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. Author manuscript; available in PMC: 2016 Jun 1.
Published in final edited form as: Crit Care Med. 2015 Jun;43(6):1265–1275. doi: 10.1097/CCM.0000000000000924

Understanding and Reducing Disability in Older Adults Following Critical Illness

NE Brummel 1,2,3, MC Balas 4, A Morandi 3,5,6, LE Ferrante 7, TM Gill 8, EW Ely 1,2,3,9
PMCID: PMC4640688  NIHMSID: NIHMS732115  PMID: 25756418

Abstract

Objective

To review how disability can develop in older adults with critical illness and to explore ways to reduce long-term disability following critical illness.

Data Sources

Review of the literature describing post-critical illness disability in older adults and expert opinion.

Results

We identified 19 studies evaluating disability outcomes in critically ill patients age 65 years and older. Newly acquired disability in activities of daily living, instrumental activities of daily living and mobility activities was commonplace among older adults who survived a critical illness. Incident dementia and less-severe cognitive impairment was also highly prevalent. Factors related to the acute critical illness, intensive care unit practices such as heavy sedation, physical restraints and immobility as well as aging physiology and coexisting geriatric conditions can combine to result in these poor outcomes.

Conclusion

Older adults who survive critical illness suffer physical and cognitive declines resulting in disability at greater rates than hospitalized, non-critically ill and community dwelling older adults. Interventions derived from widely available geriatric care models in use outside of the ICU, which address modifiable risk factors including immobility and delirium, are associated with improved functional and cognitive outcomes and can be used to complement ICU-focused models such as the ABCDEs.

Introduction

For millions each year, surviving a critical illness represents a life-altering event punctuated by physical and cognitive impairments resulting in new-onset disability (1–8). Patients of all ages are affected (8–10). Older adults (i.e., those 65 years or older), however, bear the lion’s share of this burden as the demographic most likely to become critically ill (11–14). Moreover, because the majority of patients with critical illness are older adults, the aging of the population in coming years, is expected to drive a significant increase in the number of critical illness survivors with physical impairments, cognitive impairments and disabilities (5, 7, 14, 15).

Regardless of age, critical illness survival implies resolution of the underlying illness, yet age may play an important role. In the case of respiratory failure, for example, older adults achieve physiologic recovery from their illness at least as fast as their younger counterparts (16, 17). After adjusting for potential confounders such as severity of illness, however, older adults are more likely to remain intubated and in the ICU (17). These data imply that ongoing and destructive processes—apart from those that resulted in the development of critical illness—may be responsible for poor physical and cognitive outcomes suffered by many older adults.

Critical illness survival also exists on a spectrum ranging from those who are free of disability to those who are severely disabled, a number of whom are “chronically critically ill” or “hospital dependent” (18–21). Why some patients “successfully” recover from critical illness while others do not is unknown. Thus, a better understanding of the contributions to poor long-term physical and cognitive functioning that results in disability is needed to improve the lives of the growing number of older adults who survive a critical illness each year.

The disabling process results from the complex interrelationship between a patient’s pre-illness vulnerability and the acute stress of a critical illness and treatment in an ICU (22). In older adults, the normal aging process, also known as senescence, in combination with systemic pathology from comorbid medical conditions, injuries, environmental and epigenetic factors can reduce physiologic reserves and the ability to “bounce back” from an acute stressor (23–25). Thus, a highly vulnerable patient (e.g., one who is frail or physically or cognitively impaired before their illness) may develop disability following a less severe illness (e.g., urinary tract infection). Alternatively, a patient with low vulnerability will require a greater insult (e.g., septic shock with multiple organ failures) before developing disability.

This manuscript, written by an interdisciplinary team of experts in critical care, geriatrics and gerontology, presents an integrative literature review of the epidemiology of disability in survivors of a critical illness; reviews how critical illness, in the setting of the physiology of aging, can result in disability following a critical illness; and, finally, presents expert opinion on steps that can be taken to make the ICU a more ‘friendly’ place for older adults, with the ultimate goal of reducing the component of post-ICU suffering that is long-term disability.

The development of post-critical illness disability

Optimizing long-term outcomes for survivors of critical illness must begin with a discussion of the disabling process in the setting of critical illness. This understanding will allow researchers and clinicians to communicate using the same terminology, to gain insights into how diseases and treatments may affect outcomes, to define better outcomes of importance to patients and, eventually, to enhance clinical care.

