Very old patients in the ICU in Latin America: A narrative review | Revista Española de Geriatría y Gerontología

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Fuente: elaboración propia." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Esther Sánchez Sánchez, Inmaculada Montero García" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Esther" "apellidos" => "Sánchez Sánchez" ] 1 => array:2 [ "nombre" => "Inmaculada" "apellidos" => "Montero García" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211139X2400074X?idApp=UINPBA00004N" "url" => "/0211139X/unassign/S0211139X2400074X/v1_202407240435/es/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Very old patients in the ICU in Latin America: A narrative review" "tieneTextoCompleto" => true "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Andrés Giglio, Javiera Barrientos, Andrés Ferre, Felipe Salech" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Andrés" "apellidos" => "Giglio" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "Javiera" "apellidos" => "Barrientos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Andrés" "apellidos" => "Ferre" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:4 [ "nombre" => "Felipe" "apellidos" => "Salech" "email" => array:1 [ 0 => "fhsalech@uchile.cl" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Critical Care Center, Clínica Las Condes Hospital, Santiago, Chile" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Critical Care Department, Finis Terrae University, Santiago, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "School of Medicine, Finis Terrae University, Santiago, Chile" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Geriatrics Unit, Hospital Clínico Universidad de Chile, Santiago, Chile" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "GERO, Centro Fondap de Gerosciencia y Metabolismo, Chile" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pacientes muy mayores en las UCI de Latinoamérica: una revisión narrativa" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1136 "Ancho" => 2925 "Tamanyo" => 223325 ] ] "descripcion" => array:1 [ "en" => "Knowledge and resources challenges for optimal critical care older adults in latam." ] ] ] "textoCompleto" => "IntroductionThe “very elderly” patient group, defined as those aged 80 years and older, comprises an increasing proportion of patients admitted to the intensive care unit (ICU).<a class="elsevierStyleCrossRefs" href="#bib0305">1,2</a> Older adults comprise a heterogeneous population group, where within the same age group, individuals with high functional reserves coexist with fragile and/or dependent individuals. As life expectancy increases globally, critical care clinicians are faced with more complex decisions regarding the appropriateness and likely benefits of ICU admission for this vulnerable patient population.<a class="elsevierStyleCrossRef" href="#bib0315">3</a>Very elderly ICU patients have a high severity of illness, with mean SOFA admission scores of 7–9 in cohort studies.<a class="elsevierStyleCrossRefs" href="#bib0305">1,4,5</a> Frailty is highly prevalent, affecting 23–68% in some series.<a class="elsevierStyleCrossRefs" href="#bib0330">6–9</a> Comorbid conditions like heart failure, vascular disease and dementia are also common.<a class="elsevierStyleCrossRefs" href="#bib0325">5,10</a> The accumulation of physiological changes with aging and chronic diseases contributes to reduced organ reserves and heightened complications when faced with critical insults.<a class="elsevierStyleCrossRef" href="#bib0355">11</a> Cognitive impairment is frequent, with estimates ranging from 19 to 89% experiencing delirium during ICU stay.<a class="elsevierStyleCrossRef" href="#bib0360">12</a>Current data show that octogenarians have a high severity of illness upon ICU admission and face heightened risks of functional impairment and mortality compared to younger ICU patients.<a class="elsevierStyleCrossRefs" href="#bib0305">1,13,14</a>Very elderly individuals have distinct physiological and psychosocial characteristics that can affect their ICU stay. Normal aging results in decreased organ reserve and functionality, which reduces resilience to acute insults.<a class="elsevierStyleCrossRef" href="#bib0375">15</a> Additionally, these patients frequently have significant comorbidities, frailty, and disabilities, which further complicate critical care management.<a class="elsevierStyleCrossRef" href="#bib0305">1</a> Delirium and cognitive changes are highly prevalent in this group.<a class="elsevierStyleCrossRef" href="#bib0380">16</a> Optimizing communication with patients with sensory, cognitive, or functional impairments poses unique challenges.<a class="elsevierStyleCrossRef" href="#bib0385">17</a>Risk assessment in very elderly patients is complex, as traditional scoring systems do not account for frailty, comorbidity burden, and baseline disability.<a class="elsevierStyleCrossRefs" href="#bib0390">18–20</a> This complicates the determination of the likely benefits, futility, or harm with ICU interventions.<a class="elsevierStyleCrossRef" href="#bib0395">19</a> Patients and their families may have uncertain or unrealistic prognostic awareness and expectations of ICU care, which can complicate shared decision-making regarding treatment plans.<a class="elsevierStyleCrossRef" href="#bib0405">21</a>The aging population in Latin America is rapidly increasing, presenting significant challenges to healthcare systems.<a class="elsevierStyleCrossRef" href="#bib0410">22</a> This demographic shift demands more resources for chronic disease management, long-term care, and specialized geriatric services.<a class="elsevierStyleCrossRef" href="#bib0410">22</a> It underscores the urgent need for policy reforms and investment in healthcare infrastructure to ensure sustainable care for the elderly. Critical care is not exempt from this scenario and must be prepared to face this population challenge, and knowing the current state of the art can provide valuable information to determine where it is important to generate knowledge in this field in the future.In this review of very elderly ICU patients, we focused on the following topics: triage for ICU admission, distinct clinical characteristics, prognostic elements, outcomes during and after ICU stay, and the Latin American reality for the management of these patients. We summarized recent evidence to provide perspectives on the complex management issues surrounding this growing critical care population.MethodologySearch strategyA structured literature search was conducted using the PubMed/MEDLINE database with the MeSH terms “80 and over, aged” and “critical care.” The search was limited to clinical studies and reviews in English and Spanish language of the last 20 years, between 2003 and 2023.Study selectionA total of 708 articles were screened for titles and abstracts of the retrieved bibliography. After excluding irrelevant records, 28 studies were included in this narrative review. A complementary search for economic studies on cost utilization included four articles. A specific search and Latin American studies identified just one thesis research focused on very elderly patients; however, two additional articles of elderly ICU patients were included for discussion based on their relevance.The objectives defined for this narrative review are the identification of four axes of analysis: Triage for ICU admission of very elderly patients, Specific Clinical Characteristics of this Population, Predictive elements of prognosis, ICU and post-ICU outcomes, ICU trial role and ICU Cost-utilization.ResultsEpidemiologyMultiple studies have shown that 10–15% of patients admitted to the ICU are very elderly.<a class="elsevierStyleCrossRefs" href="#bib0315">3,15</a> In simple terms, this means that every day in most ICU around the world, management decisions are made regarding very elderly individuals. With an aging global population, it is projected that ICU utilization by this patient group will continue to rise over the next decades.<a class="elsevierStyleCrossRef" href="#bib0325">5</a> Despite the population aging currently experienced by multiple regions in Latin America, including Costa Rica, Chile, Uruguay, Cuba, and others, epidemiological reports on elderly individuals in ICUs in the region are very scarce. Soto et al. reported in 2012 that 30.7% of the patients hospitalized in the ICU at a Santiago de Chile center were over 65 years old, with 10.4% being over 80 years old.