Editorials
associations between housing status and health, the unique use of propensity matching suggests that homeless patients have no additional sequelae specifically from their homelessness and indeed benefit from the same care. Indeed, this finding alone is extremely interesting and worthy of note and will no doubt be an impetus for discussion and additional study. The literature surrounding this area and general mantra suggests that homeless patients have poor medical care, a greater burden of chronic disease, and worsened outcomes (2, 4). This “disease of poverty” has been widely reported, and it is safe to say generally believed to do poorly. Whether this was because of something inherent in these patients or because of a generally worse health compared with the overall population has something that has not been evaluated until now. Propensity matching suggests that patients do not indeed suffer inherently from being homeless but are similar to equally ill-housed patients. Hence, the authors conclude that homelessness is problematic in that it prevents access to health care and results in a chronically ill cohort but that there is nothing inherently different about these patients or the care they should get in the ICU. Although these findings are of interest, there remain some questions about the matching of these patients. Indeed, matching patients’ illness severity and then suggesting that these patients benefit similarly from ICU care, which is based on a large part on treating that severity, could constitute a circular argument. Of course, there is no way to assess this because these patients are fit on their matching. For those of us who regularly care for homeless and poor patients, it does seem anecdotally as they lack prior care, and increased comorbidities result in a “sicker” patient and
difficult outcomes. Perhaps matching via diagnosis or prospectively enrolling patients into an observational trial is warranted Only a larger cohort across multiple centers can assess whether the main finding of the article is an inherent truth or is a result of the matching methodology. Finally and worthy of considerable discussion is the issue of attributable risk. Indeed, the difference of modifiable risk (potentially due to housing status and socieoeconomic status) and non–modifiable risk (disease severity upon arrival in the ICU) and the dynamics of this risk (eg, whether the sequelae of homelessness can be addressed once the patient is in the ICU) are the crucial question illuminated by this important article. I hope that rather than fostering the belief that all patients are the same when they enter the ICU to be differentiated only upon their illness and severity, this article begins a larger discussion and analysis of the demographics and socieoeconomic impact on illness of similar severity.
REFERENCES
1. Bigé N, Hejblum G, Baudel J-L, et al: Homeless Patients in the ICU: An Observational Propensity-Matched Cohort Study. Crit Care Med 2015; 43:1246–1254 2. Fazel S, Geddes JR, Kushel M: The health of homeless people in highincome countries: Descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet 2014; 384:1529–1540 3. Kornblith LZ, Kutcher ME, Evans AE, et al: The “found down” patient: A diagnostic dilemma. J Trauma Acute Care Surg 2013; 74:1548–1552 4. Lazzarino AI, Hamer M, Stamatakis E, et al: The combined association of psychological distress and socioeconomic status with allcause mortality: A national cohort study. JAMA Intern Med 2013; 173:22–27
Functional Outcomes After Critical Illness in the Elderly* Mark D. Neuman, MD, MSc Department of Anesthesiology and Critical Care; and Department of Internal Medicine Division of Geriatric Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA; and Leonard Davis Institute for Health Economics University of Pennsylvania Philadelphia, PA *See also p. 1265. Key Words: activities of daily living; aging; functional independence Supported, in part, by the institutional/departmental sources. Dr. Neuman received support for article research from the National Institutes of Health. His institution received grant support from the National Institute on Aging, Bethesda, MD (K08AG043548). Dr. Eckenhoff has disclosed that he does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000001026
1340
www.ccmjournal.org
Roderic G. Eckenhoff, MD Department of Anesthesiology and Critical Care Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA
F
or older adults, critical illnesses carry substantial risks of death and functional disability. One recent cohort study found that 53% of critically ill adults aged 70 and older either died at 30 days after hospitalization or sustained new, significant declines in their ability to perform basic activities of daily living (1). These findings echo recent (2, 3) and historical studies (4, 5) that have shown a potentially profound impact of critical illness on the ability of those older adults who survive critical illnesses to maintain their independence in the months to years that follow. Writing three decades ago, the authors of one early study on functional limitations after critical illness noted that “physicians may consider treatment a medical success while, paradoxically, the patient and family may feel it a failure if overall function declines.” (4) In this issue of Critical June 2015 • Volume 43 • Number 6
Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Editorials
