Outcomes of Elderly Survivors of Intensive Care

critical care review Outcomes of Elderly Survivors of Intensive Care* A Review of the Literature Deirdre Hennessy, MSc; Kelsey Juzwishin, MSc; Dean Yergens, BSc; Thomas Noseworthy, MD, MPH; and Christopher Doig, MD, MSc

An increasing proportion of critically ill patients are elderly (ie, > 65 years of age). This poses complex challenges and choices for the management of elderly patients. Outcome following admission to the ICU has been traditionally concerned with mortality. Beyond mortality, outcomes such as functional status and health-related quality of life (HRQOL) have assumed greater importance. This article reviews the literature, published in English from 1990 to December 2003, pertaining to HRQOL and functional status outcomes of elderly patients. Functional status and HRQOL of elderly survivors of ICUs has been underinvestigated. There is no agreement as to the optimal instrument choice, and differences between studies preclude meaningful comparison or pooling of results. (CHEST 2005; 127:1764 –1774) Key words: aged; critical care; health status; quality of life; review Abbreviations: ADL ⫽ activities of daily living; APACHE ⫽ acute physiology and chronic health evaluation; HRQOL ⫽ health-related quality of life; LOS ⫽ length of stay; PQOL ⫽ perceived quality of life; QOL ⫽ quality of life; SAPS ⫽ simplified acute physiology score; SF-36 ⫽ Medical Outcomes Study 36-item short form

patients make up between 26% and 51% E lderly of patients who are admitted to ICUs. The 1

proportion of individuals in North America aged ⱖ 65 years is projected to increase to ⬎ 20% of the population by 2026. As population demographics change, and as new technologies, pharmaceuticals, and interventions prolong lives, the proportion of elderly patients admitted to ICUs and surviving ICU stays will continue to increase. Studies that have examined only ICU or hospital survival as an outcome have had variable results, with some studies2,3 *From the Departments of Critical Care Medicine (Ms. Hennessy and Dr. Doig) and Community Health Sciences (Ms. Juzwishin and Dr. Noseworthy), and the Centre for Health and Policy Studies (Mr. Yergens), Faculty of Medicine, University of Calgary, Calgary, AB, Canada. Manuscript received July 8, 2004; revision accepted November 18, 2004. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Christopher Doig, MD, MSc, Department of Critical Care Medicine, Faculty of Medicine, University of Calgary, Room EG23G, Foothills Medical Centre, 1403 TwentyNinth St NW, Calgary, AB, Canada T2N 2T9; e-mail: cdoig@ ucalgary.ca 1764

demonstrating that elderly ICU patients experience higher mortality rates, and others1,4 – 6 concluding that age, in and of itself, is not an important predictor of outcome from ICU. Beyond mortality, health-related quality of life (HRQOL) is a fundamentally important end point of medical care. Data available on long-term outcomes such as HRQOL and functional status inform patient management, resource allocation, and policy formulation.7 Quality of life (QOL) is a multidimensional concept that covers all aspects of a person’s life that is considered to be important. HRQOL is focused on those aspects of life that directly relate to health. These include physical functioning, ability to perform daily activities, mental health, social functioning, pain, fatigue and energy, sleep, and sexual functioning. These aspects of health are influenced by many factors and are not age-dependent, albeit, the relative importance of each domain may differ by age. For instance, physical functioning in terms of playing soccer or running 1 km may not be as relevant for an elderly person, whereas social interCritical Care Review

action with friends and family may be more important.8 Functional status, defined as everyday behaviors necessary to maintain daily life (eg, activities of daily living [ADL]),9 is an extremely important contributor to HRQOL, yet should not be confused with it. The two are measured differently, with distinct tools. In one review, Black et al10 illustrated the complex relationships among physiologic impairment, functional status, and HRQOL, commenting on the discordance between decreased functional status and reported reductions in HRQOL. This may be due to a change in the individual’s expectations or perceptions, as a result of changing internal standards, and their conceptualization of QOL. Moreover, this may serve as an adaptive mechanism to critical illness.11 Indeed, Winter et al12 have demonstrated in a sample of elderly participants that unhealthy or frail elders expressed preferences for longer life under compromised health conditions more frequently than did healthy respondents, implying that our preferences for prolonging our lives alter in relation to changing health status. Other authors13 have also commented on the importance of patient’s values and perceptions in evaluating reports of HRQOL. This study reviews outcomes in terms of HRQOL and the functional status of elderly patients following discharge from critical care. We evaluated the instruments employed, the methodological rigor of the studies, and their relevance to the population in question. In addition, we provide a narrative review of the important results of each study. Materials and Methods Study Selection We conducted a comprehensive search of the MEDLINE, EMBase, and CINAHL databases for the years 1990 to December 2003. The search terms “critical care,” “critical illness,” and “health-related quality of life” were used. We initially selected all articles that were relevant to HRQOL and functional status outcomes from an adult ICU, and then narrowed the search to the outcomes of elderly patients (ie, those who were ⬎ 65 years of age). The search was limited to evaluative studies (not reviews or comments) written in English. Two authors independently reviewed the abstracts and titles found in the primary search and determined whether to obtain the full article for further scrutiny.14 Selected articles were then examined and were included if they conformed to the following criteria: enrolled elderly patients or included a cohort of elderly patients; had been admitted to the ICU (including the cardiac ICU); and studies that reported on the HRQOL and/or functional status outcomes of patients. Studies that reported on neonatal or pediatric patients were excluded, as were review articles or comments about methodological issues. Posttransplant patients were excluded because most are ⱕ 70 years of age and are therefore not representative of an elderly ICU population. Cancer patients were also excluded because of the independent www.chestjournal.org

