SPECIAL ARTICLE
Society of Critical Care Medicine Guidelines on Caring for Older Adults in the ICU
Ferrante, Lauren E.; Chaudhuri, Dipayan; Laiya Carayannopoulos, Kallirroi; et al
Critical Care Medicine March 20, 2026
DOI: 10.1097/CCM.0000000000007085
Rationale:
Older adults (those 65 years old or greater) compose a substantial proportion of the ICU population. As older adults with critical illness possess unique factors and considerations relevant to their care and outcomes, there is a need for evidence-based recommendations to guide critical care clinicians in the care of older ICU patients.
Objective:
The objective of this guideline is to develop evidence-based recommendations addressing the care of older adults during and after critical illness.
Design:
The American College of Critical Care Medicine Board convened a 22-member interprofessional panel, comprising physicians, advanced practice providers, nurses, a pharmacist, physical therapist, occupational therapist, and a patient representative. The panel included two expert methodologists specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting.
Methods:
The panel members prioritized five Population, Intervention, Comparator, and Outcomes questions. A systematic review was conducted for each question to identify the best available evidence, synthesize the evidence and assess the certainty of evidence using GRADE. The evidence-to-decision framework was used to formulate recommendations.
Results:
The panel generated two conditional recommendations and three “no recommendation” statements. The conditional recommendations are: 1) We suggest a geriatric model of care for all older adults admitted to the ICU and 2) We suggest not using antipsychotic medications for the prevention of delirium in older adults with critical illness. The three “no recommendation” statements are: 1) We make no recommendation regarding specialized post-ICU follow-up for older survivors of critical illness, 2) For older adults (age 65 and over) admitted to the ICU with vasodilatory shock, we make no recommendation with regard to targeting a mean arterial pressure (MAP) of 60–65 mm Hg as compared with usual care (MAP target > 65 mm Hg), and 3) We make no recommendation regarding the use of antipsychotic medication in the treatment of delirium in older adults with critical illness.
TABLE 1. - Caring for Older Adults in the ICU Population, Intervention, Comparator, and Outcomes Questions
| Question 1. Should Older Adults With Critical Illness Receive a Geriatrics Consultation or a Geriatric Model of Care Upon ICU Admission? | |||
|---|---|---|---|
| Population | Intervention | Comparator | Outcomes |
| Older adult patients admitted to any ICU | Geriatric consult or geriatric-specific model of care or care pathway | No geriatrics consult or no geriatric-specific model of care | Mortality |
| Subgroups to consider: | |||
| Type of ICU (surgical vs. medical vs. CV surgery) | Quality of life | ||
| Older (age ≥ 65) vs. oldest old (age ≥ 80) | Disability in functional activities post-hospital discharge | ||
| Long-term cognitive impairment | |||
| Duration of IMV | |||
| Ability to perform ADLs at long-term follow-up | |||
| Discharge to nursing home (not previously at nursing home) | |||
| Delirium | |||
| Hospital LOS | |||
| Depression, PTSD, anxiety symptoms | |||
| Question 2. Should Older Patients Who Survive Critical Illness Be Referred to Specialized Post-ICU Outpatient Follow-Up? | |||
|---|---|---|---|
| Population | Intervention | Comparator | Outcomes |
| Older adult patients who survive their ICU stay | Referral to specialized post-ICU follow-up | No specialized post-ICU follow-up | Mortality |
| Subgroups to consider: | Quality of life | ||
| Type of ICU (surgical vs. medical vs. CV surgery) | Disability in functional activities post-hospital discharge | ||
| Older (age ≥ 65) vs. oldest old (age ≥ 80) | Long-term cognitive impairment | ||
| Rehabilitation vs. just clinic | Duration of IMV | ||
| Ability to perform ADLs at long-term follow-up | |||
| Discharge to nursing home (not previously at nursing home) | |||
| Delirium | |||
| Hospital LOS | |||
| Depression, PTSD, anxiety symptoms | |||
| Question 3. Should We Aim for a Lower MAP Target (60–65 mm Hg) As Compared With Usual Care (Typically > 65 mm Hg) in Older Patients Admitted to the ICU With Vasodilatory Shock? | |||
|---|---|---|---|
| Population | Intervention | Comparator | Outcomes |
| Older adult patients admitted to ICU with shock | Lower MAP target (e.g., 60–65 mm Hg) | Usual care (typically MAP > 65 mm Hg) | Mortality |
| Subgroups to consider: | |||
| Type of vasodilatory shock (septic vs. other) | Quality of life | ||
| Specific MAP target | Disability in functional activities post-hospital discharge | ||
| Older (age ≥ 65) vs. oldest old (age ≥ 80) | Long-term cognitive impairment | ||
| Duration of IMV | |||
| Ability to perform ADLs at long-term follow-up | |||
| Discharge to nursing home (not previously at nursing home) | |||
| Delirium | |||
| Hospital LOS | |||
| Depression, PTSD, anxiety symptoms | |||
| Question 4. Should Older Patients Admitted to the ICU Receive Antipsychotics for Prevention of Delirium? | |||
|---|---|---|---|
| Population | Intervention | Comparator | Outcomes |
| Older adult patients admitted to any ICU | Antipsychotics for prevention of delirium | No antipsychotic for prevention of delirium | Mortality |
| Subgroups to consider: | Quality of life | ||
| Type of ICU (surgical vs. medical vs. CV surgery) | Disability in functional activities post-hospital discharge | ||
| Older (age ≥ 65) vs. oldest old (age ≥ 80) | Long-term cognitive impairment | ||
| Type of antipsychotic | Duration of IMV | ||
| Those at highest risk for delirium vs. all older adults | Ability to perform ADLs at long-term follow-up | ||
| Discharge to nursing home (not previously at nursing home) | |||
| Delirium | |||
| Hospital LOS | |||
| Depression, PTSD, anxiety symptoms | |||
| Question 5. Should Older Patients Admitted to the ICU Receive Antipsychotics for Treatment of Delirium? | |||
|---|---|---|---|
| Population | Intervention | Comparator | Outcomes |
| Older adult patients admitted to any ICU with delirium | Antipsychotic for treatment of delirium | No antipsychotic for treatment of delirium | Mortality |
| Subgroups to consider: | Quality of life | ||
