To review trauma in the very old as a distinct form of critical illness, focusing on assessment, care pathways and outcomes. Among very old adults, trauma is predominantly related to low-energy falls, yet is associated with substantial morbidity and mortality. Frailty, multimorbidity, and polypharmacy influence injury recognition, treatment decisions, and recovery, and current care pathway remain heterogeneous. Improved outcomes depend on early recognition, routine frailty informed assessment, and integrated multidisciplinary care aligned with patient goals. Trauma in very old adults represents a growing and distinct form of critical illness, reflecting demographic aging and increasing levels of frailty, multimorbidity, and dependency. Unlike younger populations, where trauma is typically driven by high-energy mechanisms, injury in older adults most commonly results from low-energy falls. Despite this, the consequences are often severe, with high rates of hemorrhage, traumatic brain injury and thoracic trauma, and subsequent multi-organ dysfunction requiring critical care. Age-related physiological changes, combined with multimorbidity and polypharmacy, alter responses to injury and may mask early signs of deterioration. As a result, commonly used triage systems frequently underestimate injury severity in older patients, contributing to under-triage and delays in access to specialist trauma care. Frailty is increasingly recognized as a key determinant of outcomes, influencing survival, length of stay, and functional recovery, and should be routinely assessed early in the patient pathway. Assessment of frailty and intrinsic capacity in the Emergency Department is often challenging, particularly when relatives or caregivers are unavailable to provide collateral history. Older adults should receive an in-depth assessment and documentation of pre-injury status and prior wishes; however, this is inconsistently performed in routine trauma practice. Management of older trauma patients is complex and often fragmented across specialties, with significant variability in care pathways. Decision-making is further complicated by prognostic uncertainty and the need to align interventions with patient values and baseline function. While ICU admission may improve outcomes in selected patients, survival is frequently accompanied by complications, such as delirium, sarcopenia, and long-term functional impairment. Optimizing outcomes requires a coordinated, multidisciplinary approach that integrates trauma and geriatric principles, emphasizing early recognition, tailored resuscitation, comprehensive assessment of frailty, and patient-centered care. Future priorities include improving triage accuracy and injury recognition, standardizing care pathways, and focusing on meaningful recovery in this vulnerable population.

Background Consensus-based recommendations have recently been developed to guide the delivery of quality care for very old patients (age ≥80 years) in the intensive care unit (ICU). To examine the influence of healthcare provider gender on agreement with consensus-based recommendations for the management of very old patients in ICUs. Methods Exploratory secondary analysis of survey responses from an international multiprofessional Delphi consensus on management of very old patients in ICUs by the European Society of Intensive Care Medicine. The primary analysis compared mean agreement scores between female and male participants using independent-samples t-tests. Secondary analyses included comparisons of strong agreement proportions and adjusted analyses using two-way analysis of variance and multivariable regression models including provider category and age. Results The analysis included 128 participants with available gender and clinical activity data (53 female and 75 male respondents). Female participants reported significantly higher agreement scores for several recommendations involving multidisciplinary input, including medication review, clinical pharmacist involvement, transfer to geriatric wards, dietitian support, and speech and language therapy (mean differences of approximately 7.4–11.0 points on a 0–100 scale, P <0.050). In contrast, male participants reported higher agreement for decisions to limit life-sustaining therapy based on expected functional outcome. Analysis of response proportions showed similar patterns, with females more frequently expressing strong agreement. In adjusted analyses, gender– provider specialty interactions were largely non-significant, indicating consistent effects across intensive care, emergency medicine, and geriatric medicine, except for medication review statements where a significant interaction (P=0.021) suggested variability across specialties. Conclusions In this exploratory secondary analysis, participant gender was associated with differences in agreement with selected consensus-based recommendations for the management of very old patients in ICUs, particularly those involving multidisciplinary team input. These findings highlight differences in perspectives toward specific recommendations within this international expert panel.