While different conceptual models exist to describe the disabling process, the framework originally proposed by Nagi (26), modified by Verbrugge and Jette (27), provides a robust, informative way to understand how critical illness may lead to disability. According to this model, diseases or injuries (pathology) result in dysfunction of body systems (impairments) leading to the inability to carry out basic physical and cognitive functions (functional limitations) that alter the individual’s capability to meet the demands of his or her environment (disability) (Figure 1). Hence, disability, simply defined, represents the difference between a person’s capabilities and the demands of a particular physical or social environment (27, 28).

Figure 1.

Figure 1

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A conceptual model of the disablement process and its application to a survivor of a critical illness. This framework illustrates how diseases (pathology) result in body system dysfunction (impairments) that limits an individual’s ability to perform basic actions (functional limitations) and prevent that individual from performing socially expected activities (disability). When applied to a hypothetical survivor of critical illness, the effects of critical illness alter the functioning of skeletal muscle and the brain to result in the inability to move one’s arms and legs as well as to remember and think clearly, preventing the patient from carrying out activities necessary to live independently such as ADLs (dressing, bathing, walking across a room), IADLs (managing money, cooking a meal) or to remain employed. ARDS, the acute respiratory distress syndrome; ICU, intensive care unit; ADLs, activities of daily living; IADLs, instrumental activities of daily living. Adapted with permission from Verbrugge LM, Jette AM. The disablement process. Social Science & Medicine 1994;38(1):1–14.

To illustrate this process, let us explore a hypothetical case of Mrs. D, a 67 year-old widow who, prior to her illness, lived independently and was employed as an executive secretary (Figure 1). She was mechanically ventilated in the ICU for 7 days due to pneumococcal pneumonia and severe sepsis (pathology). She was, sedated and confined to bed for the first 5 days of her illness and suffered 6 days of delirium while in the ICU (pathology). Following extubation, the ICU physical therapist notes that Mrs. D has significant muscle atrophy and weakness that is attributed to ICU-acquired weakness (impairment). With her delirium now resolved, Mrs. D’s daughter expresses concerns that her mother is having trouble thinking and remembering things (impairment). She notes that Mrs. D was “sharp as a tack” prior to her illness. After being transferred out of the ICU, Mrs. D continues to require assistance to ambulate and to lift her arms (functional limitation). She complains that she cannot complete crossword puzzles that she did easily before her illness and that she cannot recall the details of conversations with her family (functional limitation). As discharge planning progresses, Mrs. D’s daughter is nervous that her mother will be unable to manage her medications and her finances (disability in instrumental activities of daily living). She continues to require assistance to bathe, dress, and transfer from the bed to a chair (disability in basic activities of daily living). As a result of these newly acquired disabilities, Mrs. D is discharged to a skilled nursing facility, where she still resides 1 year later. She is unable to return to work (disability in employment).

Epidemiology of disability following critical illness

The declines in Mrs. D’s physical and cognitive functioning represent a common scenario for the estimated 1.4 million older adults in the United States (and many more worldwide) who survive a critical illness each year (6). We searched PubMed, CINAHL, Web of Science and Google Scholar for studies reporting disability outcomes (i.e., activities of daily living [ADLs], instrumental activities of daily living [IADLs] and mobility activities) and/or cognitive outcomes among patients treated in an ICU who were 65 years or older. We also reviewed the bibliographies of relevant citations to identify additional citations. Overall, 19 studies met these criteria (2, 3, 29–45): 17 studies reported disability outcomes (2, 29–38, 40–42, 44), 2 studies reported cognitive outcomes (3, 45) and 2 studies reported both (39, 43).

Of the studies that reported disability outcomes (Table S1), 13 were single center cohorts and 12 enrolled fewer than 300 patients. Patients were enrolled from mixed (medical and surgical) ICUs in 11 studies, from medical ICUs in 4 studies and from surgical ICUs in 2 studies. The mean age of patients enrolled in the studies ranged from 69 to 89 years. Most (10/14) of the studies that assessed ADL function used the Katz ADL (46), 2 studies used the Barthel Index (47) and 2 other studies used other measures. All four studies that assessed IADLs used the Lawton Index (48). Of the three studies that assessed mobility status (2, 35, 44) each used different scoring measures (35, 49, 50). Most studies assessed outcomes less than 12 months following critical illness.

