Neurocognitive Problems in Critically Ill Older Adults: The Importance of History

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Older adults are at greater risk for the development of neurocognitive problems during critical illness than are their younger counterparts, particularly if they have preexisting cognitive impairment. Neurocognitive problems result in longer duration of mechanical ventilation and extended intensive care unit (ICU) and hospital lengths of stay. These problems can persist after discharge and affect quality of life for both the patient and family caregivers. Accurate assessment of neurocognitive status necessarily guides selection of interventions. Consider the case of Mrs. Crane, an older woman who developed flank pain, nausea, vomiting, and altered mental status while travelling with her husband. She was first admitted emergently to a community hospital and then transferred to the University Medical Center with a diagnosis of intrahepatic abscesses. She developed septic shock and renal failure and was intubated and mechanically ventilated shortly after admission to the University Hospital. Medical management included vasopressor medications for hypotension and intermittent hemodialysis for acute renal failure. Mrs. Crane’s ICU course was notable for prolonged periods of psychomotor agitation, which were treated with intravenous lorazepam, morphine,and fentanyl. The sedative and analgesic medications were titrated to manage physiologic (hypertension, tachycardia, tachypnea) and behavioral symptoms (head thrashing, active in bed, facial grimacing, pulling at wrist restraints, “bucking” ventilator, wincing, lifting arms and legs off bed, and “resisting care”). Ventilator weaning attempts were avoided or aborted when agitation was associated with a reduction