Coma in the elderly: Etiological factors, management, and prognosis in the department of anesthesia and intensive care.

OBJECTIVE: To study the etiologies, therapeutic and prognosis factors of coma in the elderly in the Department of Anesthesia and Intensive Care of Gabriel TOURE Teaching Hospital, Mali.
MATERIALS AND METHODS: This was a prospective descriptive study of all cases of coma in the elderly, registered from February 1, 2008 to January 31, 2009 at the Department of Anesthesiology CHU Gabriel Touré, Bamako.
RESULTS: During the study period, 564 patients were admitted to the intensive care unit (ICU) in which 174 (30.85%) were older people. We collected 100 subjects with impaired consciousness, the object of our study, which represented 17.73% of all admissions in the Department of Anesthesiology during the study period and 57.47% of all admissions of older people; 66% of our subjects were male. Hypertensive patients accounted for 60% of cases. In 46% of cases, it was a coma from cardiovascular causes and in 28% of cases; it was a coma of metabolic origin. The diagnoses made in the wake of the care of the elderly in ICU were predominantly stroke (46%) and electrolyte disturbances (13%). The coma was sudden onset in 58% of cases, including 28 cases of stroke whether 48.27%. The prognosis was marked by a fatality with 51% of deaths in our sample.
CONCLUSION: The prognosis improvement of the elderly in coma through to the introduction of proxy measures.

INTRODUCTION

The physiological changes induced by age tend to weaken the elderly and increases the consumption level of care. Due to this fact, the increase in life expectancy of the population accounts from more frequent care of the elderly intensive care units (ICUs),[1] the capital of the old age, according to WHO is generally set at 60 years. In a recent study in North America, including 10 900 patients, approximately 50% were aged over 60 years.[2] In 1996 in the Ivory Coast compiled 300 cases of impaired consciousness on 6875 admissions[3] whether 5.06%. In Department of Anaesthesia and Intensive Care of Gabriel TOURE Teaching Hospital in Mali a similar study to the above[4] found 53.4% of cases of impaired consciousness with 25.38% of coma in particular. Different disorders of consciousness are generally understood as deficits or the mechanical effects of exogenous.[5] These disorders of consciousness create an emergency that must be overcome immediately. However, in our context, the lack of technical equipment makes it difficult and mostly hypothetical etiologic diagnosis.

Even if the definition of elderly is more physiological than chronological, support the elderly poses several problems:

In terms of frequency, improved medical and surgical techniques and increased life expectancy are increasing the admission of elderly patients in ICU.

In terms of ethics, the discussion about the probability of survival of the “patient” limits “aggressive therapy.”

In economic terms, the cost of intensive care is very high.

In view of this difficulty that hinders etiologic consistently support our comatose patients, our attention will focus on providing a better knowledge on the etiology and treatment of cases of coma observed in the SAR of Gabriel TOURE Teaching Hospital. This prospective study aims to investigate the etiologies, management, and prognostic factors of coma in the elderly.

MATERIALS AND METHODS

Study framework and operation

The ICU (SAR) adult versatile of Gabriel TOURE Teaching Hospital is a 9-bed unit, which receives on average 420 patients per year. The effective medical management of patients is provided daily by three anesthesiologists, 2 internal and students making function internally. At the paramedical per 12 h, groups of nurses and caregivers to help provide care to patients.

Methodology

This was a prospective descriptive study of a 12-month period from February 2008 to January 2009.

Inclusion criteria

All patients aged ≥60 years, irrespective of gender, in whom the impairment of consciousness was clinically Glasgow Coma Scale (GCS) ≤8 confirmed were chosen.

Non-inclusion criteria

Patients aged below 60 years

Patients with a GCS > 8

Patients whose admission has been made outside our study period.

Data reviewed

Age, gender, the source, medical history, the mode of onset of coma, the GCS at admission, etiology of coma, the main diagnosis, additional tests carried, established treatment, the duration of the stay, severity scores calculated within the first 24 h, T-RTS, IGSA, Trauma Index-output mode.

Capture and analysis

Entry and data analysis, statistical tests were performed using SPSS 16.0. The results were presented in the form of tables and graphs using Microsoft software and Microsoft Excel and Word 2007.