Background:Older adults represent an increasing proportion of intensive care unit admissions, but the relationship between country-level human development and outcomes after critical illness remains incompletely understood. Methods:We conducted a secondary analysis of three prospective multicentre registries, VIP1, VIP2, and COVIP, including acutely admitted older ICU patients with available Clinical Frailty Scale assessment, country-level Human Development Index (HDI), and 30-day vital status. VIP1 and VIP2 enrolled patients aged ≥80 years, whereas COVIP enrolled patients aged ≥70 years. The primary exposure was exceptionally high human development, defined as HDI ≥ 0.90 versus <0.90. The primary outcome was 30-day mortality. Associations were assessed using logistic regression with robust standard errors clustered by country, adjusting for age, sex, SOFA score, frailty, admission diagnosis, organ support modalities, and treatment-limitation decisions. Exploratory mediation analyses examined selected ICU management variables as potential pathways linking HDI to mortality. Results:Among 9920 patients included in the primary analysis, 8324 (83.9%) were treated in countries with HDI ≥ 0.90 and 1596 (16.1%) in countries with HDI < 0.90. Thirty-day mortality was lower in high-HDI countries than in lower-HDI countries (40.0% vs. 53.3%). In unadjusted analysis, HDI ≥ 0.90 was associated with lower 30-day mortality (OR 0.58; 95% CI 0.38-0.90; P = 0.016). This association persisted after multivariable adjustment (adjusted OR 0.49; 95% CI 0.31-0.80; P = 0.004) and was similar after additional adjustment for study cohort (aOR 0.49; 95% CI 0.31-0.77; P = 0.002) and ICU bed capacity (aOR 0.50; 95% CI 0.29-0.86; P = 0.013). When modelled continuously, higher HDI was associated with lower mortality after full adjustment (OR 0.33 per 0.10-unit increase; 95% CI 0.19-0.56; P < 0.001). Exploratory mediation analyses suggested that lower use of invasive mechanical ventilation in high-HDI countries may partially contribute to the observed association (NIE OR 0.86; 95% CI 0.83-0.89). Mediation analyses involving treatment-limitation decisions were more difficult to interpret because these decisions are closely linked to prognosis, clinical trajectory, and end-of-life practice. Conclusions:In this large European cohort of older critically ill patients, treatment in countries with exceptionally high human development was associated with lower 30-day mortality. The association persisted after adjustment for patient-level severity, frailty, treatment limitation, organ support, study cohort, and ICU bed capacity. These findings suggest that country-level development and ICU management patterns, particularly invasive ventilation practices, may contribute to outcome differences. Because this was an observational secondary analysis using country-level exposure data, causal interpretation should remain cautious.

BACKGROUND:Evidence on sex-related mortality differences in critically ill older adults is inconsistent, and frailty is rarely incorporated despite its major prognostic relevance in geriatric intensive care. METHODS:We performed a pooled analysis of acute ICU admissions from three prospective multinational cohorts within the Very Old Intensive Care Patients project: VIP1 and VIP2, which enrolled patients aged 80 years or older, and COVIP, which enrolled patients aged 70 years or older with COVID-19. Frailty was assessed before the acute illness using the Clinical Frailty Scale. The primary endpoint was 30-day mortality. Associations between sex and mortality were examined using robust Poisson regression adjusted for age, frailty, Sequential Organ Failure Assessment score, organ support, and treatment limitations, with Bayesian models used to estimate posterior probabilities of clinically relevant effect sizes. RESULTS:Among 10,363 acute ICU admissions, 43% were women. Women were older and more often frail, whereas men more frequently received invasive mechanical ventilation, vasopressors, and renal replacement therapy. Crude 30-day mortality was higher in men than in women (44%vs. 40%). Frailty was a strong independent predictor of mortality, with each 1-point increase in the Clinical Frailty Scale associated with an 8% increase in adjusted mortality risk (incidence-rate ratio 1.08, 95% CI 1.06-1.10). After multivariable adjustment for frailty and clinical covariates, male sex remained associated with a small residual increase in 30-day mortality (incidence-rate ratio 1.08; 95% CI 1.01-1.15). This association was attenuated with greater illness severity and more intensive organ support. Bayesian analyses yielded adjusted posterior median incidence-rate ratios of 1.04 to 1.06, and the probability of at least 10% excess mortality in men was low after adjustment (2% to 13%). CONCLUSIONS:In older critically ill adults, pre-admission frailty is a major driver of mortality. After explicit adjustment for frailty and illness severity, male sex was associated with only a small residual increase in 30-day mortality. Bayesian analyses suggest that large clinically meaningful sex-based mortality differences are unlikely after accounting for case mix and treatment intensity.

