According to research, which of the following produces the greatest risk of death?

Introduction

This question is significant because of substantial political and economic pressure for more elderly patients to be managed in their own homes, whereas previously they had been cared for in hospitals and other institutions. It is important that such changes (at the very least) do not put patients at an increased risk of adverse outcomes, such as death.

Background

There is evidence that IC and community rehabilitation is beneficial to many older people. However, it is important to be able to identify those who are at risk of deteriorating health who may benefit from hospitalisation or increased length of stay prior to discharge.

Intermediate care and rehabilitation should be available to those individuals who are likely to benefit from such services and palliative care services should be available to those who are likely to die. Although we recognise that prediction of death in the elderly is not a precise science, it is important to address this question and examine differences between different teams so we can determine whether or not patients are being correctly referred to appropriate services and whether or not changes have occurred over time.

Knowledge about survival and prognosis is important to clinicians, patients, family and other caregivers and for the planning of long-term facilities and home care. Indeed, in the acute care sector, NHS trusts regularly see their mortality statistics, appropriately corrected for case mix, as one of the routine metrics about them on public information systems.76 Such data are not available for those receiving community-based NHS services.

Literature review

A copy of the search strategy used to support the literature review for this chapter is located in Appendix 1.

There have been several studies using different algorithms to identify the community-dwelling vulnerable older people who are more likely to die at an earlier point in time but none specifically studying those receiving IC. Therefore, we describe here some key studies that focus on those at increased risk of death in old age.

Key point 35: we identified little literature of direct relevance to the question: what factors are associated with increased risk of mortality for IC patients?

Saliba et al.77 developed a screening tool that was tested on more than 6000 community-dwelling older people, who were defined as persons aged ≥ 65 years.

A complex data analysis investigated a method for identifying older people at risk of losing physical function and death. This was used to identify a vulnerable group that comprised 32% of the ≥ 65-year-olds studied. This group had a fourfold greater risk of death when compared with the rest of the population.

Unsurprisingly, increased mortality is associated with increased age and clinical instability. A study by Guerini et al.78 provided a definition of clinical instability which used routine clinical measures (such as blood pressure and heart rate) to predict increased likelihood of death on admission to a rehabilitation and aged care unit.

Chronic kidney disease, which is more common in old age, was investigated by Roderick et al.79 who showed that declining kidney function is significantly associated with an increase in all-cause and cardiovascular mortality in those > 75 years of age.

After a study of more than 9000 patients in the USA living in the community aged between 65 and 102 years of age, Kazanjian et al.80 concluded that pulse pressure appears to be the best measure for predicting mortality in older people.

Key point 36: increased mortality is related to age, limitations in physical function, functional disabilities and clinical instability, which are all issues associated with requiring IC.

The many physiological and social factors that have been investigated to determine their contribution to mortality often give rise to symptoms which increase the likelihood of hospitalisation and may still be present on early discharge and transfer to IC.

The study by Kazanjian et al.80 found that the odds of death increased with institutionalisation and with increasing cognitive and physical impairment. Although vision and hearing problems and the presence of heart disease, stroke and diabetes were all strongly related to 5-year mortality in univariate and unadjusted analyses, their contributions were minimal in the multivariate analyses. Increased body mass index was associated with lower mortality in both univariate and multivariate analyses.

Ostbye et al.,81 in a similar population-based study in Canada, confirmed the importance of sex, age, functional status, cognition and health status in predicting 5-year mortality. Accounting for cognitive status, physical status and specific disease variables led to the difference in mortality between older people in the community and in institutions being reduced.

A population-based prospective study of more than 1000 older individuals (64–85 years) in Finland by Hirvensalo et al.82 ranked participants into four groups: (1) intact mobility and physically active (mobile–active), (2) intact mobility and sedentary (mobile–sedentary), (3) impaired mobility and physically active (impaired–active) and (4) impaired mobility and sedentary (impaired–sedentary). The analysis adjusted for age, marital status, education, chronic conditions, smoking and physical exercise earlier in life. The study found a twofold increase in the risk of death in impaired–active and a three times greater risk in impaired–sedentary groups than in mobile–active groups. However, the risk of death did not differ between mobile–active and mobile–sedentary groups.

