Geriatric critical care: the elderly ICU patient · ICU Topics

Cinematic ICU scene of an elderly patient with a Clinical Frailty Scale assessment on a clipboard, a polypharmacy review chart, an early mobilisation plan and a walking aid, soft clinical-blue lighting, medical educational, no faces, no text — FigureThe geriatric critical care — the older patient is the high-risk for the ICU-acquired weakness, the delirium, and the functional decline. The frailty (the Clinical Frailty Scale) predicts the outcome better than the age; the management is the early mobilisation, the delirium prevention, the deprescribing, and the goals-of-care conversation.

Educational infographic of ageing physiology and frailty: reduced organ reserve, Clinical Frailty Scale concept, polypharmacy interactions, and delirium risk pathways on clinical-blue background — FigureAgeing physiology meets frailty — reserve declines, drugs accumulate, and delirium risk soars. CFS stratifies risk better than chronological age alone.

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ICU management of the elderly patient

Assess frailty — Clinical Frailty Scale (1-9). Frailty (≥5) predicts mortality, functional decline, institutionalisation BETTER than age or APACHE
Medication review — deprescribe unnecessary drugs, adjust doses for renal/hepatic function, avoid Beers criteria drugs (deliriogenic, anticholinergic), reduce polypharmacy
Prevent delirium — minimise sedation (propofol, dexmedetomidine), promote sleep-wake cycle, orient, family at bedside, glasses/hearing aids, early mobilisation, treat pain, avoid restraints
Early mobilisation — start day 1-2 if possible, even passive if ventilated. Prevents deconditioning, pressure ulcers, DVT. Physiotherapy, occupational therapy
Nutrition — assess for sarcopenia/malnutrition, early enteral nutrition, protein 1.2-1.5 g/kg/day, monitor for refeeding
Goals of care discussion — realistic prognosis, quality of life, advance care planning, involve family, consider palliative care, respect advance directives
Discharge planning — rehabilitation, community support, follow-up ICU clinic. Plan for post-intensive care syndrome (cognitive, physical, psychological)

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Exam practice — SAQs

SAQ — Frailty as a predictor of ICU outcomes in an elderly septic patient

10 minutes · 10 marks

An 82-year-old woman is admitted to ICU with urosepsis complicated by E. coli bacteraemia. She has hypertension, type 2 diabetes, and osteoarthritis. Her daughter reports that before admission she used a walking frame to leave the house, needed help with shopping, housework and managing her finances, and had two falls in the last six months. She takes metformin 500 mg bd, gliclazide 80 mg mane, amlodipine 10 mg daily, and oxycodone PRN. On examination: T 38.6 degrees C, HR 124, BP 84/48 on noradrenaline 0.25 mcg/kg/min, RR 28, SpO2 92 percent on 15 L via non-rebreather mask, GCS 13, lactate 4.8 mmol/L, creatinine 230 (baseline 95), Hb 88, INR 1.5. The registrar asks how you would assess and explain her prognosis.

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SAQ — Preventing and managing delirium in the elderly ventilated ICU patient

10 minutes · 10 marks

A 78-year-old man is intubated and ventilated on day 3 of his admission for severe community-acquired pneumonia (P/F 180). He is sedated with a propofol infusion at 3 mcg/kg/min and receives PRN morphine for the endotracheal tube. He has taken temazepam 20 mg nocte for 20 years for insomnia. His RASS has fluctuated between -2 and +1; CAM-ICU became positive on day 3. Overnight he pulled at his central line. His daughter reports mild cognitive impairment diagnosed last year. The consultant asks you to lead a delirium prevention and management plan.

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SAQ — Frailty assessment tools and the tracheostomy decision

10 minutes · 10 marks

An 84-year-old man is on day 4 of ICU after an emergency Hartmann procedure for a perforated sigmoid diverticulum. He remains intubated and ventilated (P/F 280, FIO2 0.35, PEEP 5) with a slow ventilatory wean. He has ischaemic heart disease, COPD, and stage 3 CKD. His wife reports that before admission he walked slowly with a stick, needed help with shopping and managing finances, had given up gardening, and had lost 5 kg over six months without trying. The surgical team asks whether a tracheostomy would be appropriate. The consultant asks you to perform and interpret a frailty assessment.

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SAQ — Polypharmacy and deprescribing in the elderly ICU patient

10 minutes · 10 marks

A 79-year-old woman weighing 52 kg is admitted to ICU after a fall at home with a fractured neck of femur. She is in acute on chronic kidney injury (creatinine 280, baseline 130) with a lactate of 2.4 and new confusion. Her GP medication list totals 12 agents: amlodipine 10 mg, doxazosin 4 mg, furosemide 40 mg bd, indapamide 1.5 mg, ibuprofen 400 mg tds PRN, glibenclamide 10 mg mane, metformin 1 g bd, aspirin 100 mg, atorvastatin 40 mg, temazepam 20 mg nocte, oxybutynin 5 mg bd, and a proton-pump inhibitor. Her serum albumin is 28 g/L. The consultant asks you to perform a medication review and deprescribing plan.

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Clinical pearls

High-yield geriatric ICU points for CICM/FFICM exam

Frailty predicts outcomes better than chronological age. A frail 70-year-old has worse outcomes than a fit 85-year-old. Clinical Frailty Scale (CFS) ≥5 predicts: mortality (2-3x higher), functional decline, institutionalisation, longer ICU stay. Assess CFS on admission — guides prognosis, goals of care.[1] }
Elderly have reduced physiological reserve. Cardiac: reduced beta-adrenergic response, stiff ventricles (diastolic dysfunction), conduction disease. Renal: reduced GFR (even with normal creatinine — sarcopenia masks), impaired concentrating ability. Respiratory: decreased chest wall compliance, reduced vital capacity, blunted hypoxic/hypercapnic drives. These reduce tolerance to stress (sepsis, surgery).[2] }
Altered pharmacokinetics in the elderly. (1) Decreased renal clearance (even with normal creatinine — use cystatin C or eGFR). (2) Increased body fat → increased Vd for lipophilic drugs (longer half-life). (3) Decreased albumin → more free drug (toxicity). (4) Decreased hepatic mass → reduced metabolism. (5) Polypharmacy → drug interactions. DOSE REDUCTION often needed.[2] }
Delirium is extremely common in elderly ICU (50-80%). Worse outcomes: longer stay, higher mortality, long-term cognitive impairment (dementia-like). Prevent: minimise sedation (especially benzodiazepines), promote sleep-wake, orient, family presence, glasses/hearing aids, early mobilisation, treat pain, avoid restraints. Treat: haloperidol or quetiapine if distressed (but do NOT routinely sedate).[4] }
Long-term cognitive impairment after critical illness. Pandharipande (NEJM 2013): 3 months after ICU, 40% of older patients had cognitive impairment equivalent to moderate TBI; 26% equivalent to mild Alzheimer's. Persisted at 12 months. Risk factors: delirium duration, older age, pre-existing impairment.[3] }
Polypharmacy — medication review is essential. Elderly patients often on 8-10+ medications. ICU admission is an opportunity to DEPRESCRIBE. Use Beers criteria (potentially inappropriate medications in elderly): benzodiazepines, anticholinergics, long-acting sulphonylureas, NSAIDs (GI bleed, AKI), first-generation antihistamines. Adjust doses for renal function. Review interactions.[2] }
Early mobilisation prevents deconditioning. Elderly lose 1-5% muscle mass per DAY of bed rest (vs younger adults 0.5%). Leads to weakness, functional decline, falls, institutionalisation. Start mobilisation DAY 1-2 if possible (even passive range of motion if ventilated). Progress to sitting, standing, walking. Physiotherapy, occupational therapy. Prevents ICU-acquired weakness.[5] }
Sarcopenia and malnutrition. Elderly have reduced muscle mass (sarcopenia). Critical illness accelerates loss (catabolism). Assess: weight, BMI (may be misleading — sarcopenic obesity), grip strength, SGA (subjective global assessment). Nutrition: early enteral, protein 1.2-1.5 g/kg/day (higher than younger — sarcopenia). Monitor for refeeding syndrome (phosphate, magnesium).[5] }
Goals of care — realistic prognosis discussion. Elderly ICU mortality: 20-40% (vs 10-15% younger). Survivors: 30-50% have new functional dependence, 20-40% need institutionalisation. Discuss: (1) Realistic prognosis (age, frailty, comorbidity). (2) Quality of life (what matters to patient). (3) Advance directives (if any). (4) Treatment limitations (consider palliative approach if poor prognosis). Involve family.[6] }
Pressure ulcers — high risk in elderly. Reduced skin perfusion, immobility, incontinence, malnutrition. Prevent: turn every 2 hours, pressure-relieving mattress, skin care, manage incontinence, nutrition. Treat: wound care, debridement, antibiotics if infected. Stage 3-4 ulcers: prolonged healing, increased mortality.[6] }
Post-intensive care syndrome (PICS) — worse in elderly. Cognitive impairment (memory, executive function), physical weakness (ICUAW, sarcopenia), psychological (PTSD, depression). Elderly have less capacity to recover — may have PERMANENT functional decline. Follow-up: ICU clinic, rehabilitation, community support, caregiver support.[3] }
Iatrogenic complications are common. Hospital-acquired infections (CAUTI, CLABSI, VAP), medication adverse events (overdose from reduced clearance), procedural complications, falls, delirium from sedation. PREVENT: minimise invasive devices, medication review, early mobilisation, infection prevention bundles. Every intervention has RISK in elderly.[6] }
Withholding and withdrawing treatment. In elderly with poor prognosis (severe frailty, end-stage disease), consider: (1) Withholding (not starting) burdensome treatment (e.g., CPR, mechanical ventilation if futile). (2) Withdrawing (stopping) treatment that is not benefiting (e.g., extubation if not recovering). (3) Palliative care focus (symptom relief, comfort). (4) Respect advance directives. (5) Family meeting.[6] }
Age alone should NOT exclude from ICU. Chronological age is a poor predictor — physiological age (frailty, comorbidity, function) matters more. Fit 85-year-old may benefit from ICU. Frail 70-year-old may not. Individualise based on: (1) Acute illness reversibility. (2) Baseline function (frailty). (3) Patient values/goals. (4) Expected quality of life. Do NOT deny ICU based on age alone.[1] }

