out appropriately within a supportive EMS infrastructure, may improve care at the end of life by preserving patient autonomy, diminishing suffering and avoiding unwanted, inappropriate resuscitative efforts. 5. Limitations This study has a number of limitations due to its retrospective nature. Little is reported on quality of life outcomes for this age group of survivors in the literature. VACAR has commenced quality
Table 4 Odds ratios [OR(95% CI)] for the associations between selected characteristics and survival to hospital for non-shockable and shockable OHCA, among 16,565 people in Melbourne, Australia, aged 65–99 years (2000–2009)a . Characteristic
Age group 65–69 70–74 75–79 80–84 85–89 90–94 95–99 Year of arrest Female sex Witnessed arrest Bystander CPR EMS response time Arrest location Home Nursing home Public place Other a
Non-shockable
Shockable
Modelb OR(95% CI)
Model 2c OR(95% CI)
Model 1b OR(95% CI)
Model 2c OR(95% CI)
1.00 0.87(0.69–1.09) 0.84(0.68–1.05) 0.78(0.62–0.97) 0.61(0.48–0.79) 0.42(0.30–0.60) 0.20(0.08–0.50)
1.00 0.93(0.73–1.19) 0.88(0.69–1.11) 0.86(0.67–1.09) 0.65(0.49–0.85) 0.45(0.31–0.65) 0.21(0.08–0.52) 1.07(1.04–1.10) 1.06(0.91–1.22) 7.43(6.36–8.68) 1.71(1.45–2.00) 0.98(0.96–0.99)
1.00 1.17(0.92–1.49) 1.24(0.98–1.58) 0.92(0.71–1.19) 0.85(0.62–1.18) 0.75(0.45–1.25) 0.12(0.01–0.93)
1.00 1.25(0.97–1.61) 1.29(1.00–1.65) 0.87(0.66–1.15) 0.82(0.59–1.15) 0.72(0.42–1.24) 0.11(0.01–0.87) 1.16(1.12–1.20) 1.38(1.12–1.70) 1.65(1.36–2.01) 1.25(1.05–1.48) 0.94(0.91–0.96)
1.00 0.62(0.49–0.79) 1.23(0.94–1.61) 0.87(0.50–1.51)
1.00 0.79(0.55–1.16) 1.19(0.98–1.44) 1.57(1.02–2.43)
Odds ratios calculated using logistic regression and those aged 65–69 years as reference. Univariate analysis. c Multivariate analysis adjusted for year in which arrest took place, sex of patient, patient having a witnessed arrest, patient receiving bystander CPR, EMS response time and location of arrest. b
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Table 5 Odds ratios [OR(95% CI)] for the associations between selected characteristics and survival to hospital discharge for non-shockable and shockable OHCA, among 16,565 people in Melbourne, Australia, aged 65–99 years (2000–2009)a . Characteristic
Age group 65–69 70–74 75–79 80–84 85–89 90–94 95–99 Year of arrest Female Witnessed arrest Bystander CPR EMS response time Arrest location Home Nursing home Public place Other
Non-shockable
Shockable
Model 1b OR(95% CI)
Model 2c OR(95% CI)
Model 1b OR(95% CI)
Model 2c OR(95% CI)
1.00 0.88(0.56–1.40) 0.57(0.35–0.93) 0.51(0.31–0.83) 0.34(0.19–0.64) 0.31(0.14–0.70) 0.38(0.09–1.58)
1.00 0.95(0.59–1.52) 0.64(0.39–1.05) 0.61(0.37–1.02) 0.45(0.24–0.84) 0.43(0.18–0.98) 0.54(0.13–2.30) 1.03(0.97–1.09) 1.08(0.78–1.50) 7.04(4.91–10.09) 1.15(0.80–1.66) 0.97(0.93–1.01)
1.00 0.81(0.61–1.08) 0.65(0.48–0.87) 0.43(0.30–0.61) 0.39(0.25–0.62) 0.18(0.06–0.51)
1.00 0.85(0.63–1.15) 0.67(0.49–0.91) 0.41(0.29–0.59) 0.39(0.24–0.62) 0.19(0.06–0.55)
1.00 0.26(0.11–0.60) 2.07(1.30–3.32) 2.22(0.99–5.01)
1.12(1.07–1.16) 1.21(0.93–1.59) 1.46(1.10–1.92) 1.32(1.04–1.66) 0.91(0.87–0.94) 1.00 0.88(0.49–1.58) 2.04(1.61–2.59) 2.23(1.37–3.63)
a
Odds ratios calculated using logistic regression and those aged 65–69 years as reference. Univariate analysis. c Multivariate analysis adjusted for year in which arrest took place, sex of patient, patient having a witnessed arrest, patient receiving bystander CPR, EMS response time and location of arrest. b