Care Medicine, Brummel et al (6) offer a thoughtful overview of available research characterizing the relationship between critical illness and the development of functional dependence among older adults. More importantly, they highlight potential strategies to improve functional outcomes of such illness among older adults. Brummel et al (6) emphasize how efforts to describe, understand, and potentially improve functional outcomes for critically ill older adults have moved over time from the margins of discourse on critical care to become a central focus of investigation and clinical practice. This review also highlights just how elusive insights have been regarding the basic epidemiology of functional decline before and after critical illness. The authors reviewed 19 studies published over 30 years that examined independence in activities of daily living after treatment in an ICU; yet only nine of these studies examined patients’ preillness functional status, information essential for the proper interpretation of data on postillness function (7). Of these nine, the majority relied on patient’s own retrospective accounts of their prior functioning, rather than prospective objective assessments (8, 9), raising concern of the potential for recall bias and limiting the ability of investigators to examine functional trajectories in detail. More recently, investigators have been able to overcome some of these limitations by taking advantage of existing large longitudinal cohort studies that prospectively collected functional status data at 1- or 2-year intervals. Combined with the likelihood that subgroups will experience critical illness, this allowed examination of the impact of that illness on subsequent function (2, 10). However, it was only this year that quantitative information on the prognostic significance of differing pre-ICU functional trajectories became available with the publication of research on outcomes after critical illness among participants in the Precipitating Events Project (1), a landmark prospective cohort study of 754 community-dwelling older adults that has included functional status assessments taken monthly for over 16 years (11). Brummel et al (6) highlight the ongoing need for research to characterize patterns and determinants of functional outcomes for critically ill older adults; yet they also provide a framework to help clinicians and investigators design and interpret interventions aimed at improving such outcomes. The heterogeneity of geriatric patients (12), and geriatric syndromes more generally (13), represents a major theme in aging research. As Brummel et al (6) point out, the nature and trajectory of functional disability—as well as the implications of a critical illness for subsequent functional independence— may vary markedly between older adults; for example, individuals with few functional impairments at baseline, a critical illness may represent a crucial precipitating event that, if survived, may place this individual on an accelerated trajectory of functional decline and disability. However, such patients have a better likelihood of functional recovery than those with established patterns of progressive functional decline prior to their critical illness; in this case, an ICU admission may be one in a series of events leading to functional dependence and death. Critical Care Medicine
By placing their discussion of post-ICU functional decline in the context of established models of the disablement process, Brummel et al (6) offer insight into the wide range of trajectories of functional disability that older adults may experience both before and after critical illness. As such, their review stresses the importance of conceptualizing functional disabilities after critical care not as isolated endpoints but instead as progressive geriatric syndromes that intersect with, and are modulated by, critical illness. The perspective offered by this review will help us understand which groups of patients are most likely to benefit in the long term from interventions aimed at limiting new functional deficits after critical illness. Such interventions may include those that focus on early physical and occupational therapy, routine delirium screening, and evidence-based sedation and ventilator management. For critically individuals who are already near the end of life even prior to their illness, the framework put forward here emphasizes the importance of effective prognostication and care planning to high-quality ICU care. Ultimately, by stressing the extent to which critical illnesses may emerge as episodes within the broader context of aging, Brummel et al (6) remind us to include the perspectives of geriatrics and gerontology in order to make sense of the outcomes of critical illness in older adults.
REFERENCES
1. Ferrante LE, Pisani MA, Murphy TE, et al: Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015 Feb 9. [Epub ahead of print] 2. Barnato AE, Albert SM, Angus DC, et al: Disability among elderly survivors of mechanical ventilation. Am J Respir Crit Care Med 2011; 183:1037–1042 3. Sacanella E, Pérez-Castejón JM, Nicolás JM, et al: Functional status and quality of life 12 months after discharge from a medical ICU in healthy elderly patients: A prospective observational study. Crit Care 2011; 15:R105 4. Goldstein RL, Campion EW, Thibault GE, et al: Functional outcomes following medical intensive care. Crit Care Med 1986; 14:783–788 5. Mundt DJ, Gage RW, Lemeshow S, et al: Intensive care unit patient follow-up. Mortality, functional status, and return to work at six months. Arch Intern Med 1989; 149:68–72 6. Brummel NE, Balas MC, Morandi A, et al: Understanding and Reducing Disability in Older Adults Following Critical Illness. Crit Care Med 2015; 43:1265–1275 7. Iwashyna TJ, Netzer G, Langa KM, et al: Spurious inferences about long-term outcomes: The case of severe sepsis and geriatric conditions. Am J Respir Crit Care Med 2012; 185:835–841 8. Chelluri L, Pinsky MR, Donahoe MP, et al: Long-term outcome of critically ill elderly patients requiring intensive care. JAMA 1993; 269:3119–3123 9. Parno JR, Teres D, Lemeshow S, et al: Two-year outcome of adult intensive care patients. Med Care 1984; 22:167–176 10. Iwashyna TJ, Ely EW, Smith DM, et al: Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010; 304:1787–1794 11. Gill TM: Disentangling the disabling process: Insights from the precipitating events project. Gerontologist 2014; 54:533–549 12. Boyd CM, Darer J, Boult C, et al: Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA 2005; 294:716–724 13. Tinetti ME, Fried T: The end of the disease era. Am J Med 2004; 116:179–185 www.ccmjournal.org
Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