Red flags

Prognosis

Long-term outcomes in elderly ICU survivors (Bagshaw 2019)

Multicentre cohort of ICU patients aged ≥80:

ICU mortality: 15-25% (higher than younger 10-15%)
Hospital mortality: 25-35%
1-year mortality: 40-50%
Functional status at 1 year (survivors): 30-40% had new functional dependence, 20-30% institutionalised
Cognitive function at 1 year: 40% had cognitive impairment (memory, executive)
Quality of life: reduced (PICS — cognitive, physical, psychological) [1]

Frailty (CFS ≥5): doubled mortality, tripled institutionalisation rate. STRONGER predictor than age, APACHE, or comorbidity index. Delirium duration: each additional day of delirium → 10% increased risk of long-term cognitive impairment.

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Physiological changes of ageing

The defining feature of geriatric critical care is loss of physiological reserve — the capacity of organ systems to up-regulate function under stress. Reserve is consumed by age-related changes (intrinsic ageing) and by lifelong disease burden. A "fit" 80-year-old and a "frail" 80-year-old differ far more in reserve than in years lived. Understanding each domain lets the intensivist anticipate failure points before they occur. [1]

Organ-system changes of ageing that matter in ICU

System	Key change	ICU consequence
Respiratory	Decreased chest-wall compliance, stiffened lung parenchyma, reduced elastic recoil (≈0.2 mL/yr FEV1), weakened respiratory muscles, reduced vital capacity, increased closing volume, blunted hypoxic/hypercapnic ventilatory drive	Rapid desaturation on apnoea/induction; lower baseline PaO₂ (≈0.3 mmHg/yr after 40); early respiratory failure with pneumonia; impaired secretion clearance; reduced tolerance for high mean airway pressures
Cardiovascular	Arterial stiffening (↑systolic BP, widened pulse pressure), left ventricular hypertrophy with diastolic dysfunction (impaired relaxation, ↑reliance on atrial kick/ preload), reduced β-adrenergic responsiveness (blunted HR response), conduction disease (AF, blocks), endothelial dysfunction	Intolerance to volume loss OR overload; prone to flash pulmonary oedema with modest fluid; high afterload-sensitive; AF common trigger; poor reserve for tachycardia/bradycardia
Renal	Loss of nephrons (≈1 mL/min/yr GFR after 40), reduced renal blood flow, impaired concentrating/diluting ability, sodium and water handling blunted, impaired renin-aldosterone response, loss of afferent autoregulation	Normal/masked creatinine (sarcopenia) with low true GFR; high risk of AKI from nephrotoxins/contrast; easy fluid and electrolyte disturbance (hypo-/hypernatraemia); dialysis more often required
Hepatic / metabolic	Reduced liver mass and blood flow (↓phase I oxidation), plasma albumin ↓, body fat ↑ (↑volume of distribution for lipophilic drugs), lean mass ↓, total body water ↓	Prolonged half-life of sedatives/analgesics (midazolam, fentanyl); more free drug when albumin low; accumulation of metabolites
Nervous system	Cerebral atrophy, ↓dopaminergic and cholinergic neurons, impaired autoregulation, sensory loss (vision, hearing), pre-existing white-matter disease	Heightened delirium susceptibility; slower processing; impaired thermoregulation; falls; pressure palsies from immobility
Immune	Immunosenescence: thymic involution, naive-T-cell depletion, inflammageing (chronic low-grade IL-6/TNF), blunted febrile response	Atypical/low-grade presentations; worse sepsis outcomes; reactivation of latent virus (VZV, CMV); poorer vaccine response
Thermoregulation	Reduced basal metabolic rate, blunted shivering, impaired vasoconstriction	Sepsis may present WITHOUT fever (normo- or hypothermia); hypothermia = poor prognostic sign
Musculoskeletal	Sarcopenia (1-2%/yr mass loss after 50), osteopenia/osteoporosis, joint stiffness	1-5% muscle loss/DAY of bed rest; ICU-acquired weakness; falls and fragility fractures on mobilisation

Net effect: each system functions adequately at rest but cannot escalate. The patient decompensates earlier and recovers more slowly — the "margin for error" is gone. [2]

Pharmacology in the elderly ICU patient

Pharmacokinetic changes of ageing — and what to do about them

Distribution

Body composition shifts

Total body water ↓ 10-15% and lean mass ↓ → LOWER volume of distribution (Vd) for water-soluble drugs (digoxin, lithium) → higher peak concentration.
Body fat ↑ → HIGHER Vd for lipophilic drugs (midazolam, diazepam, fentanyl, amiodarone, propofol) → prolonged half-life, accumulation, delayed wake-up.
Plasma albumin ↓ (esp. with inflammation) → more FREE drug for highly-bound agents (warfarin, phenytoin, midazolam) → toxicity at "normal" dose.

Metabolism

Liver mass & blood flow ↓

Phase I (oxidation/reduction via CYP450) ↓ ~1%/yr → slower conversion of prodrugs and clearance of midazolam, fentanyl, many statins.
Phase II (conjugation) relatively PRESERVED → lorazepam (glucuronidated) preferred over midazolam when a benzodiazepine is unavoidable, though both are deliriogenic.
First-pass effect reduced → higher bioavailability of oral drugs (propranolol, verapamil, morphine).

Elimination

GFR ↓ even with "normal" creatinine

Renal clearance of water-soluble drugs ↓ → accumulation of enoxaparin, gabapentin, pregabalin, vancomycin, digoxin, atenolol, lithium, water-soluble β-lactams.
Use cystatin C-based eGFR or Cockcroft–Gault for dosing; many elderly need 25-50% dose reduction and/or extended dosing intervals.
Therapeutic drug monitoring (vancomycin, aminoglycosides, antiepileptics, digoxin) is under-used and high-yield.

Pharmacodynamics

Receptor sensitivity ↑

Increased sensitivity to CNS depressants (opioids, benzodiazepines, anaesthetics) — "start low, go slow".
Blunted β-receptor response → less tachycardia for a given insult; less haemodynamic compensation.
Increased sensitivity to anticholinergics → frank delirium at doses a younger patient tolerates.

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Practical dose-adjustment rules for high-risk ICU drugs

Drug	Adjustment in the elderly
Midazolam / diazepam	Avoid if possible (deliriogenic, accumulates). If essential, dose 25-50% lower and use lorazepam or titratable propofol/dexmedetomidine instead.
Fentanyl	Lipophilic — accumulates with prolonged infusion (context-sensitive half-time rises). Bolus for procedural analgesia preferred over open infusion; monitor for delayed wake-up.
Morphine	Active metabolite (M6G) renally cleared — neurotoxic (myoclonus, delirium) in CKD. Prefer fentanyl or hydromorphone in CKD.
Enoxaparin	Renally cleared — reduce dose if CrCl <30 mL/min (e.g. once-daily) or switch to unfractionated heparin. Anti-Xa monitoring if prolonged use.
Gabapentin/pregabalin	Renally cleared — reduce dose for CrCl, or they cause oversedation and respiratory depression.
Digoxin	Narrow therapeutic index; reduce loading/maintenance; target lower serum level (0.5-0.9 ng/mL) for rate control in AF.
Sulphonylureas (gliclazide)	Long-acting hypoglycaemia risk — STOP in ICU, use insulin titration instead.
Metformin	Lactic acidosis risk in AKI/hypoperfusion — HOLD during critical illness.
NSAIDs	Avoid — AKI, GI bleed, fluid retention, heart failure exacerbation.
Diuretics	Loop diuretics less effective (reduced renal delivery); may need higher dose or combination (loop + thiazide). Watch over-diuresis in diastolic dysfunction.

Polypharmacy and deprescribing

Polypharmacy (concurrent use of ≥5 medications) affects 50-90% of ICU patients aged ≥65 and is an independent risk factor for delirium, falls, AKI, bleeding, and mortality. ICU admission — when every drug is reviewed and reconciled — is the single best deprescribing opportunity in a patient's trajectory. [1]

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Beers Criteria 2023 — highest-yield PIMs to STOP in the elderly ICU patient

CNS / sedatives

Delirium drivers

Benzodiazepines (lorazepam, diazepam, alprazolam) — deliriogenic, falls, prolonged sedation; avoid for sleep.
First-generation antihistamines (diphenhydramine, promethazine) — strong anticholinergic; the canonical delirium trigger.
Z-drugs (zolpidem, zopiclone) — delirium, falls, fractures.
Sleep aids: promote sleep-wake with environment, not sedatives.

Anticholinergic burden

Cumulative & insidious

Oxybutynin, solifenacin, tricyclics, cyclobenzaprine — high anticholinergic load → delirium, urinary retention, constipation.
Quantify burden (Anticholinergic Burden Scale); aim to reduce total load, not just one drug.

