Outcomes of Cardiac Arrest in

the Elderly
Geriatric Rounds
J anuary 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. NEJ M 2009; 361:22-31.
Case
80W, Philippino, admitted with GLF with L
intertrochanteric fracture
PMHx
CAD
CHF
DM2- insulin
OP
Profound functional disability
Firm 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 Age
Widely variable results, small retrospective studies
Survival
To Hospital Discharge- IHCA
>65 yo=18%
Ehlenbach, 2009
6 Month Survival- Both IHCA and OHCA
All 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 time
Mortality
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 NEJ M 2009
Illustrating 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 2
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.
Post-hoc analysis of two dBRCTs
Prospective, 774 comatose survivors of SCA followed for 6
months
Outcomes:
81% mortality at 6 months
- Age associated with greater mortality
Age does not statistically impact neuro outcome
Results 1: Pre- and Peri- Arrest
Results II: Independent predictors
6 Month survival=19%
Results III: Neurologic Outcome
Cerebral 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
institution
Recorded single best score
Results IV: Neurologic Outcome
27% 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
References
Carlen 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. NEJ M
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.