<a class="elsevierStyleCrossRef" href="#bib0415">23</a> Rubiano et al. conducted in 11 teaching and 8 nonteaching ICUs in Colombia during 2005, showing a prevalence of people older than 85 between 4.3 and 5.9%<a class="elsevierStyleCrossRef" href="#bib0420">24</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Physiological changes associated with agingAging is accompanied by significant physiological changes that are crucial for the management of patients in intensive care settings.<a class="elsevierStyleCrossRef" href="#bib0425">25</a> These alterations include reduced cardiac and vascular compliance, diminished lung tissue elasticity, increased thoracic cage resistance, decreased renal clearance, and sarcopenia/cachexia. One of the key changes is the alteration of venous compliance. The venous system's elasticity enables it to act as a volume reservoir, transferable to the arterial system during stress. As individuals age, their vascular system, including venous system, undergoes stiffening, leading to decreased compliance, and losing this capacity for volume reserve<a class="elsevierStyleCrossRef" href="#bib0430">26</a> rapidly bringing elderly people to states of hypovolemia when facing hemorrhagic injuries or vasodilation. Pulmonary mechanics also undergo significant changes. The elasticity of lung tissue diminishes with age, this, along with increased thoracic cage rigidity, challenges pulmonary support. The decreased lung tissue elasticity and greater resistance of the thoracic cage reduce the lungs’ capacity to expand and contract efficiently, leading to lower oxygenation levels and a higher risk of respiratory complications.<a class="elsevierStyleCrossRef" href="#bib0435">27</a> It is well known that renal clearance also declines as part of the aging process. This decrease in renal function is mainly due to a reduction in the glomerular filtration rate. This associated with changes in distribution dynamics because changes in the proportion of fat and muscular mass makes the elderly patient more susceptible to drug toxicity and fluid balance issues.<a class="elsevierStyleCrossRef" href="#bib0440">28</a> Sarcopenia, characterized by the loss of skeletal muscle function, mass, and strength, is exacerbated by prolonged immobility, corticosteroids or neuromuscular blockers commonly used in the ICU setting. This condition poses significant challenges to rehabilitation efforts due to its direct impact on patients’ physical capabilities. It results in slower and more difficult recoveries. Reduced muscle function increases patient dependency, fall risk, and hospitalization duration.<a class="elsevierStyleCrossRef" href="#bib0445">29</a> Careful monitoring and adjustment of therapeutic interventions are required to manage these physiological changes, catering to the unique needs of the aging ICU patient population.<a class="elsevierStyleCrossRef" href="#bib0425">25</a>Predictive elements of prognosisPrior status/dependencyWhile mortality traditionally has been associated with advancing age, several studies have found that age itself is less predictive than factors such as functional impairments and number of comorbidities,<a class="elsevierStyleCrossRefs" href="#bib0305">1,15,19,30</a> which probably represents the heterogeneity of the elderly population. Multiple analyses have confirmed that poor patient functionality status prior to admission predict poor ICU prognosis and recovery potential.<a class="elsevierStyleCrossRefs" href="#bib0450">30–32</a> Moreover, the trajectory of the previous functional status before admission to the ICU has proven to be a predictor of outcomes as powerful as the need for mechanical ventilation or vasoactive drugs. Ferrante et al. identified three different functionals profiles from pre-ICU status: minimal, mild to moderate, and severe disability as predictor of 1 year mortality increasing mortality by 2–3 folds respectively when compared to minimal disability.<a class="elsevierStyleCrossRef" href="#bib0465">33</a> Similar to the general adult population, higher severity of illness on admission was also consistently associated with greater mortality, as measured by the APACHE, SAPS, or SOFA scales.<a class="elsevierStyleCrossRefs" href="#bib0325">5,7</a> Sanchez-Hurtado et al. compared APACHE II with SAPS3 performance in a prospective cohort of people older than 65 years old, in two mixed ICUs in Mexico, showing that he SAPS 3 model did not show a higher performance than that shown by the APACHE II model in this population.<a class="elsevierStyleCrossRef" href="#bib0470">34</a>FrailtyFrailty describes a condition characterized by decreased physiological reserves and increased vulnerability to face injuries. Frailty on ICU admission was associated with short- and long-term mortality, functional and cognitive impairment, increased health care dependency, and impaired quality of life post-ICU discharge.<a class="elsevierStyleCrossRef" href="#bib0475">35</a> Multiple studies have demonstrated that incorporating elements such as poor mobility and frailty screening stratifies risk, with Clinical Frailty Scale (CFS) scores>4 predicting 2–4-fold higher odds of death.<a class="elsevierStyleCrossRefs" href="#bib0320">4,9,36</a> Aguilar-Frasco et al. evaluated the role of frailty assessment in predicting outcomes in older adults undergoing major abdominal surgery, showing that frail older subjects have a higher likelihood of being admitted to the ICU postoperatively than non-frail subjects.<a class="elsevierStyleCrossRef" href="#bib0485">37</a>ICU and post-ICU outcomesMortality rates remain elevated for very elderly ICU patients, both in the acute and long-term. In-hospital mortality ranges from 20 to 63%.<a class="elsevierStyleCrossRefs" href="#bib0305">1,3,4,15</a> Up to 25% of patients experience early death, considered as death in the hospital less than 30 days after discharge.<a class="elsevierStyleCrossRef" href="#bib0465">33</a> By 6–24 months, over 30–50% of octogenarians have died, with upwards of 71% mortality at 3 years in some cohorts.<a class="elsevierStyleCrossRefs" href="#bib0375">15,31,38</a> A recent thesis by Rojas et al. examined outcomes of very elderly patients admitted to an ICU in Chile. In their single-center cohort of 52 patients with a median age of 85 years (IQR 82–88.5 years), they found a 30-day mortality rate of 22% and 90-day mortality rate of 30%. Their analysis did not identify any significant associations between mortality and factors such as sex, admission diagnosis categories, number of active diagnoses, or comorbidity count. Beyond mortality, functionality is a key outcome after management in critical care units. Multiple studies have demonstrated the severe functional loss experienced by many older adults following a stay in the ICU. Among 1-year survivors in a Spanish study, only 53.1% had minimal or no dependence, and 20.3% had moderate to severe dependence, compared to 6.6% before ICU admission.<a class="elsevierStyleCrossRef" href="#bib0455">31</a> Between 19 and 89% experience delirium before ICU discharge, which is associated with higher mortality and lower functional recovery.<a class="elsevierStyleCrossRef" href="#bib0360">12</a> In Latin America, the available information points in the same direction. Dietrich et al. reported a multicenter prospective cohort study where, among the 253 patients included, they showed functional capacity losses after discharge from the intensive care unit.<a class="elsevierStyleCrossRef" href="#bib0495">39</a> The average Barthel index at the third month was 63, and 69% of people older than 80 years required a caregiver.<a class="elsevierStyleCrossRef" href="#bib0495">39</a> Nearly half of octogenarians die while actively receiving aggressive interventions, such as mechanical ventilation or renal replacement therapy,<a class="elsevierStyleCrossRef" href="#bib0305">1</a> highlighting opportunities to align treatment plans with patient values and realistic prognosis.Triage for ICU admission and ICU trialStudies have examined whether systematic ICU admission for all very elderly patients improves outcomes compared to more selective triage approaches. A large French randomized trial found that systematically admitting octogenarians increased ICU utilization (61% vs. 34%) without reducing the 6-month mortality.