Cardiovascular & endocrine

High-risk in acute illness

NSAIDs (ibuprofen, diclofenac) — AKI, heart failure, GI bleed; avoid.
Long-acting sulphonylureas (glibenclamide) — prolonged hypoglycaemia; STOP in ICU.
Digoxin >0.125 mg/day — toxicity.
Peripheral α-1 blockers (doxazosin) for hypertension — orthostatic hypotension, falls.

GI & renal

Bleeding & injury risk

Proton-pump inhibitors used >8 weeks without indication — C. difficile, fractures, B12/Mg deficiency; reassess need daily.
Aspirin for primary prevention in >70 years — bleeding risk outweighs benefit (still continue for secondary prevention).

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Delirium in the elderly ICU patient

Delirium is an acute, fluctuating disturbance of attention and awareness. It is the most common neuropsychiatric complication of critical illness in older adults, occurring in 50-80% of ventilated elderly patients and 20-50% of non-ventilated. It is NOT benign: each additional day of delirium independently predicts longer stay, higher 6- and 12-month mortality, and long-term cognitive impairment equivalent to traumatic brain injury or mild Alzheimer disease. [1]

Assessment — CAM-ICU (Confusion Assessment Method for the ICU)

Screen every shift (nursing-driven). CAM-ICU is positive when features 1 AND 2, plus either 3 OR 4 are present:

Acute onset or fluctuating course (altered from baseline, fluctuating through the day).
Inattention — cannot sustain/shift attention (e.g. squeeze hand on letter "A" in SAVEAHAART — errors >3 = positive).
Altered level of consciousness — anything other than alert (RASS ≠ 0).
Disorganised thinking — >1 wrong answer to simple yes/no questions (e.g. "Will a stone float on water?"). [1]

Alternatives: ICDSC (Intensive Care Delirium Screening Checklist — 8 items, score ≥4). 4AT for non-ICU wards. [1]

Assess pain (CPOT/BPS), sedation (RASS), and delirium (CAM-ICU) together every shift — the "PADIS triad." [4]

Risk factors for ICU delirium — and which are modifiable

Pre-existing (fixed)

Stratify risk

Older age, baseline cognitive impairment, frailty, multimorbidity.
History of depression/alcohol use, visual/hearing impairment.
Genetic: ApoE4 allele (associative).

Acute illness (partly fixed)

Treat the cause

Sepsis, hypoxia, metabolic derangement (Na, glucose, uraemia, hepatic).
Surgery/anaesthesia, pain, sleep deprivation.
Infection (esp. urinary, respiratory), constipation, urinary retention.

Iatrogenic (MODIFIABLE)

The targets of prevention

Sedatives — benzodiazepines are the strongest modifiable risk (each day of midazolam ↑ delirium).
Anticholinergics, opioids (esp. piperidine derivatives), corticosteroids.
Immobilisation, restraints, lack of daylight/sleep, ICU noise at night.
Indwelling catheters (precipitate infection and restrain mobility).

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Prevention — the multicomponent / ABCDEF bundle

Assess and manage pain — scheduled analgesia first; opioids are not the only tool (paracetamol, regional blocks). Overtreated pain and undertreated pain BOTH cause delirium.
Both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) daily — reduce ventilator days and sedation exposure. Coordinate so SAT precedes SBT.
Choice of analgesia and sedation — prefer analgesia-first, propofol or dexmedetomidine over benzodiazepines. Target light sedation (RASS 0 to −1) whenever possible.
Delirium — assess, prevent, manage — screen with CAM-ICU each shift; treat the cause (infection, hypoxia, metabolic, retention, pain) BEFORE reaching for antipsychotics.
Early mobility and exercise — passive → active → sitting → standing → walking from day 1-2; reduces delirium days and ICU-acquired weakness.
Family engagement and empowerment — orient frequently, family at bedside, sleep hygiene (lights off, earplugs/eye mask, cluster care), restore vision/hearing (glasses, hearing aids, amplifier). [1]

Adapt non-pharmacological multicomponent care from the Hospital Elder Life Program (HELP): orientation, therapeutic activities, hydration, sleep enhancement, mobility, hearing/vision aids, feeding support. [11][12]

Does drug treatment of delirium work? The evidence

Antipsychotics do NOT improve outcomes in ICU delirium (MIND-USA). A randomised, placebo-controlled trial of haloperidol and ziprasidone vs placebo in 566 ICU patients with acute respiratory failure and delirium found no difference in days alive without delirium or coma at 14 days. [10]

Implication: antipsychotics are NOT first-line, NOT prophylactic. Reserve for distressing hyperactive delirium that threatens the patient (e.g. pulling at lines, extubation risk) AFTER non-pharmacological measures and pain/cause correction. Use the lowest dose for the shortest time; monitor QTc. [1]

Dexmedetomidine reduces agitation and ventilator time (DEXCOM). In agitated delirium (predominantly mechanical-ventilation patients), adding dexmedetomidine to standard care increased ventilator-free hours at 7 days (median 145 h vs 128 h) and reduced delirium — supporting α-2 agonist use as a sedation-sparing, delirium-reducing agent rather than escalating GABAergic sedation. [15]

Frailty assessment — beyond the Clinical Frailty Scale

The Clinical Frailty Scale (Rockwood, above) is a 9-point clinical judgement of overall function and is the tool validated most widely in ICU. Two complementary concepts are useful in the exam answer: [1]

Two lenses on frailty — phenotype vs deficit accumulation

Phenotypic (Fried)

Physical frailty

Three or more of: unintentional weight loss, exhaustion, low grip strength, slow walking speed, low physical activity.
Captures sarcopenia-driven physical decline.
Hard to measure in the sedated/ventilated patient — relies on pre-illness history from family.

Deficit accumulation (Rockwood/Frailty Index)

Cumulative morbidity

Proportion of ~30-70 health deficits (comorbidities, function, cognition) present.
Frailty Index >0.25 = frail; >0.4 = very frail.
Granular and predictive; the CFS is its bedside surrogate.

Clinical Frailty Scale (CFS)

Bedside 1-9

A 1-9 pictorial judgment of function in the TWO WEEKS before acute illness.
Validated in >1 million patients; the ICU standard.
Pitfall: do NOT score the acute illness itself — score the pre-morbid baseline; base on collateral, not the patient in front of you.

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CFS interpretation in ICU — what the score changes

CFS 1-3 (fit to managing well): full-code physiology, standard aggressive therapy; outcomes approach younger patients. Frailty is NOT a reason to limit treatment.
CFS 4 (vulnerable): increased risk; mobilise early, watch for delirium and deconditioning, but offer full organ support.
CFS 5-6 (mild-moderate frailty): discuss realistic prognosis early; higher mortality (2-3×) and new functional dependence; consider tracheostomy timing carefully (extubation failure more likely).
CFS 7-8 (severe/very severe frailty): goals-of-care discussion is essential; weigh the burden vs benefit of invasive support; high chance of new institutionalisation or never returning home; palliative involvement appropriate.
CFS 9 (terminally ill): comfort-focused care; de-escalate invasive support. [1]

A meta-analysis of individual patient data (>9000 older ICU patients) confirmed the CFS is a stronger mortality predictor than age, APACHE, or comorbidity score. [6]

Post-intensive care syndrome (PICS) and the elderly

PICS is the triad of new or worsened cognitive impairment, psychiatric illness (depression, anxiety, PTSD), and physical weakness/ICU-acquired weakness that persists after critical illness. In older adults it is more frequent, more severe, and more likely to be permanent because reserve is already depleted. [1]

PICS in older adults — what to tell families

Cognitive: 30-40% of older survivors have impairment at 12 months equivalent to moderate TBI or mild Alzheimer disease; risk rises with each day of delirium. Pandharipande (NEJM 2013) — 26% had deficits equivalent to mild Alzheimer at 1 year. [3]
Physical: ICU-acquired weakness (critical-illness myopathy/neuropathy), sarcopenia — half of ventilated elderly lose >10% body mass; many never recover prior strength.
Psychiatric: depression in ~30%, PTSD and anxiety in ~20%; often unrecognised.
Functional: 30-50% of survivors aged ≥80 have new dependence in activities of daily living; 20-40% are discharged to institutional care rather than home. [5]
Mitigation: minimise sedation (esp. benzodiazepines), early mobilisation, glucose control avoiding both hyper- and hypoglycaemia, sleep protection, family involvement, and structured post-ICU follow-up (ICU clinic, rehabilitation, cognitive screening).