As survival from critical illness improves, the global burden of post-intensive care syndrome (PICS) and PICS-family continues to grow, reshaping the goals of modern intensive care. Despite growing awareness, prevention, follow-up and rehabilitation remain fragmented, and important gaps persist in the organisation of recovery-oriented care. We propose BEYOND PICS, a conceptual framework for ICU survivorship built around six complementary pillars: Begin before ICU discharge, Early follow-up and equitable access, Your journey, Ongoing multidomain assessment and rehabilitation, Networked care, and Driving improvement. Rather than describing clinical interventions to be implemented in practice, the framework promotes a coordinated recovery pathway integrating prevention, patient partnership, education, rehabilitation, multidisciplinary collaboration and continuous quality improvement across the peri-ICU continuum. BEYOND PICS is not a clinical bundle or guideline, it provides a mental model to guide the organization of care, integrating the key components of ICU survivorship into a coherent continuum of care while highlighting priorities for future research.

Background Post-intensive care syndrome (PICS) is a frequent and debilitating consequence of critical illness, yet access to structured post-ICU follow-up remains inconsistent. Methods We conducted an ESICM-endorsed, international, cross-sectional online survey using two complementary questionnaires to explore the perspectives of ICU healthcare professionals (ICU-HP) and adult ICU survivors (ICU-S), disseminated through ESICM communication channels, professional networks, patient associations, and social media. Both surveys explored post-ICU follow-up practices, access to care, perceived benefits, and unmet needs. Results A total of 276 ICU-HP from 242 hospitals across 43 countries and 106 ICU-S from 47 ICUs across 6 countries participated in the survey. Post-ICU follow-up was reported to be available by 45% of ICUs and accessed by 58.5% of patients. Among ICU survivors, 55.7% reported having received information about PICS, while 86.2% of those not informed indicated it would have been useful. Follow-up practices showed marked heterogeneity in patient selection, timing, content, and duration. Among patients who had access to post-ICU follow-up, screening of all three core PICS domains (physical, cognitive and psychological functions) was performed in only 40.7% of cases. Nevertheless, 56.4% reported feeling better following follow-up, mainly due to perceived support and improved understanding of their condition. Among ICU-HPs offering follow-up, 55.1% reported that this activity had led to changes in clinical practice within their ICU, and 97.4% expressed intent to continue their programs although limited training opportunities and a lack of formal guidance were reported by a substantial proportion of respondents. Conclusions This survey demonstrates inconsistent access to post-ICU follow-up and information about PICS, despite the perceived value of post-ICU follow-up among both ICU-S and ICU-HP. Improving post-ICU care will require dedicated training and structured guidelines, highlighting the key role of scientific societies in ICU survivorship care.

The heterogeneity of very old patients (age ≥ 80 years) and the prevalence of complex geriatric syndromes in this cohort constitute major challenges for the classical methods of evidence-based medicine to inform clinical practice. The lack of robust guidance for the management of critical conditions in these patients contributes to considerable uncertainty among practitioners and unwarranted variations of care. The European Society of Intensive Care Medicine (ESICM) initiated a Delphi study to translate the empirical knowledge of experts in this field into consensus-based recommendations for clinical practice. A multi-national group of specialists in intensive care, emergency, and geriatric medicine provided opinions on managing very old patients with critical conditions. Strong or moderate consensus was defined as having at least 90