| Type of ICU (surgical vs. medical vs. CV surgery) | Disability in functional activities post-hospital discharge | ||
| Older (age ≥ 65) vs. oldest old (age ≥ 80) | Long-term cognitive impairment | ||
| Type of antipsychotic | Duration of IMV | ||
| Hypoactive vs. hyperactive delirium | Ability to perform ADLs at long-term follow-up | ||
| Discharge to nursing home (not previously at nursing home) | |||
| Delirium | |||
| Hospital LOS | |||
| Depression, PTSD, anxiety symptoms | |||
TABLE 2. - Implications of Strong and Conditional Recommendations
| Target Audience | Strong Recommendation | Conditional Recommendation |
|---|---|---|
| For patients | Most individuals in this situation would want the recommended course of action and only a small proportion would not | The majority of individuals in this situation would want the suggested course of action, but many would not |
| For clinicians | Most individuals should receive the recommended course of action. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences | Recognize that different choices will be appropriate for different patients and that you must help each patient arrive at a management decision consistent with her or his values and preferences. Decision aids may well be useful helping individuals making decisions consistent with their values and preferences. Clinicians should expect to spend more time with patients when working toward a decision |
| For policy makers | The recommendation can be adapted as policy in most situations including for the use as performance indicators | Policymaking will require substantial debates and involvement of many stakeholders. Policies are also more likely to vary between regions. Performance indicators would have to focus on the fact that adequate deliberation about the management options has taken place |
RECOMMENDATIONS
We suggest a geriatric model of care for all older adults admitted to the ICU (conditional recommendation, very low certainty).
We make no recommendation regarding specialized post-ICU follow-up for older survivors of critical illness (conditional recommendation, low certainty).
For older adults (age 65 and over) with vasodilatory shock, we make no recommendation with regard to targeting a mean arterial pressure (MAP) of 60–65 mm Hg as compared with usual care (MAP target > 65 mm Hg) (conditional recommendation, very low certainty).
We suggest not using antipsychotic medications for the prevention of delirium in older adults with critical illness (conditional recommendation, very low certainty).
We make no recommendation regarding the use of antipsychotic medication in the treatment of delirium in older adults with critical illness (conditional recommendation, low certainty).
TABLE 3. - Caring for Older Adults in the ICU Research Priorities
| Topic | Research Priorities |
|---|---|
| Geriatric consultation or geriatric-specific model of care in the ICU | Studies that further investigate the impact of geriatric consultation or geriatric models of care in the ICU, with comparison to the standard of care |
| Geriatric consultation and geriatric models of care may both fall under the framework of “Age-Friendly” care models, which are increasingly being implemented in health systems, particularly in the U.S. future studies of age-friendly care should evaluate the impact of clearly specified components (i.e., the 4Ms of Age-Friendly Care: What Matters, Medication, Mentation, Mobility) compared with standard of care. Reporting fidelity of delivery of these components should be central to interpreting intention-to-treat and per-protocol analyses of efficacy | |
| Outcomes in future studies should focus on the goals of geriatric consultation or geriatric models of care, mortality between 30 and 90 d, and patient-centered outcomes that matter most to older adults, such as short-and long-term functional and cognitive outcomes, maintaining community independence, and mobility | |
| Specialized post-ICU outpatient follow-up | A core outcome set for older adults who survive critical illness is needed to ensure outcomes that are the most important to patients are gathered in future research |
| Address heterogeneity of older adults by evaluating whether specialized follow-up (and related interventions) is of greatest benefit in those with vulnerability factors such as biological or social frailty | |
| Studies investigating acceptability of specialized geriatric care from multiple viewpoints (patient, family/caregiver, primary care, etc) | |
| Develop a conceptual model of ideal recovery for an older adult recovering from a critical illness to tailor interventions toward recovery | |
| MAP targets in older patients admitted to ICU with vasodilatory shock | More high-quality trials investigating MAP targets in older adults with critical illness from vasodilatory shock to increase certainty of evidence |
| Determine the effects of MAP targets on longer-term, patient-centered outcomes such as functional and cognitive outcomes | |
| Evaluate whether midodrine changes the balance of benefits and harms for MAP targets in future trials conducted in this population | |
| Antipsychotics for prevention of delirium | Research exploring the balance of preventing delirium with the harm of exposing older adults to antipsychotic risks |
| Studies identifying patients that may benefit most (i.e., subgroups) from prevention of delirium or patients at the highest risk for delirium are needed | |
| Antipsychotics for treatment of delirium | Trials enrolling exclusively older adults with critical illness to investigate antipsychotic use for the treatment of delirium |
| Research on long-term outcomes of antipsychotic use in older adults with critical illness | |
| Trials reporting the quality of implementation of nonpharmacological bundles when antipsychotics are used | |
| Investigations to improve the accuracy of delirium assessment in older adults with critical illness and thereby enhance detection of treatment effects | |
| Cost-effectiveness research and resource-use research | |
| Studies investigating acceptability of antipsychotic treatment from multiple viewpoints (patient, family/caregiver, primary care, etc) |
Conclusions:
The guideline panel developed recommendations on caring for older adults during and after critical illness. Areas for future research were also identified during the guideline process.
