Critical Care and Trauma Considerations in the Geriatric Patient
Maurice F. Joyce, MD, EdM Konstantin Balonov, MD Ruben J. Azocar, MD Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts
’
Context
The rapid growth of the elderly population has had a significant impact on health care delivery. Critical care services have been especially affected, as admissions of older adults to intensive care units (ICU) continue to become increasingly common. Importantly, this trend is a worldwide phenomenon. Blot et al1 reported that admissions of patients older than the age of 75 to an ICU in a Dutch institution increased by 33% when comparing the periods between 1992 and 1996 and 2002 and 2006. Similarly, looking at data from 57 ICUs in Australia and New Zealand, Bagshaw et al2 found that in patients older than the age of 80 there was a 6% increase per year in ICU admissions between 2000 and 2005 and this segment of the population represented 14% of all ICU admissions. In the United States, approximately 42% to 52% of ICU admissions are geriatric patients and 60% of all intensive care days are attributed to this group.3 In addition, 11% of the Medicare recipients spend an average of 8 days in the ICU during the final 6 months of their lives, and about 40% of the Medicare recipients who die are admitted to the ICU during their terminal illness.4 These ICU stays represent approximately 25% of total Medicare expenditures.4 Furthermore, analysis of ICU bed utilization demonstrates that those patients older than the age of 65 occupy 25% to 50% of all beds. This larger utilization of critical care services by older adults combined with the limited REPRINTS: RUBEN J. AZOCAR, MD, DEPARTMENT OF ANESTHESIOLOGY, TUFTS MEDICAL CENTER, 800 WASHINGTON STREET, BOSTON, MA 02111. E-MAIL: [email protected] INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 52, Number 4, 95–108 r 2014, Lippincott Williams & Wilkins
www.anesthesiaclinics.com | 95
96
’
Joyce et al
resources and elevated costs of intensive care medicine is a tremendous challenge to both physicians and health care administrators. ’
Clinical Considerations
Aging itself is not pathologic per se, but rather there are physiological changes associated with aging that greatly affect critical care management. As we age, functional and structural changes occur. Although basal function of organ systems may remain the same or decrease only slightly, it is important to note that physiological reserve decreases with age, even in health, as demonstrated in Table 1.5 An additional challenge when assessing geriatric patients is the lack of correlation between physiological and chronological age based on comorbidities and, more importantly, the impact of frailty. It has been postulated that frailty might be the best indicator of overall physical and functional status.6,7 Surgical literature has shown that frailty is an excellent predictor of surgical outcomes and it is possible that a similar correlation could be applied to the critically ill.6 A summary of the most pertinent physiological changes as they relate to the elderly critical care patients are summarized in Table 1. A discussion of clinical considerations for each major system follows. ’
Neurological
Delirium is prevalent in the critically ill older adults and has a clear impact in terms of patient outcomes and health care costs. This discussion attempts to summarize the issues related to delirium during the time of critical illness. In a prospective study, McNicoll et al8 followed up on a total of 118 patients older than the age of 65 who were admitted to a medical ICU. On admission, 31% of these patients were already delirious, and of those with a normal mental status on admission 31% developed delirium while in the ICU. In the post-ICU phase, delirium was noted in 40% of the patients. In another study, the incidence of delirium in patients older than the age of 60 was 70.4% within 48 hours of admission to a medical ICU.9 In terms of outcomes, delirium has been shown to be an independent predictor of 6-month mortality and longer hospital stays.10,11 Furthermore, recent data suggest that older adults who experience delirium may develop long-term cognitive dysfunction or dementia, which adds to the severity of this process’ impact.12–14 The implications on resource utilization and overall health care costs are obvious. Clinically, delirium presents as an acute or fluctuating change in mental status where inattention is the most prominent feature. Delirium www.anesthesiaclinics.com
Critical Care and Trauma Considerations in the Geriatric Patient
Table 1.
’
97
Physiological Changes of Aging5
Organ System Central nervous system
Cardiovascular
Respiratory
Renal
Pharmacological
Changes With Aging Loss of neural tissue: 26% reduction of white matter 10%-20% reduction in cerebral blood flow Decreased number of serotonin, acetylcholine, and dopamine receptors Decline in memory, reasoning, perception Disturbed sleep/wake cycle Prone to delirium and cognitive dysfunction Diastolic dysfunction and loss of compliance of vascular bed Less responsive to catecholamines Autonomic tissue is replaced by fat and connective tissue: prone to arrhythmias—most commonly atrial fibrillation and AV block Loss of pharyngeal reflexes Decrease in chest wall compliance Decline in lung elasticity Alteration in control of ventilation Decreased diaphragm strength Increased A-a gradient Increased closing capacity Loss of renal tubular mass Decreased renal blood flow by 50% Decreased glomerular filtration rate (by 80 y old, decreased by 45%) Reduced ability to dilute and concentrate urine and conserve sodium Decreased drug clearance Decrease level of proteins Decreased protein binding Decreased lean and increased fat body mass Decreased circulating blood volume
can present as hyperactive (especially when agitation is present), hypoactive, or mixed. The use of the Confusion Assessment Method for the ICU appears to be a rapid, valid, and reliable tool in the diagnosis of delirium in the ICU.15 Once delirium is suspected, it should be considered a medical emergency and physiological causes should be investigated and resolved if present. Pharmacological management for hyperactive delirium should only be considered once underlying causes have been discarded. However, the best treatment for delirium is prevention. Interventions such as noise reduction, reorientation, cognitive stimulation, return of vision and hearing aids, proper hydration, avoidance of sleep deprivation, and pain control have been shown to be effective in the prevention of delirium.16,17 Recently in the critical care literature, 2 other interventions have been further explored: sedation and mobilization. In terms of sedation, the choice of agent has been scrutinized. Benzodiazepines, which have www.anesthesiaclinics.com
98
’
Joyce et al
been traditionally used as sedatives in the ICU especially in cases of hyperactive delirium, have been linked to the incidence of delirium in critically ill patients.18 Owing to these findings, the use of alternative sedatives such as propofol or dexmedetomidine has been increasingly studied. Pandharipande et al19 compared the use of a lorazepam infusion with the use of a dexmedetomidine infusion in mechanically ventilated patients and found that the use of a dexmedetomidine infusion resulted in more days alive without delirium or coma and more time at the targeted level of sedation than with a lorazepam infusion. This group also compared midazolam with dexmedetomidine and found similar levels of sedation with both drugs; however, patients who received dexmedetomidine spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension.20 However, it is important to note that several other trials comparing dexmedetomidine with midazolam and propofol did not demonstrate major differences among groups in terms of delirium.21 In addition, a recent systematic review and meta-analysis looking at benzodiazepine versus nonbenzodiazepine sedation suggested that the use of nonbenzodiazepine sedation reduced ICU length of stay and duration of mechanical ventilation, but resulted in a similar prevalence of delirium and short-term mortality.22 Importantly, the level of sedation and duration of sedation might also play a role. Kress et al23 introduced the concept of daily interruptions of sedative infusion in mechanically ventilated patients. The results of their trial demonstrated that such strategies decrease the total amount of sedation in addition to decreasing both the days of mechanical ventilation and the length of stay in the ICU. The minimization of sedation does not seem to influence the incidence of delirium per se, but rather allows for early mobilization. Immobility favors the development of delirium, and thus by allowing the patient to interact with his or her caregivers and initiate an early mobilization program it is possible that several ICU-related complications, including delirium, could be minimized.24–26 Overall, it seems that the level of sedation and, to a certain degree, drug selection play an important role in the occurrence of delirium. Furthermore, allowing for early mobilization seems to be one of the most vital components in delirium prevention.
