Comprehensive Assessment and Management of the Critically Ill Older Adult

 

OVERVIEW

Caring for an older adult who is experiencing a serious or life-threatening illness often poses significant challenges to critical care nurses. Although older adults are an extremely heterogeneous group, they share some age-related characteristics that leave them susceptible to a variety of geriatric syndromes and diseases. This vulnerability may influence both their ICU utilization rates and outcomes. Critical care nurses caring for this population must not only recognize the importance of performing ongoing, comprehensive physical, functional, and psychosocial assessments tailored to the older ICU patient, but must also be able to identify and implement evidence-based interventions designed to improve the care of this extremely vulnerable population.

 

BACKGROUND

A. Definition

  1. A critically ill older adult is a person 65 years of age or older who is currently experiencing, or at risk for, some form of physiological instability or alteration warranting urgent or emergent, advanced, nursing/medical interventions and monitoring.

B. Etiology/epidemiology

  1. More than half (55.8%) of all ICU days are incurred by patients older than 65 years (Angus et al., 2006).
  2. Older adults are living longer, are more racially and ethnically diverse, and often have multiple chronic conditions, and more than one-quarter report difficulty performing one or more ADLs. These factors may affect both the course and the outcome of critical illness.
  3. Once hospitalized for a life-threatening illness:
    • older adults often experience high ICU, hospital, and long-term crude mortality rates and are at risk for deterioration in functional ability and postdischarge institutional care (Balas et al., 2009, 2011; Brummel et al., 2014; Ford et al., 2007; Hennessy et al., 2005; Hopkins & Jackson, 2006; Pandharipande et al., 2013).
    • Older age is also a factor that may lead to:
      • Physician bias in refusing ICU admission (Foley et al., 2022; Mick & Ackerman, 2004)
      • The decision to withhold MV, surgery, or dialysis (Hamel et al., 1999)
      • An increased likelihood of an established resuscitation directive (Hakim et al., 1996)
    • Most critically ill older adults:
      • Demonstrate resiliency
      • Report being satisfied with their postdischarge QOL
      • Would reaccept ICU care and MV if needed (Guentner et al., 2006; Hennessy et al., 2005)
    • Chronological age alone is not an acceptable, or accurate, predictor of poor outcomes after critical illness (Elliott et al., 2014; Nagappan & Parkin, 2003).
    • Factors that may influence an older adult’s ability to survive a catastrophic illness include (Ford et al., 2007; Mick & Ackerman, 2004):
      • Severity of illness
      • Nature and extent of comorbidities
      • Diagnosis, reason for/duration of MV
      • Complications
      • Others
        1. Prehospitalization functional ability
        2. Vasoactive drug use
        3. Preexisting cognitive impairment
        4. Senescence
        5. Ageism
        6. Decreased social support
        7. The critical care environment
        8. Patient preference
    • Dementia is a common development in older adults after admission to ICU for critical illness.
      • Newly developed (incident) dementia is present in 12% to 18% of patients at 1 to 8 years postcritical illness (Brummel et al., 2014).
      • Prevalent (unknown preillness status) dementia is reported in 15% of patients postdischarge and in 10% of patients at 1 year follow-up.
      • Newly acquired, mild or moderate cognitive impairment is reported in 56% of patients at 4 years postcritical illness.

PARAMETERS OF ASSESSMENT

A. On admission to the ICU: The nurse should ask relatives or other caregivers for baseline information about the older adult’s:

  1. Memory, executive function (e.g., fine motor coordination, planning, organization of information), and overall cognitive ability (Kane et al., 2004)
    • Behavior on a typical day, how the patient interacts with others; their responsiveness to stimuli, how able they are to communicate (reading level, writing, and speech); and their memory, orientation, and perceptual patterns before the illness (Milisen & DeGeest, 2001)
  2. Medication history to assess for potential withdrawal syndromes and adverse drug events (Broyles et al., 2008; Bunditz et al., 2006)
  3. Preadmission functional ability, frailty, and nutritional status—limited preadmission functional ability, frailty, and poor nutritional status are associated with many negative outcomes for critically ill older adults (Fronczek et al., 2018; Hamidi et al., 2019) and therefore the nurse should assess the following:
    • Did the elder suffer any limitations in the ability to perform their ADL preadmission? If so, what were these limitations?
    • Does the elder use any assistive devices to perform ADL? If so, what type?
    • Where did the patient live before admission? Did they live alone or with others? What was the elder’s physical environment like (e.g., house, apartment, stairs, multiple levels)?
    • What was the older adult’s nutritional status like before admission? Do they have enough money to buy food? Do they need assistance with making meals/obtaining food? Do they have any particular food restrictions/preferences? Were they using supplements/vitamins on a regular basis? Do they have any signs of malnutrition, including recent weight loss/gain, muscle wasting, hair loss, and skin breakdown?
  4. Psychosocial factors—critical illness can render older adults unable to communicate effectively with the healthcare team, often related to physiological instability, technology that leaves them voiceless, and sedative and narcotic use (Happ, 2000, 2001); family members are therefore often a crucial source of important preadmission information:
    • What is the patient’s past medical, surgical, and psychiatric history? How did the older adult communicate prior to the critical illness? What medication was the older adult taking before coming to the ICU? Does the patient use illicit drugs, tobacco, or alcohol regularly? Do they have a history of falls, physical abuse, or confusion?
    • What is the older adult’s marital status? Who is their significant other? Will this person be the one responsible for making decisions for the older adult if they are unable to do so? Does the patient have an advance directive for healthcare? Is the patient a primary caregiver to an aging spouse, child, grandchild, or other person?
    • How would the patient describe their ethnicity? Do they practice a particular religion or have spiritual needs that should be addressed? What was their QOL like before becoming ill?

B. During ICU stay: There are many anatomic/physiological changes that occur with aging (see Table 34.1). The interaction of these changes with the acute pathology of a critical illness, comorbidities, and the ICU environment not only leads to atypical presentation of some of the most commonly encountered ICU diagnoses, but may also elevate the older adults’ risk for complications. The older adult must be systematically assessed for the following:

  1. ICU/environmental factors, including deconditioning, poor oral hygiene, sleep deprivation, pain, immobility, nutritional status, MV, hemodynamic monitoring devices, polypharmacy, high-risk medications (e.g., narcotics, sedatives, hypnotics, nephrotoxins, vasopressors), lack of assistive devices (e.g., glasses, hearing aids, dentures), noise, tubes that bypass the oropharyngeal airway, poorly regulated glucose control, Foley catheter use, stress, invasive procedures, shear/friction, and intravenous catheters.
  2. Atypical presentations of illness are commonly seen in older adults experiencing the following:
    • Myocardial infarction
    • Acute abdomen
    • Systemic infection
    • Hypoxia

NURSING CARE STRATEGIES

A. Preadmission: Based on the individual’s preadmission assessment findings, the nurse should consider:

  1. Obtaining appropriate consults (e.g., dietitian, physical/occupational/speech therapist)
  2. Implementing safety precautions
  3. Using pressure-relieving devices
  4. Organizing family meetings
  5. Providing the older adult with a consistent primary nurse
  6. Screening for risk factors placing the patient at increased likelihood of developing PICS
    • Preexisting risk factors: senescence, comorbid illnesses, and disease pathology
    • ICU syndromes/conditions: pain, delirium, and oversedation

B. During ICU admission: The nurse should attempt to:

  1. Continue to screen for ICU conditions using appropriate tools such as the RASS, CAM-ICU, and ICDSC (Bergeron et al., 2001; Ely et al., 2001a, 2001b; Riker et al., 1999; Sessler et al., 2002)
  2. Prevent the development of ICU conditions by implementing the ABCDEF bundle (see Table 34.2)
    • Assess, prevent, and manage pain using a verified pain scale such as the CPOT or BPS (Gélinas et al., 2006; Payen et al., 2001).
    • Coordinate SAT and SBT to assess need for sedation and ventilation concurrently.
    • Ensure choices of analgesic and sedative medications are appropriate for the patient’s condition.
    • Assess, prevent, and manage delirium.
    • Encourage early mobility and exercise.
    • Increase family engagement and empowerment.
  3. Foster patient communication strategies
    • Consider use of algorithm-guided assessment and communication tool selection (Happ et al., 2014).
    • Consider consulting a speech therapist to facilitate communication (Altschuler & Happ, 2019; Happ et al., 2010).
  4. Consider other appropriate interventions (see Box 34.1)

EVALUATION/EXPECTED OUTCOMES

A. Patient

  1. Preadmission functional ability will be maintained/optimized.
  2. ICU syndromes such as pain, anxiety, immobility, and delirium will be minimized.
  3. Communication between the patient, the family, and the healthcare team will be improved.