<a class="elsevierStyleCrossRef" href="#bib0500">40</a> Other analyses have shown that ICU care confers a mortality benefit over ward-based treatment,<a class="elsevierStyleCrossRef" href="#bib0505">41</a> suggesting that judicious ICU admission for some patients can improve prognosis. Robust criteria to determine the likely benefits are lacking, highlighting the need for enhanced prognostic tools and models to guide admission decisions.Systematic admission of very elderly patients to the ICU increases ICU usage without an improvement in mortality, and is associated with higher long-term mortality.<a class="elsevierStyleCrossRefs" href="#bib0500">40,42</a> In contrast, the implementation of ICU trials, or short ICU tests, for very elderly patients has been proposed,<a class="elsevierStyleCrossRef" href="#bib0515">43</a> but no specific guidelines exist to define who or how much ICU time or intensity should be proposed for these patients. Offering periods of treatment of 2–3 days, after which reassessment of clinical response to therapy, patient's wishes, and disease-specific prognosis can help guide further care.<a class="elsevierStyleCrossRefs" href="#bib0520">44,45</a> Two observational studies, 2015 and 2018, “using causal inference, showed the potential for short-term mortality benefit of ICU admission”.<a class="elsevierStyleCrossRef" href="#bib0510">42</a> It should also be noted that even after implementing ICU trials in very elderly patients, the appearance of “poor prognosis predictors”, such as those in the Cumulative Prognostic Score, could not accurately predict 100% mortality, with a 30-days survival chance of 25% in patients with poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0520">44</a>Cost utilization in the ICUStudies from Europe and North America indicate that very elderly patients undergoing ICU treatment are considerably more expensive than younger patients.<a class="elsevierStyleCrossRefs" href="#bib0530">46,47</a> This rise in cost is not limited to in-ICU treatment but is also seen in the years before and after ICU admission for these patients.<a class="elsevierStyleCrossRef" href="#bib0530">46</a> Key drivers include comorbid conditions, higher disease severity at admission, female sex, and the need for urgent care.<a class="elsevierStyleCrossRef" href="#bib0530">46</a> The patient's preference for comfort measurement over intensive life support was an independent predictor of lower management costs in both the deceased and survivors.<a class="elsevierStyleCrossRef" href="#bib0535">47</a> With an aging global population and 10–15% of ICU beds occupied by very elderly patients with higher care demands, critical care services face escalating economic pressures.<a class="elsevierStyleCrossRef" href="#bib0310">2</a> Developing sustainable frameworks to meet the needs of increasingly older patient cohorts is an important priority in this field.DiscussionThis narrative review of 28 studies showed that very elderly patients aged 80 years and older comprise an increasing proportion of ICU admissions.<a class="elsevierStyleCrossRef" href="#bib0310">2</a> These patients now represent 10–15% of ICU patients.<a class="elsevierStyleCrossRefs" href="#bib0315">3,15</a> With an aging global population, projections suggest continuing growth in ICU utilization by the very elderly over the coming decades.<a class="elsevierStyleCrossRef" href="#bib0325">5</a> Very old patients face high severity of illness on admission, with mean SOFA scores of 7–9 in cohort studies.<a class="elsevierStyleCrossRef" href="#bib0325">5</a> Mortality risk is elevated, with rates up to 25% in the first 30 days,<a class="elsevierStyleCrossRef" href="#bib0465">33</a> and as high as 70% during the subsequent years.<a class="elsevierStyleCrossRefs" href="#bib0375">15,31,38</a> Many very elderly patients die after aggressive treatments in the ICU or soon after discharge while never regaining their prior level of functioning.<a class="elsevierStyleCrossRefs" href="#bib0305">1,31,33</a>The very elderly experience more complications, higher infection rates, and increased vulnerability to physiological insults compared to younger ICU patients.<a class="elsevierStyleCrossRefs" href="#bib0315">3,5,7</a> As such, octogenarians fail to derive an equivalent survival benefit from ICU-level treatment, a difference that could be partially explained by the less treatment received by “oldest-old” patients in comparison of “young-old”.<a class="elsevierStyleCrossRefs" href="#bib0365">13,48</a> Traditional prognostic models, such as APACHE II and SOFA, underestimate mortality in this group, as they do not account for age-related vulnerabilities and poor baseline status.<a class="elsevierStyleCrossRefs" href="#bib0400">20,49</a> Recent analyses of large datasets suggest that age itself is not an independent mortality predictor but rather serves as a proxy for other unmeasured age-associated factors like frailty.<a class="elsevierStyleCrossRef" href="#bib0315">3</a>There is a pressing need to improve ICU admission decision-making and care personalization for very elderly patients.<a class="elsevierStyleCrossRefs" href="#bib0320">4,50,51</a> Existing evidence-based guidance is insufficient to reliably determine which patients could benefit from ICU-level treatment versus those unlikely to survive or recover their quality of life.<a class="elsevierStyleCrossRef" href="#bib0520">44</a> Clearer criteria and improved prediction tools accounting for frailty, functional status, and goals of care are required.<a class="elsevierStyleCrossRefs" href="#bib0315">3,6,7,11,18</a> There are also opportunities to mitigate harm through enhanced delirium prevention and monitoring,<a class="elsevierStyleCrossRef" href="#bib0560">52</a> early rehabilitation, and increased social/psychological support.<a class="elsevierStyleCrossRef" href="#bib0565">53</a> This review also highlights the urgent need to improve communication between critical care teams and geriatrics teams, which could facilitate the comprehensive assessment of patients receiving critical care, and thus ensure the continuity of care that leads them to their best functional potential or to palliative care that significantly impacts their quality of life (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>An opportunity to address the uncertainty in prognosis for these patients is the implementation of ICU trial as part of the usual care of these patients.<a class="elsevierStyleCrossRefs" href="#bib0320">4,43,54</a> Several analyses indicate judicious ICU trials of a few days, without restricting only to those with clear predicted benefit, help reassess the clinical trajectory in critical care patients such as very elderly patients facing uncertain risks and benefits from intensive care.<a class="elsevierStyleCrossRef" href="#bib0570">54</a>Enhanced shared decision-making regarding patient/family preferences, likely treatment trajectories, and prognosis could better align care with patient values.<a class="elsevierStyleCrossRefs" href="#bib0555">51,54</a> Systematically assessing frailty, baseline function, comorbidities and nutritional status facilitates further mortality and recovery risk stratification when considering ICU use.<a class="elsevierStyleCrossRefs" href="#bib0315">3,6,7,10,11,18,19</a> Tools like the Clinical Frailty Scale show promise toward enhanced prognostic discrimination and admission triage.<a class="elsevierStyleCrossRefs" href="#bib0545">49,55</a> The quality of survivorship also warrants greater incorporation when evaluating outcomes in very elderly patients after ICU discharge.<a class="elsevierStyleCrossRef" href="#bib0580">56</a> Finally, specialized geriatric ICU consultation services and care pathways may optimize decision quality and patient-centered priorities.<a class="elsevierStyleCrossRef" href="#bib0585">57</a>Implementing optimal very elderly ICU care in Latin America is a central challenge for the immediate future of our region (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The population aged 80 years and over will triple by 2050, greatly impacting critical care utilization and management.