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Caring for older adults in the ICU
733 Plays7 days ago
In this episode, Dr. Sergio Zanotti discusses the care of older adults in the ICU. He is joined by Dr. Lauren Ferrante, a pulmonary critical care physician in the medical intensive care unit at Yale New Haven Hospital. She is an Associate Professor of Medicine at the Yale School of Medicine and serves as Director, Operations Core, at the Yale Claude D. Pepper Older Americans Independence Center. Dr. Ferrante is the lead author of the recently published “Society of Critical Care Medicine Guidelines on Caring for Older Adults in the ICU."
Additional resources:
American Geriatric Society Beers Criteria (Pocket Guide)
Books mentioned in this episode:
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine. Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com. And now your host,
The Unique Needs of Older Adults in ICU
00:00:28
Speaker
Dr. Sergio Zanotti.
00:00:32
Speaker
Older adults make up a substantial share of patients admitted to the ICU. As the share of the general population age 65 and older continues to grow, this age group's representation in our ICUs will increase.
00:00:45
Speaker
In today's episode, we will discuss the care of older adults in the ICU. Our guest is Dr. Lauren Ferrante, a pulmonary critical care physician in the medical intensive care unit at Yale New Haven Hospital.
00:00:57
Speaker
She's an associate professor of medicine at the Yale School of Medicine and serves as director for operations core at the Yale Claude D. Pepper Older Americans Independence Center. Dr. Ferrante is a recognized clinician, educator, and researcher with a special interest in understanding and improving the functional outcomes of older patients in the intensive care units.
00:01:18
Speaker
Dr. Ferrante is the lead author of the recently published Society of Critical Care Medicine Guidelines on Caring for Older Adults in the ICU. Lauren, welcome to Critical Matters. Thanks so much for having me, Sergio. Happy to be here.
00:01:34
Speaker
I would like to start with you telling us why should our listeners care about this topic of older adults in the ICU?
Challenges Faced by Older ICU Patients
00:01:41
Speaker
Yeah, that's a great question and a great place to start. So I think we all know that you know when we're taking care of patients in the ICU, that a substantial proportion of them are older. um In fact, you know it's been quarter century since there was a ah paper published saying that among all ICU days, more than half of them are incurred by older adults.
00:02:04
Speaker
And that number is just going to continue to increase as the population ages. You know, the older adult population is is going to exponentially increase. up It's expected through 2050. so if you think about...
00:02:19
Speaker
just how many older adults are in the ICU and the unique care that um they often require in many ways. So because they're presenting with unique conditions like frailty, multimorbidity, disability, they're more likely to have these conditions since these are age-related conditions that increase in prevalence over time.
00:02:38
Speaker
um The care of older adults is really everyone's responsibility. There aren't enough geriatricians you know to see every older adult that we have in the ICU. And so it's really critical that we, um who are all professionals who are caring for older adults in the icu um learn how to best care for older adults.
00:03:01
Speaker
How would you define an older adult in the ICU?
00:03:06
Speaker
So older adults are traditionally defined as those who are age 65 years or older. um You know, if you talk to aging focused experts or the National Institute on Aging, for example, there are conditions where we see accelerated aging. a good example is HIV, where somebody who is older might actually be younger than that absolute cutoff. But generally, when we're talking about older adults and for this guideline that we're going to talk about today, we define older adults as those age 65 and older.
00:03:41
Speaker
and that's a widely used definition. And what is different about a critically ah older adult patient? and You mentioned frailty. Can you also mention or talk about some of the en increased risk of harms of the things we do every day and other important aspects of this population?
00:03:58
Speaker
Absolutely. So there are two way two important aspects to thinking about the unique conditions and needs of older adults. So first is who is the person who's presenting to the ICU and how do the conditions they're presenting with um affect their likelihood of having certain outcomes?
00:04:21
Speaker
And so a few years ago in 2022, we collaborated with colleagues from UCSF to look at whether age-related conditions are increasing in prevalence over time. And those conditions that we were interested in were frailty, multimorbidity,
00:04:39
Speaker
disability and functional activities, and dementia. And what we found ah using data from the Health and Retirement Study is that age these age-related conditions, specifically frailty, multimorbidity, and disability and functional activities, were increasing in prevalence over time.
00:05:00
Speaker
And so when an older adult presents to the ICU and they have one or more of those conditions, their likelihood of experiencing, um for example, poor outcomes in the ICU or after the ICU goes up.
00:05:15
Speaker
But that doesn't mean um you know that we can't intervene um or take better care
Goals and Guidelines for Older Adults in ICU
00:05:22
Speaker
of them. It just means that we have to have an eye ah to the fact that they have these conditions. We might need to and consider them in our goals of care conversations, for example, but also we need to be mindful of them because they might need some extra attention when we're thinking about their post-ICU follow-up.
00:05:40
Speaker
The other and second part um is how an older adult um is at increased risk of certain downsides to being in the ICU itself. So the actual physical ICU environment, um you know, during their critical illness.