Glycaemic control in the elderly ICU patient

Both hyper- and hypoglycaemia are harmful, and the elderly are the most vulnerable to the cognitive and cardiovascular consequences of hypoglycaemia. Moderation — not normalisation — is the goal. [1]

Glucose targets in the elderly ICU patient

Target: blood glucose 7.8-10.0 mmol/L (140-180 mg/dL) — per NICE-SUGAR and contemporary guidelines. AVOID intensive insulin therapy (4.4-6.1 mmol/L) — it increases severe hypoglycaemia (and with it falls, arrhythmia, death) without mortality benefit. [14]
Insulin: use a titrated intravenous insulin infusion for the unstable/feverish/vasopressor patient; convert to subcutaneous basal-bolus as the patient stabilises. Hold all oral hypoglycaemics during acute illness (metformin = lactic acidosis; sulphonylureas = hypoglycaemia).
Hypoglycaemia <3.9 mmol/L is an emergency — treat with 50% dextrose IV (or 10% if frail veins) and recheck; investigate (insulin error, renal failure, sepsis, adrenal insufficiency).
Diabetes technology: continuous glucose monitoring reduces hypoglycaemia exposure and nursing burden; preferred where available. [13]

Nutrition and sarcopenia

Older patients enter critical illness with depleted lean mass (sarcopenia) and micronutrient reserves; critical illness accelerates catabolism, compounding the deficit. Refeeding risk is real after even brief starvation. [1]

Nutrition principles in the elderly ICU patient

Assess early: weight, BMI (misleading in sarcopenic obesity), grip strength (where possible), Subjective Global Assessment, and a screening tool (mNUTRIC — adds inflammation; higher score predicts benefit from aggressive feeding).
Route: enteral preferred (gut trophism, fewer infections). Hold gastric feeding if high aspirates/prokinetic-resistant ileus — consider post-pyloric. Parenteral only if enteral fails after 5-7 days.
Target: protein 1.2-1.5 g/kg/day (towards the higher end in sarcopenia; some guidelines suggest up to 2.0 g/kg/day in catabolic elderly, balanced against renal tolerance). Energy ~20-25 kcal/kg/day, advancing over the first week (permissive underfeeding reduces infective complications vs early full feeding).
Timing: avoid overfeeding in the first 48 h (refeeding). Replete thiamine, phosphate, potassium, magnesium before and during feeding in the malnourished; monitor daily.
Micronutrients: vitamin D deficiency is near-universal and associated with worse outcomes — replete. Monitor sodium, phosphate, magnesium, zinc.

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Pressure injury, skin and continence

Elderly skin is thin (loss of dermal collagen), perfusion is marginal, and immobility plus incontinence make pressure injury almost inevitable without active prevention. A stage 3-4 ulcer doubles mortality and prolongs stay. [1]

Pressure-injury and skin bundle for the elderly

Risk-assess on admission (Braden or Waterlow) and reassess with any change.
Reposition every 2 hours (or continuous low-pressure/air mattress if unable).
Protect skin — barrier creams for incontinence; keep clean and dry; manage diarrhoea aggressively.
Optimise nutrition (protein, zinc, vitamin C) and hydration.
Minimise devices — remove catheters, drains, and lines the moment they are unneeded (each is a pressure point and infection portal).
Inspect high-risk areas daily — sacrum, heels, occiput, under devices (NIV masks, ETT ties, braces).

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Goals-of-care and family meetings

For many elderly patients the most important decision in ICU is not how aggressively to treat, but for how long, and toward what goal. A well-run goals-of-care conversation reduces non-beneficial treatment, improves family satisfaction, and is itself a marker of high-quality care. [1]

Elements of an effective goals-of-care conversation

Before

Prepare

Review the chart: age, frailty (CFS), comorbidities, trajectory, prior advance directives, GP records.
Gather the right people: senior clinician, nurse, the patient if they have capacity, the substitute decision-maker/family, and (where appropriate) palliative care.
Find a private space, allow enough time, silence phones.

During

The conversation

Ask what the patient understands and what matters most to them ("What would be a good outcome? What would be unacceptable?").
Give a prognostic frame honestly: "I am worried she may not survive this / may not return to her previous self." Use best-case/worst-case/most-likely language, not percentages alone.
Explore values explicitly: independence, being at home, not being a burden, prolonging life at all costs.
Align: "Given what you have told me, here is what we can offer that fits those goals..."
Make a recommendation — clinicians who avoid recommending cause more distress. Avoid passive "what do you want us to do?" framing.

After

Document and follow through

Document the discussion, the agreed plan, and any treatment limitations (AND/OR a resuscitation decision) in the chart.
Communicate to the whole team and the GP.
Set a time to review — goals of care are dynamic, not one-off.
Offer palliative care and spiritual support; arrange follow-up for the family (post-ICU clinics, bereavement services).

[7]

Withholding vs withdrawing life-sustaining treatment

Ethically and legally equivalent in most jurisdictions — there is no obligation to start a treatment that cannot benefit. Once started, treatment may be withdrawn if it is futile or no longer aligned with the patient's goals.

Common decisions: CPR (DNACPR/Not-for-CPR), mechanical ventilation, renal replacement therapy, vasopressors/inotropes, artificial nutrition/hydration at end of life.
Process: discuss with the team, then the family; agree on a time-limited trial of intensive therapy (e.g. 72 h of full support, then reassess) when prognosis is uncertain; convert to comfort-focused care if goals are not met.
Comfort during withdrawal: titrate opioids (morphine or fentanyl) and benzodiazepines for dyspnoea, pain, agitation; anticholinergic for secretions; do NOT hasten death — relieve suffering. [7]

Management summary — the geriatric ICU checklist

Geriatric ICU management pathway: frailty assessment, deprescribing, non-pharmacological delirium prevention, early mobilisation, nutrition for sarcopenia, and goals-of-care time-limited trial — FigureGeriatric ICU bundle — assess frailty, deprescribe, prevent delirium, mobilise early, feed protein, and set a time-limited trial with clear goals.

Daily geriatric ICU checklist (the geriatric 'bundle')

Frailty (CFS) documented in the chart; reflected in the goals-of-care plan.
Medication review at every round — deprescribe per Beers/STOPP; dose-adjust for current CrCl; reconcile on admission and discharge.
PADIS triad every shift — pain (CPOT), sedation (RASS target 0 to −1), delirium (CAM-ICU). Treat pain and the cause before any antipsychotic.
ABCDEF bundle running — SAT/SBT daily, dexmedetomidine/propofol over benzodiazepines, mobility progressed, family engaged, sleep protected.
Glucose 7.8-10.0 mmol/L; hold oral hypoglycaemics; hypoglycaemia treated as emergency.
Nutrition advancing to target protein 1.2-1.5 g/kg/day; refeeding monitored; vitamin D repleted.
Pressure, skin, continence — reposition, devices minimised, barrier care.
Renal function reviewed daily — avoid nephrotoxins, dose-adjust, consider RRT early if failing.
Mobilise — passive day 1, active as able; physiotherapy and occupational therapy engaged.
Family communication — predictable updates; structured goals-of-care meeting within 72 h for high-frailty/high-severity patients.
Plan for PICS and discharge — rehabilitation, post-ICU clinic, cognitive screening, caregiver support.

[1]

Additional high-yield clinical pearls

Sixteen pearls to take into the CICM/FFICM/EDIC exam

Frailty, not age, predicts outcomes. A CFS ≥5 doubles mortality and triples institutionalisation and is a stronger predictor than APACHE II or comorbidity score. Score the pre-morbid baseline from collateral, never the acutely ill patient. [1] }
Reserve is lost system-wide. Each system "works at rest but cannot escalate" — the elderly patient decompensates earlier and recovers more slowly, leaving no margin for error. [2] }
Creatinine lies in sarcopenia. A "normal" creatinine can mask a GFR of 30 mL/min — use cystatin C or Cockcroft–Gault, and dose renally-cleared drugs conservatively. [2] }
Delirium is the sixth vital sign. New confusion in an elderly inpatient is a sepsis-equivalent until proven otherwise; CAM-ICU every shift, RASS target 0 to −1. [4] }
Benzodiazepines are the strongest modifiable delirium risk. Prefer analgesia-first sedation with propofol or dexmedetomidine; reserve lorazepam for status epilepticus or alcohol withdrawal. [9] }
Antipsychotics do NOT treat delirium (MIND-USA). Haloperidol/ziprasidone gave no benefit in days alive without delirium — use only for dangerous hyperactive delirium, lowest dose, shortest time, monitor QTc. [10] }
Dexmedetomidine buys ventilator-free time (DEXCOM). In agitated delirium it increased ventilator-free hours — α-2 agonism is sedation-sparing and delirium-reducing. [15] }
Long-term cognition is at stake. Each extra day of delirium raises the risk of cognitive impairment equivalent to TBI; 26% of older survivors have Alzheimer-equivalent deficits at 1 year (Pandharipande). [3] }
ICU admission is the best deprescribing opportunity. Reconcile, screen with Beers/STOPP, hold non-essentials (statins, oral hypoglycaemics, NSAIDs), and communicate stops at discharge to avoid automatic re-prescription. [16] }
Early mobilisation is medicine. The elderly lose 1-5% muscle mass per bed-rest day; day-1-2 mobility reduces delirium, weakness, and pressure injury. [12] }
Glycaemic moderation, not normalisation. Target 7.8-10.0 mmol/L (NICE-SUGAR) — intensive control increases severe hypoglycaemia and death without benefit. [14] }
Frail patients fail extubation. Plan for it (swallow assessment, slow wean, early tracheostomy discussion); do not be caught off guard by reintubation. [8] }
Age alone must not exclude from ICU. A fit 85-year-old with reversible sepsis may do well; a frail 70-year-old may not. Individualise on reversibility, baseline function, and patient values. [7] }
Goals of care is a skill, not a checkbox. Use best-case/worst-case/most-likely framing; explore values; make a recommendation; document and review. Treatment-limitation decisions and resuscitation status follow the conversation, not precede it. [7] }
Pressure injury is a quality marker. Thin skin + immobility + incontinence make it nearly inevitable without active prevention; a stage 3-4 ulcer doubles mortality. Reposition, protect skin, remove devices. [5] }
Plan for survivorship from day 1. PICS (cognitive, physical, psychiatric) is the rule, not the exception, in elderly survivors; arrange rehabilitation, post-ICU follow-up, cognitive screening, and caregiver support before discharge. [18] }