impact of their disease on post-ICU survival and HRQOL. Disputes on the inclusion of an article were jointly reviewed and were resolved by consensus. In addition, a manual search of the reference lists of the retrieved articles and pertinent review articles was conducted, as well as a computerized search of the Science Citation Index of relevant articles. Data abstracted from the articles included information on study design, instruments used to measure HRQOL (or functional status), and the methodology of the HRQOL or functional status assessment. Methodological Assessment To assess the methodological quality of the selected articles, the reviewers developed an evaluation scheme. Two reviewers (D.H. and C.D.) independently assessed the articles using an evaluation form and then discussed the assessment of each article. Disagreements were resolved by consensus. The main aspects of the studies abstracted were as follows: sampling framework; study design; HRQOL and functional status instruments; and principal findings. Specifically, we evaluated articles based on the statement of aims, the definition of the term elderly, the instrument used for HRQOL and/or functional status assessment, a description of the exclusion/inclusion criteria, sampling, assessment of baseline HRQOL and/or functional status, follow-up period, and methods. We adopted the following criteria to assess the validity of the HRQOL and functional status instruments that were used. Was there a rationale for instrument selection? According to Staquet et al15 the justification for the selection of a particular instrument should be given, and new or unknown instruments should be described in detail. Were the psychometric properties of the instrument discussed? Was the instrument valid, reliable, and responsive? We looked for these properties to be demonstrated or cited in the article. Were all relevant domains of HRQOL and/or functional status covered? Did the instrument cover all aspects of HRQOL or functional status, or was measurement limited to physical functioning, for instance? Was the survey completed by the patient or by a proxy? In addition, the principal findings of the studies were assessed and summarized.

Results Two hundred fifteen articles were identified in the comprehensive search of the MEDLINE, Embase, and CINAHL databases. Through independent review, 72 of those articles were deemed as being potentially relevant. Further scrutiny revealed that only 16 studies specifically addressed functional status or HRQOL outcomes in elderly critical care survivors. These 16 studies are summarized in Tables 1 and 2. Characteristics of Studies Nine studies were conducted in North America,1,4,5,16 –21 six studies were conducted in Europe,3,22–26 and one study was conducted in New Zealand.27 In total, 3,247 patients were enrolled in these studies. Aims and objectives were outlined in all articles. Ten of 16 studies1,3–5,16 –18,21,25,27 specifically enrolled only elderly patients. Among these studies, the definition of the term elderly varied, CHEST / 127 / 5 / MAY, 2005

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Table 1—Summary of Patient Characteristics and Primary Findings*

Study/Year

n/N1/N2

Age, yr†

Ridley and Wallace22/1990

156/256/385

NA

Mahul et al3/ 1991

148/216/295

Chelluri et al17/ 1992 Kass et al5/1992

ICU Acuity†

ICU LOS†

Male Gender,† %

Post-ICU Discharge Mortality Rate, %

NA

33

Critical Care Review

NA

NA

76 (5)

15 (5)‡

15 (25)

50

53§

10/21/34

88 (3)

18 (5)

4 (2)

52

41

38/67/105

89 (4)

Men: 1 (1)¶ Women: 1 (1)¶

5 (6)

41

64§

Vazquez Mata et al23/1992

606/779储

NA

15 (0)

NA

Chelluri et al4/ 1993

32/97/116

65–74: 69 (0) ⱖ 75: 81 (1)

18 (1) 20 (1)

5 (1) 7 (2)

44 52

58§ 63§

Rockwood et al1/ 1993 Broslawski et al16/1995

432/757/884 27/45/68

⬍ 65: NA ⱖ 65: NA 77 (8)

17 (9) 21 (9) 19 (8)

4 (6) 4 (6) 7 (8)

63 64 53

31§ 49§ 40

Konopad et al19/ 1995

504/606储

55 (20)

17 (8)

4 (7)