00:05:59
Speaker
And so, you know, older adults are more likely to have certain conditions such as sensory impairment. For example, a majority of people over the age of 70 have hearing impairments.
00:06:11
Speaker
um and hearing loss. And so you can imagine if you're an older adult in the ICU, ICU is a noisy place, there's alarms, you're out of your comfortable home environment, you're getting medications you don't normally get, it's very disorienting. Older adults are at a much higher risk of experiencing delirium.
00:06:33
Speaker
And we know that delirium is also associated with poor outcomes during and after the ICU. um The immobility harms of the ICU also could lead to more rapid functional decline in older adults. And so if they're at greater risk, you know, also just from being in the ICU environment than younger patients.
00:06:54
Speaker
One of the aspects of critical care that has become very relevant to to us intensivists is to really understand what goal concordant care means, especially critically ill patients.
00:07:07
Speaker
What do older patients value the most, Lauren? That is such an important question, Sergio. Thank you for asking that. um So actually a very large body of research done by other other investigators, this is not part of my body of work, um a very robust body of evidence shows that older adults really value maintaining functional independence above all other outcomes. And so this has been known for a while in the geriatrics literature. There were some recent studies done ah in you know the i see the general ICU population that also supported this. But among older adults, even when they're asked to rate health outcome priorities, um
00:07:54
Speaker
including survival. so when they're asked to rate maintaining functional independence, survival, freedom from symptoms and other health health outcome priorities, more than three quarters of them ah rated maintaining functional independence as their most important health outcome priority. And only about 10% rated staying alive as their most important health outcome outcome priority.
00:08:20
Speaker
and And I think that's a very important piece of information that can frame not only our discussion today, but also frame how we we we interact and how we engage with our older patients in in the ICU. And it's also something that and for all of the ah of those who have aging parents is important to to remember because i do believe that as physicians and clinicians, we tend to prioritize safety.
00:08:50
Speaker
as opposed to independence. And sometimes those can be in conflict, correct? They can, they can sometimes. And and also it's it's helpful to have that longer term lens when speaking to patients and families about someone's goals.
Developing Guidelines for Older ICU Patients
00:09:07
Speaker
You know, so many times I think we're focused on what we can do in this moment. um And, you know, if but we all try to elicit goals of care when someone's admitted to the ICU, but perhaps, you know, in somebody where they're not having a clear trajectory within the first couple of days and, you know, things are getting more complicated, it's probably worth revisiting those goals and making sure that what we're doing is concordant with what the patient is hoping for in terms of their long-term functional recovery.
00:09:37
Speaker
Excellent. I would like to dive into the guidelines themselves. and We will use this as our framework to talk about this topic today. And as the lead author and chair, could you provide an overview at a high level of the guideline development and a little bit ah related to the methodology?
00:09:56
Speaker
Absolutely, yes. So the Caring for Older Adults in the ICU guideline is a new Society of Critical Care Medicine guideline. it was funded by the SCCM, but the American Geriatric Society sponsored the guideline and had a representative on the panel. And the guideline, um after the final version was created, was also endorsed by the American Thoracic Society.
00:10:22
Speaker
And so what we did was we first composed a panel that was interprofessional. um It also importantly included a patient representative who was an older survivor of critical illness.
00:10:35
Speaker
And we had two methodologists from the guide group at McMaster supporting guideline development. And I do want to highlight ah that my co-chairs were Nathan Bremel from The Ohio State and Bram Rochberg from McMaster.
00:10:50
Speaker
And what we did was we first voted on outcomes of importance ah that were critical or important to decision making. And as you can see in the guideline, some of the things we've talked about already were rated as very important outcomes. So for example, functional outcomes. Those were considered and voted upon in addition to more traditional outcomes like mortality.
00:11:16
Speaker
We also ah created a list of PICO questions. So we were limited to five by the SCCM as a new guideline. We generated 19 PICO questions and then the top five were selected by panel voting.
00:11:32
Speaker
And then for each question, a systematic, a structured systematic review of clinical trials only was conducted with the support of a medical librarian. um And then you probably heard about this recently in some of your other podcasts, but we used grade methodology, including the evidence to decision framework to develop the recommendations.
00:11:55
Speaker
um and I do want to highlight that grade methodology is really the most robust methodology for guideline development. um Some guidelines use you know a Delphi process with expert opinion. Grade is really a very rigorous method where you know the methodologists are pooling um results from the trials that fit the PICO question and we look at the pooled meta-analyses during the evidence to decision meetings.
00:12:24
Speaker
um and then generate strong versus conditional recommendations or importantly, a no recommendation statement in some consider in some instances.
00:12:37
Speaker
And i I think it's important to to recognize also that guidelines work within the confines of the available data. And a lot of times they will create more questions, but it's an iterative process, right? These guidelines will hopefully lead the way in what new research needs to be done. As that research gets done, the guidelines get updated. And that's the way that we
Recommendations and Research Gaps for Older Adults in ICU
00:12:59
Speaker
advance this conversation.
