#  9-25-2006

# EFFICACY OF CPR IN THE ELDERLY

Timothy Domer M.D.

Fort Defiance Indian Hospital

<Timothy.Domer@ihs.gov>

 

# History of CPR

#  

Modern CPR (closed-chest massage) was first described by Kouwenhoven and
Knickerbocker, electrical engineers working at John's Hopkins, in JAMA
in 1960. Since that time there have been changes in technique and the
addition of numerous medications used in resuscitation.

 

Early statistics are somewhat unreliable because large, formal studies
were not done. Kouwenhoven reported survival of the first 20 patients in
which closed chest message was performed at John's Hopkins in 1959-60.

 

In 1979, in the *American Journal of Public Health,* Eisenburg reported
a 28% survival if CPR were started within 4 minutes and 7% if delayed
longer than 4 minutes. He further reported a 52% survival if ACLS were
started in less than 6 minutes, dropping to 6% if delayed more than 12.

 

In 1985, in the *American Heart Journal,* Ritter reported a 34% survival
if bystander CPR was started within one minute and ACLS in less than 10.
However this dropped to 18% survival if ACLS were delayed for over 10
minutes.

 

Some studies in the 1990 showed dramatic improvement in outcomes over
those described earlier, with survival rates approaching 50%. Most of
these studies involved patients with primary cardiac disease, limited
co-morbidities who were being continuously monitored or were
defibrillated within a few minutes.

 

# Out-of hospital CPR

 

*OPALS (Ontario Prehospital Advanced Life Support)* study, presented in
May 2001 was a prospective study of all out-of-hospital cardiac arrests
in Ottawa Ontario.

 

1991-1997 -- 9,218 cardiac arrests reviewed: 343 survivors **(3.7%),**
15% had bystander CPR.

 

During this time the city had an aggressive lay-person CPR campaign.

 

1995-2000 a prospective study of consecutive out-of-hospital arrests:
1,373 arrests, mean age 68.6, 48% were bystander witnessed, CPR in 16.1
percent (75% by fire/rescue), mean time to defibrillation *5.1 minutes*.
Survival to discharge -- **3.7%.**

** **

*American Journal of Cardiology* February1990, a study of
*paramedic-witnessed* arrests in Milwaukee: 381 consecutive patients who
experienced out-of-hospital cardiac arrest, and whose arrest was
witnessed by paramedics. Patients were divided into 2 age groups:
elderly patients were greater than 70 years and younger patients were
less than 70 years. *Forty percent of patients under 70 were
resuscitated compared to thirty-three percent of those over 70 (not
statistically significant).* Forty-two percent of younger patients
demonstrated ventricular tach/fibrillation as the initial
out-of-hospital rhythm associated with the arrest, compared to only 22%
of elderly patients. Younger patients presented with CP while older
patients presented with SOB. Survival to discharge: younger -- 24%;
older -- 10%.

 

***Elderly patients can be resuscitated as successfully as younger
patients; only 10% of elderly resuscitated from paramedic-witnessed
cardiac arrests survived to discharge.***

# General Inpatients

 

A study published in the *Canadian Medical Journal* in August 2002,
sought to evaluate current overall survival of CPR in a general hospital
adult population. The setting was three major teaching hospitals.
Patients were non-ICU, non-monitored, general medical patients.

 

In the two-year study period there were 247 arrests -- 143 witnessed and
104 unwitnessed.

 

Results: Over all 37% were resuscitated, 13.4% were discharged alive and
11.3% went home.

 

**Witnessed** **arrests**-- 49% were resuscitated; 22% were discharged
alive and 19% were able to go home. ***Of patients over 70 y.o. 8% went
home. Of patients over 80 only 2.4% went home.***

**Unwitnessed** arrests -- 22% resuscitated; one patient survived to
discharge and returned home. This patient had a primary respiratory
arrest*. **No unwitnessed cardiac arrest patient was discharged
alive.***

 

Arrest type: witnessed VT/VF - 15% were discharged home.

witnessed asystole -- 3.3% discharged to home.

 

# CPR on the Elderly

 

A study in the *Annals of Intern Medicine* in August 1989 looked at CPR
survival in 503 consecutive patients age 70 or older in five Boston-area
institutions.

 

Results: Overall 22% were resuscitated, 4% were discharged alive. Of
unwitnessed arrests: 1 of 116 were discharged alive. Patients presenting
with asystole and EMD (PEA): 1 of 237 survived (0.4%).

 

Out-of-hospital arrests -- 2 of 244 survived to discharge (0.8%)

 

Initial survivors with either impaired consciousness or functional
impairment after the arrest had significantly worse chances of survival
than patients without these impairments

** **

**Nursing Home Patients**

*Journal of the American Geriatrics Society* March 1990 study looked at
all 705 out-of-hospital patients in Baltimore County MD over age 65 who
underwent resuscitation. Of these 117 lived in Nursing Homes.

***Nursing Home resuscitation***: Ninety percent were pronounced dead in
the ER, the rest survived an average of less than five days. *Only two
survived to discharge back to the NH..*

One of the two NH CPR survivors was an 87 yo female who died 8 months
after returning to the NH - demented, cachectic and with a large sacral
pressure ulcer.

***Non-NH residents***: Of the 519/588 (90%) nonresidents who died
before discharge, 433 were pronounced dead in the emergency room, 16
died in the first 24 hours, and 70 lived an average of nine days.