B. Provider

  1. Employ consistent and accurate documentation of assessment relevant to the older ICU patient.
  2. Provide consistent, accurate, and timely care in response to deviations identified through ongoing monitoring and assessment of the older ICU patient.
  3. Provide patient/caregiver with information and teaching related to their illness as well as news of transfer of care and/or discharge.

C. Institution—include QA/QI

  1. Evaluate staff competence in the assessment of older critically ill patients.
  2. Use unit-specific, hospital-specific, and national standards of care to evaluate existing practice.
  3. Identify areas for improvement and work collaboratively across disciplines to develop strategies for improving critical care to older adults.

RELEVANT PRACTICE GUIDELINES

A. Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., Davidson, J. E., Devlin, J. W., Kress, J. P., Joffe, A. M., Coursin, D. B., Herr, D. L., Tung, A., Robinson, B. R., Fontaine, D. K., Ramsay, M. A., Riker, R. R., Sessler, C. N., Pun, B., … American College of Critical Care Medicine. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine, 41(1), 263–306. https://doi.org/10.1097/CCM.0b013e3182783b72. Evidence Level VI.

B. Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., Joffe, A. M., … Alhazzani, W. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the intensive care unit. Critical Care Medicine, 46(9), e826–e873. https://doi.org/10.1097/CCM.0000000000003299

ABBREVIATIONS

ADL              activities of daily living

BPS               behavioral pain scale

CAM-ICU      confusion assessment method for the intensive care unit

CPOT            critical care pain observation tool

ICDSC           intensive care delirium screening checklist

MV                mechanical ventilation

PICS              postintensive care syndrome

QA                quality assurance

QI                  quality improvement

QOL              quality of life

RASS             richmond agitation sedation scale

SAT               spontaneous awakening trial

SBT               spontaneous breathing trial

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 34, McClerking, C., Balas, M., Kovaleva, M., Kresge, C., Wende, M. & Smith A. (2025) Comprehensive Assessment and Management of the Critically Ill Older Adult

 

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Foley, C., Bloomer, M., & Hutchinson, A. M. (2023). Factors that influence intensive care admission decisions for older people: A systematic review. Australian Critical Care, 36(2), 274–284. https://doi.org/10.1016/j.aucc.2021.12.006

Frade-Mera, M. J., Arias-Rivera, S., Zaragoza-García, I., Martí, J., Gallart, E., José-Arribas, A. S., Velasco-Sanz, T. R., Blazquez-Martínez, E., & Raurell-Torredà, M. (2022). The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study. Nursing in Critical Care, 27(6), 772–783. https://doi.org/10.1111/nicc.12740. Evidence Level IV.

Freeman-Sanderson, A., Morris, K., & Elkins, M. (2019). Characteristics of patient communication and prevalence of communication difficulty in the intensive care unit: An observational study. Australian Critical Care,32(5), 373–377. https://doi.org/10.1016/j.aucc.2018.09.002.Evidence Level VI.

Fried, L. P., Tangen, C. M., Walston, J., Newman, A. B., Hirsch, C., Gottdiener, J., Seeman, T., Tracy, R., Kop, W. J., Burke, G., McBurnie, M. A., & Cardiovascular Health Study Collaborative Research Group. (2001). Frailty in older adults: Evidence for a phenotype. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 56(3), M146–M156. https://doi.org/10.1093/gerona/56.3.M146.Evidence Level IV.

Fronczek, J., Polok, K. J., Nowak-Kózka, I., Włudarczyk, A., Górka, J., Czuczwar, M., Krawczyk, P., Ziętkiewicz, M., Nowak, Ł. R., Żukowski, M., Kotfis, K., Cwyl, K., Gajdosz, R., Bohatyrewicz, R., Biernawska, J., Grudzień, P., Nasiłowski, P., Popek, N., Cyrankiewicz, W., … Szczeklik, W. (2018). Frailty increases mortality among patients ≥ 80 years old treated in Polish ICUs. Anaesthesiology Intensive Therapy, 50(4), 245–251. https://doi.org/10.5603/AIT.a2018.0032.Evidence Level IV.