00:13:01
Speaker
Absolutely. That's really important. So you know in this guideline, we had two conditional recommendations and three no recommendation statements. But we actually learned a lot and and have there's a path forward for each of these PICOs, and each one of those advanced the science. And so just to touch on the strong versus conditional, you know we are to generate those recommendations. we For every PICO question, we consider the balance of desirable and undesirable effects, certainty of the evidence, um and then other factors like patients' values and preferences, resource considerations, feasibility, acceptability, equity. And you're kind of downgrading or upgrading recommendations based on each of those factors.
00:13:46
Speaker
um And if there isn't a very large body of evidence in a certain area to inform a PICO question, um you know, this is how we came up with two conditional recommendations, just because I think in both situations, there was a little bit of a lower certainty in evidence. There was still enough for us to make a recommendation, um but you know we did set a research agenda as part of this guideline because as we worked through these evidence to decision summaries for each PICO, we could see where future research needed to be done to inform the next iteration of this guideline.
00:14:26
Speaker
Let's dive into the actual PICO questions that were utilized for the guideline. And Lauren, what I would ask is I'll ask the PICO question as was stated by the the guideline committee.
00:14:36
Speaker
And if you could share with us the actual recommendation and then a discussion on the rationale, and then there might be other m further questions that that we can talk about on each one of these topics.
00:14:49
Speaker
So great let's go with question number equalco question number one was, should older adults with critical illness receive geriatrics consultation or a geriatric model of care upon ICU admission?
00:15:04
Speaker
So and for this PICO question, the panel generated a conditional recommendation, which stated, we suggest a geriatric model of care for all older adults admitted to the ICU.
00:15:16
Speaker
it And to address this question, we incorporated data examining a geriatric specific model of care or formal geriatrics consultation um and patients with critical illness. And we found two randomized control trials and one pilot trial. um And we also, for this question, considered indirect evidence from other inpatient locations, like ah such as trauma, surgical burn units, et cetera.
00:15:44
Speaker
um The panel considered the balance of uncertain effects from trials, which is how we ended up with a conditional recommendation, but also really noted the point estimates in the pooled meta-analyses that favor the inclusion of geriatrics principles and also noted the trivial um risk of undesirable effects of geriatric consultation or models of care.
00:16:09
Speaker
And so this is how we came up with the conditional recommendation in favor of a geriatric model of care for all older adults admitted to the ICU.
00:16:19
Speaker
And could you explain a little bit what a geriatric model of care might be? Yes, that is a great question. I was hoping you were going to ask that. So geriatric models of care, just taking a step back, have actually had a very large and robust body of evidence, including multiple randomized clinical trials in hospitalized older adults on the ward since the mid-1990s.
00:16:47
Speaker
Geriatric models of care are multi-component models of care that are implemented with an eye towards maintaining functional independence and preventing functional decline while an older adult is in the hospital.
00:17:01
Speaker
And so... By multi-component, ah I will just kind of run through a couple of those components. So first of all, the team, again, is very much focused on getting the older adult back home, maintaining functional independence, minimizing functional decline. And to that end, they have what's called a prepared environment where the environment is physically change. So for example, on a hospital ward, they widen the hallways, they they make sure the hallways are clutter free to allow patients to mobilize more frequently to mitigate functional decline in the hospital. They perform daily medication reviews to see if harmful medications can be deprescribed. So for older adults, there's a list of medications called the BEERS criteria where they that the BEERS criteria identifies medications that are harmful for older adults. And so, um, deprescribing those harmful medications is another aspect of geriatric models of care. Um, to prevent delirium, they, um, also have Things like sleep protocols to make sure patients are awake during the day, sleeping at night, that there's frequent orientation happening. So large whiteboards with orienting information, um portable hearing amplifiers if somebody cannot hear. As I mentioned to you, a majority of ah people who are age 70 and older have hearing loss.
00:18:28
Speaker
um And so those are those are just some examples. And to make this you know easier for ICUs to adapt, we published an implementation toolkit on the SCCM um website with the guideline, concurrently with the guideline. And so if you go to that implementation toolkit for the geriatric model of care, you can click the components that your ICU has to see how you might implement those. And I should highlight that the beneficial effects of implementing geriatric models of care in older adults on the ward were actually seen, even if only a few components were implemented, it didn't necessarily have to be every single component.
00:19:12
Speaker
and And I would imagine, Lauren, from what you're sharing, that this is very similar and can be integrated into the ICU liberation, ABCDF bundle, just when we have patients who are older to make sure that we add some of these components and that we are...
