As discussed earlier, elderly patients admitted to the ICU after planned surgery have reasonable long-term outcomes. On the other hand, long-term outcomes after ICU admission for unplanned surgical and medical elderly patients are rather poor. For this group, there are two broad options:
- Not admitting them to the ICU and privileging a hospitalization in a regular ward or acute care elderly unit.
- Admitting them to the ICU and conducting efforts to ensure a rapid ICU discharge.
Triage decision is one of the hardest tasks of any intensivist. Part of the difficulty is accounting for evaluation of the severity of illness, the potential benefit of being hospitalized in the ICU, and beds availability in an emergency context [25
]. Among the reasons for not admitting a patient to the ICU are: patient or family wishes for not escalating care, the futility of higher-level care (patient does not actually require intensive care, there are no expected benefits from critical care treatment or end-of-life planning). Moreover although ICU "often" is considered a safe environment by patient and family members, there are several risks associated with unnecessary intensive care (often neglected) that may delay or impede full recovery. Among the inherent risks, there is a greater exposure to nosocomial infections, iatrogenic complications from invasive monitoring, imposed bed/chair rest, sleep deprivation, delirium, increased hospital length of stay, and more restrictive visiting hours for families [26
]. All of these risks may lead to increased morbidity, cognitive impairment, and functional disability [28
As seen previously, expected benefits of medical or unplanned surgical ICU admissions of elderly patients aged 80 years and older are particularly weak and make ICU admission of these categories of patients questionable. To date, there is no randomized, controlled study available; the only available data came from observational studies with inherent limitations (retrospective collection of data at baseline, lack of a control group). Boumendil et al. recently reported in a multicenter observational study (including a majority of medical admissions) that ICU admission compared with admission to a regular ward did not improve the long-term survival of patients aged 80 years and older [30
]. These results emphasized previous data of Martínez-Sellés et al. who reported that the outcome of persons aged 90 years and older admitted with acute myocardial infarction was not influenced by an admission to a coronary care unit [31
An alternative to ICU hospitalization is admission to an acute care elderly unit. Current data suggest that elderly patients who are hospitalized for an acute medical illness suffer a functional decline afterwards [32
]. Maximizing recovery of daily life activities may allow the elderly to be discharged home and to limit the burden for caregivers. Acute care units for the elderly were created during the early 1990s and initially included four components: a prepared environment, patient-centered care, medical care review, and planning for discharge [33
]. A prepared environment is an ergonomic environment planned to limit risk of falls (e.g., uncluttered hallways and elevated toilet seats) and disorientation (e.g., using large clocks and calendar). Patient-centered care includes the daily assessment of physical, cognitive, and psychosocial function, protocols to improve self-care, continence, nutrition, mobility, sleep, skin care, mood, cognition, and daily rounds by a multidisciplinary team. A medical care review is a review of daily planned medicine and procedures and the use of protocols to minimize adverse effects. A planning for discharge is an early plan to facilitate home return and involve social workers. When posthospital care is needed, options may be large and the choice of a structure should depend on the patient's clinical status and care goals, family circumstances, and resources [34
A recent review conducted by Ahmed et al. showed that acute care for the elderly units are associated with reduced functional decline, costs, hospital length of stay, and lower readmission rates to acute care hospitals compared with usual care [35
]. The results of the prevalence and reduction of delirium were mixed. All surveys of patients, healthcare providers, and caregivers reported higher satisfaction for acute care for the elderly units.
Admitting selected elderly aged 80 years and older to the ICU
With 1-year mortality rates of 80% or 90%, it seems reasonable that some portion of elderly patients may not be best served by ICU care. The difficulty is determining which subjects should not be admitted to the ICU. During the past decade, ICU admission criteria classically include severity of illness, comorbidities, the levels of frailty and disability, the expected impact of treatment on the outcome, the expression of wishes regarding do-not-resuscitate orders, and the availability of ICU beds [36
]. Severity of illness was considered explaining "a small part of the increased hospital mortality" [36
]. On the other hand, "functional status" was considered one of the major predictors of long-term outcome [36
Recent data suggest that a greater age and a high level of severity of illness are predictive of poor outcomes. Sligl et al. reported in a multicenter British cohort study that among critically ill adult patients with pneumonia, age 80 years and older was an independent factor of death at 30 days (odds ratio (OR) = 2.54 [1.21-5.36]) as well at 1 year (3.47 [1.99-6.05]) [37
]. Blot et al. showed in a Belgium single-center cohort study that among critically ill patients with nosocomial blood stream infections, age older than 75 years was associated with higher hospital mortality rates (OR = 1.8 [2.3-2.3]) [6
]. Farfel et al. in a single-center Brazilian cohort study of elderly admitted to the ICU found that age 75 years and older was an independent risk factor of death but only for patients who required invasive mechanical ventilation (OR = 2.68 [1.58-4.56]) [38
]. Concerning severity of illness, in a large cohort of American community elderly, Gill et al. reported that injuries and illnesses leading to hospitalizations are associated with increased disability and reduced recovery [39
]. Iwashyna et al. in a national American cohort study of older patients with a mean age of 77 years demonstrated that severe sepsis is associated with cognitive impairment (moderate to severe cognitive impairment OR = 3.3 [1.5-7.25]) and functional disability (acquisition of 1.5 new functional limitation at hospitalization for severe sepsis) [40
On the other hand, some data suggest the presence of comorbidities and functional status may be poor predictors of outcome. In a large American cohort of elderly patients, Yende et al. reported that prehospitalization comorbid conditions did not influence long-term mortality after pneumonia [41
]. Barnato et al. reported in a cohort of elderly undergoing mechanical ventilation that prehospitalization functional status was not a good predictor of disability among survivors [19
]. Similarly, Roch et al. found that preadmission functional scores of elderly aged 80 years and older before ICU admission, evaluated by the Knaus classification or the Karnofsky index, did not affect hospital or 2-year mortality [17
Another challenge in the decision-making process of admission of elderly patients aged 80 years and older is that physicians' choices more often are intuitive than "rational." Overvaluing "impressions" and "intuitions" rather than using evidence-based decisions may lead to unintended consequences [42
]. In a recent study, Rodríguez-Molinero et al. showed that the decision to admit an elderly patient to the ICU was essentially based on age and the physician's estimation of functional and mental status [43
]. Unfortunately, the evaluation of functional and mental status of their patients by physicians was not concordant with evaluation by the family. For example, the functional status of patients rejected from ICU admission often was underestimated, whereas the functional status of patients admitted to the ICU often was overestimated.
Besides improving survival, one of the major goals of ICU admission for the elderly (and indeed all patients) is to avoid inherent risks and improve recovery. Then, efforts to ensure rapid discharge from the ICU (such as noninvasive care) should be promoted to limit a new or additional activity of daily living disability, which are associated with poor long-term outcomes [32