Older Adults in the Cardiac Intensive Care Unit: AHA Scientific Statement

Authors:
Damluji AA, Forman DE, van Diepen S, et al.
Citation:
Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association. Circulation 2019;Dec 9:[Epub ahead of print].

The following are key points to remember from this American Heart Association (AHA) Scientific Statement on Older Adults in the Cardiac Intensive Care Unit (CICU): Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care:

  1. Delirium is a state of an acute disturbance in awareness and attention that commonly arises during critical illness and contributes to increased hospital mortality, with estimates ranging between 17% and 33%. Older patients with cardiovascular disease (CVD), particularly those with baseline cognitive and sensory limitations, have high susceptibility to ICU–associated delirium (delirium estimate, 9-44%). Although tools to predict and identify delirium are available, new measures and therapies to prevent and treat delirium and related consequences are still needed.
  2. Frailty is a clinical state in which there is increased vulnerability to stressors with a higher likelihood of functional decline, complications, and increased mortality from disease and therapeutic interventions. Such vulnerability relates to diminished physiological reserves across multiple physiological systems. Frailty is common among older adults admitted to the CICU, with an estimate as high as 63%. Frail patients with CVD usually have poorer outcomes, with associated risks pertaining to baseline CVD, poor tolerance to medications and procedures, and physical (functional decline, falls, and cognitive impairments).
  3. Multimorbidity is a state in which ≥2 chronic medical conditions occur simultaneously. The prevalence of multimorbidity rises significantly with age, such that approximately 70% of all adults ≥75 years of age live with active coexisting multiple chronic conditions. Efforts to understand the influence of multimorbidity on CICU care and novel therapeutic approaches tailored to address this geriatric syndrome are needed; disease-specific strategies of care can inadvertently set up many older adults to develop untoward effects of multimorbidity.
  4. Polypharmacy entails the use of ≥5 medications, increasing the risk for inappropriate treatments, including medications that are not indicated, are not effective, or constitute therapeutic duplications. Older adults admitted to the CICU take an average of 12 different prescriptions that include preadmission medications, new therapies for the primary acute pathophysiology, and management of destabilized comorbidities, anxiety, delirium, or sleep. The current CICU care paradigm may increase the likelihood of harm related to polypharmacy in older adults.
  5. Immobility, bed rest, acquired muscle weakness, and pressure ulcers are consequences of CICU stay that often exacerbate or worsen pre-existing geriatric syndromes in older patients with acute CVD.
  6. Decreased oral intake, poor appetite, or prolonged periods of invasive mechanical ventilation or critical illness result in malnutrition in patients treated in the ICU, especially because acute illnesses often manifest as hypercatabolic states with increased nutrient demands. Although optimal caloric intake for older patients with acute CVD is currently unclear, enteral nutrition can be considered to prevent mucosal atrophy and to preserve muscle, which in turn may prevent disuse atrophy.
  7. The management of the most common acute CVD (such as acute myocardial infarction, heart failure, acute aortic syndrome, and pulmonary embolism) is often complicated in older patients. More studies are needed to integrate conventional CICU clinical standards to geriatric complexities.
  8. Shared decision-making, end-of-life care, and palliative care services complement care in the CICU and enhance management in older patients with acute CVD. The proven utility of palliative care suggests that it remains significantly underused in the CICU. Transitional team, multimodal approaches, and preventive care can all be integrated with CICU precepts to enhance care for an aging population.
  9. Strategies to achieve a holistic approach to each patient, that is, consistent with a CGA, remain an important goal to improve the care of older patients in the CICU. Recognizing geriatric syndromes is a key first step in choosing care that is most likely to succeed and that is most consistent with each patient’s personal goals of care. Frailty, cognitive decline, and other geriatric domains often accelerate in older adults as an effect of the CICU environment and thereby compound vulnerability to CICU-acquired weakness, weight loss, delirium, and other detrimental manifestations. Indolent and acute exacerbations of geriatric syndromes in older patients in the CICU highlight the need for studying dynamic CICU care models.

Perspective: This is an outstanding document that summarizes the opportunity to improve the management of the elderly in the CICU.

Keywords: Cognition, Comorbidity, Critical Illness, Delirium, Frail Elderly, Geriatrics, Heart Failure, Hospice and Palliative Care Nursing, Hospital Mortality, Intensive Care Units, Malnutrition, Muscle Weakness, Muscular Disorders, Atrophic, Myocardial Infarction, Palliative Care, Primary Prevention, Polypharmacy, Pulmonary Embolism, Respiration, Artificial, Terminal Care, Weight Loss


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