Open access peer-reviewed chapter

Inhospital Outcome of Elderly Patients in an Intensive Care Unit in a Sub-Saharan Hospital

By Martin Lankoande, Papougnezambo Bonkoungou, Oubian Soulemane, Ghislain Somda and Joachim Sanou

Submitted: September 18th 2018Reviewed: January 10th 2019Published: September 3rd 2019

DOI: 10.5772/intechopen.84308

Downloaded: 46

Abstract

People living more and more longer and elderly is growing and that requires change in health system including geriatric care to be innovative. The aim of this study was to analyze causes and prognosis of older patients admitted in an intensive care unit (ICU) in Sub-Sahara area. A retrospective study over 5 years of patients aged 65 years and above admitted in ICU of Yalgado Ouedraogo was carried out. Of the 2116 patients admitted in ICU, 237 (11.2%) were older. The mean age was 71.7 ± 6.1 years. Males were predominant (sex ratio = 2.4). Medical history was present in 80.6%. The Charlson mean score was 4.8 ± 1.8. Patients with coma represented 42%. Ambulatory Simplified Acute Physiologic Score (ASAPS) up to 8 was recorded in 49%. Medical diseases (60%) like nervous system (37.9%) were reported. Stroke and general surgery were the main affection. Globally treatment was based on fluid management and oxygen supply. During ICU stay, complications occurred in 37.5% like acute respiratory distress syndrome (ARDS) in 10.5%. The mean length of stay was 5.3 ± 7.4 days. The elderly mortality was 73%; those 90% died within 7 days. In multivariate analysis, shock (odds ratio: OR = 2.2, p = 0.002), severe brain trauma (OR = 9.6, p = 0.002), coma (OR 5.8 p < 0.003), surgical condition (OR = 4.2, p = 0.003), ASAPS ≥ 8 (OR = 4.3, p = 0.001), complication occurring (OR = 5.2, p = 0.001), and stroke (OR = 3.7, p = 0.001) were independent risk factors of death. Elderly patients are frequently admitted in ICU with high mortality.

Keywords

  • elderly
  • intensive care unit
  • mortality
  • Burkina Faso

1. Introduction

People aged 65 or 60 years and above are considered older [1], respectively, in developed countries and in Africa [1]. The world population grows older in most regions. In the year 2012, the global population reached 7 billion, and 562 (8%) millions of them were older. In 2015, the elderly rose by 55 million representing 8.5% of the world population [2]. In Africa, the rate of elderly (6.6% in 2015) will reach 9.6% in 2050 [2]. Like in other countries older people are increasing in Burkina Faso. This demographic transition increase health care needs especially health-care facilities, policies and training. Critical patients have increased risk because of associated morbidities [3]. These people are characterized by their frailty with risk of death. This high risk met in anesthesia and intensive care raises some voice around the world particularly in the UK where some actions like implementation of perioperative medicine were planned. The physician has a major role for health-care improvement for multimorbid and frail patients [4]. In Burkina Faso, intensive care services need to be implemented. Government-adopted politics and some physicians are in specialization in foreign countries. No guidelines are available on older patient care in our countries, and patients are treated like other patients. More and more older patients are admitted in ICU and most died. In order to reduce the number of deaths, more information need to be identified for a better evidence-based action. The aim of this study was to analyze causes and prognosis of older patients admitted in the ICU of Yalgado Hospital in Burkina Faso.

2. Methods and materials

2.1 Setting and population

A retrospective study was carried out among patients aged ≥65 years in the ICU of the teaching hospital Yalgado Ouedraogo over 5 years (January 1, 2011–December 31, 2015). The Yalgado Ouédraogo Hospital is 800-bedded hospital where no specialist in geriatric is available. The ICU is an 8-bedded unit and is poorly equipped. Data recorded after approval by the Ethical and Research Committee (Ethical and National Scientific Research and Technology Center, ENSRTC) include sociodemographic, comorbidities, diagnosis, causes of ICU admission, Glasgow Coma Score, the Ambulatory Simplified Acute Physiologic Score (ASAPS), Charlson Comorbidity Score, sepsis, shock on admission, length of stay (LOS), management, and outcome. The ASAPS [5] is a scale used for gravity evaluation for ICU patients. Patients were categorized into three groups of age (65–74 years or “young old,” 75–84 or “old old,” and >85 or oldest old).