of life follow up of all OHCA survivors but this data was not available for the time periods described in this study. The inability to adjust for co morbidity in the elderly may lead to overestimation of the association of increased age itself and survival from OHCA. We acknowledge that attitudes toward resuscitation in elders have been shown to vary based on the perceived likelihood of a successful outcome15–19 which may bias the results of this study in favor of the younger OHCA patient. Nonetheless, this study provides a benchmark for assessing OHCA in the elderly. It was not possible to cross check the ‘presumed cardiac’ OHCAs with autopsy reports; autopsies were less commonly performed in this age group. It is possible that the ‘presumed cardiac’ group of patients may include conditions such as intracerebral bleeds, drug overdose, and massive pulmonary embolism not discernable clinically. In certain circumstances, particularly in the elderly, our paramedics were called to attend because of carer’s inability to cope and their need for assistance with a patient expected to die and where resuscitation was inappropriate. Natural expected deaths attended by our paramedics are entered in the OHCA registry. There are times when resuscitation will have commenced before the patients history emerges resulting in the cessation of the attempted resuscitation; such ‘resuscitations’ may dilute survival outcomes by increasing the denominator. 6. Conclusions Outcomes for shockable rhythm OHCA in 65–89 year olds have improved through the decade. Although survival decreased with age, there was a significant group of survivors in the very old age groups. Quality of life for survivors was not assessed in this study but this information is necessary to inform the community on appropriate strategies for reducing exposure of patients and EMS teams to futile resuscitation attempts. Conflict of interest statement There are no conflicts of interest to declare.
Acknowledgments Dr Conor Deasy was supported by a Monash University overseas PhD student scholarship during this project. Ambulance Victoria provided in kind support with data extraction. References 1. Tresch D, Heudebert G, Kutty K, Ohlert J, VanBeek K, Masi A. Cardiopulmonary resuscitation in elderly patients hospitalized in the 1990s: a favorable outcome. J Am Geriatr Soc 1994;42:137–41. 2. Tresch DD, Thakur R, Hoffmann RG, Brooks HL. Comparison of outcome of resuscitation of out-of-hospital cardiac arrest in persons younger and older than 70 years of age. Am J Cardiol 1988;61:1120–2. 3. Tresch DD, Thakur RK, Hoffmann RG, Olson D, Brooks HL. Should the elderly be resuscitated following out-of-hospital cardiac arrest? Am J Med 1989;86:145–50. 4. Murphy DJ, Murray AM, Robinson BE, Campion EW. Outcomes of cardiopulmonary resuscitation in the elderly. Ann Intern Med 1989;111: 199–205. 5. Ritter G, Wolfe RA, Goldstein S, et al. The effect of bystander CPR on survival of out-of-hospital cardiac arrest victims. Am Heart J 1985;110:932–7. 6. Bonnin MJ, Pepe PE, Clark Jr PS. Survival in the elderly after out-of-hospital cardiac arrest. Crit Care Med 1993;21:1645–51. 7. Van Hoeyweghen RJ, Bossaert LL, Mullie A, et al. Survival after out-of-hospital cardiac arrest in elderly patients Belgian Cerebral Resuscitation Study group. Ann Emerg Med 1992;21:1179–84. 8. Wuerz RC, Holliman CJ, Meador SA, Swope GE, Balogh R. Effect of age on prehospital cardiac resuscitation outcome. Am J Emerg Med 1995;13:389–91. 9. Wuerz RC, Holliman CJ. Prognostic implications of age. Ann Emerg Med 1993;22:1637–8. 10. Joslyn SA, Pomrehn PR, Brown DD. Survival from out-of-hospital cardiac arrest: effects of patient age and presence of 911 Emergency Medical Services phone access. Am J Emerg Med 1993;11:200–6. 11. Kim C, Becker L, Eisenberg MS. Out-of-hospital cardiac arrest in octogenarians and nonagenarians. Arch Intern Med 2000;160:3439–43. 12. Swor RA, Jackson RE, Tintinalli JE, Pirrallo RG. Does advanced age matter in outcomes after out-of-hospital cardiac arrest in community-dwelling adults? Acad Emerg Med 2000;7:762–8. 13. Podrid PJ. Resuscitation in the elderly: a blessing or a curse? Ann Intern Med 1989;111:193–5. 14. Hazzard WR. Should the elderly be resuscitated following out-of-hospital cardiac arrest? Why not? Am J Med 1989;86:143–4. 15. Murphy DJ, Burrows D, Santilli S, et al. The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscitation. N Engl J Med 1994;330:545–9. 16. Carton RW, Brown MD. Ethical considerations and CPR in the elderly patient. Clin Chest Med 1993;14:591–9.