Disability in ADLs was highly prevalent after a critical illness, and was present in 33% to 58% of patients when follow-up occurred less than three months after the index illness and 12% to 97% for follow-up time points occurring more than six months after the index illness. Among the nine studies that reported baseline (pre-illness) ADL function, new-onset or worsened ADL disability was present in 10% to 63% of patients assessed less than 1 year and in 22% to 37% of patients assessed 1 year or more after their critical illness (29, 31, 34–37, 40–43). New or worsened IADL disability was also common and reported in 22% to 45% of patients evaluated 3 months to almost 2 years following the index illness (34, 38, 43). A single study where a number of patients were disabled in ADLs and IADLs at baseline (43% and 60%, respectively) reported no change in disability at 3-month follow-up (42). Finally, disability in mobility activities was present in 14% to 87% of patients assessed during the first year following their index illness.

Of the four studies that assessed cognitive outcomes, two were single center cohorts. Each study used a different outcome measure and assessed cognition at time points ranging from 3 months to 8 years following the index illness (Table S2) (3, 39, 43, 45). Three out of four studies assessed pre-illness cognitive functioning and reported newly developed (i.e., incident) dementia in 12% to 18% of patients who were assessed between 1 and 8 years after their illness (3, 39, 45). Prevalent dementia (i.e., unknown pre-illness dementia status), was reported in 15% of patients at hospital discharge and in 10% at 1-year follow-up (43). In addition to the incidence of dementia, one study also reported newly acquired mild to moderate cognitive impairment was present in 56% of patients—yielding an overall proportion of cognitive impairment plus dementia of 73% of patients 4 years after critical illness (39).

The findings of this review indicate that disability in ADLs, IADLs and mobility is common among older adults who survive a critical illness. They also highlight the substantial burden of newly acquired cognitive impairment and dementia following critical illness. Nevertheless, several limitations of these studies are worthy of mention. First, few studies have reported data on these important patient-centered outcomes after critical illness. Second, the majority of these studies are small, single-center cohorts that used heterogeneous assessment methods with follow-up time points that varied widely. Third, while some studies reported data on patients’ pre-illness disability, physical and/or cognitive functioning—the majority did not. Thus, the findings may be biased and the true effect of critical illness on these outcomes remains unclear (51). Nevertheless, the rates of post-critical illness disability reported in these studies are substantially higher rates than community dwelling persons (52–54) and older adults who are hospitalized without critical illness (55, 56). Finally, the results of these studies are also biased by the large number of patients who were not included in follow-up assessments due to the competing risk of death among older survivors of critical illness.

Intersections of aging physiology and critical illness

Some older adults carry a low-burden of aging-related disease and disability, remain highly functional and can be thought of as aging “successfully” (57, 58). For the vast majority, however, “normal” aging is characterized by a progressive accumulation of molecular and cellular damage due to illness, injury, environmental and epigenetic factors that lead to physiologic impairments of organ systems and an increased risk of disease, disability and death (23, 24). The rate of this decline of organ systems is controlled by homeostatic maintenance and repair mechanisms (23). Over time, maintenance and repair functions lose complexity, and maladaptive stress responses alter the body’s ability to maintain homeostasis. The degree to which these functions are altered varies from person to person and from organ system to organ system and may explain, in part, variations in the speed of aging (23). Accelerated decline of homeostatic mechanisms, which often characterizes the geriatric condition known as frailty, is present in up to one-third of all older adults and leads to a state of increased vulnerability and disproportionate changes in functional and cognitive status following an acute stressor, such as critical illness (59–64).

While aging-related alterations to homeostatic mechanisms occur in nearly all organ systems, in the context of critical illness, changes to the structure and function of skeletal muscle and/or the brain place older patients at increased risk of developing newly acquired and/or worsening disability. The effects of critical illness on other organ systems such as the aging cardiovascular, pulmonary and renal systems, have been described elsewhere (65–67).