Aim: Levetiracetam is a widely used anti-epileptic in the critical care setting that is almost exclusively (>90%) renally excreted. The altered pharmacokinetics of levetiracetam have been widely studied in intermittent haemodialysis but the evidence and guidance on dosage in continuous renal replacement therapy is varied and poorly defined. Understanding this is critical as a significant number of critically unwell patients develop renal failure requiring continuous renal replacement therapy. The aim of this systematic review is to investigate the pharmacokinetics of levetiracetam in such patients and to understand the implications on dosing strategies. Methods: A systematic review of the available literature from 2000 to November 2022 was conducted. Seven articles were identified for inclusion from 54 records. A novel hybrid model was developed to evaluate the quality of pharmacokinetic and haemofiltration data. This data was used to develop a one-compartment model that simulated dosing strategies in 10,000 patients based on an assumed steady state of 72 hr and target trough concentrations of 12-46 mcg/mL. Results: From the seven articles included, pharmacokinetic data was retrieved for 24 individual patients. Total clearance was 3.49-4.63 L/hr (mean 3.55, S.D. 0.52). Elimination half-life was 5.66-12.88 hr (mean 9.41, S.D. 2.86). Volume of distribution was 0.45-0.73 L/kg. The proportion of total clearance attributable to continuous renal replacement therapy was 52%-73% (mean 54.7%, S.D. 13.5). Our simulations demonstrate that more than half of patients who received twice daily doses of 750 mg or greater without a loading dose achieved therapeutic drug concentrations. The time to achievement of therapeutic drug concentrations was greatly reduced by the addition of a 60 mg/kg loading dose (up to a maximum of 4.5 g). The use of a reduced loading dose or twice daily doses of 500 mg or less without loading were more likely to result in prolonged sub-therapeutic drug concentrations. Conclusion: Levetiracetam clearance in haemofiltration is similar to healthy adults with normal renal function (GFR > 90 mL/min). The use of reduced doses due to renal failure in critically ill patients may result in sub-therapeutic drug concentrations in a high number of patients. A twice daily dosing of 750-1000 mg with an initial loading dose of 60 mg/kg should be considered in such patients alongside therapeutic drug monitoring.

Purpose: There are limited data about the outcome of old intensive care (ICU) patients suffering from Covid-19 in the post-vaccination era. This study distinguishes the pre- and post-acute illness living conditions of ICU survivors from non-survivors. Methods: This prospective international multicenter study included 642 old (>= 70 years) ICU patients, including data ranging from pre-illness condition to functional 90-days follow-up. The primary endpoint was the difference of living conditions of ICU-survivors before ICU admission and 90-days after ICU discharge. Secondary outcomes were 90-days mortality, and quality of life. Results: A total of 642 patients were included. Significantly more ICU survivors lived at their own homes without support before ICU admission than non-survivors (p = 0.016), while more non-survivors resided in nursing homes (p = 0.016). ICU mortality was 39 %, 30-days and 90 days mortality were 47 %and 55 %. After 90 days, only 22 % maintained the same living conditions. Surviving patients viewed ICU admission positively after 90 days, while relatives were more uncertain. Quality of life indicated a self-reported average score of 60 (50-75). Conclusion: Living conditions influence the outcome of critically ill old patients suffering from Covid-19. Only a minority returned to their initial habitat after ICU survival. Trial registration number NCT04321265

BACKGROUND:Recent consensus-based recommendations on the management of people aged ≥80 years in intensive care units (ICUs) were developed to guide the management of quality care. OBJECTIVE:To understand perceived barriers and facilitators to consensus-based recommendations to support their implementation into multi-professional and disciplinary clinical practice. METHODS:Analysis of comments made by an international multiprofessional group of intensive care, emergency and geriatric medicine specialists in the Delphi consensus on the management of people aged ≥80 years in ICUs. Barrier and facilitators were analysed using the Theoretical Domains Framework. RESULTS:Care statement comments were provided by 99 of the 124 (79.8%) participants completing the Delphi first round; primarily identifying barriers (239/258; 92.6%). Most participants identified limitations in the environmental context and resources within the healthcare system (152, 63.6%); predominantly limitations in resources/material resources, with staffing (60, 25.1%), and beds or facilities (30, 12.6%) concerns. Potentially modifiable domains focused on inadequate knowledge (25, 10.5%), beliefs about consequences (18, 7.5%), care goals (16, 6.7%) and social/professional role and identity (16, 6.7%). Facilitators focused on improving staff knowledge, particularly amongst geriatric medicine and intensive care medicine specialities, and environmental context and resources (both 8, 42.1%). CONCLUSIONS:The environmental context and resources domain was the most common barrier identified. Behaviour change opportunities are centred on the domains knowledge, beliefs about consequences, goals and social/professional role and identity. Linked behaviour change techniques can be identified and developed according to local healthcare context to support implementation of care recommendations.