2.2 Statistical analysis

Quantitative data were presented as mean and standard deviation. Their variations were analyzed using ANOVA test. Qualitative data are presented as numbers and percentages and variations analyzed using the chi-square test. Chi-square test helped to compare survivors to non-survivors with p ≤ 0.05. Analysis was performed with the Epidemiologic Info package 7.1.5.0.

3. Results

Among 2116 patients admitted in ICU, 237 (11.2%) were older. The mean age was 71.7 ± 6.1 years; the sex ratio was 2.4. A total of 173 deaths were observed (73%). Demographic and facility characteristics of deaths of patients are summarized in Table 1.

CharacteristicFrequencyPercentage
Age (years)65–74 years16770.5
75–84 years5824.5
More 84 years125
GenderMale16770.5
Female7029.5
ResidencyUrban15967.1
Rural area7832.9
ProfessionRetired4832.6
Housewife3725.2
Farmer3121.1
Public/private3121.1
Referral facilitiesDistrict hospital10745.1
Regional hospital3916.5
Dispensary31.3
Teaching hospitala198
Private hospital6929.1

Table 1.

Demographic characteristics of patients (n = 237).

Teaching Hospital (YO: 8; Blaise Compaoré Hospital: 6; Sourou Sanou Hospital = 5).


Comorbidity was identified in 80.6%. The Charlson mean score was 4.79 ± 1.83 [IC 95%; 2–12]. The mean score of Glasgow scale was 4.8 ± 1.2. Medical history and comorbidity are described in Table 2. Among the patients, 42% were admitted with coma. The ASAPS ≥8 was recorded as 49%. Clinical data are summarized in Table 3. Medical condition (60%) and nervous disease (37.9%) were the main diagnosis. Neurology disease and general surgery were the main affection by specialty (Figure 1). Stroke was the most frequent (27.4%) followed by peritonitis (Table 3). Intensive care was based on fluid, pain killers, and oxygen supply. During hospitalization, complications occurred in 37.5%, and ARDS was the most frequent (10.5%). In total, 173 older patients died (73%). The length of stay was 5.3 ± 7.4 days [IC 95%; 1–58] (Table 4).

Medical historyFrequencyPercentage
High blood pressure12050.6
Diabetes5623.6
Ulcer156.3
Heart disease93.8
Kidney failure83.4
Stroke41.7
Asthma41.7
HIV/AIDS31.3
Lymphoma20.8
Live cancer20.8
Esophagus stenosis10.4
Esophagitis10.4
Liver abscess10.4
Goiter disease10.4
None6025.3
Charlson score<32510.5
4–513958.6
6–75322.3
≥8208.4

Table 2.

Past history and comorbidity (N = 237).

Clinical dataNumberPercentage
Admission condition
 Medical condition18377.2
 Surgical condition5422.8
Diseases
 Stroke6527.4
 Prostate tumor2711.4
 Sepsis2610.9
 Trauma/burn2510.5
 Bowel obstruction135.5
 Heart disease182.5
 Diabetic acute metabolic complications208.4
 Kidney failure166.7
 Othera2711.4
 Total237100
Complications
 Sepsis2510.5
 Acute respiratory distress syndrome3842.7
 Shock156.3
 Coma1921.3
 Bed sores83.4
 Acute pulmonary edema52.1
 Pulmonary aspiration52.1
 Pulmonary embolism10.4
 Otherb52.1
Outcomes
 Death in ICU17373
 Transfer to other ward4820.2
 Hospital discharge with physician authorization104.2
 Discharge without physician authorization62.5
 Total237100

Table 3.

Diagnosis and outcome of patients (n = 237).

aOther: anemia (n = 3), dehydratation (n = 2); bHernia, blood disorder, ulcer, hydronephrosis, asthma, skin disease, leukemia.

Figure 1.

Nature of disease (n = 237).