54

25

McHugh et al27/ 1997

31/80/97

5.7 (0)# 6.0 (1)#

34 h (7 h) 42 h (5 h)

4943

18

Roche et al20/ 1999

216/222/2,164

75–79: 76 (1) ⱖ 80: 82 (0) 62 (1)

13 (0)

NA

96

15

Niskanen et al24/ 1999

368/470/718

12 (7)

14 (12)

66

3

56 (15)

NA

39

Primary Finding Patients with good premorbid HRQL experienced a significant decrease in HRQOL post-ICU discharge; younger patients and trauma patients demonstrated a significant decrease in HRQOL post-ICU discharge; elderly patients maintain a similar level of HRQOL pre-ICU admission and post-ICU discharge Age, previous health status, and SAPS predicted 1-year mortality rate for ICU survivors; 103 patients were alive at 1 year, 72% had a relatively good functional status allowing an independent life, and 82% had the same or improved functional status 8 of 10 survivors described their HRQOL as fair or good, 18 ⫾ 10 mo after ICU discharge; 69% would agree to a readmission to ICU Pre-ICU admission and post-ICU discharge functional status were not significantly different in those patients who survived to 1 year post-ICU discharge; severity of illness was the most significant predictor of mortality post-ICU admission, while pre-ICI admission functional status was not Mean HRQOL of all survivors was worse 12 mo after ICU discharge; elderly (⬎ 75 yr) survivors experienced the greatest decrease in mean HRQOL 12 mo after ICU discharge Functional status was similar between two elderly groups of patients at 1, 6, and 12 mo post-ICU discharge; PQOL was not significantly different between the two groups at follow-up, although PQOL increased slightly in the two groups over time ADL were similar in elderly and younger patients 1 year after ICU discharge; elderly patients were more positive in regard to health than younger ICU survivors Functional status at 6 mo post-ICU discharge was improved or unchanged in 77% of survivors; functional status at 6 mo was unrelated to age and severity of illness, but was correlated with ICU LOS A significant decrease occurred in the level of activity and ADL at 1 year post-ICU discharge in elderly patients (ie, ⬎ 65 yr); perceived HRQOL increased for the age group ⱖ 75 yr of age after ICU discharge; there was no change in family support or outlook of patients after ICU discharge Patients in both the old and very old groups have satisfactory HRQOL post-ICU discharge, with some associated increased reliance on family and friends; 92% of patients would be willing to undergo the cardiac surgery again Baseline function was worse for elderly patients (ie, ⱖ 65 yr); however, there was no difference in recovery at 6 wk post-ICU discharge; 52% of the entire cohort recovered to baseline function by 6 weeks; baseline function was a determinant of both 6-wk and 6-mo recovery HRQOL of patients with prolonged ICU LOS is generally good but not at the level of the general Finnish population; recovery of the psychosocial aspects of life was quicker than with other aspects; patients in the age group {mtequ] 65 yr had an HRQOL that was similar to the general population in the pain and psychosocial dimensions

*Values given as mean (SD), unless otherwise indicated. NA ⫽ demographic not available; n ⫽ No. of patients who completed the HRQOL or functional status assessment; N1 ⫽ No. of patients discharged alive from the ICU or eligible for the study; N2 ⫽ No. of patients of interest who were admitted to the ICU during the study period; SAPS ⫽ simplified acute physiology score. †The demographics quoted in the majority of studies were those of the entire cohort. In some cases, the demographics quoted were those of the enrolled population.17,18,19,21,23 ‡Determined by SAPS. §The 1-year mortality rate. ¶Determined by organ system failure score. 储Only N1 and N2 values available. #Determined by clinical severity score.

NA 43.4 4 (6) 74 (11) 164/318/797

NA

34 NA 3 (7) 342/591/672

Udekwu et al21/ 2001 Kleinpell and Ferrans18/2002

8 (7) 77 (6)

143/263/370 Eddleston et al26/ 2000

49 (12)

19 (6)

4

52

NA

Reasonable hospital survival rate (53%) in elderly patients receiving prolonged mechanical ventilation; patients experienced moderate disabilities at follow-up that somewhat influenced their perceived HRQOL At 3 mo post-ICU discharge, 80% of patients were satisfied with their HRQOL; older men (ie, ⬎ 65 yr) demonstrated significantly better health in some domains of the SF-36 than younger men; younger women demonstrated significantly better health in some domains of the SF-36 than older women (ie, ⬎ 65 yr) Functional levels after ICU discharge were low for this elderly group of patients; the majority of patients reported a high perceived HRQOL after ICU discharge Sample had relatively good HRQOL 4–6 mo after ICU discharge; factors that predicted perceived HRQOL were social support, perceived future health, days of hospitalization, and hospital readmission since ICU discharge 60 58 76 (5) 30/50/75 Montuclard et al25/2000

