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Management and outcomes in critically ill nonagenarian versus octogenarian patients

Abstract

Background

Intensive care unit (ICU) patients age 90 years or older represent a growing subgroup and place a huge financial burden on health care resources despite the benefit being unclear. This leads to ethical problems. The present investigation assessed the differences in outcome between nonagenarian and octogenarian ICU patients.

Methods

We included 7900 acutely admitted older critically ill patients from two large, multinational studies. The primary outcome was 30-day-mortality, and the secondary outcome was ICU-mortality. Baseline characteristics consisted of frailty assessed by the Clinical Frailty Scale (CFS), ICU-management, and outcomes were compared between octogenarian (80–89.9 years) and nonagenarian (> 90 years) patients. We used multilevel logistic regression to evaluate differences between octogenarians and nonagenarians.

Results

The nonagenarians were 10% of the entire cohort. They experienced a higher percentage of frailty (58% vs 42%; p < 0.001), but lower SOFA scores at admission (6 + 5 vs. 7 + 6; p < 0.001). ICU-management strategies were different. Octogenarians required higher rates of organ support and nonagenarians received higher rates of life-sustaining treatment limitations (40% vs. 33%; p < 0.001). ICU mortality was comparable (27% vs. 27%; p = 0.973) but a higher 30-day-mortality (45% vs. 40%; p = 0.029) was seen in the nonagenarians. After multivariable adjustment nonagenarians had no significantly increased risk for 30-day-mortality (aOR 1.25 (95% CI 0.90–1.74; p = 0.19)).

Conclusion

After adjustment for confounders, nonagenarians demonstrated no higher 30-day mortality than octogenarian patients. In this study, being age 90 years or more is no particular risk factor for an adverse outcome. This should be considered– together with illness severity and pre-existing functional capacity - to effectively guide triage decisions.

Trial registration

NCT03134807 and NCT03370692.

Peer Review reports

Introduction

The proportion of older patients has increased significantly over time. In 2030, there will be more than 30 million people over the age of 90 (nonagenarians) in 35 industrialised countries [1]. Consequently, health care providers nowadays perform medical procedures on very old patients (from surgery to oncological therapies), which were previously considered unfeasible because of age or age-related deterioration in physical and mental performance [2]. Similarly, the rate of older patients (> 80 years) in intensive care units (ICU) is increasing [3,4,5,6]. Today, older patients utilise a disproportionate amount of health care resources compared to their relative proportion of the total population [3, 7].

In particular, the extent to which “old age” per se is a risk factor and the extent to which different groups of old patients differ from one another regarding the prognosis is the subject of continuing debate. Older patients suffer worse outcomes than younger patients undergoing intensive care [8, 9], but some studies failed to establish age as an independent predictor of mortality in older ICU patients [10, 11]. However, most prognostic studies demonstrated an almost linear relationship between chronological age and mortality after the age of 40 [12]. In this respect, patients ageing 80 years and more represent a particular challenge to intensive care medicine [13, 14]. Still, there are no large studies that further differentiate this group of very old ICU patients and it is unclear if being a nonagenarian is a risk factor for adverse outcomes. We hypothesize that critically ill nonagenarians have an elevated 30-day mortality compared to octogenarians. To address this hypothesis, we performed a retrospective cohort study comprised of two large, multinational prospective observational cohorts [13,14,15]. This post-hoc analysis combined data from the VIP-1 and VIP-2 studies to compare octo- and nonagenarians regarding 30-day mortality (primary outcome) and ICU mortality (secondary outcome), the distribution of risk factors, and the intensive care management [13,14,15].

Methods

Study subjects

The very old intensive care patients (VIP) studies, VIP1 and VIP2, were prospective, multi-centre studies, registered on ClinicalTrials.gov (ID: NTC03134807, NCT03370692). Both studies included very old intensive care patients (VIPs), defined as patients admitted to an ICU and aged 80 years or older. The main results from these studies have been published previously [1314, 16, 17]. In summary, for both studies, each participating ICU could include either consecutive patients admitted over a six-month period or the first 20 consecutive patients fulfilling the inclusion criteria (all patients aged 80 years or older). The data collection for VIP1 took place between October 2016 and February 2017 and between May 2018 to May 2019 for VIP2. Both studies used similar inclusion criteria as described elsewhere [13]. Informed consent was obtained from study participants. Local ethical committees might have waived the need of informed consent.

In this post-hoc analysis of these two studies, all patients admitted acutely (non-electively) with complete data on age, gender, clinical frailty score (CFS), sequential organ failure assessment (SOFA) score, and ICU mortality were included. For this study, the elective patients included in VIP1 were excluded as their outcomes differ significantly compared with those admitted acutely, as previously shown [18]. The primary endpoint of this study was ICU-mortality, and the secondary endpoint was 30-day-mortality.

Scales, scores, and limitations in life-sustaining therapy

The SOFA score was recorded on admission; it could be calculated manually or using an online calculator. Frailty was assessed by the clinical frailty scale (CFS). The CSF distinguishes nine classes of frailty from very fit (CFS 1) to terminally ill (CFS 9). The respective visual and simple description for this assessment tool was used with permission [19,20,21].

