SHOZAB AHMED

Care of Elderly in the ICU

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

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

Aging Population

60 years ago, 8% of the world population was aged 60 years and over

10% by the year 2005By 2050, 45% of the patient population would

be over age 60 years

Aging Population

What is Wrong with Getting Old?

Is age alone a big factor in determining poor prognosis?

So if not just the age what is it?

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

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

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

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

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

Delirium

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

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

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)

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

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 effectsMight interact with other medicationsIncrease risk of falls, delirium and rebound

insomnia

Age Related Changes in the Respiratory System

Age Related Changes in CVS

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.

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 commonMore older paitents died during hospitalization

and more likely to end up in SNF

Sepsis and Age

Increased risk of nosocomial infection Infection Control Hospital epidemiology 2007:28

Increased risk of severe sepsis Crit. Car Medicine 2001:29

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

Summary

ICU population is agingWeigh the benefits of intensive careBaseline 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

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

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

Physician are often unaware of their patient’s treatment preferences

4556 patientsPhysicians did not knew preferences in 25%

of the casesTheir assessment was correct in only 45% of

the cases

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 May;48(5 Suppl):S70-4.

Questions?????