CharacteristicsAll patients (N = 237)Non-survivors (n = 173)Survivors (n = 64)P value
Age (mean; years)71.7 ± 6.171.6 ± 5.972.1 ± 6.40.5
 Age group (%)
 65–74167 (70.4)123 (73.6)44 (26.3)0.7
 75–8458 (24.5)42 (72.4)16 (27.6)0.9
 85 above12 (5.1)8 (66.6)4 (33.3)0.6
Gender
 Male (n = 167)167 (70.4)127 (76.05)40 (23.9)0.1
 Female (n = 70)70 (29.6)46 (65.7)24 (34.3)
Residency area
 Urban159 (67.1)97(61)62(39)0.3
 Rural78 (32.9)62(79.5)16(20.5)
Reference specialty (%)
 Emergency service134 (56.4)108 (80.6)26 (20.4)0.001
 Medicine21 (8.8)14 (66.6)7(33.8)0.4
 Surgery54 (22.8)49 (90.7)5(9.3)0.003
Reasons for admission
 ACS133 (56.1)109 (81.9)24 (18)<0.001
 Poor condition6 (2.5)3 (50)3 (50)0.3
 Burn11 (4.6)7 (63.64)4 (36.4)0.4
 ARDS9 (3.8)7 (77.7)2 (22.2)1
 Shock78 (32.9)47 (60.3)31 (39.7)0.002
Charlson score (Median)4.8 ± 1.84.6 ± 1.75.09 ± 2.040.12
  ≥ 820 (8.4)11 (55)9 (45)0.03
  < 8217 (91.6)103 (47.4)76 (52.6)0.4
Glasgow coma score (mean value)9.64 ± 4.018.9 ± 3.811.8 ± 3.60.03
  < 842.0669 (88.4)9 (11.5)<0.001
  ≥ 857.958 (68.2)76 (31.8)
ASAPS (mean)7.9 ± 3.58.6 ± 3.55.8 ± 2.6<0.001
 ASAPS ≥8150 (87)13
 ASAPS <8109 (63.5)36.6
Diagnosis
 Stroke65 (27.4)57 (87.69)8 (12.31)0.001
 Peritonitis22 (9.3)18 (81.82)4 (18.18)0.4
 AMCDA20 (8.4)10 (50)10 (50)0.01
 SBTB19 (8)18 (94.74)1 (5.26)0.02
 Bowel obstruction13 (5.5)7 (53.85)6 (46.15)0.1
 Burn10 (4.2)6 (60)4 (40)0.4
 Severe infection10 (4.2)8 (80)2 (2)0.7
 Prostatic adenoma9 (3.8)5 (55.56)4 (44.44)0.2
 Heart disease6 (2.5)4 (66.67)2 (33.33)0.6
 Prostatic cancer5 (2.1)1 (20)4 (80)0.01
 Inguinal hernia5 (2.1)3 (60)2 (40)0.6
 OtherC53 (22.4)36 (67.92)17 (32.0)0.1
Complications occurred in ICU
 Yes = 8989 (37.5)80 (89.9)9 (10.1)<0.001
 No = 148148 (62.5)93 (62.8)55 (37.2)
Mechanical ventilation2 (0.8)2 (100)0Ki = 0.7
Length of stay (mean)5.3 ± 7.45.2 ± 85.5 ± 5.10.8

Table 4.

Comparison of survivors and non-survivor’s patients (n = 237).

ACS, alteration of consciousness; ARDS, acute respiratory distress syndrome, AAMCD, acute metabolic complication of diabetes; BSBT, severe brain trauma, COther disease, ASAPS: ambulatory simplified acute physiologic scale.

Most patients were between 64 and 74 years old. There was significant difference in terms of group of age, between patients with a Charlson score up to 8 versus less than 8 (p = 0.001) and those with complications occurring in ICU versus no complications occurring (p = 0.01) (Table 5). In multivariate analysis, surgery, coma, shock, stroke, and severe brain trauma were independent risks factors of death (Table 6).

