This book, part of the European Society of Intensive Care Medicine (ESICM) textbook series, provides detailed up-to-date information on the care of the critical ill very old (≥80 years) patients in the ICU.
The very old are expanding fast in our populations, and this is mirrored in our hospitals and ICUs as well. During the last decade, a lot more information about the group of critical ill elderly has been published, and several large networks cooperate in performing multinational studies in this field, one of them with roots in the ESICM. This book will give readers knowledge about the current epidemiology of elderly ICU patients, in patients centered outcomes and factors affecting these outcomes. A large part is devoted to age related changes in vital organ functions, and the specific geriatric “syndromes” like frailty, cognitive decline, reduced activity of daily living, sarcopenia and immunosenecence. This is all important for the practicing intensivists to know about. In addition, specific groups of the elderly in the ICU are also described like the elderly patients with trauma or sepsis.The book is written jointly by intensivists and geriatricians, often working in teams and originating from many different countries. This herald a new era in the collaboration between these two groups in order to improve care and rehabilitation. We have a lot to learn from each other, as both groups have a holistic view of our patients although with different perspectives.
This book should be of value for all working in adult ICUs, physicians as well as nurses. It will hopefully lead to a better understanding of the particular challenges posed by this important sub-group of ICU patients and how to manage his group in a way that combine respect for life as well as death and includes patients and caregivers in this process.
Author(s): Hans Flaatten, Bertrand Guidet, Hélène Vallet
Series: Lessons from the ICU
Publisher: Springer
Year: 2022
Language: English
Pages: 589
City: Cham
Preface
Contents
Contributors
Abbreviations
I: Introduction: The Very Old ICU Patients
1: The Demography of Ageing and the Very Old Critical Ill Patients
1.1 Introduction: Demography of Ageing
1.2 Diversity Within Europe
1.3 General Health Issues in the Very Old
1.4 ICU Admission of the Very Old
1.5 The Very Old in the ICU
Conclusions
References
2: Objectives of ICU Management for Very Old Patients
2.1 Introduction
2.2 Characteristics of Very Old Patients
2.3 ICU Admission of an Older Patient
2.3.1 Admission Criteria: What About Age?
2.3.2 Prognostic Tools for Older ICU Patients
2.3.3 Admission Criteria and Pre-ICU Triage
2.4 What Are the Objectives of ICU Care in Older Patients?
2.4.1 Time for Post ICU Geriatric Units?
Practical Implications
Conclusion
Take-Home Messages
References
II: Age-Related Physiological Changes
3: Aged-Related Physiological Changes: CNS Function
3.1 Introduction
3.2 CNS Ageing
3.2.1 General Cellular Age-Related Changes in the Brain
3.2.1.1 β -Amyloid and Tau Protein Accumulation
3.2.1.2 Autophagia
3.2.1.3 Oxidative Stress
3.2.1.4 Neuroinflammation
3.2.2 Specific Cellular Type Age-Related Changes in the Brain
3.2.2.1 Neurone
3.2.2.2 Neuroglia
3.2.2.3 Microglia
3.2.2.4 Vascular Unit
3.2.3 Specific Anatomical Age-Related Changes in the Brain
3.2.3.1 Global Age-Related Variations
3.2.3.2 PFC and Dopamine System
3.2.3.3 Hippocampus and Cholinergic System
3.3 Ageing Consequences for CNS Functions
3.3.1 Cognitive Profile
3.3.1.1 Attention
3.3.1.2 Memory
3.3.1.3 Decision Making
3.3.2 Movement
3.3.2.1 Functional Dispersion of Motor CNS Activity
3.3.2.2 Movement and Cognition
3.3.3 Affective and Emotional Aspects
3.3.3.1 Late-Onset Disorders
3.3.3.2 Personality
3.3.3.3 Well-Being Paradox
Practical Implications
Conclusion
Take-Home Messages
References
4: Age-Related Physiology Changes: Cardiovascular Function in the Very Old Critically Ill Patient
