KPPIA Yogyakarta

November 2021

Geriatric Patient and Intensive Care

Rudyanto Sedono

Department of Anesthesiology and Intensive Care

Faculty of Medicine Universitas Indonesia
Cipto Mangunkusumo Hospital
Jakarta
 Older patients

Vital signs are increasingly reflective of age and pathological changes in

organ systems.
The resultant constriction of homeostatic capacity leads to a loss of
regulatory and adaptive mechanisms such that insults are often not
always met with an appropriate and timely response (eg, aging-related
sympathetic dysregulation leading to postural hypotension).
Clinically, this reduced capacity has 2 outcomes:
1. A constriction in the range of the vital signs (reduced variability)
2. A reduction in the ability to compensate when stressed

In the older patient, clinicians should use a personalized

reference range and consider values outside of the
individualized range as a marker for underlying disease

Chester et al. J Am Med Dir Assoc 2011; 12: 337–343

 Increasing Blood Pressure with Age

(National Center for Health Statistics. Health, United States, 2004 With Chartbook on
Trends in the Health of Americans. Hyattsville, Maryland: 2004.)

Chester et al. J Am Med Dir Assoc 2011; 12: 337–343

 Vital Sign Changes with Aging
Age-related mechanisms
of vital sign change Blood Pressure

Molecular Oxidative and mechanical damage to vascular endothelium

Heightened inflammatory response:
o cytokines
o growth factors
o collagen
o elastases and metaloproteinases
Decreased arterial wall pliability

Structural/ Organ Increased left ventricular wall thickness

Diastolic dysfunction owing to:
o increased wall thickness
o less cardiac filling

Systemic Arterial stiffness requires higher systolic pressures to pump blood

Increased pulse pressure

Compensation to stress Reduction in endogenous cellular repair capability owing to damaged

cardiomyocytes & vascular endothelium
Altered intracellular protein expression
Mitochondrial aging & changes in signal transduction cascades
Loss of responsiveness to sympathetic stimuli

Chester et al. J Am Med Dir Assoc 2011; 12: 337–343

 Vital Sign Changes with Aging
Age-related mechanisms Pulse
of vital sign change

Molecular Desensitization of sympathetic receptors disrupts

intracellular signaling

Structural/ Organ Temporarily decreased perfusion owing to:

o decreased baroreflex sensitivity
o delayed reaction

Systemic Altered cardiac output and increased resting heart rate

Maximum heart rate is more limited with age

Compensation to stress Less sympathetic responsiveness hinders ability of

cardiovascular system to adjust when stimulated
Less adaptability in heart rate is associated with falls, frailty

Chester et al. J Am Med Dir Assoc 2011; 12: 337–343

 Vital Sign Changes with Aging
Age-related mechanisms
Respiratory Rate
of vital sign change

Molecular Increased elastases

o degrade elastic tissue
o reduce compliance
o cause dilation of airspaces

Structural/ Organ Altered chest wall shape owing to:

o kyphosis
o osteoporosis
o costal cartilage calcification
Increased work of breathing:
o altered diaphragm shape
o decreased compliance

Systemic Less elastic recoil & chest wall compliance results in air trapping,
thus increased residual volumes & decreased tidal volumes
Increased respiratory rate compensates for less tidal volume

Compensation to stress Weakened respiratory muscles, less compliant chest wall, &
increased work of breathing diminish ability to adapt to stress
Less sensitivity of chemoreceptors & mechanoreceptors causes
decreased response to hypoxia & hypercapnia

Chester et al. J Am Med Dir Assoc 2011; 12: 337–343

 Vital Sign Changes with Aging
Age-related mechanisms
Temperature
of vital sign change

Molecular Decreased T-cell function owing to prolonged antigenic exposure

Less apoptosis in agedresistant T cells
Structural changes in hypothalamic mineralocorticoid receptors
cause hypothalamic-pituitary axis hyperactivity

Structural/ Organ Dysfunctional/deficient hypothalamic mineralocorticoid receptors

increase nighttime cortisol levels
Hypothalamic suprachiasmatic nucleus hyperactivity

Systemic Reduced ability to maintain body heat owing to:

o less subcutaneous fat
o reduced peripheral vasoconstriction
o decreased cardiac output
o dysregulated circadian rhythm
o loss of muscle mass
Compensation to stress Loss of heat maintenance & thermogenesis mechanisms
Heightened vulnerability to hot and cold stressors
Lower core body temperature hinders ability to regulate body
temperature

Chester et al. J Am Med Dir Assoc 2011; 12: 337–343

Interaction between frailty, comorbidity, and disability in older patients

Comorbidity
Disability
Disease processes
Functional limitations
resulting from
resulting from
biology
impairments
and exposure

Frailty
Increased vulnerability
to disease and
adverse events

McDermid and Bagshaw. Best Practice & Research Clinical Anaesthesiology 25 (2011) 439–449
 Elderly and ICU

Elderly admissions to intensive care are common and increasing.

