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either. The physician always should ask a depressed patient

about any suicidal ideation. As a practical matter, very few

ICU patients have the means to commit suicide in the unit,

but knowing the patient’s feelings about suicide may help the

physician to gauge the level of depression.

In addition to these cognitive factors, assessing the

patient’s self-esteem often serves as a clue to depression. The

patient who is grieving normally usually feels sad in reaction

to losses sustained or anticipated. The grieving individual

may appear sad but still maintain a proper sense of self-

esteem: “I’m okay, really—I’m still a good person despite my

medical problem.” The depressed individual, on the other

hand, feels worthless and useless: “I’m washed up—a burden

to my family.”

Another way of identifying the depressed individual

engages the physician in using his or her own feelings as an

assessment tool. Depressed patients often generate a feeling

of depression in their physicians; they also may produce a

sense of aversion so that the physician is eager to get away

from the bedside. An appropriately grieving patient, on the

other hand, usually generates a sense of sympathy and sad-

ness in the physician. Thus the physician who is sensitive to

his or her own responses to a patient may be able to confirm

a diagnosis of depression quite readily.

Differential Diagnosis

The key differential diagnosis in a patient who is being con-

sidered for a diagnosis of depression is appropriate grief or

organic mood disturbances. A number of conditions may

produce depressive symptoms. It is completely normal for an

individual to experience sadness and some emotional with-

drawal in response to a loss. Disease often produces a sense

of loss for many individuals, and it may be difficult for the

physician to differentiate appropriate grieving from a clinical

depression. One should consider the degree of dysfunction as

an indicator of depression. Thus, when a patient’s emotional

state is seriously interfering with medical recovery or compli-

ance with medical care, some form of treatment should be

offered. Depression becomes a likely diagnosis when the

patient makes a decision to terminate treatment for a disease

whose prognosis is favorable.

Certain medical conditions frequently produce depressive

symptoms. Examples are Cushing’s disease, hypothyroidism,

and pancreatic carcinoma. Virtually all the organic causes

described in the section on delirium also can produce

depressive states. In fact, a smoldering delirium may be mis-

taken for depression unless cognitive function is assessed.

Some hypoxic individuals, for example, will appear lethargic

and depressed. Medications such as β-blockers, corticos-

teroids, digoxin, cimetidine, levodopa, diazepam, and antihy-

pertensives may produce a depressive picture. Some

dopamine antagonists such as prochlorperazine or metoclo-

pramide produce psychomotor retardation or akathisia that

may mimic depression. A recent study indicated that the

presence of depression at baseline in patients with acute

coronary syndromes predicted failure to return to work and

not feeling better at 1 year. This study provided support for

the assessment of depression in identifying individuals at risk

for poorer outcomes.

Treatment

A key point in the treatment of depression is for the physi-

cian to recognize that depression is a painful and serious

condition that should not be considered “normal.” Just

because a knifing victim might be expected to exsanguinate

and experience a fall in blood pressure, medical treatment is

not withheld; similarly, the identification of depression war-

rants appropriate interventions. In serious cases of depres-

sion, there may be a substantial risk of failing to provide

treatment. A depressed patient is poorly compliant and

poorly motivated to participate in recovery—or may fail to

take adequate nutrition and participate in other aspects of

recovery such as being weaned from a ventilator.

The initial treatment of depression in the ICU should

emphasize psychosocial measures. To the extent possible, the

patient should be permitted to feel some control over what is

happening. Nurses should offer the patient a choice when-

ever possible. For example, the patient can be asked whether

or not pain medication is needed, whether it is time to be

moved, etc. Asking the patient to help plan the day’s bath and

hygiene schedule is very helpful. Encouraging the family to

visit as much as possible also may help to counter depression.

The physician can help to reduce depression by providing

realistic encouragement and support.

If these measures fail to reduce the depression, psychiatric

consultation is indicated followed by pharmacologic treat-

ment. The consultant will inquire about the patient’s psychi-

atric history, particularly to see if some specific antidepressant

medication has been successful in the past. If so, that drug

should be used. If the patient has not had a prior trial of anti-

depressant, a psychostimulant such as dextroamphetamine or

methylphenidate should be considered unless there is a med-

ical contraindication such as tachyarrhythmia. With the usual

starting dextroamphetamine dosage of 2.5 mg at 7 a.m. and

1 p.m., there is little risk of side effects. In an occasional

patient, there may be some increase in blood pressure or

pulse, but these are usually minimal and do not require stop-

ping the trial. If the patient fails to respond to the preceding

dosage, on the next day one can double the dosage to 5 mg

given twice. The maximum dosage is 15 mg twice daily, but

this level is rarely necessary. The medication is given early in

the day so as not to interfere with sleep. Many people have the

misconception that dextroamphetamine may worsen appetite

because it has been used in the past for dieting; in depressed

patients, however, it generally improves appetite.