46 (14)‡

53 (24)

Table 1—Continued

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with four studies enrolling patients ⱖ 65 years of age, three studies enrolling patients ⱖ 70 years of age, one study enrolling patients ⱖ 75 years of age, and two studies enrolling patients ⱖ 85 years of age. Combined, these studies enrolled 822 patients with a mean (⫾SD) age ranging from 69 ⫾ 0.30 years4 to 89.4 ⫾ 3.5 years.5 The remaining six studies enrolled patients with a mean age ranging from 49 ⫾ 11.57 years26 to 62 ⫾ 0.74 years.20 These studies did not always provide the enrollment stratified by age; therefore, it was not possible to estimate the total number of elderly patients (ie, those ⱖ 65 years of age) who had been included. The definition of the term elderly was also variable in these latter studies, with four studies defining patients ⱖ 65 years of age as elderly, while the remaining two studies defined elderly as ⱖ 60 years of age and ⱖ 75 years of age, respectively. The sex distribution of the study sample was provided in 12 articles. Men comprised between 41%5 and 96%20 of the patients (the study including 96% men was performed at a Veterans Affairs hospital20). Thirteen studies indicated a mean (⫾SD) ICU length of stay (LOS) ranging from 3.25 ⫾ 6.47 days21 to 52.5 ⫾ 23.8 days.25 Montuclard et al25 specifically studied patients with a long LOS (ie, ⬎30 days), resulting in a mean LOS of 52.5 days. A variety of measures were used to determine acuity of illness on admission to the ICU. APACHE (acute physiology and chronic health evaluation) II score was reported in 12 studies,1,4,16 –21,23–26 and the mean APACHE II score ranged from 7.77 ⫾ 6.6321 to 21 ⫾ 9.1 Of the remaining studies, two3,25 used the simplified acute physiology score, one5 used an organ dysfunction score, and one27 used the clinical severity score. All studies, except two, reported a post-ICU mortality rate that ranged from 3%24 to 64%.5 In general, all studies were conducted at a single center in multidisciplinary or medical/surgical ICUs. Mahul et al3 and Rockwood et al1 conducted the only multicenter studies detailed here. Exclusion and inclusion criteria were discussed with a variable degree of detail in all studies. Most studies focused on surviving patients; however, some studies outlined specific exclusion criteria based on the research question. Nine of 16 studies were prospective1,3 in nature, three were cross-sectional, two were retrospective,15,25 one was a mixed prospective/retrospective design,5 and in one, the study design could not be determined. The vast majority of studies (14 of 16 studies) used a consecutive sampling method. However, Broslawski et al16 used a random sample, and Roche et al20 used a convenience sample recruiting patients who had been admitted from Monday to CHEST / 127 / 5 / MAY, 2005

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Table 2—Summary of Study Design and HRQOL/Functional Status Instruments Used* Study/Year

Validity of Instruments Cited or Discussed

Baseline Assessment and Follow-up

Katz ADL, PQOL, RDC

ADL, not cited; PQOL, yes; RDC, not formally validated

Multicenter, prospective longitudinal

Homemade questionnaire

No

Single-center, retrospective, cross-sectional

Homemade questionnaire

No

Baseline, retrospective at time of follow-up; followup, 1–3 years post-ICU discharge Baseline, obtained from patients or a proxy shortly after ICU admission; Follow-up. 1, 6, and 12 mo after ICU discharge Baseline, not assessed; follow-up: 18 ⫾}10 mo after ICU discharge

Single-center cohort study (retrospective and prospective)

ADL

ADL, not cited

Patient Type/Setting

Study Design

Measure Used

Ridley and Wallace 199022

All patients/ multidisciplinary ICU

Single-center, retrospective, cross-sectional

Mahul et al3/1991

Patients ⱖ 70 yr/3 university hospitals and 1 community hospital ICU

Chelluri et al17/1992

Patients ⱖ 85 yr/medical/surgical ICU in a tertiary hospital Patients ⱖ 85 yr/community. teaching hospital ICU

Kass et al5/1992

Vazquez Mata et al23/1992

All patients/medicalsurgical ICU of a reference hospital Patients ⱖ 65 yr/ICU in a tertiary hospital

Single-center, prospective, longitudinal

Fernandez questionnaire

Fernandez, yes (cited)