# Post-resuscitation Functional Status

 

A study in the *Archives of Internal Medicine* in 1997 that looked at
functional status (ability to perform ADLs) among CPR survivors, 56% had
baseline or improved function and 44% had worse function. Those with the
best outcomes were less than 55 years old. **Patients over 75 had a
five-fold increase in the probability (over 80% chance) of worse
function compared to younger patients.** Patients who deteriorated lost
an average of 4 ADLs. Only 30% ever reached their previous baseline.
Patients who suffered a cardiac arrest after the *fourth* hospital day
had over a 8-fold (over 90%) increase in chance of functional
deterioration.

**Summary**: Patients over 70 who have *unwitnessed arrests,* whether in
or out of hospital, have essentially *no* chance for survival for
discharge to home

*Witnessed* *arrests,* with CPR started immediately, carry a 2- 10 %
chance of survival to discharge.

Patients over 75 who survive to discharge, have an 80% chance for
significant deterioration in post-CPR function. Hospitalized patients
who survive an arrest occurring after the fourth hospital day have a 90%
chance of significant functional deterioration.

*Nursing Home patients* have less than 1% chance of surviving - to
return to the NH.

***In other words, a person over age 75 who has a witnessed cardiac
arrest in which CPR is started immediately by paramedics has
approximately a 2% chance of being discharge to home with cognition and
function intact. This individual has a 98% chance that this will not be
the outcome.***

***The greater the co morbidities, the smaller the chance for surviving
intact.***

# How do Facts and Information Influence Patient and Family Decisions on CPR

NEJM February 24, 1994

 

This is a study of *informed* decisions. Some studies have shown that
70-90% of elderly outpatients want CPR in the event of a cardiac arrest.
Other studies have indicated that 40-80 percent of hospitalized elderly
and one-third of NH patients or surrogates want CPR.

 

This study was designed to evaluate any change in that desire after
patients learns the facts regarding the efficacy of CPR.

 

Study: 287 ambulatory patients with a mean age of 77 were interviewed.
Forty one percent opted for CPR before learning the probabilities of
survival. After learning the chance of survival was less than 20% the
number dropped to 22% opting for CPR. Only 6% of those 86 or older opted
for CPR.

 

Of the patients with chronic illness with a life expectancy of less than
one year 11% opted for CPR. After understanding that the chance of
survival was less than 5% the number dropped to 5%.

 

Effect of DNR orders on hospitalization for non-cardiac arrest
conditions

 

Journal of the American Geriatric Society, January 2004, looked at
hospitalizations for pneumonia of patients with and without DNR orders.
Thirty-six NHs, 4,000 residents. *Sixty percent* of patients had DNR
orders. *Two percent* had "Do-not-hospitalize" orders.

 

Patients with DNR orders in general were older, more cognitively
impaired and white. When controlled for severity of illness from the
pneumonia 32% of those without a DNR order were hospitalized, compared
to 23% of those with a DNR order.

 

The study found that the presence of a DNR order was an independent
variable in the decision to hospitalize.

 

The accompanying editorial starts with the words: *"What should a
do-not-resuscitate order have to do with the decision to hospitalize a
nursing home resident? Absolutely nothing!"*

 

A DNR order is just that -- in the event of a cardio-pulmonary arrest no
attempt will be made to resuscitate the patient. Nothing else should be
implied. Other therapies should be discussed with the patient or
guardian on the merits of the particular therapy.

 

Do-not-hospitalize should be a separate order. The decision for
palliative care only is independent from a DNR order and should not be
implied.

 

AGS Position Statement - Imminent cardiopulmonary Arrest in
incapacitated elderly without advanced directives or surrogates -
1-1-98:

*For urgent, life-threatening situations, such as imminent
cardiopulmonary arrest, health care providers and institutions should
develop methods to make decisions for incapacitated persons without
surrogates. These methods might include allowing the attending physician
and a consulting physician to make certain choices within established
protocols subject to retrospective review.*

*Rationale*

*Resuscitation of patients with serious underlying illness is associated
with a poor outcome (1-3). Although physiologic resuscitation can
sometimes be achieved, function is not restored or may worsen despite
resuscitation, consigning the patient to a lingering death on artificial
life support. Patients should not be forced to receive inappropriate
treatment because they lack a surrogate decision-maker.*

AGS Position Statement

THE CARE OF DYING PATIENTS\
AGS Ethics Committee\
\
Updated November, 2002

Background

Dying is the final portion of the life cycle for all of us. Providing
excellent, humane care to patients near the end of life, when curative
means are either no longer possible or, no longer desired by the
patient, is an essential part of medicine. The American Geriatrics
Society (AGS) recognizes that most people near the end of life want to
live as fully as they can. They want their health care providers to
honor their wishes and goals and to help them maintain their dignity and
independence while relieving symptoms and maximizing comfort. For
physicians and health care providers to provide excellent care to dying
patients and their families, they need expertise as well as compassion.
Physicians who care for dying patients often find this work fulfilling,
a source of pride, and even a privilege. Making excellent care for dying
patients regularly available will require improvements in systems for
service delivery and in professional education.

**Definitions**

Patients who are dying

*Within this document, people are considered to be dying when they are
sick with a progressive condition that is expected to end in death and
for which there is no treatment that can substantially alter the
outcome. Thus, people are dying when they have illnesses such as
advanced dementia or severe congestive heart failure, in addition to
illnesses more routinely recognized as terminal, such as advanced
cancer. Care of dying patients also encompasses patients who have
elected to forgo available treatments that might forestall death, such
as dialysis for end stage renal disease.*

Palliative care

Within this document, palliative care refers to care directed toward the
quality of life of patients who are dying, including the relief of pain
and other symptoms, attention to the psychological, emotional, social
and spiritual needs of the patient, and the provision of support for the
dying patient and the patient\'s family.

* *