Skip to main content
SpringerLink
Log in

Critical Care

  • Chapter
Principles and Practice of Geriatric Surgery

  • 312 Accesses

Abstract

Care of the elderly patient with critical illness is frequently more challenging than that of younger patients for several reasons. Co-morbidity is more frequent and may complicate the primary problem. Treatment goals may differ markedly from those of younger patients, and the likelihood that they can be achieved may be less. Normal, age-related declines in maximal organ system function limit the ability of the elderly patient to respond to and recover from critical illness, even in the absence of chronic medical conditions. Every effort must be made to minimize unnecessary physiologic and metabolic stresses. Homeostatic mechanisms are predictably less sensitive and effective in the elderly patient, and our clinical care must be meticulous. It is the purpose of this chapter to examine how elderly patients with critical illness differ from younger patients in terms of altered physiologic and metabolic responses, clinical outcomes, decision-making, and specific therapies.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 74.99
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Warner MA, Hosking MP, Lobdell CM, Melton LJ III. Effects of referral bias on surgical outcomes: a population-based study of surgical patients 90 years of age or older. Mayo Clin Proc 1990;65:1185–1191.

    Article  PubMed  CAS  Google Scholar 

  2. Shock NW, Greulich RC, et al. (eds). Normal Human Aging: The Baltimore Longitudinal Study of Aging. NIH Publ. no. 84–2450. Washington, DC: US Government Printing Office, 1984.

    Google Scholar 

  3. Moore FD, Olesen KH, McMurrey JD, Parker HV, Ball MR, Boyden CM. The Body Cell Mass and Its Supporting Environment. Philadelphia: Saunders, 1963.

    Google Scholar 

  4. Metter EJ, Con wit R, Tobin J, Fozard JL. Age-associated loss of power and strength in the upper extremities in women and men. J Gerontol 1997;52A:B267-B276.

    Article  Google Scholar 

  5. Young A. Exercise physiology in geriatric practice. Acta Med Scand 1986;(suppl. 711):227–232.

    Google Scholar 

  6. Griffiths RD. Muscle mass, survival, and the elderly patient. Nutrition 1996;12:456–458.

    Article  PubMed  CAS  Google Scholar 

  7. Watters JM, Clancey SM, Moulton SB, Briere KM, Zhu J-M. Impaired recovery of strength in older patients after major abdominal surgery. Ann Surg 1993;218:380–393.

    Article  PubMed  CAS  Google Scholar 

  8. Seymour DG, Vaz FG. Aspects of surgery in the elderly: preoperative medical assessment. Br J Hosp Med 1987;37: 102–112.

    PubMed  CAS  Google Scholar 

  9. Kinney JM, Lister J, Moore FD. Relationship of energy expenditure to total exchangeable potassium. Ann NY Acad Sci 1963;110:711–722.

    Article  PubMed  CAS  Google Scholar 

  10. Tzankoff SP, Norris AH. Effect of muscle mass decrease on age-related BMR changes. J Appl Physiol 1977;43:1001–1006.

    PubMed  CAS  Google Scholar 

  11. Waiters JM, Redmond ML, Desai D, March RJ. Effects of age and body composition on the metabolic responses to elective colon resection. Ann Surg 1990;212:89–96.

    Google Scholar 

  12. Shock NW. Energy metabolism, caloric intake and physical activity of the aging. In: Carlson LA (ed) Nutrition in Old Age. 10th Symposium of the Swedish Nutrition Foundation. Uppsala: Almqvist & Wiksell, 1972:12–23.

    Google Scholar 

  13. Wilmore DW. The Metabolic Management of the Critically 111. New York: Plenum, 1977:22, 28, 169.

    Google Scholar 

  14. Harris JA, Benedict FG. Standard basal metabolism constants for physiologists and clinicians. In: A Biometric Study of Basal Metabolism in Man. Philadelphia: Lippincott, 1919:233–250.

    Google Scholar 

  15. McGandy RB, Barrows CH Jr, Spanias A, Meredith A, Stone JL, Norris AH. Nutrient intakes and energy expenditure in men of different ages. J Gerontol 1966;21:587.

    Article  Google Scholar 

  16. Verbrugge LM, Gruber-Baldini AL, Fozard JL. Age differences and age changes in activities: Baltimore Longitudinal Study of Aging. J Gerontol 1996;51B:S30–S41.