1341
associations between housing status and health, the unique use of propensity matching suggests that homeless patients have no additional sequelae specifically from their homelessness and indeed benefit from the same care. Indeed, this finding alone is extremely interesting and worthy of note and will no doubt be an impetus for discussion and additional study. The literature surrounding this area and general mantra suggests that homeless patients have poor medical care, a greater burden of chronic disease, and worsened outcomes (2, 4). This “disease of poverty” has been widely reported, and it is safe to say generally believed to do poorly. Whether this was because of something inherent in these patients or because of a generally worse health compared with the overall population has something that has not been evaluated until now. Propensity matching suggests that patients do not indeed suffer inherently from being homeless but are similar to equally ill-housed patients. Hence, the authors conclude that homelessness is problematic in that it prevents access to health care and results in a chronically ill cohort but that there is nothing inherently different about these patients or the care they should get in the ICU. Although these findings are of interest, there remain some questions about the matching of these patients. Indeed, matching patients’ illness severity and then suggesting that these patients benefit similarly from ICU care, which is based on a large part on treating that severity, could constitute a circular argument. Of course, there is no way to assess this because these patients are fit on their matching. For those of us who regularly care for homeless and poor patients, it does seem anecdotally as they lack prior care, and increased comorbidities result in a “sicker” patient and
difficult outcomes. Perhaps matching via diagnosis or prospectively enrolling patients into an observational trial is warranted Only a larger cohort across multiple centers can assess whether the main finding of the article is an inherent truth or is a result of the matching methodology. Finally and worthy of considerable discussion is the issue of attributable risk. Indeed, the difference of modifiable risk (potentially due to housing status and socieoeconomic status) and non–modifiable risk (disease severity upon arrival in the ICU) and the dynamics of this risk (eg, whether the sequelae of homelessness can be addressed once the patient is in the ICU) are the crucial question illuminated by this important article. I hope that rather than fostering the belief that all patients are the same when they enter the ICU to be differentiated only upon their illness and severity, this article begins a larger discussion and analysis of the demographics and socieoeconomic impact on illness of similar severity.
REFERENCES
1. Bigé N, Hejblum G, Baudel J-L, et al: Homeless Patients in the ICU: An Observational Propensity-Matched Cohort Study. Crit Care Med 2015; 43:1246–1254 2. Fazel S, Geddes JR, Kushel M: The health of homeless people in highincome countries: Descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet 2014; 384:1529–1540 3. Kornblith LZ, Kutcher ME, Evans AE, et al: The “found down” patient: A diagnostic dilemma. J Trauma Acute Care Surg 2013; 74:1548–1552 4. Lazzarino AI, Hamer M, Stamatakis E, et al: The combined association of psychological distress and socioeconomic status with allcause mortality: A national cohort study. JAMA Intern Med 2013; 173:22–27
Functional Outcomes After Critical Illness in the Elderly* Mark D. Neuman, MD, MSc Department of Anesthesiology and Critical Care; and Department of Internal Medicine Division of Geriatric Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA; and Leonard Davis Institute for Health Economics University of Pennsylvania Philadelphia, PA *See also p. 1265. Key Words: activities of daily living; aging; functional independence Supported, in part, by the institutional/departmental sources. Dr. Neuman received support for article research from the National Institutes of Health. His institution received grant support from the National Institute on Aging, Bethesda, MD (K08AG043548). Dr. Eckenhoff has disclosed that he does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000001026
1340
www.ccmjournal.org
Roderic G. Eckenhoff, MD Department of Anesthesiology and Critical Care Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA
F
or older adults, critical illnesses carry substantial risks of death and functional disability. One recent cohort study found that 53% of critically ill adults aged 70 and older either died at 30 days after hospitalization or sustained new, significant declines in their ability to perform basic activities of daily living (1). These findings echo recent (2, 3) and historical studies (4, 5) that have shown a potentially profound impact of critical illness on the ability of those older adults who survive critical illnesses to maintain their independence in the months to years that follow. Writing three decades ago, the authors of one early study on functional limitations after critical illness noted that “physicians may consider treatment a medical success while, paradoxically, the patient and family may feel it a failure if overall function declines.” (4) In this issue of Critical June 2015 • Volume 43 • Number 6
Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Editorials