Aging skeletal muscles in critical illness

Roughly half of persons older than 65 years have clinically significant diminished skeletal muscle mass and strength due to age-related changes known as sarcopenia (68). The causes of sarcopenia are multifactorial and include disuse atrophy, changes in endocrine function, inflammation, and nutritional deficiencies (68, 69). Sarcopenia is characterized by a decrease in the size, number and composition of muscle fibers, remodeling of motor units, increased intramuscular lipid concentration, inflammation, oxidative stress and loss of anabolic stimuli (70, 71). The end result of sarcopenia is reduced muscle power and strength, progressive weakness, fatigue, slow gait speeds and difficulty ambulating long distances (68, 70, 72). Sarcopenia is associated with a variety of poor clinical outcomes including increased length of hospital stay, an increased risk of readmission and death (73–76).

During critical illness, inflammation alters the atrophy-hypertrophy-signaling pathways within skeletal muscle, resulting in acute muscle wasting in the first few days of illness, particularly among those with multiple organ failures (77–79). This imbalance between muscle breakdown and recovery represents an additional degenerative insult that cannot be appropriately countered in aging muscle and may, in part, explain the higher incidence of ICU-acquired weakness among older patients (78, 80).

Immobility, even among patients who were ambulatory prior to their illness, is common during hospitalization (81–83). For patients of all ages, bed rest results in losses in muscle mass, strength and aerobic capacity (84); yet, these losses are accelerated by roughly a factor of three among older adults (85). In non-critically ill older patients, even short periods (e.g., 1–2 days) of reduced activity or bed rest can result in disability and nursing home admission (86, 87).

Thus, the skeletal muscles of older adults in the ICU face the concurrent insults of inflammation and bed rest, which are intensified by both the severity and duration of the underlying critical illness. The end result is muscle atrophy, weakness and diminished aerobic capacity, leading to the inability to carryout basic self-care activities (i.e., disability) following critical illness.

The aging brain in critical illness

Aging results in a variable trajectory of declines in cognitive abilities, particularly in working memory, short-term memory and processing speed (88–90). In the aging brain, oxidative stress, epigenetic factors, diminished autophagy, decreased insulin/IGF-1 signaling, impaired stress responses and clearance of toxic proteins in combination, alter hormonal and immunologic feedback mechanisms (89, 91–95). Loss of these feedback mechanisms can result in exuberant inflammatory responses to acute stress, resulting in neurodegeneration, which then drives additional inflammation. Thus, the aging brain can be caught in a vicious cycle that, over time, results in neuronal loss and clinically significant cognitive decline.

The acute stress of critical illness and age-related changes to the brain make critically ill older adults particularly susceptible to developing delirium (96). Delirium results from the complex interaction of a patient’s underlying vulnerability, neurotransmitter imbalances, inflammatory responses, oxidative stress, physiologic stressors and metabolic derangements that result in the large-scale disruption of neural networks, resulting in fluctuating acute confusion, altered consciousness, inattention and disorganized thinking (96–100).

In some cases, delirium may resolve without long-term consequences. Nevertheless, evidence now supports an association between delirium and long-term cognitive sequelae including dementia and accelerated cognitive decline (8, 101–103). In critically ill patients delirium duration is one of the strongest independent predictors of significant cognitive deficits after critical illness (8, 104). Although the precise mechanisms are unclear, it is hypothesized that delirium, triggered by an acute insult, initiates or exacerbates the pathologic age-related structural, immune, neurochemical and neurohormonal brain changes. This results in a cycle of neuroinflammation and neurodegeneration leading to cognitive impairment (95, 105, 106).

Reducing post-critical illness disability

Post-critical illness disability results from the interaction of a patient’s baseline health status and vulnerability to the acute stress of critical illness with the effects of the acute illness itself and treatment practices during and after the ICU admission (55, 107, 108). Thus, because it is not (yet) possible to prevent aging, to reverse vulnerability in the setting of critical illness which is most often an unplanned event, or to completely avoid critical illness-related organ system impairments, the focus of preventing disabilities should lie with the identification of critically ill patients who are at risk for developing/exacerbating disabilities and in addressing specific iatrogenic contributors to post-critical illness disability.

