Quality of life in patients aged 80 or over after ICU discharge

The study was performed at the Saint Joseph Hospital, a 460-bed tertiary-care non-university hospital for adults, located in Paris, France. The hospital provides services in all the medical specialties and in all fields of surgery except neurosurgery. The ICU is a 10-bed medical unit that admits about 400 patients per year (mean age, 62 years), of whom 70% have medical conditions. In our ICU, we have no predefined admission criteria. Our triage process has been described elsewhere [9].

From January 1, 2005, to December 31, 2006, we included all patients aged 80 years or over at ICU admission. Patients who were admitted several times during the study period had only their first stay included in the study. For each patient, the attending intensivist completed a case-report form in a database using data-capture software (RHEA, Outcomerea, Rosny Sous Bois, France). The following information was recorded prospectively: age and sex; admission category (medical, scheduled surgery, or unscheduled surgery); invasive procedures (number of arterial and/or venous central lines, endotracheal and noninvasive ventilation, dialysis, and tracheotomy); use of vasoactive agents and inotropic support; and patient location prior to ICU admission (with transfer from wards defined as being in the same hospital or another hospital before ICU admission). Nine reasons for ICU admission were defined prospectively before the study (respiratory failure, heart failure, renal failure, coma, multiple organ failure, chronic obstructive pulmonary disease, monitoring, trauma, and scheduled surgery). Co-morbidities were assessed using the McCabe score [11] and the Knaus classification system [12]. The McCabe score distinguishes two categories of underlying diseases based on whether death is likely to occur within five years or within one year [11]. Severity of the acute illness and organ dysfunction were measured at ICU admission using the Simplified Acute Physiology Score (SAPS II) [13], the Logistic Organ Dysfunction (LOD) score [14], and the Sepsis-Related Organ Assessment (SOFA) [15]. Withholding and withdrawal decisions, which were made according to the recommendations of the Francophone Society for Critical Care (SRLF) [16], were recorded; as well as lengths of the stays in the ICU and acute-care hospital and vital status at ICU and hospital discharge.

Information on prior self-sufficiency was obtained from the patient or family members, either at admission or within the first few days after admission, according to standard practice in our unit. Self-sufficiency was evaluated using the modified Katz Index of Activities of Daily Living (ADL), which assesses the ability to perform six basic daily activities (bathing, dressing, toileting, transferring, continence, and feeding) on a seven-point scale where zero indicates complete dependence and six complete independence [17].

Long-term quality of life was assessed using the WHOQOL-BREF and WHOQOL-OLD questionnaires developed by the World Health Organization (WHO) [18, 19]. The WHOQOL-BREF, which is the abbreviated version of the WHOQOL-100 [19], is a cross-culturally developed and validated questionnaire that can be used in specific cultural settings to collect data suitable for subsequent comparison across cultures. It has 26 items that cover four domains: physical health, psychological health, social relationships, and environment. It also measures the individual's perceptions of quality of life and health via two items ('How would you rate your quality of life?' and 'How satisfied are you with your health?'), each rated from 1 (very poor/dissatisfied) to 5 (very good/satisfied). The WHOQOL-OLD was developed as an add-on module that can be used with other WHOQOL instruments to specifically address important facets of quality of life in older adults [18]. It has 24 items that cover six facets (sensory abilities; autonomy; past, present, and future activities; social participation; death and dying; and intimacy). The WHOQOL-BREF questionnaire is available on the web [20] and from national WHO field centers. Domain scores are calculated from the items then converted to an overall percentile scale that ranges from very poor (0%) to very good (100%).

Outcomes one year after ICU discharge were assessed over the phone. Patients who failed to answer the first call were called again on different days, for a total of four calls. When we were unable to contact the patient by phone, we sought vital status information by calling the primary care physician and by looking for a death certificate at the appropriate registry office (or consulate if the patient was not French). The Katz Index and the WHOQOL-OLD and WHOQOL-BREF questionnaires were completed during a telephone interview conducted by one of us (AT). Because quality of life is a subjective personal concept that cannot be readily evaluated by relatives, only the patients completed the quality-of-life questionnaires. In contrast, relatives were asked for information on self-sufficiency that could not be obtained from the patients. The institutional review board waived requirement for written informed consent at ICU admission. Each patient received information about their inclusion in the study at ICU discharge and at the beginning of the phone call, and then asked to consent to the interview.

Quantitative data are reported as mean ± SD if normally distributed and as median (interquartile range (IQR)) otherwise. Qualitative data are reported as n (%). WHOQOL scores were calculated using the files created in SPSS by the WHO. The control group was a random sample of the general population matched on age and sex to our patients and derived from the sample used to validate the French version of the WHOQOL-OLD. Comparisons of self-sufficiency before and after the ICU stay and comparisons of WHOQOL scores after the ICU stay in our patients and in the general population were done using the Wilcoxon test for paired data. Statistical analyses were performed using SAS software (SAS 9.1, SAS Institute, Cary, NC, USA).

During the two-year study period, among the 630 consecutive admissions to our ICU, 115 (18.2%) were for patients aged 80 years or over (mean age, 84 ± 3 years; range, 80 to 92). There were seven readmissions (one patient readmitted twice and five patients readmitted once each, of whom two were alive after one year and completed our evaluation). We excluded two patients with missing data, which left 106 patients for the study. These patients had a mean age of 84 ± 2 years. Among them, 69 (65.1%) had medical conditions, 21 (19.8%) required unscheduled surgery, and 68 (64%) were transferred from wards. At admission, the mean Simplified Acute Physiology Score was 45 ± 18.3 points and the mean Logistic Organ Dysfunction score was 5.4 ± 3.5 points. During the ICU stay, 63 (59.4%) required ventilatory assistance, 48 (45.3%) epinephrine/norepinephrine, and 20 (18.9%) dialysis. The median ICU stay was six days (IQR, 3 to 11) and the median post-ICU hospital stay was eight days (IQR, 0 to 18.5).

Of the 106 patients, 40 (37.7%) died in the ICU and 39 (36.8%) had treatment-limitation decisions, which consisted in withholding life-support in 22 (20.8%) patients and withdrawing life support in 20 (18.9%) patients, with three patients having both categories of decisions.

Of the 66 (62.2%) patients discharged alive from the ICU, eight died before hospital discharge. Hospital mortality was 48/106 (45.2%). In addition, 25 patients died before the one-year evaluation. Thus, one-year mortality was 73/106 (68.9%). Of the 33 survivors at one year, seven refused the evaluation (two were unhappy with our institution, one stated having insufficient time, two had hearing loss, and two lived at home but did not answer our multiple calls). Of the 26 remaining patients, three had dementia that precluded them from completing the evaluation. Self-sufficiency in these three patients was assessed by the relatives; they had ADL scores of 4, 4, and 2, respectively. Quality of life was not assessed in these three patients.

Quality of life was therefore assessed in 23 patients, whose mean age was 84 ± 3 years; there were 17 (73.9%) males (Table 1). Mean time from ICU discharge to evaluation was 471 ± 121 days (25^th to 75^th:375 to 583), due to difficulties experienced in locating some of the patients. Mean phone call duration was 42 ± 14 minutes. As shown in Table 2, self-sufficiency was not modified after the ICU stay compared to the pre-ICU status (median index values, 6 vs. 6, respectively). Table 3 compared quality-of-life data in the 23 patients and in the general population matched on sex and age. The survivors had significantly higher scores for psychological health; social relationships; environment; fear of death and dying; expectations about past, present, and future activities; and intimacy (friendship and love). Of the 23 patients, 18 (78%) said they would agree to another ICU admission should the need occur in the future.