Nutrition in the critically ill elderly (geriatric) patient CHRISTINA NIEUWOUDT RD(SA) SASPEN/CCSSA CONGRESS 2017
CONTENT WHO is the critically ill elderly (geriatric) patient? WHY look at the critically ill elderly? WHAT do we know about outcome in this group? WHAT do we know about nutrition in the critically ill elderly patient? TAKE HOME MESSAGE 2
Who is the elderly (geriatric) patient? GERIATRICS geron = old man iatros = healer Medical care of older or elderly people Body age over time Signs: muscle loss, wrinkling, feeling 3
Who is the elderly (geriatric) patient? No standard definition for elderly >65 years of age? Different life expectancies Mechanism of aging poorly understood Nickson C. 2015 http://lifeinthefastlan.com/the-elderly-and-critical-care/ 4
Who is the elderly (geriatric) patient? Increased risk of morbidity and mortality Partly due to frailty rather than age per se Age alone has poor discriminatory ability in predicting outcome 5
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Who is the elderly (geriatric) patient? Physiological changes Cardiovascular Myocardial fibrosis Systolic hypertension Autonomic response declines = increased risk hypotension Capillary permeability increases 7
Who is the elderly (geriatric) patient? Physiological changes Respiratory Progressive loss of function; increased risk of aspiration Decreased sensitivity of respiratory center Loss of alveolar gas exchange Stiffening of lungs = decreased compliance 8
Who is the elderly (geriatric) patient? Physiological changes Central nervous system Brain size & neuronal mass decreases Progressive decrease sympathetic & parasympathetic responsiveness Reduced thirst response Change in pain threshold 9
Who is the elderly (geriatric) patient? Physiological changes Renal Decrease in mass reduced GFR Susceptible to hypovolemia, overload, electrolyte abnormalities Decreased clearance of drugs Hepatic Decreased blood flow Decreased clearance of drugs 10
Who is the elderly (geriatric) patient? Physiological changes Thermoregulation Impaired = risk hypothermia Endocrine Less able to shiver(loss of muscle mass) Hyperglycemia & Diabetes Lower BMR 11
Who is the elderly (geriatric) patient? Physiological changes Immunity Response impaired (less bone marrow, thymus, spleen) Bone marrow response to anemia lower Hypercoagulability = risk DVT Pharmacokinetics Action prolonged More sensitive to CNS depressants 12
Who is the elderly (geriatric) patient? PATHOLOGICAL CHANGES Increased risk of acquired disease Falls Cancer Polypharmacy and associated risks Cardiovascular disease Obesity, inactivity & OSAS COPD Renal failure, prostate hypertrophy, UTIs 13
Who is the elderly (geriatric) patient? PATHOLOGICAL CHANGES Dementia: 10% >65yrs 20%> 85yrs More strokes Decreased vision Gait disturbances Predisposed to delirium Postoperative cognitive dysfunction (POCD) common 14
Who is the elderly (geriatric) patient? SARCOPENIA Greek sarx = flesh; penia = loss Age-related loss of skeletal muscle mass & strength Loss of function & frailty Hanna JS. JPEN 2015; (39) 273-81 15
Who is the elderly (geriatric) patient? FRAILTY = independently associated with increased risk of morbidity and mortality = increased risk of medical critical illness = increased requirement for rehabilitation = cost of care 16
Who is the elderly (geriatric) patient? NO clear definition reduced ambulatory speed, hand grip strength, time to rise from a seated position, activities of daily living (ADL) chronic exhaustion, weight loss, malnutrition. 17
Who is the elderly (geriatric) patient? IMPACT = the reduced ability to compensate for intrinsic and extrinsic physiologic insults (such as injury or illness) with advancing age, culminating in increasing severity of illness and death. 18
Why look at the critically ill elderly? Between 2015 and 2050, the proportion of the world's population over 60 years will nearly double from 12% to 22%. By 2020, the number of people aged 60 years and older will outnumber children younger than 5 years. In 2050, 80% of older people will be living in low- and middle-income countries. The pace of population ageing is much faster than in the past. All countries face major challenges to ensure that their health and social systems are ready to make the most of this demographic shift. http://www.who.int/mediacentre/factsheets/fs404/en/ 19
