ICU Adults: Sicker, More Disabled Now Than Before
Older adults being admitted to intensive care units (ICU) in the US now are older, more frail, and much more likely to have pre-existing disabilities and multimorbidities than their counterparts admitted to ICUs 17 years ago, a nationally representative survey of older adults indicated.
Over the 17-year study period, the prevalence of disability and frailty each rose 8 percentage points while the prevalence of multimorbidity grew 17 percentage points, Julien Cobert, MD, assistant professor of anesthesia, University of California, San Francisco, and colleagues report. Furthermore by 2015, “nearly one quarter of older adults admitted to the ICU had disability, half had frailty, and three quarters had disability,” the investigators add. The study was published online January 10 in Chest.
Age at first ICU admission increased by only about 1 year over the same interval, so patients admitted to the ICU in 2015 were not appreciably older than those who were admitted in 1998. On the other hand, as the population continues to age, the prevalence of geriatric conditions will likely further increase, the authors predict, with the possible exception of dementia, the incidence of which remained stable over the 17-year interval assessed.
If age alone doesn’t seem to explain all of what’s going on with older ICU admissions in more recent years, what else might be sending more debilitated, more frail, and sicker patients to the ICUs now? “My suspicion is that we are getting better at preventing critical illness and managing complications earlier, so I think the type of patients being managed [outside the ICU] tend to be sicker than they used to be and patients who used to come to the ICU are probably now avoiding that ICU stay because they are being better managed on the hospital floors and in the outpatient setting,” Cobert told Medscape Medical News.
“There are also increasing numbers of stepdown or transitional care units where practitioners can manage high-risk patients who previously would have come to the ICU but who now don’t need to,” he added.
That means that older adults who do require ICU care are indeed in real need of ICU care, as Cobert suggested.
For the study, Cobert and colleagues determined rates of disability, dementia, frailty, and multimorbidity among older adults admitted to the ICU between 1998 and 2015. “Disability, dementia, frailty, and multimorbidity were identified on responses to HRS [Health and Retirement Study] surveys prior to ICU admission,” investigators explain. Disability was defined by the need for assistance with one or more activities of daily living; frailty was defined by deficits in two or more domains of physical, nutritive, cognitive, or sensory function; and multimorbidity represented three or more self-reported chronic diseases, investigators explain.
The presence of dementia was assessed using both cognitive and functional measures. The final cohort included 6084 participants. Across the 17-year interval, age at first ICU admission increased from 77.6 years in 1998 to 78.7 years in 2015 (P < .001), investigators report.
Some 15.5% were disabled in 1998 compared to 24% in 2015 (P = .001). “Adjusted rates of dementia remained stable,” the authors note, at 10.4% in 1998 to 12.8% in 2015.
On the other hand, frailty increased from 36.6% in 1998 to 45% in 2015 (P = .04) while multimorbidity increased from 54.4% in 1998 to 71.8% in 2015 (P < .001). “Secondary analyses showed disability in each individual ADL [activity of daily living] grew over the study period as well,” the investigators observe.
For example, needing assistance with walking increased from 4.8% to 12.9% (P < .001) while the need for help bathing increased from 9.7% to 15.1%, although these changes were not significant. Hearing loss, vision loss, and inability to lift 10 pounds all showed increasing trends over time — although, again, they were not significant.
On the other hand, the incidence of reported falls rose notably from 31.8% in 1998 to 44.9% in 2015 (P < .001), investigators add.
Overall, 18.5% of the entire cohort had a greater than 50% risk of mortality at 4 years, as measured by the Lee index at the HRS interview prior to admission.
Based on their findings, Cobert and colleagues strongly advocate for the incorporation of geriatric-focused interventions in ICU units. For example, avoidance of benzodiazepines may be helpful in preventing delirium in older ICU patients even though in his own view, “it’s more ‘bundled’ care that has been shown to be beneficial,” Cobert noted.
In the critical care medicine world, practitioners often incorporate the so-called ABCDEF bundle, an evidence-based guide for changes needed to optimize recovery and outcomes in ICU patients. These changes may be as simple as early mobilization — even patients on a ventilator who are mobilized early are less prone to delirium, Cobert pointed out.
Practitioners also simply need to treat humans like humans, Cobert suggested: ensure patients are allowed to wear their eyeglasses or hearing aids if they need them, that they know when it’s daytime vs nighttime, and try to minimize all the beeping and the alarms to promote restorative sleep — “all the things we can modify from an environmental standpoint to make things better for the patient,” he emphasized.
This sounds like a tall order, especially in these turbulent times of burgeoning COVID-19 patients. But when asked how feasible it might be to make ICUs more geriatric-friendly, Colbert was adamant: “No matter how strained an ICU is, ensuring that we allow our older patients to maintain and retain their dignity is really important — not only for patients but also for healthcare providers,” he insisted.
“I think people are already doing a pretty good job in general at adopting geriatric principles, but I also think that incorporating checklists and bundles like the ABCDEF bundle is really important too as checklists and bundles can actually create more efficient use of the services needed and lead to better outcomes even in these extraordinary times,” Cobert said.
Commenting on the study, Bertrand Guidet, MD, professor of intensive care, Sorbonne Universite, Paris, France, noted that in France, patients admitted to the ICU are definitely older now than they were 20 years ago, where the mean age has increased from roughly 52 years 20 years ago to 62 years today. “In Western ICUs now, patients over the age of 80 account for at least 15% of ICU admissions, so there is a need to adopt the new concept of geriatric intensive care,” he told Medscape Medical News.
By this Guidet means that intensivists such as himself need to work together with geriatricians because they need their expertise. He also feels ICU providers must use specific tools such as the Clinical Frailty Scale (CFS), which is highly predictive of mortality at 1 month in elderly ICU patients and allows providers to reach more appropriate patient-centered decisions about whether to continue care.
“The case mix is changing over time,” Guidet confirmed. “And since we are now dealing more and more with old patients, we need specific tools to assess them,” he said. Very old patients are also very vulnerable, he added, and practitioners need to be very cautious when it comes to drug use, lines, and drains.
Guidet also stressed that it’s not only mortality that practitioners must consider but also the patient’s potential for functional decline and quality of life upon discharge. Practitioners also need to consider the burden of care that may be put upon the caregiver at home because if an old patient goes back home, they need to ask: Who will be in charge of the patient?
“This is the kind of shared decision-making that needs to happen in the ICU and it should include the patient, family members, and if possible, a geriatrician,” Guidet said. Guidet was the lead author on the large VIP2 study in which the impact of frailty, cognition, activities of daily living, and comorbidities were assessed among patients over the age of 80 years who were admitted to European ICUs.
In a large cohort of 3920 patients with a median age of 84 years, investigators were able to confirm that frailty assessment using the CFS ably predicted short-term mortality and that because it’s easy to measure, CFS data should be routinely collected for all elderly ICU patients to help with decision-making.
The study was funded by the National Institute on Aging. Cobert and Guidet have disclosed no relevant financial relationships.
Chest. Published online January 10, 2022. Abstract
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