Dextroamphetamine has the advantage of being essen-

tially free of side effects in most patients; some may have

slight tremor or anxiety. A rare patient may develop persecu-

tory feelings with this drug, but typically only at much higher

doses. The tremendous advantage of dextroamphetamine is

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the rapidity of response when it is successful. The physician

often can observe a beneficial effect 1–2 hours after the first or

second dose. Many patients report improved mood, energy,

appetite, and will to live. The response rate varies in different

studies from 48 to 80% improvement in depressive symptoms.

A number of other agents are effective and well tolerated

for the treatment of depression. An example is fluoxetine,

which was the first serotonin reuptake inhibitor released in

the United States. Although fluoxetine has essentially no

anticholinergic or blood pressure effects, it elevates many

other drug plasma levels by displacing them from their

plasma protein binding sites. This makes fluoxetine an unde-

sirable medication for most ICU patients. Other newer

agents have been developed that appear well suited for use in

ICU patients. Citalopram, sertraline, and venlafaxine are

effective antidepressants that share fluoxetine’s lack of blood

pressure and anticholinergic effects but are associated with

fewer drug interactions. Bupropion has little blood pressure

or anticholinergic effect, but in its immediate-release form it

has been associated with a higher incidence of seizures than

other antidepressants. All these agents have the limitations of

being available only in oral formulations and taking 1–4

weeks to have an effect.

Tricyclic antidepressants can be considered for ICU

patients, but like the newer agents mentioned briefly earlier,

they take 1–4 weeks to show an effect. Their anticholinergic

and quinidine-like side effects also can cause problems.

Tricyclic antidepressants also have the disadvantage of pro-

ducing marked α-adrenergic blockade, which can have trou-

blesome effects on blood pressure. If treatment with a

tricyclic is elected, nortriptyline is the best choice because it

has the least effect on postural hypotension and only modest

anticholinergic effects. It also has a clear therapeutic window

of maximum effectiveness of 50–150 ng/mL.

Current Controversies and Unresolved Issues

Depression may be hard to differentiate at times from normal

grief and sadness, so it would be useful to have a biologic

marker for the condition. Several years ago there was excite-

ment about using the dexamethasone suppression test as a

marker for major depression. Although this was of important

research significance, it has not been useful clinically because

50% of patients will suppress but still have the disorder.

Therefore, the test is of very little significance in trying to

decide on a diagnosis. It will be important for further research

in depression to develop biologic markers the clinician can use.

Another important area for further research involves the

identification of subtypes of depression so that specific phar-

macotherapy can be tailored appropriately. There have been

attempts to differentiate depression by global measures of

neurotransmitter levels. Cerebrospinal fluid and urinary lev-

els of methoxyhydroxyphenylglycol (MHPG) and serotonin

have been used to predict response to serotonergic and nora-

drenergic antidepressants. These efforts have not yet pro-

duced clinically useful applications.



Anxiety & Fear

ESSENTIALS OF DIAGNOSIS



Overt terror and panic.



Hypervigilance.

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Fear of being alone.



Autonomic arousal.

General Considerations

Anxiety is the unpleasant feeling associated with an unknown

internal stimulus and is out of proportion to the threat from

the environment. Fear, on the other hand, is the same feeling

state but derived from a known external stimulus and propor-

tionate to the threat. Obviously, in the ICU these two feelings

are hard to distinguish, and they will be discussed here under

the term fear, which refers to both entities.

Fear is often prominent when the patient first enters the

ICU because of awareness of a substantial threat to his or her

continued existence resulting from the medical or surgical

problem that necessitated the admission. The ICU patient

may be reacting not only to the fear of death but to other

unspoken fears as well. The patient may be anxious about

how the family is responding to the illness and may have con-

cerns about ability to return to work or may harbor unreal-

istic ideas about the nature of the problem and the treatment

required. For example, some patients jump to the conclusion

that they will need open-heart surgery for any type of cardiac

problem. The patient also may associate the illness with a

loved one who had a similar problem. For example, one 59-

year-old man admitted to the coronary care unit feared he

would not survive his heart attack because his father had

died of one at the same age. Asking the patient about whom

he or she knows who had the same medical problem or treat-

ment may reveal a significant factor contributing to the

patient’s fear. A recent study indicated that the risk of devel-

oping posttraumatic stress disorder was linked with anxiety

during the time in the ICU. The study further found that

perceived social support was negatively correlated with

symptoms of posttraumatic stress disorder.

Fear and anxiety may produce significant physiologic

changes. Catecholamine and corticosteroid levels may fluctu-

ate along with anxiety levels. It has been demonstrated that

the perception of physical or emotional stress results in the

activation of several brain regions—serotonergic, cate-

cholaminergic, and perhaps cholinergic nuclei. These path-

ways are apparently then integrated by unknown mechanisms

into the hypothalamus. The end result of this complex

response is the secretion of glucocorticoids. Evidence also has

accumulated for a variety of links between the serotonergic

region and the hypothalamic-pituitary axis that may underlie

the connection between stress and mood. A recent study

found that the risk of cardiocirculatory complications was

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PSYCHIATRIC PROBLEMS

439

decreased by a factor of 2 in periods of unrestrictive visiting

policies in an ICU. This also was correlated with a greater

reduction in anxiety score and less of an increase in thyroid-

stimulating hormone during the course of admission. A

restrictive visiting policy was associated with a nonsignifi-

cant increase in mortality rate. The authors concluded the

unrestrictive visiting policy might decrease cardiovascular

complications through lessened anxiety and a more desirable

hormonal profile.

