Executive Summary: Society of Critical Care Medicine Guidelines on Caring for Older Adults in the ICU

For the past 25 years, older adults, defined as those 65 years old or older, have composed more than half of all ICU days in the United States (1). With the number of older Americans projected to increase from 58 million in 2022 to 82 million by 2050, the proportion of ICU patients who are older is expected to rise (2–4). Caring for older patients in critical care settings requires knowledge of their unique factors and considerations, such as geriatric syndromes and outcomes that matter most to this growing demographic (5). The Board of the American College of Critical Care Medicine convened a multidisciplinary panel to develop focused, evidence-based recommendations on caring for older adults in the ICU. The panel conducted a systematic review of the published scientific literature, focusing on patient-oriented, clinically relevant outcomes to answer Patient, Intervention, Comparator, and Outcomes (PICO) questions regarding the care of older adults in the ICU. The clinical practice recommendations were developed according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process (3). This clinical practice guidelines reflect the state of knowledge at the time of publication. The full guidelines may be accessed via (6). RECOMMENDATIONS The panel made two conditional recommendations as presented below. A “Conditional” recommendation reflects a low degree of certainty in the appropriateness of the patient care strategy for all patients. It requires that the clinician use clinical knowledge and expertise and strongly considers the individual patient’s values and preferences to determine the best course of action. The ultimate judgment regarding any specific care must be made by the treating clinician and the patient, taking into consideration the individual circumstances of the patient, available treatment options, and resources. The remaining three PICO questions addressed in these guidelines resulted in no recommendation being made due to inconsistent or insufficient evidence. Future research is needed on several topic areas covered by this guideline. A summary of research priorities for each topic is presented in Table 3 of the full guidelines (6). We suggest a geriatric model of care for all older adults admitted to the ICU (conditional recommendation, very low certainty of evidence). Remarks: The parameters in geriatric models of care may vary depending on hospital, resources, and expertise available. The included studies intentionally incorporated geriatric principles into the care of older adults (e.g., removal of unnecessary tethering devices, addressing hearing impairment, improving functional and cognitive outcomes through occupational therapy). A systematic literature search was completed, and three studies investigating a geriatric-specific model of care or formal geriatrics consultation were included in discussion with the panel (7–9). The GRADE evidence synthesis showed very low certainty across all evaluated outcomes due to risk of bias, imprecision, and indirectness. In one randomized controlled trial (RCT), mortality and hospital length of stay showed an uncertain effect (7). In another RCT, activities of daily living outcomes showed an uncertain effect (8). Pooled analysis from these two RCTs showed an uncertain effect on in-hospital delirium and discharge to a nursing home. The final included study, a pre-/post-intervention pilot trial, suggested that a three-component ICU intervention reduced incident delirium (9). Despite uncertain effects in the evidence, the panel determined the desirable effects of a geriatric model of care are small to moderate, especially in considering that many of the point estimates fall on the side of benefit and align with outcomes that matter most to older adults. Undesirable effects were determined trivial by the panel, highlighting the perceived lack of harms in a geriatric model of care. There was no evidence to address cost effectiveness of the interventions. With regard to equity, the panel acknowledged that geriatricians may not be widely available in critical care settings. However, the panel noted that geriatric models of care can be implemented without a geriatrician and that implementation of age-friendly principles would improve equitable care for older adults with critical illness. We suggest not using antipsychotic medications for the prevention of delirium in critically ill older adult patients (conditional recommendation, very low certainty evidence). Remarks: The antipsychotic drugs used in the included studies were haloperidol and quetiapine. A systematic literature search was completed, and three RCTs investigating the prevention of delirium in adults with critical illness (but not exclusively over the age of 65) were included (10–12). The GRADE evidence synthesis showed very low certainty across all evaluated outcomes due to indirectness, risk of bias, inconsistency, and imprecision. Pooled analysis of the three RCTs showed an uncertain effect on the incidence and duration of delirium. Likewise, pooled effects of mortality, duration of invasive mechanical ventilation, ICU length of stay, hospital length of stay, and adverse events showed uncertain effects. The panel was limited in its ability to make conclusions for older adults based on this evidence, particularly in light of the trials not being conducted exclusively in this population. The panel expressed concern about the potential harms of routine antipsychotic use in older patients with critical illness, acknowledging that antipsychotics are included in high-risk medication lists for older adults and have been clearly associated with adverse events in other studies of older adults (13–15). There was no evidence to address cost effectiveness of the interventions, and the panel expressed concern about the role of social determinants of health, race, ethnicity, and language in detecting delirium in older adults. RESEARCH AGENDA We developed a research agenda for the care of older adults in the ICU, presented in Table 3 of the main guidelines document (6). In addition to the research agenda outlined in each area, the panel acknowledged the dearth of critical care trials that exclusively enroll older persons. The panel also noted that many critical care trials enrolling the general ICU population often have age cutoffs for upper limit that are not justified scientifically. With the aging of the population, it is imperative that the critical care research community designs clinical trials that exclusively enroll older adults and prioritizes improved inclusion of older adults in critical care clinical trials in the general ICU population.