C. Deasy et al. / Resuscitation 82 (2011) 398–403 17. Russell RJ, Campbell AJ, Allison GM, Caradoc-Davies TH, Busby WJ. Informed consent for cardiopulmonary resuscitation in elderly patients. N Z Med J 1991;104:312–3. 18. Hillier TA, Patterson JR, Hodges MO, Rosenberg MR. Physicians as patients Choices regarding their own resuscitation. Arch Intern Med 1995;155:1289–93. 19. Schonwetter RS, Walker RM, Kramer DR, Robinson BE. Resuscitation decision making in the elderly: the value of outcome data. J Gen Intern Med 1993;8:295–300. 20. Phillips RS, Wenger NS, Teno J, et al. Choices of seriously ill patients about cardiopulmonary resuscitation: correlates and outcomes SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Am J Med 1996;100:128–37. 21. Hakim RB, Teno JM, Harrell Jr FE, et al. Factors associated with do-not-resuscitate orders: patients’ preferences, prognoses, and physicians’ judgments SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Ann Intern Med 1996;125:284–93. 22. Smith KL, Peeters A, McNeil JJ. Results from the first 12 months of a fire firstresponder program in Australia. Resuscitation 2001;49:143–50. 23. Australian Resuscitation Council. Guidelines. http://www.resus.org.au.
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24. Ambulance Victoria. Clinical practice guidelines. http://www.ambulance.vic. gov.au/Paramedics/Qualified-Paramedic-Training/Clinical-PracticeGuidelines.html. 25. Australian Institute of Health and Welfare. Australia’s health 2006. Canberra: AIHW; 2006. AIHW Cat. No. AUS 73. 26. World Health Organization. The world health report 2005. Geneva: WHO; 2005. 27. ABS (Australian Bureau of Statistics). Population Projections. cat no.3222.0; 2006–2101. 28. Richmond RL. The changing face of the Australian population: growth in centenarians. Med J Aust 2008;188:720–3. 29. Cummins RO. Ethical Aspects of CPR and ECC. In: Textbook of advanced cardiac life support. Dallas: American Heart Association; 1994. 30. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005;112(24 Suppl.):IV1–203. 31. Scott IA, Guyatt GH. Cautionary tales in the interpretation of clinical studies involving older persons. Arch Intern Med 2010;170:587–95. 32. Stiell I, Nichol G, Wells G, et al. Health-related quality of life is better for cardiac arrest survivors who received citizen cardiopulmonary resuscitation. Circulation 2003;108:1939–44.
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Clinical paper
Out-of-hospital cardiac arrests in the older age groups in Melbourne, Australia夽 C. Deasy a,b,∗ , J.E. Bray a , K. Smith a,b , L.R. Harriss a,b , S.A. Bernard a,b , P. Cameron b , on behalf of the VACAR Steering Committee a b
Ambulance Victoria, Australia Monash University, Department of Epidemiology and Preventive Medicine, Alfred Hospital, Level 3 Burnet Building, 89 Commercial Road, Melbourne 3004, Australia
a r t i c l e
i n f o
Article history: Received 7 September 2010 Received in revised form 2 November 2010 Accepted 15 December 2010
Keywords: Cardiac arrest Out-of-hospital Elderly Octogenarians Nonagenarians Centenarians Outcomes EMS Emergency Medical Services Emergency Resuscitation Cardiopulmonary resuscitation CPR
a b s t r a c t Background: Controversy exists around CPR in the elderly. The characteristics and outcomes of out-ofhospital cardiac arrest (OHCA) in this age group were studied in Melbourne, Australia. Methods: The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for all OHCAs not witnessed by Emergency Medical Services (EMS) occurring in those aged 65 years and older. Results: Between 2000 and 2009 there were 30,006 OHCAs of which 9703 (32%) were in people 65–79 years of age, 6430 (21%) in octogenarians, 1530 (5%) in nonagenarian and 40 (0.1%) in centenarians. Rates of attempted resuscitation decreased with advancing age: 48% for those aged 65–79 years, 39% for octogenarians, 31% for nonagenarians and 17% for centenarians. Similarly rates of survival to hospital discharge decreased with age: 8% for those aged 65–79 years, 4% for octogenarians, 2% for nonagenarians; for 65–79 year olds, octogenarians and nonagenarians survival if in VF/VT was – 17%, 10% and 4%; asystole – 1%, 1% and 0.5%; and PEA – 6%, 3% and 3%, respectively. Multivariable logistic regression shows that between 2000 and 2009 rates of transportation with return of spontaneous circulation have improved for both shockable and non-shockable rhythms [OR 95% CI 1.07(1.04–1.10) and 1.16(1.12–1.20), respectively] but survival to hospital discharge has improved in the shockable rhythm group only [OR 1.12(1.07–1.16)]. Conclusion: Outcomes for OHCA with shockable rhythm have improved over the last 10 years for people aged 65 years and over. Quality of life studies should be performed to help inform the community and EMS on appropriate resuscitative efforts. © 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Many investigators