<a class="elsevierStyleCrossRef" href="#bib0590">58</a> The absence of articles focused on this specific population, with most grouping patients aged 65 years or older with mean ages around 70–75 years, does not allow robust characterization while also limiting coordinated efforts. Two prior studies in the region examining elderly ICU patients reported mortality rates from 24 to 30%, with a high prevalence of comorbidities and geriatric syndromes in 85% of their patients.<a class="elsevierStyleCrossRefs" href="#bib0415">23,59</a> A recent Chilean study specifically focused on 52 very elderly ICU patients over 82 years old described a 30-day mortality rate of 22% and 90-day mortality of 30%, without significant demographic or clinical differences identified between survivors and non-survivors.<a class="elsevierStyleCrossRef" href="#bib0600">60</a> As one of the only experiences concentrated expressly on this growing Latin American ICU population, these preliminary results showcase comparable outcomes to international cohorts and younger elderly regional patients, while underscoring the need for expanded evidence guiding prognosis and optimized care models.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>ConclusionVery elderly patients now comprise 10–15% of ICU admissions and have distinct age-related risks; outcomes remain uncertain, but with a relevant, at least transitory, loss of prior functional status. There is a pressing need to improve shared decision-making, risk stratification incorporating frailty, functional assessments, judicious ICU trials, and post-ICU support as the aging population will continue to drive more very elderly patients into critical care.Additional research should further inform appropriate usage, enhance personalized care models, elevate the incorporation of patient goals/preferences, and promote quality survivorship for this particularly vulnerable population. Ultimately, more humanistic, patient-centered approaches may help address the uncertainties surrounding the very elderly in the ICU by aligning treatments with individual patient values and realistic prognoses.Conflict of interestThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres2230185" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1867612" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2230186" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1867613" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methodology" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Search strategy" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Study selection" ] ] ] 6 => array:3 [ "identificador" => "sec0025" "titulo" => "Results" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Epidemiology" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Physiological changes associated with aging" ] 2 => array:3 [ "identificador" => "sec0040" "titulo" => "Predictive elements of prognosis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Prior status/dependency" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Frailty" ] ] ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "ICU and post-ICU outcomes" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "Triage for ICU admission and ICU trial" ] 5 => array:2 [ "identificador" => "sec0065" "titulo" => "Cost utilization in the ICU" ] ] ] 7 => array:2 [ "identificador" => "sec0070" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-05-05" "fechaAceptado" => "2024-08-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1867612" "palabras" => array:5 [ 0 => "Aged, 80 and over" 1 => "Very elderly" 2 => "Critical care" 3 => "Critical care unit" 4 => "Latin America" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1867613" "palabras" => array:4 [ 0 => "Edad: 80 años y más" 1 => "Muy anciano" 2 => "Cuidados intensivos" 3 => "Latinoamérica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The population of very elderly patients (aged 80 years and older) in intensive care units (ICUs) is steadily growing. These patients have unique physiological, cognitive, functional, and social characteristics that affect their entire ICU course. Immobility, delirium, dysphagia, malnutrition, and polypharmacy are among the most common geriatric syndromes in these patients, and they contribute to a higher risk of acute and long-term functional decline and mortality. Risk assessment in very elderly patients is complex, as traditional ICU scoring systems do not account for frailty and baseline disability, making difficult the determination of likely benefits, futility, or harm with ICU interventions. The importance of shared decision-making for treatment plans is critical, as very elderly patients and their families may have uncertain or unrealistic prognostic awareness and expectations of ICU care. Considering the gap between the rapid aging of the population and the socio-health development in Latin America, this population is an important determinant of stress on healthcare systems, however, data on these population is scarce. This review, based on a comprehensive literature search, summarizes recent evidence on triage for ICU admission, specific clinical characteristics, predictive elements of prognosis, and ICU and post-ICU outcomes for very elderly patients while also analyzing the challenges to improve management in the Latin American region." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La población de pacientes muy ancianos (de 80 y más años) en las unidades de cuidados intensivos (UCI) crece de forma sostenida. Estos pacientes tienen características fisiológicas, cognitivas, funcionales y sociales únicas que afectan sus trayectorias en las UCI. La inmovilidad, el delirium, la disfagia, la malnutrición y la polifarmacia están entre los síndromes geriátricos más frecuentes en estos pacientes, los que contribuyen a un aumento del riesgo de deterioro funcional tanto agudo como a largo plazo, así como de mortalidad. La evaluación de riesgo del paciente muy anciano es compleja, dado que los puntajes predictivos tradicionales de cuidados intensivos no consideran la fragilidad y la condición basal, haciendo difícil la determinación de los posibles beneficios, futilidad o daño con las intervenciones de las UCI. La importancia de la decisión conjunta de los planes terapéuticos es crítica, en el contexto que los pacientes muy ancianos y sus familias pueden tener incertidumbre o expectativas poco realistas del impacto de los cuidados de las UCI. Considerando la brecha entre el envejecimiento acelerado y el desarrollo sociosanitario en Latinoamérica, esta población es una fuente de estrés en los sistemas de salud, pese a ello, la información en esta población es escasa. Esta revisión, basada en una revisión comprensiva de la literatura, resume la evidencia reciente del triage de admisión a las UCI, características clínicas específicas, elementos predictivos de pronóstico y desenlaces de las UCI y post-UCI en los pacientes muy ancianos, al mismo tiempo que analiza los desafíos de mejorar su manejo en Latinoamérica." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2526 "Ancho" => 2508 "Tamanyo" => 283709 ] ] "descripcion" => array:1 [ "en" => "Epidemiology of older adults at ICU." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2301 "Ancho" => 2508 "Tamanyo" => 338797 ] ] "descripcion" => array:1 [ "en" => "Interaction between frailty/disability, comprehensive geriatric assessment and intensity of management in critical care older adults." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1136 "Ancho" => 2925 "Tamanyo" => 223325 ] ] "descripcion" => array:1 [ "en" => "Knowledge and resources challenges for optimal critical care older adults in latam." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:60 [ 0 => array:3 [ "identificador" => "bib0305" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The very elderly admitted to ICU: a quality finish?" 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Very old patients in the ICU in Latin America: A narrative review

Pacientes muy mayores en las UCI de Latinoamérica: una revisión narrativa

Andrés Giglioa,b, Javiera Barrientosc, Andrés Ferrea,b, Felipe Salechd,e,

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fhsalech@uchile.cl

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a Critical Care Center, Clínica Las Condes Hospital, Santiago, Chile

b Critical Care Department, Finis Terrae University, Santiago, Chile

c School of Medicine, Finis Terrae University, Santiago, Chile

