ICU pharmacist helps lead clinical guidelines for older adult care

Multidisciplinary panel, including Lisa Burry, highlights need for more critical care trials involving older adults

An international panel of experts, including Lisa Burry, associate professor (status) at the Leslie Dan Faculty of Pharmacy, recently published new guidelines for the care of older adults in the intensive care unit (ICU). The guidelines, available through the Society of Critical Care Medicine, not only provide recommendations to improve care for this population but, importantly, also highlight the need for more research on critical care for older adults.

"... as we move toward more precision medicine, we are learning that we can’t expect treatments to have the same effects or harms in different ICU populations.”

“One of the most important pieces of the guideline is identifying the current gaps in evidence and setting the research agenda priorities,” says Burry, also a clinical pharmacy specialist at Sinai Health. “As the population ages, older adults are going to become a bigger share of the population, but they’re not well-represented in ICU-related clinical trials. And as we move toward more precision medicine, we are learning that we can’t expect treatments to have the same effects or harms in different ICU populations.”

According to the Canadian Institute for Health Information (CIHI), older adults make up more than half of ICU admissions in Canada, and this number is expected to grow as the population ages Older adults are more likely to experience frailty or disability and often take multiple medications, increasing the complexity of care required in the ICU. Despite this, there have been no specific recommendations to guide the care of older adults in the ICU.

As an expert in ICU pharmacy in Canada, Burry was invited to be part of the multi-disciplinary expert panel, composed of physicians, nurses, and physical and occupational therapists.

The panel reviewed the existing evidence on treating older adults in the ICU related to five important questions: models of care for patients, preventing and treating delirium, target measurements for a patient’s mean arterial pressure, and referring patients to specialized follow-up after an ICU admission.

While there was not enough evidence to make any recommendations relating to some of the questions, they did make two conditional recommendations.

The first suggestion is that ICUs should implement a model of care for older adults that addresses their unique needs, for example by addressing hearing loss, removing unnecessary tethering devices such as catheters or restraints, and improving cognitive and functional outcomes through occupational therapy.

The second is that health care providers should not use antipsychotic medications in older adults to prevent delirium in the ICU, because of the higher risk of potential harm associated with these medications in this population.

The panel acknowledged that not all hospitals have access to specialized geriatric care, so the specific implementation could vary based on the individual hospital’s resources; however, some level of geriatric care is feasible for any ICU team and can be targeted specifically to those with frailty, disability, or cognitive impairment. The guidelines also include implementation guides to help frontline health care workers.

“Most ICUs won't have a geriatrician available to consult, but these guidelines are meant to raise awareness that special populations may have unique needs,” says Burry. “The guidelines make this information accessible and help health care workers – even those without specialized training with older adults – think about whether these patients may need different drugs or doses of drugs and how their care needs may differ.”

Lack of evidence in older adults highlights need for more research

In addition to the panel’s recommendations, the guidelines also shed light on the lack of research on older adults in the ICU. The panel found that there are very few critical care trials specifically focused on older adults, and some trials that enrol ICU patients have age cut-offs.

As a result, the panel included a robust research agenda in the guidelines that outlines key priorities to generate the evidence required to make strong recommendations for the research questions examined in the guidelines.

“To be able to make strong recommendations about caring for older adults in the ICU, we need evidence specific to this population, but trials that are exclusively about this population are lacking,” says Burry.

“As the Canadian population ages and older adults make up an even bigger share of ICU patients, we need to have trials that are designed for older adults and that prioritize research questions that will improve their care.”