’
Cardiovascular
Overall, the cardiovascular performance in severely ill geriatric patients is affected by the lack of reserve, which might not be apparent under normal circumstances, but becomes very significant under stress conditions such as blood loss, sepsis, or hypoxia. The aging heart is www.anesthesiaclinics.com
Critical Care and Trauma Considerations in the Geriatric Patient
’
99
characterized by progressive decrease in the number of myocytes and an increase in the collagen tissue and fat.27 As a result, the heart becomes less responsive to sympathetic stimulation. In addition, these changes contribute to the high incidence of sick sinus syndrome, bundle branch blocks, and atrial fibrillation. The latter is the most common arrhythmia in critically ill patients with a particularly high incidence in patients over 80 years of age.28,29 Furthermore, there is impaired diastolic relaxation contributing to the development of diastolic heart failure. This fact paired with problems with heart rate variability and the distensibility of the blood vessels makes the geriatric patient extremely sensitive to deficits in intravascular blood volume.30 The dependence of left ventricular filling on atrial contraction in patients with marked diastolic dysfunction increases with age.31 Therefore, atrial fibrillation is poorly tolerated by this group of patients. Because of aging, the ability of the heart to compensate for a decrease in cardiac output by increasing the heart rate significantly declines. Thus, the cardiac performance becomes much more dependent on preload. However, the age-related decrease in atrial distensibility and ventricular compliance predisposes geriatric patients to a higher incidence of pulmonary edema. In these settings, maintenance of sinus rhythm becomes very important as the contribution of atrial contraction to ventricular filling increases. Changes in arterial stiffness result in increased pulse wave velocity throughout the vascular system and might lead to increased vascular impedance and secondary changes in the myocardium, including myocardial hypertrophy. Risk of acute coronary syndrome also increases with age. Compared with patients with ST-elevation myocardial infarction (STEMI), those with unstable angina and non-STEMIs are more likely to be elderly and have a worse prognosis.32 Medical treatment of an elderly patient with acute coronary syndrome includes b-blockers, antiplatelet therapy, ACEinhibitors, and nitroglycerin. The risk of significant adverse reactions such as gastrointestinal hemorrhage due to aspirin or renal failure due to administration of ACE-inhibitors is, however, higher in the geriatric population. Percutaneous coronary interventions, including angioplasty and intracoronary stents, have been demonstrated to be superior to fibrinolytic therapy in patients over 70 years of age.33 However, advanced age and comorbidities should be seriously considered when making a decision about surgical revascularization, as its risks increase markedly in patients aged 75 years and older. The prevalence of valvular heart disease, particularly aortic stenosis, increases with age. Aortic stenosis may cause symptoms of syncope, angina, and congestive heart failure. The only effective therapy is aortic valve replacement. Elderly patients do benefit from aortic valve replacement and often do well long term. Patients diagnosed with aortic stenosis should be assessed with regard to the degree of stenosis www.anesthesiaclinics.com
100
’
Joyce et al
and left ventricular function. Pharmacologic therapy should be aimed at control of the heart rate and relief of pulmonary congestion if present, keeping in mind that overly aggressive diuresis may worsen hemodynamics. The incidence of conduction heart disease increases in parallel with advancing age, which explains why a significant number of elderly patients present with either a permanent pacemaker or implantable cardioverter-defibrillator. Although the management of these devices is usually provided by electrophysiologists, some useful information can be obtained from the manufacturer’s card that is carried by the patient, a chest radiograph that shows lead position and integrity, and an electrocardiogram with rhythm strip.34 Details of electrical patterns should be apparent from the rhythm strip and interrogation findings. ’
Pulmonary
Declines in both chest wall compliance and the elasticity of lung parenchyma contribute to the overall decline in respiratory function in elderly patients and pose a challenge in the pulmonary management of critically ill elderly patients to the intensivist. This challenge is magnified by comorbid conditions such as delirium or stroke, which may predispose the patient to further pulmonary decline or other complications such as aspiration. Thus, it is imperative that an elderly patient’s pulmonary functional status is maximized through measures such as early mobilization and strict maintenance of aspiration precautions, especially for those patients who are at the most high risk. A particular concern is the treatment of respiratory failure in this population. It is well known that the incidence of acute lung injury rises markedly with age.35 Although patients older than the age of 70 have been shown to recover from the acute phase of acute lung injury at similar rates to younger patients, they are less likely to remain extubated and ultimately discharged from the ICU.36 Thus, the use of noninvasive ventilation strategies in this population has been extensively investigated, especially in certain disease states such as chronic obstructive pulmonary disease exacerbations.37,38 These studies on elderly patients admitted with acute hypercapnic respiratory failure because of chronic obstructive pulmonary disease demonstrated that noninvasive ventilation is an effective treatment and can prevent the need for intubation. ’
Renal
The significant decline in renal function, as evidenced by the marked decrease in glomerular filtration rate (GFR) in elderly patients, has multiple implications for the management of these patients as they www.anesthesiaclinics.com
Critical Care and Trauma Considerations in the Geriatric Patient
’
101
are at high risk for acute kidney injury.39 Most notably, special attention must be given to pharmacologic management, and nephrotoxic agents should be avoided. Renally excreted medications should be carefully dosed according to GFR.40 It is important to note that serum creatinine level is a poor marker of GFR in elderly patients owing to decreases in lean body mass and creatinine production; thus, estimates must be made using the Cockcroft and Gault formula. However, this estimate can be unreliable in critically ill elderly patients because of factors such as immobility and associated muscle breakdown. The clinician should also attempt to utilize alternative imaging techniques such as ultrasonography to avoid intravenous contrast, as it could have catastrophic effects on already diminished renal function. An additional area of concern in critically ill elderly patients is the frequent long-term use of bladder catheters. Owing to the high risk of catheter-associated urinary tract infections and possible subsequent bacteremia, it is imperative to remove catheters as soon as possible and use alternatives such as condom catheters. The use of urinary catheter reminders and stop orders has been shown to reduce the rate of catheter-associated urinary tract infections in addition to reducing the frequency of inappropriate catheterization.41
’
Trauma
Traumatic injuries to patients over the age of 65 are a major public health concern. As individuals live longer and continue to engage in an active lifestyle, the incidence of traumatic injury has increased markedly in the elderly population. Data from the New York State Trauma Registry showed a 17.6% increase in traumatic injuries in patients between 75 and 85 years of age between 1994 and 1998.42 Falls are the leading cause of trauma, followed by motor vehicle accidents and pedestrian-related collisions.43 Unfortunately, elderly trauma victims have higher mortality rates and poorer long-term functional outcomes compared with younger patients with similar injuries.44,45 Geriatric trauma victims, aged 75 and older, have the highest mortality rates (86.1 to 296.6 deaths per 100, 000).46 Although diminishing physiological reserve seems to be a clear explanation for the higher mortality rates and poorer long-term outcomes, there are opportunities to enhance the care of the geriatric trauma patient. An important factor is the volume of geriatric trauma patients. A recent study suggests that higher rates of in-hospital mortality, major complications, and failure to rescue were associated with a low volume of geriatric trauma patients. The authors suggest that outcomes might be improved with differentiated pathways in the care of geriatric trauma patients.47 For example, the creation of a “geriatric-specific” www.anesthesiaclinics.com
102
’
Joyce et al
trauma triage system would avoid over or under triage of these patients and improve outcomes.48 In general, the same trauma principles apply to all trauma victims with a primary survey focusing on Airway, Breathing, Circulation, Deficits, and Exposure (ABCDE). However, there are special considerations for the geriatric patients that are summarized in Table 2.45 After completion of the primary survey, a careful secondary survey looking for other injuries common in the older adult, such as fractures, will complete the assessment. It is also important to look for signs of elder abuse. The field of geriatric trauma continues to evolve, and it is clear that the geriatric patients that suffer a traumatic injury require special considerations for triage and management.49
’
Outcomes
Mortality rates of critically ill geriatric patients are higher than in the age-matched and sex-matched general population. In a recent study from France, patients older than the age of 80 who were admitted to a single ICU had reported hospital and 2-year mortality rates of 55% and 79%, respectively.50 However, measuring outcomes in the critically ill elderly patients solely by survival may be misleading, as post-ICU quality of life and personal preferences might be just as important and are frequently overlooked when caring for these patients. In a study on 900 octogenarians, Rady et al51 reported that this group not only had higher hospital mortality (10% vs. 6%, P < 0.1) but also had higher discharge rates to subacute care facilities (35% vs. 18%, P < 0.1). Importantly, those patients who did not go home had a higher mortality than those who were discharged home (31% vs. 17%). In the French study, it was also reported that physical function of long-term hospital survivors was greatly altered.50 Age alone might not be the sole determinant of these outcomes. A recent study looked at patients aged 75 and older who suffered cardiac arrest at 6 interventional cardiology centers in the United States. The goal of the study was to determine whether aggressive care of elderly patients was warranted. The investigators reported that age was independently associated with outcome only when correction for donot-resuscitate status was excluded, and that functional outcomes of elderly survivors were similar to younger patients. They concluded that the exclusion of patients older than the age of 75 from aggressive care is not warranted on the basis of age alone.7 It is intuitive to think that the presence of comorbidities and one’s functional status will have a significant impact on overall outcomes. Yet, there is evidence to suggest the contrary. Yende et al52 found that the presence of comorbidities did not significantly impact long-term www.anesthesiaclinics.com
Critical Care and Trauma Considerations in the Geriatric Patient
Table 2.