Clinical Features

The physician can observe fear in many guises in the ICU.

Patients with a past history of generalized anxiety, panic, or

“nervous” disorders should be expected to have increased

fearfulness in the ICU. Some patients will demonstrate their

terror and panic overtly. Others may appear hypervigilant,

constantly scanning the environment. Others will talk exces-

sively or seek the presence of the nurse so as not to be left

alone. Some patients will fight going to sleep because of fear

of dying while asleep. Blood pressure and heart rate may be

elevated as the autonomic accompaniments of fear ensue.

Some patients may exhibit their fear by major denial of

illness. These individuals may attempt to demonstrate their

good health by exercising in the coronary care unit. Others

will try to sign out of the hospital against medical advice.

Fear is perhaps recognized most easily in the patient being

weaned from the ventilator “before I’m ready.” These patients

often show stark terror as the ventilator settings are reduced.

In such cases, anxiety may grossly interfere with medical

treatment.

Furthermore, anxiety related to experiences in the ICU

does not dissipate at the door on departure from the unit.

Patients may continue to have nightmares and experience

episodes of hypervigilance and panic even after returning to

home care, thus suggesting the diagnosis of posttraumatic

stress disorder (PTSD). Research is still needed to help pre-

dict which individuals are at the greatest risk for develop-

ment of this syndrome. Some studies have linked its

development to adverse experiences in the ICU. One study

found that the presence of delusional memories of events in

the ICU—as opposed to factual memories—indicated an

increased risk for PTSD-related symptoms and panic follow-

ing discharge from the ICU.

Differential Diagnosis

Anxiety and fear can be confused with the agitation of delir-

ium. The delirious patient, however, will have significant cog-

nitive impairment that is usually not present in the anxious

patient. The physician should continuously assess the anxious

patient for organic factors that could contribute to anxiety.

Medications such as corticosteroids, theophylline, and lido-

caine can produce anxiety and fearfulness. Medical conditions

such as hypoxia, pulmonary emboli, pheochromocytoma,

Cushing’s disease, and early drug or alcohol withdrawal may

have anxiety as a major symptom (Table 18–3).

Treatment

The best treatment of anxiety is prevention. Psychologically

preparing a patient for surgery can have a beneficial effect.

These efforts, as well as those offered by the patient’s primary

physician, can be very effective in preventing anxiety. Similarly,

the physician can intervene postoperatively to minimize

patients’ anxiety. One study suggests that playing a brief tape-

recorded message from the surgeon—explaining that surgery

went well, giving an orientation to the ICU, and reassuring the

patient about early recovery—markedly reduces anxiety.

Nonetheless, for many patients, fear and anxiety will

develop in the ICU. The first step in treating the fearful

patient involves exploring precisely what the patient is most

fearful about. This information may be obtained directly

from the patient who is prepared properly and trusts the

physician. The physician can start by saying, “Most people

have some worries or fears in this situation. What are yours?”

This approach normalizes the presence of fears and makes it

easier to talk about them. Whatever the patient brings up as

a concern should be explored.

Pulmonary disorders

COPD

Pulmonary embolus

Asthma

Hypoxia

Drugs

Drug withdrawal

Drug intoxication (eg, amphetamines, cocaine)

Infections

Tuberculosis

Brucellosis

Cardiac disorders

Mitral valve prolapse

Paroxysmal atrial tachycardia

Subacute infective endocarditis

Angina

Endocrine and metabolic disorders

Insulinomas

Carcinoid tumors

Pheochromocytomas

Hypoglycemia

Thyroid disease

Hypocalcemia

Porphyria

Cushing’s disease

Neurologic disorders

Multiple sclerosis

Akathisia

Temporal lobe epilepsy

Table 18–3. Medical disorders commonly associated

with anxiety.

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Another valuable technique for helping a patient deal

with fear is reframing the patient’s view of the situation. For

example, one 45-year-old African-American wanted to sign

himself out of the coronary care unit, saying he refused to

believe that he had had a bad heart attack. The doctors

repeatedly tried to warn the patient of the risks of not accept-

ing hospital treatment. The patient responded by doing 10

one-handed push-ups. Finally, psychiatric consultation was

requested. The psychiatrist realized that frightening the

patient only escalated his fear and increased his need to deny

the fear by signing out against advice. The psychiatrist sug-

gested to the patient that it took a strong man to put up with

the bed rest and testing the cardiologists wanted. The con-

sultant suggested that the patient could prove his strength in

this way. In essence, the patient no longer had to equate stay-

ing in the unit as a loss of strength and self-esteem. With this

reframing of his medical care, the patient accepted the

remainder of his treatment without difficulty.