Elderly patients admitted to ICU often receive less intensive therapy

and are more likely to be have “not-for-resuscitation” orders.

Elderly patients higher observed mortality in critical illness; however, in

selected patients characterized by a low burden of comorbid disease
and functional independent, short-term outcomes are generally good.

Rapid response systems (i.e. Medical Emergency Teams) and critical

care outreach may have relevance for the timely identification and
“rescue” of “at-risk” hospitalized elderly patients, while also provide
appropriate triage and opportunity to advance care planning and
therapeutic goals.

McDermid and Bagshaw. Best Practice & Research Clinical Anaesthesiology 25 (2011) 439–449
 Chronic Critical Illness in Geriatric Patients

Chronic critical illness is used to describe patients who survive the

initial acute episode of critical illness but persistently remain
dependent on intensive care.
It is typically defined as need for mechanical ventilation for more than
6 hours per day for more than 21 consecutive days with concurrent
neurologic changes, endocrine alterations, muscle wasting,
predisposition to infection, and changes in body composition, including
loss of lean body mass.
Elderly patients are especially vulnerable to develop chronic critical
illness, with its prevalence peaking from 75 to 79 years of age.

Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
 Chronic Critical Illness in Geriatric Patients

Chronic critical illness involves systemic derangement of immunologic

function, persistent inflammation, neurocognitive issues, endocrine
imbalance, malnutrition, and muscle wasting.
Due to elevated levels of catecholamine and glucocorticoids, the
metabolism is shifted to the catabolic phase. There is a marked
decrease in the pulsatile secretion of anterior pituitary hormones.
A majority of critically ill patients suffer from neuromuscular
weakness, which is broadly classified into critical illness
polyneuropathy (CIP), critical illness myopathy (CIM), and combined
CIM/CIP.

Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
 Respiratory System Age-Related Changes

Decreased vital capacity (VC)

Decreased forced expiratory volume in 1 second (FEV1)
Increased functional residual capacity (FRC)
Increased residual volume (RV)
Reduced elastic recoil of the lung
Reduced arterial partial pressure of oxygen (PaO2)
Increased O2 arterial-alveolar (A–a) gradient
Increased chest wall stiffness, kyphoscoliosis
Decreased respiratory muscle strength
Decreased respiratory center sensitivity to hypoxia and hypercarbia

Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
 Lung volumes and aging

Corcoran and Hillyard. Best Practice & Research Clinical Anaesthesiology 25 (2011) 329–354
 Respiratory Critical Care in the Elderly

The incidence of acute respiratory distress syndrome rises with age and
is likely related to the increased incidence of sepsis with increasing age.
Age-related changes in pulmonary function include a decrease in forced
vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and
arterial partial pressure of oxygen (PaO2) and an increase in the
oxygen arterial-alveolar (A –a) gradient.
Both the incidence of pulmonary embolism and the mortality from
pulmonary embolism increase with age.
There are no specific guidelines related to optimal ventilator modalities
for older patients.
For older patients with ventilator-associated pneumonia, aspiration or
microaspiration often is a contributing factor.
Local hospital antibiograms should be used when treating patients with
ventilatorassociated pneumonia.

Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
Neurocognitive Dysfunction and Geriatric Neurocritical Care

Acute brain dysfunction is common among the elderly population

and is often unrecognized, leading to long-term consequences.
Increased hospital length of stay, increased hospital cost, increased
morbidity and mortality, and reduced quality of life have all been
attributed to acute brain dysfunction in elderly patients.
Changes in structure, function, metabolism, and blood flow in the
aging brain lead to cognitive impairments, most frequently episodic
memory changes, and an increased risk of delirium in the acute
setting.
Education of healthcare professionals in diagnosing and managing
delirium has been shown to reduce delirium rates and is a cost-
effective delirium prevention strategy.
Management of delirium is comprised of both pharmacologic and
nonpharmacologic interventions.
Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
 Geriatric Cardiovascular Critical Care
Aging is associated with an increased incidence of cardiovascular
diseases, including ischemic heart disease, heart failure, atrial
fibrillation, hypertension, valvular heart disease, pulmonary
hypertension, and peripheral vascular disease.
Progressive central aortic dilatation, increased thickness of the
arterial wall, increased vascular stiffness, and altered nitric oxide –
induced vasodilation occur with advancing age, leading to elevated
mean arterial pressure and increased pulse pressure.
Elderly patients are more likely to present with non-ST-segment-
elevation myocardial infarction (NSTEMI) as opposed to ST-
segment-elevation myocardial infarction (STEMI), and frequently
present with nonspecific complaints including weakness, syncope,
and increasing confusion.
The elderly comprise the majority of patients with heart failure with
preserved ejection fraction (HFpEF).
Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
 Effect of arterial stiffening on increased left ventricular
hypertrophy and systolic and diastolic dysfunction

Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
 Immune Response and Infections in the Elderly

For individuals older than age 65, infections are a major source of
morbidity and mortality.
The innate immune system consists of neutrophils and macrophages,
epithelial barriers, natural killer cells, dendritic cells, complement
proteins, and the nonspecific defenses such as the production of mucus
and antimicrobial peptides and mucociliary function. With aging,
changes in the innate immune system result in chronic inflammation.
The adaptive immune system consists of B and T lymphocytes, which,
respectively, affect humoral and cellular immune responses. Both show
age-related decreases in number and diversity.
The impact of aging seems to be larger on the adaptive immune system
than on the innate immune system.

Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
 Stress Response to Surgery in the Elderly

Surgical trauma triggers a robust stress response, the characteristics

of which are generally altered with aging, becoming the primary
mechanism driving further injury and perioperative organ dysfunction
in older adults.
With aging, the allostatic response becomes impaired, and there may
be an exaggerated or inadequate peak response, as well as a sluggish
return to baseline.
Aging increases vulnerability to surgical stress, ischemia-reperfusion
injury, and critical illness that is related to decreases in physical
resilience characterized by immunosenescence, loss of mitochondrial
function and nutrient sensing, and impaired recovery following
surgical stressors.

Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
 Stress Response to Surgery in the Elderly

Increasing evidence suggests that prehabilitation, healthy diet,

nutrition, and exercise for seniors in anticipation of surgical stressors
are effective interventions to promote physical resilience.
The influence of age as a modifier of subsequent insults and “second
hits ” (e.g., postoperative infection) and its impact on outcome
trajectories are extremely complex. The intestinal microbiota
decreases in abundance and function following surgical trauma, and a
virulent and resistant pathobiome emerges, rendering the stressed
host more vulnerable to infection.
Postoperative pain trajectories differ by age and are amenable to
interventions aimed at elderly patients.

Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
 Ethical Issues: Withdrawing, Withholding, and Futility

In most Western jurisdictions, withdrawing or withholding life-

sustaining treatment (LST) at a competent patient ’s request is
considered morally equivalent and is supported ethically and legally.
Decisions to withdraw or withhold therapies in opposition to
patient/surrogate wishes may be supportable on futility arguments
but is more complex and subject to legal challenge.
The concept of futility may have limited usefulness at the bedside
but is a critical concept in understanding the perspectives of
multiples parties in withdraw or withhold decisions.
Open communication and respectful discourse between the
physician and patient or their surrogates are prerequisites for
resolving differences in values and finding an appropriate therapeutic
pathway.

Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
 Geriatric Critical Care Units:
Model for Interdisciplinary Approach

The interdisciplinary team members of a geriatric critical care unit

(GCCU) should include physician, nurses, registered dietitian, physical
and occupational therapy, respiratory therapy, pharmacist, and family
members.
Structural elements of a geriatric-focused intensive care unit (ICU)
are meticulously designed to ensure optimal and efficient use of the
space that also targets the specificneeds of the elderly patients.
A quiet environment at all times of the day is essential to the
adequate rest and recovery of elderly patients.

Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
 Geriatric Critical Care Units:
Model for Interdisciplinary Approach

Monitor alarms should be adjusted to patient ’s baseline status, and

frequency of alarms must be minimized to avoid unwarranted
“noise, ” which can exacerbate sleep disturbances and potentially
increase the frequency of delirium.
Palliative care medicine (PCM) may be ideal to help manage a variety
of nonmedical issues experienced by the family, such as guilt, anger,
fear, sparse information, unrealistic expectations, misperceptions, life
circumstance adjustment, and conflict resolution. Indeed, having a
PCM team member regularly round with the ICU team in a geriatric-
focused ICU helps enable appropriate medical care.

Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018
 Geriatric Critical Care Units:
Model for Interdisciplinary Approach

Akhtar and Rosenbaum ed. Principles of Geriatric Critical Care. Cambridge University Press 2018