4.1 Introduction
4.2 Physiology of Cardiovascular Ageing with Clinical Relevance for Intensive Care
4.2.1 Atria
4.2.2 Ventricles
4.2.3 Myocardium
4.2.4 Valves
4.2.5 The Conduction System
4.2.6 Vascular
4.2.7 Coronary Arteries
4.3 Circulatory Failure: Types of Shock
Practical Implications
Circulatory Monitoring: Particular Aspects in the Elderly
1. Cannulation
2. Invasive and Non-invasive Blood Pressure Measurement
3. Central Venous Pressure (CVP) Measurement
4. Assessment of Cardiac Output
5. Assessment of Fluid Responsiveness
Conclusion
Take-Home Messages
References
5: Age-Related Changes of the Kidneys and their Physiological Consequences
5.1 (Patho)Physiology of Renal Ageing
5.2 Histological and Morphologic Aspects
5.3 Renal Function/Functional Alterations
5.3.1 Determination of GFR in the Elderly
5.3.1.1 Estimation of GFR
5.3.1.2 Measurement of GFR
5.3.2 Changing GFR in the Elderly
5.3.3 Renal Tubular Function in the Elderly
5.4 Consequences on Drug Therapy
5.4.1 Dosing
5.4.2 Diuretic Resistance
5.5 AKI – Aspects when Treating Very Old Patients
Take-Home Message
References
6: Immunological Changes
6.1 Introduction to the Chapter
6.2 How Does the Immune System Function?
6.2.1 Innate Immune System Changes with Aging
6.2.2 Adaptive Immune Changes with Aging
6.3 Inflammaging
6.4 Case of COVID-19
6.5 Case of Sepsis
6.6 Rethinking the Concept of Immunosenescence
Conclusion
Practical Implications
Take-Home Messages
References
7: Drug Metabolism
7.1 Introduction
7.2 Adverse Drug Reactions
7.3 Frailty
7.4 Changes in Pharmacokinetics in the Elderly
7.5 Absorption After Oral Drug Administration
7.6 Absorption After Non-oral Drug Administration
7.7 Bioavailability
7.8 Distribution
7.8.1 Body Composition
7.8.2 Protein Binding
7.9 Metabolism
7.9.1 The Impact of Genetic Polymorphisms on Drug Metabolism in the Elderly
7.10 Excretion
7.11 Knowledge Gap: Under-Representation of Older Patients in Clinical Trials
Conclusions
Take-Home Messages
References
III: Geriatric Syndroms
8: Multimorbidity
8.1 Introduction
8.2 Multimorbidity in the Older Population: What Do We Know?
8.2.1 History and Conceptual Definition
8.2.2 Operational Definitions
8.2.3 Epidemiology
8.2.4 Consequences and Prognosis
8.2.5 Models and Quality of Care
8.3 Multimorbidity and Critical Care
8.3.1 Multimorbidity and Decision of ICU Admission
8.3.2 Management of Multimorbidity in the ICU
8.3.2.1 Avoiding a Cascade of Organ Failures
8.3.2.2 Avoiding Adverse Drug Events
Box 8.1 Tools to Evaluate the Severity of Chronic Health Conditions at Bedside of the Patient