In some ICUs, the psychiatric consultant or liaison nurse

may teach relaxation with the aid of audiotapes. Some

patients may be receptive to learning self-hypnosis. These

techniques may help by restoring the patient’s sense of con-

trol over the environment. These techniques also may be

helpful in the patient being weaned from the ventilator.

If psychosocial interventions do not work or are not

available, medication can be used. Lorazepam is the antianx-

iety drug of choice. Its intermediate half-life (10–20 hours) is

long enough to prevent the withdrawal syndrome that can

occur with shorter-acting agents but not so long that the

drug tends to accumulate. Lorazepam is metabolized in a

one-step conjugation and so can be used in patients with

liver disease. For most patients with mild to moderate anxi-

ety, the dosage of lorazepam is 1–2 mg (depending on age

and weight) every 4–6 hours. For more severe anxiety, one

may double these dosages. Antidepressants such as sertraline

and citalopram also can be useful against anxiety. As with

their use in depression, however, they can take up to 4 weeks

to have a significant effect and must be given orally. When

anxiety is extreme and interfering grossly with the patient’s

care, a shift to antipsychotic medications has been advocated.

Although haloperidol has been advocated for this purpose,

newer agents also should be considered. A recent report

described the use of risperidone for patients with irritability

and hostility. The authors noted that this agent caused fewer

side effects than haloperidol, imposed fewer risks than ben-

zodiazepines, and was effective with a more rapid onset than

antidepressants.

Current Controversies and Unresolved Issues

There is a continuing quest for the anxiolytic agent that gives

relief without clouding the sensorium or producing trouble-

some withdrawal states. For example, triazolam is a popular

sedative benzodiazepine in some regions because it has a

short half-life that makes it unlikely to produce a hangover.

The short half-life, however, has a major disadvantage in

that it may lead to withdrawal syndromes the next day, leav-

ing the patient anxious until the next dose is given. Until the

neurotransmitter systems involving various agents such as

γ-aminobutyric acid are further elucidated, the quest for the

ideal agent will have to continue.



Staff Issues

The ICU staff considered as a group has many psychological

features similar to those found in individual health

providers. Many doctors and nurses, for example, bring cer-

tain psychological motivations to their work. They may feel a

strong need to save and rescue their patients. They also may

demand perfection from themselves. In some sense, whether

it is consciously realized or not, the ICU staff may make the

same demand as a group. This may be manifested in attempts

to save the unsalvageable patient and reluctance to let any

patient die. On the other hand, many patients have unclear

prognoses, and these may be particularly challenging for the

staff. Research suggests that the most difficult patients for

staff to care for are those with multisystem failure and a poor

prognosis.

A useful equation for conceptualizing a staff’s self-esteem

is the following:

In this equation, how staff feel about themselves is equal to

what realistic achievement they can accomplish “divided by”

their expectations. The equation represents a shorthand way of

viewing how the relationship between expectations and

achievements influence self-esteem. In instances where the

expectation is one of omnipotence, unless the achievement is

perceived as a perfect performance, the staff will end up feel-

ing like a failure. In this equation, we should note that the real-

istic achievement is relatively fixed within a narrow range

accomplished by most competent staff. The variable that can

be adjusted most easily is the denominator—expectations. If

staff are successful in reducing this value, the staff can feel

much more satisfied with their accomplishments. This issue is

highlighted when staff have to deal with a dying patient. When

staff are able to shift their expectations away from an unrealis-

tic omnipotent fantasy of saving the patient, they can shift to a

more realistic one such as providing a comfortable, dignified

death. Such a goal is much more easily accomplished.

Identifying Staff Problems

Staff issues often can be identified in staff attitudes toward

patients. For example, following a period in which there had

been an unusually high number of deaths in an ICU, an 80-

year-old patient was admitted to the unit with pneumonia.

She required intubation and ventilation. Although her infec-

tion was controlled rapidly, she had difficulty being weaned

from the ventilator. Staff nurses began to voice concerns such

Self-esteem

realistic achievement

expectatio

nns

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PSYCHIATRIC PROBLEMS

441

as, “Why are we putting such effort into an 80-year-old

woman? She won’t make it anyhow.” When those concerns

were raised in a staff meeting, other staff members pointed

out that the patient had been living independently until her

pneumonia developed and that her only current problem

was one of pulmonary mechanics that should clear with

time. This discussion helped the staff to perceive that their

view of the patient had been unfairly pessimistic, probably

related to the several recent deaths that had led to a sense of

inadequacy, helplessness, and group depression. They left the

meeting with a clearer understanding of what they could

accomplish with the patient. She eventually was weaned from

the ventilator and returned to her home.

Interventions

There are various approaches to helping the ICU staff deal

with the stress of working with critically ill patients. Units

emphasizing a culture of cooperation and communication

have a reduced length of stay, increased staff longevity, and a

higher perceived quality of care. These observations reinforce

earlier recommendations to schedule regular staff meetings,

including in the invitation a psychiatrist or social worker

familiar with the unit. Ideally, both physicians and nursing

staff should attend this meeting. Staff should raise any feel-

ings they have about patients or ward situations. These feel-

ings can be clarified, shared, and discussed with others.