Single-center, prospective, longitudinal

ADL, PQOL, CES-D

ADL, not cited; PQOL, not cited

Rockwood et al1/ 1993

All patients/2 multidisciplinary ICUs

Multicenter, prospective convenience sample

ADL, health attitudes

ADL, not cited; health attitudes, not cited

Broslawski et al16/ 1995

Patients ⱖ 65 yr/ICU

Single-center, prospective random sample

ADL, IADL, MMS

ADL, IADL, and MMS: not cited

Chelluri et al4/1993

Critical Care Review

Baseline, ADL obtained for patients admitted to ICU from a skilled nursing facility (100%) or from home (66%); follow-up, 1 year post-hospital discharge or until death Baseline, assessed; followup, 12 mo post-ICU discharge Baseline, functional status (not PQOL or CES-D) assessed at baseline; follow-up, for ADL, PQOL, and CES-D at 1, 6, and 12 mo post-ICU discharge Baseline, functional status and health attitudes not assessed; follow-up, functional status and health attitudes assessed 1 year post-ICU discharge Baseline, functional and mental status assessed; follow up, functional and mental status assessed 6 mo post-ICU discharge

Method of Administration Mailed/self-administered

Mailed, self-administered/ telephone interview

Telephone interview

Nursing home records/staff or interview with the patient or the primary informal caregiver

Interview

Interview

Telephone interview

Telephone interview

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Table 2—Continued Konopad et al19/1995

All patients/medicalsurgical ICU

Single-center, prospective

Spitzer ADL

McHugh et al27/1997

Cardiac surgery patients ⱖ 75 yr/ICU

Single-center, retrospective, cross-sectional

PQOL

Roche et al20/1999

A sample of patients/ ICUs in a Veterans Affairs hospital

Single-center prospective convenience sample

Zubrod scale

Zubrod scale validated for cancer patients but not ICU patients

Niskanen et al24/ 1999

All patients/ multidisciplinary ICU in a tertiary hospital Patients ⱖ 70 yr/ medical-surgical ICU in a tertiary, university hospital

Single-center inception cohort study

ADL, NHP

ADL, not cited; NHP, yes (cited)

Single-center prospective cohort study

Katz ADL, PQOL, NHP

Eddleston et al26/ 2000

All patients/ university hospital ICU

Single-center prospective

HADS, SF-36

ADL, not for French population; PQOL, validated for use in ICU, but not validated for elderly population; NHP, yes (cited) HADS, yes (cited); SF-36, yes (cited)

Udekwu et al21/2001

Patients ⱖ 70 yr/surgical ICU

Single-center, retrospective, cross-sectional

ADL, PQOL

ADL, not cited; PQOL, not cited

Kleinpell and Ferrans18/2002

Patients ⱖ 45 yr/ medical or surgical ICU in a community hospital

Single-center, retrospective, cross-sectional

QLI, SIP

QLI, yes (cited); SIP, yes (cited)

Montuclard et al25/ 2000

Spitzer ADL, not validated for use in ICU patients PQOL, yes

CHEST / 127 / 5 / MAY, 2005

Baseline, assessed; followup, 6 and 12 mo postICU discharge Baseline, assessed; followup, 34.8 ⫾ 2.0 mo postoperatively Baseline, functional status assessed; follow-up, functional status assessed 6 wk and 6 mo post-ICU discharge Baseline, not assessed; follow-up, QOL and ADL 6 mo after ICU discharge Baseline, retrospectively for ADL and PQOL (not NHP); follow-up 1, 557 ⫾ 117 d; follow-up 2, 2 yr after the follow-up 1

Personal interview/telephone interview Mailed/self-administered

Baseline, QOL not assessed; follow-up, 3 mo after ICU discharge QOL and ICU-related psychological morbidity assessed Baseline, assessed for ADL but not PQOL; follow-up, at a median of 21 mo after ICU discharge Baseline, not assessed; follow-up, 4–6 mo after ICU discharge

Personal interview

Personal interview/telephone interview

Mailed/self-administered

Telephone interview

Interview

Mail/self-administered

*CES-D ⫽ Center for Epidemiological Studies depression scale; HADS ⫽ hospital anxiety and depression scale; RDC ⫽ Rosser disability categories; NHP ⫽ Nottingham health profile; SIP ⫽ sickness impact profile; IADL ⫽ instrumental ADL; QLI ⫽ Quality of Life Index ; MMS ⫽ mini-mental state.