have studied outcomes after cardiac arrest in elders, with varying results.1–12 Some have suggested that resuscitation for elders with cardiac arrest is rarely effective4,13,14 and that cardiopulmonary resuscitation (CPR) in this age group may be a ‘curse’.13 Unfortunately, conclusions from these studies lack control for appropriate predictors, combine in-hospital and out-of-hospital arrests (study populations known to have very different outcomes), have small sample sizes, and use nonstandard definitions of outcome and “elderly.” Most studies are based on data from cardiac arrests occurring in the 1990s. These limitations make meaningful comparisons difficult. Attitudes toward resuscitation in elders have been shown to vary based on the perceived likelihood of a success-
夽 A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.12.016. ∗ Corresponding author at: Monash University, Department of Epidemiology and Preventive Medicine, Alfred Hospital, Level 3 Burnet Building, 89 Commercial Road, Melbourne 3004 Australia. Tel.: +61 41 6486887. E-mail address: [email protected] (C. Deasy). 0300-9572/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2010.12.016
ful outcome.15–19 To assist with the decisions regarding the end of life, it is important for physicians to provide patients and their families with accurate data that reflect the age-related potential of survival.20,21 The patient’s age may also affect paramedic and physician behaviour during resuscitative efforts and provision of immediate post resuscitative care. To allow an objective assessment by clinicians of likelihood of survival and appropriateness of resuscitation following out-of-hospital cardiac arrest (OHCA) in elderly patients, the characteristics and outcomes of OHCA were studied in Melbourne, Australia. 2. Methods The study setting was Melbourne, Australia which has an estimated population of 3.9 million. At last census 331,262 were aged 65–79 years, 110,429 were aged 80–89 years, 19,259 aged 90–99 years, and 573 were aged 100 years or older. Emergency call takers use the advanced Medical Priority Dispatch System©and Ambulance Victoria are the sole provider of ambulance services. Ambulance paramedics who have some advanced life support skills (laryngeal mask airway, intravenous epinephrine) and mobile
C. Deasy et al. / Resuscitation 82 (2011) 398–403
intensive care ambulance (MICA) paramedics who are authorized to perform endotracheal intubation and administer a wider range of cardiac drugs. MICA paramedics are dispatched to patients with critical illness, including patients with cardiac arrest. In addition, a fire-fighter first responder program operates for cardiac arrests in the inner two-thirds of Melbourne’s area.22 The pre-hospital cardiac arrest protocols follow the recommendations of the Australian Resuscitation Council.23,24 Since December 2007, all patients attended by paramedics have patient care data collected in an electronic patient record. Previous years involved a paper patient care record (PCR). Selected data from PCRs is collected from patients in cardiac arrest and stored on the Victorian Ambulance Cardiac Arrest Registry (VACAR). The VACAR also includes some data from the hospital record for those patients transferred to hospital, including outcome. Specific circumstances exist under which Ambulance Victoria paramedics are permitted not to attempt resuscitation or may cease resuscitation.24 Reasons for not resuscitating may include presence of rigor mortis and obvious signs of death; such patients are entered in the VACAR registry also. VACAR was searched for all OHCAs occurring in patients aged 65 years and over between the years 2000–2009, that were unwitnessed by Emergency Medical Services (EMS). 2.1. Ethics approval VACAR has been classified as a quality assurance project by the ethics committee at the Department of Health, Victoria. Ethical approval for outcome data was given by individual treating hospitals. This study was approved by the Research Committee of Ambulance Victoria and Monash University Human Research Ethics Committee. 2.2. Statistical analysis All data were entered into an Access software cardiac arrest registry database (Microsoft, Redmond, WA, USA). Statistical calculations were performed using STATA software (Version 10.0 Stata Corporation, College Station, TX, USA). Chi-square analyses were used for categorical variables. Continuous variables were compared using the t-test (normal distribution) or Mann–Whitney (skewed distribution). Factors effecting paramedic decision to attempt resuscitation, factors associated with return of spontaneous circulation and transport to hospital, and factors associated with patient survival to hospital discharge were examined in a multivariable logistic regression analysis in the presumed cardiac aetiology group. This logistic regression analysis was limited to those aged less