The interdisciplinary team members of a geriatric critical care unit (GCCU) should include physician, nurses, registered dietitian, physical and occupational therapy, respiratory therapy, pharmacist, and family members.
Structural elements of a geriatric-focused intensive care unit (ICU) are meticulously designed to ensure optimal and efficient use of the space that also targets the specific needs of the elderly patients.
A quiet environment at all times of the day is essential to the adequate rest and recovery of elderly patients.
Monitor alarms should be adjusted to patient’s baseline status, and frequency of alarms must be minimized to avoid unwarranted “noise,” which can exacerbate sleep disturbances and potentially increase the frequency of delirium.
Palliative care medicine (PCM) may be ideal to help manage a variety of nonmedical issues experienced by the family, such as guilt, anger, fear, sparse information, unrealistic expectations, misperceptions, life circumstance adjustment, and conflict resolution. Indeed, having a PCM team member regularly round with the ICU team in a geriatric-focused ICU helps enable appropriate medical care.
Postdischarge medication should be resumed as soon as possible because failure to resume preadmission medications leads to untoward events, ranging from withdrawal syndromes, to hyper- or hypoglycemia, to heart failure.
The geriatric population, defined as patients 65 years of age and older, is growing at an unprecedented rate within the United States and other Western nations. This population has experienced a nearly 25 percent increase from 2003 to 2013 (35.9 million in 2003 to 44.7 million in 2013). This population is expected to double to nearly 98 million by 2060. The geriatric population will make up 21.4 percent of the US population by 2040. The “older” geriatric population (85 years of age and older) is expected to triple from 6.1 million in 2013 to 14.6 million in 2040 . As this “Silver Tsunami” approaches, it is critical to thoroughly understand this population and the medical complexities inherent to it in order to optimize care of critically ill elderly patients.
The correlation between chronologic and physiologic age is not necessarily linear. By way of example, Ma et al. investigated the correlation between aging and insulin secretion and demonstrated a decline from maturation to approximately 45 years of age, with stabilization in decline until after 55 years of age, followed by a further decline . The accumulation of various physiologic conditions and medical diseases that may be either spontaneous (genetic mutations) or acquired (external exposures) may accelerate one’s physiologic age in relation to chronologic age. The interactions and processes that influence how an individual is affected by the accumulation of physiologic insults is complex and poorly understood. Accelerated physiologic age is likely to diminish the reserve with which one may address further challenges such as septic shock, injury, or stroke; of course, the inverse is also true and may augment recovery at an unexpectedly rapid pace. This discrepancy in both chronologic and physiologic ages results in differences in morbidity and mortality among cohorts and appears to be more pronounced among the elderly.
Elderly patients with a more advanced physiologic age may be described as being more frail than those with a “younger” physiologic age. Frailty has a variety of dimensions and definitions, but common features of frailty include weight loss, decreased strength, exhaustion, slowness, and reduced activity level . Other dimensions associated with frailty include cognitive impairment, falls, anemia, and increased numbers of identified comorbidities . This state of weakness leads one to be vulnerable to various stressors and may be manifested as healthcare-related morbidity and mortality, including worse perioperative outcomes [5–8]. Multiple instruments that assess frailty have been developed to objectively assess for frailty. The Comprehensive Geriatric Assessment (CGA) encompasses all areas of geriatric frailty, including cognitive function, mobility, activities of daily living (ADLs) functioning, mood, and nutrition. Because the CGA is labor intensive, other shorter questionnaires have been developed to assess frailty in elderly individuals and include the Hopkins Frailty Score, the Edmonton Frail Scale, and the Groningen Frailty Indicator (GFI). One study demonstrated that a score of greater than 3 on the GFI is associated with increased in-hospital mortality, increased serious complications, and increased hospital length of stay . These instruments to assess frailty are invaluable in assessing operative risk so as to appropriately inform patients and families of associated risks with operative intervention.