The Katz Activities of Daily Living (Katz ADL) scale is a widely used graded instrument to assess disability in chronically ill or older patients. It evaluates six primary and psychosocial functions: bathing, dressing, going to the toilet, transferring, feeding, and continence. The patient receives 1 point for every independent and 0 for every dependent activity (6 = independent patient, 0 = very dependent patient). For the patients in the VIP2 trial, disability was defined by Katz ADL score ≤ 4.

For cognitive decline, VIP2 utilised the Short form of Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). IQCODE is a questionnaire, completed by carers, with 16 questions about cognitive decline over the past 10 years. For each question, 1 to 5 points can be assigned. An average of 3 points per question is considered “normal”. A cumulative IQCODE of ≥3.5 is regarded as “cognitive decline” [19,20,21].

The burden of co-morbidity was assessed using the co-morbidity and polypharmacy score (CPS) [22]. The CPS calculates the total number of chronic diagnoses and drugs taken. Standard ICU procedures were also documented.

In addition, limitations of therapy, such as withholding or withdrawing treatment, were recorded. Withholding life-sustaining therapy (e.g. mechanical ventilation, renal replacement therapy, cardiopulmonary resuscitation) was defined as not performing a measure that was indicated; withdrawing was defined as stopping any kind of life-sustaining therapy. All these decisions were at the discretion of the treating physicians and documented according to international recommendations. VIP2 recorded the exact date of treatment limitation, but VIP1 did not give specific details. Thus, the present analysis used withholding or withdrawing treatment as binary information at any time during the ICU-stay.

Statistical analysis

Post-hoc power calculations using the 7110 octogenarians and 790 nonagenarians, primary outcome event rates of 40% versus 45%, and an alpha of 0.05, the power of the study to detect differences in 30-day mortality is 77%. Continuous data points are expressed as median ± interquartile range. Differences between independent groups were calculated using the Mann Whitney U-test. Categorical data are expressed as numbers (percentage). The chi-square test was applied to calculate differences between groups. Sensitivity analysis, analysing only patients with SOFA scores below the 75th percentile SOFA score of 10 (i.e. all patients with SOFA < 10) was performed. Univariable and multivariable logistic regression analysis was performed to assess associations with treatment limitations and mortality. Odds ratios (OR) and adjusted odds ratios (aOR) with respective 95% confidence intervals (CI) were calculated. Two sequential random effects, multilevel logistic regression models were used to evaluate the impact of being a nonagenarian on ICU- and 30-days- mortality. All patients with valid data on ICU-mortality were included. First, a baseline model with being nonagenarian as a fixed effect and ICU as random effect (model-1) was fitted. Second, to model-1, patient characteristics (SOFA, CFS, sex) (model-2) were added to the model. Adjusted odds ratios (aOR) with respective 95% confidence intervals (CI) were calculated. Sensitivity analysis, analysing only patients with and without any treatment limitation was performed. All tests were two-sided, and a p-value of < 0.05 was considered statistically significant. SPSS version 23.0 (IBM, USA) and MedCalc Statistical Software version 19.1.3 (MedCalc Software bv, Ostend, Belgium; https://www.medcalc.org; 2019) were used for all statistical analyses.

Results

Study population

This study included 7900 patients. 10% of the patients were nonagenarians. Table 1 displays the baseline characteristics of nonagenarians versus octogenarians. Nonagenarians were predominantly female (57% versus 46%, p < 0.001), evidenced higher rates of frailty (58% vs 42%; p < 0.001), disability (44% vs. 26%; p < 0.001) and cognitive decline (50% vs. 31%; p < 0.001) but lower SOFA scores at admission (6 + 5 vs. 7 + 6; p < 0.001). Specific ICU-treatment strategies were used, with octogenarians receiving higher rates of organ support (renal replacement therapy, mechanical ventilation, vasoactive drugs), while for nonagenarians there were higher rates of treatment limitation (40% vs. 33%; p < 0.001; Table 1). After discharge from the ICU, most patients had a treatment limitation; 1053 octogenarians (55% of all octogenarians leaving the ICU alive) and 182 (85%) nonagenarians left the ICU with treatment limitations in place.

Table 1 Baseline characteristics in the total cohort, nonagenarians versus octogenarians

Survival analysis in the total cohort

The overall ICU mortality was 27% (N = 2134 of 7900 patients), the 30-day-mortality was 39% (N = 3080 of 7555 patients). Compared to the octogenarians the nonagenarians had a similar ICU mortality (27% vs. 27%; p = 0.973), but a higher 30-day-mortality (45% vs. 40%; p = 0.029, Fig. 1). Nonagenarians showed a significantly longer length of ICU-stay (84 h versus 54 h, p < 0.001).