than 100 years of age; numbers of patients in the age group greater than 100 years of age were small prohibiting meaningful analysis. An arrest was presumed to be of cardiac aetiology unless it was known or likely to have been caused by trauma, submersion, drug overdose, asphyxia, exsanguination, or any other non-cardiac cause as evident from the case record. Separate analyses were performed for cardiac arrests where the presenting rhythm was shockable (VF/VT) and non-shockable (asystole and PEA). Hospital survival data was unavailable for 1% of 65–79 year olds, 0.5% of octogenarians and 0.5% of nonagenarians; these cases were not included in survival and outcomes analysis. The Odds ratio for age group is given in reference to the 65–79 year old age group and for location of arrest to arrest in the home. 3. Results Between 2000 and 2009 there were 30,006 OHCAs attended by paramedics. Of these, 9703 (32%) were aged 65–79 years, 6430
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(21%) were octogenarians, 1530 (5%) were nonagenarian and 40 (0.1%) were centenarians. Resuscitation was attempted in 48% of 65–79 year olds (10 year range 44–55%), 39% (10 year range 38–42%) of octogenarians, 31.6% (10 year range 23–39%) of nonagenarians and 17% of centenarians. Table 1 describes the Utstein data elements characterizing OHCA for all adults and those in elderly age groups. Asystole was more common as the presenting rhythm for octogenarians, nonagenarians and centenarians than for those aged 65–79 years and shockable rhythm less common. Pulseless electrical activity (PEA) was seen in similar proportions in those aged over 65 years. Fewer cardiac arrests occurred in the home or in public places in octogenarians and nonagenarians compared with those aged 65–79 years while significantly more occurred in nursing homes. However, less cardiac arrests in octogenarians and nonagenarians were witnessed and less received bystander CPR compared with those aged 65–79 years. Where resuscitation was attempted octogenarians achieved a return of spontaneous circulation (ROSC) in 31% of cases and nonagenarians in 20%, compared with ROSC rates of 36% achieved in those aged 65–79 years. Octogenarians and nonagenarians were less likely to be transported to hospital with ROSC compared with those aged 65–79 years (Table 1). Where EMS attempted resuscitation, overall survival to hospital discharge was significantly lower for octogenarians (4%) and nonagenarians (2%) compared with those aged 65–79 years (8%). Of the 40 centenarians attended, 7 (17%) had an attempted resuscitation and only one person survived to hospital discharge. When survival was examined by initial monitored rhythm (Table 1), differences were seen in survival rates for shockable rhythms and PEA. Significantly higher survival rates were seen in those aged 65–79 years with a shockable rhythm (VF/pulseless VT) (17%) compared with octogenarians (10%, p = 0.005) and nonagenarians (4%, p = 0.002). Survival was also greater in the younger age group for PEA (6%) when compared with octogenarians (3%, p = 0.004). The number of bed days for those who survived to hospital discharge was available for 73% of those aged 65–79 years, 76% for octogenarians and 90% for nonagenarians. The median (IQR) length of stay was 16 (10–27) days for those aged 65–79 years, 17 (9–24) days for octogenarians and 9 (7–11) days for nonagenarians. Discharge direction of survivors is shown in Table 2. Most survivors were discharged to the level of care from which they originated with the majority of cases discharged home. One octogenarian and two nonagenarians who sustained the OHCA in a nursing home and were discharged from hospital back to the same nursing home. The paramedic decision to commence resuscitation for OHCAs with cardiac aetiology and a non-shockable rhythm was analyzed; age was divided into five year age groups with the 65–69 year old age group as the reference age and known Utstein elements as predictors (Table 3). The decision to resuscitate was most strongly associated with the arrest being witnessed, the patient having bystander CPR and the arrest occurring in a public place. ‘Transported with return of spontaneous circulation’ was analyzed separately for shockable and non-shockable rhythms, using known Utstein elements as predictors. More recent year of arrest was a positive predictor of transportation with return of spontaneous circulation in both non-shockable and shockable OHCA. Having a witnessed OHCA was the strongest predictor of being transported with ROSC in the non-shockable group (Table 4). Survival to hospital discharge was analyzed separately for shockable and non-shockable rhythms, using known Utstein elements as predictors (Table 5). Survival to hospital discharge was associated with more recent year of arrest, bystander CPR and faster EMS response times for shockable OHCA only.