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Friday. The length of time during which patients were screened and recruited varied widely between studies. Chelluri et al4 recruited patients for just 3 months, while Montuclard et al25 enrolled patients over a 66-month period. Ten studies3–5,16,19 –23,25 attempted to estimate the baseline health status that existed prior to the patients’ ICU admission. Of these, seven studies completed a baseline assessment at ICU admission or as soon after ICU admission as possible. Ridley and Wallace,22 Udekwu et al,21 and Montuclard et al25 assessed baseline retrospectively. Baseline assessment included functional status measures in seven studies and HRQOL measures in four studies. Patients were followed up after ICU discharge in all studies. The follow-up time varied from 1 month18 to 36 months.24 A variety of methods were used to obtain functional status and HRQOL information at follow-up. Seven studies4,5,17,18,19,23,24 used personal interview, six studies1,14,15,17,18,23 used telephone interview, five studies3,16,20,22,25 used mailed/self-administered surveys, one study5 used nursing home records, and one study5 used staff interviews. Four studies3,5,17,18 used two methods of follow-up. The use of proxy respondents was reported in 10 studies.1,3,5,14,15,17,18,19,21,23 Sixteen functional status and HRQOL instruments were used in the 16 studies reviewed. Only 6 of 16 studies17,18,23–26 provided an adequate rationale for selecting the instrument used in the study. The most commonly used instrument to assess functional status was the index of the ADL instrument, which was used in nine studies.1,4,5,14,17,19,20,22,23 The index of ADL was developed to measure the physical functioning of elderly and chronically ill patients. It assesses independence in the following six activities: bathing; dressing; toileting; transferring from bed to chair; continence; and feeding. The ADL instrument was most often used with another instrument, except in the study by Kass et al,5 who used ADL alone to follow-up patients who were ⱖ 85 years of age up to a year after their discharge from the ICU. The most common HRQOL assessment was completed using the perceived QOL (PQOL) instrument, which was used in five studies.4,19,20,23,25 The PQOL is a measure of the patients’ subjective perception of HRQOL. It has 11 component questions that require a response from 0 to 100, with higher score denoting greater satisfaction. All other instruments were used only once, with the exception of the Nottingham Health Profile, which was used twice.22,23 In addition, two studies5,15 utilized informal questionnaires that elicited information about condition (ie, dead or alive), residence, functional status, QOL, willingness to undergo critical care again, and impression of the ICU. Seven stud1770

ies1,3,4,5,14,15,24 did not comment on the psychometric properties (ie, validity, responsiveness, and reliability) of the instruments used. Of those studies that discussed the validity of the instruments, three studies3,20,22 described one or more instruments were used as not validated for a critically ill or elderly population. These were usually the qualitative descriptors of functional status and ADL, such as the Rosser Disability Categories, the Spitzer ADL, the Zubrod scale, and the ADL index score. Of the nine studies that discussed validity, seven discussed responsiveness and/or reliability to some degree. Overall, there was no uniform approach to selecting instruments for measuring HRQOL and functional status. Moreover, the psychometric properties of the instruments selected were not adequately discussed. Indeed, few instruments chosen were valid, responsive, and reliable. None of the studies reviewed reported age-standardized HRQOL or functional status scores. Principal Findings of Studies The principal findings of the studies will be grouped by findings of improved or unchanged HRQOL/functional status and worsened HRQOL/ functional status post-ICU. Studies Showing Improved or Unchanged HRQOL and/or Functional Status Ridley and Wallace22 assessed HRQOL before and after ICU admission with a variety of instruments. This study demonstrated a significant decrease in the HRQOL of younger patients post-ICU discharge, while elderly patients maintained a similar HRQOL pre-ICU admission and post-ICU discharge. This study had significant limitations, including the retrospective assessment of baseline status and the use of a nonvalidated questionnaire. Mahul et al,3 suggested that the majority of elderly survivors reported an unchanged or improved functional status post-ICU discharge. The scope of this questionnaire was limited, and its psychometric properties were not discussed. Although it claimed to be a QOL questionnaire, no questions regarding subjective HRQOL were asked. In a cohort of patients ⱖ 85 years of age, Chelluri et al17 found that the majority of patients reported their HRQOL as fair to good after ICU discharge and that 69% of survivors would agree to undergo intensive therapy again if it were needed. This was a retrospective study, and it enrolled a very small number of patients (only 10 were available for follow-up). Kass et al,5 demonstrated that functional status pre-ICU admission and post-ICU discharge Critical Care Review