Identifying high-risk older patients

Outside the ICU, several tools exist to identify patients at risk for post-hospital disability(109–112). Although the content of these tools differ slightly, each incorporates the patient’s pre-illness functional and cognitive status, highlighting the important contribution of baseline status to post-hospital outcomes. Despite an association with improved survival and ability to reside in their own home following a hospitalization (113), few hospitalized older adults undergo functional and cognitive status assessments during hospitalization (114). This practice is even less common in the ICU, where few clinicians have training in assessment techniques. Additional barriers to functional and cognitive status assessment in critically ill patients include the inability of many patients to communicate directly due to endotracheal tubes, sedation and/or delirium, as well as time constrains of the busy ICU workflow. These barriers, however, may be overcome using a pragmatic functional and cognitive assessment adapted for the unique needs of critically ill patients (Table 1).

Table 1.

Pragmatic functional and cognitive assessment for older adults with critical illness

Domain Assessed
Activities of Daily Living Mobility Cognition
As soon as possible
after ICU admission
(use surrogate to
obtain information,
as needed)		 Katz ADL Index(46)a:

Is assistance required to:
1) Bathe or shower
2) Get dressed
3) Get to the restroom
4) Transfer from bed to chair
5) Control bladder or bowels
6) Eat a meal

Consider high risk for post-critical illness
disability if requires assistance to complete
any ADL.		 Sit→Stand→Walk

Assess patient’s ability to:
1) Sit up in bed
2) Stand at edge of bed
3) Walk a few feet (using assistive devices, if
needed)

Consider high risk for post-critical illness
disability if unable to get out of bed and
stand.		 If patient alert and non-delirious: Mini–Cog,
or,
If patient comatose or delirious: IQCODE (perform with
surrogate)

Mini-Cog(158):
1) 3-item recall (e.g., Banana, Sunrise, Chair)
2) Ask patient to draw a clock face showing the time as
11:10 (patient should draw circle, numbers and hands at
appropriate time)
3) Ask patient to recall 3 words

(1 point for each correct word, 2 points for correct clock)

Consider high risk for post-critical illness disability if scores
<2 points

IQCODE(159)a:
16-question tool comparing current cognitive functioning to
10 years ago. See supplementary materials for IQCODE
questionnaire.

(Scores range from 1 to 5 where 1 indicates much improved
functioning, 5 indicates much worse functioning and 3
indicates no change)

Consider high risk for post-critical illness disability if scores
3.44 or greater.
Daily while in ICU Have patient perform ADLs. Sit→ Stand → Walk Delirium screening
Directly observe or obtain information from
patient’s family, bedside nurses, physical
or occupational therapists.		 Directly observe or obtain information from
patient’s family, bedside nurses, physical or
occupational therapists.		 Use CAM-ICU or ICDSC
Consider high risk for post-critical illness
disability if requires assistance to complete
any ADL.		 Consider high risk for post-critical illness
disability if requires assistance to get out of
bed and stand.		 Each day of delirium increases risk for post-critical illness
disability
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a

The complete Katz Index of Activities of Daily Living (Katz ADL) instrument and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) instrument may be found supplementary materials. CAM-ICU, Confusion Assessment Method for the ICU; ICDSC, Intensive Care Delirium Screening Checklist.

Addressing modifiable risk factors for disability

Two of the most common and modifiable risk factors for subsequent functional and cognitive decline are immobility and delirium. Immobility is an “under-recognized epidemic” among hospitalized older adults with deleterious effects on subsequent physical and cognitive function (62, 87, 115, 116). Delirium, present in up to 80% of all mechanically ventilated patients, is among the strongest predictors of subsequent cognitive impairment and also contributes to long-term disability in ADLs (8, 104, 117, 118). Both immobility and delirium exacerbate underlying age-related physiologic changes; thus, efforts to shorten their duration (or prevent their occurrence all together) can have substantial impacts on post-critical illness outcomes (116, 119, 120).

For over half a century, the untoward effects of immobility and delirium have been the focus of clinicians caring for hospitalized older adults outside of the ICU, yet only recently has become the focus of those caring for the critically ill (108, 121–128). Thus, geriatricians have had a significant head start in preventing and managing immobility and delirium through interdisciplinary “geriatric care models” (119, 129–132). Within the last decade, however, ICU-focused interdisciplinary strategies, such as the “ABCDE bundle,” have been described and implemented (133–138). Using a synthesis of the literature and expert opinion, we now will discuss how components of geriatric care models can be used to complement the ABCDE bundle and other “best practices” of ICU care.