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C. Deasy et al. / Resuscitation 82 (2011) 398–403
Table 1 Modified Utstein template describing OHCA characteristics among 30,006 people in Melbourne, Australia (2000–2009). Utstein element
All OHCA
65–79 years
Octogenarians
Nonagenarians
Centenarians
Absence of signs of circulation and/or considered for resuscitation Age median (IQR) years Female sex (%) Resuscitation not attempted n (%) First monitored rhythm n (%) Shockable (VF/pulseless VT) Non-shockable Asystole PEA Location of arrest n (%) Home Public place Nursing home Other Arrest not witnessed CPR before EMS arrival n (%) EMS response time Median (IQR) min Aetiology n (%) Presumed cardiac Trauma Overdose Other Where resuscitation attempted n (%) Outcome Any ROSC Survived event Discharged alive Survival based on initial rhythm n (%) VF/pulseless VT Asystole PEA
30,006
9,609 (32%)
6,430 (21.4%)
1,530 (5.1%)
40 (0.1%)
70 (52–80) 34.5 16,943 (56)
73 (69–76) 34 5,016 (52)
84 (81–86) 44 3,888 (60)*
92 (91–94) 59 1,047 (68)*
100 (100–101) 67 33 (82)
4,485 (15)
1,711 (18)
722 (11)*
90 (6)*
2 (5)
*
*
21,984 (73) 3,533 (12)
6,638 (69) 1,260 (13)
4,798 (75) 910 (14)
1,214 (79) 226 (15)
36 (90)* 2 (5)
23,035 (77) 2,372 (8) 2,350 (8) 2,249 (7) 20,514 (68) 7,080 (24)
7,931 (82) 562 (6) 561 (6) 555 (6) 6,241 (65) 2,315 (24)
4,998 (78)* 216 (3)* 1,016 (16)* 200 (3) 4,450 (69)* 1,232 (17)*
1,024 (67)* 34 (2)* 452 (29)* 20 (1) 1,105 (72)* 259 (4)*
27 (67) 0 11 (27) 2 (5) 33 (82) 6 (15)
7 (6–9)
7 (6–9)
7 (6–9)
7 (6–10)
7 (5–10)
22,564 (75) 1,376 (5) 1,926 (6) 4,140 (13)
8,312 (86) 150 (2) 48 (0.5) 1,099 (11)
5,764 (90)* 63 (1)* 19 (0.3)* 564 (9)
1,440 (94)* 6 (0.4)* 6 (0.4) 78 (5)
35 (87) 0 1 (2.5) 4 (10)
4,416 (34) 3,713 (28) 1,105 (8)
1,640 (36) 1357 (29) 389 (8)
797 (31)* 649 (25)* 111 (4)*
98 (20)* 80 (17)* 10 (2)*
3 (42) 2 (29) 1 (14)
830 (19) 78 (1.5) 197 (6)
290 (17) 26 (1.5) 73 (6)
74 (10)* 10 (1) 27 (3)*
3 (4)* 1 (0.5) 6 (3)
1 (100)
Chi-square test comparing octogenarian and nonagenarians to the 65–79 year old age group. * p < 0.05.
4. Discussion Previous studies looking specifically at OHCA in older age groups age groups have been based on data from OHCAs occurring during the 1980s and 1990s however treatments, EMS systems as well as elderly population demographics have evolved since then. We report increasing survival in those aged 65–79 years and octogenarians who experienced shockable rhythm OHCA throughout the last 10 years, while there have been a handful of survivors in the nonagenarians and a single survivor in the centenarian age group. Australia has the fourth highest life expectancy for men and women in the world, behind Japan, France and Italy, but ahead of Sweden, Switzerland, Spain, Canada, Singapore, New Zealand, Norway, the United Kingdom and the US.25,26 Projections based on a series of assumptions that take into account recent trends in fertility, mortality and migration predict that one in four Australians will be 65 years or older by 2056 and that those aged 85 years or over will make up 5–7% of Australia’s population, compared with only 1.6% currently.27 Centenarians are the fastest growing age segment of the Australian population. Their numbers have increased by 8.5% per year over the past 25 years.28
As the number of elderly persons increase, the dilemmas of whom to resuscitate and when increase. The decision can be highly complex, made even more difficult by the lack of reliable outcome data and in particular quality of life outcome data. Ideally, it should be an informed consensual plan made by the patient with the physician in collaboration with family members well in advance of the event. However this is rarely the reality with EMS and emergency department personnel often confronting difficult late-night decisions to initiate or withhold resuscitation. The American Heart Association (AHA) has long maintained that “except in narrowly defined circumstances . . . professional first responders are expected to always attempt BLS [basic life support] and ACLS”.29 The AHA’s most recent ethical guidelines reiterate this imperative: You must start CPR.30 The imperative to “always resuscitate” offers clarity but can have substantial emotional, moral, and financial costs. Currently our outcome measures of success for treatment of the elderly in OHCA are based on ROSC rates and survival, metrics for measuring the quality of death, the dignity offered to the dying elderly patient and the quality of acute bereavement support for their families are lacking. Scott and Guyatt state that because of the greater risk of harm and the lesser potential for benefit in older patients and
Table 2 Discharge direction of OHCA survivors for elderly age groups in Melbourne, Australia (2000–2009). Discharge direction
65–79 years (n = 389) n (%)
Octogenarians (n = 111) n (%)
Nonagenarians (n = 10) n (%)
Normal residence Rehabilitation Nursing home Unknown
268 (72.4) 77 (20.8) 20 (5.4) 24 (5)
71(67) 23 (21.9) 7 (6.7)a 10 (9)
3(30) 3(30) 3(30)a 1 (10)
a
One octogenarian and two nonagenarians had sustained the OHCA in a nursing home.