Fig. 1
figure1

Comparison of 30-day and ICU-mortality. A: ICU-mortality [%], B: 30-day-mortality [%]. * = p < 0.05

Comparison of nonagenarians versus octogenarians in the multilevel logistic regression models

After the adjustment for the ICU cluster as a random effect (model-1), nonagenarians had an increased risk for withholding life-sustaining therapy (aOR 1.54 (95% CI 1.22–1.94; p = < 0.001)), but not for withdrawal (aOR 1.03 (95% CI 0.77–1.39; p = 0,82)). Nonagenarians received significantly less mechanical ventilation, renal replacement therapy and vasoactive drugs. There was no difference between both age groups regarding the use of mechanical ventilation, vasopressors, and ICU-mortality, but an increased risk for 30-day-mortality (aOR 1.39 (95% CI 1.13–1.72); p = 0.002). After adding patient-specific confounders (model-2), nonagenarians demonstrated no significant risks compared to octogenarians (Table 2)

Table 2 Associations of primary exposure (being nonagenarian) with mortality and management strategies in a multilevel logistic regression model

Discussion

This study examines the largest multi-centre prospectively recruited group of intensive care patients of 90 years and older published to date. Nonagenarians differ in their baseline risk distribution, management, and clinical outcomes from octogenarians. Nonagenarians had higher rates of frailty, cognitive impairment, and disability. However, when compared with octogenarians, nonagenarians had a lower illness severity and required less organ support. After adjustment for relevant confounders, the 30-day mortality did not differ between both groups.

Our results are in line with other studies looking at older ICU patients: Fuchs et al. evaluated a cohort of more than 7000 surgical and medical ICU patients and found age, especially above 75 years, to be an independent risk factor for mortality [9, 23]. In a large retrospective analysis of 1,807,531 patients admitted to an ICU between 1997 and 2016, Jones et al. reported increased mortality in patients older than 84 years, although they had a similar illness severity at ICU admission compared to younger patients [23]. Conversely, in a study evaluating 5882 patients after cardiac arrest, age alone was only a weak predictor of mortality [24]. In a recent study by Roedl et al., a survival rate of 46% with a good neurological outcome was reported for nonagenarians after cardiac arrest [11]. Recently, Druwé et al. performed a subgroup analysis on out-of-hospital cardiac arrests with a special interest in the resuscitation attempts in octogenarians: Most physicians considered cardiopulmonary resuscitation to be appropriate even in older patients with poor outcome perspectives [25]. Furthermore, in another study by Becker et al., the ICU mortality of nonagenarians was low at 30% and, importantly, the one-year survival was 50%, indicating outcomes “better than expected” in nonagenarians [26]. Of note, the study by Becker et al. was a single-centre study, and the number of patients who received vasoactive drugs was lower when compared to the patients in our multi-centre study. Therefore, we propose the higher mortality rates reported in the present study may be more representative of a “real-world scenario”.

Demoule et al. performed a matched case-control study in 36 nonagenarians admitted to an ICU. They were matched according to sex with 72 controls: ICU admissions chosen from the 20- to 69-year age range. They found no differences in the reason for admission, but nonagenarians suffered significantly less from pre-existing co-morbidities. Advanced life-support interventions were used equally. ICU and intra-hospital mortality, as well as the length of stay, did not differ significantly between nonagenarians and the control group [27]. Despite differences in the absolute length of stay, the trend of a shorter length of stay for older (nonagenarian) intensive care patients is consistent with previous studies [28].

Interestingly, being a nonagenarian was independently associated with the decision for withholding life-sustaining therapy, but not for withdrawing it. After adjustment for patient characteristics, nonagenarians evidenced no particular risk for treatment limitations compared to octogenarians. These findings contradict the usual expectation that physicians in general tend to be more reluctant to provide organ support to nonagenarians compared to similarly sick octogenarians. In nonagenarians, ICU re-triage should be emphasised: after an initial intensive care treatment for up to 48 h, patients should be critically evaluated in cooperation with their family and/ or carers and discharged to a normal ward for best-supportive care if further intensive care seems unethical, unjustified, or unlikely to improve outcomes. However, modern intensive care medicine is not limited to life-sustaining measures. Even beyond invasive ventilation, renal replacement therapy or cardiopulmonary resuscitation, intensive care medicine can provide valuable treatment for the patient, which might be intensified palliative therapy. Based on our data, being a nonagenarian does not represent a particular risk factor for adverse outcomes. Application of ICU re-triage could help to reduce the economic burden of ICU care in very old patients, in addition to unethical intensive care and distress caused to health care providers.

Mortality was similar between octogenarians and nonagenarians at ICU discharge and after 30 days. The long-term outcomes of the VIP2 study are awaited and will answer the question of whether this effect remains stable further over time.

An important limitation is, that we have no information about pre-ICU triage decisions, although this might be an important factor for the differences in disease illness scores and frailty between nonagenarians and octogenarians. Furthermore, this study only provides detailed information up to ICU-discharge and there was a significant rise in mortality during the 30 days after ICU-discharge, but we do not have detailed data on decisions made and developments during this period. Another limitation is that no a priori sample size calculation was made to detect a difference in the mortality between nonagenarians and octogenarians. Our post-hoc power calculation shows that the present study is likely underpowered for the primary outcome, and thus the reporting results that are at a higher risk of false positive results. However, this was counterbalanced by using a multilevel model to adjust for relevant confounders.

Conclusion

Nonagenarian ICU patients demonstrated higher rates of frailty but had less acute organ dysfunction than octogenarians. After adjustment for multiple relevant confounders, nonagenarians did not suffer from worse outcomes compared to octogenarian ICU patients. Rather than being a nonagenarian, the severity of illness, functional capacity – and of course the patients’ will - should guide triage decisions.

