Transcript Critical Care for Older Adults

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Critical Care for Older Adults
Dorothy W. Bird, MD*
Lisa B. Caruso, MD, MPH†
Suresh Agarwal, MD, FACS*
Boston University Medical Center
Department of Surgery*, Department of Medicine- Geriatric
Services†
™
Introduction
• Older adults (age >65yo) are the fastest growing
segment of the US population (ref: 1,2)
• Almost HALF of all ICU admissions are older adults (ref:
1,2)
– Exacerbation of chronic illness
– New onset of illness or trauma
• By 2030 20% of Americans will be >65yo (ref: 1)
• By 2050 5% of Americans will be >85yo (ref: 1)
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Introduction
• Older adults differ from their younger ICU counterparts in
several ways:
– Physiology (cardiopulmonary, renal)
– Drug metabolism
– Nutritional needs
– Susceptibility to delirium
– ICU outcomes
– Closer to end of life
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Cardiovascular Changes
• Age-related changes in collagen, elastin→loss of recoil
(ref: 3)
– Increased systolic blood pressure
– Widened pulse pressure (ref: 1)
– Progressive left ventricular stiffness, thickness
→Diastolic Dysfunction (ref: 1,2,3)
• Less able to tolerate atrial fibrillation
• Increased sensitivity to volume overload
• Increased susceptibility to heart failure
• Increased preload dependency
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Cardiovascular Changes
• Fewer cardiac myocytes (ref: 2,4)
• Fibrosis/loss of autonomic tissue (ref: 2)
– Conduction abnormalities (sick sinus, a-fib, BBB)
• Diminished sensitivity to β-adrenergic stimulation (ref: 1,2,3,4)
– Stroke volume, preload more important for increasing cardiac
output
– Even minor hypovolemia can cause cardiac impairment
(Increased preload dependency)
– Diminished response to norepinephrine, isoproterinol,
dobutamine
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Cardiovascular Risk Factors
• Increased prevalence of coronary artery disease in older
adults (ref: 1,2,3)
– May present as heart failure, pulmonary edema,
arrhythmias
– Myocardial ischemia more likely to go unrecongnized
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Pulmonary Changes
• Increased chest rigidity (ref: 1,2,3,4), kyphosis (ref: 2)
– Increased work of breathing
• Decreased forced total lung capacity, vital capacity,
FEV11,3
• Decreased inspiratory, expiratory force (ref: 1,2)
• Diminished respiratory muscle strength (↓25%) (ref: 1,4)
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Pulmonary Changes
• Premature closure of terminal airways (ref: 3)
– V-Q mismatch (ref: 2,3)
– Decrease in PaO2 controversial (ref: 3,4)
• Expected PaO2= 100 – 0.325 x age
– Increased A-a gradient (ref: 1,3)
• Expected P(A-a)O2 = (age +10) x 0.25
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Pulmonary Changes
• Blunted Ventilatory control (ref: 2,3)
– Diminished response to hypoxia (↓50%)
– Diminished response to hypercapnia (↓40%)
• Reduced cough, mucociliary clearance (ref: 2,3)
• Impaired pulmonary immunity (ref: 2,3)
• Diminished gag (ref: 3)
• Difficulty swallowing (ref: 2,3)
– Increased risk of aspiration
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Cardiopulmonary Summary
Cardiopulmonary BASICS:
• Decreased cardiac and respiratory reserves can lead to
rapid decompensation in older adults and slower
response time in correction
• Pulmonary insult (pneumonia) can trigger heart failure
exacerbation
• Acute respiratory failure can result from hemodynamic
shock
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Renal Changes
• Decreased creatinine clearance (CC), decreased GFR
(ref: 1,2,3)
– Cockroft-Gault Estimated CC = (140-age) x wt(kg)/72
x serum creatinine
– Adjust medication dosage based on estimated CC,
not serum creatinine!
