Critical care clinics
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Surgical procedures on geriatric patients are not always benign, but postoperative mortality and morbidity is improving. Optimal care depends on our ability to recognize potential risk factors and intervene in a positive manner. Not all the data are complete, and we are missing several key randomized trials, but investigators have identified many areas for possible intervention. Hopefully, in the near future, more concrete recommendations can be given for this very large and important topic of perioperative anesthetic issues in the elderly.
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A substantial proportion of patients admitted to intensive care units (ICUs) are elderly patients. Based upon population growth, patient preference, and current physician practice, the number of elderly patients who receive critical care services is likely to increase substantially over the next 10 to 20 years. ⋯ Elderly patients frequently receive less aggressive care in the ICU and probably consume a lower relative proportion of ICU resources than younger patients. However, this does not necessarily result in worse outcomes.
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Patients who are critically ill often develop a variety of psychiatric symptoms, which require assessment and treatment. The most common psychiatric disorder in the intensive care unit is delirium. Depressed mood and anxiety also occur, at times as discrete disorders, but more often secondary to delirium. Patients with severe mental illnesses, such as schizophrenia and bipolar affective disorder, also may become critically ill--assessment and management of these patients often requires specialized psychiatric care and is not addressed here.
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As the number of elderly patients receiving oncologic therapies increases, the need for better outcome predictors for the critically ill elderly with cancer increases. Physicians should not view age as an indicator of poor ICU outcome, as many elderly patients with cancer will derive the same benefit from intensive care as their younger counterparts. ⋯ These parameters, in addition to clinical judgment, can be helpful in deciding who will benefit from ICU care regardless of age. Oncologists and critical care physicians will need to collaborate and change the paradigm of ICU care for the elderly.
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As the geriatric population in the United States increases and better management of chronic diseases improves survival, more elderly will become critically ill and potentially require treatment in an intensive care unit (ICU). Dan Callahan has written, "... we will live longer lives, be better sustained by medical care, in return for which our deaths in old age are more likely to be drawn out and wild." Although no health care provider hopes for a drawn out and wild death for elderly patients, many geriatric persons will succumb to disease and die after having chosen and received ICU care. Recent data suggest that, on average, 11% of Medicare recipients spend more that 7 days in the ICU within 6 months before death.