Availability of data and materials

The anonymised data can be requested from the authors if required. The datasets analysed during the current study are not publicly available due to the different local institutional and/or licensing committees but are available from the corresponding author on reasonable request.

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Acknowledgements

VIP-2-STUDY GROUP:

Hospital City ICU Name

Austria

Medical University Innsbruck Innsbruck Division of Intensive Care and Emergency Medicine, Department of Internal Medicine Michael Joannidis
Medical University Graz Graz Allgemeine Medizin Intensivstation Philipp Eller
Medical University of Innsbruck Innsbruck Department of Neurology, Neurocritical Care Unit Raimund Helbok
Hospital of St. John of God Wienna ICU B5 René Schmutz

Belgium

AZ Maria Middelares Ghent Ghent Department of Intensive Care Joke Nollet
OLVrouw Hospital Aalst Aalst Department of Intensive Care Nikolaas de Neve
AZ Sint-Lucas Ghent Department of Intensive Care Pieter De Buysscher
Ghent University Hospital Ghent Department of Intensive Care Sandra Oeyen
AZ Sint-Blasius Dendermonde Department of Intensive Care Walter Swinnen

Croatia

Clinical Hospital Centre Split Split Institute for Intensive Medicine Marijana Mikačić

Denmark

Bispebjerg Hospital Copenhagen Intensiv Terapi Afsnit Anders Bastiansen
Regionshospitalet Randers Randers ITA Andreas Husted
Sygehus Lillebælt, Kolding Sygehus Kolding Bedøvelse og Intensiv Bård E. S. Dahle
Aarhus University Hospital Aarhus Intensive Care East Christine Cramer
Viborg Regional Hospital Viborg Department of Anaesthesiology and Intensive Care Christoffer Sølling
Nordsjællands Hospital, University of Copenhagen Hillerød Department of Anaesthesiology and Intensive Care Dorthe Ørsnes
Regions Hospital Herning Herning Intensiv Herning Jakob Edelberg Thomsen
Vejle Vejle A710 Vejle Jonas Juul Pedersen
Regionshospital Nordjylland Hjørring Hjørring Intensiv Mathilde Hummelmose Enevoldsen
Aarhus University Hospital Aarhus Intensive Care North Thomas Elkmann

England

Yeovil District Hospital Yeovil Intensive Care Unit Agnieszka Kubisz-Pudelko
Peterborough City Hospital Petersborough Critical Care Unit Alan Pope
Queen Elizabeth Hospital   Critical Care Queen Elizabeth Hospital Amy Collins
Croydon University Hospital Croydon Croydon University Hospital ITU Ashok S. Raj
Royal Devon & Exeter NHS Foundation Trust Exeter Intensive Care Unit Carole Boulanger
South Tyneside District Hospital South Shields ITU Christian Frey
Maidstone Maidstone Intensive Care/High Dependency Ciaran Hart
University Hospital Southampton Southampton General Intensive Care Unit Clare Bolger
St George’s University Hospitals NHS Foundation trust London Cardiothoracic Intensive Care Unit (CTICU) Dominic Spray
Norfolk and Norwich University Hospital Norwich Critical care complex Georgina Randell
Royal Free Hospital NHS Foundation Trust London ICU 4 Helder Filipe
Royal Liverpool University Hospital Liverpool Intensive care Ingeborg D Welters
Royal Hampshire County Hospital Winchester ICU Irina Grecu
St George’s University Hospitals NHS Foundation trust London Acute Dependency Unit Jane Evans
Blackpool Victoria Hospital Blackpool General Critical Care Unit Jason Cupitt
Worthing Hospital Worthing ICU Jenny Lord
James Cook University Hospital Midlesbrough ICU 2 and 2 Jeremy Henning
Tunbridge Wells Hospital Pembury Intensive care unit Joanne Jones
St George’s University Hospitals NHS Foundation trust London Neuro Intensive Care Jonathan Ball
James Paget University Hospital Norfolk ICU/HDU Julie North
Royal Papworth Hospital NHS Foundation Trust Cambridge ICU Kiran Salaunkey
Royal Sussex County Hospital Brighton Level 7 Laura Ortiz-Ruiz De Gordoa
Salisbury Salisbury Radnor Louise Bell
Royal Bolton Hospital Bolton Royal Bolton CRITICAL CARE Madhu Balasubramaniam
Chelsea and Westminster Hospital London Adult Intensive Care Unit Marcela Vizcaychipi
Countess of Chester Hospital Chester Intensive Care Unit Maria Faulkner
Hampshire Hospitals Foundation Trust Basingstoke Basingstoke and North Hampshire Hospital McDonald Mupudzi
Hinchingbrooke Hospital Huntingdon Critical Care Megan Lea-Hagerty
Russells Hall Hospital Dudley Intensive Care Unit Russells Hall Michael Reay
Royal Cornwall Hospital Trust Cornwall Critical Care Unit Michael Spivey
Northern Devon Healthcare NHS Trust Barnstaple North Devon District Hospital Nicholas Love
Chesterfield Royal Hospital Chesterfield Intensive Care Unit Nick Spittle Nick Spittle
Royal Bournemouth Hospital Bournemouth Bournemouth Critical Care Unit Nigel White
Dorset County Dorchester ICU DCH Patricia Williams
Surrey and Sussex Healthcare NHS Trust Redhill East Surrey Hospital Patrick Morgan
Darent Valley Dartford ICU Phillipa Wakefield
Royal Surrey County Hospital Guildford Royal Surrey Rachel Savine
Wirral University Teaching Hospital Birkenhead Critical care Reni Jacob
Musgrove Park Hospital Taunton Critical care Unit Richard Innes
Kent and Canterbury Hospital Canterbury K&C ITU Ritoo Kapoor
West Suffolk NHS Foundation Trust Bury St Edmunds Critical Care Sally Humphreys
QAH Portsmouth Dept Critical Care QAH (DCCQ) Steve Rose
Whiston Hospital Liverpool Ward 4E Susan Dowling
St George’s University Hospitals NHS Foundation trust London General Intensive care Susannah Leaver
North Tees University Hospital Stockton on Tees Critical Care Unit Tarkeshwari Mane
Bradford Teaching Hospitals NHS Foundation Trust Bradford Bradford Royal Infirmary Tom Lawton
Medway Maritime Hospital Medway Adult Intensive Care Unit Vongayi Ogbeide
University Hospital Lewisham Lewisham ICU/HDU Lewisham Waqas Khaliq
St Richards Hospital Chichester Itchenor Yolanda Baird