Conclusions and Perspectives
Take-Home Messages/Practical Implications
References
9: Multipharmacy on the Older Adult
9.1 Introduction
9.1.1 Concepts
9.1.1.1 Polypharmacy
9.1.1.2 PIM
9.1.1.3 Prescribing Cascade
9.2 Epidemiology of Drug Therapy
9.3 Pharmacokinetics and Pharmacodynamics
9.4 Consequences of Polypharmacy
9.5 Risk Factors Involved in Polypharmacy
9.6 Drugs with Anticholinergic Effects (DACEs) and Anticholinergic Burden
9.7 Polypharmacy and Geriatric Syndromes: Frailty and Cognitive Impairment
9.8 Medications and Therapeutic Goals
9.9 Management of Polypharmacy in the Elderly
9.9.1 Practical Approach to Prescribing Medications to Older Adults
References
10: Sarcopenia: An Overview
Practical Implications
10.1 Introduction
10.2 Sarcopenia
10.3 Assessment of Muscle Mass, Strength, and Performance
10.4 The Etiology of Sarcopenia
10.5 Prevalence and Outcomes of Sarcopenia
10.6 The Management of Sarcopenia
10.7 Cachexia
10.8 The Etiology of Cachexia
10.9 The Overlap Between Cachexia and Sarcopenia
10.10 Management of Cachexia
10.11 Acute Sarcopenia
Conclusions
Take-Home Messages
References
11: Geriatric Syndromes: Frailty
11.1 Introduction
11.2 Frailty Definition and Pathophysiology
11.3 Frailty Models
11.4 Instruments for Assessing Frailty in Critically Unwell Older People
11.4.1 Modified Phenotype Model
11.4.2 Cumulative Deficit Model
11.4.3 Clinical Frailty Scale
11.4.4 Identifying Frailty Using Routine Electronic Health Record Data
11.5 Epidemiology of Frailty
11.5.1 Epidemiology of Frailty in Critical Care Units
11.6 Clinical Utility of Frailty in Critical Care
11.6.1 Prognosis
11.6.2 Identifying People for Therapeutic Interventions
11.6.3 The Future: Frailty as a Therapeutic Target?
Box 11.1
Conclusion
Take-Home Messages
References
12: Malnutrition
12.1 Introduction
12.2 Definition and Risk Factors of Malnutrition in the Elderly
12.3 Nutritional Assessment in ICU and Prognosis
12.4 Nutritional Intervention in Critically Ill Older Adults
Conclusion
Take-Home Messages
References
13: Functional Status and Older Age
13.1 Introduction
13.2 Normal Ageing and Predictors for Change in Functional Status
13.2.1 Changes in Functional Status in Normal Ageing
13.2.2 Risk Factors and Predictors of Change in Functional Status
13.2.3 Successful Ageing
13.3 Measurement of Functional Status
13.3.1 Instruments Used to Measure Functional Status in the Older Person
13.3.1.1 Mobility
13.3.1.2 Self-Care
13.3.2 Instruments Used to Measure Functional Status in the ICU Setting
13.4 Functional Status and Its Impact on ICU Triage and Outcomes
13.4.1 Functional Status and Outcomes
13.4.1.1 Mortality Outcomes
13.4.1.2 Physical Function Outcomes
13.4.2 Changes in Pre-illness Functional Status as a Predictor of Outcomes
13.4.3 Functional Status and ICU Triage
Practical Implications
Conclusion
Take-Home Messages
References
14: Comprehensive Geriatric Assessment (CGA)
14.1 Introduction
14.1.1 History of Comprehensive Geriatric Assessment (CGA)
14.2 What Is Comprehensive Geriatric Assessment (CGA)?
14.3 Scores and CGA
14.4 Impact of CGA on Patient’s Prognosis
14.4.1 Mortality
14.4.2 Functional Autonomy
14.4.3 Institutionalization
14.5 Limits of CGA
14.6 CGA and ICU
14.6.1 At ICU Admission
14.6.2 During ICU Stay
14.6.3 After ICU Discharge
Conclusion
Take-Home Messages
References
IV: Triage
15: Pre-ICU Triage: The Very Old Critically Ill Patient
15.1 Introduction
15.2 Principles of Triage
15.3 Key Issues in the Very Old
15.3.1 Avoidance of Age Prejudice
15.3.2 The Effect of Age on Outcome Prognosis
15.3.3 Are There Better Alternative Prognosticators of Outcome than Age?
15.3.4 Quality of Life as an Outcome
15.3.5 Respecting Individual Autonomy
15.4 The Potential Use of the “Time-Limited Trial” at Pre-admission Triage
15.5 Practical Implications: An Overall Approach to Triage Including the Very Old
15.5.1 Proposed Framework and Bedside Advisory Tool
Practical Implications
15.5.2 Justification and Limitations
Conclusion
Take-Home Messages
References
16: Decision-Making Under Resource Constraints
16.1 Introduction
16.2 Availability and Utilisation of ICU Resources Under Constraints
16.3 Prognostication for Individual Patients
16.4 Triage in ICU
16.5 The Role of Age and Geriatric Conditions for Triage Decisions
Conclusions
Practical Implications
Clinical Protocols
Take-Home Messages
References
17: The Very Old Critically Ill Patients Risk Scores for the Very Old, Achievable?
17.1 Introduction
17.2 The Prognostic Determinants of General Severity Scores and General Prognostic Models
17.3 Presence and Degree of Physiological Dysfunction
17.4 Health Status of the Patient Before Critical Illness
Conclusion
Take-Home Messages
References
V: Usual ICU Procedures
18: Ventilation
Practical Implications
18.1 Introduction
18.2 High Flow Nasal Cannulae
18.3 HFNC in AHRF
18.4 Other Indications for HFNC
18.5 Failure of HFNC in AHRF
18.6 Development of NIMV
18.7 NIMV for the Treatment of AECOPD
18.8 NIMV for the Treatment of Acute Cardiogenic Pulmonary Edema
18.9 NIMV for the Treatment of AHRF
18.10 Noninvasive Mechanical Ventilation for Weaning from Mechanical Ventilation
18.11 NIMV for Post-extubation Support
18.12 NIMV in the Postoperative Setting
18.13 Invasive Mechanical Ventilation
18.14 Invasive Versus Noninvasive Ventilation for Patients with COVID-19 and ARF
18.15 Liberation from Mechanical Ventilation in the Elderly
Conclusions
Take-Home Message
References
19: Vasoactive Drugs
19.1 Introduction
Practical Implication
19.2 Fluid Resuscitation
19.3 Vasoactive Medication
Practical Implication
19.4 Blood Pressure Targets in Elderly ICU Patients
Conclusion
Take-Home Messages
References
20: Acute Kidney Injury and Renal Replacement Therapy in the Very Old Critically Ill Patient