00:19:29
Speaker
targeting by design and with intention a couple of things that may make a huge difference for them and we will definitely link and in the show notes the implementation toolkit that that is wonderful because there's no excuse right if you don't have a geometrician rounding with you there are still a couple of things that you can implement that can make a huge difference for this patient population but Absolutely. And as we talked about, it's really not feasible. You know, the geriatrician workforce is very limited in size and there is there's just no way that they can see all older adults who are present in the ICU. And so it's really kind of incumbent upon us all to learn these principles and how to implement these geriatric models of care.
00:20:12
Speaker
Excellent. PICO question number two in the guidelines reads, should older patients who survived critical illness be referred to specialized post-ICU outpatient follow-up?
00:20:26
Speaker
So for this PICO question, the panel um stated, we make no recommendation regarding specialized post-ICU follow-up for older survivors of critical illness.
00:20:38
Speaker
And i will walk through how we came to that no recommendation statement. So we found 24 randomized control trials for this PICO question, but none were done specifically in older adults.
00:20:51
Speaker
We contacted the authors of the 24 RCTs for subgroup data by age, um and we were sent data from five of those randomized control trials.
00:21:03
Speaker
So in the pooled analyses with those five trials, there was an uncertain effect on all of the outcomes that we looked at, including mortality, health-related quality of life, the SF36 physical and mental health components, respectively, and the hospital anxiety and depression scale.
00:21:24
Speaker
and There was also a lot of heterogeneity in the post-ICU interventions. Many of the randomized controlled trials didn't specify intervention components or really comment on fidelity. And so with all of that in mind, the panel really could not make a recommendation, um you know, but we did note in our table where future areas of research, you know, might be recommended.
00:21:50
Speaker
would be needed just to kind of look at this, especially considering um a study that would be conducted exclusively in older adults. There's an increased recognition in critical care of how difficult the road is for survivors once they leave the ICU. And a lot of institutions have it really focused on post-intensive care syndrome and it picks at clinics.
00:22:15
Speaker
And even though we don't have all the data and the studies we want, this is still ah obviously an area of interest and there might be specific things that we need to learn and do for our older patients. So we definitely will need to keep an eye on what comes out in research in terms of this area.
00:22:32
Speaker
Absolutely.
00:22:36
Speaker
Moving on to PICO question number three relates to MAP targets and shock. And the question reads, should we aim for a lower mean arterial pressure target of 60 to 65 millimeters of mercury compared with usual care, equal above 65 millimeters of mercury as a target in older patients with vasodilatory shock?
00:23:00
Speaker
Yes. So for this PICO, the panel stated for older adults age 65 and older with vasodilatory shock, we make no recommendation with regards to targeting a mean arterial pressure of 60 to 65 as compared to usual care defined as a MAP target greater than 65 millimeters of mercury.
00:23:21
Speaker
And so for this PICO question, when we looked at the literature, we could only identify one randomized controlled trial that addressed this specific question.
00:23:32
Speaker
And looking at that one trial, there was and was a negative trial. So there was an uncertain effect on 28-day mortality, mortality at longest follow-up, quality of life, cognitive impairment, duration of invasive mechanical ventilation, hospital length of stay, need for RRT, and risk of serious adverse events.
00:23:52
Speaker
um Although it was a negative trial after adjustment for covariates, there was a signal towards decreased mortality. But the primary analysis was negative. And more importantly, with one randomized controlled trial um and the very low certainty of evidence, the panel felt that it could not make a recommendation for the intervention agreed that further research was needed.
00:24:16
Speaker
um We did note that patients in the lower MAP target group had less exposure to vasopressors, which of course could be considered a positive. But even with this trial being very high quality, the fact that it was only one and that making a recommendation for a lower MAP target in a guideline statement based on one trial was not something the panel was comfortable with, especially because it could change practice around the world.
00:24:43
Speaker
And so we really felt that future research was needed ah to more thoroughly address this question for older adults. Lauren, any comments i on the recommendation the Surviving Sepsis Campaign made in this area?
00:24:59
Speaker
Yeah, so I did see that. We both presented our guidelines at the Society of Critical Care Medicine meeting. um And, you know, I was not, I did not serve on that guideline panel, so I was not part of the evidence decision summary meeting. um i Can't imagine that other trials were found that we didn't find, but I suppose that that is possible. And I have not yet looked at their evidence to decision summary. But, you know, at least for this panel that was focused entirely on older adults, we did not feel that there was enough evidence to make ah to change the current standard of care in terms of MAC targets for older adults. um
00:25:43
Speaker
and that more research would be needed. and I'm sure the surviving sepsis panel would you know but never disagree that more research is needed in a given area. So that's all I can really say about that. And I think it's it's it's interesting because we were talking about it and we talked about it in the previous previous episode. And the truth is that The Surviving Justice Campaign guidelines did not give a strong recommendation, but they're opening the door to that there might be groups of patients in whom a lower target may be may be considered.
00:26:15
Speaker
But again, i do i do agree that the need for more research is recognized by by all. it But it's also... yeah Sorry, go ahead. Oh, sorry, go ahead.