Variables65–74 years
n = 167 (70.4%)
75–84 years
n = 58 (24.5%)
Over 84 years
n = 12 (5.1%)
P value
Age (mean; years)68.3 ± 2.878.2 ± 2.586.6 ± 1.6<0.001
Gender
 Male (n = 167)1184090.9
 Female (n = 70)49183
Reasons for admission
 ACS923360.9
Poor condition682650.6
 Burn7210.7
 ARDS13600.4
 Shock11420.4
Charlson score4.55.16.30.001
  ≥ 812530.1
  < 8155539
Glasgow score (mean)9.7 ± 4.029.4 ± 4.18.8 ± 3.50.6
  < 812530.1
  ≥ 8155539
ASAPS (Mean)7.9 ± 3.88.08 ± 2.98.1 ± 2.70.9
 ASAPS ≥8652580.1
 ASAPS <8772240.4
Complications in ICU0.01
 Yes = 89651950.6
 No = 148102397
Mechanical ventilation2000.6
Length of stay (LOS)5.3 ± 6.85.6 ± 9.22.7 ± 2.20.4
Death123 (73.6)42 (72.4)8 (66.6)0.2

Table 5.

Comparison of patients according to age group (n = 237).

ACS, Alteration of consciousness; ARDS, Acute respiratory distress syndrome; ICU, Intensive care unit; ASAPS, Ambulatory simplified acute physiologic scale.

DiagnosisAdjusted OR (CI 95%)p
Medical condition without comaReference
 Surgery4.2 [2.4–10.3]0.003
 Coma at admission2.9 [1.6–5.4]0.001
 Coma in ICU5.8 [2.3–14.6]0.001
 Shock during admission2.2 [1.6–4.0]0.002
 ASAPS ≥84.3 [1.1–8.5]0.001
 Stroke3.7 [1.6–8.7]0.001
 Severe brain trauma9.6 [1.2–75.1]0.02
Complications in ICU0.001
 NoReference
 Yes5.2 [2.4–11.3]0.001

Table 6.

Risk factors for ICU mortality of elderly patients.

ACS, alteration of consciousness; ARDS, acute respiratory distress syndrome; ICU, intensive care unit; ASAPS, ambulatory simplified acute physiologic scale.

4. Discussion

Older patients accounted for 11.2% of ICU admission. This rate is comparable to the 10% of Owojuyigbe et al. [6] findings in Nigeria but less than the findings in the United States (42–52%). Better health-care system organization, life expectancy improvement explains high prevalence in developed countries. In Burkina Faso, the elderly accounted 2.4% of the population [7]. Elderly mortality (73%) is high compared to Belayachi et al. [8] reports (44.7%) in Morocco and Wade et al. [9] (42.8%) at Senegal. The high mortality reported in developing countries compared to developed countries may be due to inadequate care, late consultation, poverty, and poor equipment of ICU.

The mean age (71.7) in this study was comparable to Owojuyigbe et al. [6] report (73 years) and Belayachi et al. [8] report (72 years). In Porto, Abelha et al. [10] reported 64.1 years. The age varies according to regions and studies. Patients were mostly males, but there is no correlation between gender and outcome in this study. In other studies, [8], [10] report similar finding, while Fowler et al. reported higher mortality with female patient [11]. In this study, the majority lives in urban area (67.1%) and was retired (32.6%). Patients were referred from district hospital (45.1%). In Burkina Faso, district hospitals are so far to the National Referral Hospital, and patients travel so far in poor condition that causes delay to care and worsens prognosis. In our study, 49.4% had high Charlson comorbidity score. Older patients have many comorbidities which reduce their capability, increase disability, decrease quality of life, and increase risk of death [12]. In the literature, it has been reported that the pooled mortality risk for elderly people with multimorbidity was high compared with those with one chronic disease or none [12, 13]. Alteration of consciousness was found in 56.1% and shock in 32.9%. Our findings were comparable to those reported by Vosylius et al. [14]. ASAPS ≥8 was recorded in 49%. The delay to consult and care worsens patient condition. Medical condition was the main diagnosis, and stroke was most frequent (27.4%) followed by peritonitis. Our findings are different with Belayachi et al. [8] who found that respiratory infections were most predominant. Diagnoses vary according to study, social environment, and countries [6, 8, 11, 14].