Identification of exaggerated expectations or other problems

such as group depression can be investigated and resolved.

Junior staff can gain broader perspectives from more experi-

enced staff. These meetings also can facilitate communica-

tion and humor, which are important ways for a staff to cope.

They can help staff deal with the multisystem patient with a

poor prognosis. Staff can become more comfortable realizing

that they are doing the best job possible with this difficult

population and accepting death if it becomes clear that the

patient will have to die despite the best critical care that could

be offered. Recent studies have found that clinicians perceive

conflict in up to 78% of cases requiring decision making for

critically ill patients. The conflict was perceived to occur with

equal frequency between staff and family members and

within the staff. While the presence of conflict was not always

felt to be detrimental, it can be disruptive and lead to morale

problems. Thus meetings in which such issues can be identi-

fied and discussed will benefit the ICU team.

In addition to staff meetings, there are a host of practical

interventions that can help staff deal with the stress of work-

ing in an ICU. Nursing and physician staff can be encouraged

to take adequate time off for restorative recreation and fam-

ily life. Some institutions schedule fewer but longer shifts in

order to provide longer stretches of time off. House staff

might be given the afternoon off on the day following a night

on call—which is probably the single most important vari-

able in reducing house staff distress. Providing strong med-

ical and nursing directors is extremely helpful for staff

dealing with the ambiguities of complex illnesses. Having the

services of an ethicist and a chaplain available on a regular

basis can be an invaluable support strategy. Another measure

to prevent the development of burnout in ICU staff is creat-

ing a system in which staff rotate between the ICU and other

settings to remove staff from the constant stress of the ICU.

Current Controversies and Unresolved Issues

The difficulty of working in an ICU undoubtedly will persist.

As technological advances allow staff to sustain life in the

face of severe, previously untreatable conditions, the ethical

and philosophical tensions these situations give rise to are

likely to increase. Helping the staff to cope with these stres-

sors will remain an ongoing challenge.

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0019

Care of the Elderly Patient

Shawkat Dhanani, MD, MPH

Dean C. Norman, MD

The elderly are a highly heterogeneous group, and the physi-

cal and medical heterogeneity increases with age. Individuals

over 65 years of age—with or without chronic diseases—vary

widely in their physical, behavioral, and cognitive functions.

Any clinician can relate the “Tale of Two Octogenarians” seen

in practice on the same day: the end-stage patient afflicted

with Alzheimer’s disease seen at the nursing home and the

vigorous retiree seen after his golf game for monitoring of his

historically well-controlled hypertension.

Physiologic rather than chronological age is a better pre-

dictor of the health status of the elderly. An abrupt decline in

physical function or any organ system is almost certainly due to

disease and not due to “normal aging.” Therefore, symptoms in

the geriatric population should not be attributed automatically

to old age, and it is important to look for potentially reversible

causes of symptoms. Moreover, treatable conditions should not

be undertreated for fear of side effects of medication.

Improvement or maintenance of functional status is the

major goal of medical care in the geriatric population.

Functional disability occurs faster and takes longer to correct

in the elderly, necessitating early preventive measures. Active

efforts should be made to maintain functional level even dur-

ing intensive care. Even small changes in function can make

large differences in the quality of life. For example, regaining

the ability to oppose the thumb to other fingers may enable a

geriatric patient to become independent in feeding.

Prevention of iatrogenic diseases is also important. For exam-

ple, close attention should be paid to prevent the develop-

ment of pressure ulcers. A pressure ulcer can develop in just

few hours, and the mortality rate of those who develop the

lesions in the first 2 weeks of intensive care has been reported

to be as high as 73%. Other iatrogenic problems in the ICU

include aspiration pneumonia, sepsis, GI bleeding, delirium,

drug toxicity and interactions, and renal insufficiency.

Multiple concurrent illnesses, cognitive and sensory

impairments, age-related changes in physiology and phar-

macodynamics, increased vulnerability to delirium, and

complications from immobility make management of acute

illness in the elderly a clinical challenge for all physicians and

other health care providers who care for patients in this age

group.



Physiologic Changes with Age

The Aging Heart

Heart disease is the leading cause of death in people over

75 years of age and the fourth most prevalent chronic disease

in the elderly. Nearly 30% of elderly people have some abnor-

mality affecting the heart. Moreover, occult cardiac disease can

cause marked functional impairments in otherwise apparently

healthy elderly people. Coronary atherosclerosis increases

exponentially with age and, in the elderly, can present as heart

failure, pulmonary edema, arrhythmias, or exercise intoler-

ance rather than as angina or obvious myocardial infarction.

