Team Members.

The interdisciplinary team members of a GCCU are nearly indistinguishable from those that comprise any other high-functioning critical care unit with an important exception. A GCCU also specifically incorporates additional key team members possessing specific expertise in geriatric medical and surgical care. These unique team members are the key in addressing the spectrum of care needs seen in critically ill geriatric patients in contrast to their more youthful counterparts. We will discuss the team members and their specific roles, as well as the structural components on the ICU in which they practice, in further detail below. It is important to recognize that most facilities will not have a separate and specifically designated GCCU but will instead have a functional one, as defined by the presence of the GCCU team in a more general ICU setting (Figure 15.1).

Figure 15.1 Geriatric ICU multiprofessional team. This diagram demonstrates the multiplicity of team members who interact with geriatric ICU patients for optimal outcomes.

Structural Elements of a Geriatric-Focused ICU.

The physical organization that makes up the geriatric-focused ICU is just as critical as the team that surrounds and cares for the patient. This unit must be meticulously designed to ensure optimal and efficient use of the space that also targets the specific needs of the elderly patients. As with all ICUs, the rooms should be arranged so that patients are easily visible from multiple vantage points within the unit. This ensures that all patients are adequately observed, given the high potential for delirium in the elderly. All rooms should have direct access to large windows with outside views and access to bright natural light. This will optimize attempts to normalize the sleep-wake cycle for these patients, in whom sleep hygiene is critical. Additionally, each room should have large sliding-glass doors that allow adequate noise control while closed and allow adequate visualization of the patient while drawn. A quiet environment at all times of the day is essential to the adequate rest and recovery of elderly patients. Additionally, monitor alarms should be adjusted to patient’s baseline status and frequency of alarms must be minimized. This unwarranted “noise” can exacerbate sleep disturbances, in a population that is critically dependent on restful sleep to minimize frequency of delirium.

Hygiene is also an essential element of patients within a geriatric specific ICU. Patients and care providers must have ready access to sinks, soap and hand sanitizer upon entry and exit from each of the patient’s room. Each patient room must be equipped with a shower and toilet, that are accessible and safety hand-rails, non-slip flooring, and sturdy seating for safety. Showers should be ideally large enough to accommodate the patient and a care provider for hygiene assistance, as well as physical or occupational therapy, for training in the use of assistive devices for hygiene. Toilets should be raised to ensure the patient’s ability to sit comfortably and stand up, without leading to imbalance and inadvertent fall. The room should also be large enough to accommodate family members. Of necessity, a respite area for the family is also ideal, especially during prolonged periods of critical illness. A variety of ICU designs that specifically address these elements are available from different critical care organizations.

Other elements to optimize the effectiveness of a geriatric specific intensive care unit include large font, high contrast signage, within the rooms that facilitate frequent re-orientation. A mechanism to update the day, date and time as well as the shift based care provider are essential to enhance orientation; attention should be paid to ensuring accuracy and frequent updating as necessary, especially with provider changes. A mechanism to communicate daily goals and the changing treatment plan to both the patient and the patient’s family members helps shape expectations and provides opportunities for family input and education. Specific attention is required to ensure that information is visible and large enough to be readable by the potentially visually impaired patient.

Functional Elements of a Geriatric-Focused ICU.

There are multiple functional elements within a geriatric-specific ICU that must come together to ensure effective and efficient care and to optimize outcomes. These elements include physical therapy on site, as well as various elements that facilitate adequate communication between care providers, patients, and their families. Assistive devices such as prescription glasses, electronic devices that speak for the patient or translate between languages, hearing aids that enable effective communication with those who may have impaired auditory or vocal capabilities should not be ignored. A large number of apps and other programs are available for laptops, tablets, and handheld devices. Larger television monitors and controls that accommodate decreased grip strength, as well as reduced digital dexterity from arthritis and related conditions, further enable comfort and communication and reduce frustration for patients with impairments. They further provide geriatric patients with some control over their environment at a time when they have become dependent in an unfamiliar hospital/critical care environment.

The physical plant of the ICU designed for geriatric patients should have adequate conference room space that is accessible to all team members. This space should be linked to the electronic health record (including imaging), be suitable for educational conference presentations, and be able to display Web-based educational presentations as well. The space is ideally tasked as a confidential space for care transition handoffs and interdisciplinary care planning. A separate space that is more comfortable and less formal may be ideal for family meetings, but the conference space may be used in this way for larger meetings as well. Of course, daily plans and goals of care also may be part of the rounding process to continue to engage the patient in those plans when appropriate.