Red flags — additional

Geriatric ICU red flags that should trigger action today

New confusion or reduced RASS → screen CAM-ICU, treat pain/infection/hypoxia/metabolic cause FIRST; antipsychotic only if dangerous. [4] }
CFS ≥5 not yet documented in the chart → score it (collateral history) and book a goals-of-care meeting within 72 h. [1] }
Patient still on home benzodiazepine / anticholinergic / long-acting sulphonylurea → STOP; review against Beers criteria. [16] }
Glucose <3.9 mmol/L → emergency; treat and review insulin/oral-agent error and renal function. [14] }
Sedation deeper than RASS −2 without a clear indication → de-escalate; SAT/SBT today. [9] }
Immobile >24 h → mobilise today (passive at minimum); pressure-area check. [12] }
Rising creatinine or falling urine output in a patient on nephrotoxin/contrast → review drugs, dose-adjust, consider early RRT. [2] }
Family expressing "they would not want this" / signs of conflict → convene a structured goals-of-care meeting; consider palliative care and ethics input early. [7] }
Discharge planned without rehabilitation or follow-up arranged → incomplete plan; arrange post-ICU clinic, cognitive screening, caregiver support. [18] }

References

[1]Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people CMAJ, 2005.PMID 16129869
[2]Ferrante LE, Vallet H, Ho JQ, Brummel NE, et al. Challenges and strategies in the care of older adults across the continuum of intensive and post-intensive care medicine Intensive Care Med, 2026.PMID 41428207
[3]Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness N Engl J Med, 2013.PMID 24088092
[4]Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU) JAMA, 2001.PMID 11730446
[5]Heyland DK, Garland A, Bagshaw SM, et al. Recovery after critical illness in patients aged 80 years or older: a multi-center prospective observational cohort study Intensive Care Med, 2015.PMID 26306719
[6]Bruno RR, Wernly B, Bagshaw SM, et al. The Clinical Frailty Scale for mortality prediction of old acutely admitted intensive care patients: a meta-analysis of individual patient-level data Ann Intensive Care, 2023.PMID 37133796
[7]Ferrante LE, Chaudhuri D, et al. Society of Critical Care Medicine Guidelines on Caring for Older Adults in the ICU Crit Care Med, 2026.PMID 41860322
[8]Fernando SM, McIsaac DI, Rochwerg B, Bagshaw SM, et al. Frailty and invasive mechanical ventilation: association with outcomes, extubation failure, and tracheostomy Intensive Care Med, 2019.PMID 31595352
[9]Devlin JW, Skrobik Y, Gelinas C, Needham DM, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU Crit Care Med, 2018.PMID 30113379
[10]Mart MF, Boehm LM, Kiehl AL, et al. Long-term outcomes after treatment of delirium during critical illness with antipsychotics (MIND-USA): a randomised, placebo-controlled, phase 3 trial Lancet Respir Med, 2024.PMID 38701817
[11]Inouye SK, Bogardus ST, Baker DI, et al. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program J Am Geriatr Soc, 2000.PMID 11129764
[12]Marra A, Ely EW, Pandharipande PP, et al. The ABCDEF Bundle in Critical Care Crit Care Clin, 2017.PMID 28284292
[13]Adigbli DK, Hammond NE, Finfer S, et al. Managing blood glucose in the intensive care unit Intensive Care Med, 2025.PMID 39714614
[14]NICE-SUGAR Study Investigators, Finfer S, et al. Intensive versus conventional glucose control in critically ill patients N Engl J Med, 2009.PMID 19318384
[15]Reade MC, Eastwood GM, Bellomo R, et al. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial JAMA, 2016.PMID 26975647
[16]American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults J Am Geriatr Soc, 2023.PMID 37139824
[17]Fernando SM, McIsaac DI, Perry JJ, Bagshaw SM, et al. Frailty and Associated Outcomes and Resource Utilization Among Older ICU Patients With Suspected Infection Crit Care Med, 2019.PMID 31135504
[18]Muscedere J, Bagshaw SM, Kho M, et al. Frailty, Outcomes, Recovery and Care Steps of Critically Ill Patients (FORECAST): a prospective, multi-centre, cohort study Intensive Care Med, 2024.PMID 38748266

[1]

ICU management of the elderly patient

Assess frailty — Clinical Frailty Scale (1-9). Frailty (≥5) predicts mortality, functional decline, institutionalisation BETTER than age or APACHE
Medication review — deprescribe unnecessary drugs, adjust doses for renal/hepatic function, avoid Beers criteria drugs (deliriogenic, anticholinergic), reduce polypharmacy
Prevent delirium — minimise sedation (propofol, dexmedetomidine), promote sleep-wake cycle, orient, family at bedside, glasses/hearing aids, early mobilisation, treat pain, avoid restraints
Early mobilisation — start day 1-2 if possible, even passive if ventilated. Prevents deconditioning, pressure ulcers, DVT. Physiotherapy, occupational therapy
Nutrition — assess for sarcopenia/malnutrition, early enteral nutrition, protein 1.2-1.5 g/kg/day, monitor for refeeding
Goals of care discussion — realistic prognosis, quality of life, advance care planning, involve family, consider palliative care, respect advance directives
Discharge planning — rehabilitation, community support, follow-up ICU clinic. Plan for post-intensive care syndrome (cognitive, physical, psychological)

[1] [1]

Exam practice — SAQs

SAQ — Frailty as a predictor of ICU outcomes in an elderly septic patient

10 minutes · 10 marks

[1]

SAQ — Preventing and managing delirium in the elderly ventilated ICU patient

10 minutes · 10 marks

[1]

SAQ — Frailty assessment tools and the tracheostomy decision

10 minutes · 10 marks

[1]

SAQ — Polypharmacy and deprescribing in the elderly ICU patient

10 minutes · 10 marks

[1]

Clinical pearls

High-yield geriatric ICU points for CICM/FFICM exam

Frailty predicts outcomes better than chronological age. A frail 70-year-old has worse outcomes than a fit 85-year-old. Clinical Frailty Scale (CFS) ≥5 predicts: mortality (2-3x higher), functional decline, institutionalisation, longer ICU stay. Assess CFS on admission — guides prognosis, goals of care.[1] }
Elderly have reduced physiological reserve. Cardiac: reduced beta-adrenergic response, stiff ventricles (diastolic dysfunction), conduction disease. Renal: reduced GFR (even with normal creatinine — sarcopenia masks), impaired concentrating ability. Respiratory: decreased chest wall compliance, reduced vital capacity, blunted hypoxic/hypercapnic drives. These reduce tolerance to stress (sepsis, surgery).[2] }
Altered pharmacokinetics in the elderly. (1) Decreased renal clearance (even with normal creatinine — use cystatin C or eGFR). (2) Increased body fat → increased Vd for lipophilic drugs (longer half-life). (3) Decreased albumin → more free drug (toxicity). (4) Decreased hepatic mass → reduced metabolism. (5) Polypharmacy → drug interactions. DOSE REDUCTION often needed.[2] }
Delirium is extremely common in elderly ICU (50-80%). Worse outcomes: longer stay, higher mortality, long-term cognitive impairment (dementia-like). Prevent: minimise sedation (especially benzodiazepines), promote sleep-wake, orient, family presence, glasses/hearing aids, early mobilisation, treat pain, avoid restraints. Treat: haloperidol or quetiapine if distressed (but do NOT routinely sedate).[4] }
Long-term cognitive impairment after critical illness. Pandharipande (NEJM 2013): 3 months after ICU, 40% of older patients had cognitive impairment equivalent to moderate TBI; 26% equivalent to mild Alzheimer's. Persisted at 12 months. Risk factors: delirium duration, older age, pre-existing impairment.[3] }
Polypharmacy — medication review is essential. Elderly patients often on 8-10+ medications. ICU admission is an opportunity to DEPRESCRIBE. Use Beers criteria (potentially inappropriate medications in elderly): benzodiazepines, anticholinergics, long-acting sulphonylureas, NSAIDs (GI bleed, AKI), first-generation antihistamines. Adjust doses for renal function. Review interactions.[2] }
Early mobilisation prevents deconditioning. Elderly lose 1-5% muscle mass per DAY of bed rest (vs younger adults 0.5%). Leads to weakness, functional decline, falls, institutionalisation. Start mobilisation DAY 1-2 if possible (even passive range of motion if ventilated). Progress to sitting, standing, walking. Physiotherapy, occupational therapy. Prevents ICU-acquired weakness.[5] }
Sarcopenia and malnutrition. Elderly have reduced muscle mass (sarcopenia). Critical illness accelerates loss (catabolism). Assess: weight, BMI (may be misleading — sarcopenic obesity), grip strength, SGA (subjective global assessment). Nutrition: early enteral, protein 1.2-1.5 g/kg/day (higher than younger — sarcopenia). Monitor for refeeding syndrome (phosphate, magnesium).[5] }
Goals of care — realistic prognosis discussion. Elderly ICU mortality: 20-40% (vs 10-15% younger). Survivors: 30-50% have new functional dependence, 20-40% need institutionalisation. Discuss: (1) Realistic prognosis (age, frailty, comorbidity). (2) Quality of life (what matters to patient). (3) Advance directives (if any). (4) Treatment limitations (consider palliative approach if poor prognosis). Involve family.[6] }
Pressure ulcers — high risk in elderly. Reduced skin perfusion, immobility, incontinence, malnutrition. Prevent: turn every 2 hours, pressure-relieving mattress, skin care, manage incontinence, nutrition. Treat: wound care, debridement, antibiotics if infected. Stage 3-4 ulcers: prolonged healing, increased mortality.[6] }
Post-intensive care syndrome (PICS) — worse in elderly. Cognitive impairment (memory, executive function), physical weakness (ICUAW, sarcopenia), psychological (PTSD, depression). Elderly have less capacity to recover — may have PERMANENT functional decline. Follow-up: ICU clinic, rehabilitation, community support, caregiver support.[3] }
Iatrogenic complications are common. Hospital-acquired infections (CAUTI, CLABSI, VAP), medication adverse events (overdose from reduced clearance), procedural complications, falls, delirium from sedation. PREVENT: minimise invasive devices, medication review, early mobilisation, infection prevention bundles. Every intervention has RISK in elderly.[6] }
Withholding and withdrawing treatment. In elderly with poor prognosis (severe frailty, end-stage disease), consider: (1) Withholding (not starting) burdensome treatment (e.g., CPR, mechanical ventilation if futile). (2) Withdrawing (stopping) treatment that is not benefiting (e.g., extubation if not recovering). (3) Palliative care focus (symptom relief, comfort). (4) Respect advance directives. (5) Family meeting.[6] }
Age alone should NOT exclude from ICU. Chronological age is a poor predictor — physiological age (frailty, comorbidity, function) matters more. Fit 85-year-old may benefit from ICU. Frail 70-year-old may not. Individualise based on: (1) Acute illness reversibility. (2) Baseline function (frailty). (3) Patient values/goals. (4) Expected quality of life. Do NOT deny ICU based on age alone.[1] }