France

CH Francois Mitterand Pau Reanimation polyvalente Antoine Romen
Hôpital Privé Claude Galien Quincy sous Sénart Polyvalente Arnaud Galbois
Saint Antoine Paris Medecine Intensive Reanimation Bertrand Guidet
Germon and Gauthier Béthune Médecine Intensive Réanimation Christophe Vinsonneau
Hôpital Ambroise Paré Boulogne Billancourt Medecine Intensive Reanimation Cyril Charron
CH Dr. Schaffner Lens Reanimation polyvalente Didier Thevenin
Hopital Européen Georges Pompidou Paris Médecine Intensive Réanimation Emmanuel Guerot
CHU de Besançon Besançon Département de Anesthésie Réanimation Chirurgicale Guillaume Besch
Hôpital Cochin Paris Médecine Intensive Réanimation Guillaume Savary
Victor Dupouy Argenteuil Service de Réanimation Polyvalente et USC Hervé Mentec
Centre Hospitalier Général Cambrai Réanimation polyvalente Jean-Luc Chagnon
Dieppe General Hospital Dieppe Médecine Intensive Réanimation Jean-Philippe Rigaud
CHU Dijon Bourgogne Dijon Medecine intensive-Réanimation Jean-Pierre Quenot
CH Bigorre Tarbes service de réanimation polyvalente Jeremy Castanera
CH de Charleville-Mézières Charleville-Mezieres Medecine Intensive Reanimation Jérémy Rosman
CHU Amiens Amiens Reanimaiton medicale Julien Maizel
Groupe Hospitalier Paris Saint Joseph Paris Réanimation polyvalente Kelly Tiercelet
CHU de Besançon Besancon Réanimation Médicale Lucie Vettoretti
CH DAX Dax Réanimation polyvalente Maud Mousset Hovaere
Louis Mourier Colombes Réanimation médico-chirurgicale Messika Messika
Tenon Paris Service de Réanimation Médico Chirurgicale Michel Djibré
Groupe Hospitalier Sud Ile de France Melun Département de médecine intensive Nathalie Rolin
Clinique Du Millenaire Montpellier Reanimation Chirurugicale II et III Philippe Burtin
Marne La Vallee Jossigny Reanimation Polyvalente Pierre Garcon
CHU Lille Lille Critical Care Center Saad Nseir
CHU de Caen Caen Service de Réanimation Médicale Xavier Valette

Germany

Klinikum rechts der Isar TU München München Toxikologische Intensivstation Christian Rabe
University Hospital Ulm Ulm Anesthesiologic Intensive Care Department Eberhard Barth
Katholisches Krankenhaus St. Johann Nepomuk Erfurt Klinik für Innere Medizin II/ Kardiologie und Internistische Intensivmedizin Henning Ebelt
Klinikum rechts der Isar, School of Medicine, Technical University of Munich München Intensivstation IS2/L2a Kristina Fuest
Jena University Hospital, Department of Internal Medicine I Jena Internistische Intensivstation Marcus Franz
West German Heart and Vascular Center Essen (WHGZ) Essen INTK Michael Horacek
Universitätsmedizin der Johannes Gutenberg-Universität Mainz Mainz Anästhesie-Intensivstation Michael Schuster
University Hospital Frankfurt Frankfurt am Main Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy Patrick Meybohm
University Hospital Düsseldorf Düsseldorf MI1/2 Raphael Romano Bruno
Robert-Bosch-Krankenhaus Stuttgart 1D Sebastian Allgäuer
Heidelberg University Hospital Heidelberg Station 13 IOPIS Simon Dubler
Klinikum rechts der Isar, School of Medicine, Technical University of Munich München Intensivstation IS1 / M2b Stefan J Schaller
University Hospital Leipzig Leipzig Department of Anesthesiology and Intensive Care Medicine Stefan Schering
St Vincenz Hospital Limburg/Lahn Intensive care unit Stephan Steiner
Hannover Medical School Hannover 44 Thorben Dieck
Universitätsklinikum Knappschaftskrankenhaus Bochum Bochum Operative IBA Tim Rahmel
Universitätsklinikum Schleswig-Holstein Lübeck IKI 12a Tobias Graf

