Elderly ICU patients' and their family members' experiences of post-operative delirium: A qualitative study.

Hospitalization of patients in an intensive care unit (ICU) is associated with a series of psychological problems for their family members called family intensive care unit syndrome (FICUS). Nonetheless, family members of patients in ICU often receive little attention from health care providers. Exploring family members' experiences of their patients' hospitalization in ICU helps health care providers focus more clearly on their problems. This study aimed to explore FICUS-related experiences among the family members of patients in ICU. This was a qualitative content analysis study. This qualitative study was conducted in 2019. Participants were 14 family members of patients in ICU who were purposively selected from three hospitals in Tehran, Iran. Data were collected using semi-structured interviews and were analyzed using qualitative content analysis. Participants' experiences of FICUS fell into four categories, that is, threat to psychological well-being (with four subcategories), threat to physical health (with three subcategories), threat to social health (with three subcategories), and change in spiritual orientation (with two subcategories). The 12 subcategories of these categories were emotional disturbances, hopelessness, changes in sleep pattern, mood changes, physical symptoms, aggravation of the existing illnesses, negligence towards personal health, alteration in social interactions, alteration in the burden of responsibility, alternation in the life process, resort to spiritual beliefs, and spiritual conflict, respectively. FICUS symptoms are not limited to psychological problems, rather they include a wide range of psychological, physical, social, and spiritual problems, which can affect the different aspects of family members' lives. Along with care delivery to patients in ICU, health care providers should provide care and support to patients' family members. FICUS is a major threat to health among the family members of patients in ICU. Careful assessment of these family members helps identify family members who are at risk for FICUS and identify FICUS effects on their decisions and health status.

The family members of intensive care unit (ICU) patients play a crucial role in modern ICUs. These individuals are predisposed to the development of post-intensive care syndrome in family members (PICS-F), a syndrome experienced by family members of ICU patients in response to critical illness and characterised by new or worsening psychological symptoms. This study sought to evaluate the levels of anxiety and depression exhibited by the family members of patients hospitalised in the ICU. It also aimed to identify the risk factors associated with the experience of PICS-F, which should assist with its prevention in the future. The study sample comprised 164 ICU patients and their family members. Sociodemographic data were gathered at the time of ICU admission and 3months after discharge, and the family members were screened for emotional distress using the Hospital Anxiety and Depression Scale (HADS). Comparison tests were used to test for an association between family/patient characteristics and a positive HADS score. In addition, a multivariable logistic regression model was constructed to identify the independent factors associated with a positive HADS score. Emotional distress was identified in 24% of the family members 3months after their relatives had been discharged from the ICU. A number of personal traits were found to be associated with emotional distress in the family members, namely unemployment (p = .008), smoking/drinking habits (p = .036) and personal history of psychopathology (p = .045). In the multiple logistic regression analyses, only unemployment was found to be an independent factor associated with both anxiety and depression in the family members (OR = 2.74, CI 95%: 1.09-6.93). No association was found between the patients' characteristics and emotional distress in the family members. The findings of this study indicate an association between emotional distress in the family members of ICU patients and their personal traits, thereby building on the prior literature by suggesting that patient characteristics are less pertinent to the experience of PICS-F. Unemployment may represent a meaningful risk factor for emotional distress in family members (a potential marker of PICS-F), given its relationship with family members' positive HADS scores post-ICU discharge. These findings should influence preventative strategies concerning PICS-F by illustrating the need to assess family characteristics and demographics early in a patient's ICU stay and, consequently, allowing for the early identification of at-risk individuals and the prompt implementation of adequate support services.

Data regarding the epidemiology and diagnosis of invasive aspergillosis in the critically ill population are limited, with data regarding elderly patients (≥75 years old) even scarcer. We aimed to further compare the epidemiology, characteristics and outcome of elderly versus nonelderly critically ill patients with invasive aspergillosis (IA) Prospective, international, multicenter observational study (AspICU) including adult intensive care unit (ICU) patients, with a culture and/or direct examination and/or histopathological sample positive for Aspergillus spp. at any site. We compared clinical characteristics and outcome of IA in ICU patients using two different diagnostic algorithms. Elderly and nonelderly ICU patients with IA differed in a number of characteristics, including comorbidities, clinical features of the disease, mycology testing, and radiological findings. No difference regarding mortality was found. According to the clinical algorithm, elderly patients were more likely to be diagnosed with putative IA. Elderly patients had less diagnostic radiological findings and when these findings were present they were detected late in the disease course. The comparison between elderly survivors and nonsurvivors demonstrated differences in clinical characteristics of the disease, affected sites and supportive therapy needed. All patients who were diagnosed with proven IA died. Increased vigilance combined with active search for mycological laboratory evidence and radiological confirmation are necessary for the timely diagnosis of IA in the elderly patient subset. Although elderly state per se is not a particular risk factor for mortality, a high SOFA score and the decision not to administer antifungal therapy may have an impact on survival of elderly patients.