was not significantly different in those patients who survived to 1 year after ICU discharge. In comparing two groups of elderly patients, Chelluri et al4 also found that functional status and HRQOL, measured before hospital admission and after hospital discharge, did not differ significantly. Specifically, functional ability in the younger age group (ie, 65 to 74 years of age) showed a significant reduction at 1 month but returned to prehospitalization status at 6 months. The older age group did not show a significant change in functional status during the follow-up period, and HRQOL was similar between the two groups at three time points after ICU discharge (1 month, 6 months, and 12 months). Rockwood et al1 also compared functional status between a young age group and an old age group. This study revealed that there was no difference in ADL between young and old survivors of the ICU. In addition, these investigators elicited the patients’ attitudes about their own health status, beliefs, and attitudes toward the ICU. They found that the elderly demonstrated more positive health attitudes than younger patients. In a study of 45 elderly patients, Broslawski et al16 demonstrated that functional status was improved or unchanged at 6 months after ICU discharge, and that functional status post-ICU discharge was unrelated to age and severity of illness but correlated with length of ICU stay. Konopad et al,19 reported that perceived HRQOL increased in the group of patients who were ⬎ 75 years of age, after ICU discharge. While the instrument chosen was simple, short, and easy to understand, it was not validated for critically ill patients, and there is no evidence for its reliability. When McHugh et al27 compared two elderly groups, they showed that both groups had satisfactory HRQOL post-ICU discharge, and that 92% of patients would undergo surgery and an ICU stay again, if needed. Roche and coworkers20 compared the recovery of functional status in younger and older survivors using the Zubrod scale. Although baseline function was worse in elderly ICU survivors, there was no difference in recovery to baseline function at 6 weeks. Baseline function was a determinant of 6-week and 6-month recovery. Niskanen et al,24 in the only population-based study detailed here, also reported on ADL at 6 months after ICU discharge. Specifically, 85% of respondents performed their basic ADL independently at this time point. In addition, Niskanen et al24 demonstrated that the HRQOL of patients with prolonged ICU stays is generally good. However, when their HRQOL was compared to that of the Finnish general population, it was revealed the ICU survivors had a significantly lower HRQOL. The recovery of the psychosocial aspects of life was quicker than the recovery of all of the other domains assessed. In www.chestjournal.org

addition, patients in the group of patients who were ⱖ 65 years of age experienced HRQOL that was similar to the general population in the pain and psychosocial dimensions. Eddleston et al26 demonstrated that at 3 months post-ICU discharge, 80% patients were satisfied with their HRQOL. Older men (ie, those ⬎ 65 years of age) demonstrated significantly better health in some domains of the Medical Outcomes Study 36-item short form (SF-36) than did younger men. Younger women demonstrated significantly better health in some domains of the SF-36 than did older women. These authors used the SF-36 and the hospital anxiety and depression scale, both of which have been previously used in a critical care setting. Kleinpell and Ferrans18 reported that their patient sample had relatively good HRQOL at 4 to 6 months after ICU discharge. Factors that predicted perceived HRQOL were social support, perceived future health, days of hospitalization, and hospital readmission since ICU discharge. Studies Showing Worsened HRQOL and/or Functional Status In contrast to the studies quoted above, Montuclard et al25 saw a significant reduction in the ability of patients to perform ADL in all domains except feeding. This assessment was performed a mean (⫾ SD) time of 557 ⫾ 117 days after ICU discharge. This difference may be due to the fact that the mean age of the cohort in the study by Montuclard et al25 was ⱖ 70 years and the follow-up period took place over a longer period of time. In addition, Montuclard et al25 showed that, although patients experienced moderate disabilities at follow-up, HRQOL was only somewhat influenced. Udekwu et al21 also demonstrated a significant reduction in ADL post-ICU discharge. This study, like that of Montuclard et al,25 included patients who were ⱖ 70 years old and showed that the majority of patients, while they experienced substantial functional limitations after ICU discharge, reported a high self-perceived health status. Notably, in the largest study reviewed here, Vazquez Mata et al,23 using the Fernandez QOL questionnaire, found that the elderly cohort of their patient sample had the greatest reduction in HRQOL post-ICU discharge compared to baseline. Their questionnaire covered oral communications, sphincter control, fine motor control, physical exercise, mobility and dependence, medications, and work or other activities, and had been previously used and validated by the same group. CHEST / 127 / 5 / MAY, 2005

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Discussion Using a priori defined selection criteria, 16 studies, involving 3,247 patients, were identified that assessed the HRQOL and/or functional status of elderly critical care survivors. Generally, these studies have reported that critically ill elderly patients have good functional status and/or HRQOL following discharge from the ICU. However, Montuclard et al25 demonstrated in a unique inception cohort of patients with ICU LOS of ⬎ 30 days that independence in ADL was decreased significantly after the ICU stay, except for feeding. The unique inclusion of patients with an ICU LOS of ⬎ 30 days must be considered when assessing whether the persistent reduction in functional status experienced by these patients can be generalized to most elderly ICU survivors. Udekwu et al21 also demonstrated a reduction in functional status in a study with a mean ICU LOS of 3.25 ⫾ 6.47 days. The authors qualified this by commenting that although ADL decreased considerably, the number of completely independent patients only decreased modestly. A total of 10 studies4,16 –19,21,22,24,25,27 demonstrated that the HRQOL was relatively good, that patients were satisfied, or that there was no change from premorbid HRQOL. A notable exception was Vazquez Mata et al,23 who demonstrated that the elderly cohort of their patient sample had the greatest reduction in HRQOL, in comparison to younger groups, post-ICU discharge. Interestingly, the instrument used in this study concentrated on physical functioning. A subjective assessment of HRQOL was not included as the investigators required all patients who had been admitted to the ICU, or their surrogate, to complete the questionnaire. Subjective assessments may have revealed limited physical capacity, yet patients still reported a reasonable HRQOL after ICU discharge. Indeed, this was the case in the two studies21,25 outlined earlier, which described a reduction in functional status post-ICU, while the PQOL was not significantly different than scores in healthy patients living in the community. The studies reviewed here did not give a consistent definition of the term elderly. It is generally accepted that an elderly person is aged ⱖ 65 years, and, indeed, most of the studies adopted that definition. However, it is not useful to consider all persons over the age of 65 years as a homogeneous “elderly” group. Djaiani and Ridley28 highlighted the differences between elderly ICU survivors (ie, those ⱖ 70 years of age) and very elderly ICU survivors (ie, those ⱖ 85 years of age) by demonstrating significantly increased mortality among the very elderly at 1 year post-ICU discharge. Only three studies categorized the elderly into deciles of age (eg, 65 to 74 1772