20.1 Introduction
20.2 Acute Kidney Injury in the Very Old Critically Ill Patient
20.2.1 AKI Epidemiology in the ICU
20.2.2 AKI Etiologies in the Very Old Patient
20.3 Renal Replacement Therapy in the ICU: Should This Therapy be Initiated in the Elderly?
20.3.1 A Clinical But Also an Ethical Dilemma
20.3.2 Temporality and Principle of Collegiality for the Decision-Making Process
20.3.3 The Patient’s Role in the Decision: The Principle of Autonomy
20.3.4 Principles of Beneficence, Non-maleficence, and Distributive Justice
20.4 How to Provide RRT in the Very Old Critically Ill Patient?
20.4.1 Dialysis Catheter
20.4.2 Which RRT Modality for the Elderly Population in the ICU?
20.4.3 Optimization of the Critical Care Rehabilitation Phase: Impact of the RRT Modality Choice
Conclusion
Take-Home Messages
References
21: Sedation and Analgesia
Practical Implications
Suggested Clinical Management Strategy
21.1 Introduction
21.2 Pain
21.2.1 Scope of the Problem
21.2.2 Assessment
21.2.3 Treatment
21.3 Sedation
21.3.1 Scope of the Problem
21.3.2 Assessment
21.3.3 Treatment: Choice of Sedative
21.4 Delirium
21.4.1 Scope of the Problem
21.4.1.1 Pathophysiology
21.4.2 Assessment
21.4.3 Outcomes
21.4.4 Prevention and Treatment
21.4.4.1 Non-pharmacological
21.4.4.2 Pharmacological
21.5 Implementation of Pain, Analgesia, and Delirium Guidelines and the ABCDEF Bundle
Conclusion
Take-Home Messages
References
22: Nutrition: The Very Old Critically Ill Patients
22.1 Introduction
22.2 Nutrition Therapy Improves Outcome
22.3 Characteristics of the Very Old in a Multidisciplinary ICU
22.4 Specific Clinical Difficulties
22.5 Nutritional Status as Basis for Therapy
22.6 Energy, Protein and Micronutrient Needs
22.7 Refeeding Syndrome
22.8 Practical Issues
22.9 Monitoring Response to Feeding
22.10 The Post-ICU Period
Conclusion
Take-Home Messages
References
VI: Withhold and Withdraw Therapy
23: Limitation of Life-Sustaining Treatments
23.1 Introduction
23.2 General Consideration in Old Critically Ill Old Population
23.3 Limitation of Life-Sustaining Treatments
23.4 Reporting of Limitation of LST
23.5 Determinants of LLST
23.6 Implication of Patients and Caregivers in the Decision-Making Process
23.7 How
23.8 Treatment During the ICU Stay
23.9 Time-Limited Trial
Box 23.1 Rationale for Time-Limited Trial
Box 23.2 Organization of Family Meetings (According to Quill) [73]
