Older adults currently account for over half of all intensive care unit admissions. Although advances in critical care medicine have led to improved survival, critical illness is still associated with high short-term and long-term morbidity and mortality.
Areas of Uncertainty:
Elderly survivors of critical illness often have long-lasting physical, cognitive, and psychological disabilities. Several iatrogenic risk factors for post-critical illness impairments have been identified, including delirium
, deep sedation, and inadequate analgesia. Multicomponent interventions or bundles, which target many of these risk factors, have been shown to improve patient outcomes. However, there is limited literature that addresses the optimal pharmacologic management of analgesia and sedation in elderly critically ill patients who are known to have altered pharmacokinetics and pharmacodynamics. There are also uncertainties regarding the treatment and prophylaxis of delirium
in this patient population.
Various interventions can improve the pharmacologic management of pain, agitation, and delirium
and subsequently improve outcomes in critically ill elderly patients. Pain should be managed with multimodal therapy and opioids should be used judiciously. Benzodiazepines should be avoided and dexmedetomidine may be the best first-line sedative in this population. Only patients with hyperactive delirium
should receive treatment with antipsychotics and there is likely no role of antipsychotics for delirium
prophylaxis. New literature suggests that dexmedetomidine may be effective for the prevention and treatment of intensive care unit delirium
Elderly patients are more sensitive to centrally acting medications and often require lower doses than younger patients because of alterations in pharmacokinetics. A newer medication, dexmedetomidine, has demonstrated some benefit over other sedatives and may have a role in the management of delirium
. Overall, more research is needed on the pharmacologic management of pain, sedation, and delirium
in the elderly critically ill population.