Greece

Asklepieio Voulas Athens ICU Anastasia Koutsikou
Xanthi General Hospital Xanthi Xanthi ICU Aristeidis Vakalos
Sismanoglio - Amallia Fleming G. H Marousi - Athens Attika Sismanoglio Bogdan Raitsiou
General Hospital Agios Pavlos Thessaloniki ICU Agios Pavlos Elli Niki Flioni
General Hospital of Larissa Larissa General ICU Evangelia Neou
Lamia General Hospita Lamia Lamia ICU Fotios Tsimpoukas
University Hospital of Ioannina Ioannina Intensive Care Unit Georgios Papathanakos
General Hospital of Athens Korgialeneio Mbenakeio Red Cross Athens ICU Giorgos Marinakis
General Hospital of Eleusis Thriassio Eleusis ICU Latsio Ioannis Koutsodimitropoulos
KONSTANTOPOULEION GEN. HOSPITAL Athens General ICU Kounougeri Aikaterini
Sotiria Hospital Athens ICU 1st Department of Pulmonary Medicine Athens Medical School, National and Kapodistrian University of Athens Nikoletta Rovina
General Hospital of Patra Achaia ICU Stylliani Kourelea
G Gennimatas Hospital of Thessaloniki Thessaloniki ICU G GENNIMATAS Polychronis Tasioudis
Agioi Anargiroi Hospital Athens General ICU Vasiiios Zidianakis
Theagenio Theassaloniki Meth Theagenio Vryza Konstantinia
University General Hospital Ahepa Thessaloniki Metha Zoi Aidoni

Ireland

Mater Misericordiae University Hospital Dublin Department of Critical Care Medicine Brian Marsh
University Hospital Limerick Limerick UHL ICU Catherine Motherway
University Hospital Galway Galway General ICU Chris Read
St James’s Hospital Dublin ICU Ignacio Martin-Loeches

Italy

Arnas Ospedale Civico De Christina Benfratelli Palermo Terapia Intensiva Polivalente Con Trauma Center Andrea Neville Cracchiolo
Istituto Ortopedico Rizzoli Bologna TIPO Aristide Morigi
San Giuseppe Empoli Terapia Intensiva Italo Calamai
Humanitas Reseach Hospital Milan General ICU Stefania Brusa

Libya

Al-Zawia University Hospital Al-Zawia ICU Ahmed Elhadi
Alkhums Hospital Alkhums ICU Ahmed Tarek
Elkhadra Hospital Tripoli ICU Ala Khaled
Abo Selim Trauma Hospital Tripoli ICU Hazem Ahmed
Tripoli Medical Center Tripoli CCU Wesal Ali Belkhair

Netherland

Medisch Spectrum Twente Enschede Intensive Care Center Alexander D. Cornet
Erasmus Medical Center Rotterdam ICU adults Diederik Gommers
UMC Utrecht Utrecht ICU departement Dylan de Lange
Albert Schweitzer Ziekenhuis Dordrecht ICU asz Eva van Boven
Isala Hospital Zwolle Intensive Care Jasper Haringman
Diakonessenhuis Utrecht Utrecht Intensive care Lenneke Haas
Haga Ziekenhuis The Hague ICU Lettie van den Berg
Canisius Wilhelmina Ziekenhuis Nijmegen C38 Oscar Hoiting
Jeroen Bosch Ziekenhuis Den Bosch IC JBZ Peter de Jager
Medical Centre Leeuwarden Leeuwarden Department of Intensive Care Rik T. Gerritsen
Zuyderland Medical Center Heerlen Zuyderland Heerlen Tom Dormans
University Medical Center Groningen Groningen Department of Critical Care Willem Dieperink

Norway

Førde Central Hospital Førde Department of Emergency Medicine and Inensive Care Alena Breidablik Alena Breidablik
Kongsberg Kongsberg Intensivavdelingen Anita Slapgard
Sykehuset Østfold Grålum Intensiv Anne-Karin Rime
Sykehuset Telemark Skien Intensiv Skien Bente Jannestad
Haukeland University Hospital Bergen General ICU Britt Sjøbøe
Ålesund Ålesund Medisinsk intensiv Eva Rice
Ålesund hospital Ålesund Dept. Anesthesia and Intensive Care, Surgical ICU Finn H. Andersen
Kristiansund sykehus Helse Møre og Romsdal HF Kristiansund N Intensiv Kristiansund Hans Frank Strietzel
Namsos Sykehus Namsos Intensivavdeling Jan Peter Jensen
Haukeland University Hospital Bergen Medisinsk intensiv og overvåkning (MIO) Jørund Langørgen
Oslo University Hospital Oslo Intensive Care section Ullevaal Kirsti Tøien
Stavanger University Hospital Stavanger Department of Intensive Care Kristian Strand
Haugesund sjukehus Haugesund Intensivavdelingen Michael Hahn
St Olavs University Hospital Oslo Hovedintensiv Pål Klepstad