Airway Breathing
Circulation
Exposure
103
Clinical Considerations in the Geriatric Trauma Patient45
Trauma ABCDE
Deficit
’
Clinical Considerations in the Geriatric Trauma Patient Macroglossia: upper airway obstruction Lower esophageal sphincter tone: higher risk of aspiration Arthritic process: decreased neck mobility, difficult airway Chest wall rigidity: decreased compliance Costocondral calcification: tendency to rib fractures and its complications Higher closing volume: increases ventilation/perfusion mismatch Diastolic dysfunction: diastolic heart failure Changes in conduction system: tendency to arrhythmias Poor response to catecholamines: end diastolic volume dependence in stress b-blocker use: further decrease on cathecolamine response Anticoagulants: increase tendency to bleed Thin walls of the bridging veins in the dura: prone to tear and lead to subdural hematoma Atherosclerotic plaques in the arterial system: increased likelihood of stroke Skin/thermoregulation changes: hypothermia
ABCDE indicates Airway, Breathing, Circulation, Deficits, and Exposure.
mortality after pneumonia. Similarly, a recent study suggests that prehospitalization functional status is not a predictor of disability among survivors.53 Furthermore, Roch et al50 suggested that preadmission functional scores of patients older than the age of 80 did not affect the 2year mortality rate. A plausible explanation for these findings is that all elderly patients experience a decrease in their basal functional status, even when in health, and any severe critical illness may be sufficient to lead to severe organ dysfunction and disability or even death. In other words, severe critical illness may act as the great equalizer. Another possibility is that we are looking at the wrong variable. Frailty, described as the accumulation of small, individually insignificant deficits that lead to heightened vulnerability to adverse events and a predisposition for potential catastrophic decompensation, might be a much better predictor of morbidity and mortality of critically ill elderly patients.6 However, currently, there are no studies to support this hypothesis. Outcomes might also be influenced by the cause of ICU admission. Data suggest that planned surgical admissions have better survival and quality of life after ICU discharge than unplanned surgical admissions and medical admissions. In a study by Bagshaw et al,2 postsurgical admissions were reported as the main reason for admission of the elderly patients to the ICU. This group had an ICU mortality of 12%, and a hospital mortality of 25% with 72% of those who survived being discharged home. Similarly, in analyzing elderly patients who underwent elective surgery at 1 year postsurgery, de Rooij54 found that 57% www.anesthesiaclinics.com
104
’
Joyce et al
were living. Although these reported mortality rates do not seem encouraging, it is important to note that they are much better than those for emergency surgical or medical ICU admissions. In the study by de Rooij, patients who required emergency surgery had an 89% mortality rate between ICU admission and follow-up and a 90% mortality rate in medical admissions. Furthermore, Tabah et al55 found that the 1-year mortality for unscheduled surgery was 67%, and the 1-year mortality for emergent medical admissions was 80%. Specific disease states might also play a role in outcomes. Sligl et al56 reported that in patients with pneumonia, age over 80 was an independent risk factor of death at 30 days [odds ratio (OR) = 2.54] and at 1 year (OR = 3.47). Similarly, Blot et al1 reported that in patients with blood stream infections, age over 75 correlated with higher hospital mortality rates (OR = 1.8). In analyzing outcomes in those who survived a critical illness, Iwashywa et al57 reported that geriatric patients with severe sepsis had a higher incidence of cognitive impairment (OR = 3.3) and functional disability (1.5 new functional limitations). Finally, physician’s perceptions may play a significant role in outcomes. Rocker et al58 suggested that physicians’ belief that life support is not wanted or that survival is unlikely is strongly associated with death and may have effects on the decision making around limitation or withdrawal of support. These poor overall outcomes in the elderly population combined with the high cost and limited amount of ICU resources poses an ethical dilemma to the intensivist. There is discussion in the literature about futile, disproportionate, or inappropriate care in the ICU when advanced life-sustaining measures are used in patients with poor long-term expectations secondary to more chronic organ dysfunctions, comorbidities, and/or a poor quality of life. Some authors argue that this disproportionate care is a violation of basic bioethical principles, increases suffering of patients and relatives, and leads to compassion fatigue and moral distress in health care providers.59 The rationing of critical care services is very controversial and extensive discussion of this topic is beyond the scope of this article. A solution to this issue is complex and must involve patients, physicians, and the global health care system.60–62 From the patient’s perspective, more advanced health care planning is very important as it also considers one’s individual wishes. It is imperative to educate intensivists in end-of-life issues and implement evidence-based guidelines to determine those patients who will not derive benefit from the ICU to allow intensivists to provide the best support to patients and their families. A good example is to discern between treating an acute critical illness but not terminal pathology. Providing guidance in establishing goals of care at the end of life is an important role for the intensivist. Family experience during ICU and hospitalization, as well as after www.anesthesiaclinics.com
Critical Care and Trauma Considerations in the Geriatric Patient
’
105
patient’s death, may be an important outcome to consider and measure. Finally, the health care system might need to expand ICU care resources if more stringent rationing is not an option.
The authors have no conflicts of interest to disclose.