Assessment of Frailty.

Frailty, defined as physiologic decline across multiple organ systems, making the patient vulnerable to even minor external stressors [12], has a prevalence of nearly 15 percent in those 65 years of age and older and up to 30 percent in patient older than 85 years. Chronic illnesses have been found to worsen frailty significantly, as demonstrated in a study by Bandeen-Roche et al [13]. Within this study, for each chronic condition there was a steep prevalence gradient from robust (or nonfrail) to frail. This increase was most striking for diabetes, heart disease, pulmonary disease, osteoporosis, and stroke. Additionally, those who require assistance in ADLs were significantly more likely to be considered frail than those who lived independently. Non-nursing-home patients who live in residential care settings are twice as likely to be frail than their independent counterparts [13].

Frail older adults are at major risk for postoperative complications. Hence the geriatric population should be assessed, if possible, in the preoperative setting for frailty. There are several instruments to measure frailty. Examples include the timed Up and Go (TUG) test, the Groningen Frailty Index (Table 15.1), and the Edmonton Frailty Scale (EFS), which has been validated in the preoperative setting for elective surgery. An exhaustive review by de Vries et al. identified the Frailty Index as the most suitable instrument as an evaluative outcome measure although there are a large number of other instruments that may be useful [14]. Based on the sound evidence that frail surgical patients do worse than more robust patients, preoperative evaluation should include assessment of frailty for both prognostic and therapeutic considerations. With this evaluation of frailty, patients and families can be appropriately counseled as to realistic outcomes and potential complications. Additionally, from a functional standpoint, those deemed frail may be referred for early and intensive physical therapy evaluation and treatment (i.e., optimization) to improve acute postsurgical outcomes and improve long-term quality of life. Therefore, frailty assessment in geriatric-specific ICUs should be performed on every patient when appropriate to determine a baseline and a care plan consistent with those findings to improve outcomes.

Treatment of Preexisting Conditions.

Many elderly patients present with chronic .preexisting conditions, and many more are found to have previously unrecognized medical conditions such as poorly controlled diabetes, chronic obstructive pulmonary disease (COPD), and coronary artery disease on admission to the ICU. For those with known disease, the intensivist must decide on the advisability of continuing or revising the preexisting regimen. One must weigh the risks and benefits for each medication as well as assess the potential interactions of home medications with the therapeutic agents being used to treat the acute processes that led to the admission. Prime examples include vitamin K antagonists or antiplatelet agents being used for atrial fibrillation or other thromboembolism prevention. Often the decision has already been made prior to elective admission, and the intensivist must instead decide on the timing of resumption of those agents. Having an integrated team structure in the geriatric-focused ICU that includes the surgical team helps facilitate discussions such as those in the table.

Due to the complexities of medication management among the elderly population, a geriatric-focused pharmacist is an ideal ICU team member. The specialized pharmacist may assist in medication reconciliation and appropriate dosing. Pharmacists who specialize in the care of critically ill elderly patients understand the physiologic and pharmacologic changes that accompany aging. Understanding the changes in renal and hepatic function and the effect of these changes on medication clearance assist in the appropriate dosing of such medications. These pharmacists may assist with negative medication interactions and counsel physicians and the care team about adverse reactions that may occur with certain medications among older patients (i.e., benzodiazepines and any number of medications contained on the Beers list). In a study of 90 patients taking five or more medications (excluding those with heart failure), the home medication list was compared with the list proposed by the acute care facility. A total of 1,045 home medications were reviewed, of which 290 discrepancies were noted between what the patients were prescribed preadmission and what the providers believed the patients were prescribed, with the most common discrepancy being dose optimization (45.5 percent). The remainder of the discrepancies included adding therapy (27.6 percent), other (15.2 percent), and discontinuing therapy (11.7 percent). Pharmacists intervened in nearly 50 percent of the cohort with a projected cost saving of more than $2 million in a single facility, assuming an average of 1.6 interventions per patient and an average cost of $8,750 per preventable adverse drug event [15].