Poland

Szpital Wojewódzki w Bełchatowie Bełchatów Oddział Intensywnej Terapii Aleksandra Biernacka
Heliodor Swiecicki Clinical Hospital at the Karol Marcinkowski Medical University in Poznan Poznań Anaesthesiology intensive care and pain treatment Department Anna Kluzik
University Hospital in Zielona Góra Zielona Góra Clinical Department od Anesthesiology and Intensiv Care Bartosz Kudlinski
Regional Teaching Hospital Bielsko-Biała Department of Anaesthesiology and Intensive Care Dariusz Maciejewski
St. John Grande Hospital Kraków Oddział Anestezjologii i Intensywnej Terapii Dorota Studzińska
The John Paul II Hospital Krakow Department of Anesthesiology and Intensive Care Hubert Hymczak
Uniwersyteckie Centrum Kliniczne w Gdańsku Gdańsk Klinika Anestezjologii i Intensywnej Terapii Jan Stefaniak
Pomeranian Medical University Szczecin Department of Anesthesiology and Intensive Care Joanna Solek-Pastuszka
University Hospital in Cracow Kraków Anaesthesiology and Intensive Care Unit No.1 Joanna Zorska
Regionalne Centrum Zdrowia w Lubinie Lubin Oddział Anestezjologii i Intensywnej Terapii Katarzyna Cwyl
University Clinical Center Katowice Katowice Department of Anaesthesiology and Intensive Care - School of Medicine in Katowice, Medical University of Silesia Lukasz J. Krzych
Teching Hospital No 2 Szczecin Department Anaesthesiology Intensive Therapy and Acute Poisoning Maciej Zukowski
4th Military Hospital in Wrocław Wrocław Anesthesia and Intensive Care Unit Małgorzata Lipińska-Gediga
Centrum Chorób Płuc Łódź Oddział Anestezjologii i Intensywnej Terapii Marek Pietruszko
The Dr. Wł. Biegański Regional Specialist Hospital in Łódź Łódź Department of Anaesthesiology and Intensive Therapy - Centre for Artificial Extracorporeal Kidney and Liver Support Mariusz Piechota
Central Clinical Hospital CKD - University Medical College in Lodz Lodz Anaesthesia and Intensive Care Clinic Marta Serwa
First Independent Teaching Hospital No. 1 Lublin II Department of Anesthesiology and Intensive Care Miroslaw Czuczwar
Krakowski Szpital Specjalistyczny im. Jana Pawła II Kraków Thoracic Anaesthesia and Respiratory ICU Mirosław Ziętkiewicz
Wroclaw Medical University Wroclaw Department of Anesthesiology and Intensve Therapy Natalia Kozera
Szpital św.Anny W Miechowie Miechów Oddział Anestezjologii i Intensywnej Terapii Paweł Nasiłowski
University Hospital in Krakow Krakow ICU Skawinska Paweł Sendur
Infant Jesus Teaching Hospital Warsaw I Department of Anaesthesiology and Intensive Care Paweł Zatorski
Regional Hospital in Bialystok Bialystok Department of Anaesthesiology and Intensive Care Piotr Galkin
Opole University Hospital Opole Department of Anesthesiology and Intensive Care Ryszard Gawda
University Hospital in Bialystok Bialystok Department of Anaesthesiology and Intensive Therapy Urszula Kościuczuk
Dr Antoni Jurasz University Hospital in Bydgoszcz Bydgoszcz Department of Anesthesia and Critical Care Waldemar Cyrankiewicz
Saint Lucas Hospital, Konskie Konskie Intensive Care Department Wojciech Gola

Portugal.

Centro Hospitalar do Porto Oporto Serviço de Cuidados Intensivos 1 Alexandre Fernandes Pinto
Hospital S. José, CHULC EPE Lisboa UCI Neurocríticos e Trauma Ana Margarida Fernandes
Hospital São Francisco Xavier Lisbon Unidade Cuidados Intensivos Polivalente Ana Rita Santos
Hospital da Luz Lisboa UCI Hospital da Luz Cristina Sousa
Hospital de Viseu Viseu UCIP Inês Barros
Hospital Professor Doutor Fernando Fonseca EPE Amadora Serviço de Medicina Intensiva SMI Isabel Amorim Ferreira
Hospital Garcia de Orta - HGO Almada Serviço de Medicina Intensiva Jacobo Bacariza Blanco
Hospital São Bernardo - CH Setúbal Setúbal Serviço de Cuidados Intensivos João Teles Carvalho
Centro Hospitalar de Trás Montes e Alto Douro Vila Real Serviço de Medicina Intensiva Jose Maia
Lusiadas Lisboa Lisboa UCI- Lusiadas Nuno Candeias
CHMT-Abrantes Abrantes SMI Nuno Catorze

Russia.

Privolzhskiy District Medical Center Nizhniy Novgorod Department of Anesthesiology and Intensive Care Vladislav Belskiy

Spain.