In healthy subjects, the resting heart rate does not change

with age, but the maximum heart rate with exercise decreases

with age (Table 19–1). It can be calculated by the following

formula: 208 – (0.7 × age). Age-related changes in collagen

and elastin contribute to progressive stiffness and loss of

recoil of elastic tissues. In the systemic arteries, this process

contributes to an increase in systolic blood pressure. Systolic

pressure rises approximately 6–7 mm Hg per decade, but

diastolic pressure changes little with age and even may fall

starting in the sixth decade. In addition, the systolic pressure

may be underestimated by the cuff sphygmomanometer in

the elderly. Resistance to blood flow leads to increased left

ventricular wall tension and compensatory left ventricular

hypertrophy. The myocardium is also affected by changes in

collagen and elastin that cause stiffness of the left ventricle

that can result in diastolic dysfunction. The left ventricular

filling rate during early diastole declines markedly with age

(approximately a 50% reduction between age 20 and age 80).

Enhanced active filling in late diastole during atrial contrac-

tion compensates for decreased passive diastolic filling, and

this explains the vulnerability of older persons to congestive



CHAPTER 19

444

heart failure when atrial fibrillation or flutter occurs.

Decreased filling also makes the elderly more vulnerable to

small decreases in venous filling with volume loss or when

given opioids, diuretics, or positive-pressure ventilation. On

the other hand, systolic function is relatively preserved in the

healthy elderly.

Despite these disturbances, cardiac output at rest remains

relatively constant across the life span. During low- and

medium-intensity exercise, increases in stroke volume com-

pensate for the lower heart rates observed in the elderly. This

increase in stroke volume with exercise is the result of an

increase in end-diastolic volume by as much as 30% (Frank-

Starling law). However, with high-intensity exercise, a decline

in cardiac output is observed owing largely to the age-related

decline in maximum heart rate. This hemodynamic profile is

strikingly similar to that observed in younger patients who

exercise in the presence of β-adrenergic blockade. Since

β-adrenergic modulation of pacemaker cells partly explains

the increased heart rate during exercise, this observation led

to the hypothesis—later confirmed—that diminished response

to β-adrenergic modulation is one of the most notable age-

related changes in the cardiovascular system. Chronotropic

and inotropic responses of the aging heart to norepinephrine,

isoproterenol, and dobutamine are diminished. Virtually all

studies show higher mean circulating blood norepinephrine

and epinephrine levels in the elderly than in younger persons.

Both arterial dilation and venous dilation in response to

β-adrenergic stimulation decrease with age. This deficiency

in arterial dilation in addition to any age-related structural

changes within the large vessels may contribute to increased

vascular impedance in advancing age.

The Aging Lung

Cross-sectional population studies consistently show a pro-

gressive age-related decline in pulmonary function. The

decrements in flow rates and lung volumes are not uniform

throughout life but tend to accelerate with age. Given the

large individual differences in the elderly, longitudinal stud-

ies would be preferable for observing the change in pul-

monary function, which is influenced not only by age but

also by environmental factors such as smoking, air pollution,

infections, and other comorbid conditions.

Age-related changes in collagen and elastin produce a

decrease in lung compliance, but this is not physiologically

significant. However, rigidity of the chest wall with aging has

measurably negative mechanical implications resulting in

significantly increased work of breathing. Starting around

age 35 years, there is a decrease in forced vital capacity (FVC)

averaging 14–30 mL per year and a decrease in forced expi-

ratory volume in 1 second (FEV

) averaging 23–32 mL per

year for nonsmoking men. Nonsmoking women show

slightly lesser rates of decline (FVC 15–24 mL per year and

FEV

19–26 mL per year). All expiratory flow rates decrease

with age and tend to fall faster in men, taller individuals, and

those with increased airway reactivity. The decrease in FVC is

associated with an elevation in functional residual capacity

(FRC) and residual volume (RV). Only minor changes occur

in total lung capacity.

Age-related changes in lung structure and chest wall

mechanics lead to premature closure of terminal airways. This

phenomenon occurs predominantly in the dependent parts of

the lungs that are the best perfused, accounting for increasing

ventilation-perfusion mismatching that results in a progressive

decrease in arterial oxygen tension (Pa

) and an increased

alveolar-arterial oxygen difference—P(

–a)

—with age. The

following equation predicts Pa

at sea level in the adult:

(mm Hg) = 100 – 0.325 × age (years)

The normal value for the P(

–a)

at rest for a given age

can be calculated as follows:

–a)

(mm Hg) = (age + 10) × 0.25

Based on this formula, a 90-year-old subject will have a

predicted Pa

of 71 mm Hg and a maximum normal

–a)

of 25 mm Hg at sea level.

Changes in position also influence the Pa

.Pa

is 6–10

mm Hg lower in the supine position than in the upright posi-

tion in the elderly. Postoperative hypoxemia is especially com-

mon in the elderly, in whom it may persist for several days.

There is no significant change in arterial pH or P

with age.

Ventilatory control is also affected by age and is more

striking compared with the changes in lung volumes and

Table 19–1. Summary of age-related change in cardiac

physiology.