Fulton, A. T., Gozalo, P., Mitchell, S. L., Mor, V., & Teno, J. M. (2014). Intensive care utilization among nursing home residents with advanced cognitive and severe functional impairment. Journal of Palliative Medicine,17(3), 313–317. https://doi.org/10.1089/jpm.2013.0509.Evidence Level IV.

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Gélinas, C. (2007). Management of pain in cardiac surgery ICU patients: Have we improved over time? Intensive & Critical Care Nursing, 23(5), 298–303. https://doi.org/10.1016/j.iccn.2007.03.002.Evidence Level IV.

Gélinas, C., Fillion, L., Puntillo, K. A., Viens, C., & Fortier, M. (2006). Validation of the critical-care pain observation tool in adult patients. American Journal of Critical Care, 15(4), 420–427. https://doi.org/10.1037/t33641-000. Evidence Level IV.

Guentner, K., Hoffman, L. A., Happ, M. B., Kim, Y., Dabbs, A. D., Mendelsohn, A. B., & Chelluri, L. (2006). Preferences for mechanical ventilation among survivors of prolonged mechanical ventilation and tracheostomy. American Journal of Critical Care: An Official Publication, American Association of Critical-Care Nurses,15(1), 65–77. http://ajcc.aacnjournals.org/content/15/1/65.long. Evidence Level IV.

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Hakim, R. B., Teno, J. M., Harrell, F. E., Knaus, W. A., Wenger, N., Phillips, R. S., Layde, P., Califf, R., Connors, A. F., Jr., & Lynn, J. (1996). Factors associated with do-not-resuscitate orders: Patients’ preferences, prognoses, and physicians’ judgments. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatment. Annals of Internal Medicine, 125(4), 284–293. https://doi.org/10.7326/0003-4819-125-4-199608150-00005.Evidence Level IV.

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Hamidi, M., Zeeshan, M., Leon-Risemberg, V., Nikolich-Zugich, J., Hanna, K., Kulvatunyou, N., Saljuqi, A. T., Fain, M., & Joseph, B. (2019). Frailty as a prognostic factor for the critically ill older adult trauma patients. American Journal of Surgery, 218(3), 484–489. https://doi.org/10.1016/j.amjsurg.2019.01.035. Evidence Level III.

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Happ, M. B. (2001). Communicating with mechanically ventilated patients: State of the science. AACN Clinical Issues, 12(2), 247–258. https://doi.org/10.1097/00044067-200105000-00008. Evidence Level V.

Happ, M. B., Baumann, B. M., Sawicki, J., Tate, J. A., George, E. L., & Barnato, A. E. (2010). SPEACS-2: Intensive care unit “communication rounds” with speech language pathology. Geriatric Nursing, 31(3), 170–177. https://doi.org/10.1016/j.geri nurse.2010.03.004. Evidence Level V.

Happ, M. B., Garrett, K. L., Tate, J. A., DiVirgilio, D., Houze, M. P., Demirci, J. R., George, E., & Sereika, S. M. (2014). Effect of a multi-level intervention on nurse-patient communication in the intensive care unit: Results of the SPEACS trial. Heart & Lung: Journal of Critical Care, 43(2), 89–98. https://doi.org/10.1016/j.hrtlng.2013.11.010. Evidence Level III.

Happ, M. B., Seaman, J. B., Nilsen, M. L., Sciulli, A., Tate, J. A., Saul, M., & Barnato, A. E. (2015). The number of mechanically ventilated ICU patients meeting communication criteria. Heart & Lung: Journal of Critical Care, 44(1), 45–49. https://doi.org/10.1016/j.hrtlng.2014.08.010. Evidence Level III.

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Heydari, A., Sharifi, M., & Moghaddam, A. B. (2020). Family participation in the care of older adult patients admitted to the Intensive Care Unit: A scoping review. Geriatric Nursing, 41(4), 474–484. https://doi.org/10.1016/j.gerinurse.2020.01.020. Evidence Level V.

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Istanboulian, L., Rose, L., Gorospe, F., Yunusova, Y., & Dale, C. M. (2020). Barriers to and facilitators for using augmentative and alternative communication and voice restorative strategies for adults with an advanced airway in the intensive care unit: A scoping review. Journal of Critical Care,57, 168–176. https://doi.org/10.1016/j.jcrc.2020.02.015. Evidence Level V.

