Elderly Concerns in ICU

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LESS than a generation ago, a 75-year-old patient admitted to a hospital intensive care unit (ICU) was an infrequent occurrence in Malaysia. This was because ICUs were few in number.  

In addition, the public did not have as high an expectation then that their elderly relative could survive a critical illness.  

There was a greater acceptance of death as the natural outcome, and one to be faced with equanimity. The demand exceeded the limited supply of ICU facilities and it was argued that a younger patient possessed a greater potential to achieve good functional recovery after treatment.  

These factors were applied as selection criteria against the admission of elderly patients to the ICU.  

Since 2000, the Government has increased intensive care facilities manifold. A similar expansion has been observed in university hospitals and some private hospitals to meet the needs of many types of specialised surgery, including cardiac or neurosurgery. Specialised treatments for diseases affecting the elderly are more widely available.  

In the last 10 years, the proportion of critically ill elderly patients has increased to more than 50% of current ICU admissions and two-thirds of the total ICU-bed-days in general intensive care units are occupied by elderly patients. These statistics carry major implications for patients and society.  

Reasons for elderly admission to ICU  

Elderly patients carry a higher burden of illness compared to younger age groups. Stroke, diabetes, hypertension, heart failure, chronic respiratory disease, acute infection and cancer increase their chances of being admitted to hospital.  

Furthermore, chronic medical conditions retard their response to treatment, slowing down recovery and prolonging the length of stay in hospital. Failure of an organ system, for example the heart, in an elderly patient increases the likelihood of failure in another system such as the lungs.  

A critical illness in an elderly patient requires complex analytical skills to unravel the cause of illness, the effects, and the treatments that will make a difference.  

When this patient is admitted to ICU, care is provided by doctors and nurses who closely monitor the progress of each organ system and provide several treatments simultaneously to achieve the desired improvement.  

These treatments include assisting breathing with a respirator through a special face mask or a tube placed into the lungs to support the failing circulation, kidney dialysis, artificial liver support, brain resuscitation, treatment of hormonal (endocrine) emergencies, nutrition, and antimicrobial, antifungal and antiviral treatment for severe infections. They also include support of the psychological and emotional kind for the patient and his family.  

The chances of recovery from critical illness depend on three factors: the organ failure is treated before it becomes irreversible; the overall expected outcome is a good quality of life; and the supply of ICU facilities is sufficient to meet all demands.  

The first is quantifiable following the start of treatment by tracking improvements of body function known as physiological scores.  

The second relies on subjective ratings and ethical judgements of “what is a good quality of life?” in which it is seldom possible to find a unanimous opinion.  

The last is quantifiable by matching demand to resources. Where resources are not sufficient to meet demand, the doctor has a role in assigning priority of admission to the intensive care based on the first two criteria.  

Multiple organ support  

An example of critical illness in an elderly is a 75-year-old man with chronic hepatitis B infection and a large liver cancer in the right liver lobe.  

Cancer surgery removes two-thirds of the liver and survival will depend on the remaining one-third to function well during and after surgery – to perform vital liver functions such as creating and storing energy from food, synthesising protein and molecules and vitamins for metabolic processes throughout the body, metabolising and excreting the body’s own products and ingested foods, drugs and toxins, and manufacturing bile salts to aid food digestion.  

Chronic hepatitis B infection results in progressive damage to the liver called cirrhosis. A cirrhotic liver is less able to perform the above functions and such a patient may be undernourished due to poor appetite.  

A cirrhotic liver, being metabolically less active, produces less heat and the patient can become severely hypothermic during prolonged liver resection surgery. Heat loss is worsened by massive blood loss, requiring large amounts of fluid and blood transfusion.  

During surgery, poor liver function results in accumulation of metabolites, including lactic acid. The recovery of the liver will require several days over which other organ systems, such as the lungs, heart, kidneys and brain, are at risk of failing.  

Awareness of agony  

The elderly patient, on waking up in the intensive care unit, might be aware and later recall some of the following experiences: awareness of a breathing tube in his throat, an inability to speak, an inability to breathe on his own or swallow, discomfort during coughing because of sputum in the lungs, awareness of other tubes placed in his nose, abdomen and bladder, an unfamiliar room, an uncomfortable bed, a clouded sensation of being half asleep caused by sedative drugs, a painful sensation from the operation scar, a feeling of nausea from the painkiller drug, a blurring of vision due to not wearing spectacles, an unfamiliar nurse, an unfamiliar doctor, a lack of eye contact, an absence of a smile from the doctor or nurse, the use of a language different from the patient’s mother tongue, an inability to understand what the doctor or nurse is “shouting” at them, many types of strange machines with flashing displays and alarm noises, an inability to remember time or the reason for being in that place, an inability to move because of restraints placed on his wrists and ankles, a sense of indignity at being naked except for a blanket, and an overwhelming sense of panic, fear or distress from a feeling of helplessness and incomprehension.  

Such encounters can also cause emotional distress for the patient’s relatives. Images of these encounters can recur as flashbacks long after the event and result in the patient experiencing panic attacks.  

Preparation before ICU  

It is the ideal for all elderly patients facing major surgery and requiring an admission to ICU to have an opportunity to learn about the nature of the surgery and the intensive care that follows such surgery.  

This should enable the patient and family to be better prepared and psychologically motivated towards an early recovery. The amount of information which needs to be conveyed to the patient, such as in the liver cancer example, can be extremely large and this amount of information can result in a patient having difficulty remembering everything that has been told.  

