Journal of the American Geriatrics Society
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We examined predictors of hospital and 6-month mortality in older Medical Intensive Care Unit (MICU) patients with particular attention to age and functional status. Age is generally thought to be strongly associated with intensive care outcomes, but this relationship may be confounded by age-related changes. These age-related changes may be approximated by changes in functional status (FS). ⋯ We found that among patients without functional limitations, the oldest group was no more likely to die than the youngest group. Age and functional status had a significant interaction: patients older than 75 years with functional limitations were almost six times more likely to die in hospital compared to the reference group of patients between 50-64 years old without functional limitations. We conclude that functional status is an important predictor of outcome in older MICU patients.
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Advanced age has been proposed as one criterion for limiting the use of life-sustaining medical treatment, but very little is known about current practices. We retrospectively studied utilization rates of intensive care (IC) and cardiopulmonary resuscitation (CPR) in admissions to a university hospital over 1 year (n = 9,998), to test whether these treatments are used more selectively for elderly patients. Overall utilization rates did not vary by age. ⋯ Despite more selective use, survival rates were lower for elderly than for younger patients receiving IC (88% vs 78%, P less than 0.001). CPR showed similar but non-significant trends. Intensive care is being used less frequently prior to death for elderly patients, based on diagnosis and functional status as well as chronologic age.
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Randomized Controlled Trial Clinical Trial
Cognitive function after spinal or general anesthesia for transurethral prostatectomy in elderly men.
Cognitive functions in 53 elderly men who underwent a transurethral prostatectomy were assessed pre-operatively and 4 days and 3 months post-operatively. Thirteen patients had a preference for one particular type of anesthesia, and the remaining 40 were randomly allocated to receive either spinal or general anesthesia. ⋯ No difference in post-operative performance was found in the patient groups with pre-operative Mini-Mental State Examination scores above or under their age-specific norm. It is concluded that neither hospitalization nor the two forms of anesthesia investigated cause a decrease in cognitive function in elderly men.
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Although many clinicians routinely recommend a base-line preoperative electrocardiogram (ECG) and obtain frequent postoperative ECGs to screen for myocardial infarction or ischemia, the diagnostic utility of screening perioperative ECGs is unknown. The present analysis evaluates the sensitivity and specificity of the perioperative ECG and examines its value as a predictor of early postoperative cardiac events and outcomes during the postoperative year. ECGs obtained preoperatively and on the first 3 postoperative days in 206 men undergoing transurethral prostate resection were analyzed using the Minnesota Code. ⋯ The specificity of any ECG change for perioperative infarction was 78%; of ST segment changes only, 95%. Only one of the patients (2%) who had postoperative ECG changes had a cardiac event in the year after surgery. Routine perioperative ECGs is of little diagnostic/predictive utility in situations in which the incidence of perioperative myocardial infarction is low.
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Do-not-resuscitate (DNR) orders have become an accepted part of medical practice. While these orders have been extensively evaluated in acute care hospitals, little is known about their use in the long-term care setting. We reviewed the medical records of all admissions to a chronic care hospital over a 13-month period, collecting data on selected patient characteristics, use of DNR orders, and patient outcomes during the 6-week period following admission. ⋯ They were no more likely to be transferred emergently to an acute care hospital (5% vs 9%, P greater than 0.2). We conclude that DNR orders are not infrequently used, and physicians rarely make the decision unilaterally. Patients with DNR orders have a high likelihood of dying and are infrequently transferred to acute care facilities.