’
References
1. Blot S, Cankurtaran M, Petrovic M, et al. Epidemiology and outcome of nosocomial bloodstream infection in elderly critically ill patients: a comparison between middleaged, old, and very old patients. Crit Care Med. 2009;37:1634–1641. 2. Bagshaw SM, Webb SA, Delaney A, et al. Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis. Crit Care. 2009;13:R45. 3. Marik PE. Management of the critically ill geriatric patient. Crit Care Med. 2006;34:S176–S182. 4. Lewis M. Aging demographics and anesthesia. In: Barnett Sheila. ed. Manual of Geriatric Anesthesia. 1st ed. New York: Springer: 2013;3–14. 5. Cook DJ, Rooke GA. Priorities in perioperative geriatrics. Anesth Analg. 2003; 96:1823–1836. 6. McDermid RC, Stelfox HT, Bagshaw SM. Frailty in the critically ill: a novel concept. Crit Care. 2011;15:301. 7. Seder DB, Patel N, McPherson J, et al. Geriatric experience following cardiac arrest at six Interventional Cardiology Centers in the United States 2006–2011: interplay of age, do-not-resuscitate order, and outcomes. Crit Care Med. 2014;42:289–295. 8. McNicoll L, Pisani MA, Yon Zhang, et al. Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc. 2003;51:591–598. 9. Pisani MA, Murphy TE, Van Ness PH, et al. Characteristics associated with delirium in older patients in a medical intensive care unit. Arch Intern Med. 2007;167: 1629–1634. 10. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291: 1753–1762. 11. Thomason JW, Shintani A, Peterson JF, et al. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 nonventilated patients. Crit Care. 2005;9:R375. 12. Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369:1306–1316. 13. McCusker J, Cole M, Dendukuri N, et al. Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study. CMAJ. 2001;165:575–583. 14. Rockwood K, Cosway S, Carver D, et al. The risk of dementia and death after delirium. Age Ageing. 1999;28:551–556. 15. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001;286:2703–2710. 16. Vida´n MT, Sa´nchez E, Alonso M, et al. An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. J Am Geriatr Soc. 2009;57:572029–572036. www.anesthesiaclinics.com
106
’
Joyce et al
17. Inouye SK, Bogardus ST Jr, Baker DI, et al. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. J Am Geriatr Soc. 2000;48:1697–1706. 18. Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology. 2006;104:21–26. 19. Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs. lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007;298:2644–2653. 20. Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs. midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301:489–499. 21. Jakob SM, Ruokonen E, Grounds RM, et al. Dexmedetomidine vs. midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012;307:1151–1160. 22. Fraser GL, Devlin JW, Worby CP, et al. Benzodiazepine versus nonbenzodiazepinebased sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials. Crit Care Med. 2013;41(suppl 1):S30–S38. 23. Kress JP, Pohlmans AS, O’Connoir MF, et al. Daily interruption of sedative infusion in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342: 1471–1477. 24. Pawlik AJ. Early mobilization in the management of critical illness. Crit Care Nurs Clin North Am. 2012;24:481–490. 25. Kress JP. Sedation and mobility: changing the paradigm. Crit Care Clin. 2013;29: 67–75. 26. Brummel NE, Girard TD. Preventing delirium in the intensive care unit. Crit Care Clin. 2013;29:51–65. 27. Morley JE, Reese SS. Clinical implications of the aging heart. Am J Med. 1989;86: 77–86. 28. Heinz G. Atrial fibrillation in the intensive care unit. Intensive Care Med. 2006;35: 345–348. 29. Rials SJ, Marinchak RA, Kowey PR. Arrhythmias in the elderly. Cardiovasc Clin. 1992;22:139–157. 30. Oxenham H, Sharpe N. Cardiovascular aging and heart failure. Eur J Heart Fail. 2003;5:427–434. 31. Swinne CJ, Shapiro EP, Lima SD, et al. Age-associated changes in left ventricular diastolic function during isometric exercise in normal subjects. Am J Cardiol. 1992;69:823–826. 32. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 Guideline update for the management of patients with unstable angina and non-ST segment elevation myocardial infarction—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2002;40:1366–1374. 33. Assali AR, Moustapha A, Sdringola S, et al. The dilemma of success: percutaneous coronary interventions in patients > or = 75 years of age—successful but associated with higher vascular complications and cardiac mortality. Catheter Cardiovasc Interv. 2003;59:195–199. 34. Stone KR, Mc Pherson CA. Assessment and management of patients with pacemakers and implantable cardioverter defibrillators. Crit Care Med. 2004;32:S155–S165. 35. Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence and outcomes of acute lung injury. N Engl J Med. 2005;353:1685–1693. 36. Ely EW, Wheeler AP, Thompson BT, et al. Recovery rate and prognosis in older persons who develop acute lung injury and the acute respiratory distress syndrome. Ann Intern Med. 2002;136:25–36. www.anesthesiaclinics.com
Critical Care and Trauma Considerations in the Geriatric Patient
’
107
37. Balami JS, Packham SM, Gosney MA. Non-invasive ventilation (NIV) for respiratory failure due to acute exacerbations of chronic obstructive pulmonary disease (COPD) in older patients. Age Ageing. 2006;35:75–78. 38. Connolly MJ. Non-invasive ventilation in elderly patients with acute exacerbations of COPD: bringing pressure to bear. Age Ageing. 2006;35:1–2. 39. Chronopoulos A, Rosner MH, Cruz DN, et al. Acute kidney injury in elderly intensive care patients: a review. Inten Care Med. 2010;36:1454–1464. 40. Cheung CM, Ponnusamy A, Anderton JG. Management of acute renal failure in the elderly patient. Drugs Aging. 2008;25:455–476. 41. Meddings J, Rogers MA, Macy M, et al. Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis. 2012;55:923–929. 42. Hannan EL, Waller CH, Farrell LS, et al. Elderly trauma inpatients in New York State: 1994-1998. J Trauma. 2004;56:1297–1304. 43. Pudelek B. Geriatric trauma: special need for a special population. AACN Clin Issues. 2002;13:61–72. 44. Jacobs DG. Special considerations in geriatric injury. Curr Opin Crit Care. 2003;9: 53–59. 45. Awargal S, Azocar RJ. Trauma and the geriatric patient. In: Barnett SR. ed. Manual of Geriatric Anesthesia. New York: Springer: 2013;193–202. ˜ o AM, Anderson RN. Deaths: injuries, 2002 [USA]. Natl Vital Stat Rep. 46. Minin 2006;54:1–125. 47. Matsushima K, Schaefer EW, Won EJ, et al. Positive and negative volumeoutcome relationship in the geriatric trauma population. JAMA Surg. 2014;149: 319–326. 48. Werman HA, Erskine T, Caterino J, et al. Development of statewide geriatric trauma triage criteria. Prehosp Disaster Med. 2011;26:170–179. 49. Bonne S, Schuerer DJ. Epidemiology and evolving geriatric trauma principles. Clin Geriatr Med. 2013;29:137–150. 50. Roch A, Wiramus S, Pauly V, et al. Long term outcome in medical patients aged 80 or over following admission to an intensive care unit. Crit Care. 2011;15:R36. 51. Rady MY, Johnson DJ. Hospital discharge to care facility: a patient-centered outcome for the evaluation of intensive care for octogenarians. Chest. 2004;126: 1583–1591. 52. Yende S, Angus DC, Ali IS, et al. Influence of comorbid conditions on long-term mortality after pneumonia in older people. J Am Geriatr Soc. 2007;55:518–525. 53. Barnato AE, Albert SM, Angus DC, et al. Disability among elderly survivors of mechanical ventilation. Am J Respir Crit Care Med. 2011;183:1037–1042. 54. de Rooij SE. Cognitive, functional, and quality-of-life outcomes of patients aged 80 and older who survived at least 1 year after planned or unplanned surgery or medical intensive care treatment. J Am Geriatr Soc. 2008;56:816–822. 55. Tabah A, Philippart F, Timsit JF, et al. Quality of life in patients aged 80 or over after ICU discharge. Crit Care. 2010;14:R2. 56. Sligl WI, Eurich DT, Marrie TJ, et al. Age still matters: prognosticating short-and long-term mortality for critically ill patients with pneumonia. Crit Care Med. 2010;38:2126–2132. 57. Iwashyna TJ, Ely EW, Smith DM, et al. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA. 2010;304:1787–1794. 58. Rocker G, Cook D, Sjokvist P, et al. Level of Care Study Investigators; Canadian Critical Care Trials Group: clinician predictions of intensive care unit mortality. Crit Care Med. 2004;32:1149–1154. 59. Kompanje EJ, Piers RD, Benoit DD. Causes and consequences of disproportionate care in intensive care medicine. Curr Opin Crit Care. 2013;19:630–635. www.anesthesiaclinics.com
108
’
Joyce et al
60. Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32:638–643. 61. Truog RD, Brock DW, Cook DJ, et al. Task Force on Values, Ethics, and Rationing in Critical Care (VERICC): rationing in the intensive care unit. Crit Care Med. 2006;34:958–963. 62. Miller DH. “The rationing of intensive care. Crit Care Clin. 1994;10:135–143.
