Geriatric patients have a poorer rate of survival compared to younger people. Many factors contributed, including the changes in physiology and comorbidity. A study in 2007 showed that patients aged older than 80 years old had a higher mortality rate. Other studies have shown that the mortality of the elderly was high (20%-55%) in the ICU.11,12 A multi-centre study showed that the length of stay of geriatric patients in ICU was between 10 to 23 days.13 Based on our result, the mortality rate of geriatric patients in ICU was 38.6%, and the mean length of stay was 6.9 ± 7.0 days.
In the present study, we found high use of mechanical ventilation among geriatric ICU patients. The use of invasive mechanical ventilation was common not only in normal age but also in all geriatric patients admitted to the ICU. A study in a district hospital in Spain showed that about 39% of elderly patients in the ICU were intubated and required mechanical ventilation.14 Another research in Glasgow also discovered that continuous assisted ventilation use contributed significantly to the risk of mortality in ICU patients. ICU patients with both non-invasive or invasive mechanical ventilation had a two times higher risk of death than those without the use.12 A large data study in Taiwan revealed that 70% of intubated ICU patients were older than 65 years. Only 3 out of 10 elderly patients admitted to the ICU, both with acute respiratory failure and using mechanical ventilation, survived in one-year observation.15 The mechanism causing this is diffuse alveolar damage. Several aetiologies such as cytokine-laden pneumonia, aspiration, direct injury by ventilation pressure may cause profound fluid and cellular exudation. The tissue overload then proceeds to hamper the perfusion of oxygen into the blood. Elderly patients had higher levels of inflammatory mediators and endothelial activation markers such as interleukins. Moreover, the aged population had a much higher Angiotensin-2 expression in circulation, meaning that SARS-Cov-2 was capable of infecting the bloodstream and causing cytokine storms in elderly patients.16
Not only assisted ventilation, but our data also demonstrated a high use of vasopressors and inotropic agents among subjects. A similarly multi-centre study in France13 revealed that the vasopressor requirement was quite high, with more than half of patients subjected to vasopressor infusion. The consistent use of vasoactive agents found in our research centres could occur due to sepsis, septic shock, or cardiogenic shock in elderly patients. In Indonesia, the most frequent type of vasopressor used is norepinephrine. With an average initial MSOFA score of 5 in our study, admitted patients to the ICU were in multiple organ failure states. On the other hand, a study in Libya17 showed that inotropic use in the elderly in ICU was in one out of four patients and the mortality rate was nearly in two out of five elderly patients. Heart failure is understandably found in geriatrics, mainly because of a stiffening of arteries and a certain decreased ejection fraction of the heart due to ventricular muscle hypertrophy and fibrosis, especially in those with hypertensive heart disease. Although the use of inotropic was proven to be effective in acute settings, prolonged use was not recommended because of a high rate of documented mortality.18 Dobutamine and dopamine, both potent adrenergic agonists, increased the ejection fraction of an already failed heart but also increase the risk of death in a chronic setting.18–20
We found that several factors impact 30 days survival mortality rate in our study. It includes COVID-19 status, and several comorbidities, according to Charlson Index. One of the tools that classified the prognostic comorbidities and the comorbidities themselves is the Charlson index. We found that the higher the Charlson index, the higher the mortality rate. Score 5 had the highest mortality rate, reaching 2 out of 3 patients. A higher score indicated a poorer prognostic 21 Our result aligns with a previous study that patients with >80 years old in ICU have poorer outcomes than in younger patients.22
COVID-19 status has affected the survival rate in intensive care, especially in geriatrics. A study in Portugal discovered that the COVID-19 death rate was 16.8% among elderly patients admitted to the ICU. Furthermore, patients ≥70 years old have six times more likely to die than patients <70 years old.6 Even in short time follow-up, the mortality rate of geriatric patients with COVID-19 in ICU is relatively high, reaching up to 80% in several studies.23–25 A comparison using Indonesian Task Force big data showed that although the most common age group admitted to the hospital in the COVID-19 pandemic was 31-45 years old, the elderly population experienced the most mortality rate (>60 years old) with roughly 18%.26
The high mortality rate in our geriatric patients is also related to pre-existing underlying diseases. Our study, which found ten particular comorbidities affecting the death rate, is in line with a previous study in Libya, which presented a significant association between mortality and comorbidities, such as diabetes, chronic pulmonary disease, asthma, malignant neoplasm, and immunosuppression patients.17 A study in China27 showed that the most common comorbidities found in the elderly were cerebrovascular diseases, diabetes, gastroduodenal ulcer, and tumor without metastasis. In Indonesia, the three most common comorbidities identified in all COVID-19 patients were vascular-related disorders, such as high blood pressure, diabetes, and cardiovascular disease.26 Pre-existing diabetes mellitus is a characteristic found in more than 80% of fatal COVID-19 cases in patients older than 80 years.28 A study in the US asserted that almost 90% of elderly and seriously ill patients with COVID-19 suffered from comorbidities such as hypertensive heart disease and diabetes mellitus.29 As mentioned earlier and to conclude, multiple comorbidities increase the probability of mortality from COVID-19.28 Hypertension was the most frequent comorbid found in elderly patients in the ICU, followed closely by diabetes and moderate or severe renal disease. The activation of the renin-angiotensin-aldosterone system in several tissues influences arterial hypertension by constricting the vessels.30 Conventional administration of antihypertensive agents, such as Angiotensin Receptor Blockers or Angiotensin-Converting Enzyme Inhibitors, positively alter the Angiotensin-Converting Enzyme 2 (ACE2) expression, making it easier for SARS-CoV-2 to infiltrate pneumocytes and ultimately deteriorating the severity and mortality of the infection. This condition, coupled with the stiffness of the artery wall, may worsen the disease progressivity due to increased systemic vascular resistance that then burdens an already increased myocardial demand.20,30,31
In addition to mortality, the SOFA score was also used to determine the outcome of therapy. SOFA score consisted of physiological variables from respiratory, cardiovascular, liver, renal, and neurological systems. A low SOFA score in geriatric patients is taken into account for the survivability in COVID-19.32 However, in this study, SOFA scores on admission day and 30 days after ICU admission were not statistically different but clinically the result may be acceptable. We deduced the robust number of non-survived subjects 30 days after ICU admission; or because the length of stay was too long, both of which prompt the physiological function almost to return to baseline.
We found several limitations in our study. Firstly, there were obstacles in baseline day data collection. In this study, we frequently encountered either incomplete or missing records. Therefore, we may have missed more comorbidities or failed to calculate the precise SOFA score that accounted for the subjects and contributed to their condition before and on admission. Secondly, most hospitals we surveyed were central general public hospitals as we intentionally did not include private hospitals. Intensivists at those hospitals may have better resources and experience than intensivists in other less inferior or private hospitals, mainly because the public hospitals also act as teaching hospitals where they host residents and in-training consultants. Lastly, we admitted that there could also possibly be a distinguished disparity between urban and rural medical settings, thus our results may represent the standard of ICU care in bigger cities but not in lower-level hospitals. Future researchers should consider doing a more extensive and strictly monitored study with a greater sample size to minimize the aforementioned limitations.