- There are no international guidelines about which older adults should be admitted to the ICU because the benefits are uncertain
- Pain, delirium and oversedation need attention because these problems have been tied to increased morbidity and mortality
- Attention to the needs of relatives is important both to benefit patients and as an aspect of high-quality care in its own right
- For patients 80 and older, the strongest predictors of surviving a critical illness are the severity of the illness and pre-morbid functional status, not age per se
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With life expectancy continuing to rise in Western countries, patients ages 80 and older are increasingly being admitted to the ICU. There are no international guidelines about which older adults should be admitted because the benefits of ICU care are uncertain, especially considering the higher prevalence of frailty in this population.
As part of a review in the European Journal of Surgical Oncology, Lorenzo Berra, MD, anesthesiologist in the Department of Anesthesia, Critical Care and Pain Medicine and medical director for Respiratory Care, and Riccardo Pinciroli, MD, researcher at Massachusetts General Hospital, and their colleague Francesca Tardini, MD, anesthesiologist at the Department of Anesthesia and Critical Care at the University of Milano-Bicocca in Italy, outline considerations for making ICUs more geriatric-friendly.
Issues for Patients
Pain, delirium and oversedation have been tied to increased morbidity and mortality:
- Pain increases the risk of post-traumatic stress disorder if untreated. Even in the short term, untreated pain has consequences, including higher energy expenditure and immunomodulation
- Delirium increases the risk of death and long-term cognitive impairment. In older patients there is evidence of effectiveness for early mobilization, eyeglasses, hearing aids and "sleep bundles" (maintaining regular sleep–wake cycles and reducing nighttime light, noise and awakenings for nursing care)
- Light sedation is a strategy to improve patient outcomes. "The 3Cs" are to keep the patient calm, comfortable and cooperative. The trend is to replace benzodiazepines as first-line sedatives with shorter-acting, more easily titrated agents such as propofol and dexmedetomidine
Issues for Families
Attention to the needs of relatives is important both to benefit patients and as an aspect of high-quality care in its own right.
- Physician–family Communication: There's evidence that holding a scheduled family meeting early in the course of ICU care, including an explanation of major ICU interventions and common procedures, improves family satisfaction
- Visitation Policies: Lifting restrictions on visiting hours and the number of visitors helps patients feel supported, helps families feel less anxious and more satisfied and increases opportunities for physician–family communication
- Post–Intensive Care Syndrome: This refers to the appearance or worsening of problems related to physical status, cognition and mood after ICU discharge. It can affect families as well as patients, and families may benefit from counseling
- Follow-up: No data in the literature support greater effectiveness of one follow-up path compared with another, but there's general consensus that follow-up clinics are useful for both patients and families
No reliable markers distinguish survivors from non-survivors at the time of ICU admission. For patients 80 and older, the strongest predictors of surviving a critical illness are the severity of the illness and pre-morbid functional status, not age per se.
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