www.anesthesiaclinics.com
Maurice F. Joyce, MD, EdM Konstantin Balonov, MD Ruben J. Azocar, MD Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts
’
Context
The rapid growth of the elderly population has had a significant impact on health care delivery. Critical care services have been especially affected, as admissions of older adults to intensive care units (ICU) continue to become increasingly common. Importantly, this trend is a worldwide phenomenon. Blot et al1 reported that admissions of patients older than the age of 75 to an ICU in a Dutch institution increased by 33% when comparing the periods between 1992 and 1996 and 2002 and 2006. Similarly, looking at data from 57 ICUs in Australia and New Zealand, Bagshaw et al2 found that in patients older than the age of 80 there was a 6% increase per year in ICU admissions between 2000 and 2005 and this segment of the population represented 14% of all ICU admissions. In the United States, approximately 42% to 52% of ICU admissions are geriatric patients and 60% of all intensive care days are attributed to this group.3 In addition, 11% of the Medicare recipients spend an average of 8 days in the ICU during the final 6 months of their lives, and about 40% of the Medicare recipients who die are admitted to the ICU during their terminal illness.4 These ICU stays represent approximately 25% of total Medicare expenditures.4 Furthermore, analysis of ICU bed utilization demonstrates that those patients older than the age of 65 occupy 25% to 50% of all beds. This larger utilization of critical care services by older adults combined with the limited REPRINTS: RUBEN J. AZOCAR, MD, DEPARTMENT OF ANESTHESIOLOGY, TUFTS MEDICAL CENTER, 800 WASHINGTON STREET, BOSTON, MA 02111. E-MAIL: [email protected] INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 52, Number 4, 95–108 r 2014, Lippincott Williams & Wilkins
www.anesthesiaclinics.com | 95
96
’
Joyce et al
resources and elevated costs of intensive care medicine is a tremendous challenge to both physicians and health care administrators. ’
Clinical Considerations
Aging itself is not pathologic per se, but rather there are physiological changes associated with aging that greatly affect critical care management. As we age, functional and structural changes occur. Although basal function of organ systems may remain the same or decrease only slightly, it is important to note that physiological reserve decreases with age, even in health, as demonstrated in Table 1.5 An additional challenge when assessing geriatric patients is the lack of correlation between physiological and chronological age based on comorbidities and, more importantly, the impact of frailty. It has been postulated that frailty might be the best indicator of overall physical and functional status.6,7 Surgical literature has shown that frailty is an excellent predictor of surgical outcomes and it is possible that a similar correlation could be applied to the critically ill.6 A summary of the most pertinent physiological changes as they relate to the elderly critical care patients are summarized in Table 1. A discussion of clinical considerations for each major system follows. ’
Neurological
Delirium is prevalent in the critically ill older adults and has a clear impact in terms of patient outcomes and health care costs. This discussion attempts to summarize the issues related to delirium during the time of critical illness. In a prospective study, McNicoll et al8 followed up on a total of 118 patients older than the age of 65 who were admitted to a medical ICU. On admission, 31% of these patients were already delirious, and of those with a normal mental status on admission 31% developed delirium while in the ICU. In the post-ICU phase, delirium was noted in 40% of the patients. In another study, the incidence of delirium in patients older than the age of 60 was 70.4% within 48 hours of admission to a medical ICU.9 In terms of outcomes, delirium has been shown to be an independent predictor of 6-month mortality and longer hospital stays.10,11 Furthermore, recent data suggest that older adults who experience delirium may develop long-term cognitive dysfunction or dementia, which adds to the severity of this process’ impact.12–14 The implications on resource utilization and overall health care costs are obvious. Clinically, delirium presents as an acute or fluctuating change in mental status where inattention is the most prominent feature. Delirium www.anesthesiaclinics.com
Critical Care and Trauma Considerations in the Geriatric Patient
Table 1.
’
97
Physiological Changes of Aging5
Organ System Central nervous system
Cardiovascular
Respiratory
Renal
Pharmacological
Changes With Aging Loss of neural tissue: 26% reduction of white matter 10%-20% reduction in cerebral blood flow Decreased number of serotonin, acetylcholine, and dopamine receptors Decline in memory, reasoning, perception Disturbed sleep/wake cycle Prone to delirium and cognitive dysfunction Diastolic dysfunction and loss of compliance of vascular bed Less responsive to catecholamines Autonomic tissue is replaced by fat and connective tissue: prone to arrhythmias—most commonly atrial fibrillation and AV block Loss of pharyngeal reflexes Decrease in chest wall compliance Decline in lung elasticity Alteration in control of ventilation Decreased diaphragm strength Increased A-a gradient Increased closing capacity Loss of renal tubular mass Decreased renal blood flow by 50% Decreased glomerular filtration rate (by 80 y old, decreased by 45%) Reduced ability to dilute and concentrate urine and conserve sodium Decreased drug clearance Decrease level of proteins Decreased protein binding Decreased lean and increased fat body mass Decreased circulating blood volume
can present as hyperactive (especially when agitation is present), hypoactive, or mixed. The use of the Confusion Assessment Method for the ICU appears to be a rapid, valid, and reliable tool in the diagnosis of delirium in the ICU.15 Once delirium is suspected, it should be considered a medical emergency and physiological causes should be investigated and resolved if present. Pharmacological management for hyperactive delirium should only be considered once underlying causes have been discarded. However, the best treatment for delirium is prevention. Interventions such as noise reduction, reorientation, cognitive stimulation, return of vision and hearing aids, proper hydration, avoidance of sleep deprivation, and pain control have been shown to be effective in the prevention of delirium.16,17 Recently in the critical care literature, 2 other interventions have been further explored: sedation and mobilization. In terms of sedation, the choice of agent has been scrutinized. Benzodiazepines, which have www.anesthesiaclinics.com
98
’
Joyce et al
been traditionally used as sedatives in the ICU especially in cases of hyperactive delirium, have been linked to the incidence of delirium in critically ill patients.18 Owing to these findings, the use of alternative sedatives such as propofol or dexmedetomidine has been increasingly studied. Pandharipande et al19 compared the use of a lorazepam infusion with the use of a dexmedetomidine infusion in mechanically ventilated patients and found that the use of a dexmedetomidine infusion resulted in more days alive without delirium or coma and more time at the targeted level of sedation than with a lorazepam infusion. This group also compared midazolam with dexmedetomidine and found similar levels of sedation with both drugs; however, patients who received dexmedetomidine spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension.20 However, it is important to note that several other trials comparing dexmedetomidine with midazolam and propofol did not demonstrate major differences among groups in terms of delirium.21 In addition, a recent systematic review and meta-analysis looking at benzodiazepine versus nonbenzodiazepine sedation suggested that the use of nonbenzodiazepine sedation reduced ICU length of stay and duration of mechanical ventilation, but resulted in a similar prevalence of delirium and short-term mortality.22 Importantly, the level of sedation and duration of sedation might also play a role. Kress et al23 introduced the concept of daily interruptions of sedative infusion in mechanically ventilated patients. The results of their trial demonstrated that such strategies decrease the total amount of sedation in addition to decreasing both the days of mechanical ventilation and the length of stay in the ICU. The minimization of sedation does not seem to influence the incidence of delirium per se, but rather allows for early mobilization. Immobility favors the development of delirium, and thus by allowing the patient to interact with his or her caregivers and initiate an early mobilization program it is possible that several ICU-related complications, including delirium, could be minimized.24–26 Overall, it seems that the level of sedation and, to a certain degree, drug selection play an important role in the occurrence of delirium. Furthermore, allowing for early mobilization seems to be one of the most vital components in delirium prevention.
