The intensive care unit: How to make this unfriendly environment geriatric-friendly

Patients 80 years old or older are increasingly being admitted to intensive care units, particularly in western countries, where life expectancy is constantly increasing. The benefits of intensively treating critically ill elderly patients are uncertain. The high mortality rate in the presence of underlying chronic diseases is a factor. More generally, frailty, defined as an impaired resilience following a health stressor event, must be taken into account. No consensus exists on the risk-benefit ratio to admit octogenarians to the ICU. Treatment decisions should account for life expectancy but also tailored to the needs and wishes of patients and next-of-kins. The cohort of elderly patients is known to be the most vulnerable to functional decline and cognitive impairment, including neuropsychological complications, such as delirium. Interventions directed at reducing the incidence of delirium may mitigate brain injury associated with critical illness, potentially being the single most effective intervention in this population. A multimodal approach to analgesia should be considered to avoid untreated pain and its consequences. Sleep protocols can effectively reduce the risk of delirium. Notably, the deployment of “sleep bundles” (regular sleep-wake rhythms, reduced night-time light, noise control strategies), may be helpful. As well, adequate nutritional support, spontaneous awakening trials, early mobilization, and physical therapy are crucial to prevent physical deconditioning. The psychological consequences of critical illness for both patients and caregivers are also being increasingly recognized. Attention to the needs of families is essential, due to its positive effects on patients and as a quality improvement goal by itself. Death and dying in the ICU is a more frequent outcome in the elderly population. A real culture for the management of distress and grieving is a required skill for the ICU staff. Privacy and adequate palliative care should be contemplated for an ethical and comfortable end of life.