d Geriatrics Unit, Hospital Clínico Universidad de Chile, Santiago, Chile

e GERO, Centro Fondap de Gerosciencia y Metabolismo, Chile

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    "titulo" => "Very old patients in the ICU in Latin America&#58; A narrative review"
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        "titulo" => "Pacientes muy mayores en las UCI de Latinoam&#233;rica&#58; una revisi&#243;n narrativa"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Knowledge and resources challenges for optimal critical care older adults in latam&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The &#8220;very elderly&#8221; patient group&#44; defined as those aged 80 years and older&#44; comprises an increasing proportion of patients admitted to the intensive care unit &#40;ICU&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">1&#44;2</span></a> Older adults comprise a heterogeneous population group&#44; where within the same age group&#44; individuals with high functional reserves coexist with fragile and&#47;or dependent individuals&#46; As life expectancy increases globally&#44; critical care clinicians are faced with more complex decisions regarding the appropriateness and likely benefits of ICU admission for this vulnerable patient population&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Very elderly ICU patients have a high severity of illness&#44; with mean SOFA admission scores of 7&#8211;9 in cohort studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a> Frailty is highly prevalent&#44; affecting 23&#8211;68&#37; in some series&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">6&#8211;9</span></a> Comorbid conditions like heart failure&#44; vascular disease and dementia are also common&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">5&#44;10</span></a> The accumulation of physiological changes with aging and chronic diseases contributes to reduced organ reserves and heightened complications when faced with critical insults&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">11</span></a> Cognitive impairment is frequent&#44; with estimates ranging from 19 to 89&#37; experiencing delirium during ICU stay&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Current data show that octogenarians have a high severity of illness upon ICU admission and face heightened risks of functional impairment and mortality compared to younger ICU patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">1&#44;13&#44;14</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Very elderly individuals have distinct physiological and psychosocial characteristics that can affect their ICU stay&#46; Normal aging results in decreased organ reserve and functionality&#44; which reduces resilience to acute insults&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">15</span></a> Additionally&#44; these patients frequently have significant comorbidities&#44; frailty&#44; and disabilities&#44; which further complicate critical care management&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">1</span></a> Delirium and cognitive changes are highly prevalent in this group&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">16</span></a> Optimizing communication with patients with sensory&#44; cognitive&#44; or functional impairments poses unique challenges&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">17</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Risk assessment in very elderly patients is complex&#44; as traditional scoring systems do not account for frailty&#44; comorbidity burden&#44; and baseline disability&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">18&#8211;20</span></a> This complicates the determination of the likely benefits&#44; futility&#44; or harm with ICU interventions&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">19</span></a> Patients and their families may have uncertain or unrealistic prognostic awareness and expectations of ICU care&#44; which can complicate shared decision-making regarding treatment plans&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">21</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The aging population in Latin America is rapidly increasing&#44; presenting significant challenges to healthcare systems&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">22</span></a> This demographic shift demands more resources for chronic disease management&#44; long-term care&#44; and specialized geriatric services&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">22</span></a> It underscores the urgent need for policy reforms and investment in healthcare infrastructure to ensure sustainable care for the elderly&#46; Critical care is not exempt from this scenario and must be prepared to face this population challenge&#44; and knowing the current state of the art can provide valuable information to determine where it is important to generate knowledge in this field in the future&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In this review of very elderly ICU patients&#44; we focused on the following topics&#58; triage for ICU admission&#44; distinct clinical characteristics&#44; prognostic elements&#44; outcomes during and after ICU stay&#44; and the Latin American reality for the management of these patients&#46; We summarized recent evidence to provide perspectives on the complex management issues surrounding this growing critical care population&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Search strategy</span><p id="par0040" class="elsevierStylePara elsevierViewall">A structured literature search was conducted using the PubMed&#47;MEDLINE database with the MeSH terms &#8220;80 and over&#44; aged&#8221; and &#8220;critical care&#46;&#8221; The search was limited to clinical studies and reviews in English and Spanish language of the last 20 years&#44; between 2003 and 2023&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Study selection</span><p id="par0045" class="elsevierStylePara elsevierViewall">A total of 708 articles were screened for titles and abstracts of the retrieved bibliography&#46; After excluding irrelevant records&#44; 28 studies were included in this narrative review&#46; A complementary search for economic studies on cost utilization included four articles&#46; A specific search and Latin American studies identified just one thesis research focused on very elderly patients&#59; however&#44; two additional articles of elderly ICU patients were included for discussion based on their relevance&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The objectives defined for this narrative review are the identification of four axes of analysis&#58; Triage for ICU admission of very elderly patients&#44; Specific Clinical Characteristics of this Population&#44; Predictive elements of prognosis&#44; ICU and post-ICU outcomes&#44; ICU trial role and ICU Cost-utilization&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Epidemiology</span><p id="par0055" class="elsevierStylePara elsevierViewall">Multiple studies have shown that 10&#8211;15&#37; of patients admitted to the ICU are very elderly&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">3&#44;15</span></a> In simple terms&#44; this means that every day in most ICU around the world&#44; management decisions are made regarding very elderly individuals&#46; With an aging global population&#44; it is projected that ICU utilization by this patient group will continue to rise over the next decades&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">5</span></a> Despite the population aging currently experienced by multiple regions in Latin America&#44; including Costa Rica&#44; Chile&#44; Uruguay&#44; Cuba&#44; and others&#44; epidemiological reports on elderly individuals in ICUs in the region are very scarce&#46; Soto et al&#46; reported in 2012 that 30&#46;7&#37; of the patients hospitalized in the ICU at a Santiago de Chile center were over 65 years old&#44; with 10&#46;4&#37; being over 80 years old&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">23</span></a> Rubiano et al&#46; conducted in 11 teaching and 8 nonteaching ICUs in Colombia during 2005&#44; showing a prevalence of people older than 85 between 4&#46;3 and 5&#46;9&#37;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">24</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Physiological changes associated