Hospital De Bellvitge Barcelona UCI Africa Lores
Hospital General Universitario de Albacete Albacete UCI Polivalente Angela Prado Mira
Hospital Clinic of Barcelona Barcelona Respiratory Intensive Care Unit Catia Cilloniz
Hospital Universitario Río Hortega Valladolid UVI Polivalente y Coronaria David Perez-Torres
Universitario La Paz Madrid Surgical ICU Emilio Maseda
General Universitario de Castellón Castellón Servicio de Medicina Intensiva Enver Rodriguez
Hospital Universitario Río Hortega Valladolid UVI Neurocríticos Trauma y Quemados Estefania Prol-Silva
Hospital de Tortosa Verge de la Cinta Tortosa Servei de Medicina Intensiva Gaspar Eixarch
Parc Taulí Sabadell Parc Taulí Gemma Gomà
Clínico Universitario de Valencia Valencia Surgical Intensive Care Unit Gerardo Aguilar
Hospital Universitario de Torrejon Torrejon de Ardoz, Madrid Intensive Care UNit Gonzalo Navarro Velasco
Hospital General de Catalunya Barcelona HGC Marián Irazábal Jaimes
Hospital Universitario Sagrado Corazon Barcelona Intensive Care Unit Mercedes Ibarz Villamayor
Hospital reina Sofía Murcia Reina Sofía Noemí Llamas Fernández
Complejo Hospitalario de Segovia Segovia ICU Segovia Patricia Jimeno Cubero
Universitario de Getafe Getafe Intensive Care and Burn Unit Sonia López-Cuenca
Germans Trias i Pujol Hospital Badalona General ICU Teresa Tomasa
Centralsjukhuset i Karlstad Karlstad IVA Anders Sjöqvist

Sweden.

Umeå University Umeå Department of Surgical and Perioperative Sciences, Anestesiology and Intensive Care Medicine Camilla Brorsson
Vrinnevisjukhuset Norrköping IVA Norrköping Fredrik Schiöler
Sundsvall Hospital Sundsvall Sundsvall ICU Henrik Westberg
Blekingesjukhuset Karlskrona Intensivvårdsavdelning 31 Jessica Nauska
Alingsås Lasarett Alingsås Intensivvårdsavdelningen Joakim Sivik
Västervikssjukhus Västervik IVA Västervikssjukhus Johan Berkius
Sahlgrenska University Hospital/ Område 3/ Mölndals sjukhus Göteborg IVA avd 227 Karin Kleiven Thiringer
Linköping University Hospital Linköping ICU Linköping Lina De Geer
Linköping University Hospital Linköping Cardiothoracic Intensive Care Unit Sten Walther

Switzerland.

Hopitaux Universitaires de Genève Geneva Adult Intensive Care Unit Filippo Boroli
University of Bern Inselspital Bern Department of Intensive Care Medicine Joerg C. Schefold
Fribourg Hospital Fribourg Intensive Care Unit Leila Hergafi
Centre Hospitalier Universitaire Vaudois Lausanne Service de médecine intensive adulte Philippe Eckert

Turkey.

Ordu University Training and Research Hospital Ordu General ICU Ismail Yıldız

Ukraine.

Dnipro Mechnikov Regional Clinical Hospital Dnipro Intensive Care Unit of Polytrauma Ihor Yovenko
European Wellness Academy, Luhansk Regional Clinical Hospital Luhansk ICU 1 Yuriy Nalapko
European Wellness Academy, Luhansk Regional Clinical Hospital Luhansk ICU 2 Yuriy Nalapko

Wales.

Glan Clwyd Hospital Bodelwyddan Critical Care Richard Pugh

Financial disclosure statement

No (industry) sponsorship has been received for this investigator-initiated study.

Funding

This study was endorsed by the ESICM. Free support for running the electronic database and was granted from the dep. of Epidemiology, University of Aarhus, Denmark. Financial support for creation of the e-CRF and maintenance of the database was possible from a grant (open project support) by Western Health region in Norway) 2018 who also funded the participating Norwegian ICUs. DRC Ile de France and URC Est helped conducting VIP2 in France. Open Access funding enabled and organized by Projekt DEAL.

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BW, RRB and CJ analysed the data and wrote the first draft of the manuscript. HF and BG and DL contributed to statistical analysis and improved the paper. MK and AB and AM and FA and AA and SF and MC and SC and LF and ML and JM and BM and RM SO and CÖ and BP and IS and WS and AV and XW and SL and CB and SW and JS and MJ and YN and ME JF and TZ gave guidance and improved the paper. All authors read and approved the final manuscript.

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Correspondence to Christian Jung.

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The primary competent ethics committee was the Ethics Committee of the University of Bergen, Norway. A study protocol was provided to participating centres. Every participating centre obtained ethics approval according to local legislation. A copy of the ethics approval was sent to the study coordinator before start of the study. Institutional research ethic board approval was obtained from each study site. This was a prerequisite for participation in the study. All methods were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by the local institutional and/or licensing committees. Written informed consent was obtained of all included subjects, except for patients from VIP2 of sites where study inclusion was explicitly granted without written informed consent. The inclusion of deceased patients was strictly in accordance with the requirements of the local competent ethics committees. In most cases, the consent of the patient or the legal guardian was mandatory (see above). The studies conducted were observational studies. No examinations (e.g. blood sampling) or tissue sampling took place.

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Bruno, R.R., Wernly, B., Kelm, M. et al. Management and outcomes in critically ill nonagenarian versus octogenarian patients. BMC Geriatr 21, 576 (2021). https://doi.org/10.1186/s12877-021-02476-4

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Keywords

  • Octogenarians
  • Nonagenarians
  • Frailty
  • Intensive care medicine
  • Outcome