However, not all patients are fortunate enough to have surgery planned in advance. Many elderly patients require emergency surgery, such as for a burst stomach ulcer, an acute obstruction to a colon cancer, a leak in an abdominal aneurysm, or a severe infection from a gangrenous diabetic foot.  

Under emergency circumstances, many major events occur within a short time and processing large amounts of such information impairs an elderly person’s ability to make rational judgements.  

The phenomenon of a patient or the family picking up the phrase “but the surgeon said it was only to be a small operation?” as the main event, despite the fact that the surgeon had also explained that there was a risk due to a patient’s heart problem, is an example of how a patient can subconsciously select information to fit in best with his perception of a sudden illness.  

Complications of prolonged stay  

Events which can occur through a prolonged stay in the intensive care include infection of the lungs, in the urine or the bloodstream, an increased tendency to have pressure sores due to being bedridden, the increased risk of developing blood clots in the lower limbs (deep venous thrombosis), and the occurrence of bleeding due to the formation of small stomach ulcers.  

Preventive strategies are applied using established medical and nursing protocols to minimise the risk of these occurrences.  

Psychological support  

After several days have passed in ICU, familiarity takes hold and the patient becomes acquainted with routine aspects of care provided by doctors and nurses, recognises nurses and doctors, and learns the concept of time as a measure of recovery.  

New events occur, such as the reversal of regular night sleep-day awake patterns, leading to the patient being awake during the night and sleeping during the day, in turn leading to exhaustion, depression, frustration and anger.  

Nightmares, hallucinations and out-of-body perceptual experiences have been reported by elderly patients in ICU. Mental stress, particularly from not understanding or not knowing what will happen in the future, contributes to these experiences and their resolution requires a combination of supportive psychological, emotional and motivational management as well as drug therapy.  

Effective communication  

The doctors and nurses who look after elderly patients should anticipate these signs of emotional distress and inability to cope and provide counsel, psychological support and effective treatment.  

Doctors and nurses are taught to communicate effectively with elderly patients in the ICU – making eye contact with the patient, smiling, nodding, use of sign language, use of written communication.  

Communication is enhanced with the help of translators, by liberal expressions from staff of praise and positive reinforcement when the patient has achieved a task, and by direct questions and answers about what the patient is feeling.  

Motivational psychology plays a strong role in engaging the patient in his own recovery from a critical illness.  

Under ideal circumstances, the patient should have daily communication from the attending doctor, and this comprises discussion of progress during the previous 24 hours and major issues of care in the coming 24 hours.  

Patients and relatives should be encouraged to ask questions and obtain answers that are satisfactory.  

Feeding 

The elderly patient needs feeding to be recommenced early following an operation so as to provide nutrients for the build up of healthy tissue and energy reserves. The ideal method is to be fed through a nasogastric tube, called enteral nutrition (EN), but this may not always be feasible.  

An alternative acceptable method is to feed using a drip in the arm or the neck, called parenteral nutrition (PN). In special circumstances, both EN and PN can be combined to provide the benefits of both.  

However, the preparation of PN is tailored to each individual’s needs and strict attention must be paid to achieving bacterial sterility to minimise the risk of causing bloodstream infection.  

Long-term changes in lifestyle  

Some changes occurring during a hospital admission may result in a drastic alteration in an elderly person’s lifestyle as well as alter his mental and emotional ability to handle change.  

Examples are, loss or amputation of a limb, a permanent loss of kidney function, a stroke, a need for a tracheostomy tube to assist removal of lung secretions or to help with lung oxygenation through a respirator, and the need to relearn many habits in the presence of a tracheostomy, such as swallowing, breathing, coughing, and speaking.  

The patient should be taught to handle one day at a time and to aim for a long-term picture in which lifestyle changes are necessary but manageable.  

End of life issues 

The chances of an elderly patient making a successful recovery will diminish with an increasing number of organs in failure. The overall risk of mortality for an elderly patient with one organ failure is around 20 to 50% in a Malaysian ICU. When three organs have failed in an elderly patient, the statistical probability of death, calculated using a prediction score known as the APACHE-II, is greater than 99%.  

Under these circumstances, intensive treatment can prolong the heartbeat for a time, but is very unlikely to improve the chances of survival. 

When death becomes inevitable, the professional duty of doctors is to convey the message to the patient and relatives and to maximise comfort measures including psychological support, which ease the burden of suffering.  

Many patients are unable to make specific requests for support of their spiritual and religious needs and awareness of these needs helps the patient to obtain a greater sense of relief.  

Treatments which are not contributory to survival may be slowly withdrawn and treatments which increase comfort and pain relief should be stepped up.  

Euthanasia, or mercy killing by a doctor’s use of or sanctioning of specific treatments to hasten death, is illegal.  

Living wills  

Patients who wish to retain the ability for their own decision making with regard to provision of comfort in the terminal stages of life may author a living will, stating their wishes concerning the types of treatment and the circumstances in which these could be applied.  

They may also specify what treatments they would not like to be given and allow the withdrawal of such treatments if started.  

Living wills address some of the concerns of patients about being in control and being in comfort at the end of life.  

At present, there is no statutory or Malaysian medical professional sanction or prohibition on an individual’s use of a living will.  

Malaysian doctors have the discretion to exercise their professional judgement in the interpretation of a patient’s living will according to the circumstances of the patient.  

(Written by Dr Patrick S. K. Tan)