As the population ages, the number of very elderly patients (≥ 90 years, nonagenarians) admitted to intensive care units (ICUs) is increasing. This trend raises concerns about the appropriateness of ICU care for this age group, especially due to the uncertainty surrounding their prognosis. Some studies suggest that elderly ICU patients have outcomes similar to slightly younger patients, but skepticism remains due to clinical judgment, cultural attitudes, and resource allocation concerns. We reassessed the 30-day mortality risk of nonagenarians admitted to ICUs using data from the VIP1, VIP2, and COVIP registries. Bayesian statistical methods, including Markov Chain Monte Carlo (MCMC) simulations, were used to estimate the relative risk (RR) of mortality for nonagenarians compared to octogenarians (80–89 years). Various prior assumptions (non-informative, pessimistic, and skeptical) were incorporated. The analysis adjusted for key variables such as SOFA score, frailty, and treatment limitations. A total of 8,408 patients were included, consisting of 807 nonagenarians and 7,601 octogenarians. The 30-day mortality rate was 45

Bacterial infections of the respiratory tract contribute to significant morbidity and mortality worldwide. Early recognition of lower respiratory tract infections is fundamental for the management and prevention of complications such a sepsis. Common respiratory infections such as community-acquired, hospital-acquired pneumonia, atypical bacterial infection, and acute infective exacerbations of chronic disease such as chronic obstructive pulmonary disease and bronchiectasis are caused by a wide range of pathogens which can be treated in the community or in the hospital setting based on assessment of severity. Antibiotics are by far the most commonly used pharmacological intervention in the management of bacterial infections. Antibiotics have different and unique mechanisms of action against bacteria and several guidelines exist to direct treatment of chest infections. However, with inappropriate use of antibiotics, the resistance of bacteria to antimicrobials has seen significant growth globally, causing concern to the public health. Other pharmacological interventions for the management of infections and sepsis are in the development phase.

Background Invasive pulmonary aspergillosis is a complication of severe COVID-19, with regional variation in reported incidence and mortality. We describe the incidence, risk factors and mortality associated with COVID-19-associated pulmonary aspergillosis (CAPA) in a prospective, multicentre UK cohort. Methods From March 2020 to March 2021, 266 mechanically ventilated adults with COVID-19 were enrolled across 5 UK hospital intensive care units (ICUs). CAPA was defined using European Confederation for Medical Mycology and the International Society for Human and Animal Mycology criteria and fungal diagnostics performed on respiratory and serum samples. Results Twenty-nine of 266 patients (10.9%) had probable CAPA, 14 (5.2%) possible CAPA and none proven CAPA. Probable CAPA was diagnosed a median of 9 (IQR 7–16) days after ICU admission. Factors associated with probable CAPA after multivariable logistic regression were cumulative steroid dose given within 28 days prior to ICU admission (adjusted OR (aOR) 1.16; 95% CI 1.01 to 1.43 per 100 mg prednisolone-equivalent), receipt of an interleukin (IL)-6 inhibitor (aOR 2.79; 95% CI 1.22 to 6.48) and chronic obstructive pulmonary disease (COPD) (aOR 4.78; 95% CI 1.13 to 18.13). Mortality in patients with probable CAPA was 55%, vs 46% in those without. After adjustment for immortal time bias, CAPA was associated with an increased risk of 90-day mortality (HR 1.85; 95% CI 1.07 to 3.19); however, this association did not remain statistically significant after further adjustment for confounders (adjusted HR 1.57; 95% CI 0.88 to 2.80). There was no difference in mortality between patients with CAPA prescribed antifungals (9 of 17; 53%) and those who were not (7 of 12; 58%) (p=0.77). Interpretation In this first prospective UK study, probable CAPA was associated with corticosteroid use, receipt of IL-6 inhibitors and pre-existing COPD. CAPA did not impact mortality following adjustment for prognostic variables.