’
Cardiovascular
Overall, the cardiovascular performance in severely ill geriatric patients is affected by the lack of reserve, which might not be apparent under normal circumstances, but becomes very significant under stress conditions such as blood loss, sepsis, or hypoxia. The aging heart is www.anesthesiaclinics.com
Critical Care and Trauma Considerations in the Geriatric Patient
’
99
characterized by progressive decrease in the number of myocytes and an increase in the collagen tissue and fat.27 As a result, the heart becomes less responsive to sympathetic stimulation. In addition, these changes contribute to the high incidence of sick sinus syndrome, bundle branch blocks, and atrial fibrillation. The latter is the most common arrhythmia in critically ill patients with a particularly high incidence in patients over 80 years of age.28,29 Furthermore, there is impaired diastolic relaxation contributing to the development of diastolic heart failure. This fact paired with problems with heart rate variability and the distensibility of the blood vessels makes the geriatric patient extremely sensitive to deficits in intravascular blood volume.30 The dependence of left ventricular filling on atrial contraction in patients with marked diastolic dysfunction increases with age.31 Therefore, atrial fibrillation is poorly tolerated by this group of patients. Because of aging, the ability of the heart to compensate for a decrease in cardiac output by increasing the heart rate significantly declines. Thus, the cardiac performance becomes much more dependent on preload. However, the age-related decrease in atrial distensibility and ventricular compliance predisposes geriatric patients to a higher incidence of pulmonary edema. In these settings, maintenance of sinus rhythm becomes very important as the contribution of atrial contraction to ventricular filling increases. Changes in arterial stiffness result in increased pulse wave velocity throughout the vascular system and might lead to increased vascular impedance and secondary changes in the myocardium, including myocardial hypertrophy. Risk of acute coronary syndrome also increases with age. Compared with patients with ST-elevation myocardial infarction (STEMI), those with unstable angina and non-STEMIs are more likely to be elderly and have a worse prognosis.32 Medical treatment of an elderly patient with acute coronary syndrome includes b-blockers, antiplatelet therapy, ACEinhibitors, and nitroglycerin. The risk of significant adverse reactions such as gastrointestinal hemorrhage due to aspirin or renal failure due to administration of ACE-inhibitors is, however, higher in the geriatric population. Percutaneous coronary interventions, including angioplasty and intracoronary stents, have been demonstrated to be superior to fibrinolytic therapy in patients over 70 years of age.33 However, advanced age and comorbidities should be seriously considered when making a decision about surgical revascularization, as its risks increase markedly in patients aged 75 years and older. The prevalence of valvular heart disease, particularly aortic stenosis, increases with age. Aortic stenosis may cause symptoms of syncope, angina, and congestive heart failure. The only effective therapy is aortic valve replacement. Elderly patients do benefit from aortic valve replacement and often do well long term. Patients diagnosed with aortic stenosis should be assessed with regard to the degree of stenosis www.anesthesiaclinics.com
100
’
Joyce et al
and left ventricular function. Pharmacologic therapy should be aimed at control of the heart rate and relief of pulmonary congestion if present, keeping in mind that overly aggressive diuresis may worsen hemodynamics. The incidence of conduction heart disease increases in parallel with advancing age, which explains why a significant number of elderly patients present with either a permanent pacemaker or implantable cardioverter-defibrillator. Although the management of these devices is usually provided by electrophysiologists, some useful information can be obtained from the manufacturer’s card that is carried by the patient, a chest radiograph that shows lead position and integrity, and an electrocardiogram with rhythm strip.34 Details of electrical patterns should be apparent from the rhythm strip and interrogation findings. ’
Pulmonary
Declines in both chest wall compliance and the elasticity of lung parenchyma contribute to the overall decline in respiratory function in elderly patients and pose a challenge in the pulmonary management of critically ill elderly patients to the intensivist. This challenge is magnified by comorbid conditions such as delirium or stroke, which may predispose the patient to further pulmonary decline or other complications such as aspiration. Thus, it is imperative that an elderly patient’s pulmonary functional status is maximized through measures such as early mobilization and strict maintenance of aspiration precautions, especially for those patients who are at the most high risk. A particular concern is the treatment of respiratory failure in this population. It is well known that the incidence of acute lung injury rises markedly with age.35 Although patients older than the age of 70 have been shown to recover from the acute phase of acute lung injury at similar rates to younger patients, they are less likely to remain extubated and ultimately discharged from the ICU.36 Thus, the use of noninvasive ventilation strategies in this population has been extensively investigated, especially in certain disease states such as chronic obstructive pulmonary disease exacerbations.37,38 These studies on elderly patients admitted with acute hypercapnic respiratory failure because of chronic obstructive pulmonary disease demonstrated that noninvasive ventilation is an effective treatment and can prevent the need for intubation. ’
Renal
The significant decline in renal function, as evidenced by the marked decrease in glomerular filtration rate (GFR) in elderly patients, has multiple implications for the management of these patients as they www.anesthesiaclinics.com
Critical Care and Trauma Considerations in the Geriatric Patient
’
101
are at high risk for acute kidney injury.39 Most notably, special attention must be given to pharmacologic management, and nephrotoxic agents should be avoided. Renally excreted medications should be carefully dosed according to GFR.40 It is important to note that serum creatinine level is a poor marker of GFR in elderly patients owing to decreases in lean body mass and creatinine production; thus, estimates must be made using the Cockcroft and Gault formula. However, this estimate can be unreliable in critically ill elderly patients because of factors such as immobility and associated muscle breakdown. The clinician should also attempt to utilize alternative imaging techniques such as ultrasonography to avoid intravenous contrast, as it could have catastrophic effects on already diminished renal function. An additional area of concern in critically ill elderly patients is the frequent long-term use of bladder catheters. Owing to the high risk of catheter-associated urinary tract infections and possible subsequent bacteremia, it is imperative to remove catheters as soon as possible and use alternatives such as condom catheters. The use of urinary catheter reminders and stop orders has been shown to reduce the rate of catheter-associated urinary tract infections in addition to reducing the frequency of inappropriate catheterization.41
’
Trauma
Traumatic injuries to patients over the age of 65 are a major public health concern. As individuals live longer and continue to engage in an active lifestyle, the incidence of traumatic injury has increased markedly in the elderly population. Data from the New York State Trauma Registry showed a 17.6% increase in traumatic injuries in patients between 75 and 85 years of age between 1994 and 1998.42 Falls are the leading cause of trauma, followed by motor vehicle accidents and pedestrian-related collisions.43 Unfortunately, elderly trauma victims have higher mortality rates and poorer long-term functional outcomes compared with younger patients with similar injuries.44,45 Geriatric trauma victims, aged 75 and older, have the highest mortality rates (86.1 to 296.6 deaths per 100, 000).46 Although diminishing physiological reserve seems to be a clear explanation for the higher mortality rates and poorer long-term outcomes, there are opportunities to enhance the care of the geriatric trauma patient. An important factor is the volume of geriatric trauma patients. A recent study suggests that higher rates of in-hospital mortality, major complications, and failure to rescue were associated with a low volume of geriatric trauma patients. The authors suggest that outcomes might be improved with differentiated pathways in the care of geriatric trauma patients.47 For example, the creation of a “geriatric-specific” www.anesthesiaclinics.com
102
’
Joyce et al
trauma triage system would avoid over or under triage of these patients and improve outcomes.48 In general, the same trauma principles apply to all trauma victims with a primary survey focusing on Airway, Breathing, Circulation, Deficits, and Exposure (ABCDE). However, there are special considerations for the geriatric patients that are summarized in Table 2.45 After completion of the primary survey, a careful secondary survey looking for other injuries common in the older adult, such as fractures, will complete the assessment. It is also important to look for signs of elder abuse. The field of geriatric trauma continues to evolve, and it is clear that the geriatric patients that suffer a traumatic injury require special considerations for triage and management.49
’
Outcomes
Mortality rates of critically ill geriatric patients are higher than in the age-matched and sex-matched general population. In a recent study from France, patients older than the age of 80 who were admitted to a single ICU had reported hospital and 2-year mortality rates of 55% and 79%, respectively.50 However, measuring outcomes in the critically ill elderly patients solely by survival may be misleading, as post-ICU quality of life and personal preferences might be just as important and are frequently overlooked when caring for these patients. In a study on 900 octogenarians, Rady et al51 reported that this group not only had higher hospital mortality (10% vs. 6%, P < 0.1) but also had higher discharge rates to subacute care facilities (35% vs. 18%, P < 0.1). Importantly, those patients who did not go home had a higher mortality than those who were discharged home (31% vs. 17%). In the French study, it was also reported that physical function of long-term hospital survivors was greatly altered.50 Age alone might not be the sole determinant of these outcomes. A recent study looked at patients aged 75 and older who suffered cardiac arrest at 6 interventional cardiology centers in the United States. The goal of the study was to determine whether aggressive care of elderly patients was warranted. The investigators reported that age was independently associated with outcome only when correction for donot-resuscitate status was excluded, and that functional outcomes of elderly survivors were similar to younger patients. They concluded that the exclusion of patients older than the age of 75 from aggressive care is not warranted on the basis of age alone.7 It is intuitive to think that the presence of comorbidities and one’s functional status will have a significant impact on overall outcomes. Yet, there is evidence to suggest the contrary. Yende et al52 found that the presence of comorbidities did not significantly impact long-term www.anesthesiaclinics.com
Critical Care and Trauma Considerations in the Geriatric Patient
Table 2.