with aging</span><p id="par0060" class="elsevierStylePara elsevierViewall">Aging is accompanied by significant physiological changes that are crucial for the management of patients in intensive care settings&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">25</span></a> These alterations include reduced cardiac and vascular compliance&#44; diminished lung tissue elasticity&#44; increased thoracic cage resistance&#44; decreased renal clearance&#44; and sarcopenia&#47;cachexia&#46; One of the key changes is the alteration of venous compliance&#46; The venous system&#39;s elasticity enables it to act as a volume reservoir&#44; transferable to the arterial system during stress&#46; As individuals age&#44; their vascular system&#44; including venous system&#44; undergoes stiffening&#44; leading to decreased compliance&#44; and losing this capacity for volume reserve<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">26</span></a> rapidly bringing elderly people to states of hypovolemia when facing hemorrhagic injuries or vasodilation&#46; Pulmonary mechanics also undergo significant changes&#46; The elasticity of lung tissue diminishes with age&#44; this&#44; along with increased thoracic cage rigidity&#44; challenges pulmonary support&#46; The decreased lung tissue elasticity and greater resistance of the thoracic cage reduce the lungs&#8217; capacity to expand and contract efficiently&#44; leading to lower oxygenation levels and a higher risk of respiratory complications&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">27</span></a> It is well known that renal clearance also declines as part of the aging process&#46; This decrease in renal function is mainly due to a reduction in the glomerular filtration rate&#46; This associated with changes in distribution dynamics because changes in the proportion of fat and muscular mass makes the elderly patient more susceptible to drug toxicity and fluid balance issues&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">28</span></a> Sarcopenia&#44; characterized by the loss of skeletal muscle function&#44; mass&#44; and strength&#44; is exacerbated by prolonged immobility&#44; corticosteroids or neuromuscular blockers commonly used in the ICU setting&#46; This condition poses significant challenges to rehabilitation efforts due to its direct impact on patients&#8217; physical capabilities&#46; It results in slower and more difficult recoveries&#46; Reduced muscle function increases patient dependency&#44; fall risk&#44; and hospitalization duration&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">29</span></a> Careful monitoring and adjustment of therapeutic interventions are required to manage these physiological changes&#44; catering to the unique needs of the aging ICU patient population&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Predictive elements of prognosis</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Prior status&#47;dependency</span><p id="par0065" class="elsevierStylePara elsevierViewall">While mortality traditionally has been associated with advancing age&#44; several studies have found that age itself is less predictive than factors such as functional impairments and number of comorbidities&#44;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">1&#44;15&#44;19&#44;30</span></a> which probably represents the heterogeneity of the elderly population&#46; Multiple analyses have confirmed that poor patient functionality status prior to admission predict poor ICU prognosis and recovery potential&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">30&#8211;32</span></a> Moreover&#44; the trajectory of the previous functional status before admission to the ICU has proven to be a predictor of outcomes as powerful as the need for mechanical ventilation or vasoactive drugs&#46; Ferrante et al&#46; identified three different functionals profiles from pre-ICU status&#58; minimal&#44; mild to moderate&#44; and severe disability as predictor of 1 year mortality increasing mortality by 2&#8211;3 folds respectively when compared to minimal disability&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">33</span></a> Similar to the general adult population&#44; higher severity of illness on admission was also consistently associated with greater mortality&#44; as measured by the APACHE&#44; SAPS&#44; or SOFA scales&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">5&#44;7</span></a> Sanchez-Hurtado et al&#46; compared APACHE II with SAPS3 performance in a prospective cohort of people older than 65 years old&#44; in two mixed ICUs in Mexico&#44; showing that he SAPS 3 model did not show a higher performance than that shown by the APACHE II model in this population&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Frailty</span><p id="par0070" class="elsevierStylePara elsevierViewall">Frailty describes a condition characterized by decreased physiological reserves and increased vulnerability to face injuries&#46; Frailty on ICU admission was associated with short- and long-term mortality&#44; functional and cognitive impairment&#44; increased health care dependency&#44; and impaired quality of life post-ICU discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">35</span></a> Multiple studies have demonstrated that incorporating elements such as poor mobility and frailty screening stratifies risk&#44; with Clinical Frailty Scale &#40;CFS&#41; scores<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4 predicting 2&#8211;4-fold higher odds of death&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">4&#44;9&#44;36</span></a> Aguilar-Frasco et al&#46; evaluated the role of frailty assessment in predicting outcomes in older adults undergoing major abdominal surgery&#44; showing that frail older subjects have a higher likelihood of being admitted to the ICU postoperatively than non-frail subjects&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">37</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">ICU and post-ICU outcomes</span><p id="par0075" class="elsevierStylePara elsevierViewall">Mortality rates remain elevated for very elderly ICU patients&#44; both in the acute and long-term&#46; In-hospital mortality ranges from 20 to 63&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">1&#44;3&#44;4&#44;15</span></a> Up to 25&#37; of patients experience early death&#44; considered as death in the hospital less than 30 days after discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">33</span></a> By 6&#8211;24 months&#44; over 30&#8211;50&#37; of octogenarians have died&#44; with upwards of 71&#37; mortality at 3 years in some cohorts&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">15&#44;31&#44;38</span></a> A recent thesis by Rojas et al&#46; examined outcomes of very elderly patients admitted to an ICU in Chile&#46; In their single-center cohort of 52 patients with a median age of 85 years &#40;IQR 82&#8211;88&#46;5 years&#41;&#44; they found a 30-day mortality rate of 22&#37; and 90-day mortality rate of 30&#37;&#46; Their analysis did not identify any significant associations between mortality and factors such as sex&#44; admission diagnosis categories&#44; number of active diagnoses&#44; or comorbidity count&#46; Beyond mortality&#44; functionality is a key outcome after management in critical care units&#46; Multiple studies have demonstrated the severe functional loss experienced by many older adults following a stay in the ICU&#46; Among 1-year survivors in a Spanish study&#44; only 53&#46;1&#37; had minimal or no dependence&#44; and 20&#46;3&#37; had moderate to severe dependence&#44; compared to 6&#46;6&#37; before ICU admission&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">31</span></a> Between 19 and 89&#37; experience delirium before ICU discharge&#44; which is associated with higher mortality and lower functional recovery&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">12</span></a> In Latin America&#44; the available information points in the same direction&#46; Dietrich et al&#46; reported a multicenter prospective cohort study where&#44; among the 253 patients included&#44; they showed functional capacity losses after discharge from the intensive care unit&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">39</span></a> The average Barthel index at the third month was 63&#44; and 69&#37; of people older than 80 