Introduction: Cases of major trauma in the very old (over 80 years) are increasingly common in the intensive care unit (ICU). Predicting outcome is challenging in this group of patients as chronological age is a poor marker of health and poor predictor of outcome. Increasingly, decisions are guided by the use of organ dysfunction scores of both acute conditions (e.g., sequential organ failure assessment [SOFA] score) and chronic health issues (e.g., clinical frailty scale [CFS]). Recent work suggests that increased CFS is associated with a worse outcome in elderly major trauma patients. We aimed to test whether this association held true in the very old (over 80) or whether SOFA had a stronger association with 30-day outcome. Methods: Data from the very elderly intensive care patient (VIP)-1 and VIP-2 studies for patients over 80 years old with major trauma admissions were merged. These participants were recruited from 20 countries across Europe. Baseline characteristics, level of care provided, and outcome (ICU and 30-day mortality) were summarised. Uni- and multivariable regression analyses were undertaken to determine associations between CFS and SOFA score in the first 24 h, type of major trauma, and outcomes. Results: Of the 8,062 acute patients recruited to the two VIP studies, 498 patients were admitted to intensive care because of major trauma. Median age was 84 years, median SOFA score was 6 (IQR 3, 9), and median CFS was 3 (IQR 2, 5). Survival for 30 days was 54%. Median and interquartile range of CFS were the same for survivors and non-survivors. In the logistic regression analysis, CFS was not associated with increased mortality. SOFA score (p < 0.001) and trauma with head injury (p < 0.01) were associated with increased mortality. Conclusions: Major trauma admissions in the very old are not uncommon, and 30-day mortality is high. We found that CFS was not a helpful predictor of mortality. SOFA and trauma with head injury were associated with worse outcomes in this patient group.

OBJECTIVES: Across guidelines, protein dosing for critically ill patients with obesity varies considerably. The objective of this analysis was to evaluate whether this population would benefit from higher doses of protein. DESIGN: A post hoc subgroup analysis of the effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicenter, pragmatic, registry-based randomized trial. SETTING: Eighty-five adult ICUs across 16 countries. PATIENTS: Patients with obesity defined as a body mass index (BMI) greater than or equal to 30 kg/m(2) (n = 425). INTERVENTIONS: In the primary study, patients were randomized into a high-dose (>= 2.2 g/kg/d) or usual-dose protein group (<= 1.2 g/kg/d). MEASUREMENTS AND MAIN RESULTS: Protein intake was monitored for up to 28 days, and outcomes (time to discharge alive [TTDA], 60-d mortality, days of mechanical ventilation [MV], hospital, and ICU length of stay [LOS]) were recorded until 60 days post-randomization. Of the 1301 patients in the primary study, 425 had a BMI greater than or equal to 30 kg/m(2). After adjusting for sites and covariates, we observed a nonsignificant slower rate of TTDA with higher protein that ruled out a clinically important benefit (hazard ratio, 0.78; 95% CI, 0.58-1.05; p = 0.10). We found no evidence of difference in TTDA between protein groups when subgroups with different classes of obesity or patients with and without various nutritional and frailty risk variables were examined, even after the removal of patients with baseline acute kidney injury. Overall, 60-day mortality rates were 31.5% and 28.2% in the high protein and usual protein groups, respectively (risk difference, 3.3%; 95% CI, -5.4 to 12.1; p = 0.46). Duration of MV and LOS in hospital and ICU were not significantly different between groups. CONCLUSIONS: In critically ill patients with obesity, higher protein doses did not improve clinical outcomes, including those with higher nutritional and frailty risk.