C. Deasy et al. / Resuscitation 82 (2011) 398–403 Table 3 Odds ratios [OR(95% CI)] for the associations between selected characteristics and paramedic attempted resuscitation for non-shockable OHCA, among 15,084 people in Melbourne, Australia, aged 65–105 years (2000–2009)a . Characteristic Age group, years 65–69 70–74 75–79 80–84 85–89 90–94 95–99 100–105 Year of arrest Female sex Witnessed arrest Bystander CPR given EMS response time Location of arrest Home Nursing home Public place Other
Model 1b OR(95% CI)
Model 2c OR(95% CI)
1.00 0.87(0.76–0.99) 0.80(0.71–0.91) 0.71(0.63–0.81) 0.59(0.52–0.66) 0.57(0.48–0.67) 0.46(0.34–0.63) 0.20(0.07–0.56)
1.00 0.90(0.77–1.05) 0.82(0.70–0.95) 0.77(0.66–0.89) 0.59(0.50–0.70) 0.58(0.47–0.70) 0.44(0.31–0.62) 0.23(0.07–0.72) 0.99(0.98–1.00) 0.88(0.81–0.96) 8.12(7.36–8.96) 4.76(4.25–5.34) 0.98(0.97–0.99) 1.00 0.84(0.74–0.96) 2.51(1.95–3.21) 2.04(1.29–3.25)
a Odds ratios calculated using logistic regression and those aged 65–69 years as reference. b Univariate analysis. c Multivariate analysis adjusted for year in which arrest took place, sex of patient, patient having a witnessed arrest, patient receiving bystander CPR, EMS response time and location of arrest.
the greater variability in treatment effects, the quality of evidence supporting substantial benefit and limited harm ideally should be more stringent in older versus younger populations.31 Nowhere is this more relevant than in the area of out-of-hospital cardiac arrest. Our study shows that although octogenarians were less likely to survive than their 65–79 year old counterparts they had a 10.5% survival rate when the initial rhythm was shockable and a 4% survival overall when resuscitation was attempted. Survival for nonagenarians who were found in a shockable rhythm was significantly less at 4%. There was one centenarian found in ventricular fibrillation who
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represents the one survivor in the centenarian age group having been successfully defibrillated. We report an increasing rate of transportation with ROSC for both shockable and non-shockable rhythm OHCA and an increased survival to hospital discharge for shockable OHCA over the period 2000–2009. This corresponds to changes that have occurred through the decade in the demographics of the older population and their health status, EMS resuscitation provision, CPR guideline changes and introducing compression-focused dispatcher CPR instructions.30,32 An increasing number of OHCAs occur in nursing homes as age increases; 6% of OHCAs in the 65–79 year old age group occurred in a nursing home, while 16% of OHCAs in octogenarians and 29% of nonagenarians OHCAs occurred in a nursing home. In keeping with this is the decrease seen in OHCAs occurring in the home as age increases (Table 1). Given that patients who enter nursing homes usually do so due to increased infirmity and frailty it stands to reason that paramedics are less likely to attempt resuscitation in those over 65 years who sustain their OHCA in a nursing home (Table 3). The extent of the difference in survival between OHCA occurring in the home and those occurring in a nursing home is noteworthy; survival to hospital discharge for non-shockable rhythm cardiac arrests occurring in nursing homes was 74% worse than when the arrest occurred in the home (Table 5). Informing patients, their families and caregivers on issues around end of life and allowing an informed and appropriate decision be made regarding whether they would want an attempted resuscitation is a challenge for nursing homes and the General Practitioners and all Health Professionals that serve them. A community-wide approach to expected natural deaths occurring outside of a hospital when carried out appropriately within a supportive EMS infrastructure, may improve care at the end of life by preserving patient autonomy, diminishing suffering and avoiding unwanted, inappropriate resuscitative efforts. 5. Limitations This study has a number of limitations due to its retrospective nature. Little is reported on quality of life outcomes for this age group of survivors in the literature. VACAR has commenced quality
Table 4 Odds ratios [OR(95% CI)] for the associations between selected characteristics and survival to hospital for non-shockable and shockable OHCA, among 16,565 people in Melbourne, Australia, aged 65–99 years (2000–2009)a . Characteristic
Age group 65–69 70–74 75–79 80–84 85–89 90–94 95–99 Year of arrest Female sex Witnessed arrest Bystander CPR EMS response time Arrest location Home Nursing home Public place Other a
Non-shockable