23.10 Quality of Death
Take-Home Messages
Clinical Protocol
References
VII: Outcomes After Intensive Care
24: Outcomes After Intensive Care: Survival
24.1 Introduction
24.2 Limitations of Crude Survival
24.3 Survival After a Defined Procedure or Admission
24.4 Survival After a Fixed Period
24.5 Survival in Specific Cohorts
24.6 The Effect of Age
24.7 The Effect of Gender
24.8 The Effect of Severity of Disease
24.9 The Effect of Frailty
24.10 The Effect of Limitation of Care
24.11 What Is the Reported Mortality of Elderly ICU Patients?
24.12 The Future of Reporting Mortality
Box
Take-Home Messages
References
25: Outcomes After Intensive Care: Functional Status
25.1 Introduction
25.2 Framing Functional Status
Box 25.1 Brief Geriatric ICF Core Set with 29 Categories that Reflect the Most Relevant Health-Related Problems of Community-Living Older Adults Without Dementia
25.3 Instruments and Measures
25.4 Measuring Functional Status in the Old and Critically Ill
25.5 Functional Status in the Old After Intensive Care
Practical Implications
Conclusion
Take-Home Messages
References
26: Cognitive Disorders: Outcomes After Intensive Care
26.1 Introduction
26.2 Epidemiology and Generalities
26.2.1 The Different Stages of NCD
Box 26.1 DSM-5 Criteria for Major Neurocognitive Disorder (Previously Called Dementia)
26.2.2 Multiple Lesions Are Mainly Responsible for NCD in Older Patients
26.2.3 Cognitive Reserve
26.3 Delirium in ICU
26.4 Relationship Between Cognitive Status Before ICU Stay, Delirium, and Post-ICU NCD
Practical Implications: How to Reduce the Impact of ICU Stay on Post-ICU NCD?
Clinical Protocol
Box 26.2 The ABCDEF Building Blocks of ICU Delirium Management (7 www.iculiberation.org)
Conclusions
Take-Home Messages
References
27: Rehabilitation
27.1 Geriatric Rehabilitation: General Principles
27.2 Multidisciplinary Approach
27.3 Assessment of Rehabilitation Potential
27.4 Rehabilitation Interventions for the Critically Ill Very Old Patient
27.5 Barriers to Early Rehabilitation
27.6 Transitions Out of the ICU
27.7 Future Directions
Take-Home Messages
References
28: The Caregiver
28.1 Introduction
28.2 Definitions and Roles of Caregivers
28.2.1 The Recorder
28.2.2 The Manager
28.2.3 The Decision-Maker
28.2.4 The Carer
28.3 Caregiver Burden and Measurements
28.3.1 Post-Intensive Care Syndrome-Family (PICS-F)
28.3.2 Relationship Between Caregiver and Care Recipient After ICU Admission
28.3.3 Psychological Effects
28.3.4 Physical Effects
28.3.5 Socioeconomic Effects
28.3.6 Measurements
28.3.7 Coping Strategies
28.4 Interventions to Support Caregivers
28.4.1 Communication Strategies
28.4.2 Digital Means
28.4.3 Use of Diaries
28.4.4 Bereavement Support
28.4.5 Discharge Support
28.4.6 Peer Support
References
VIII: Specific Diseases and Conditions
29: Acute Respiratory Failure
Practical Implications
29.1 Introduction
29.2 Changes in Respiratory Physiology Associated with Aging
Box 29.1 Specific Considerations on Acute Respiratory Failure in Elderly Patients