years required a caregiver&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">39</span></a> Nearly half of octogenarians die while actively receiving aggressive interventions&#44; such as mechanical ventilation or renal replacement therapy&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">1</span></a> highlighting opportunities to align treatment plans with patient values and realistic prognosis&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Triage for ICU admission and ICU trial</span><p id="par0080" class="elsevierStylePara elsevierViewall">Studies have examined whether systematic ICU admission for all very elderly patients improves outcomes compared to more selective triage approaches&#46; A large French randomized trial found that systematically admitting octogenarians increased ICU utilization &#40;61&#37; vs&#46; 34&#37;&#41; without reducing the 6-month mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">40</span></a> Other analyses have shown that ICU care confers a mortality benefit over ward-based treatment&#44;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">41</span></a> suggesting that judicious ICU admission for some patients can improve prognosis&#46; Robust criteria to determine the likely benefits are lacking&#44; highlighting the need for enhanced prognostic tools and models to guide admission decisions&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Systematic admission of very elderly patients to the ICU increases ICU usage without an improvement in mortality&#44; and is associated with higher long-term mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">40&#44;42</span></a> In contrast&#44; the implementation of ICU trials&#44; or short ICU tests&#44; for very elderly patients has been proposed&#44;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">43</span></a> but no specific guidelines exist to define who or how much ICU time or intensity should be proposed for these patients&#46; Offering periods of treatment of 2&#8211;3 days&#44; after which reassessment of clinical response to therapy&#44; patient&#39;s wishes&#44; and disease-specific prognosis can help guide further care&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">44&#44;45</span></a> Two observational studies&#44; 2015 and 2018&#44; &#8220;using causal inference&#44; showed the potential for short-term mortality benefit of ICU admission&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">42</span></a> It should also be noted that even after implementing ICU trials in very elderly patients&#44; the appearance of &#8220;poor prognosis predictors&#8221;&#44; such as those in the Cumulative Prognostic Score&#44; could not accurately predict 100&#37; mortality&#44; with a 30-days survival chance of 25&#37; in patients with poor prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Cost utilization in the ICU</span><p id="par0090" class="elsevierStylePara elsevierViewall">Studies from Europe and North America indicate that very elderly patients undergoing ICU treatment are considerably more expensive than younger patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">46&#44;47</span></a> This rise in cost is not limited to in-ICU treatment but is also seen in the years before and after ICU admission for these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">46</span></a> Key drivers include comorbid conditions&#44; higher disease severity at admission&#44; female sex&#44; and the need for urgent care&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">46</span></a> The patient&#39;s preference for comfort measurement over intensive life support was an independent predictor of lower management costs in both the deceased and survivors&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">47</span></a> With an aging global population and 10&#8211;15&#37; of ICU beds occupied by very elderly patients with higher care demands&#44; critical care services face escalating economic pressures&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">2</span></a> Developing sustainable frameworks to meet the needs of increasingly older patient cohorts is an important priority in this field&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">This narrative review of 28 studies showed that very elderly patients aged 80 years and older comprise an increasing proportion of ICU admissions&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">2</span></a> These patients now represent 10&#8211;15&#37; of ICU patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">3&#44;15</span></a> With an aging global population&#44; projections suggest continuing growth in ICU utilization by the very elderly over the coming decades&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">5</span></a> Very old patients face high severity of illness on admission&#44; with mean SOFA scores of 7&#8211;9 in cohort studies&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">5</span></a> Mortality risk is elevated&#44; with rates up to 25&#37; in the first 30 days&#44;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">33</span></a> and as high as 70&#37; during the subsequent years&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">15&#44;31&#44;38</span></a> Many very elderly patients die after aggressive treatments in the ICU or soon after discharge while never regaining their prior level of functioning&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">1&#44;31&#44;33</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The very elderly experience more complications&#44; higher infection rates&#44; and increased vulnerability to physiological insults compared to younger ICU patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">3&#44;5&#44;7</span></a> As such&#44; octogenarians fail to derive an equivalent survival benefit from ICU-level treatment&#44; a difference that could be partially explained by the less treatment received by &#8220;oldest-old&#8221; patients in comparison of &#8220;young-old&#8221;&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">13&#44;48</span></a> Traditional prognostic models&#44; such as APACHE II and SOFA&#44; underestimate mortality in this group&#44; as they do not account for age-related vulnerabilities and poor baseline status&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">20&#44;49</span></a> Recent analyses of large datasets suggest that age itself is not an independent mortality predictor but rather serves as a proxy for other unmeasured age-associated factors like frailty&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">3</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">There is a pressing need to improve ICU admission decision-making and care personalization for very elderly patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">4&#44;50&#44;51</span></a> Existing evidence-based guidance is insufficient to reliably determine which patients could benefit from ICU-level treatment versus those unlikely to survive or recover their quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">44</span></a> Clearer criteria and improved prediction tools accounting for frailty&#44; functional status&#44; and goals of care are required&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">3&#44;6&#44;7&#44;11&#44;18</span></a> There are also opportunities to mitigate harm through enhanced delirium prevention and monitoring&#44;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">52</span></a> early rehabilitation&#44; and increased social&#47;psychological support&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">53</span></a> This review also highlights the urgent need to improve communication between critical care teams and geriatrics teams&#44; which could facilitate the comprehensive assessment of patients receiving critical care&#44; and thus ensure the continuity of care that leads them to their best functional potential or to palliative care that significantly impacts their quality of life &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">An opportunity to address the uncertainty in prognosis for these patients is the implementation of ICU trial as part of the usual care of these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">4&#44;43&#44;54</span></a> Several analyses indicate judicious ICU trials of a few days&#44; without restricting only to those with clear