Why look at the critically ill elderly? The intersection of a rapidly aging population with increasing frailty and the need for critical care services present a perfect storm. Many of the same mechanisms underlying sarcopenia of aging are present and amplified in the myopathy of critical illness. Acute inflammatory crises triggered by events such as sepsis, pulmonary decompensation, emergency surgery, and trauma likely result in profound muscle wasting via TNF-α mediated catabolism, mitochondrial dysfunction, and MPS reduction. 20
Why look at the critically ill elderly? Number of elderly admitted to ICU will increase US: >65 yrs = 50% of ICU admissions 2030 >70mil over 65 years (20% population) Oldest-old >85 years fastest growing group Elderly has more comorbid conditions Malnutrition, cognitive & functional impairment Do guidelines/protocols take this into consideration? Brophy, et al., J Neurol Disord 2015, 3:1 21
What do we know about outcome in this group? EUROPEAN AND US STUDIES: ICU mortality: 30-35% 12 month mortality: 60-70% Severity of illness strongest predictor of short term survival Comorbidities strongest predictor of long term survival Significant comorbidities plus prolonged ICU stay=<5% survival Heyland D https://www.criticalcarenutrition.com/resources/ presentations 22
What do we know about outcome in this group? Limited data on functional outcomes/qol No studies have comprehensively evaluated the determinants of long-term quality of life or functional recovery after critical illness in very elderly persons. 23
What do we know about outcome in this group? FACTORS THAT PREDICT OUTCOME Age Comorbidity Diagnosis e.g. infection v GI disorder Functional status: physical, cognitive, social OTHER: Low BMI, malnutrition, delirium, adverse drug events, nosocomial infections, pressure ulcers De Rooij SE et al Critical Care 2005 (9) R307 24
What do we know about outcome in this group? CONCLUSION: Very elderly represents a distinct and important subgroup of patients Prognosis more dependent on severity of illness, functional status before admission than age itself. 25
WHAT do we know about nutrition in the critically ill elderly patient? HOSPITAL MALNUTRITION Common 1/3 upon admission Affects outcome Cost Overlooked Tappenden KA et al. J Acad Nutr Diet 2013 (113): 1219 26
WHAT do we know about nutrition in the critically ill elderly patient? BUT WHAT ABOUT SARCOPENIA? Hanna JS. JPEN 2015; (39) 273-81 Wischmeyer PE et al. Curr Opin Crit Care 2017 Aug;23(4):269-278 27
WHAT do we know about nutrition in the critically ill elderly patient? VERY LITTLE SPECIFIC FOR VERY ELDERLY but we need to do the basics right to be able to hit the target 28
WHAT do we know about nutrition in the critically ill elderly patient? BASICS Identify at risk for or malnourished Sarcopenia and frailty screening on admission Identify metabolic, exercise and LBM reserve 29
WHAT do we know about nutrition in the critically ill elderly patient? NUTRITION THERAPY Early nutrition assessment Avoid unnecessary starvation Avoid restrictive diets Ensure appropriate protein intake higher than current Leucine & HMB and other Ongoing monitoring/measuring of nutrition status Hanna JS. JPEN 2015; (39) 273-81 Wischmeyer PE et al. Curr Opin Crit Care 2017 Aug;23(4):269-278 Cohen J et al. Advances in Critical Care 2014 30
WHAT do we know about nutrition in the critically ill elderly patient? NUTRITION THERAPY CANNOT HAPPEN IN ISOLATION Early physical therapy program Consideration for alternative muscle stimulation in the bedridden Hanna JS. JPEN 2015; (39) 273-81 Wischmeyer PE et al. Curr Opin Crit Care 2017 Aug;23(4):269-278 Cohen J et al. Advances in Critical Care 2014 31
TAKE HOME MESSAGE Premature baby Geriatric frail patient travelled much further along life s path What can he/she expect? What should we do to care for them? 32
PATIENT POPULATION WITH UNIQUE NEEDS LISTEN TO THEIR NEEDS CARE SHOULD CONTINUE BEYOND ICU INTENSIFY DURING RECOVERY PHASE RESEARCH EVOLVE TECHNOLOGY AND THERAPIES FOR BETTER DELIVERY OF CARE and ULTIMATELY OUTCOME 33