Critical care nursing for older adults: pathophysiological and functional considerations

The aging of the population brings into health care practice, including ICUs, an increasing prevalence of people with chronic conditions with corresponding expectations of eventual decline in function. These age-related health problems, however, do not have a precise moment of onset, nor a single and unambiguous cause. By their nature, chronic conditions do not have an end that can be modified easily, and ordinarily, they are related to parameters other than physiology alone. Aged individuals often are distinguished as a medicalized cohort on the basis of sheer numbers of comorbidities and predisposition toward frequent hospitalizations, without regard for the potential for adaptation to life despite complex health factors. Some care providers, health economists, and bioethicists propose using the existence of chronic conditions and assumed physical decompensation asa valid basis for restricting individuals and groups, by means of rationing, from consideration for intensive care and treatment. In view of studies demonstrating that covert rationing of ICU resources to critically ill older patients already is taking place, there isa need to continue to examine institutional policies that permit care providers to act as gatekeepers, ostensibly with benign intent, but presumably without patients' knowledge or acceptance. On the other hand, there is evidence that older ICU patients do equally well as younger and middle-aged patients in terms of discharge from the hospital with subsequent recovery of function. Thus, age alone is not a useful marker for limiting access to ICUs. Rather, a comprehensive evaluation is the foundation for diagnostic accuracy and health care decision-making for older individuals. Assessment and maintenance of the older person's functional status are fundamental concerns of geriatric and critical care specialists. Evaluation of an individual's baseline abilities in physical, mental, social, and psychological spheres is necessary before limitation of care realistically can be considered. Intensive care unit hospitalizations for catastrophic or critical illness are not necessarily terminal events. Ongoing functional assessment will help to illuminate the impact of chronicity on an older person's capacity for self care, and may help to guide health care decision-making regarding use of critical care resources. Accordingly, assuring equitable access to essential intensive care services, devoid of concerns about age constraints, will help to ensure the autonomy that is central to older adults' achievement of a fulfilling and productive old age.