Older ICU survivors: Care should focus on improving functional outcomes

A 79-year-old man has managed to live independently in his apartment, despite requiring help for grocery shopping and driving due to mild cognitive impairment. This changes when he is admitted to the intensive care unit (ICU) for pneumonia. There, he spends 5 days on mechanical ventilation and develops delirium during his clinical course.  

The man returns home but becomes increasingly dependent in activities and instrumental activities of daily living. He never achieves functional recovery. A month later, he is taken to a nursing home for long-term care.

He is an example conjured by Dr Lauren Ferrante, an assistant professor of medicine at Yale University in New Haven, Connecticut, US.

Speaking at the Asia Pacific Intensive Care Symposium (APICS) 2021 virtual conference, Ferrante highlights the need to understand and improve post-ICU functional outcomes of older adults. The risk of functional or cognitive decline after a critical illness matters for everyone regardless of age, she says. But what makes it an “impactful problem” among older adults is that for them, functional independence is the number one health outcome priority, with staying alive only a distant second. [Arch Intern Med 2011;171:1856-1858]

“It's really helpful to take a step back and think about the whole picture for a given patient, especially an older adult. ‘What were they like before they were in the ICU?’ and ‘Did they have any of these pre-ICU vulnerability factors that might influence their outcomes?’,” according to Ferrante.

Functional status, frailty, multimorbidity, cognitive status, sensory impairment, socioeconomic/neighbourhood advantage, and social isolation are some of the most important factors that can influence post-ICU functional outcomes in the elderly. [Crit Care Med 2012;40:502-509; JAMA Intern Med 2015;175:523-529; Chest 2018;153:1378-1386]

Ferrante expounds on social risk factors, particularly social isolation, which has become increasingly relevant in the light of the COVID-19 pandemic. She mentions that in a recent study currently under review, social isolation conferred an increased burden of disability in the year after an ICU hospitalization as well as death.

“Older adults plus the COVID wards led to a perfect storm,” she says. “We know that even in the hospitals, older adults are socially isolated.  [They] are more likely to be hearing impaired, and it's difficult to hear staff through masks and PPE. Many hospitals suspended mobility programmes, and there were medication shortages, leading to the use of benzodiazepines in the ICU.”

As if the illness is not bad enough, older patients face another set of challenges after their discharge from the ICU. Ferrante notes that some of the older ICU survivors who are unable to leave their home for physical therapy and thus referred for home health rehabilitation utilization never actually receive home rehabilitation. Meanwhile, others only receive an average of 1.1 visits per week and for just a few weeks.

Additionally, during the recovery phase, intervening illnesses and injuries leading to hospitalization, emergency visit, or restricted activity are quite common in the year after critical illness, as Ferrante points out. These intervening hospitalizations, in turn, are significantly associated with a lower likelihood of functional recovery. [Crit Care Med 2021;49:956-966]

In improving ICU models of care for older adults, Ferrante argues that a lot can be gleaned from non-ICU geriatrics literature, which shows that many millions more of older adults survive a non-ICU hospitalization.

A systematic review of nearly 7,000 patients has demonstrated that Acute Care for Elders (ACE) model—a well-studied geriatric model of care—is associated with fewer falls, less delirium, less functional decline at hospital discharge, shorter lengths of stay, fewer nursing home discharges, and lower costs. [J Am Geriatr Soc 2012;60:2237-2245]

Components of the ACE model, according to Ferrante, have been widely implemented on the medical ward but have not really made their way into the ICU. “So, when I think about how to apply these concepts in the ICU, I think of them as something that could potentially be added to the ABCDEF bundle,” which is the current paradigm of care in the ICU.

Ferrante suggests making changes, that is additions and subtractions, to the physical ICU environment, to prevent cognitive and functional decline. These include addressing sensory impairment, preserving sleep, and maintaining orientation.

“Another ACE concept that we have in the ICU but perhaps could be developed even further is that of early mobilization of older ICU patients [as opposed to bedrest],” she says. “And although many of us are very good about mobilizing patients even on the ventilator, we should do this for our older adults and consider adding occupational therapy if patients need help with activities/instrumental activities of daily living or have neurologic deficits.”