Airway Breathing
Circulation
Exposure
103
Clinical Considerations in the Geriatric Trauma Patient45
Trauma ABCDE
Deficit
’
Clinical Considerations in the Geriatric Trauma Patient Macroglossia: upper airway obstruction Lower esophageal sphincter tone: higher risk of aspiration Arthritic process: decreased neck mobility, difficult airway Chest wall rigidity: decreased compliance Costocondral calcification: tendency to rib fractures and its complications Higher closing volume: increases ventilation/perfusion mismatch Diastolic dysfunction: diastolic heart failure Changes in conduction system: tendency to arrhythmias Poor response to catecholamines: end diastolic volume dependence in stress b-blocker use: further decrease on cathecolamine response Anticoagulants: increase tendency to bleed Thin walls of the bridging veins in the dura: prone to tear and lead to subdural hematoma Atherosclerotic plaques in the arterial system: increased likelihood of stroke Skin/thermoregulation changes: hypothermia
ABCDE indicates Airway, Breathing, Circulation, Deficits, and Exposure.
mortality after pneumonia. Similarly, a recent study suggests that prehospitalization functional status is not a predictor of disability among survivors.53 Furthermore, Roch et al50 suggested that preadmission functional scores of patients older than the age of 80 did not affect the 2year mortality rate. A plausible explanation for these findings is that all elderly patients experience a decrease in their basal functional status, even when in health, and any severe critical illness may be sufficient to lead to severe organ dysfunction and disability or even death. In other words, severe critical illness may act as the great equalizer. Another possibility is that we are looking at the wrong variable. Frailty, described as the accumulation of small, individually insignificant deficits that lead to heightened vulnerability to adverse events and a predisposition for potential catastrophic decompensation, might be a much better predictor of morbidity and mortality of critically ill elderly patients.6 However, currently, there are no studies to support this hypothesis. Outcomes might also be influenced by the cause of ICU admission. Data suggest that planned surgical admissions have better survival and quality of life after ICU discharge than unplanned surgical admissions and medical admissions. In a study by Bagshaw et al,2 postsurgical admissions were reported as the main reason for admission of the elderly patients to the ICU. This group had an ICU mortality of 12%, and a hospital mortality of 25% with 72% of those who survived being discharged home. Similarly, in analyzing elderly patients who underwent elective surgery at 1 year postsurgery, de Rooij54 found that 57% www.anesthesiaclinics.com
104
’
Joyce et al
were living. Although these reported mortality rates do not seem encouraging, it is important to note that they are much better than those for emergency surgical or medical ICU admissions. In the study by de Rooij, patients who required emergency surgery had an 89% mortality rate between ICU admission and follow-up and a 90% mortality rate in medical admissions. Furthermore, Tabah et al55 found that the 1-year mortality for unscheduled surgery was 67%, and the 1-year mortality for emergent medical admissions was 80%. Specific disease states might also play a role in outcomes. Sligl et al56 reported that in patients with pneumonia, age over 80 was an independent risk factor of death at 30 days [odds ratio (OR) = 2.54] and at 1 year (OR = 3.47). Similarly, Blot et al1 reported that in patients with blood stream infections, age over 75 correlated with higher hospital mortality rates (OR = 1.8). In analyzing outcomes in those who survived a critical illness, Iwashywa et al57 reported that geriatric patients with severe sepsis had a higher incidence of cognitive impairment (OR = 3.3) and functional disability (1.5 new functional limitations). Finally, physician’s perceptions may play a significant role in outcomes. Rocker et al58 suggested that physicians’ belief that life support is not wanted or that survival is unlikely is strongly associated with death and may have effects on the decision making around limitation or withdrawal of support. These poor overall outcomes in the elderly population combined with the high cost and limited amount of ICU resources poses an ethical dilemma to the intensivist. There is discussion in the literature about futile, disproportionate, or inappropriate care in the ICU when advanced life-sustaining measures are used in patients with poor long-term expectations secondary to more chronic organ dysfunctions, comorbidities, and/or a poor quality of life. Some authors argue that this disproportionate care is a violation of basic bioethical principles, increases suffering of patients and relatives, and leads to compassion fatigue and moral distress in health care providers.59 The rationing of critical care services is very controversial and extensive discussion of this topic is beyond the scope of this article. A solution to this issue is complex and must involve patients, physicians, and the global health care system.60–62 From the patient’s perspective, more advanced health care planning is very important as it also considers one’s individual wishes. It is imperative to educate intensivists in end-of-life issues and implement evidence-based guidelines to determine those patients who will not derive benefit from the ICU to allow intensivists to provide the best support to patients and their families. A good example is to discern between treating an acute critical illness but not terminal pathology. Providing guidance in establishing goals of care at the end of life is an important role for the intensivist. Family experience during ICU and hospitalization, as well as after www.anesthesiaclinics.com
Critical Care and Trauma Considerations in the Geriatric Patient
’
105
patient’s death, may be an important outcome to consider and measure. Finally, the health care system might need to expand ICU care resources if more stringent rationing is not an option.
The authors have no conflicts of interest to disclose.
