Outcomes of Cardiac Arrest in the Elderly

Geriatric RoundsJanuary 12, 2010

Ben Wilson

Context: CPR by Default

“Cardiopulmonary resuscitation (CPR) evolved from a specific intervention applied in limited clinical situations to the default response to cardiac arrest in or out of the hospital, an evolution accompanied by a dramatic decline in survival rates after CPR.”-Ehlenbach WJ et al. NEJM 2009; 361:22-31.

Case

80W, Philippino, admitted with GLF with L intertrochanteric fracturePMHx– CAD– CHF– DM2- insulin– OP

Profound functional disabilityFirm R1 LOC

My Purpose

Are age and comorbid burden useful in determining those who are unlikely to survive a code, and therefore, in helping to guide LOC discussions?

Outcomes of SCA: Stratified by AgeWidely variable results, small retrospective studies…

Survival– To Hospital Discharge- IHCA

>65 yo= 18% – Ehlenbach, 2009

– 6 Month Survival- Both IHCA and OHCAAll comers= 19%>80 yo = 6%<45 yo = 32%

– Rogove, 1995

Neurologic outcome– Not statistically different between the youngest and oldest at 6 months

– Rogove, 1995

PLAN: Review these two studies

• Retrospective cohort of 160 Million medicare patients >65 yo, 1992-2005

• ~435 000 had SCA and underwent CPR

• 18% survived to hospital d/c

Results I: Change over timeMortality– No improvement in mortality over time

Frequency of CPR– More patients receiving CPR

Increase from 4 to 5% of all hospital deaths– Implication: More CPR yet same mortality…

Disability– More disability, via institutional surrogate

Results II: Age and Comorbidity

Table 1 from NEJM 2009Illustrating age and comorbidity and nursing home effect

Results III: Multivariate Analysis

First Conclusion

Age and comorbidity increase mortality

Most impressed with functional status, as implied by nursing home residency prior to admsision– Functional component captures something that a

simple list of comorbidities fails to capture

Study 2Rogove HL, Safar P, Sutton-Tyrrell K, Abramson, NS. Old age does not negate good cerebral outcome after cardiopulmonary resuscitation: analyses from the brain resuscitation clinical trials. CCM 1995; 23(1):18-25.

Post-hoc analysis of two dBRCTsProspective, 774 comatose survivors of SCA followed for 6 months

Outcomes: 81% mortality at 6 months

- Age associated with greater mortalityAge does not statistically impact neuro outcome

Results 1: Pre- and Peri- Arrest

Results II: Independent predictors

•6 Month survival= 19%

Results III: Neurologic OutcomeCerebral Performance Category– 1=conscious, alert, normal function or mild db– 2=conscious, alert, moderate disability– 3=conscious, severe disability– 4=comatose or in a persistent vegetative state– 5=brain dead

Scores of 1 and 2=“good”Good= functionally independent outside of an institutionRecorded single best score…

Results IV: Neurologic Outcome27% had a “good neurologic outcome” scored at least once in the first 6 months– What does this mean?

Of survivors at 6 months, 86% had “good outcomes”

Age did was not statistically related to neurologic outcome– <45 yo: 29% had good outcome (n=120)– >81 yo: 20% had good outcome (n=49)– Power to validate this trend?

Conclusions from Study II

Age and comorbid burden decrease survival

Neurological outcomes following resuscitation from cardiac arrest are not dramatically worse in the elderly vs the non-elderly

Case Conclusion and Impact on Practice

Case: patient died– No code details

What I would do differently– Would have better appreciated the prognostic burden

of her severe functional impairment – Allow more accurate prognostication and stronger

direction to a non-resuscitative LOC

Conclusions

Functional status= strongest non-modifiable RF for survival following CPR for SCA

Chronologic age and the number of comorbidites are independent predictors of poor outcome

ReferencesCarlen PL, Gordon M. Cardiopulmonary resuscitation and neurological complications in the elderly. Lancet 1995; 345: 1253-1254.Ehlenbach WJ et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. NEJM 2009; 361:22-31.Peberdy MA et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58:297-308.Rogove HL, Safar P, Sutton-Tyrrell K, Abramson, NS. Old age does not negate good cerebral outcome after cardiopulmonary resuscitation: analyses from the brain resuscitation clinical trials. CCM 1995; 23(1):18-25.