Heart rate At rest: unchanged

Maximal heart rate with

exercise: decreases

Stroke volume At rest: unchanged

With exercise: increases

Ejection fraction At rest: unchanged

With exercise: fails to increase as

much as in younger subjects

Cardiac output At rest: unchanged

Low- and medium-intensity exercise:

unchanged

High-intensity exercise: fails to

increase as much as in younger

subjects

Early diastolic left ventricular

filling rate

Decreases

Late diastolic left ventricular

filling rate (atrial ”kick”)

Increases

Ventricular compliance Decreases



CARE OF THE ELDERLY PATIENT

445

flow rates. The ventilatory response to hypoxemia is reduced

by half in healthy elderly men 64–73 years of age, whereas the

response to hypercapnia is reduced by 40%. Reasons for

these decreased responses are unclear. Suggested explana-

tions include altered central or peripheral chemoreceptor

function as well as reduction in neuromuscular inspiratory

output.

Right atrial, pulmonary artery, and pulmonary capillary

wedge pressures are unchanged in the healthy elderly at rest.

In contrast, the older person’s increases in pulmonary artery

and pulmonary capillary wedge pressures with exercise are

significant, and increases in pulmonary artery resistance are

highly significant with age.

There is a reduction in the effectiveness of cough and

mucociliary clearance with aging and a decline in the cellular

and humoral components of pulmonary immunity. These

changes predispose the older population to pulmonary

infections. Similarly, a diminished gag reflex, dyscoordina-

tion of swallowing, prolonged periods in the supine position,

and sedation contribute to an increased risk of aspiration.

Table 19–2 summarizes these findings.

The Aging Kidney

Many cross-sectional and longitudinal studies of large

human populations have shown a steady decline in creati-

nine clearance with age. As in any other area, the decline in

renal function with age is highly variable among individuals.

In general, changes owing to disease and to aging are in the

same direction and are additive. With aging, there is a loss of

nephrons at a rate of 0.5–1% per year. By the seventh decade

of life, there is a 30–50% loss of functioning glomeruli owing

to age alone. This loss occurs primarily in the renal cortex,

with relative sparing of the medulla. A progressive reduction

in renal plasma flow also has been demonstrated with age. A

50% reduction has been shown between young adulthood

and the eighth decade, averaging 10% per decade.

The major clinically relevant renal functional defect aris-

ing from these histologic and physiologic changes is a pro-

gressive decline, after maturity, in the glomerular filtration

rate (GFR). Age-adjusted normative standards for creatinine

clearance have been established. The rate of decline has been

estimated as 8 mL/min/1.73 m

per decade after the fourth

decade (or 0.8 mL/min per year). This rather drastic age-

related loss of renal function is not completely reflected in

the serum creatinine because of the proportionate decline in

skeletal muscle mass. Therefore, in order to make an estima-

tion of the glomerular filtration rate in the elderly, the serum

creatinine value should be incorporated in the Cockcroft and

Gault formula that takes into account the age, sex, and

weight of the patient:

Estimated creatinine clearance =

In women, the result should be multiplied by 0.85. For

obese individuals (body mass index [BMI] ≥ 30), ideal rather

than actual body weight should be used.

For the preceding reasons, dosage adjustments of medica-

tions excreted primarily by the kidneys should not be based

on serum creatinine values but rather on measured or esti-

mated creatinine clearance. Drugs that are excreted predom-

inantly through kidneys and have low therapeutic indices

(eg, digoxin, procainamide, and vancomycin) require close

monitoring of serum levels.

Since medullary nephrons, which are relatively spared

compared with cortical nephrons, have reduced concentrat-

ing ability, the elderly tend to excrete more free water. They

release more antidiuretic hormone in response to hyper-

tonicity, yet water retention is less than in younger individu-

als because of reduced end-organ response in older persons.

Older individuals tend to have diminished thirst perception

and diminished awareness of volume contraction. The

response to aldosterone is impaired, and the ability to con-

serve sodium is limited.

The age-related decline in other renal functions such as

urine concentration and dilution, tubular secretion and

reabsorption, and hydrogen ion secretion render the elderly

more susceptible to disorders of fluid, electrolyte, and acid-

base imbalance. Low renin and aldosterone levels can con-

tribute to hyperkalemia and hyponatremia.



Management of the Elderly Patient

in the ICU

Clinical Presentation of Disease in the Elderly

Elderly patients may present with multiple pathologic

processes in different organ systems. Various studies have

found an average of three to four medical conditions in

ambulatory older patients and five to nine medical diagnoses

among elderly patients in chronic care facilities.

[140 age (years)] body weight (kg)

72 se

−×

rrum creatinine (mg/dL)

Forced vital capacity (FVC) Decreases

Forced expiratory volume in 1 second (FEV

) Decreases

Residual volume Increases

Arterial P

Decreases

Alveolar-arterial oxygen difference Increases

Arterial P

Unchanged

Ventilatory response to hypoxia or

hypercapnia

Decreases

Mucociliary clearance Decreases

Table 19–2. Summary of age-related changes in

pulmonary physiology.



CHAPTER 19

446

Owing in part to the progressive decrease in physiologic

reserve with age and comorbidity, the elderly may have

unusual presentations of diseases. The onset of a disease in

the elderly generally affects the most vulnerable organ system

first. This explains the frequent apparent lack of relation

between the presenting symptom and the underlying disease.