Recommended interventions to improve functional and cognitive outcomes

Members of the ICU team should assessment a patient’s functional and cognitive status as soon as possible after admission either through direct patient evaluation or from the patient’s surrogate, to identify patients at high risk for post-critical illness disability. Additionally, because functional and cognitive status can fluctuate during a hospitalization, daily monitoring should be performed to alert clinicians to potential changes.

The ABCDE bundle is advocated by a number of professional societies including the Society for Critical Care Medicine and combines evidence-based strategies to reduce the harms associated with sedation, mechanical ventilation, delirium and immobility in critically ill patients of all ages. While a complete description of each of the components of the ABCDE bundle is beyond the scope of this review, excellent resources that detail the specific components of the ABCDE bundle and the evidence behind them are available at both www.iculiberation.org and www.icudelirium.org. Briefly, the ABCDE bundle includes daily spontaneous Awakening and spontaneous Breathing trial Coordination (“ABC”), Choosing to sedate patients only when necessary and to “lighter” levels (“C”), screening for Delirium (“D”) and the Early mobilization/physical and occupational therapy (“E”). Implementation of the ABCDE bundle is independently associated with a doubling of the odds of a patient being mobilized out of bed and a 45% decrease in the odds of developing delirium (139). Additionally, individual components of the ABCDEs are associated with improved functional status at hospital discharge and decreased mortality following critical illness (116, 140).

Older adults, however, face additional risk factors for poor functional and cognitive outcomes not addressed by the ABCDE bundle, including social isolation, enforced dependence in ADLs, restraints, poor nutrition, polypharmacy, and unnecessary medical tests and procedures (119, 129, 132). To address these risk factors, three widely-implemented “geriatric care models” — The Acute Care for Elders (ACE) model, the Hospital Elder Life Program (HELP) and the Nurses Improving Care for Healthsystem Elders (NICHE) — were developed (119, 129, 132). The specific interventions contained in these programs differ; yet, each addresses the risk factors faced more commonly by older adults. In general, each care model reduce falls, prevent functional decline, decrease the proportion of patients who develop delirium, shorten hospital length of stay and increase the likelihood of being discharged to home (130, 141). Whether these same outcomes can be achieved in older adults who are critically ill is an area in need of further research.

Nevertheless, given their association with improved outcomes in less-severely ill older adults, we propose a group of evidence-based interventions that can be used to complement existing ICU best-practices and care bundles to reduce functional and cognitive decline among older adults with critical illness (Figure 2). Because ICUs differ with regard to the specifics by which patient care is delivered, there is no one-size-fits-all approach to implementing these suggested interventions. Yet, because one common thread running thorough modern ICU practice is close, collaborative interdisciplinary patient care, the ICU serves as an ideal environment to adapt and implement components of these geriatric care models. For example, preventing inappropriate medication use requires cooperation between physicians, pharmacists and bedside nurses each of whom contribute to the process of ordering, dispensing and administering medications and communicating these changes to the next level of care. Technologies ranging from simple checklists, to electronic medical records, computerized dashboards and telemedicine have been used to augment therapeutic intervention delivery in severe sepsis and prevent iatrogenic harms such as central line infections and thus could serve as a model for implementing the proposed interventions (142–145).

Figure 2.

Figure 2

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Interventions adapted for the ICU from geriatric care models may be used to improve care for older adults with critical illness. PT/OT, Physical and Occupational Therapy; ACE, Acute care for elders; GEM, Geriatric evaluation and management

The aforementioned assessment tools and interventions are intended to be a pragmatic approach to caring for critically ill older adults; thus, they are far from comprehensive. To address better the specific age-related issues that affect over half of all ICU patients (1), critical care clinicians are encouraged to further their knowledge of clinical geriatrics and to seek help from experts trained in the care of older adults. Several educational resources are available both in print (e.g., American Geriatrics Society’s Geriatrics at your Fingertips) (146) and online (e.g., the Portal of Geriatrics Online Education [www.pogoe.org] and the Hartford Institute for Geriatric Nursing’s “Try This” series [www.hartfording.org/practice/try_this]). ICU clinicians and educators seeking to develop even greater expertise in the care of older adults may be eligible for “mini-fellowships” in geriatrics sponsored by the Donald W. Reynolds Foundation, which provide intensive courses in geriatrics and geriatrics education as well as follow-up support to enhance these endeavors (147). In the future, the development of collaborative training programs between critical care medicine and geriatrics, two specialties that already share a number of overlapping “Entrustable Professional Activities” (148–150), will enable trainees to face better the important challenges of caring for older adults with critical illness.

