Intensive care units see on average 19 million patients admitted each year, a statistic recorded prior to the outbreak of the SARS-CoV-2 coronavirus pandemic this year, which has since only increased this number. Much research has been done looking at short-term acute care and survival outcomes of this life-threatening virus with potential to cause severe acute respiratory syndromes in those who become exposed to it. Where the research is lacking, however, is in the long-term effects of extended stays in intensive care units for these patients and their families. Of the average 19 million ICU admittances, only about 14 million of those people will be discharged, and roughly 2.3 million of those people will suffer from permanent functional disability and require help with functions of daily living for the rest of their lives.
The term “Post Intensive Care Syndrome” (PICS) was originally coined by a task force of the Society of Critical Care Medicine (SCCM) and was used to describe the worsening of physical and mental health following discharge after an extended stay in an intensive care unit. Upon discharge, these people develop increased fatigue, muscle weakness, difficulty swallowing, cloudy thinking, difficulty concentrating, poor memory, and sleep disturbances. They also increasingly suffer from depression (19-37%) and anxiety (32-40%), as well as post-traumatic stress disorder (19-22%), which has been shown to last up to 8 years after discharge. Older patients often experience these symptoms more severely. Three months following discharge, only about half of people will regain functional capacity. They will develop an average of 1.5 new limitations of activities of daily living (compared to 0.5 in older non-ICU counterparts). The definition of PICS has also been updated to include the mental health of the patients’ families as well, who often experience severe depression (17.9%) and anxiety (15-24%) even 6 months after the discharge of their loved ones. The prevalence of decreased functional ability in older survivors combined with poor mental health in the patients’ families has resulted in decreased quality of life for these patients and an increased need for community services and higher rates of institutionalization into nursing homes and rehabilitation facilities.
More than 3 million people to date have been infected with COVID, with approximately 3% of those patients requiring intensive care and mechanical ventilation. While this is only a small percentage of the total, the length of ICU stay and duration of mechanical ventilation is an average of up to 3 weeks, much longer than an average ICU patient. In addition, roughly one-third of the patients are over 60 years of age. In order to prevent the development of PICS in elderly patients beginning recovery from COVID-19, a multidisciplinary transition of care plan needs to be in place. One of the best ways to start is with patient-centered intensive care using the ABCDEF bundle. This evidence-based guide involving coordinated care has shown to be the best way to optimize patient recovery. The components are as follows:
Assess, prevent, manage pain
Both spontaneous awakening and spontaneous breathing trials
Choice of analgesia and sedation
Delirium: assess, prevent, manage
Early mobility and exercise
Family engagement and empowerment
Increasingly, it is shown that making healthcare decisions based on what matters most to the patient results in better outcomes of care. Keeping the family involved and informed in these decisions as well also helps with the mental health aspects and can greatly reduce stress when they feel their loved one’s needs are being met and they are well cared for.
One of the most important steps early on in the recovery of these geriatric COVID patients is going to be high quality transfers to a nursing facility or geriatric ward. These transfers should include instructions with information regarding nutrition, rehabilitation, psychological support, and a complete medication reconciliation. Each patient should also undergo a comprehensive assessment to evaluate any medical conditions and identify new physical, cognitive, or mental disturbances. The results of this assessment will allow geriatric teams in an institutional or home setting to provide a coordinated care effort to overcome any functional decline. Supportive measures can be adapted in a facility to help overcome any potential obstacles to care, or social workers can work with the patients’ families to reduce any care-related or social burdens and build confidence in the level of care being delivered. Through these efforts and working together, the effect of the COVID-19 pandemic on these high-risk individuals can be diminished, and the quality of life of both the patients and their families improved.

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Reference: Michel, J., Maggi, S. & Ecarnot, F. Raising awareness of the needs of older COVID patients after hospital discharge. Aging Clin Exp Res (2020).

Jessica Metzger

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