SHoZAB AHMED

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Care of Elderly in the ICU

• SHoZAB AHMED

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Definition of Old Age

• Fixed age thresholds
• Objective and provides comparison with historical
  data
• 65-75 years young old
• 75-85 years old old
• 85-90 years oldest old

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Definition of Old Age

• Health related definition of old age
• Concept of frailty/vulnerability
• No agreement in the definition
• Increased risk of experiencing a specific event
  (fall, loss of self sufficiency,
  institutionalization, or death)
• State of vulnerability to insults such that the
  outcome after a specific health related event
  will be poor than in the non-frail patients
  receiving the same care and having similar
  apparent health

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Aging Population

• 60 years ago, 8 of the world population was aged
  60 years and over
• 10 by the year 2005
• By 2050, 45 of the patient population would be
  over age 60 years

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Aging Population
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What is Wrong with Getting Old?
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• Is age alone a big factor in determining poor
  prognosis?

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• So if not just the age what is it?

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• Diagnosis
• One of the key factors in determining prognosis
• Pts 80-84 mortality was 85 if the diagnosis was
  sepsis compared to 58 if the diagnosis was GIB
• On Mechanical ventilation mortality was 62 if
  the cause was pneumonia vs 41 in trauma patients
• Geriatric patients with head trauma has twice the
  mortality and functional disability as compared
  to young patients

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• Co-Morbidity
• Total burden of illness unrelated to a patients
  principal diagnosis, contributes to clinical
  outcomes(e.g., mortality, surgical results,
  complication rates, functional status and length
  of stay) as well as to economic outcomes (
  resource utilization, discharge destination and
  intensity of treatments

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• Age does predispose to co-morbid conditions and
  impair performance status that does affect
  mortality

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Age related changes in CNS

• Cognitive impairment
• Dementia
• In patients 65 and over prevalence is anywhere
  from 10.3-18.8
• Study of older ICU patients found a prevalence of
  preexisting cognitive impairment to be between 31
  and 42
• Dementia is one of the strongest risk factors for
  the development of delerium

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What is Delerium?

• Acute disorder of attention and global cognitive
  function characterized by acute onset and
  fluctuating symptoms
• Prevalence rates of 70-87 in older medical ICU
  patients
• Risk factors
• Advanced age
• Critical illness
• Multiple medical procedures and interventions

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Delirium

• Complications
• Increased morbidity
• Increased mortality
• Nursing home placement
• Longer length of ICU and hospital stays
• Costlier hospitalization

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Age Related Changes in CNS

• Sleep
• Roughly 30 of those 50 yrs. and older suffer
  from sleeping problems
• More than 80 above 65 yrs. reports some degree
  of disrupted sleep

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Sleep

• Aging itself does not affect quantity but affects
  sleep architecture
• Sleep is shallower, with more of night spent in
  lighter sleep stages
• Fewer sleep spindles and smaller amplitude K
  complexes
• Decrease time spent in slow wave sleep (stage 3)

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Sleep

• Meta-Analysis of 65 studies showed
• Gradual reduction in of slow wave sleep
• REM sleep latency
• Sleep efficiency
• Increase in the of stage 1 and 2
• When mental and physical illness are controlled
  for REM sleep latency, wake after sleep onset
  etc. and the of REM sleep remains relatively
  stable in old age

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Sleep

• Sleep disorder and insomnia are quite prevalent
  in ICU
• Higher rate of sedative-hypnotic medication
  prescriptions
• Up to 41 to 96 of older patients in general and
  surgical wards respectively receive such
  prescriptions
• Greater negative effects
• Might interact with other medications
• Increase risk of falls, delirium and rebound
  insomnia

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Age Related Changes in the Respiratory System
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Age Related Changes in CVS
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Age Related Changes in Renal System

• Marked decline in renal function
• Decrease in renal blood flow, atrophy of the
  afferent and efferent arterioles, decrease in
  renal tubular cells
• Decrease ability to conserve sodium and water and
  excrete H
• Decrease in GFR about 45 by age 85
• Serum creatinine remains unchanged due to
  decrease in lean body mass and decrease
  creatinine production.

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Sepsis and Age

• Age is an important risk factor for developing
  sepsis
• People more than 65 years of age comprise of 65
  of cases with sepsis
• Compared to the young cohort the RR of older
  patients developing sepsis is 14
• Respiratory system and Genitourinary system was
  the most common site for infection
• GN sepsis was more common
• More older paitents died during hospitalization
  and more likely to end up in SNF

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Sepsis and Age

• Increased risk of nosocomial infection
• Infection Control Hospital epidemiology 200728
• Increased risk of severe sepsis
• Crit. Car Medicine 200129

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Age and Nutritional Status

• Protein-calorie malnutrition is common in older
  adults at admission and may develop quickly
  during hospitalization
• Diminished muscle mass? hospital malnutrition?
  further weakness
• Increased mortality in underweight older adults
• Low albumin, pre-albumin associated with
  increased post-op mortality in older adults

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Summary

• ICU population is aging
• Weigh the benefits of intensive care
• Baseline comorbidities, functional status,
  quality of life, acuity of illness and likelihood
  of recovery must be considered
• Aging alone is not a risk factor for mortality or
  poor prognosis
• There is a lack of prognostic tool for the
  elderly population
• Know your patient wishes Communicate

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• Pt preferences
• Do not necessarily prefer life extending
  treatments
• Focused on relieving pain and discomfort
• Population of patients with limited life
  expectancy and aged 60 years or older
• 74 stated they would not choose treatment if the
  burden of treatment were high and the anticipated
  outcome survival with severe functional
  impairment
• 88 of patients opted not to undergo treatment if
  cognitive impairment was the expected outcome

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• Another study
• Pt 65 and older willingness to receive CPR
  decreased from 41 to 22 after learning their
  probability of survival
• Only 6 of patients aged 86 years and more opted
  for CPR

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• Physician are often unaware of their patients
  treatment preferences
• 4556 patients
• Physicians did not knew preferences in 25 of the
  cases
• Their assessment was correct in only 45 of the
  cases

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• Patients, their surrogate decision-makers, and
  their physicians were interviewed about
  prognosis, communication, and goals of medical
  care.
• Based on age, diagnoses, comorbid illnesses, and
  acute physiology data, the SUPPORT Prognostic
  Model provided estimates of 6-month survival on
  study days 1, 3, 7, and 14.
• Hospital costs were estimated from hospital
  billing data.
• CONCLUSIONS
• Prolonged ICU stays were expensive and were often
  followed by death or disability.
• Patients reported low rates of discussions with
  their physicians about their prognoses and
  preferences for life-sustaining treatments.
• Many preferred that care focus on palliation and
  believed that care was inconsistent with their
  preferences.
• Patients were more likely to receive care
  consistent with their preferences if they had
  discussed their care preferences with their
  physicians.

J Am Geriatr Soc. 2000 May48(5 Suppl)S70-4.
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• Questions?????