Role of Clinical Ethicists in Making Decisions About Levels of Care in the Intensive Care Unit

Background Aging is a significant issue worldwide, and Korea is one of the most rapidly aging countries. Along with the demographic transition, the age structure of intensive care unit (ICU) patients changes as well.Methods The aim of this study was to analyze the change in age distribution of the ICU patients over the last 10 years and its effect on clinical outcomes. Single-center, retrospective analysis of all patients aged ≥18 years admitted to either the medical or surgical ICU at St. Paul’s Hospital, The Catholic University of Korea, between January 2005 and December 2014 was conducted. For clinical outcome, in-hospital mortality, duration of ICU stay, and hospital stay were analyzed. Cost analysis was performed to show the economic burden of each age strata.Results A total of 10,366 ICU patients were admitted to the chosen ICUs during the study period. The proportion of elderly patients aged ≥65 years increased from 47.9% in 2005 to 63.7% in 2014, and the proportion of the very elderly patients aged ≥80 years increased from 12.8% to 20.7%. However, this increased proportion of elderly patients did not lead to increased in-hospital mortality. The percent of ICU treatment days attributable to elderly patients increased from 51.1% in year 2005 to 64.0% in 2014. The elderly ICU patients were associated with higher in-hospital mortality compared to younger age groups.Conclusions The proportion of elderly patients admitted to ICUs increased over the last decade. However, overall in-hospital mortality has not increased during the same period.

The population is aging. We examined changes in the proportion of elderly (≥ 80 years) intensive care unit (ICU) patients during 2005-2011 and the association between age and mortality controlling for preexisting morbidity. Through the Danish National Patient Registry, we identified a cohort of 49,938 ICU admissions (47,596 patients) in Northern Denmark from 2005 to 2011. Patients were subdivided in age groups (15-49, 50-64, 65-79 and ≥ 80 years) and calendar year. We estimated 30-day and 31-365-day mortality and mortality rate ratios (MRRs), stratified by admission type (medical and elective/acute surgical patients). Mortality was compared between age groups adjusting for sex and preexisting morbidity using 50-64-year-olds as reference. The proportion of elderly patients increased from 11.7% of all ICU patients in 2005 to 13.8% in 2011. Among the elderly, the 30-day mortality was 43.7% in medical, 39.6% in acute surgical, and 11.6% in elective surgical ICU patients. The corresponding adjusted 30-day MRRs compared with the 50-64-year-olds were 2.7 [95% confidence interval (CI) 2.5-3.0] in medical, 2.7 (95% CI 2.4-3.0) in acute surgical, and 5.2 (95% CI 4.1-6.6) in elective surgical ICU patients. The 31-365-day mortality among elderly patients was 25.4% in medical, 26.9% in acute, and 11.9% in elective surgical ICU patients, corresponding to adjusted MRRs of 2.5 (95% CI 2.1-2.9), 2.2 (95% CI 1.9-2.5), and 1.9 (95% CI 1.6-2.3), respectively. During 2005-2011, there was an 18% increase in the proportion of elderly ICU patients. Advancing age is associated with increased mortality even after controlling for preexisting morbidity.

Psychiatric management of Patients in intensive care units.

End-of-Life Decision Making, Organ Donation, and Critical Care Nurses

Providing a palliative approach in an ICU is not an oxymoron and is within our reach today. Implementing a palliative approach will better ensure the needs of older patients and their families are met. Investing in developing the palliative care capabilities of ICUs and implementing appropriate policies that support the delivery of best evidence-based palliative care, will help ICU clinicians move seamlessly from implementing intensive therapies focusing on cure to palliation and relief of symptoms and care of families.

Voices from the intensive care unit: A qualitative study on communication between family members and nurses.