00:26:27
Speaker
I was just going to say, you know, i think that I think that's an important point, certain groups, right? And I think well what concerns us is that we don't want to make a blanket statement for all older adults, age 65 and older with vasodilatory shock because, know, You know, if you worry, if you think about that, that's like that's a huge, huge swath of the ICU population, as we've already discussed.
00:26:49
Speaker
There's so much heterogeneity in that group. There's a higher prevalence of hypertension, for example, and I i would be worried about relative hypotension and the risk of um adverse events there, for example. Like, you know, and and I realized this one trial, you know, it was a negative trial even in terms of those secondary outcomes. But if you think about the heterogeneity among the older adult population, if we have a larger, you know, with one trial, it's hard you may just not have had a large enough sample size to see adverse effects from relative hypotension. and so that, that was our concern that just with one trial and making it, you know,
00:27:31
Speaker
The older adult population is such a huge part, um a huge and heterogeneous part of the ice component of the IC population that we just weren't there yet And I agree. and And ultimately, I just bring it up just to illustrate also the complexities of creating guidelines, the complexity of care we provide, right? There's so many so much more questions than answers, but it's something that as clinicians, we should always be grappling. We should not be certain, right? We should always be questioning at the bedside, am I doing the right thing for this patient that I'm carrying? And
00:28:07
Speaker
It ultimately illustrates from my perspective the the fact that also through how you interpret the literature also depends on what question are you trying to answer and through what lens are you looking at it, right? And you were very focused on creating an environment that focuses on our older patients. And and and and I do agree. I mean, I see where where the guideline committee came through with this recommendation, but just important for for our discussion.
00:28:37
Speaker
Thanks for this comment. Yeah. the The fourth a question that the guidelines addressed reads, should older patients admitted to the ICU receive antipsychotics for the prevention of delirium?
00:28:53
Speaker
Yes. So for this PICO, the panel made a conditional recommendation stating, we suggest not using antipsychotic medications for the prevention of delirium in and older adults with critical illness.
00:29:08
Speaker
and so For this PICO question, um we were able to find three randomized control trials that investigated specifically haloperidol and pitiopine for the prevention of delirium in adults with critical illness.
00:29:22
Speaker
um Importantly, no study reporting data on older adults were conducted nor were subgroup data available. But we still looked at the pooled results and we found that prophylactic antipsychotic administration had an uncertain effect on the in this PICO we looked at incidents and duration of delirium, mortality, duration of ah invasive mechanical ventilation, lengths of stay and adverse effects.
00:29:50
Speaker
However, the panel here discussed widespread issues with the known harms in older adults of antipsychotics, i talking a lot also about the Beers criteria, as we discussed earlier in this podcast, and also discussed widespread issues with inappropriate prescription and continuation of antipsychotics during and after um the ICU.
00:30:13
Speaker
And so given the known harms in older adults and these issues with inappropriate prescription and continuation of antipsychotics, the panel recommended against using antipsychotic medications routinely for the prevention of delirium in older adults in the ICU and framed this as a conditional recommendation.
00:30:34
Speaker
And we all recognize the importance of delirium in terms of patient outcomes, morbidity, and increased mortality can cause. We also, i think as clinicians at the bedside, have been frustrating from the lack of true treatments for delirium. But prevention is something that we can do. And even though the recommendation around antipsychotics couldn't be, I mean, we we don't really recommend that.
00:30:58
Speaker
Could you tell us what works for prevention of delirium or what what do you utilize in your practice in older and older patients? Yes, absolutely. That's a really important question. So I do want to highlight that, you know, I would say prevention, our goal is to prevent delirium in all patients in the ICU, right? Like i once somebody is delirious, it's much harder, I think, to ah to break that cycle. um And so for older adults, there is actually a lot of evidence showing that non-pharmacologic interventions work for the prevention of delirium A great example of that is Sharon Inouye's help program, the Hospital Elder Life Program, which actually you could call one of those geriatric models of care that we talked about earlier. um And that program really focuses on um doing a number of things that we can certainly do in the ICU. And so, for example, in my practice, um
00:31:56
Speaker
You know, when I see an older patient, I'm always very tuned in as to whether they have sensory impairment and they might need a portable amplifier so that they can hear me or if they have hearing aids, whether they're in and on, um if they have glasses, if they're visually impaired, ah just because sensory deprivation can increase the risk of delirium.
00:32:18
Speaker
I walk around the ICU and as I'm seeing my patients, I spend a lot of time opening window shades and talking to our staff just to make sure that during the day people are not napping all day. That still happens more than I would like it to. i will be honest with you. i mean, a short nap is okay, but we definitely don't want our patients sleeping all day. um and the lights should be on and the window shades should be up um during the day. And we should you know allow them to sleep overnight as clinical care allows for. um
00:32:49
Speaker
I never use benzodiazepines. I mean, you know, except in certain, for example, something like alcohol withdrawal, maybe, you know, like a specific condition where they're indicated, but just for routine sedation,
00:33:02
Speaker
um i I really avoid them, and that's actually true for all patients, but especially for older adults. They are so just deliriogenic medications, and just avoiding them entirely is just the better way to go.