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Renal Changes
• Concealed renal insufficiency (ref: 2)
– Reduced GFR despite NORMAL serum creatinine
– May be due to increased prevalence of hypertension,
diabetes in elderly
– Present in 13.9% of elderly patients
– Associated with increased risk of adverse reaction
with hydrophilic medications
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Renal Changes
• Loss of nephrons (0.5-1%/year) (ref: 2,3)
• Reduced renal plasma flow (10%/decade) (ref:1,2,3)
• Reduced concentrating ability of medullary nephrons
(ref: 1,2,3)
• Less responsive to ADH (ref: 2,3)
– More free water loss→ dehydration, electrolyte
imbalance (hyperkalemia, hyponatremia)
– Thiazide-induced hyponatremia common in older
adults
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Nutrition
• Protein-calorie malnutrition is common in older adults at
admission and may develop quickly during hospitization
(ref: 1,2,3)
• Diminished muscle mass→ hospital malnutrition→
further weakness (ref: 2,3)
• Increased mortality in underweight older adults (ref: 3)
• Low albumin, pre-albumin associated with increased
post-op mortality in older adults
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Nutrition
• Assess nutritional status in all older adults:
– pre-albumin
– transferrin
– indirect calorimetry
– CRP: marker of inflammation, inverse relationship
with pre-albumin
• Nutritional support should begin within 24h of ICU
admission (ref: 2)
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Medications
• Adverse drug reaction is the most common iatrogenic disorder in
older adults (ref: 3)
• Age is an independent risk factor for adverse drug interaction2
• Increased body fat (25-50%), decreased body water in older adults
(ref: 1,3)
– Hydrophilic drugs (digoxin, theophylline) have lower volume of
distribution—reach higher levels faster
– Lipophilic drugs (psychotropics) have larger volume of
distribution—progressive accumulation
• Impaired drug excretion (renal, hepatic) (ref: 3)
• EFFECT: increased half-life, longer duration of action of many
medications (ref: 3)
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Medications
• Reduced serum albumin→ higher free drug levels→ greater
pharmacologic effect (ref: 3)
• Decreased cytochrome p450 activity→ reduced elimination
(especially warfarin, theophylline) (ref: 3)
• Altered sensitivity of receptors to commonly used medications (ref:
3)
– More sensitive: warfarin, narcotics, sedatives, anticholinergics
– Less sensitive: β-adrenergic agonists/antagonists
• Polypharmacy (ref: 2,3)
– Probability of adverse drug interaction:
• 7% if on >5 medications, 24% if on >10 medications
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Medications
• Drugs most often associated with adverse reactions (ref: 2):
– Digitalis
– ACE-I
– Hypoglycemics
• Contrast-induced nephrotoxicity- increased in older adults (ref: 2)
– Ensure preventative measures are taken when using contrast
studies!
• When starting medications: Start low, go slow!
– Especially with sedatives and anti-psychotics!
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Delirium
• Seen in 1/3-1/2 of hospitalized older adult patients (ref:
2,3)
• Up to 70% of older adults in ICU (ref: 2,3)
• Can lead to loss of mobility, atrophy, contractures,
pressure ulcers, falls, thromboembolism, incontinence,
anorexia, constipation, de-motivation (ref: 3)
• Associated with prolonged hospitalization, nursing home
placement, increased mortality (ref: 2,3)
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Delirium
• Predisposing factors: (ref: 2,3)
– Prior cognitive impairment: patients with dementia are 5x more
likely to develop delirium!
– Structural brain disease
– Chronic illness
– Sleep deprivation
– Drug/alcohol use
– Unfamiliar surroundings/social isolation
• Use of sedatives, psychotropics, restraints can worsen symptoms,
increase risk of aspiration, ulcers, etc. (ref: 3)
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Delirium
• Indicative of diffuse brain dysfunction (ref: 3)
• Associated with four disease classes: (ref: 2,3)
– Primary cerebral disease (infection, tumor, stroke,
dementia)
– Systemic illness (infection, cardiac, pulmonary,
hepatic, uremia, endocrine)
– Intoxication (EtOH, drugs, toxins)
– Withdrawal (EtOH, benzodiazepine, barbiturates)
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Delirium
• Prevention,Treatment (ref: 2,3)
– Identify underlying cause!
– Minimize offending medications
• neuroleptics, opioids, anticholinergics, sedatives, H2-blockers
– Constant observation, minimize restraints!