Shockable
Modelb OR(95% CI)
Model 2c OR(95% CI)
Model 1b OR(95% CI)
Model 2c OR(95% CI)
1.00 0.87(0.69–1.09) 0.84(0.68–1.05) 0.78(0.62–0.97) 0.61(0.48–0.79) 0.42(0.30–0.60) 0.20(0.08–0.50)
1.00 0.93(0.73–1.19) 0.88(0.69–1.11) 0.86(0.67–1.09) 0.65(0.49–0.85) 0.45(0.31–0.65) 0.21(0.08–0.52) 1.07(1.04–1.10) 1.06(0.91–1.22) 7.43(6.36–8.68) 1.71(1.45–2.00) 0.98(0.96–0.99)
1.00 1.17(0.92–1.49) 1.24(0.98–1.58) 0.92(0.71–1.19) 0.85(0.62–1.18) 0.75(0.45–1.25) 0.12(0.01–0.93)
1.00 1.25(0.97–1.61) 1.29(1.00–1.65) 0.87(0.66–1.15) 0.82(0.59–1.15) 0.72(0.42–1.24) 0.11(0.01–0.87) 1.16(1.12–1.20) 1.38(1.12–1.70) 1.65(1.36–2.01) 1.25(1.05–1.48) 0.94(0.91–0.96)
1.00 0.62(0.49–0.79) 1.23(0.94–1.61) 0.87(0.50–1.51)
1.00 0.79(0.55–1.16) 1.19(0.98–1.44) 1.57(1.02–2.43)
Odds ratios calculated using logistic regression and those aged 65–69 years as reference. Univariate analysis. c Multivariate analysis adjusted for year in which arrest took place, sex of patient, patient having a witnessed arrest, patient receiving bystander CPR, EMS response time and location of arrest. b
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Table 5 Odds ratios [OR(95% CI)] for the associations between selected characteristics and survival to hospital discharge for non-shockable and shockable OHCA, among 16,565 people in Melbourne, Australia, aged 65–99 years (2000–2009)a . Characteristic
Age group 65–69 70–74 75–79 80–84 85–89 90–94 95–99 Year of arrest Female Witnessed arrest Bystander CPR EMS response time Arrest location Home Nursing home Public place Other
Non-shockable
Shockable
Model 1b OR(95% CI)
Model 2c OR(95% CI)
Model 1b OR(95% CI)
Model 2c OR(95% CI)
1.00 0.88(0.56–1.40) 0.57(0.35–0.93) 0.51(0.31–0.83) 0.34(0.19–0.64) 0.31(0.14–0.70) 0.38(0.09–1.58)
1.00 0.95(0.59–1.52) 0.64(0.39–1.05) 0.61(0.37–1.02) 0.45(0.24–0.84) 0.43(0.18–0.98) 0.54(0.13–2.30) 1.03(0.97–1.09) 1.08(0.78–1.50) 7.04(4.91–10.09) 1.15(0.80–1.66) 0.97(0.93–1.01)
1.00 0.81(0.61–1.08) 0.65(0.48–0.87) 0.43(0.30–0.61) 0.39(0.25–0.62) 0.18(0.06–0.51)
1.00 0.85(0.63–1.15) 0.67(0.49–0.91) 0.41(0.29–0.59) 0.39(0.24–0.62) 0.19(0.06–0.55)
1.00 0.26(0.11–0.60) 2.07(1.30–3.32) 2.22(0.99–5.01)
1.12(1.07–1.16) 1.21(0.93–1.59) 1.46(1.10–1.92) 1.32(1.04–1.66) 0.91(0.87–0.94) 1.00 0.88(0.49–1.58) 2.04(1.61–2.59) 2.23(1.37–3.63)
a
Odds ratios calculated using logistic regression and those aged 65–69 years as reference. Univariate analysis. c Multivariate analysis adjusted for year in which arrest took place, sex of patient, patient having a witnessed arrest, patient receiving bystander CPR, EMS response time and location of arrest. b
of life follow up of all OHCA survivors but this data was not available for the time periods described in this study. The inability to adjust for co morbidity in the elderly may lead to overestimation of the association of increased age itself and survival from OHCA. We acknowledge that attitudes toward resuscitation in elders have been shown to vary based on the perceived likelihood of a successful outcome15–19 which may bias the results of this study in favor of the younger OHCA patient. Nonetheless, this study provides a benchmark for assessing OHCA in the elderly. It was not possible to cross check the ‘presumed cardiac’ OHCAs with autopsy reports; autopsies were less commonly performed in this age group. It is possible that the ‘presumed cardiac’ group of patients may include conditions such as intracerebral bleeds, drug overdose, and massive pulmonary embolism not discernable clinically. In certain circumstances, particularly in the elderly, our paramedics were called to attend because of carer’s inability to cope and their need for assistance with a patient expected to die and where resuscitation was inappropriate. Natural expected deaths attended by our paramedics are entered in the OHCA registry. There are times when resuscitation will have commenced before the patients history emerges resulting in the cessation of the attempted resuscitation; such ‘resuscitations’ may dilute survival outcomes by increasing the denominator. 6. Conclusions Outcomes for shockable rhythm OHCA in 65–89 year olds have improved through the decade. Although survival decreased with age, there was a significant group of survivors in the very old age groups. Quality of life for survivors was not assessed in this study but this information is necessary to inform the community on appropriate strategies for reducing exposure of patients and EMS teams to futile resuscitation attempts. Conflict of interest statement There are no conflicts of interest to declare.
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