00:33:16
Speaker
um we have an early mobility program in our ICU, which I run since we started it 10 years ago. and we screen and mobilize our older ICU patients the same way we screen and mobilize all of our patients in the icu So irrespective of age, they're getting screened for mobility from admission, and then we start to mobilize them um as early as we possibly can.
00:33:41
Speaker
um And so those are just some examples ah of you know how these non-pharmacologic strategies can actually help prevent delirium.
00:33:53
Speaker
Excellent. And the last question on the on the PICO questions of the guidelines is similar, but relates to treatment. So should older patients admitted to the ICU receive antipsychotics for treatment of delirium?
00:34:08
Speaker
Yes, so for this PICO question, the panel stated, we make no recommendation regarding the use of antipsychotic medication and the treatment of delirium in older adults with critical illness.
00:34:20
Speaker
And so for this PICO, we found um six randomized control trials that investigated this question, and we were able to obtain subgroup data on older adults from two RCTs that investigated haloperidol compared to placebo.
00:34:37
Speaker
We found um that there was an uncertain effect on delirium and coma-free days, on hospital length of stay, duration of invasive mechanical ventilation, et cetera.
00:34:48
Speaker
um Because of the aid ICU trial being part of this whole meta-analysis, we did find a possible reduction in mortality, um low certainty. um and there was, you know, in the in the discussion, we we looked at, the pooled analyses and and all of this data and considered that um There was really an unclear balance of effects and also the fact that in this case, we did not have subgroup data or stratified analyses of older adults from all of six of the RCTs from which we could draw firmer conclusions. and so In light of all that, plus considering you know the harms of antipsychotics, we've already talked about, the panel could make no recommendation in this area.
00:35:37
Speaker
And you know I'll just say, like as we as I noted earlier, we generated a research agenda as we worked through the evidence to decision summaries. and And one thing that came up is if we as a field are going to continue to do trials of antipsychotics for the treatment of delirium, um it might be time you know we really should be making sure we have um better inclusion of older adults, not just for these trials, but I think for all clinical trials because, but or exclusively enrolling older adults, but you know, we we having more data here really would have helped a lot in terms of being able to make a recommendation one way or another. But right now, just considering the balance of everything I described, we could really just make no recommendation.
00:36:25
Speaker
And this remains a ah big challenge for all patients in the ICU. What do we really do to treat delirium, right? I mean, we talked about some interventions that work for prevention, and we should be very focused on that. And I do still believe that recognizing delirium is is very important in the first step when it occurs.
00:36:43
Speaker
But treatment has been still elusive, I guess, in terms of Yeah.
00:36:49
Speaker
Exactly. And, you know, one thing that we talked about, and you'll see it as the very first um thing that we're calling for in the research agenda, it's it's probably time to have a trial that is exclusively enrolling older adults in the ICU and to look at different treatment strategies, you know, for the treatment of delirium.
00:37:08
Speaker
So... Well, let's let's talk about the future research agenda. And as you mentioned, one of the big in advantages or or outcomes of doing these these guidelines and reviewing the literature in depth is that we identify potential holes or areas where we could focus our our efforts.
00:37:29
Speaker
But what are some of the key areas for future research in older adults in the ICU? Yes, that's a great question. And so for anybody who's listening to this podcast and ends up, you know, pulling the main guideline manuscript, you could find our research agenda in this entirety in table three um in the main manuscript. um And so some, we you could see that we've called for a lot of different areas. so I'll just highlight a few. The first one is to really have more studies that look at the impact of geriatric models of care in the ICU.
00:38:02
Speaker
um We noted that there is a very big push right now towards the age-friendly health systems model. um Many of you are probably aware that the Center for Medicare and Medicaid Services now requires hospitals to attest how they are capturing the four M's of age-friendly care in their inpatient quality reporting, the four M's being what matters, medication, mentation, and mobility. um and And we believe that, you know, the future right now, it's just an attestation requirement, but in the future, it's probably gonna be tied to payment.
00:38:36
Speaker
um And so we think there's actually gonna be a lot of interest in this space and looking at how, you know, inpatient care incorporates geriatric models. So that's one area. um As we already talked about, we thought it would be very important to do more trials of MAP targets, ah specifically in older adults, just because it is such a heterogeneous group. We want to be sure that we're not causing harm um due to relative hypotension. um We, again, did highlight that it is probably time and overdue for trials that exclusively enroll older adults in the ICU, especially in certain key areas, so not just the map target area, but also you know different strategies for the treatment of delirium. um And that those studies that exclusively enroll patients age 65 and older, that that work probably also does need to be done in terms of post-ICU outpatient follow-up.
