Der demografische Wandel mit der Veränderung der Altersstruktur hin zu älteren Menschen und die Zunahme der chronischen Erkrankungen sowie der Fortschritt der Medizin führen dazu, dass immer mehr geriatrische Patienten intensivmedizinisch behandelt [1], d. h. auch infolge schwerer respiratorischer Insuffizienz beatmungspflichtig werden. Diese Entwicklung führt zu besonderen Herausforderungen an die medizinische Versorgung und das Management der Intensivpatienten im höheren Alter. Im Laufe des intensivmedizinischen Behandlungsprozesses ist die Frage nach der Sinnhaftigkeit der Behandlung regelmäßig zu stellen.
Abstract
Changing demography with more older people and more patients with chronic diseases as well as the progress of medicine leads to more geriatric patients treated in intensive care and requiring mechanical ventilation due to severe respiratory insufficiency.
Frailty is associated with a more complicated intensive care stay, more difficult convalescence and with a higher mortality.
In principle, geriatric expertise should be brought in as early as possible in the course of intensive care treatment for older patients in order to carry out adequate risk stratification and, depending on the extent of the impairment, to plan discharge or early rehabilitation.
In older and frail patients preexisting chronic ventilatory insufficiency often leads to prolonged weaning. Patients with weaning failure should be referred to a specialized weaning center. Part of the assessment will be whether out-of-hospital invasive or non invasive ventilation is indicated and the wish of the patient.
In intensive care the likelihood of a successful outcome and the patient’s wishes must constantly be re-evaluated. This is particularly true in older patients. In addition it should be clarified with the patients and relatives what constitutes “success”; for example a patient may consider intensive care “worth it” if the ultimate goal is discharge to their own home but not if nursing home care and tracheostomy ventilation is the best that can be achieved. It may become apparent that a successful outcome is unlikely and then withdrawal of invasive ventilation is appropriate.
Schlüsselwörter
Geriatrie - Frailty - Intensivmedizin - maschinelle Beatmung - prolongiertes Weaning - Weaning-Einheit - außerklinische Beatmung - Ethik am Lebensende
Keywords
geriatrics - frailty - intensive care medicine - mechanical ventilation - prolonged weaning - weaning unit - home mechanical ventilation - ethics - end of life issues
