Studies of ambulatory and hospitalized older patients show that functional decline is predicted by the interaction of baseline risk (vulnerability) with acute events (noxious stimuli). We hypothesized that chronic medical conditions and acute illnesses predict which older survivors of critical illness (CI) will not return home on hospital discharge. To test this we developed a prediction model using information commonly available to intensivists.
Using an existing database, we retrospectively analyzed all first admissions of medical ICU patients ≥ 65 yrs, excluding patients not living at home prior to admission. Chronic medical conditions (neurodegenerative disorder; diabetes mellitus >5 years; stage IV solid organ malignancy; advanced heart, lung, liver, or kidney disease) and acute (first 72hrs intensive care) illnesses (mechanical ventilation [MV], acute renal failure requiring dialysis, and severe neuromuscular dysfunction) were recorded, along with age, APACHE II score, and body mass index. Logistic regression was performed, with discharge to a location other than home serving as the dependant variable.
737/789 charts were available; 167 met study criteria. 61/167 (36.5%) older survivors of CI did not return home on discharge. These patients were older (76 [71-80] vs. 72 [67-77], p=.003), sicker (APACHE II score 23.7 ± 6.8 vs. 17.3 ± 5.5, p<.001), and received more MV (52.5% versus 16%, p<.001). None of the chronic medical conditions analyzed predicted not returning home on discharge. After adjustment, odds ratios for not returning home on discharge were: age (2.2/10yrs), APACHE II (4.8/10 pts), MV (4.2). Our model was only 60.7% sensitive for predicting this outcome.
Even if survival could be predicted, routinely available information about chronic medical conditions does not predict which older patients will be unable to return home on discharge.
Assessment of baseline physical and cognitive function may be necessary to more accurately predict functional decline and transfer to other health care facilities following CI.
B.K. Gehlbach, None.