Older Adults in the Cardiac Intensive Care Unit

The population is aging, and an increasing number of older adults are living with cardiovascular disease (CVD).¹ With advancing age, the prevalence of conditions that increase vulnerability to adverse outcomes also increases; these vulnerability factors are often called “geriatric syndromes”². Geriatric syndromes do not fit neatly into organ-based categories of disease, but nonetheless are commonly encountered in clinical care; examples include cognitive impairment, frailty, and delirium. The American College of Cardiology, American Heart Association, American Geriatrics Society, and the National Institutes of Health have all emphasized the importance of integrating geriatric syndromes into cardiac care, but uptake has been slow. Barriers to integration most commonly include a perceived inability to intervene on geriatric conditions in clinical practice, and the belief that priority should be given to disease-oriented conditions which may have time-sensitivity in terms of treatment.³ The American Heart Association’s scientific statement “Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care” breaks down these barriers by discussing individual geriatric syndromes and their importance to the prognostication and management of cardiac conditions commonly encountered in the cardiac intensive care unit (CICU).³

The authors focus on 4 of the most common and impactful geriatric syndromes encountered in critical care: delirium, polypharmacy, multimorbidity, and frailty. Delirium, an acute disturbance of awareness and attention, is common in older hospitalized patients and in the ICU.⁴ Older adults are more likely to have baseline cognitive and sensory deficits that increase the likelihood of developing delirium, and environmental factors inherent to the ICU (bright light, sleep disruption, malnutrition, tethering devices) are more likely to precipitate delirium. Delirium is also more likely to occur among older adults with polypharmacy (the use of ≥ 5 medications), with older adults admitted to the ICU on a staggering average of 13 prescriptions per patient.⁵ The vast majority of patients with polypharmacy will also meet criteria for the geriatric syndrome of multimorbidity (≥ 2 chronic conditions), which is present in more than two-thirds of the older adult population.⁶

The final geriatric syndrome discussed in this statement, frailty, has been extensively studied in the cardiac literature as well as in the broader critical care literature. Frailty, defined as a state of decreased physiologic reserve that confers increased vulnerability to adverse outcomes, and its precursor, prefrailty, are common in the older CVD population. As one example of its importance in the CVD population, frailty has been associated with an increased risk of delirium and cognitive decline at one month after cardiac surgery, compared with non-frail patients.⁷ This increased propensity to adverse outcomes has also been demonstrated in the broader critical care outcomes literature, with frail patients suffering from a higher burden of post-ICU disability, loss of independence, and mortality after a critical illness.^8-10

Many older adults may have multiple geriatric syndromes, all of which increase vulnerability to adverse outcomes in the setting of an acute stressor,¹¹ and may even interact to magnify adverse outcomes.¹² In addition to the acute insult of the critical illness itself, older patients must contend with stressors from the ICU environment. Immobility leads to muscle wasting and bedsores, sensory overload (via alarms and bright lights) can disrupt the circadian rhythm and precipitate delirium, tethering devices increase immobility and the risk of falls, caloric insufficiency can contribute to muscle wasting – the list goes on. In the face of this seemingly uphill battle, can we integrate the assessment and management of geriatric syndromes into CICU practice to improve the outcomes of critically ill older adults?

To address this question, the authors first provide a comprehensive review of the literature on common CICU diagnoses (specifically, acute MI, heart failure, acute valvular heart disease, acute aortic dissection, and pulmonary emboli) in the context of geriatric syndromes. Three points are to be noted from this part of the statement. First, the existence of so many studies, including RCTs, devoted to answering questions specifically about the older CVD population is both laudable (as a model for other specialties) and promising for the future. With the expansion of geriatric cardiology in recent years,¹³ resources should continue to be directed towards closing remaining knowledge gaps in the cardiovascular care of older adults.¹⁴ Second, some of this research should focus on developing CVD risk prediction models that incorporate geriatric factors; for example, the authors highlight that the most commonly used cardiac surgery risk scores do not capture factors such as frailty and disability. Third, taken as a whole, the data suggest that chronological age alone should generally not be used to make treatment decisions; assessing the presence and severity of geriatric syndromes is often more informative when weighing the risks and benefits of treatments. For example, frailty and multimorbidity are common in heart failure, and the severity of these and other geriatric syndromes is likely to be more informative than chronological age when discussing mechanical circulatory support as a potential treatment option. Notably, the importance of geriatric syndromes over chronological age is a finding has been demonstrated across specialties, including those outside of cardiology and critical care medicine.¹⁵ Despite their importance, geriatric syndromes are rarely included in discussions about goals of care and treatment preferences; moreover, the studies presented in this AHA statement demonstrate that end-of-life discussions and palliative care are greatly underutilized in the CICU. With a recent study demonstrating that true shared decision-making only occurs a minority of the time in the ICU,¹⁶ future research should explore how to best integrate geriatric syndromes into shared decision-making in the CICU.

Finally, the authors provide a helpful and comprehensive table of management principles for the optimal CICU care of older adults. Recommendations include early mobilization, minimizing sedation, de-prescribing unnecessary medications, frequent orientation, the provision of sensory aids, nutritional support, and physical and occupational therapy, with each individual recommendation supported by a strong evidence base. This type of model promoting the integration of geriatric principles into critical care practice has also been proposed in the broader critical care literature,¹⁷ lending hope to a future where older patients in any ICU can receive care that addresses geriatric syndromes with equal importance as disease-specific conditions.

This 2019 AHA Scientific Statement on Older Adults in the Cardiac Intensive Care Unit highlights the need for geriatric syndromes to be considered in the assessment, management, and process of care for all commonly encountered CICU diagnoses. Although many knowledge gaps remain, the strong evidence base in the CICU and broader geriatric critical care literature supports moving away from a disease-specific approach in critical care and towards a more holistic approach to the critically ill older adult. With this AHA statement, clinicians, researchers, and policy makers have a clear guide towards a future of comprehensive, patient-centered care for the older CICU patient.