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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
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young old
old old
oldest old
Definition of Old Age
 Health related definition of old age
 Concept of frailty/vulnerability
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No agreement in the definition
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Increased risk of experiencing a specific event (fall, loss of self
sufficiency, institutionalization, or death)
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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
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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
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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
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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
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74% stated they would not choose treatment if the burden of
treatment were high and the anticipated outcome survival with
severe functional impairment
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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
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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?????