years, 75 to 84 years, and ⬎ 85 years). This method is more sensitive to change in functional status and/or HRQOL related to age within the groups. Clearly, the variation among studies with regard to the definition of the term elderly poses an insurmountable difficulty in comparing results across studies. Another limitation of these studies, which precluded the comparison and pooling of results, is the inconsistency with regard to the choice and quality of instruments used to measure HRQOL. Almost half of the studies did not comment on the validity, reliability, or responsiveness of the instruments. In contrast, the choice of functional status instrument was consistent, with ADL being the most commonly used instrument, albeit the measurement properties of the ADL have had limited investigation in critical care survivors. While there is some evidence of its validity and responsiveness, reliability has not been demonstrated.10 Functional status measures in themselves are useful, and provide some insight into prognosis and prospects for independence, yet they may paint a negative picture of recovery and thus should be used in conjunction with an HRQOL measure. The policy implications of this work are highly relevant. Both the number of elderly ICU occupants and the costs of critical care are increasing. Elderly patients are known to use more hospital resources, particularly ICU resources.29,30 Callahan31 suggested that one way to limit increasing costs in the healthcare system was to ration care based on age, while Levinsky32 argued that if care was to be rationed, it should be done on the basis of the potential for benefit. Indeed, a 2003 study by Cook et al33 suggested that decision making by physicians in the ICU was not based on age. These investigators demonstrated that the withdrawal of mechanical ventilation was based on a number of factors, including physicians’ predictions of patients’ future cognitive status. However, physician’s predictions of patient’s future cognitive status, and thus their QOL, may not be accurate. A report by Frick and coworkers34 concluded that the future QOL of patients cannot be reliably predicted by either doctors or nurses. Despite this, as the population ages and health-care costs mount, it is likely that health-care professionals may consider age as an important criterion for restricting ICU admission. The findings in the accumulated literature suggest that age should not be the only determinant; that a decision to restrict expensive ICU care is multidimensional. Any such decision must consider not only age and HRQOL but also the interplay of other complex factors, such as evidence of potential benefit and societal values. It should be noted that the results of these studies could well Critical Care Review

overestimate the subsequent health status of critically ill elderly patients, particularly because only those who are predicted to survive the ICU would be admitted. Additional research is required and should aim to broaden the evidence base on all aspects of HRQOL and the functional status of elderly ICU survivors and critically ill elderly not admitted to the ICU. This current review has limitations. It is possible that we did not identify all relevant outcome studies relating to functional status and HRQOL in elderly ICU survivors. We located only English language studies that were published between 1990 and December 2003. Despite these potential limitations, this review has a number of important findings. First, there is a very small number of articles that specifically address the functional status and HRQOL of elderly ICU patients. This review identified 16 articles published in 13 years, which is lamentable in light of the fact that the elderly are the fastest growing population in the ICU. In a previous review by Heyland et al,35 64 articles relating to HRQOL of a general critically ill adult population were identified from 1992 to 1995. These authors estimated that this number constituted ⬍ 2% of all relevant ICU articles. The number of articles published on elderly ICU survivors is paltry even in comparison to this figure. Second, there was a lack of a uniform approach to HRQOL assessment especially, with only one HRQOL instrument being used twice in 16 studies. This is a huge limitation because it precludes the comparison of results between studies and limits the ability of reviewers to aggregate results in a meaningful way. Notwithstanding this, HRQOL assessment has evolved in the past few years. There are now a number of publications7,10,36,37 that have suggested suitable, reliable, and valid instruments for the assessment of both functional status and HRQOL following critical care. It is hoped that these reviews will guide the correct choice of instrument in future studies. In conclusion, further research is warranted into the outcomes of elderly patients in the ICU. Future studies should be well-designed, prospective, longitudinal trials using validated, reliable, and responsive measures. Improved evidence will lead to better decisions in the management of elderly patients in the ICU, and ultimately will support their independence and optimize their QOL.

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