Abstract Background Premorbid conditions influence the outcome of acutely ill adult patients aged 80 years and over who are admitted to the ICU. The aim of this study was to determine the influence of such premorbid conditions on 6 month survival. Methods Prospective cohort study in 242 ICUs from 22 countries including patients 80 years or above, admitted over a 6 months period to an ICU between May 2018 and May 2019. Only emergency (acute) ICU admissions in adult patients ≥ 80 years of age were eligible. Patients who were admitted after planned/elective surgery were excluded. We measured the Clinical Frailty Scale (CFS), the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), disability with the Katz activities of daily living (ADL) score, comorbidities and a Polypharmacy Score (CPS). Results Overall, the VIP2 study included 3920 patients. During ICU stay 1191 patients died (30.9%), and another 436 patients (11.1%) died after ICU discharge but within the first 30 days of admission, and an additional 895 patients died hereafter but within the first 6 months after admission (22.8%). The 6 months mortality was 64%. The median CFS was 4 (IQR 3–6). Frailty (CFS ≥ 5) was present in 26.6%. Cognitive decline (IQCODE above 3.5) was found in 30.2%. The median IQCODE was 3.19. A Katz ADL of 4 or less was present in 27.7%. Patients who surviving > 6 months were slightly younger (median age survivors 84 with IQR 81–86) than patients dying within the first 6 months (median age 84, IQR 82–87, p = 0.013), were less frequently frail (CFS > 5 in 19% versus 34%, p < 0.01) and were less dependent based on their Katz activities of daily living measurement (median Katz score 6, IQR 5–6 versus 6 points, IQR 3–6, p < 0.01). Conclusions We found that Clinical Frailty Scale, age, and SOFA at admission were independent prognostic factors for 6 month mortality after ICU admission in patients age 80 and above. Adding other geriatric syndromes and scores did not improve the model. This information can be used in shared-decision making. ClinicalTrials.gov: NCT03370692.

The demographic shift, together with financial constraint, justify a re-evaluation of the trajectory of care of very old critically ill patients (VIP), defined as older than 80 years. We must avoid over- as well as under-utilisation of critical care interventions in this patient group and ensure the inclusion of health care professionals, the patient and their caregivers in the decision process. This new integrative approach mobilises expertise at each step of the process beginning prior to intensive care unit (ICU) admission and extending to long-term follow-up. In this review, several international experts have contributed to provide recommendations that can be universally applied. Our aim is to define a minimum core dataset of information to be shared and discussed prior to ICU admission and to facilitate the shared-decision-making process with the patient and their caregivers, throughout the patient journey. Documentation of uncertainty may contribute to a tailored level of care and ultimately to discussions around possible limitations of life sustaining treatments. The goal of ICU care is not only to avoid death, but more importantly to maintain an acceptable quality of life and functional autonomy after hospital discharge. Societal consideration is important to highlight, together with alternatives to ICU admission. We discuss challenges for the future and potential areas of research. In summary, this review provides a state-of-the-art current overview and aims to outline future directions to address the challenges in the treatment of VIP.

Prognosis determines major decisions regarding treatment for critically ill patients. Statistical models have been developed to predict the probability of survival and other outcomes of intensive care. Although they were trained on the characteristics of large patient cohorts, they often do not represent very old patients (age ≥ 80 years) appropriately. Moreover, the heterogeneity within this particular group impairs the utility of statistical predictions for informing decision-making in very old individuals. In addition to these methodological problems, the diversity of cultural attitudes, available resources as well as variations of legal and professional norms limit the generalisability of prediction models, especially in patients with complex multi-morbidity and pre-existing functional impairments. Thus, current approaches to prognosticating outcomes in very old patients are imperfect and can generate substantial uncertainty about optimal trajectories of critical care in the individual. This article presents the state of the art and new approaches to predicting outcomes of intensive care for these patients. Special emphasis has been given to the integration of predictions into the decision-making for individual patients. This requires quantification of prognostic uncertainty and a careful alignment of decisions with the preferences of patients, who might prioritise functional outcomes over survival. Since the performance of outcome predictions for the individual patient may improve over time, time-limited trials in intensive care may be an appropriate way to increase the confidence in decisions about life-sustaining treatment.