Red flags

Prognosis

Long-term outcomes in elderly ICU survivors (Bagshaw 2019)

Multicentre cohort of ICU patients aged ≥80:

ICU mortality: 15-25% (higher than younger 10-15%)
Hospital mortality: 25-35%
1-year mortality: 40-50%
Functional status at 1 year (survivors): 30-40% had new functional dependence, 20-30% institutionalised
Cognitive function at 1 year: 40% had cognitive impairment (memory, executive)
Quality of life: reduced (PICS — cognitive, physical, psychological) [1]

[1]

Physiological changes of ageing

Organ-system changes of ageing that matter in ICU

System	Key change	ICU consequence
Respiratory	Decreased chest-wall compliance, stiffened lung parenchyma, reduced elastic recoil (≈0.2 mL/yr FEV1), weakened respiratory muscles, reduced vital capacity, increased closing volume, blunted hypoxic/hypercapnic ventilatory drive	Rapid desaturation on apnoea/induction; lower baseline PaO₂ (≈0.3 mmHg/yr after 40); early respiratory failure with pneumonia; impaired secretion clearance; reduced tolerance for high mean airway pressures
Cardiovascular	Arterial stiffening (↑systolic BP, widened pulse pressure), left ventricular hypertrophy with diastolic dysfunction (impaired relaxation, ↑reliance on atrial kick/ preload), reduced β-adrenergic responsiveness (blunted HR response), conduction disease (AF, blocks), endothelial dysfunction	Intolerance to volume loss OR overload; prone to flash pulmonary oedema with modest fluid; high afterload-sensitive; AF common trigger; poor reserve for tachycardia/bradycardia
Renal	Loss of nephrons (≈1 mL/min/yr GFR after 40), reduced renal blood flow, impaired concentrating/diluting ability, sodium and water handling blunted, impaired renin-aldosterone response, loss of afferent autoregulation	Normal/masked creatinine (sarcopenia) with low true GFR; high risk of AKI from nephrotoxins/contrast; easy fluid and electrolyte disturbance (hypo-/hypernatraemia); dialysis more often required
Hepatic / metabolic	Reduced liver mass and blood flow (↓phase I oxidation), plasma albumin ↓, body fat ↑ (↑volume of distribution for lipophilic drugs), lean mass ↓, total body water ↓	Prolonged half-life of sedatives/analgesics (midazolam, fentanyl); more free drug when albumin low; accumulation of metabolites
Nervous system	Cerebral atrophy, ↓dopaminergic and cholinergic neurons, impaired autoregulation, sensory loss (vision, hearing), pre-existing white-matter disease	Heightened delirium susceptibility; slower processing; impaired thermoregulation; falls; pressure palsies from immobility
Immune	Immunosenescence: thymic involution, naive-T-cell depletion, inflammageing (chronic low-grade IL-6/TNF), blunted febrile response	Atypical/low-grade presentations; worse sepsis outcomes; reactivation of latent virus (VZV, CMV); poorer vaccine response
Thermoregulation	Reduced basal metabolic rate, blunted shivering, impaired vasoconstriction	Sepsis may present WITHOUT fever (normo- or hypothermia); hypothermia = poor prognostic sign
Musculoskeletal	Sarcopenia (1-2%/yr mass loss after 50), osteopenia/osteoporosis, joint stiffness	1-5% muscle loss/DAY of bed rest; ICU-acquired weakness; falls and fragility fractures on mobilisation

Net effect: each system functions adequately at rest but cannot escalate. The patient decompensates earlier and recovers more slowly — the "margin for error" is gone. [2]

Pharmacology in the elderly ICU patient

Pharmacokinetic changes of ageing — and what to do about them

Distribution

Body composition shifts

Total body water ↓ 10-15% and lean mass ↓ → LOWER volume of distribution (Vd) for water-soluble drugs (digoxin, lithium) → higher peak concentration.
Body fat ↑ → HIGHER Vd for lipophilic drugs (midazolam, diazepam, fentanyl, amiodarone, propofol) → prolonged half-life, accumulation, delayed wake-up.
Plasma albumin ↓ (esp. with inflammation) → more FREE drug for highly-bound agents (warfarin, phenytoin, midazolam) → toxicity at "normal" dose.

Metabolism

Liver mass & blood flow ↓

Phase I (oxidation/reduction via CYP450) ↓ ~1%/yr → slower conversion of prodrugs and clearance of midazolam, fentanyl, many statins.
Phase II (conjugation) relatively PRESERVED → lorazepam (glucuronidated) preferred over midazolam when a benzodiazepine is unavoidable, though both are deliriogenic.
First-pass effect reduced → higher bioavailability of oral drugs (propranolol, verapamil, morphine).

Elimination

GFR ↓ even with "normal" creatinine

Renal clearance of water-soluble drugs ↓ → accumulation of enoxaparin, gabapentin, pregabalin, vancomycin, digoxin, atenolol, lithium, water-soluble β-lactams.
Use cystatin C-based eGFR or Cockcroft–Gault for dosing; many elderly need 25-50% dose reduction and/or extended dosing intervals.
Therapeutic drug monitoring (vancomycin, aminoglycosides, antiepileptics, digoxin) is under-used and high-yield.

Pharmacodynamics

Receptor sensitivity ↑

Increased sensitivity to CNS depressants (opioids, benzodiazepines, anaesthetics) — "start low, go slow".
Blunted β-receptor response → less tachycardia for a given insult; less haemodynamic compensation.
Increased sensitivity to anticholinergics → frank delirium at doses a younger patient tolerates.

[2]

Practical dose-adjustment rules for high-risk ICU drugs

Drug	Adjustment in the elderly
Midazolam / diazepam	Avoid if possible (deliriogenic, accumulates). If essential, dose 25-50% lower and use lorazepam or titratable propofol/dexmedetomidine instead.
Fentanyl	Lipophilic — accumulates with prolonged infusion (context-sensitive half-time rises). Bolus for procedural analgesia preferred over open infusion; monitor for delayed wake-up.
Morphine	Active metabolite (M6G) renally cleared — neurotoxic (myoclonus, delirium) in CKD. Prefer fentanyl or hydromorphone in CKD.
Enoxaparin	Renally cleared — reduce dose if CrCl <30 mL/min (e.g. once-daily) or switch to unfractionated heparin. Anti-Xa monitoring if prolonged use.
Gabapentin/pregabalin	Renally cleared — reduce dose for CrCl, or they cause oversedation and respiratory depression.
Digoxin	Narrow therapeutic index; reduce loading/maintenance; target lower serum level (0.5-0.9 ng/mL) for rate control in AF.
Sulphonylureas (gliclazide)	Long-acting hypoglycaemia risk — STOP in ICU, use insulin titration instead.
Metformin	Lactic acidosis risk in AKI/hypoperfusion — HOLD during critical illness.
NSAIDs	Avoid — AKI, GI bleed, fluid retention, heart failure exacerbation.
Diuretics	Loop diuretics less effective (reduced renal delivery); may need higher dose or combination (loop + thiazide). Watch over-diuresis in diastolic dysfunction.

Polypharmacy and deprescribing

[1]

Beers Criteria 2023 — highest-yield PIMs to STOP in the elderly ICU patient

CNS / sedatives

Delirium drivers

Benzodiazepines (lorazepam, diazepam, alprazolam) — deliriogenic, falls, prolonged sedation; avoid for sleep.
First-generation antihistamines (diphenhydramine, promethazine) — strong anticholinergic; the canonical delirium trigger.
Z-drugs (zolpidem, zopiclone) — delirium, falls, fractures.
Sleep aids: promote sleep-wake with environment, not sedatives.

Anticholinergic burden

Cumulative & insidious

Oxybutynin, solifenacin, tricyclics, cyclobenzaprine — high anticholinergic load → delirium, urinary retention, constipation.
Quantify burden (Anticholinergic Burden Scale); aim to reduce total load, not just one drug.

Cardiovascular & endocrine

High-risk in acute illness

NSAIDs (ibuprofen, diclofenac) — AKI, heart failure, GI bleed; avoid.
Long-acting sulphonylureas (glibenclamide) — prolonged hypoglycaemia; STOP in ICU.
Digoxin >0.125 mg/day — toxicity.
Peripheral α-1 blockers (doxazosin) for hypertension — orthostatic hypotension, falls.