The authors concluded that mobility impairments predicted mortality and dependence. However, among people with impaired mobility, physical activity was associated with lower risks, whereas the risk did not differ according to activity level among those with intact mobility. Despite their overall greater risk, mobile-impaired people may be able to prevent further disability and mortality by physical exercise. Interestingly, increasing independent activity is one of the key aims of IC.

Key point 37: even when mobility is impaired, physical activity is associated with a lower risk of death.

Secondary analysis of data

The statistical methodology was undertaken as described in Appendix 2. Reported probabilities of mortality were calculated using a model, which included age, sex, LoC at admission, route of referral and the location where the patient was receiving care.

Results

The percentage of deaths in the first study (COOP)1 was 1.3% (n = 25) and 3.4% (n = 212) in the second study (EEICC).2 Overall, 237 patients (3%) recruited to the two studies died during IC. In the seven teams participating in both studies, percentage of death was 1.4% (n = 281) in the first study and 2.1% (n = 1462) in the second. However, most teams show a low percentage of deaths with nine teams for which no recruited patients died. Team COOP-C had the greatest percentage of deaths (Table 11).

TABLE 11

Number and percentage of deaths by team

Key point 38: there is an indication that patients in the more recent study (EEICC) had more complex conditions.

The results of the modelling are presented in Table 12. Mortality was higher among males than females (OR 1.23, 95% CI 1.07 to 1.44; p = 0.021) and increased with age (OR per 10-year increase 1.23, 95% CI 1.07 to 1.43; p = 0.004). Mortality was also higher among LoCs of 2 and 3, and lower when patients were receiving care in their own home.

TABLE 12

Model coefficients: probability of death

The literature suggests that older people in the community with increased number and severity of impairments have a higher probability of death. This is borne out when examining the severity of the TOM rating scale on admission and the numbers of deaths related to each scale point.

To assess the impact of TOM scores at admission, each was added in turn to the above model (separately). In each case, there was a significant association (p < 0.001) between the score at admission and probability of death. This is illustrated by Table 13, showing the relationship between each of the four TOM scores and death. Ninety-four patients with a score of less than three on impairment died, compared with 65 with a score of three or above (a scale point of three on the TOM scale is termed moderate/severe to severe).

TABLE 13

Therapy outcome measure scores and probability of death

Key point 39: those patients well enough to receive IC in their own home have the lowest probability of death. Those receiving these services in an institutional setting have the highest probability.

Discussion

There has been an increase in deaths of patients referred to intermediate/community care over time. This is associated with a greater number of patients receiving these services who have more complex and severe health and social care needs. These findings are in line with the literature related to deaths within the community of older people. However, this needs to be placed in the context of the evidence that even the best geriatric medical acute unit expects a mortality rate of around 15–20% of patients at 3 months after admission.83 The determinants of death in inpatient care are the same as we found in these community studies (i.e. severity and complexity of health condition and previous functional health status). Although IC services may have seen a rise in mortality, they are receiving patients at a lower risk of death compared with the population they are likely to have come from (i.e. mortality rates in the region of 1–3% could be interpreted as indicating appropriate selection of patients for IC services).

Another important issue is related to whether or not IC and community rehabilitation are appropriate or inappropriate services in caring for those coming to the end of their life.

Conclusion

Many surveys have concluded that, generally, people would prefer to die in their own home,84 but unfortunately people with palliative and supportive care needs are generally explicitly excluded from the IC trials, so we have little or no evidence about providing palliative care in IC services to work with. However, there is a trend in developing services, which integrate rehabilitation and IC services with those of palliative care for older people with a broad range of disabilities and health-care challenges. Moving more of this care into the community may well be appropriate but it is important to consider that a recent meta-analysis (of more than 10,000 patients) indicated the value of comprehensive geriatric assessment to reducing deterioration of health, and yet costs increased.85 Consideration needs to be given to the skill mix to support these patients appropriately.

Key point 40: there is a case for integrating palliative care services for older people with IC/community rehabilitation because the complexity of cases being cared for in the community is increasing.