    Article  Google Scholar 

  17. Frankenfield DF, Cooney RN, Smith JS, Rowe WA. Age-related differences in the metabolic response to injury. J Trauma 2000;48:49.

    Article  PubMed  CAS  Google Scholar 

  18. Rogers MA, Hagberg JM, Martin WH III, Ehsani AA, Hol-loszy JO. Decline in VO2max with aging in master athletes and sedentary men. J Appl Physiol 1990;69:2195–2199.

    Google Scholar 

  19. Dehn MM, Bruce RA. Longitudinal variations in maximal oxygen intake with age and activity. J Appl Physiol 1972; 33:805–807.

    PubMed  CAS  Google Scholar 

  20. Lakatta EG. Cardiovascular reserve capacity in healthy older humans. Aging Clin Exp Res 1994;6:213–223.

    CAS  Google Scholar 

  21. Lakatta EG. Cardiovascular regulatory mechanisms in advanced age. Physiol Rev 1993;73:413–467.

    PubMed  CAS  Google Scholar 

  22. Stratton JR, Cerqueira MD, Schwartz RS, et al. Differences in cardiovascular responses to isoproterenol in relation to age and exercise training in healthy men. Circulation 1992;86:504–512.

    Article  PubMed  CAS  Google Scholar 

  23. Rich MW, Imburgia M. Inotropic response to dobutamine in elderly patients with decompensated congestive heart failure. Am J Cardiol 1990;65:519–521.

    Article  PubMed  CAS  Google Scholar 

  24. Strandell T. Circulatory studies on healthy old men with special reference to the limitation of the maximal physical working capacity. Acta Med Scand 1964;175:1–44.

    Google Scholar 

  25. Port S, Cobb FR, Coleman RE, Jones RH. Effect of age on the response of the left ventricular ejection fraction to exercise. N Engl J Med 1980;303:1133–1137.

    Article  PubMed  CAS  Google Scholar 

  26. Gee MH, Gottlieb JE, Albertine KH, Kubis JM, Peters SP, Fish JE. Physiology of aging related to outcome in the adult respiratory distress syndrome. J Appl Physiol 1990;69: 822–829.

    PubMed  CAS  Google Scholar 

  27. Hall JC, Tarala RA, Hall JL, Mander J. A multivariate analysis of the risk of pulmonary complications after laparotomy. Chest 1991;99:923–927.

    Article  PubMed  CAS  Google Scholar 

  28. Catley DM, Thornton C, Jordan C, Lehane JT, Royston D, Jones JG. Pronounced, episodic oxygen desaturation in the postoperative period: its association with ventilatory pattern and analgesic regimen. Anesthesiology 1985;63:20–28.

    Article  PubMed  CAS  Google Scholar 

  29. Lawrence VA, Hilsenbeck SG, Mulrow CD, Dhanda R, Sapp J, Page CP Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. J Gen Intern Med 1995;10:671–678.

    Article  PubMed  CAS  Google Scholar 

  30. Smetana GW. Preoperative pulmonary evaluation. N Engl J Med 1999;340:937–944.

    Article  PubMed  CAS  Google Scholar 

  31. Sorbini CA, Grassi V, Solinas E, Muiesan G. Arterial oxygen tension in relation to age in healthy subjects. Respiration 1968;25:3–13.

    Article  PubMed  CAS  Google Scholar 

  32. Pontoppidan H, Beecher HK. Progressive loss of protective reflexes in the airway with the advance of age. JAMA 1960;174:77–81.

    Article  Google Scholar 

  33. Kronenberg RS, Drage CW. Attenuation of the ventilatory and heart rate responses to hypoxia and hypercapnia with aging in normal men. J Clin Invest 1973;52:1812–1819.

    Article  PubMed  CAS  Google Scholar 

  34. Peterson DD, Pack AI, Silage DA, Fishman AP. Effects of aging on ventilatory and occlusion pressure responses to hypoxia and hypercapnia. Am Rev Respir Dis 1981;124: 387–391.

    PubMed  CAS  Google Scholar 

  35. Leblanc P, Ruff F, Milic-Emili J. Effects of age and body position on “airway closure” in man. J Appl Physiol 1970;28: 448–451.

    PubMed  CAS  Google Scholar 

  36. Brandi LS, Bertolini R, Janni A, Gioia A, Angeletti CA. Energy metabolism of thoracic surgical patients in the early postoperative period: effect of posture. Chest 1996;109: 630–637.