Background This study aimed to develop and validate a nomogram for predicting acute kidney injury (AKI) in elderly patients in the intensive care unit (ICU). Methods Population data regarding elderly patients in ICU were derived from the Medical Information Mart for Intensive Care IV database from 2008 to 2019. The nomogram model was constructed from the training set using LASSO regression and logistic regression analysis, and the performance of the model was evaluated by decision curve analysis, calibration curve, and receiver operating characteristic (ROC) curve. Results According to inclusion and exclusion criteria, 14,373 elderly ICU patients were studied, of which 10,061 (70%) were assigned to the training set, and 4,312 (30%) were allocated to the validation set. Multivariate logistic analysis revealed that age, weight, myocardial infarction, congestive heart failure, dementia, diabetes, paraplegia, cancer, sepsis, body temperature, blood urea nitrogen, mechanical ventilation, urine volume, Sequential Organ Failure Assessment (SOFA) score, and Simplified Acute Physiology Score II (SAPS II) were independent risk factors for AKI in elderly ICU patients. The AUC values for the 15-factor nomogram were 0.812 (95% CI 0.802–0.822) and 0.802 (95% CI 0.787–0.818) in the training and validation sets, respectively. For clinical application, a simplified nomogram was constructed, which included age, weight, urine volume, SOFA score, and SAPS II, with the AUCs of 0.780 (95% CI 0.769–0.790) and 0.776 (95% CI 0.760–0.793), respectively. Calibration curve and decision curve analyses confirmed the models’ high prediction accuracy and clinical value. Conclusions The nomogram developed in this study shows excellent predictive performance for AKI in elderly patients in the ICU.

BackgroundSepsis still threatens the lives of more than 300 million patients annually and elderly patients with sepsis usually have a more complicated condition and a worse prognosis. Existing studies have shown that both Hematocrit (HCT) and albumin (ALB) can be used as potential predictors of sepsis, and their difference HCT-ALB has a significant capacity to diagnose infectious diseases. Currently, there is no relevant research on the relationship between HCT-ALB and the prognosis of elderly sepsis patients. Therefore, this study aims to explore the association between HCT-ALB and mortality in elderly patients with sepsis.MethodsThis study was a multi-center retrospective study based on the Medical Information Mart for Intensive Care (MIMIC-IV) database and the eICU Collaborative Research Database (eICU-CRD) in elderly patients with sepsis. The optimal HCT-ALB cut-off point for ICU mortality was calculated by the Youden Index based on the eICU-CRD dataset, and multivariate logistic regressions were conducted to explore the association between HCT-ALB and ICU/hospital mortality in the two databases. Subgroup analyses were performed for different parameters and comorbidity status.ResultsThe number of 16,127 and 3043 elderly sepsis patients were selected from two large intensive care databases (eICU-CRD and MIMIC-IV, respectively) in this study. Depending on the optimal cut-off point, patients in both eICU-CRD and MIMIC-IV were independently divided into low HCT-ALB (< 6.7) and high HCT-ALB (≥ 6.7) groups. The odds ratio (95%confidence interval) [OR (95CI%)] of the high HCT-ALB group were 1.50 (1.36,1.65) and 1.71 (1.58,1.87) for ICU and hospital mortality in the eICU-CRD database after multivariable adjustment. Similar trends in the ICU and hospital mortality [OR (95%CI) 1.41 (1.15,1.72) and 1.27 (1.07,1.51)] were observed in MIMIC-IV database. Subgroup analysis showed an interaction effect with SOFA score in the eICU-CRD database however not in MIMIC-IV dataset.ConclusionsHigh HCT-ALB (≥ 6.7) is associated with 1.41 and 1.27 times ICU and hospital mortality risk in elderly patients with sepsis. HCT-ALB is simple and easy to obtain and is a promising clinical predictor of early risk stratification for elderly sepsis patients in ICU.

Survival from critical illness has improved in recent years, leading to increased attention to the sequelae of such illness. Neuromuscular weakness in the intensive care unit (ICU) is common, persistent, and has significant public health implications. The differential diagnosis of weakness in the ICU is extensive and includes critical illness neuromyopathy. Prolonged immobility and bedrest lead to catabolism and muscle atrophy, and are associated with critical illness neuromyopathy and ICU-acquired weakness. Early mobilization therapy has been advocated as a mechanism to prevent ICU-acquired weakness. Early mobilization is safe and feasible in most ICU patients, and improves outcomes. Implementation of early mobilization therapy requires changes in ICU culture, including decreased sedation and bedrest. Various technologies exist to increase compliance with early mobilization programs. Drugs targeting muscle pathways to decrease atrophy and muscle-wasting are in development. Additional research on early mobilization in the ICU is needed.

