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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #16, #27, #29, #31, #42, #43


Learning Objectives

  • Summarize the epidemiology of critical illness among older adults.

  • Review age-related changes in physiology relevant to care of the older adult with a critical illness.

  • Describe recent data on long-term physical, cognitive, and mental health outcomes among survivors of a critical illness.

  • Explore the evidence-based ABCDE bundle as a means by which to improve clinical outcomes for older, critically ill adults.

  • Describe the role of palliative care in modern intensive care unit (ICU) clinical practice.

Key Clinical Points

  1. Over half of all critically ill patients admitted to the ICU are 65 years and older.

  2. The majority of patients admitted to an ICU survive. Yet survivorship from critical illness is often fraught with long-lasting physical disabilities, cognitive impairment, and other mental health problems.

  3. Deep sedation and prolonged immobility, once mainstays of ICU care, are important contributors to poor short- and long-term outcomes.

  4. The evidence-based ABCDE bundle that seeks to Assess, prevent, and manage pain; perform Both spontaneous awakening and breathing trials; Choose proper analgesia and sedation; monitor, prevent, and manage Delirium; and perform Early mobility and exercise is associated with improved short-term clinical outcomes.

  5. The burden of physical and psychological symptoms in patients with a critical illness is high. Application of palliative care principles to address these symptoms, spiritual needs, medical treatment preferences and goals for care, inclusion of family members in decision-making discussions, and planning for transitional care when appropriate are important components of ICU care for older adults.


On average, Americans will be admitted to an ICU at least twice in their lives and will spend 4 days in the ICU during the last 6 months of their lives; one in five, in fact, will die in an ICU. These statistics are particularly relevant to older adults, their caregivers, and their clinicians given that well over half of all patients admitted to ICUs are 65 years or older. The age-specific incidence of mechanical ventilation for older adults is nearly five times greater than their younger counterparts (Figure 18-1). The incidences of sepsis (ie, infection leading to organ dysfunction) and the acute respiratory distress syndrome (ie, severe respiratory failure)—the most common reasons for admission to an ICU—are highest among older adults, and mortality from these syndromes increases with age. Sepsis is the most common reason older adults are admitted to the hospital, with admission rates outpacing those for acute myocardial infarction nearly fourfold.

FIGURE 18-1.

The incidence of mechanical ventilation and age. After adjusting for population growth, the number of patients who were mechanically ventilated increased by 11% from 1996 to 2002. While most of this increase was due to younger patients requiring mechanical ventilation, patients age 64 and older had a five ...

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