RESULTS

Male sex was predominant in 66% of cases with a sex ratio of 1.94; extreme ages being of 60 and 90 years. Subjects in the age group of 60–65 years were most represented amounting to 35% of the cases, out of which 18 were sent by the SAU (home emergency service) and 10 were from other hospital services of Gabriel TOURE Teaching Hospital, respectively, 51.42% and 28.57% [Table 1].

Table 1

Characteristics of patients hospitalized

The diagnosis made in the wake of the care of elderly patients in the ICU was predominantly stroke (46%). Stroke was more common in men than in women, respectively, 67.39% and 32.60% [Table 2].

Table 2

Leading diagnoses of patients who died

The hypertensive patients accounted for 60% of the subjects; 63.33% were male. Patients with a history of diabetes and/or hypertension accounted for 67% of subjects in the sample. The subjects of the age group of 60-65 years were most affected by the cardiovascular and metabolic diseases associated or not, including hypertension, diabetes, and hypertension and stroke, respectively, 25.71%, 11.42%, and 14.28% [Table 3].

Table 3

Clinical features

Support the SAR was made between 12 and 24 h after the onset of impaired consciousness in 42% of subjects [Table 4].

Table 4

Distribution of patients according to the time between the onset of impaired consciousness and admission

The antipyretic and analgesic were administered, respectively, in 79% and 69% of cases [Table 5].

Table 5

Distribution of patients according to established treatment

According to the T-RTS score, the majority of subjects in our sample had a probability of death or above 50% with a T-RTS score between 9 and 11. We identified 51% of deaths in our study, which may be superimposed on the T-RTS score predictor. IGSA score showed 39% of subjects in our sample with a probability of death equal to 70% [Table 6].

Table 6

Mortality and severity indicator

Patients admitted with a GCS scale between 3 and 5 died within 12% of cases and 23.53% of all subjects died [Table 7].

Table 7

Evolution of patients according to initial glasgow coma scale

DISCUSSION

Constraints of the study

All the difficulties we have encountered throughout our study may be attributed to a lack of documented scientific data on the elderly and a lack of comparative data, because there are no studies prospectively evaluating the benefit of resuscitation for these patients.[6]

Epidemiological data

During the study period which lasted 12 months, 564 patients were admitted to the ICU of whom 174 (30.85%) were older people. In this sample of 174 elderly, we collected 100 subjects with impaired consciousness, the object of our study, who represented 17.73% of all admissions in the Department of Anaesthesiology during the study period and 57.47% of all admissions of older people.

The frequency of coma in ICUs varies in the literature and is related to admission, transfer of patients, and management of available resources and financing of care. This effect could possibly increase in the next few years if nothing is done, given the delay in the management of many diseases that can cause impaired consciousness.

Male sex was predominant in 66% of the cases with a sex ratio of 1.94; extreme ages being 60 and 90 years. Subjects in the age group of 60-65 years were most represented 35% of the cases, of which 18 were sent by the SAU (home emergency service) and 10 were from other hospital services of Gabriel TOURE Teaching Hospital, accounting for 51.42% and 28.57%, respectively.

Clinical and management data

Medical history

The hypertensive patients accounted for 60% of the subjects of whom 63.33% were male. Patients with a history of diabetes and/or hypertension accounted for 67% of the subjects in the sample. The subjects of the age group of 60–65 years were most affected by the cardiovascular and metabolic diseases associated or not, including hypertension, diabetes, and hypertension and stroke, respectively, 25.71%, 11.42%, and 14.28%.

Our results differ from those of[3] who found that 44% of patients had a history of diabetes and/or hypertension. The frequency of cardiovascular and metabolic diseases alone or in combination could be related to the age of our comatose patients (60–90 years).

Onset of altered consciousness and admission

The management was made between 1 and 24 h in 71% of cases. The evacuation could be done within 24 h for patients from private institutions and other health facilities if there was an early warning system (telephone, radio, and others) and rapid transit.

Glasgow coma scale

Patients admitted in emergency with a GCS between 6 and 8 represented 79%. Our results are similar to those[4] who found in his study, 80.8% of patients with a GCS between 6 and 8.

Additional tests

In our study, laboratory tests and CT (computed tomography) were the main complementary tests performed in 98% and 61% of cases, respectively. In 8% of cases the cause of coma was not confirmed because of the lack of paraclinical facility, which was in part due to the economic condition of the families. This could also explain the fact that in our study, treatment was instituted in 82% of the cases.

Our results are similar to those[7] who found that the coma was confirmed by additional tests in 85.2% of cases.