Families are reporting loss of interactions and communication in response to restrict isolation measures. Other tangible losses include income, access to resources, engagement, involvement in decision-making process and other planned activities. Listening to families' needs, concerns and say has been identified as one of the most important and least accomplished health care providers' roles in the intensive care units (ICUs). (1) To explore the experiences and concerns of Arab family members and health care professionals facing the challenges during ICU isolation, and (2) to develop recommendations for enhancing family support and improving effective communication to better address the needs of families during ICU isolation. This study utilizes a qualitative descriptive phenomenological design. We analysed data gained from 32 family members' concerns during their ICU patients' stay in isolated room settings and 21 health care providers' reflections through 2 focused groups recruited from Emirati and Egyptian ICUs. Thematic analysis revealed two main themes. The first theme, Family Members' Perspectives, highlights families' emotional and logistical challenges, including fears about infection, frustration over delayed updates and barriers to advocating for their loved ones. Subthemes include (a) family experiences and emotional challenges and (b) family-derived recommendations, such as implementing regular video calls, providing detailed patient updates and allowing occasional controlled visits to the ICU. The second theme, Health Care Providers' Perspectives, reflects HCPs' professional challenges in balancing family engagement with clinical demands. Subthemes include (a) challenges faced by HCPs, such as time constraints and communication difficulties, and (b) HCP-derived suggestions, including the integration of liaison nurses, social workers and revised visitation policies to enhance family-centred care. Families expressed concerns regarding the post-ICU discharge plan, prognosis and treatment quality. They proposed regular calls and video conferences as key methods for expressing preferences, emphasizing the importance of their active involvement during isolation. In response, health care providers acknowledged the imbalance in family-centred care and recommended expanding the ICU team to include social workers, psychologists and liaison nurses to better address the holistic needs of patients and families in isolation. This study underscores the critical role of family support and involvement in ICU care, specifically highlighting the responsibilities of ICU nurses. It calls for targeted policy modifications, the implementation of structured communication strategies and the establishment of a supportive environment to enhance family engagement. By equipping ICU nurses with the necessary resources, training and tools, these strategies aim to optimize family-centred care, improve the quality of communication and ultimately contribute to better patient outcomes in intensive care settings.

To describe the trends in short-term and long-term mortality in very elderly intensive care unit (ICU) patients between 2008 and 2014. A retrospective cohort study was conducted using data from the National Intensive Care Evaluation Foundation from 31 Dutch ICUs. Generalized linear mixed-effects models were used to determine the change in adjusted short-term mortality (ICU/hospital deaths) and long-term mortality (3, 6, and 12months after ICU admission) over the period 2008-2014 in very elderly patients and in patients less than 80years old admitted to the ICU. A total of 216,196 patients admitted to 31 ICUs in the period from 2008 to 2014 were included in the study, including 28,284 (13.1%) very elderly patients (80years or older). Follow-up data for determination of 3-, 6-, and 12-month mortality were available for, respectively, 210,005 (97.1%), 202,551 (93.7%), and 176,847 (81.8%) ICU admissions. The crude ICU and in-hospital mortality decreased, respectively, from 17.6% to 13.0% and from 30.7% to 21.0%. The annual risk-adjusted ICU and in-hospital mortality of very elderly patients (adjusted for APACHE III score, comorbidities, and admission type) decreased significantly during the study period [adjusted odds ratio 0.97 (0.95-0.99) and 0.92 (0.91-0.93), respectively]. Additionally, the annual risk-adjusted 3-, 6-, and 12-month mortality decreased significantly from 2008 to 2014 [adjusted odds ratio 0.96 (0.95-0.97), 0.96 (0.94-0.97), and 0.97 (0.95-0.98), respectively]. A similar significant annual decrease in risk-adjusted short-term and long-term mortality was observed in patients aged less than 80years. Both short-term and long-term risk-adjusted mortality decreased significantly during the study period in both very elderly ICU patients and patients aged less than 80years in the Netherlands. This study clearly shows that in our setting very elderly patients benefit almost as much as their younger counterparts from improvement in quality of care over time.