Individualized Care for Older Patients
00:39:37
Speaker
um We found in our own work that older adults are generally pretty well plugged in with their doctors and medication management, but there are many other areas where they need extra attention in terms of post-ICU care.
00:39:51
Speaker
um And so again, a large trial enrolling just patients 18 and older is probably, you know, there's been a number of those, but it's probably time for a trial or trials that are looking just at those age 65 and older.
00:40:06
Speaker
Excellent. Are there any ongoing studies that you're aware of that you're excited about? um Yes, well, I guess I could tell you about one of ours. So we actually, one of the um geriatric models of care studies that we that was included in the pooled meta-analysis for the first PICO question was a pilot trial that we did where patients you know, recognizing how successful geriatric models of care have been on the hospital ward, but also recognizing we have some components of those models in the ABCDEF bundle, i had mapped the two onto each other and identified three interventions that we could deliver as a geriatrics bundle in the ICU. um And those three components of the intervention were giving everyone a portable hearing, older adults specifically, this is a trial ah conducted among those age 65 and older in the ICU. The intervention group got a portable hearing amplifier to treat hearing loss. There was a deprescribing intervention by ICU pharmacy where they used their training that they already had in the Beers criteria from pharmacy school to deprescribe and potentially inappropriate medications. in older ICU patients.
00:41:29
Speaker
um And older ICU patients also got occupational therapy as a default because occupational therapy focuses a lot on function. So things like ADLs, IADLs, cognitive function. um it's a different lens and a kind of a key part of care in those geriatric models that we've discussed.
00:41:49
Speaker
And so we delivered those three interventions as a geriatrics bundle and showed, um at least in a preliminary way, this being a pilot trial, that ah the effect was less delirium.
00:42:02
Speaker
And so we've written the and submitted the larger trial for that. um But, you know, hopefully our study is funded by, you know, but also I think we'd love to see more studies in this area. um i hope that we'll have many more um Yeah, so that's one study, you know, that we have completed the pilot, but now we're going to be looking to do a larger trial.
00:42:23
Speaker
Great. And plenty of opportunity for for great studies. And like you mentioned at the introduction, this is not only a very prevalent group of patients in our ICUs, but it's only going to get larger.
00:42:37
Speaker
And I do believe that being more intentional and trying to answer these questions can make a huge difference or and for our patients. Lauren, i would I would like to end with some practical advice. This is aria obviously an area of interest for your research, but also you're a practicing intensivist.
00:42:58
Speaker
Could you share pitfalls to avoid when caring for older patients in the ICU?
00:43:05
Speaker
Yes. um So I think a very important pitfall, and I wish I could show you a picture. I'll try to describe it. There are so many times where I think...
00:43:18
Speaker
you know into I see professionals, or whatever, you know all across all interprofessionals. like We look at the person in front of us who's in a hospital gown and under a white sheet, and we make presumptions based on the age of a person just by looking at them.
00:43:37
Speaker
And if you, you know, that you one thing I always try to like teach trainees and mentees is that you cannot assess age-related conditions such as frailty or, you know, cognitive impairment or any of these things just by looking at someone.
00:43:52
Speaker
um The 80-year-old who is in the hospital gown and under the white sheet, you know for all you know, they could be running three times a week and playing pickleball every other day, right? They might be very active and fit and robust, um but you can't necessarily tell that just by looking at them in the hospital. And so I think that that's a really important pitfall to avoid is just to make sure that you have assessed the some of these age-related conditions in the patient in front of you rather than presuming that you know what their baseline status is like just you know by their chronological age alone.
Integrating Geriatric Principles into ICU Care
00:44:32
Speaker
We know that those factors we talked about at the beginning of this podcast, like frailty, for example, um or disability and functional activities, those factors are more strongly associated with outcomes than chronological age alone. And so it's really important to assess those.
00:44:50
Speaker
um And then I would say the other pitfall to avoid is is kind of along those lines, like when you're thinking about these important high-quality practices that we implement in the icu with early mobilization being one of them, for example, ah to not...
00:45:08
Speaker
I guess, be ageist in how we implement those. Like everybody should just be screened the same way and deliver that intervention in the same way. um Because you know if they screen in for early mobility, we could trust that our physical therapy colleagues you know and nursing can determine can it can deliver their skilled to rehab intervention. and so I would just say you know not to exclude people from these high quality practices like early mobilization.
00:45:37
Speaker
Any pearls of advice for better care of positive things that we can do more of? Yes, absolutely. so um, So I would say, you know, for pearls of advice, ah so first of all, it kind of along the lines of the last comment I made, without presuming, you know, we don't want to presume again what someone's baseline functional status is like, but actually incorporating that question into the conversation can be so enlightening, um both in terms of where the patient is starting from, but actually who the person is in front of you. And so I will talk to the patient and or the family, know who whoever I'm having the conversation with, just about how well, you know what what is this person's daily life like like? Think back to maybe one month before the ICU admission. um
00:46:28
Speaker
And I might learn that they are living independently and driving to the grocery store and you know, completely taking care of themselves. And actually, there's a lot of value in understanding someone's baseline functional status. It gives you you know a better sense of how they might do, what their long-term outcomes might be like, but also just a better picture of the person. and then you can tie that in and kind of transition that to to try to learn what matters most to them.