Care Medicine, Brummel et al (6) offer a thoughtful overview of available research characterizing the relationship between critical illness and the development of functional dependence among older adults. More importantly, they highlight potential strategies to improve functional outcomes of such illness among older adults. Brummel et al (6) emphasize how efforts to describe, understand, and potentially improve functional outcomes for critically ill older adults have moved over time from the margins of discourse on critical care to become a central focus of investigation and clinical practice. This review also highlights just how elusive insights have been regarding the basic epidemiology of functional decline before and after critical illness. The authors reviewed 19 studies published over 30 years that examined independence in activities of daily living after treatment in an ICU; yet only nine of these studies examined patients’ preillness functional status, information essential for the proper interpretation of data on postillness function (7). Of these nine, the majority relied on patient’s own retrospective accounts of their prior functioning, rather than prospective objective assessments (8, 9), raising concern of the potential for recall bias and limiting the ability of investigators to examine functional trajectories in detail. More recently, investigators have been able to overcome some of these limitations by taking advantage of existing large longitudinal cohort studies that prospectively collected functional status data at 1- or 2-year intervals. Combined with the likelihood that subgroups will experience critical illness, this allowed examination of the impact of that illness on subsequent function (2, 10). However, it was only this year that quantitative information on the prognostic significance of differing pre-ICU functional trajectories became available with the publication of research on outcomes after critical illness among participants in the Precipitating Events Project (1), a landmark prospective cohort study of 754 community-dwelling older adults that has included functional status assessments taken monthly for over 16 years (11). Brummel et al (6) highlight the ongoing need for research to characterize patterns and determinants of functional outcomes for critically ill older adults; yet they also provide a framework to help clinicians and investigators design and interpret interventions aimed at improving such outcomes. The heterogeneity of geriatric patients (12), and geriatric syndromes more generally (13), represents a major theme in aging research. As Brummel et al (6) point out, the nature and trajectory of functional disability—as well as the implications of a critical illness for subsequent functional independence— may vary markedly between older adults; for example, individuals with few functional impairments at baseline, a critical illness may represent a crucial precipitating event that, if survived, may place this individual on an accelerated trajectory of functional decline and disability. However, such patients have a better likelihood of functional recovery than those with established patterns of progressive functional decline prior to their critical illness; in this case, an ICU admission may be one in a series of events leading to functional dependence and death. Critical Care Medicine
By placing their discussion of post-ICU functional decline in the context of established models of the disablement process, Brummel et al (6) offer insight into the wide range of trajectories of functional disability that older adults may experience both before and after critical illness. As such, their review stresses the importance of conceptualizing functional disabilities after critical care not as isolated endpoints but instead as progressive geriatric syndromes that intersect with, and are modulated by, critical illness. The perspective offered by this review will help us understand which groups of patients are most likely to benefit in the long term from interventions aimed at limiting new functional deficits after critical illness. Such interventions may include those that focus on early physical and occupational therapy, routine delirium screening, and evidence-based sedation and ventilator management. For critically individuals who are already near the end of life even prior to their illness, the framework put forward here emphasizes the importance of effective prognostication and care planning to high-quality ICU care. Ultimately, by stressing the extent to which critical illnesses may emerge as episodes within the broader context of aging, Brummel et al (6) remind us to include the perspectives of geriatrics and gerontology in order to make sense of the outcomes of critical illness in older adults.
REFERENCES
1. Ferrante LE, Pisani MA, Murphy TE, et al: Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015 Feb 9. [Epub ahead of print] 2. Barnato AE, Albert SM, Angus DC, et al: Disability among elderly survivors of mechanical ventilation. Am J Respir Crit Care Med 2011; 183:1037–1042 3. Sacanella E, Pérez-Castejón JM, Nicolás JM, et al: Functional status and quality of life 12 months after discharge from a medical ICU in healthy elderly patients: A prospective observational study. Crit Care 2011; 15:R105 4. Goldstein RL, Campion EW, Thibault GE, et al: Functional outcomes following medical intensive care. Crit Care Med 1986; 14:783–788 5. Mundt DJ, Gage RW, Lemeshow S, et al: Intensive care unit patient follow-up. Mortality, functional status, and return to work at six months. Arch Intern Med 1989; 149:68–72 6. Brummel NE, Balas MC, Morandi A, et al: Understanding and Reducing Disability in Older Adults Following Critical Illness. Crit Care Med 2015; 43:1265–1275 7. Iwashyna TJ, Netzer G, Langa KM, et al: Spurious inferences about long-term outcomes: The case of severe sepsis and geriatric conditions. Am J Respir Crit Care Med 2012; 185:835–841 8. Chelluri L, Pinsky MR, Donahoe MP, et al: Long-term outcome of critically ill elderly patients requiring intensive care. JAMA 1993; 269:3119–3123 9. Parno JR, Teres D, Lemeshow S, et al: Two-year outcome of adult intensive care patients. Med Care 1984; 22:167–176 10. Iwashyna TJ, Ely EW, Smith DM, et al: Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010; 304:1787–1794 11. Gill TM: Disentangling the disabling process: Insights from the precipitating events project. Gerontologist 2014; 54:533–549 12. Boyd CM, Darer J, Boult C, et al: Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA 2005; 294:716–724 13. Tinetti ME, Fried T: The end of the disease era. Am J Med 2004; 116:179–185 www.ccmjournal.org
Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
1341