Thus delirium, functional impairment, frequent falls, incon-

tinence, and syncope could be the presenting manifestations

of a variety of illnesses such as congestive heart failure, pneu-

monia, myocardial infarction, urinary tract infection, or GI

bleeding. Moreover, painless myocardial infarction may

occur in up to 30% of cases. This emphasizes the need for a

thorough evaluation when searching for the cause of non-

specific symptoms.

Drug Therapy

Iatrogenic illness is common and often preventable in the

elderly. The incidence of iatrogenic problems among acutely

hospitalized geriatric patients is close to one in three. By far

the most common iatrogenic disorders in the elderly are

adverse drug reactions. Changes in pharmacokinetics and

pharmacodynamics and polypharmacy predispose geriatric

patients to adverse reactions and drug interactions.

Pharmacokinetics is the study of the time course of

absorption, distribution, metabolism, and excretion of drugs

and their metabolites from the body. Absorption and metab-

olism are minimally affected by aging. Distribution is affected

by changes in body composition. For example, aging is asso-

ciated with an increased percentage of fat (50% increase in

men and 25% increase in women from age 40 to age 80) and

a concomitant decrease of total body water. Thus medications

that distribute in the water space (ie, hydrophilic drugs such

as digoxin and theophylline) have a lower volume of distribu-

tion and tend to reach higher levels in a shorter time in an

older patient. On the other hand, drugs that are lipid-soluble

(ie, lipophilic drugs such as the psychotropics) will have a

larger volume of distribution, resulting in progressive accu-

mulation of these drugs. The net effect of this will be to

increase the half-life of these drugs and prolong the duration

of action. This effect is further compounded by impaired

drug excretion because both renal and, to a lesser extent,

hepatic function tend to decrease with age.

In addition, some plasma protein levels may alter with age.

For example, serum albumin often falls with chronic comor-

bid conditions, resulting in higher free drug levels and a

potential for greater pharmacologic effect at the same dosage

or total serum level for protein bound drugs (eg, phenytoin).

As discussed earlier, renal function tends to decrease with

age, but concurrent changes in muscle mass keep the serum

creatinine constant at approximately 1 mg/dL, often masking

the declining renal function. Thus measurement of creati-

nine clearance or estimation with the Cockcroft and Gault

formula should be used to assess the GFR and make the nec-

essary adjustment in dosages of drugs excreted by the kid-

neys (see Chapter 4).

Cytochrome P450 enzymatic activity tends to decrease

with age. Warfarin and theophylline are examples of drugs

eliminated by this system. On the other hand, normal aging

does not significantly impair the conjugation capacity of the

liver. There is also a decrease in hepatic blood flow with age.

Compared with renal function, hepatic function is extremely

difficult to quantitate. Only sparse data are available on

hepatic drug metabolism in aging human subjects, and evi-

dence for altered hepatic metabolism in humans is largely

indirect and frequently inconsistent. For example, in studies

with antipyrine (a useful model compound for the study of

drug metabolism), large individual variation frequently

exceeds the effect of age such that only 3% of the variance in

metabolic clearance is explained by age alone.

Pharmacodynamics is the study of the physiologic

response to a drug or combination of drugs and is based on

drug-receptor interactions. For reasons that are not well

understood, the aging process appears to be associated with

an altered sensitivity of receptors for many commonly used

medications. In general, elderly subjects are more sensitive to

some medications, including warfarin, narcotics, sedatives,

and anticholinergic medications, and less sensitive to others,

such as β-adrenergic agonists and antagonists. However,

given the marked heterogeneity of the elderly as a group,

careful individualization should be the general rule when

drawing conclusions about such matters.

Because of multiple diseases and polypharmacy in the eld-

erly, the clinician always should check for possible drug-drug

and drug-disease interactions before prescribing any new

medication. The probability of a significant drug-drug inter-

action is nearly 7% for patients using more than 5 drugs and

24% for those using more than 10 medications. Special atten-

tion should be paid when prescribing medications with long

half-lives or with anticholinergic or potential CNS side effects.

Adverse drug effects can mimic almost any clinical syn-

drome in geriatrics and should be considered in the differen-

tial diagnosis of vague symptoms or deterioration of

function. For example, timolol eye drops—a β-blocker used

for glaucoma treatment—may be absorbed systemically and

can cause cardiac decompensation in a patient with poor

cardiac function.

Hydration and Nutrition

Hydration status is a major concern in the hospitalized eld-

erly. One of the most common reasons for electrolyte abnor-

malities or fluid disturbances in this population is

dehydration. Contributing factors may include laxative or

diuretic use, the presence of fever or infection, decreased

ability to recognize or express thirst, and limited access to

water. There is also an age-related decline in urine concen-

trating ability, which can lead to frequent urination and fluid

loss. Accurate fluid balance assessment is essential in nutri-

tional screening because alterations in hydration state may

contribute to inaccurate anthropometric and biochemical

markers. Because of the high prevalence of congestive heart