Finally, co-management strategies, such as the hip fracture “Orthogeriatric” model (i.e., co-management by both the orthopedic surgeon and a geriatrician) have been used to improve outcomes, including reductions in delirium and length of stay, improve functional status and mortality among older adults could serve as a potential care model for older adults in the ICU (151–154).

Directions for Future Research

Today, older adults who survive a critical illness are suffering with the burdens of disability, physical and/or cognitive impairments that previous generations did not face due to death and effective interventions are needed to aid this growing segment of the population. The central role that hospitalization for a critical illness plays in the development of disability afterwards is becoming clear. Nevertheless, future research is needed to understand better how the trajectory of a patient’s pre-illness functional status as well as factors relating to the patient’s critical illness and ICU treatment result in post-critical illness disabilities. Additionally, deeper knowledge of the unique contributions of post-ICU physical and cognitive dysfunction and mental health impairments to the disabling process should be sought. Interventions, that can be implemented throughout the continuum of critical illness from the earliest days in the ICU to a variety of post-ICU settings (e.g., hospital ward, rehabilitation facilities, nursing facilities and home) to prevent, treat and rehabilitate disabilities in this vulnerable and growing segment of the population should be studied and implemented. Although in need of testing in survivors of critical illness, physical exercise, resistance training and nutritional supplementation which are effective in improving physical functioning among those with aging related muscle loss (e.g., sarcopenia) (155) as well as cognitive rehabilitation that is associated with improve cognitive functioning in patients with acquired brain injuries (e.g., traumatic brain injury and stroke) (156, 157) may serve as readily available platforms by which to reduce disability after critical illness.

Conclusions

For the 1.4 million older adults in the US (and many more worldwide) who survive a critical illness each year, the subsequent months and years are fraught with significant declines in functional and cognitive status, resulting in long-term disability for as many as 2 out of every 3 patients. We argue that aging physiology, complications of critical illness, and common ICU practices contribute significantly to the development of post-critical illness disability.

Interventions derived from widely available geriatric care models in use outside of the ICU, which address modifiable risk factors including immobility and delirium, are associated with improved functional and cognitive outcomes and can be used to complement ICU-focused models such as the ABCDEs.

Supplementary Material

1

Acknowledgments

Financial Disclosures:

Dr. Brummel is supported by the National Institute on Aging under award number R03AG045095 and the Vanderbilt Clinical and Translational Scholars Program. Dr. Balas is supported by Alzheimer's Association. Dr. Ferrante is supported by the National Institute on Aging under award number T32AG19134. Dr. Gill is the recipient of an Academic Leadership Award from the National Institute on Aging under award number K07AG043587 and is supported by the National Institute on Aging/Yale Claude D. Pepper Older Americans Independence Center under award number P30AG21342. Dr. Ely is supported by the Veterans Affairs Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC) and by the National Institute on Aging under award number R01AG035117.

Dr. Balas and has received honoraria from ProCe, the France Foundation, Hospira, and Hillrom. Dr. Gill has received honoraria from Novartis. Dr. Ely has received research grants and/or honoraria from Hospira, Orion, and Abbott.

Footnotes

Conflicts of Interest:

The other authors report no other conflicts of interest.

Copyright form disclosures: Dr. Brummel received grant support and support for article research from the National Institutes of Health (NIH). Dr. Balas consulted for ProCe, the France Foundation, Hospira, Hillrom, Centers for Disease Control, and Cynosure Health. Her institution received grant support from the Alzheimer’s Association and from the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative. Dr. Ferrante received support for article research from the NIH. Her institution received grant support from the NIA/NIH. Thomas M. Gill C/F (received grant support from the NIH; received support for article research from the NIH. Dr. Ely received grant support from the NIH and VA; consulted for Hospira, Abbott, Orion, and Masimo; and received support for article research from the NIH. Dr. Morandi disclosed that he does not have any potential conflicts of interest.

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