Advanced age alone does not preclude successful outcome [9]. In multivariate analysis, independent risk factors were surgical conditions, coma, shock during admission, ASAPS ≥8, stroke, and severe brain trauma. These findings are comparable to literature reports [9, 3, 15]. There is no difference between age groups in terms of mortality. The mean LOS was short, while 46.6% of patients died within 3 days and 90% of patient died within a week. For patients over 84 years, LOS was shorter, and inhospital mortality was less than in patients aged less than 84 years. The family usually refuse care and discharge once a poor outcome is pronounced. This explains the relatively low mortality rate and short stay of this group of age. Elderly patients living in rural area die more than those in urban area, but this rate is not significant. The overall poor outcomes may be due to late consultation and poor quality of care due to the inadequate facilities and equipment and lack of medications due to poverty. Even most of our patients live in urban area and was retired care are not generally provided continuously because of financial barrier. Retired people do not have insurance in public hospital but only in private sector which does not have ICU. Delay to consultation may be related to limited education, traditional healing practice, poverty, and poor transportation. In Africa elderly consider conventional medicine as for infant and their family geriatric disease is associated to end of live. That sometime delay use of conventional medicine. The LOS was short in our study compared to other study (Belayachi et al. [8], 6.6 days; Fuchs et al., 9 days), but some authors found a longer LOS (12.9–23 days) [10, 16]. In our study mortality was high (73%) compared to literature [10, 11, 14, 15]. Comorbidity, frailty, low number of physicians and nurses, insufficiency of skills, lack of equipment, and insurance are some hypotheses to explain mortality. Geriatric training implementation, a good follow-up, and perioperative medicine implementation can reduce admission in ICU. In order to improve elderly care, we need to make policies, sensitize people for early consultation, and implement universal health coverage. Our study showed that most patients have comorbidities. Multimorbidity is especially common among older adults, and its negative consequences include higher disability, decrease in quality of life, and increased risk of death. The insufficiency of follow-up, limitation of skills on geriatric care, and insufficiency of hospital equipment increase risk of death.

Most of the people of Burkina Faso live in the rural area and are farmers. Cultural and financial barriers are most important in this area where people practice traditional healing because they consult later to modern health services. Diagnosis is mostly performed at an advanced condition where treatment is compromised. So the universal health coverage is not implemented, and people have to make direct payment before care. Even with most people who are living in the urban area and retried, the social security of our country does not give possibility of prepayment but only reimbursement and this situation delay care. In response to the recommendations of the World Health Organization and United Nations Assembly on Aging, our country made policies and defines laws to protect older people in the year 2015, but these laws are still unimplemented because of the lack of decree. By promoting specialization in geriatry, implementation of policies protecting older people, Burkina Faso government demonstrated a will to promote elderly well-being and health care. The national program of social protection of older people initiated in 2016 will improve health care with a better follow, universal health promotion. In the particular case of intensive care services, the national society of anesthesiology must implement perioperative medicine course. More commitment and investment are needed to enhance of the elderly care. This study has limitations due to retrospective character and long-term outcome data missing. The impact of hospitalization, biologic abnormality, the APACHE, and SOFA score on outcome was not evaluated. This study showed that most of those who live in urban area raise an issue of representativeness for the population, and we cannot generalize these findings.

5. Conclusions

Older patients were frequently admitted in the ICU of Yalgado hospital. Patients are mostly “young old” but have comorbidities. Patients were admitted with the serious condition. LOS was short which indirectly means poor management with early death. Mortality is high. The main factors of death are shock, severe brain trauma, coma, surgical condition, complication occurring, and stroke. The public must be sensitized to consult early and respect medical advices. Health-care worker must improve their skills and adapted care to older people. The implementation of geriatric center can allow improved care for a low rate of death.

Conflict of interest

None.

Notes/thanks/other declarations

Thanks to Dr. Ghislain for data collection.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3.0 License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Martin Lankoande, Papougnezambo Bonkoungou, Oubian Soulemane, Ghislain Somda and Joachim Sanou (September 3rd 2019). Inhospital Outcome of Elderly Patients in an Intensive Care Unit in a Sub-Saharan Hospital, Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs) and Resource-Limited Settings, Jasneth Mullings, Camille-Ann Thoms-Rodriguez, Affette M. McCaw-Binns and Tomlin Paul, IntechOpen, DOI: 10.5772/intechopen.84308. Available from:

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