    Article  PubMed  CAS  Google Scholar 

  37. Krieger BP, Ershowsky PF, Becker DA, Gazeroglu HB. Evaluation of conventional criteria for predicting successful weaning from mechanical ventilatory support in elderly patients. Crit Care Med 1989;17:858–861.

    Article  PubMed  CAS  Google Scholar 

  38. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16:31–41.

    Article  PubMed  CAS  Google Scholar 

  39. Garella S, Matarese RA. Renal effects of prostaglandins and clinical adverse effects of non-steroidal anti-inflammatory agents. Medicine 1984;63:165–181.

    Article  PubMed  CAS  Google Scholar 

  40. Hill GL. Implications of critical illness, injury, and sepsis on lean body mass and nutritional needs. Nutrition 1998;14: 557–558.

    Google Scholar 

  41. Vaughan MS, Vaughan RW, Cork RC. Postoperative hypothermia in adults: relationship of age, anesthesia, and shivering to rewarming. Anesth Analg 1981;60: 746–751.

    Article  PubMed  CAS  Google Scholar 

  42. Sessler DI. Mild perioperative hypothermia. N Engl J Med 1997;336:1730–1737.

    Article  PubMed  CAS  Google Scholar 

  43. Kurz A, Sessler DI, Lenhardt R. Perioperative normother-mia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 1996;334:1209–1215.

    Article  PubMed  CAS  Google Scholar 

  44. Frank SM, Fleisher LA, Breslow MJ. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events: a randomized clinical trial. JAMA 1997;227: 1127–1134.

    Article  Google Scholar 

  45. Jones SR. Fever in the elderly. In: Mackowiak P (ed) Fever: Basic Mechanisms and Management. New York: Raven, 1991:233–242.

    Google Scholar 

  46. DuBois EF. Fever and the Regulation of Body Temperature. Springfield, IL: Charles C Thomas, 1948.

    Google Scholar 

  47. Scalea TM, Simon HM, Duncan AO, et al. Geriatric blunt multiple trauma: improved survival with early invasive monitoring. J Trauma 1990;30:129–134.

    Article  PubMed  CAS  Google Scholar 

  48. Finelli FC, Jonsson J, Champion HR, Morelli S, Fouty WJ. A case control study for major trauma in geriatric patients. J Trauma 1989;29:541–548.

    Article  PubMed  CAS  Google Scholar 

  49. McDaniel DD, Stone JG, Faltas AN, et al. Catheter-induced pulmonary artery hemorrhage. J Thorac Cardiovasc Surg 1981;82:1–4.

    PubMed  CAS  Google Scholar 

  50. Clowes GHA Jr, Del Guercio LR. Circulatory response to trauma of surgical operations. Metabolism 1960;9:67.

    PubMed  CAS  Google Scholar 

  51. Moore FA, Haenel JB, Moore EE, Whitehill TA. Incommensurate oxygen consumption in response to maximal oxygen availability predicts postinjury multiple organ failure. J Trauma 1992;33:58–67.

    Article  PubMed  CAS  Google Scholar 

  52. Shiozaki T, Kishikawa M, Hiraide A, et al. Recovery from postoperative hypothermia predicts survival in extensively burned patients. Am J Surg 1993;165:326–330.

    Article  PubMed  CAS  Google Scholar 

  53. Porter JM, Ivatury RR. In search of the optimal end points of resuscitation in trauma patients: a review. J Trauma 1998;44:908–914.

    Article  PubMed  CAS  Google Scholar 

  54. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN 1987;11: 8–13.

    Article  CAS  Google Scholar 

  55. . Watters JM, Moulton SB, Clancey SM, Blakslee JM, Monaghan R. Aging exaggerates glucose intolerance following injury. J Trauma 1994;37:786–791.

    Article  PubMed  CAS  Google Scholar 

  56. Bessey PQ, Watters JM. Glucose metabolism following trauma and sepsis. In: Burke PA, Forse RA (eds) Clinical Responses to Injury and Sepsis: Mechanisms of Survival and Repair. New York: Marcel Dekker (in press).

    Google Scholar 

  57. Walker J, Cole M, Bessey PQ. Insulin protocol provides rapid, safe, and effective glucose control and saves time (in press).

    Google Scholar 

  58. Clevenger FW, Rodriguez DJ. Demarest GB, Osler TM, Olson SE, Fry DE. Protein and energy tolerance by stressed elderly patients. J Surg Res 1992;52:135–139.