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Jolivot, P. A., Hindlet, P., Pichereau, C., Fernandez, C., Maury, E., Guidet, B., & Hejblum, G. (2014). A systematic review of adult admissions to ICUs related to adverse drug events. Criti-cal Care, 18(5), 643. https://doi.org/10.1186/s13054-014-0643-5.Evidence Level V.

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Kim, S., Anstey, K. J., & Morty, M. E. (2022). Who displays dementia-related stigma and what does the general public know about dementia? Findings from a nationally representative survey. Aging & Mental Health, 27(6), 1111–1119. https://doi.org/10.1080/13607863.2022.2040428.Evidence Level IV.

Kovaleva, M. A., Kleine’ll, R., Dietrich, M. S., Jones, A., Boon, J., Duggan, M., Dennis, B., Lauderdale, J., & Maxwell, C. (2023). Caregivers’ experience with Tele-Savvy Caregiver Program post-hospitalization. Geriatric Nursing, 51, 156–166. https://doi.org/10.1016/j.gerinurse.2023.03.002

Kruser, J. M., Aaby, D. A., Stevenson, D. G., Pun, B. T., Balas, M. C., Barnes-Daly, M. A., Harmon, L., & Ely, E. W. (2019). Assessment of variability in end-of-life care delivery in Intensive Care Units in the United States. JAMA Newtork Open, 2(12), e1917344. https://doi.org/10.1001/jamanetworkopen.2019.17344

Kulakova, D., Stolt, M., Scott, P. A., Papastavrou, E., & Suhonen, R. (2020). Unmet care needs of older people: A scoping review. Nursing Ethics,28(2), 149–178. https://doi.org/10.1177/0969733020948112. Evidence Level V.

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Morandi, A., Piva, S., Ely, E. W., Nainan Myatra, S., Salluh, J. I. F., Amare, D., Azoulay, E., Bellelli, G., Csomos, A., Fan, E., Fagoni, N., Girard, T. D., Heras La Calle, G., Inoue, S., Lim, C. M., Kaps, R., Kotfis, K., Koh, Y., Misango, D., … Latronico, N. (2017). Worldwide survey of the “Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment” (ABCDEF) Bundle. Critical Care Medicine, 45(11), e1111–e1122. https://doi.org/10.1097/CCM.0000000000002640.Evidence Level IV.

Needham, D. M., Wozniak, A. W., Hough, C. L., Morris, P. E., Dinglas, V. D., Jackson, J. C., … Hopkins, R. O. (2014). Risk factors for physical impairment after acute lung injury in a national, multicenter study. American Journal of Respiratory & Critical Care Medicine,189(10), 1214–1224. https://doi.org/10.1164/rccm.201401-0158OC. Evidence Level IV.

Nordness, M. F., Hayhurst, C. J., & Pandharipande, P. (2021). Current Perspectives on the assessment and management of pain in the Intensive Care Unit. Journal of Pain Research, 14, 1733–1744. https://doi.org/10.2147/JPR.S256406. Evidence Level V.

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Pun, B. T., Balas, M. C., Barnes-Daly, M. A., Thompson, J. L., Aldrich, J. M., Barr, J., Byrum, D., Carson, S. S., Devlin, J. W., Engel, H. J., Esbrook, C. L., Hargett, K. D., Harmon, L., Hielsberg, C., Jackson, J. C., Kelly, T. L., Kumar, V., Millner, L., Morse, A., … Ely, E. W. (2019). Caring for critically ill patients with the ABCDEF Bundle: Results of the ICU liberation collaborative in over 15,000 adults. Critical Care Medicine, 47(1), 3–14. https://doi.org/10.1097/CCM.0000000000003482. Evidence Level IV.

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Seaman, J. B., Arnold, R. M., Scheunemann, L. P., & White, D. B. (2017). An integrated framework for effective and efficient communication with families in the adult intensive care unit. Annals of the American Thoracic Society,14(6), 1015–1020. https://doi.org/10.1513/AnnalsATS.201612-965OI. Evidence Level VI.

Seaman, J. B., Barnato, A. E., Sereika, S. M., Happ, M. B., & Erlen, J. A. (2017). Patterns of palliative care service consultation in a sample of critically ill patients at high risk of dying. Heart Lung, 46(1), 18–23. https://doi.org/10.1016/j.hrtlng.2016.08.008.Evidence Level IV.

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