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Column: Key steps can help older patients recover from a stay in the ICU

By Judith Graham, KAISER HEALTH NEWS | September 15, 2016

About Navigating Aging

Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health care system.

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For more Kaiser Health News coverage of aging, click here.

Your 80-something-year-old dad has just been admitted to the hospital’s intensive care unit after a stroke or a heart attack. Now, he’s surrounded by blinking monitors, with tubes in his arms and alarms going off around him.

You’re scared and full of uncertainty. Will the vital, still-healthy man you’ve known recover and be able to return home?

Increasingly, the answer is yes. As many as 1.4 million seniors survive a stay in the ICU every year. And most go home, with varying degrees of disability.

ICUs are responding to older patients’ needs by helping them try to regain functioning — something that families need to pay attention to as well.

“There’s a growing recognition that preparing patients and families for recovery needs to start in the ICU,” said Dr. Meghan Brooks Lane-Fall, assistant professor of critical care at the Hospital of the University of Pennsylvania.

Making this transition more difficult is older patients’ vulnerability to a set of physical, cognitive and psychological problems known as “post-ICU syndrome.” This includes muscle weakness and other physical impairments, problems with thinking and memory, and symptoms of depression, anxiety and post-traumatic stress.

Researchers have been documenting the extent of these difficulties in recent years. At Yale School of Medicine, Dr. Lauren Ferrante studied 291 adults age 70 or older who were admitted to the ICU and found that 52.3 percent regained their “pre-ICU” level of functioning. The remainder became more impaired or died. Generally, physical recovery occurred within six months of being discharged from the hospital.

Emotional recovery can take longer. In a recent analysis of 38 studies, researchers found that about one-third of ICU patients, both young and old, develop depressive symptoms that persist through 12 months of follow-up.

For doctors, the challenge is to distinguish between older patients who are likely to recover from an ICU stay and those who are not. Sadly, a large number of older adults die in the ICU or later on in the hospital, especially those who are very old and frail.

For families, the challenge is to communicate an older patient’s wishes clearly and consistently to ICU physicians.

“Typically, doctors will be focused on technical concerns such as a patient’s hemoglobin or oxygen levels,” said Alison Turnbull, an assistant professor of critical care medicine at Johns Hopkins University. “Your job is help them remember the big picture — the patient’s goals and values.”

Here are several things you and your family can do to enhance the potential for a meaningful recovery:

  • Be present. “Sit with your loved one,” advised Ferrante of Yale. “Talk to them. Tell them what’s happening — ‘You’re here because you have pneumonia.’” Doing so can help prevent delirium — an acute state of mental incoherence — and alleviate anxiety.
  • Stay informed. Every day, be sure to ask, “What’s the plan for today?” And “try to have a sit-down meeting with a physician within the first day and three to four days thereafter,” said Dr. Douglas White, director of the Program on Ethics and Decision Making in Critical Illness at the University of Pittsburgh. Among the questions that should guide these conversations: “Will this treatment help my loved one achieve her goals?” Turnbull suggested.
  • Emphasize recovery. “Once life-threatening problems have been resolved, start to ask doctors and nurses, ‘What can we do today to improve mom’s function?’” White said. Helping ICU staff understand your loved one’s cues is “hugely important” and will help staff know when something isn’t working and how to respond, Lane-Fall noted.
  • Minimize sedation. The use of sedatives like benzodiazepines and narcotics can cause delirium and should be minimized, to the extent possible, in older patients, said Dr. Jason Katz, medical director of the critical care service at the University of North Carolina School of Medicine. If your loved one is heavily sedated, ask a physician if medication can be safely cut back.
  • Bring in essentials. Ferrante has found that unaddressed hearing and vision problems in the ICU can compromise recovery, most likely by contributing to disorientation and delirium. So, make sure your family member has eyeglasses and a hearing aid on hand.
  • Mobilize early. Once someone is stabilized, make sure they’re getting out of bed and walking around, if they can. The sooner a physical therapist and occupational therapist come in and start working with a patient to build strength and capacity, the better.
  • Get them eating. It’s common for older adults to lose significant weight in the ICU — a health risk in itself. Keep an eye on what they’re getting in the way of nutrition and, as soon as possible, ask if they can start eating on their own.
  • Create an ICU diary. Having friends, family members, nurses and others write daily about what happened in the ICU can help patients deal with post-ICU anxiety related to not knowing what happened and feeling out of control.
  • Prepare for home. More than half of seniors who survive a stay in the ICU are sent home without support from home health aides. So, family members should get as much practical information as they can from nurses and therapists before leaving the ICU. It surely will come in handy later.

— Kaiser Health News coverage of late life and geriatric care is supported by The John A. Hartford Foundation.