00:46:55
Speaker
um And then I kind of just coming back to some of the other like things that we've talked about during this podcast, you know just keeping in mind like some of these age-related conditions we talked about, like you can actually make a big difference in the ICU for...
00:47:11
Speaker
Hearing loss is probably a really good example. um All hospitals stock those portable amplifiers. They're like the little headphones. They look like a Walkman, if you remember what those look like. um And they're very inexpensive and they're stocked by hospitals. It's just that people forget to ask for them. But something small like that can make a huge like a huge difference in the um and the care of your patient.
00:47:35
Speaker
Excellent. Lauren, we'd like to finish the podcast with a couple of questions that are unrelated to the clinical topic. Would that be okay? Sure. So the first question relates to books.
00:47:48
Speaker
Is there a book that you read recently that had an impact on you?
00:47:54
Speaker
Yeah, oh so I think, so I actually read a a lot. I'm always reading different books and i enjoy different kinds of books. i I like novels, I enjoy reading historical fiction. i heard about a good biography coming out, so I might read that soon.
00:48:11
Speaker
And I would say they all impact me in some way. i can't say there was any one book that did more than others. Maybe I'll just share the last book I read. it was called The Correspondent by Virginia Evans. It actually just came out in the last couple of months. um And in fact, it kind of really, it's it's actually about an older woman um who communicates with her family and friends entirely through correspondence, meaning specifically through letter writing. um
00:48:42
Speaker
But there, and it's just, it's just a beautiful novel and reading the letters, it's it's lovely to read them, but you're, there are also all of these other themes. She's actually losing her vision ah due to a rare condition where you lose your vision rapidly when you're older. And, but as the book goes on, she her ability to kind of open her eyes and and see like the family and friends that have surrounded her for entire life and improves as she's losing her vision, which I really, i really loved that theme of the book.
00:49:12
Speaker
So I would say if you're able to find it, I highly recommend it. um thiss called Again, it's called The Correspondent. We will definitely add a link in the in the show notes. So thanks for sharing that.
00:49:24
Speaker
The second question is about changing your mind. you tell us something you have changed your mind about in the last few years?
00:49:34
Speaker
Oh, yes. I mean, I, I guess, you know, this isn't such a positive note, so glad it's not the last question, but I guess I always thought that the infrastructure around science in this country was something that was going to continue to grow and was something that was not going to change.
00:49:55
Speaker
And I would say over the last few years, I've been a little discouraged and have changed my mind. Like my prior perceptions have been changed. Like I now realize that it's much more fragile than I ever thought.
00:50:07
Speaker
And I had always thought that, you know, hopes that, or I just assumed that infrastructure around science would be robust through different administrations. But I guess i I've definitely changed my mind about that view. um you know, and have learned and learning like everybody else to live with the uncertainty. and I think it just makes me appreciate the scientific infrastructure we have in this, in this country more and to hope that we will go back to, you know, ah continue to keep that infrastructure robust so that we can continue to advance. So going to be a leader in in research and advancing science around the world. Absolutely. And I do believe as as physicians and as clinicians, we we all recognize the value that science has in improving lives.
00:50:55
Speaker
And I agree. I hope that that that trend ah changes and continues to to move in the right direction in the future. To close, what would you want every listener to know? It could be a quote or a final thought.
00:51:13
Speaker
Absolutely. Thanks. Yeah, that's a good question. i think just going back to the, um you know, the the topic of this podcast, since that's why you had me on, i i think it's really important that we all don't view older adults as other, you know, we're we're actually all aging every day. um and ah one day we're all going to be older adults, but I think, you know, given all the things that we've talked about, you know, geriatricians are not going to be able to care for everyone. um This is actually, you know, older adults are our ICU population now. It's not like there's some different, you know, small proportion of ICU population. Like, I think it's important that we change our mindset about older adults um and really just realize, like, this is our ICU population. um And if we learn some of these principles and just how to best care for them, and this should just be part of our standard of care.
Podcast Subscription and Resources
00:52:13
Speaker
um
00:52:14
Speaker
And it's actually a really key part of providing the best high quality care to our ICU, to our patients, all of our ICU patients as intensivists.
00:52:25
Speaker
Excellent. Well, I want to thank you and for for taking the time to talk with us today and sharing your expertise. Also, thank you and the whole a guideline committee for their work on such a valuable area, and which is caring for our older patients in the ICU. And I look forward to having you back on the podcast, Lauren.
00:52:47
Speaker
Thanks again for having me, Sergio. This was great. Thanks again.
00:52:53
Speaker
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00:53:07
Speaker
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