GI & renal

Bleeding & injury risk

Proton-pump inhibitors used >8 weeks without indication — C. difficile, fractures, B12/Mg deficiency; reassess need daily.
Aspirin for primary prevention in >70 years — bleeding risk outweighs benefit (still continue for secondary prevention).

[16]

Delirium in the elderly ICU patient

Assessment — CAM-ICU (Confusion Assessment Method for the ICU)

Screen every shift (nursing-driven). CAM-ICU is positive when features 1 AND 2, plus either 3 OR 4 are present:

Acute onset or fluctuating course (altered from baseline, fluctuating through the day).
Inattention — cannot sustain/shift attention (e.g. squeeze hand on letter "A" in SAVEAHAART — errors >3 = positive).
Altered level of consciousness — anything other than alert (RASS ≠ 0).
Disorganised thinking — >1 wrong answer to simple yes/no questions (e.g. "Will a stone float on water?"). [1]

Alternatives: ICDSC (Intensive Care Delirium Screening Checklist — 8 items, score ≥4). 4AT for non-ICU wards. [1]

Assess pain (CPOT/BPS), sedation (RASS), and delirium (CAM-ICU) together every shift — the "PADIS triad." [4]

Risk factors for ICU delirium — and which are modifiable

Pre-existing (fixed)

Stratify risk

Older age, baseline cognitive impairment, frailty, multimorbidity.
History of depression/alcohol use, visual/hearing impairment.
Genetic: ApoE4 allele (associative).

Acute illness (partly fixed)

Treat the cause

Sepsis, hypoxia, metabolic derangement (Na, glucose, uraemia, hepatic).
Surgery/anaesthesia, pain, sleep deprivation.
Infection (esp. urinary, respiratory), constipation, urinary retention.

Iatrogenic (MODIFIABLE)

The targets of prevention

Sedatives — benzodiazepines are the strongest modifiable risk (each day of midazolam ↑ delirium).
Anticholinergics, opioids (esp. piperidine derivatives), corticosteroids.
Immobilisation, restraints, lack of daylight/sleep, ICU noise at night.
Indwelling catheters (precipitate infection and restrain mobility).

[9]

Prevention — the multicomponent / ABCDEF bundle

Assess and manage pain — scheduled analgesia first; opioids are not the only tool (paracetamol, regional blocks). Overtreated pain and undertreated pain BOTH cause delirium.
Both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) daily — reduce ventilator days and sedation exposure. Coordinate so SAT precedes SBT.
Choice of analgesia and sedation — prefer analgesia-first, propofol or dexmedetomidine over benzodiazepines. Target light sedation (RASS 0 to −1) whenever possible.
Delirium — assess, prevent, manage — screen with CAM-ICU each shift; treat the cause (infection, hypoxia, metabolic, retention, pain) BEFORE reaching for antipsychotics.
Early mobility and exercise — passive → active → sitting → standing → walking from day 1-2; reduces delirium days and ICU-acquired weakness.
Family engagement and empowerment — orient frequently, family at bedside, sleep hygiene (lights off, earplugs/eye mask, cluster care), restore vision/hearing (glasses, hearing aids, amplifier). [1]

Does drug treatment of delirium work? The evidence

Frailty assessment — beyond the Clinical Frailty Scale

Two lenses on frailty — phenotype vs deficit accumulation

Phenotypic (Fried)

Physical frailty

Three or more of: unintentional weight loss, exhaustion, low grip strength, slow walking speed, low physical activity.
Captures sarcopenia-driven physical decline.
Hard to measure in the sedated/ventilated patient — relies on pre-illness history from family.

Deficit accumulation (Rockwood/Frailty Index)

Cumulative morbidity

Proportion of ~30-70 health deficits (comorbidities, function, cognition) present.
Frailty Index >0.25 = frail; >0.4 = very frail.
Granular and predictive; the CFS is its bedside surrogate.

Clinical Frailty Scale (CFS)

Bedside 1-9

A 1-9 pictorial judgment of function in the TWO WEEKS before acute illness.
Validated in >1 million patients; the ICU standard.
Pitfall: do NOT score the acute illness itself — score the pre-morbid baseline; base on collateral, not the patient in front of you.

[1]

CFS interpretation in ICU — what the score changes

CFS 1-3 (fit to managing well): full-code physiology, standard aggressive therapy; outcomes approach younger patients. Frailty is NOT a reason to limit treatment.
CFS 4 (vulnerable): increased risk; mobilise early, watch for delirium and deconditioning, but offer full organ support.
CFS 5-6 (mild-moderate frailty): discuss realistic prognosis early; higher mortality (2-3×) and new functional dependence; consider tracheostomy timing carefully (extubation failure more likely).
CFS 7-8 (severe/very severe frailty): goals-of-care discussion is essential; weigh the burden vs benefit of invasive support; high chance of new institutionalisation or never returning home; palliative involvement appropriate.
CFS 9 (terminally ill): comfort-focused care; de-escalate invasive support. [1]

A meta-analysis of individual patient data (>9000 older ICU patients) confirmed the CFS is a stronger mortality predictor than age, APACHE, or comorbidity score. [6]

Post-intensive care syndrome (PICS) and the elderly

PICS in older adults — what to tell families

Cognitive: 30-40% of older survivors have impairment at 12 months equivalent to moderate TBI or mild Alzheimer disease; risk rises with each day of delirium. Pandharipande (NEJM 2013) — 26% had deficits equivalent to mild Alzheimer at 1 year. [3]
Physical: ICU-acquired weakness (critical-illness myopathy/neuropathy), sarcopenia — half of ventilated elderly lose >10% body mass; many never recover prior strength.
Psychiatric: depression in ~30%, PTSD and anxiety in ~20%; often unrecognised.
Functional: 30-50% of survivors aged ≥80 have new dependence in activities of daily living; 20-40% are discharged to institutional care rather than home. [5]
Mitigation: minimise sedation (esp. benzodiazepines), early mobilisation, glucose control avoiding both hyper- and hypoglycaemia, sleep protection, family involvement, and structured post-ICU follow-up (ICU clinic, rehabilitation, cognitive screening).

Glycaemic control in the elderly ICU patient

Glucose targets in the elderly ICU patient

Target: blood glucose 7.8-10.0 mmol/L (140-180 mg/dL) — per NICE-SUGAR and contemporary guidelines. AVOID intensive insulin therapy (4.4-6.1 mmol/L) — it increases severe hypoglycaemia (and with it falls, arrhythmia, death) without mortality benefit. [14]
Insulin: use a titrated intravenous insulin infusion for the unstable/feverish/vasopressor patient; convert to subcutaneous basal-bolus as the patient stabilises. Hold all oral hypoglycaemics during acute illness (metformin = lactic acidosis; sulphonylureas = hypoglycaemia).
Hypoglycaemia <3.9 mmol/L is an emergency — treat with 50% dextrose IV (or 10% if frail veins) and recheck; investigate (insulin error, renal failure, sepsis, adrenal insufficiency).
Diabetes technology: continuous glucose monitoring reduces hypoglycaemia exposure and nursing burden; preferred where available. [13]

Nutrition and sarcopenia

Nutrition principles in the elderly ICU patient

Assess early: weight, BMI (misleading in sarcopenic obesity), grip strength (where possible), Subjective Global Assessment, and a screening tool (mNUTRIC — adds inflammation; higher score predicts benefit from aggressive feeding).
Route: enteral preferred (gut trophism, fewer infections). Hold gastric feeding if high aspirates/prokinetic-resistant ileus — consider post-pyloric. Parenteral only if enteral fails after 5-7 days.
Target: protein 1.2-1.5 g/kg/day (towards the higher end in sarcopenia; some guidelines suggest up to 2.0 g/kg/day in catabolic elderly, balanced against renal tolerance). Energy ~20-25 kcal/kg/day, advancing over the first week (permissive underfeeding reduces infective complications vs early full feeding).
Timing: avoid overfeeding in the first 48 h (refeeding). Replete thiamine, phosphate, potassium, magnesium before and during feeding in the malnourished; monitor daily.
Micronutrients: vitamin D deficiency is near-universal and associated with worse outcomes — replete. Monitor sodium, phosphate, magnesium, zinc.

[1]

Pressure injury, skin and continence

Pressure-injury and skin bundle for the elderly

Risk-assess on admission (Braden or Waterlow) and reassess with any change.
Reposition every 2 hours (or continuous low-pressure/air mattress if unable).
Protect skin — barrier creams for incontinence; keep clean and dry; manage diarrhoea aggressively.
Optimise nutrition (protein, zinc, vitamin C) and hydration.
Minimise devices — remove catheters, drains, and lines the moment they are unneeded (each is a pressure point and infection portal).
Inspect high-risk areas daily — sacrum, heels, occiput, under devices (NIV masks, ETT ties, braces).

[1]

Goals-of-care and family meetings

Elements of an effective goals-of-care conversation

Before

Prepare

Review the chart: age, frailty (CFS), comorbidities, trajectory, prior advance directives, GP records.
Gather the right people: senior clinician, nurse, the patient if they have capacity, the substitute decision-maker/family, and (where appropriate) palliative care.
Find a private space, allow enough time, silence phones.

