Transcript G ICU
Care of Elderly in the ICU
SHOZAB AHMED
Definition of Old Age
Fixed age thresholds
Objective and provides comparison with historical data
65-75 years
75-85 years
85-90 years
young old
old old
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 2005
By 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 10.318.8%
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 effects
Might interact with other medications
Increase 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 common
More 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 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
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 patients
Physicians did not knew preferences in 25% of the
cases
Their 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?????