Due to the unique aspects of the elderly population, including significant differences in physiologic age that may not correspond to chronologic age and the associated frailty, the elderly population requires special consideration to optimize outcomes after illness or surgical interventions and avoid nonbeneficial outcomes such as organ failure, nursing home residence, cognitive failure, chronic pain, failed obligations, long length of stay, and death in a chronic care facility . Much as in other domains where targeted teams with focused areas of excellence have improved outcomes, geriatric critical care follows suit.
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.
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.
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.
Due to the complexities of the elderly surgical patient who requires intensive care in the perioperative period, multiple teams and care providers are crucial to the comprehensive care of these patients. This team approach ensures that every aspect of the patient’s care is optimized. Ideally, a representative from each discipline having an impact on care would be present on rounds to ensure that their domain issues are addressed and incorporated seamlessly into the daily overall care plan. Recognizing that some members may be incorporated into teams in more than one ICU, a mechanism to communicate plans and queries to team members who cannot attend rounds is essential. White boards, glass door panels, and goals sheets (electronic and paper) have all been used successfully.
Interprofessional rounds should include, but are not limited to, physician, nurses, registered dietitian, physical and occupational therapy, respiratory therapy, pharmacist, and family members who are integral to the care of each elderly patient. Input from each team member is necessary to ensure that a single, congruent plan is developed. This prevents potential breakdowns in communication between different team members, allows each team member to voice their specific plans for the day, and addresses any questions/concerns associated with each patient’s care plan.
Family involvement in daily rounds as members of the care team is also beneficial. Incorporation of the family not only ensures that the daily care plan is clearly communicated but also allows real-time discussion and problem solving among other members of the team and the family. The elaboration of goals of care is facilitated by having an engaged and informed family. In fact, such discussions may be incorporated into rounds and eliminate the potential stigma associated with the “afternoon family meeting.” Moreover, having direct family communication on rounds appears to reduce the number of nurse phone calls during the day for information gathering, thus allowing more time for the bedside care. Designating a spokesperson helps facilitate intrafamily communication as well. Since the geriatric-focused ICU will likely use several consultants on a regular basis, having the abundance of information funneled to the family at a regular time is not only efficient but also sets reasonable expectations for the patient (when they can participate), the family, and team members. Teams expand when there are concomitant medical conditions requiring specialist evaluation that are not the primary reason for admission.
Elderly patients who require intensive care for various surgical issues often have a long list of preexisting medical conditions that complicate the care of the presenting problem. Additionally, patients with serious surgical disease processes may do so with little to no previous medical attention, leading to new diagnoses of a variety of preexisting but undiagnosed conditions. Therefore, the newly diagnosed medical comorbidities are often poorly controlled and make management of the presenting surgical disease process much more difficult. That the elderly, even at an advanced age, substantially engage with surgical services is illustrated by an exploration of Medicare decedents who in 2008 (n = 1,802,029 patients) were parsed by those who had surgery within 1 year (31.9 percent), 1 month (18.8 percent), and 1 week (8 percent) of their death . Decedents spanned 65 to 98 years of age. Not surprisingly, those who were operated on had a longer ICU stay and hospital length of stay, were more frequently readmitted, and did so at a higher total cost. The ability to tolerate and recover from surgical management is influenced by comorbidities and their impact on the elderly patient – an analysis that can potentially be assessed using a frailty metric.
Frailty, defined as physiologic decline across multiple organ systems, making the patient vulnerable to even minor external stressors , 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 . 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 .
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 . 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.
Can the person perform the following tasks without assistance:
|Vision||Does the patient encounter problems due to impaired vision?|
|Hearing||Does the patient encounter problems due to impaired hearing?|
|Nutrition||Has the patient undergone unintentional weight loss over the past 6 months (6 kg/6 months or 3 kg/3 months)?|
|Comorbidity||Does the patient use four or more types of medications?|
|Cognition||Does the patient have problems or complaints about memory?|
|Physical fitness||How would the patient rate their own physical fitness (0–10; 0=very bad, 10=very good)?|
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 .
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 . 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 .
Assessment of Pain and 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 .
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 . Finally, agitation should be addressed with reassurance and reorientation, with sedatives administered for failure of nonpharmacologic therapy, or to preserve patient or staff safety.