’
References
1. Blot S, Cankurtaran M, Petrovic M, et al. Epidemiology and outcome of nosocomial bloodstream infection in elderly critically ill patients: a comparison between middleaged, old, and very old patients. Crit Care Med. 2009;37:1634–1641. 2. Bagshaw SM, Webb SA, Delaney A, et al. Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis. Crit Care. 2009;13:R45. 3. Marik PE. Management of the critically ill geriatric patient. Crit Care Med. 2006;34:S176–S182. 4. Lewis M. Aging demographics and anesthesia. In: Barnett Sheila. ed. Manual of Geriatric Anesthesia. 1st ed. New York: Springer: 2013;3–14. 5. Cook DJ, Rooke GA. Priorities in perioperative geriatrics. Anesth Analg. 2003; 96:1823–1836. 6. McDermid RC, Stelfox HT, Bagshaw SM. Frailty in the critically ill: a novel concept. Crit Care. 2011;15:301. 7. Seder DB, Patel N, McPherson J, et al. Geriatric experience following cardiac arrest at six Interventional Cardiology Centers in the United States 2006–2011: interplay of age, do-not-resuscitate order, and outcomes. Crit Care Med. 2014;42:289–295. 8. McNicoll L, Pisani MA, Yon Zhang, et al. Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc. 2003;51:591–598. 9. Pisani MA, Murphy TE, Van Ness PH, et al. Characteristics associated with delirium in older patients in a medical intensive care unit. Arch Intern Med. 2007;167: 1629–1634. 10. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291: 1753–1762. 11. Thomason JW, Shintani A, Peterson JF, et al. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 nonventilated patients. Crit Care. 2005;9:R375. 12. Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369:1306–1316. 13. McCusker J, Cole M, Dendukuri N, et al. Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study. CMAJ. 2001;165:575–583. 14. Rockwood K, Cosway S, Carver D, et al. The risk of dementia and death after delirium. Age Ageing. 1999;28:551–556. 15. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001;286:2703–2710. 16. Vida´n MT, Sa´nchez E, Alonso M, et al. An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. J Am Geriatr Soc. 2009;57:572029–572036. www.anesthesiaclinics.com
106
’
Joyce et al
17. Inouye SK, Bogardus ST Jr, Baker DI, et al. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. J Am Geriatr Soc. 2000;48:1697–1706. 18. Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology. 2006;104:21–26. 19. Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs. lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007;298:2644–2653. 20. Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs. midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301:489–499. 21. Jakob SM, Ruokonen E, Grounds RM, et al. Dexmedetomidine vs. midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012;307:1151–1160. 22. Fraser GL, Devlin JW, Worby CP, et al. Benzodiazepine versus nonbenzodiazepinebased sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials. Crit Care Med. 2013;41(suppl 1):S30–S38. 23. Kress JP, Pohlmans AS, O’Connoir MF, et al. Daily interruption of sedative infusion in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342: 1471–1477. 24. Pawlik AJ. Early mobilization in the management of critical illness. Crit Care Nurs Clin North Am. 2012;24:481–490. 25. Kress JP. Sedation and mobility: changing the paradigm. Crit Care Clin. 2013;29: 67–75. 26. Brummel NE, Girard TD. Preventing delirium in the intensive care unit. Crit Care Clin. 2013;29:51–65. 27. Morley JE, Reese SS. Clinical implications of the aging heart. Am J Med. 1989;86: 77–86. 28. Heinz G. Atrial fibrillation in the intensive care unit. Intensive Care Med. 2006;35: 345–348. 29. Rials SJ, Marinchak RA, Kowey PR. Arrhythmias in the elderly. Cardiovasc Clin. 1992;22:139–157. 30. Oxenham H, Sharpe N. Cardiovascular aging and heart failure. Eur J Heart Fail. 2003;5:427–434. 31. Swinne CJ, Shapiro EP, Lima SD, et al. Age-associated changes in left ventricular diastolic function during isometric exercise in normal subjects. Am J Cardiol. 1992;69:823–826. 32. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 Guideline update for the management of patients with unstable angina and non-ST segment elevation myocardial infarction—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2002;40:1366–1374. 33. Assali AR, Moustapha A, Sdringola S, et al. The dilemma of success: percutaneous coronary interventions in patients > or = 75 years of age—successful but associated with higher vascular complications and cardiac mortality. Catheter Cardiovasc Interv. 2003;59:195–199. 34. Stone KR, Mc Pherson CA. Assessment and management of patients with pacemakers and implantable cardioverter defibrillators. Crit Care Med. 2004;32:S155–S165. 35. Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence and outcomes of acute lung injury. N Engl J Med. 2005;353:1685–1693. 36. Ely EW, Wheeler AP, Thompson BT, et al. Recovery rate and prognosis in older persons who develop acute lung injury and the acute respiratory distress syndrome. Ann Intern Med. 2002;136:25–36. www.anesthesiaclinics.com
Critical Care and Trauma Considerations in the Geriatric Patient
’
107
37. Balami JS, Packham SM, Gosney MA. Non-invasive ventilation (NIV) for respiratory failure due to acute exacerbations of chronic obstructive pulmonary disease (COPD) in older patients. Age Ageing. 2006;35:75–78. 38. Connolly MJ. Non-invasive ventilation in elderly patients with acute exacerbations of COPD: bringing pressure to bear. Age Ageing. 2006;35:1–2. 39. Chronopoulos A, Rosner MH, Cruz DN, et al. Acute kidney injury in elderly intensive care patients: a review. Inten Care Med. 2010;36:1454–1464. 40. Cheung CM, Ponnusamy A, Anderton JG. Management of acute renal failure in the elderly patient. Drugs Aging. 2008;25:455–476. 41. Meddings J, Rogers MA, Macy M, et al. Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis. 2012;55:923–929. 42. Hannan EL, Waller CH, Farrell LS, et al. Elderly trauma inpatients in New York State: 1994-1998. J Trauma. 2004;56:1297–1304. 43. Pudelek B. Geriatric trauma: special need for a special population. AACN Clin Issues. 2002;13:61–72. 44. Jacobs DG. Special considerations in geriatric injury. Curr Opin Crit Care. 2003;9: 53–59. 45. Awargal S, Azocar RJ. Trauma and the geriatric patient. In: Barnett SR. ed. Manual of Geriatric Anesthesia. New York: Springer: 2013;193–202. ˜ o AM, Anderson RN. Deaths: injuries, 2002 [USA]. Natl Vital Stat Rep. 46. Minin 2006;54:1–125. 47. Matsushima K, Schaefer EW, Won EJ, et al. Positive and negative volumeoutcome relationship in the geriatric trauma population. JAMA Surg. 2014;149: 319–326. 48. Werman HA, Erskine T, Caterino J, et al. Development of statewide geriatric trauma triage criteria. Prehosp Disaster Med. 2011;26:170–179. 49. Bonne S, Schuerer DJ. Epidemiology and evolving geriatric trauma principles. Clin Geriatr Med. 2013;29:137–150. 50. Roch A, Wiramus S, Pauly V, et al. Long term outcome in medical patients aged 80 or over following admission to an intensive care unit. Crit Care. 2011;15:R36. 51. Rady MY, Johnson DJ. Hospital discharge to care facility: a patient-centered outcome for the evaluation of intensive care for octogenarians. Chest. 2004;126: 1583–1591. 52. Yende S, Angus DC, Ali IS, et al. Influence of comorbid conditions on long-term mortality after pneumonia in older people. J Am Geriatr Soc. 2007;55:518–525. 53. Barnato AE, Albert SM, Angus DC, et al. Disability among elderly survivors of mechanical ventilation. Am J Respir Crit Care Med. 2011;183:1037–1042. 54. de Rooij SE. Cognitive, functional, and quality-of-life outcomes of patients aged 80 and older who survived at least 1 year after planned or unplanned surgery or medical intensive care treatment. J Am Geriatr Soc. 2008;56:816–822. 55. Tabah A, Philippart F, Timsit JF, et al. Quality of life in patients aged 80 or over after ICU discharge. Crit Care. 2010;14:R2. 56. Sligl WI, Eurich DT, Marrie TJ, et al. Age still matters: prognosticating short-and long-term mortality for critically ill patients with pneumonia. Crit Care Med. 2010;38:2126–2132. 57. Iwashyna TJ, Ely EW, Smith DM, et al. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA. 2010;304:1787–1794. 58. Rocker G, Cook D, Sjokvist P, et al. Level of Care Study Investigators; Canadian Critical Care Trials Group: clinician predictions of intensive care unit mortality. Crit Care Med. 2004;32:1149–1154. 59. Kompanje EJ, Piers RD, Benoit DD. Causes and consequences of disproportionate care in intensive care medicine. Curr Opin Crit Care. 2013;19:630–635. www.anesthesiaclinics.com
108
’
Joyce et al
60. Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32:638–643. 61. Truog RD, Brock DW, Cook DJ, et al. Task Force on Values, Ethics, and Rationing in Critical Care (VERICC): rationing in the intensive care unit. Crit Care Med. 2006;34:958–963. 62. Miller DH. “The rationing of intensive care. Crit Care Clin. 1994;10:135–143.
www.anesthesiaclinics.com