During

The conversation

Ask what the patient understands and what matters most to them ("What would be a good outcome? What would be unacceptable?").
Give a prognostic frame honestly: "I am worried she may not survive this / may not return to her previous self." Use best-case/worst-case/most-likely language, not percentages alone.
Explore values explicitly: independence, being at home, not being a burden, prolonging life at all costs.
Align: "Given what you have told me, here is what we can offer that fits those goals..."
Make a recommendation — clinicians who avoid recommending cause more distress. Avoid passive "what do you want us to do?" framing.

After

Document and follow through

Document the discussion, the agreed plan, and any treatment limitations (AND/OR a resuscitation decision) in the chart.
Communicate to the whole team and the GP.
Set a time to review — goals of care are dynamic, not one-off.
Offer palliative care and spiritual support; arrange follow-up for the family (post-ICU clinics, bereavement services).

[7]

Withholding vs withdrawing life-sustaining treatment

Common decisions: CPR (DNACPR/Not-for-CPR), mechanical ventilation, renal replacement therapy, vasopressors/inotropes, artificial nutrition/hydration at end of life.
Process: discuss with the team, then the family; agree on a time-limited trial of intensive therapy (e.g. 72 h of full support, then reassess) when prognosis is uncertain; convert to comfort-focused care if goals are not met.
Comfort during withdrawal: titrate opioids (morphine or fentanyl) and benzodiazepines for dyspnoea, pain, agitation; anticholinergic for secretions; do NOT hasten death — relieve suffering. [7]

Management summary — the geriatric ICU checklist

Daily geriatric ICU checklist (the geriatric 'bundle')

Frailty (CFS) documented in the chart; reflected in the goals-of-care plan.
Medication review at every round — deprescribe per Beers/STOPP; dose-adjust for current CrCl; reconcile on admission and discharge.
PADIS triad every shift — pain (CPOT), sedation (RASS target 0 to −1), delirium (CAM-ICU). Treat pain and the cause before any antipsychotic.
ABCDEF bundle running — SAT/SBT daily, dexmedetomidine/propofol over benzodiazepines, mobility progressed, family engaged, sleep protected.
Glucose 7.8-10.0 mmol/L; hold oral hypoglycaemics; hypoglycaemia treated as emergency.
Nutrition advancing to target protein 1.2-1.5 g/kg/day; refeeding monitored; vitamin D repleted.
Pressure, skin, continence — reposition, devices minimised, barrier care.
Renal function reviewed daily — avoid nephrotoxins, dose-adjust, consider RRT early if failing.
Mobilise — passive day 1, active as able; physiotherapy and occupational therapy engaged.
Family communication — predictable updates; structured goals-of-care meeting within 72 h for high-frailty/high-severity patients.
Plan for PICS and discharge — rehabilitation, post-ICU clinic, cognitive screening, caregiver support.

[1]

Additional high-yield clinical pearls

Sixteen pearls to take into the CICM/FFICM/EDIC exam

Frailty, not age, predicts outcomes. A CFS ≥5 doubles mortality and triples institutionalisation and is a stronger predictor than APACHE II or comorbidity score. Score the pre-morbid baseline from collateral, never the acutely ill patient. [1] }
Reserve is lost system-wide. Each system "works at rest but cannot escalate" — the elderly patient decompensates earlier and recovers more slowly, leaving no margin for error. [2] }
Creatinine lies in sarcopenia. A "normal" creatinine can mask a GFR of 30 mL/min — use cystatin C or Cockcroft–Gault, and dose renally-cleared drugs conservatively. [2] }
Delirium is the sixth vital sign. New confusion in an elderly inpatient is a sepsis-equivalent until proven otherwise; CAM-ICU every shift, RASS target 0 to −1. [4] }
Benzodiazepines are the strongest modifiable delirium risk. Prefer analgesia-first sedation with propofol or dexmedetomidine; reserve lorazepam for status epilepticus or alcohol withdrawal. [9] }
Antipsychotics do NOT treat delirium (MIND-USA). Haloperidol/ziprasidone gave no benefit in days alive without delirium — use only for dangerous hyperactive delirium, lowest dose, shortest time, monitor QTc. [10] }
Dexmedetomidine buys ventilator-free time (DEXCOM). In agitated delirium it increased ventilator-free hours — α-2 agonism is sedation-sparing and delirium-reducing. [15] }
Long-term cognition is at stake. Each extra day of delirium raises the risk of cognitive impairment equivalent to TBI; 26% of older survivors have Alzheimer-equivalent deficits at 1 year (Pandharipande). [3] }
ICU admission is the best deprescribing opportunity. Reconcile, screen with Beers/STOPP, hold non-essentials (statins, oral hypoglycaemics, NSAIDs), and communicate stops at discharge to avoid automatic re-prescription. [16] }
Early mobilisation is medicine. The elderly lose 1-5% muscle mass per bed-rest day; day-1-2 mobility reduces delirium, weakness, and pressure injury. [12] }
Glycaemic moderation, not normalisation. Target 7.8-10.0 mmol/L (NICE-SUGAR) — intensive control increases severe hypoglycaemia and death without benefit. [14] }
Frail patients fail extubation. Plan for it (swallow assessment, slow wean, early tracheostomy discussion); do not be caught off guard by reintubation. [8] }
Age alone must not exclude from ICU. A fit 85-year-old with reversible sepsis may do well; a frail 70-year-old may not. Individualise on reversibility, baseline function, and patient values. [7] }
Goals of care is a skill, not a checkbox. Use best-case/worst-case/most-likely framing; explore values; make a recommendation; document and review. Treatment-limitation decisions and resuscitation status follow the conversation, not precede it. [7] }
Pressure injury is a quality marker. Thin skin + immobility + incontinence make it nearly inevitable without active prevention; a stage 3-4 ulcer doubles mortality. Reposition, protect skin, remove devices. [5] }
Plan for survivorship from day 1. PICS (cognitive, physical, psychiatric) is the rule, not the exception, in elderly survivors; arrange rehabilitation, post-ICU follow-up, cognitive screening, and caregiver support before discharge. [18] }

Red flags — additional

Geriatric ICU red flags that should trigger action today

New confusion or reduced RASS → screen CAM-ICU, treat pain/infection/hypoxia/metabolic cause FIRST; antipsychotic only if dangerous. [4] }
CFS ≥5 not yet documented in the chart → score it (collateral history) and book a goals-of-care meeting within 72 h. [1] }
Patient still on home benzodiazepine / anticholinergic / long-acting sulphonylurea → STOP; review against Beers criteria. [16] }
Glucose <3.9 mmol/L → emergency; treat and review insulin/oral-agent error and renal function. [14] }
Sedation deeper than RASS −2 without a clear indication → de-escalate; SAT/SBT today. [9] }
Immobile >24 h → mobilise today (passive at minimum); pressure-area check. [12] }
Rising creatinine or falling urine output in a patient on nephrotoxin/contrast → review drugs, dose-adjust, consider early RRT. [2] }
Family expressing "they would not want this" / signs of conflict → convene a structured goals-of-care meeting; consider palliative care and ethics input early. [7] }
Discharge planned without rehabilitation or follow-up arranged → incomplete plan; arrange post-ICU clinic, cognitive screening, caregiver support. [18] }

References

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[3]Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness N Engl J Med, 2013.PMID 24088092
[4]Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU) JAMA, 2001.PMID 11730446
[5]Heyland DK, Garland A, Bagshaw SM, et al. Recovery after critical illness in patients aged 80 years or older: a multi-center prospective observational cohort study Intensive Care Med, 2015.PMID 26306719
[6]Bruno RR, Wernly B, Bagshaw SM, et al. The Clinical Frailty Scale for mortality prediction of old acutely admitted intensive care patients: a meta-analysis of individual patient-level data Ann Intensive Care, 2023.PMID 37133796
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[8]Fernando SM, McIsaac DI, Rochwerg B, Bagshaw SM, et al. Frailty and invasive mechanical ventilation: association with outcomes, extubation failure, and tracheostomy Intensive Care Med, 2019.PMID 31595352
[9]Devlin JW, Skrobik Y, Gelinas C, Needham DM, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU Crit Care Med, 2018.PMID 30113379
[10]Mart MF, Boehm LM, Kiehl AL, et al. Long-term outcomes after treatment of delirium during critical illness with antipsychotics (MIND-USA): a randomised, placebo-controlled, phase 3 trial Lancet Respir Med, 2024.PMID 38701817
[11]Inouye SK, Bogardus ST, Baker DI, et al. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program J Am Geriatr Soc, 2000.PMID 11129764
[12]Marra A, Ely EW, Pandharipande PP, et al. The ABCDEF Bundle in Critical Care Crit Care Clin, 2017.PMID 28284292
[13]Adigbli DK, Hammond NE, Finfer S, et al. Managing blood glucose in the intensive care unit Intensive Care Med, 2025.PMID 39714614
[14]NICE-SUGAR Study Investigators, Finfer S, et al. Intensive versus conventional glucose control in critically ill patients N Engl J Med, 2009.PMID 19318384
[15]Reade MC, Eastwood GM, Bellomo R, et al. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial JAMA, 2016.PMID 26975647
[16]American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults J Am Geriatr Soc, 2023.PMID 37139824
[17]Fernando SM, McIsaac DI, Perry JJ, Bagshaw SM, et al. Frailty and Associated Outcomes and Resource Utilization Among Older ICU Patients With Suspected Infection Crit Care Med, 2019.PMID 31135504
[18]Muscedere J, Bagshaw SM, Kho M, et al. Frailty, Outcomes, Recovery and Care Steps of Critically Ill Patients (FORECAST): a prospective, multi-centre, cohort study Intensive Care Med, 2024.PMID 38748266