You are asked to review an 88-year-old man who has fallen from a ladder. He is in the ED with a large subdural haematoma (SDH) and significant mid-line shift on CT scan. His GCS is 6/15. He has a past medical history that includes atrial fibrillation (treated with warfarin and digoxin), chronic renal impairment (creatinine 190 µmol/L), non-insulin-dependent diabetes and mild cognitive impairment.
a) List the factors in this patient’s history that suggest his outcome may be poor?
b) Outline how age-related changes in cardio-respiratory physiology and response to medications would impact on the management of this patient
Response to medications
A more detailed all-systems look at age-related changes in the response to critical illness can be found in Question 8 from the second paper of 2007:"What are the age related factors which adversely affect outcome in the elderly (>65 years) critically ill patient?"
How did the college arrive at this answer?
What are the predictors of poor outcome in traumatic brain injury?
As far as age-related physiological changes go...
From this article on geriatric cardiology, I quote the following physiological changes associated with age:
Langlois, Jean A., Wesley Rutland-Brown, and Marlena M. Wald. "The epidemiology and impact of traumatic brain injury: a brief overview." The Journal of head trauma rehabilitation 21.5 (2006): 375-378.
Steyerberg, Ewout W., et al. "Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics." PLoS medicine 5.8 (2008): e165.
Stocchetti, Nino, et al. "Traumatic brain injury in an aging population." Journal of neurotrauma 29.6 (2012): 1119-1125.
Amacher, Loren A., and David E. Bybee. "Toleration of head injury by the elderly." Neurosurgery 20.6 (1987): 954-958.
Jamjoom, Abdulhakim, et al. "Outcome following surgical evacuation of traumatic intracranial haematomas in the elderly." British journal of neurosurgery 6.1 (1992): 27-32.
Cheitlin, Melvin D. "Cardiovascular physiology—changes with aging." The American journal of geriatric cardiology 12.1 (2003): 9-13.
Shi, Shaojun, and Ulrich Klotz. "Age-related changes in pharmacokinetics."Current drug metabolism 12.7 (2011): 601-610.
Corsonello, A., C. Pedone, and R. Antonelli Incalzi. "Age-related pharmacokinetic and pharmacodynamic changes and related risk of adverse drug reactions." Current medicinal chemistry 17.6 (2010): 571-584.
Carbonin, P., et al. "Is age an independent risk factor of adverse drug reactions in hospitalized medical patients?." Journal of the American Geriatrics Society39.11 (1991): 1093-1099.
Timiras, Paola S., ed. Physiological basis of aging and geriatrics. CRC Press, 2013.
Janssens, J. P., J. C. Pache, and L. P. Nicod. "Physiological changes in respiratory function associated with ageing." European Respiratory Journal 13.1 (1999): 197-205.