Postdischarge medication resumption is a key event that benefits from a systems-based approach. Failure to resume preadmission medications leads to untoward events ranging from withdrawal syndromes, to hyper- or hypoglycemia, to heart failure [16]. Factors associated with this unique failure include rushed discharges, sparse discharge orders, compromised patient or caregiver cognition, and lack of discharge medication counseling and medication reconciliation. A dedicated pharmacist or advanced practice providers can be anticipated to play a key role in the successful transition from inpatient to outpatient for those receiving care in a geriatric-focused ICU [17].

Delirium.

Delirium is defined as an acute change in mental status that waxes and wanes and is due to a generalized medical condition. The incidence of delirium ranges from 14 to 56 percent of all hospitalized patients, and it affects up to 80 percent of patients in ICUs, with a higher incidence among the elderly population. Additionally, delirium is associated with a nearly 33 percent mortality [18].

There are multiple classifications of delirium that include hyperactive, hypoactive, and mixed forms. While hyperactive delirium is easy to identify based on the patient’s frequently agitated state, hypoactive may be more difficult to identify and diagnose. In hypoactive delirium, patients often appear to be sleeping or have a depressed mental status. Thus this form of delirium goes unrecognized and untreated. For these reasons and because delirium is so prevalent among the geriatric population, patients should be assessed for delirium every shift by the nursing staff. Objective measures of delirium should be used to make a formal diagnosis. To diagnose delirium of all types, the patients must maintain a reasonable level of consciousness, as assessed by the Richmond Agitation and Sedation Scale (RASS). Once this has been established, objective methods to evaluate for delirium include the Delirium Rating Scale–Revised (DRS-R), the Intensive Care Delirium Symptoms Checklist (ICDSC), and the Memorial Delirium Assessment Scale (MDAS). However, the Confusion Assessment Method–ICU (CAM-ICU) has become the assessment method of choice in many ICUs due to its ease of administration. These instruments were discussed in greater detail in Chapter 5.

Logically, the best treatment for delirium is the prevention of delirium. There are multiple measures that can be implemented in the geriatric-specific ICU to prevent delirium. Patients with hearing or visual deficits should have access to their hearing aids and eyeglasses. This allows an easier time with patient communication and reorientation as needed. Patients should be routinely reoriented to person, place, date, and time instead of when they are recognized to be disoriented; reclaiming orientation is more difficult than maintaining it in the first place.

Another nonpharmacologic means of delirium prevention is the maintenance of a normal sleep-wake cycle. This can be accomplished with environmental interventions such as shades that can block out ambient light during the evening hours. Televisions should be turned off at night, and when appropriate, doors should be closed to reduce noise from within the nursing station of the ICU. Staff should make a conscious effort to minimize the noise level in the unit to allow for better sleep hygiene. Additionally, adjusting nursing workflow to avoid a scheduled hourly interaction with the patient allows for sleep instead of establishing a night of broken sleep as part of the workflow plan. For example, avoid changing intravenous (IV) tubing at 11 p.m., IV site evaluation and relabeling at 2 a.m., bed bath at 4 a.m., and others and instead move tasks that can be scheduled to occur during waking hours instead of at night. Similarly, morning chest x-rays can be obtained at 6 a.m. instead of 5 a.m., and laboratory draws can occur after the chest x-ray. This may require altering shifts for allied health personnel or adopting some of the work by the unit staff, but it should be an essential part of an overall plan for the geriatric-focused ICU.

Should delirium develop within a geriatric patient, life-threatening yet reversible medical conditions such as hypoxia, sepsis, myocardial infarction, and so on should be quickly identified. Pharmacologic treatment ideally should be a last resort to minimize further consequences of delirium. Staff should differentiate between pain, anxiety, and agitation. Pain should be treated with an appropriate analgesic regimen that may include acetaminophen, opiates, or nonsteroidal agents. Anxiety should be treated with anxiolytics when necessary. Of note, some elderly patients may demonstrate paradoxical agitation instead of sedation when treated with benzodiazepine agents; the at-risk population cannot be more precisely defined at present. Therefore, many recommend using typical or atypical antipsychotic agents as the preferred alternative to benzodiazepines in the elderly. One notable exception is the elderly patient who is already on a regular dose of benzodiazepine, for whom cessation may precipitate withdrawal symptoms; it is unlikely that this patient population will demonstrate paradoxical agitation to continuation therapy [19]. Finally, agitation should be addressed with reassurance and reorientation, with sedatives administered for failure of nonpharmacologic therapy, or to preserve patient or staff safety.