Treatment instituted

The treatment was instituted in 82% of cases. This was mainly antipyretic and analgesic in 79% and 69% of cases, respectively. It was mainly symptomatic and nonspecific, especially as the additional tests for a large majority were not made for lack of financial means and third-party payment. The appropriate management of elderly patients in the ICU depends on both adequate financial means available to the patient's family and the resources available to the SAR (equipment, drugs).

Etiological data

Cause of coma

In our series, three groups of causes dominated our study: coma from cardiovascular origin (46%), metabolic (28%), and coma caused by trauma (17%). Cases of cardiovascular disease could be explained by the frequency of certain risk factors in the Malian population, such as hypertension and diabetes. In Mali, hypertension is the most common diseases in adults and its prevalence reaches 10% of the population.[8] Regarding diabetes, 1.4% of the population is diabetic, 8.4% of patients have postprandial blood glucose limit to suspect diabetes,[9] diabetes being a precursor to infection. There is therefore an emergence of these risk factors in Mali.

Diagnosis

The diagnoses made in the wake of the care of the elderly in the ICU were predominantly stroke (46%) and these were more common in men than in women, respectively, 67.39% and 32.60%. The coma was sudden onset in 58% of cases, including 28 cases (48.27%) of stroke. In 42% of the cases, it was gradual onset in 18 stroke cases and 6 cases of metabolic disorders, respectively, 42.85% and 14.28%, of all the progressive onset of coma. Cases of cardiovascular disease could be explained by the emergence of risk factors, such as hypertension and diabetes in Mali.[810]

Support medic

The treatment instituted was made in full in 18% of the cases and mostly in comas of metabolic origin, that is, 50% and was done partly in 82% of cases, mostly in comas of cardiovascular origin, 48.78%. This difference could be explained by the heaviness of the investigations, sometimes very expensive in a neurologic coma, which is not the case in the coma of metabolic origin.

Facts about the evolution of coma

We identified 51% of deaths in the SAR and 49% of patients were transferred to other inpatient services UHC or allowed to return home at the request of the family. The percentage of deaths (51%) is explained by the predominance of elderly patients with a precarious financial situation and the difficulty of care due to lack of appropriate service level for effective resuscitation in the intensive care setting.

T-RTS score

According to the T-RTS score, the majority of subjects in our sample had a probability of death or above 50% whether a T-RTS score between 9 and 11. We identified 51% of deaths in our study, which may be superimposed on the T-RTS score predictor. Our results differ from those[11] found that 55.8% of patients with T-RTS score between 9 and 11.

Score IGSA

IGSA score showed 39% of subjects in our sample with a probability of death equal to 70%. Our results corroborate a study made by[12] showing that total mortality increased with the value of the IGS, whatever the type of patient. This mortality is higher for medical patients.

Score champion

By score of champion, 96% of subjects in our sample had a mixed prognosis with a score between 10 and 14. Our results are similar to those[11] in which 78.9% of patients had a score of champion severe or critical.

Length of stay

The length of stay was an average of 1–5 days and involving 58% of subjects. We identified 51 deaths among the elderly of which 34 died within 5 days after admission to the SAR. The mortality rate is significantly higher here, in the case of a coma from cardiovascular causes (46%), which is the leading cause of death in our etiology.

This could be due to late detection and correction of poor risk factors, such as hypertension and diabetes.

Outcome of coma

In our series, 51% of patients had died. The majority of patients in whom treatment was done in part had died—88.68% of all deceased patients.

This result could be explained by the fact that in most cases, treatment was not necessarily set the specific treatment needed. Initially, it was recognized symptomatic rotated to the clinical signs and circumstances of occurrence; the second time, this treatment was often based on the level of patient's life. For a GCS between 6 and 8, the death rate was 73.59%.

According to a study conducted,[13] mortality in the elderly in the ICU is higher than that of younger patients (mortality with patients 20-29 years is half of the mortality of patients whose age > 60 years).

CONCLUSION

Coma in the elderly, as defined, is a medical emergency and treatment. The cost-benefit ratio is unfavorable for the elderly because its more productive life expectancy is shorter and rehabilitation to longer life. In order to improve the prognosis of coma significantly in the elderly, a better understanding of the etiology and a review is necessary complementary precise, fast, and focused.

Maybe we should set up centers to take better care of elderly patients.