predicted benefit&#44; help reassess the clinical trajectory in critical care patients such as very elderly patients facing uncertain risks and benefits from intensive care&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">54</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Enhanced shared decision-making regarding patient&#47;family preferences&#44; likely treatment trajectories&#44; and prognosis could better align care with patient values&#46;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">51&#44;54</span></a> Systematically assessing frailty&#44; baseline function&#44; comorbidities and nutritional status facilitates further mortality and recovery risk stratification when considering ICU use&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">3&#44;6&#44;7&#44;10&#44;11&#44;18&#44;19</span></a> Tools like the Clinical Frailty Scale show promise toward enhanced prognostic discrimination and admission triage&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">49&#44;55</span></a> The quality of survivorship also warrants greater incorporation when evaluating outcomes in very elderly patients after ICU discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">56</span></a> Finally&#44; specialized geriatric ICU consultation services and care pathways may optimize decision quality and patient-centered priorities&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">57</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Implementing optimal very elderly ICU care in Latin America is a central challenge for the immediate future of our region &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The population aged 80 years and over will triple by 2050&#44; greatly impacting critical care utilization and management&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">58</span></a> The absence of articles focused on this specific population&#44; with most grouping patients aged 65 years or older with mean ages around 70&#8211;75 years&#44; does not allow robust characterization while also limiting coordinated efforts&#46; Two prior studies in the region examining elderly ICU patients reported mortality rates from 24 to 30&#37;&#44; with a high prevalence of comorbidities and geriatric syndromes in 85&#37; of their patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">23&#44;59</span></a> A recent Chilean study specifically focused on 52 very elderly ICU patients over 82 years old described a 30-day mortality rate of 22&#37; and 90-day mortality of 30&#37;&#44; without significant demographic or clinical differences identified between survivors and non-survivors&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">60</span></a> As one of the only experiences concentrated expressly on this growing Latin American ICU population&#44; these preliminary results showcase comparable outcomes to international cohorts and younger elderly regional patients&#44; while underscoring the need for expanded evidence guiding prognosis and optimized care models&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0125" class="elsevierStylePara elsevierViewall">Very elderly patients now comprise 10&#8211;15&#37; of ICU admissions and have distinct age-related risks&#59; outcomes remain uncertain&#44; but with a relevant&#44; at least transitory&#44; loss of prior functional status&#46; There is a pressing need to improve shared decision-making&#44; risk stratification incorporating frailty&#44; functional assessments&#44; judicious ICU trials&#44; and post-ICU support as the aging population will continue to drive more very elderly patients into critical care&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Additional research should further inform appropriate usage&#44; enhance personalized care models&#44; elevate the incorporation of patient goals&#47;preferences&#44; and promote quality survivorship for this particularly vulnerable population&#46; Ultimately&#44; more humanistic&#44; patient-centered approaches may help address the uncertainties surrounding the very elderly in the ICU by aligning treatments with individual patient values and realistic prognoses&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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              "titulo" => "ICU and post-ICU outcomes"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The population of very elderly patients &#40;aged 80 years and older&#41; in intensive care units &#40;ICUs&#41; is steadily growing&#46; These patients have unique physiological&#44; cognitive&#44; functional&#44; and social characteristics that affect their entire ICU course&#46; Immobility&#44; delirium&#44; dysphagia&#44; malnutrition&#44; and polypharmacy are among the most common geriatric syndromes in these patients&#44; and they contribute to a higher risk of acute and long-term functional decline and mortality&#46; Risk assessment in very elderly patients is complex&#44; as traditional ICU scoring systems do not account for frailty and baseline disability&#44; making difficult the determination of likely benefits&#44; futility&#44; or harm with ICU interventions&#46; The importance of shared decision-making for treatment plans is critical&#44; as very elderly patients and their families may have uncertain or unrealistic prognostic awareness and expectations of ICU care&#46; Considering the gap between the rapid aging of the population and the socio-health development in Latin America&#44; this population is an important determinant of stress on healthcare systems&#44; however&#44; data on these population is scarce&#46; This review&#44; based on a comprehensive literature search&#44; summarizes recent evidence on triage for ICU admission&#44; specific clinical characteristics&#44; predictive elements of prognosis&#44; and ICU and post-ICU outcomes for very elderly patients while also analyzing the challenges to improve management in the Latin American region&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La poblaci&#243;n de pacientes muy ancianos &#40;de 80 y m&#225;s a&#241;os&#41; en las unidades de cuidados intensivos &#40;UCI&#41; crece de forma sostenida&#46; Estos pacientes tienen caracter&#237;sticas fisiol&#243;gicas&#44; cognitivas&#44; funcionales y sociales &#250;nicas que afectan sus trayectorias en las UCI&#46; La inmovilidad&#44; el <span class="elsevierStyleItalic">delirium</span>&#44; la disfagia&#44; la malnutrici&#243;n y la polifarmacia est&#225;n entre los s&#237;ndromes geri&#225;tricos m&#225;s frecuentes en estos pacientes&#44; los que contribuyen a un aumento del riesgo de deterioro funcional tanto agudo como a largo plazo&#44; as&#237; como de mortalidad&#46; La evaluaci&#243;n de riesgo del paciente muy anciano es compleja&#44; dado que los puntajes predictivos tradicionales de cuidados intensivos no consideran la fragilidad y la condici&#243;n basal&#44; haciendo dif&#237;cil la determinaci&#243;n de los posibles beneficios&#44; futilidad o da&#241;o con las intervenciones de las UCI&#46; La importancia de la decisi&#243;n conjunta de los planes terap&#233;uticos es cr&#237;tica&#44; en el contexto que los pacientes muy ancianos y sus familias pueden tener incertidumbre o expectativas poco realistas del impacto de los cuidados de las UCI&#46; Considerando la brecha entre el envejecimiento acelerado y el desarrollo sociosanitario en Latinoam&#233;rica&#44; esta poblaci&#243;n es una fuente de estr&#233;s en los sistemas de salud&#44; pese a ello&#44; la informaci&#243;n en esta poblaci&#243;n es escasa&#46; Esta revisi&#243;n&#44; basada en una revisi&#243;n comprensiva de la literatura&#44; resume la evidencia reciente del <span class="elsevierStyleItalic">triage</span> de admisi&#243;n a las UCI&#44; caracter&#237;sticas cl&#237;nicas espec&#237;ficas&#44; elementos predictivos de pron&#243;stico y desenlaces de las UCI y post-UCI en los pacientes muy ancianos&#44; al mismo tiempo que analiza los desaf&#237;os de mejorar su manejo en Latinoam&#233;rica&#46;</p></span>"
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                      "doi" => "10.1097/CCM.0000000000001024"
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                      "doi" => "10.1016/j.arr.2022.101832"
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                  "contribucion" => array:1 [
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