SHOZAB AHMED Care of Elderly in the ICU

Definition of Old Age Fixed age thresholds  Objective and provides comparison with historical data  years young old  years old old  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 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 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 %  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.J Am Geriatr Soc May;48(5 Suppl):S70-4.

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