    Article  PubMed  CAS  Google Scholar 

  59. Chandra RK. Effect of vitamin and trace-element supplementation on immune responses and infection in elderly subjects. Lancet 1992;340:1124–1127.

    Article  PubMed  CAS  Google Scholar 

  60. Girodon F, Lombard M, Galan P, et al. Effect of micronutri-ent supplementation on infection in institutionalized elderly subjects: a controlled trial. Ann Nutr Metab 1997;41: 98–107.

    Article  PubMed  CAS  Google Scholar 

  61. Parikh SS, Chung F. Postoperative delirium in the elderly. Anesth Analg 1995;80:1223–1232.

    PubMed  CAS  Google Scholar 

  62. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med 1993;118:219–223.

    Article  PubMed  CAS  Google Scholar 

  63. Moller JT, Cluitmans P, Rasmussen LS, et al. Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study. Lancet 1998;351:857–861.

    Article  PubMed  CAS  Google Scholar 

  64. Shannon ML, Lehman CA. Protecting the skin of the elderly patient in the intensive care unit. Crit Care Nurs Clin North Am 1995;8:17–28.

    Google Scholar 

  65. Chelluri L, Grenvik A. Intensive care for critically ill elderly: mortality, costs, and quality of life. Arch Intern Med 1995; 155:1013–1022.

    Article  PubMed  CAS  Google Scholar 

  66. Mayer-Oakes SA, Oye RK, Leake B. Predictors of mortality in older patients following medical intensive care: the importance of functional status. J Am Geriatr Soc 1991;39: 862–868.

    PubMed  CAS  Google Scholar 

  67. Ridley S, Jackson R, Findlay J, Wallace P. Long term survival after intensive care. BMJ 1990;301:1127–1130.

    Article  PubMed  CAS  Google Scholar 

  68. Wu AW, Rubin HR, Rosen MJ. Are elderly people less responsive to intensive care? J Am Geriatr Soc 1990;38: 621–627.

    PubMed  CAS  Google Scholar 

  69. Heuser MD, Case LD, Ettinger WH. Mortality in intensive care patients with respiratory disease: is age important? Arch Intern Med 1992;152:1683–1688.

    Article  PubMed  CAS  Google Scholar 

  70. Zaren B, Bergström R. Survival compared to the general population and changes in health status among intensive care patients. Acta Anaesthesiol Scand 1989;33:6–12.

    Article  PubMed  CAS  Google Scholar 

  71. McClish DK, Powell SH, Montenegro H, Nochomovitz M. The impact of age on the utilization of intensive care resources. J Am Geriatr Soc 1987;35:983–988.

    PubMed  CAS  Google Scholar 

  72. Nicolas F, Le Gall JR, Alperovitch A, Loirat P, Villers D. Influence of patients’ age on survival, level of therapy and length of stay in intensive care units. Intensive Care Med 1987;13:9–13.

    Article  PubMed  CAS  Google Scholar 

  73. McLauchlan GJ, Anderson ID, Grant IS, Fearon KCH. Outcome of patients with abdominal sepsis treated in an intensive care unit. Br J Surg 1995;82:524–529.

    Article  PubMed  CAS  Google Scholar 

  74. Djaiani G, Ridley S. Outcome of intensive care in the elderly. Anaesthesia 1997;52:1130–1136.

    Article  PubMed  CAS  Google Scholar 

  75. . Sage WM, Rosenthal MH, Silverman JF. Is intensive care worth it? An assessment of input and outcome for the critically ill. Crit Care Med 1986;14:777–782.

    Article  PubMed  CAS  Google Scholar 

  76. Rockwood K, Noseworthy TW, Gibney RTN, et al. One-year outcome of elderly and young patients admitted to intensive care units. Crit Care Med 1993;21:687–691.

    Article  PubMed  CAS  Google Scholar 

  77. . Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification. Crit Care Med 1985;13: 818–829.

    Article  PubMed  CAS  Google Scholar 

  78. Margulies DR, Lekawa ME, Bjerke S, Hiatt JR, Shabot MM. Surgical intensive care in the nonagenarian: no basis for age discrimination. Arch Surg 1993;128:753–758.

    Article  PubMed  CAS  Google Scholar 

  79. Kass JE, Castriotta RJ, Malakoff F. Intensive care unit outcome in the very elderly Crit Care Med 1992;20:1666–1671.

    Article  PubMed  CAS  Google Scholar 

  80. Dragsted L, Qvist J, Madsen M. Outcome from intensive care. IV. A 5-year study of 1308 patients: long-term outcome. Eur J Anaesthesiol 1990;7:51–62.