29.3 Changes in Cardiovascular Physiology and ARF
29.4 Inflammatory Response and Immune Function in ARF
29.5 Diagnosis of ARF
29.6 Causes of ARF
29.7 Susceptibility of the Elderly to ARDS
29.8 Treatments of ARDS in the Elderly
29.9 Weaning the Elderly Patient from the Ventilator After ARF
29.10 Outcome of ARF in the Elderly
29.11 Outcome of ARF in Elderly Patients with COVID-19
Conclusion
Take Home Message
References
30: Sepsis in Older Adults
30.1 Introduction to the Chapter
30.2 Definition
30.3 Epidemiology
30.4 Diagnosis
30.5 Pathogen Detection in Elderly
30.6 Immunity
30.7 Pathophysiology
30.8 Treatment of Sepsis in Elderly
30.8.1 Fluid Resuscitation
30.8.2 Vasopressors (See Also 7 Chap. 19)
30.8.3 Antibiotics
30.8.4 Sedation
30.8.5 Corticosteroids
30.8.6 Glucose Control
30.8.7 Thromboembolic Prophylaxis
30.8.8 Stress Ulcer Prophylaxis (SUP)
30.9 Medication: Pharmacokinetics and Pharmacodynamics (See Also 7 Chap. 7)
30.10 Outcomes: Mortality, Predictive Values of Scoring Systems, Functional Outcome, and Quality of Life
30.11 Triage and Medical Ethics
30.12 Cost Burden of Very Old Patients with Sepsis
Conclusion
Take Home Message
References
31: Acute Kidney Injury
Practical Implications
31.1 Introduction
31.2 AKI Definitions
31.3 AKI Epidemiology
31.4 Risk Factors for AKI in Elderly ICU Patients
31.5 Pathophysiology of AKI
31.6 Diagnosis of AKI in Aged ICU Patients
31.7 Treatment of AKI in the Elderly
Take-Home Messages
References
32: The Very Old Critically Ill Patient Neurointensive Care
32.1 Introduction
32.2 Epidemiology
32.2.1 Traumatic Brain Injury
32.2.2 Stroke
32.2.3 Epilepsy
32.2.4 Brain Tumors
32.3 Physiology of the Aging Central Nervous System
32.3.1 Structural Modifications
32.3.1.1 Neurons
32.3.1.2 Vessels
32.3.2 Functional Modifications
32.4 Therapeutic Particularities of the Elderly Subject
32.4.1 Cerebral Hemodynamics
32.4.1.1 Intracranial Hypertension
32.4.1.2 Cerebral Autoregulation and Hemodynamic Objectives
32.4.2 Sedation Analgesia in the Elderly
32.5 Outcomes and Ethical Considerations
32.5.1 Mortality
32.5.2 Functional Outcome
Conclusion
Take Home Message
References
33: Postoperative Patients: Planned Surgery
33.1 Overview: ICU Admission Is Part of a Global Clinical Path (See . Table 33.1)
33.2 Postoperative Morbidity and Mortality in the Very Old Surgical Patient
33.2.1 Surgical Risk and Risk of Postoperative Complications in the Elderly
33.2.2 Is Age the Main Risk Factor?
33.3 How to Decide About ICU Admission in the Elderly
33.3.1 Lack of Guidelines and Specific Triage Criteria
33.3.2 Basic Principles for Appropriate Triage
33.3.3 Liberal Versus Restrictive Attitude: How This Element May Influence the Choice
33.3.4 Advantages and Risks of ICU Admission
33.4 Circumstances for ICU Admission
33.4.1 The Decision Is Taken Before Surgery (Direct Admission)
33.4.2 The Decision Is Taken in the PACU
33.4.3 The Decision Is Taken in the Surgical Ward (Indirect or Intermediate Admission)
33.4.4 Critical Considerations
33.5 Postoperative Complications and ICU Admission
33.5.1 Cardiac Complications
33.5.2 Respiratory Complications
33.5.3 Postoperative Delirium
33.6 Specific Problems Related to the Different Kinds of Surgery
33.6.1 Cardiac Surgery
33.6.2 Abdominal Surgery
33.6.3 Orthopedics
33.7 Discharge
33.8 Outcome
33.9 Final Considerations
References
34: Postoperative Patients: Urgent Surgery
34.1 Introduction
34.2 Hip Fracture Surgery
34.2.1 Orthogeriatric Care: Improving Hip Fracture Outcomes
Box 34.1 Goals of Treatment of the Orthogeriatric Care Models
34.2.1.1 Models of Orthogeriatric Interventions
34.2.1.2 Outcome After Integrated Orthogeriatric Care
34.2.1.3 Which Is the Best Model?
34.2.2 Postoperative Geriatric Complications
34.3 Generalization of the Postoperative Geriatric Model: An Unmet Need
Conclusion
Practical Implications
Take-Home Messages
References
35: Delirium
35.1 Introduction
35.2 Definition and Classification
35.3 Epidemiology
35.4 Pathogenesis
Box 35.1 Risk Factors for Delirium
Box 35.2 Precipitating Factors for Delirium on Very Old Patient
35.5 Clinical Presentation
35.6 Diagnosis
35.6.1 Physical Examination
35.6.2 Evaluation Scales
35.6.3 Searching for Precipitating Factors
35.6.4 Laboratory and Instrumental Tests
35.7 Differential Diagnosis
35.8 Prevention
Practical Implications
35.9 Management
35.9.1 Etiological Treatment
35.9.2 Supportive Therapy: Nonpharmacological Treatment
35.9.3 Supportive Therapy: Pharmacological Treatment
35.9.4 Special Circumstances: End-Life Patients
35.10 Prognosis
Conclusion
Take-Home Messages
References
36: Logistic Challenges and Constraints in Intensive Care During a Pandemic
36.1 Introduction
36.2 Flexibility
36.3 Prioritization
36.4 Pre- and Post-ICU Care of COVID-19 Patients
36.5 When Resources Are Limited
The Elderly Patient with Uncertain Prognosis
36.6 “The Day After”
Take-Home Message
References
IX: Future Developments
37: Future Challenges for Geriatric Intensive Care
37.1 Introduction
37.2 Future Organization: Intensive Care for the Very old
37.3 Cooperation with Who and When
37.4 Research Agenda from 2017, Where Are We Now?
37.5 Future Changes in Critical Care of the Elderly
References
