Loss of autonomy among elderly patients after a stay in a medical intensive care unit (ICU): A randomized study of the benefit of transfer to a geriatric ward

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Abstract

In order to evaluate changes in the functional autonomy of elderly patients after a stay in a medical intensive care unit (ICU), and the impact of post-ICU management in geriatric ward, we included in a randomized controlled trial 45 patients aged ≥75 years. They were assessed for functional autonomy before ICU stay, just after ICU discharge, just after hospital discharge, and 6 months later. The patients were randomly divided into two post-ICU management groups: “geriatric ward” and “standard care”. Autonomy was usually recovered rapidly, but the degree of recovery depended on the patient's previous autonomy (p < 0.0001). At the last assessment, 41% of the patients had recovered their previous autonomy. The mean Barthel indexes were 81.5 ± 30.4 in the geriatric management arm and 70.5 ± 33.4 in the standard management arm (p = 0.4). The study was prematurely ended due to insufficient recruitment flow. These results underline the rapid loss of autonomy after a stay in a medical ICU. Early specific intervention to improve the autonomy of elderly patients seems an attractive solution that could be assessed by randomized controlled trial. Above all, our results should also serve as a basis for further controlled randomized studies in this setting.

Introduction

Fragile elderly people are at an increased risk of death and loss of autonomy, reflecting a lack of “physiological reserves” (Bergman et al., 2007). The apparent potential for recovery can affect the decision to admit an elderly person to an ICU (Boumendil et al., 2007). Geriatric wards have been shown to preserve patients’ autonomy (Stuck et al., 1993), but there are no studies of this issue in the early post-ICU period. We report preliminary results on changes in the physical, mental and social autonomy of patients more than 75 years old after a stay in an ICU, according to whether they were transferred to a dedicated geriatric ward or to a general ward.

Section snippets

Study design

We conducted a randomized controlled study with direct individual benefit designed to compare the benefit of specific geriatric management compared with standard management after a stay in an ICU among patients over 75 years of age. The study took place at a university hospital in Paris, France, between February 2003 and January 2005. The study was halted prematurely by the sponsor (Caissse Nationale d’Assurance Maladie—CNAM) because patient accrual was too slow (Fig. 1).

Patients

Patients aged at least

Study population

Forty-five patients were enrolled during the first 2 years of the study, whereas an accrual rate of 65 patients per year was expected. Fig. 1 shows the rate of patient accrual and the reasons for ineligibility. Unexpected reasons for ineligibility included the large number of patients requiring highly specialized care after their stay in the ICU; the number of patients living more than 50 km from the hospital; and language problems preventing the collection of informed consent (n = 66). Another 16

Discussion

This study of 45 patients aged at least 75 years shows that autonomy is usually recovered rapidly after discharge from an ICU, and that the degree of recovery depends on the level of autonomy prior to ICU admission.

Recruitment of acute-care elderly patients to this type of prospective study is notoriously difficult (Berkman et al., 2001). The accrual rate was slow in our study, owing to unexpected reasons for exclusion. The main problem was urgent patient transfer from the ICU (<24 h), and

Conclusion

Recovery of autonomy by elderly patients after a stay in an ICU seems to depend mainly on two factors: the level of autonomy prior to ICU admission, and the type of in-hospital care they receive after being discharged from the ICU. Transfer to a specifically designed geriatric ward rather than to a general ward should be an attractive way to reduce this loss of autonomy. This strategy should be clearly assessed in future randomized control trials. Our study could serve as a basis for further

Conflict of interest statement

None.

Acknowledgement

This research project was made possible through a financial grant allocated by the scientific committee of the Caissse Nationale d’Assurance Maladie (CNAM).

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