– Well-lighted, predictable environment
– Eyeglasses, hearing aids, dentures
– Frequent reorientation by staff and family
– Establish normal sleep-wake cycle
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Postoperative Cognitive Dysfuntion
(POCD)
• Acute, short-term disorder of cognition, memory,
attention following surgery (ref: 2)
• Present in 26% non-cardiac surgery older adults at 1
week post-op, 9.9% at 3 months (ref: 2)
• Present in 80% of older adults after cardiac surgery by
discharge, 50% at 6 weeks post-op (ref: 2)
• May be first sign of hypoxemia, sepsis, electrolyte
imbalance! Usually idiopathic (ref: 2)
– Suspected interaction between anesthesia and agerelated change in neurotransmitters (ref: 2)
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POCD
• Prognosis
– Good: transient symptoms in most sufferers (ref: 2)
– Prolonged POCD: may last months→ years (ref: 2)
• Risk factors
– AGE! (ref: 2)
– Also: duration of anesthesia, post-op infection,
respiratory complicaions (ref: 2)
– Age is the only risk factor for prolonged POCD (ref: 2)
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Pressure Ulcers
• Associated with immobility in older adults
• 50% pressure ulcers occur in those >70yo (ref: 3)
• Sites:
– sacrum, ischial tuberosities, hip, heel, elbow, knee, ankle,
occiput
• Found in 28% of those confined to bed or chair for 1 week (ref: 3)
• High mortality
– 73% mortality if develops in first 2 weeks of hospitalization (ref:
3)
– May lead to sepsis→ 60% mortality if ulcer is cause (ref: 3)
• Now considered a “never event”- no reimbursement
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Pressure Ulcers
• Prevention
– Frequent repositioning: q2 hours (ref. 3)
– Avoid pressure on bony prominences (ref. 3)
• Rest back on pillows at 30-degree angle from bed
– Head of bed not more than 30 degrees (ref. 3)
– Do not tuck sheets at foot of bed (ref. 3)
• Allow feet to assume natural position
• Protect heels by elevating feet with pillows
– Lift patients to move, do not drag (ref. 3)
– Pat skin dry, do not rub (ref. 3)
– Reduce contact with soilage (fecal, urinary incontinence) (ref. 3)
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Pressure Ulcers
• Prevention
– Ensure adequate nutrition, hydration, pain control (ref.
3)
– Early mobilization (ref. 3)
– Rehab service consult (ref. 3)
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Outcomes
• Age is associated with
progressive risk of ICU
death2
– Mortality: 36.8% in
>65yo; 14.8% <45yo
(ref. 2)
– 1-year post-ICU
survival: 47% in ≥65yo,
83% <35yo (ref. 2)
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age
ICU survival
3-mo
survival
<75
80%
75-79
68%
54%
80-84
75%
56%
≥85
69%
51%
From: Somme et al. Intensive Care Med 2003: 29:21372143
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Outcomes
• Octegenarian hospital survivors discharged to subacute
facility have higher mortality compared to those
discharged to home (31% vs. 17%) (ref. 2)
• Likelihood of discharge to subacute facility directly
related to preadmission comorbidities (ref. 2)
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Optimizing ICU Use
GOAL: Minimize misery, maximize dignity
• ICU care should provide temporary physiologic support
for reversible conditions (ref. 2)
• Decision to admit older adults should be based on:
patient comorbidities, acuity of illness, prior functional
status, patient’s wishes (ref. 2)
• Always clarify and document advanced directives and
wishes for intubation, CPR, vasoactive medication
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References
1. Nagappan R, Parkin G. Geriatric critical care. Crit Care
Clin 2003:253-270.
2. Marik, PE. Management of the critically ill geriatric
patient. Crit Care Med 2006; 34(9):S176-S182.
3. Dhanani S, Norman DC. Chapter 19. Care of the elderly
patient. In: Bongard FS. Current diagnosis and
treatment critical care. 3rd ed. New York: McGrawHill;2008.
4. Delerme, A, Ray P. Acute respiratory failure in the
elderly: diagnosis and prognosis. Age and Aging
2008;37:251-257.
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