Clustering analysis of geriatric and acute characteristics in a cohort of very old patients on admission to ICU

Abstract

Purpose The biological and functional heterogeneity in very old patients constitutes a major challenge to prognostication and patient management in intensive care units (ICUs). In addition to the characteristics of acute diseases, geriatric conditions such as frailty, multimorbidity, cognitive impairment and functional disabilities were shown to influence outcome in that population. The goal of this study was to identify new and robust phenotypes based on the combination of these features to facilitate early outcome prediction. Methods Patients aged 80 years old or older with and without limitations of life-sustaining treatment and with complete data were recruited from the VIP2 study for phenotyping and from the COVIP study for external validation. The sequential organ failure assessment (SOFA) score and its sub-scores taken on admission to ICU as well as demographic and geriatric patient characteristics were subjected to clustering analysis. Phenotypes were identified after repeated bootstrapping and clustering runs. Results In patients from the VIP2 study without limitations of life-sustaining treatment ( n = 1977), ICU mortality was 12% and 30-day mortality 19%. Seven phenotypes with distinct profiles of acute and geriatric characteristics were identified in that cohort. Phenotype-specific mortality within 30 days ranged from 3 to 57%. Among the patients assigned to a phenotype with pronounced geriatric features and high SOFA scores, 50% died in ICU and 57% within 30 days. Mortality differences between phenotypes were confirmed in the COVIP study cohort ( n = 280). Conclusions Phenotyping of very old patients on admission to ICU revealed new phenotypes with different mortality and potential need for anticipatory intervention. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06868-x.

Geriatrische Syndrome mit intensivmedizinischer Relevanz

“…Spätestens nach zwei bis drei Tagen der intensivmedizinischen Versorgung sollte eine erneute Bewertung der Situation erfolgen. Zukünftig kann die Eingruppierung der Patient*innen in reproduzierbare Phänotypen, die auf akutmedizinischen und geriatrischen Merkmalen beruhen, zur Prognoseeinschätzung und spezifischen intensivmedizinischen Therapie hilfreich sein [ 35 ].…”

Tailoring treatments to older people in intensive care. A way forward

“…However, this view has proven to be superficial, as Mousai and colleagues showed while reporting divergent outcomes across the clusters (Fig. 1) [11]. While 30-day mortality reached 57% in the VIP2 patients with age-related conditions and high SOFA scores, it was only 7% among the oldest old patients presenting very mild age-related impairments and low SOFA scores.…”

“…In this issue of Intensive Care Medicine, Mousai and colleagues offer cutting-edge knowledge on this topic [11]. These authors examined the heterogeneity of people aged 80 years and older in critical care by clustering analysis of bedside clinical variables assessed on admission to ICUs in 22 European countries, integrating the VIP2 cohort study [5].…”

“…Besides demographic factors, reasons for ICU admission, and SOFA scores, the authors considered information on age-related conditions, which allowed them to identify seven clusters with distinct phenotypes (Fig. 1) [11]. Notably, Mousai and colleagues confirmed the validity of the clusters by providing external validation in another dataset comprising critical care patients affected by coronavirus disease 2019 (COVID-19) (the COVIP study) and by incorporating initially excluded patients with limitations of life-sustaining treatment into sensitivity analyses [7].…”

“…While 30-day mortality reached 57% in the VIP2 patients with age-related conditions and high SOFA scores, it was only 7% among the oldest old patients presenting very mild age-related impairments and low SOFA scores. Other specific profiles denoting respiratory, cardiac, and renal failure had a 30-days mortality rate of around 10%, with only the phenotype presenting age-related conditions approaching nearly 20% of mortality risk, despite low SOFA scores [11].…”