    Google Scholar 

  81. Yinnon A, Zimran A, Hershko C. Quality of life following intensive medical care. Q J Med 1989;264:347–357.

    Google Scholar 

  82. Chelluri L, Pinsky MR, Donohoe MP, Grenvik A. Long-term outcome of critically ill elderly patients requiring intensive care. JAMA 1993;269:3119–3123.

    Article  PubMed  CAS  Google Scholar 

  83. Uhlmann RF, Pearlman RA. Perceived quality of life and preferences for life-sustaining treatment in older adults. Arch Intern Med 1991;151:495–497.

    Article  PubMed  CAS  Google Scholar 

  84. Cohen IL, Lambrinos J. Investigating the impact of age on outcome of mechanical ventilation using a population of 41,848 patients from a statewide database. Chest 1995;107: 1673–1680.

    Article  PubMed  CAS  Google Scholar 

  85. Cohen IL, Lambrinos J, Fein IA. Mechanical ventilation for the elderly patient in intensive care: incremental charges and benefits. JAMA 1993;269:1025–1029.

    Article  PubMed  CAS  Google Scholar 

  86. Swinburne AJ, Fedullo AJ, Bixby K, Lee DK, Wahl GW. Respiratory failure in the elderly: analysis of outcome after treatment with mechanical ventilation. Arch Intern Med 1993;153:1657–1662.

    Article  PubMed  CAS  Google Scholar 

  87. Pesau B, Falger S, Berger E, et al. Influence of age on outcome of mechanically ventilated patients in an intensive care unit. Crit Care Med 1992;20:489–492.

    Article  PubMed  CAS  Google Scholar 

  88. Dardaine V, Constans T, Lasfargues G, Perrotin D, Ginies G. Outcome of elderly patients requiring ventilatory support in intensive care. Aging Clin Exp Res 1995;7:221–227.

    CAS  Google Scholar 

  89. Murphy DJ, Murray AM, Robinson BE, Campion EW. Outcomes of cardiopulmonary resuscitation in the elderly. Ann Intern Med 1989;111:199–205.

    Article  PubMed  CAS  Google Scholar 

Download references

Authors
  1. James M. Watters
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Palmer Q. Bessey
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Department of Surgery, Yale University School of Medicine, New Haven, CT, 06520, USA

    Ronnie A. Rosenthal MD (Associate Professor, Chief, Surgical Service) (Associate Professor, Chief, Surgical Service)

  2. Department of Veterans Affairs, VA Connecticut Healthcare System, West Haven, 06516, CT, USA

    Ronnie A. Rosenthal MD (Associate Professor, Chief, Surgical Service) (Associate Professor, Chief, Surgical Service)

  3. Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, 10461, NY, USA

    Michael E. Zenilman MD (Associate Professor and Vice-Chairman, Chief of Surgery) (Associate Professor and Vice-Chairman, Chief of Surgery)

  4. Jack D. Weiler Hospital of the Albert Einstein College of Medicine, Bronx, 10461, NY, USA

    Michael E. Zenilman MD (Associate Professor and Vice-Chairman, Chief of Surgery) (Associate Professor and Vice-Chairman, Chief of Surgery)

  5. Wyoming Valley Surgical Associates, Kingston, 18704, PA, USA

    Mark R. Katlic M.D. (Chief of Thoracic Surgery) (Chief of Thoracic Surgery)

  6. Wyoming Valley Healthcare System, Wilkes-Barre, 18702, PA, USA

    Mark R. Katlic M.D. (Chief of Thoracic Surgery) (Chief of Thoracic Surgery)

Rights and permissions

Reprints and permissions

Copyright information

© 2001 Springer Science+Business Media New York

About this chapter

Cite this chapter

Watters, J.M., Bessey, P.Q. (2001). Critical Care. In: Rosenthal, R.A., Zenilman, M.E., Katlic, M.R. (eds) Principles and Practice of Geriatric Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4757-3432-4_18

Download citation

  • DOI: https://doi.org/10.1007/978-1-4757-3432-4_18

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4757-3434-8

  • Online ISBN: 978-1-4757-3432-4

  • eBook Packages: Springer Book Archive

Publish with us

Policies and ethics

Search

Navigation