SCCMPod-567 CCM: Caring for Older Adults in the ICU

Dr. Bulloch: Hello and welcome to the 2026 Congress edition of the Society of Critical Care Medicine podcast. I'm your host, Marilyn Bulloch. Today, I am speaking with Dr. Bram Rochwerg, MD, MSC, FRC, PC, and Dr. Lauren Ferrante, MD, MHS, about the 2026 Congress session, Compassionate and Evidence-Based Care. Dr. Rochwerg is an associate professor and intensivist and researcher based at McMaster University in Hamilton, Canada. His main focus of research includes intravenous fluid use and sepsis and the role of corticosteroids in acute hypoxic respiratory failure. He has gained expertise in meta-analyses, network meta-analysis, and conduct of randomized controlled trials.

His other area of focus is clinical practice guideline methodology, and he currently works with many international organizations supporting their guideline development project. He leads the internal medicine section at the Society of Critical Care Medicine and is vice chair for the Canadian Critical Care Trials Group, co-vice chair for the Surviving Sepsis Campaign Guidelines, and is an associate editor at Critical Care Medicine. Dr. Ferrante is an associate professor of medicine in the section of Pulmonary Critical Care and Sleep Medicine at Yale School of Medicine, the director of the operations core of the Yale Claude D. Pepper Older Americans Independence Center, and an attending physician in the medical intensive care unit at Yale New Haven Hospital. Her research program, funded by the National Institute on Aging, is centered at the interface of critical care medicine and geriatrics with the overarching goal of understanding and improving the functional outcomes of critically ill older adults. Welcome.

You both sound very busy, so I'm honored that you could make some time to talk with us today, and I know our listeners appreciate you being here today. Before we get started, do either one of you have any disclosures to report?

Dr. Ferrante: No disclosures, and thanks for having us.

Dr. Bulloch: Well, I am thrilled.

Dr. Rochwerg: Not for me either. It's a pleasure to be here.

Dr. Bulloch: For our audience today, what you may not realize is that I've had the opportunity to work with both of our guests today in planning the aging track here at Congress, which for many of you may not have had the opportunity to attend Congress in person, I highly encourage you to watch these sessions on Congress Digital. There was a lot of intentional and good work in tune, and I think you'll find them all very valuable, but I want to start with the big one, right? So, SCCM has a new guideline, and really one that is needed.

I mean, when we think about our population and how many people are aging and that silver tsunami is hit, right? So, we have a new guideline on the caring for older adults in the ICU. Let's start there.

Tell us about this guideline.

Dr. Ferrante: So, we're thrilled to finally see this guideline to fruition. It's been a few years of work, but I think probably let's just start with how important and how needed this guideline is. As you noted, the population is aging, but actually for the past 20 or 25 years, older adults have been about half of our ICU population.

And we really expect that number to keep increasing because the worldwide older adult population is going to double by 2050. And so, we still have a ways to go. The care of older adults in the ICU really impacts all of us, all of us who are taking care of ICU patients, both in the ICU and thereafter.

And so, we felt that it was time for us to have the first guideline on caring for older adults in the ICU. And I was delighted to co-chair this guideline with Bram and also with our colleague, Nathan Rummel from the Ohio State University.

Dr. Rochwerg: The Ohio State—

Dr. Ferrante: The Ohio State. And as Bram mentioned, he has expertise in guideline methodology, which was really helpful to have him as a co-chair and also our two methodologists.

Dr. Rochwerg: Yeah, I think it was great that SCCM took this on. They have this portal for member-initiated guideline topics through the Board of Regents. And we sort of recognized that a lot of the hard work and longstanding area of focus that Lauren and Nate had in this area, that this was such an important topic area that society would get excited about.

And so, we submitted this through the portal. We're very fortunate that it got taken up as a guideline of interest. And it's a culmination of the last couple of years of work on this guideline, prioritizing PICOs, working through the process, summarizing the evidence, which as Lauren says, was hugely helpful from our methodologists, Dipayan and Laiya, that did a ton of work in supporting the guideline. But it’s so great to see the product. And not only is it helpful, Marilyn, but it's also very rigorously put together, you know. And so, I think that that really helps with the validity of the guideline and folks knowing that they can apply the recommendations to their practice, knowing that the methodology underlying this guideline was really robust.

Dr. Bulloch: And this guideline, which was released yesterday for our listeners who are listening this later today, is March 23rd. So, it was just released yesterday. It's very exciting for you to see all this hard work that you've put into. And it should be available for SCCM membership on the website. Not to discourage anybody from going to your session, because I know that it's going to be wonderful, but can you give us like a sneak peek as to what's in the guideline?

Dr. Ferrante: Yes, definitely. So, the first thing I'll say is we had this amazing interprofessional panel. And I think this topic really, you know, this is so relevant, again, to everybody who's working in the ICU. And so, you can imagine when you have this very experienced and diverse and thoughtful group, I think we generated 19 PICO questions on which to vote. But we, you know, of course, had to pick.

Dr. Bulloch: You can't pick them all.

Dr. Ferrante: So, we chose five, our top five. And so, we'll revisit those other ones, hopefully, with the next guideline update. But basically, the current guideline focuses on a few key issues. So, geriatric models of care, and whether those should be applied in the ICU. We'll get into later a little bit how we define that. We look at MAP targets, we look at antipsychotics for the prevention of delirium and, separately, for the treatment of delirium, and then also post-ICU follow-up.

Dr. Bulloch: And when I think about the older adult and things that are highly impacted, those are all very relevant in my mind. I think sometimes clinicians forget that as you age, you have these physiologic changes that occur. You're not the same as you were when you were 50.

And there are a lot of important things. I'm a pharmacist. So, I think that my attention naturally draws to the antipsychotics, but I can see value in all of them.

But for you, what do you think will have the most impact?

Dr. Ferrante: Well, we were able to make two conditional recommendations. Do you want to share what they were?

Dr. Rochwerg: Yeah, sure. Part of the challenge, as you can imagine, is that evidence-based addressing this, especially specific to older adults, is limited, right? And so, ideally, we would have been able to make strong recommendations for a lot of these, provide clear guidance, but the reality of the situation is, is that the evidence-based doesn't allow for perhaps as strong guidance as we would love to be able to give. And so, happy to mention the recommendations. But I would say, Marilyn, a big part of this effort too was identifying research priorities for the future as well, right?

So, the conditional recommendations that we made, great, but a big impetus for future folks that are aging-friendly and interested in doing research around aging-friendly topics to really focus in on these areas and produce more primary research so that the updates can maybe provide stronger guidance.

Dr. Bulloch: I can't imagine how difficult this was. I know in my own research, when I've tried to look at geriatric medication inclusion in drug trials, it's abysmal. I mean, it is absolutely horrible to see how little they are studied.

So, how did you do it?

Dr. Ferrante: That's a great question. So, just to be clear, the field of geriatric critical care research has really exploded in the last 10, 15 years. And that was part of what provided the impetus for this guideline as we also have a cadre of experts now in this area.

But a lot of that research is observational. And so, with great methodology in our guideline development process, we wanted to, you know, you extract randomized controlled trials. And so, that's where we ran into some of the difficulty that Bram already described.

And so, our methodologists were amazing. They worked with the medical librarian, with the panel, and what they actually did was reach out to the authors of the randomized controlled trials in the areas that we were focusing on to see if we could get subgroup data focused on older adults. And that's wonderful that they did that, but I think it really highlights the need for randomized controlled trials that exclusively enrolled older adults because then we would have the data from the primary analysis and the publication, and it would be a more robust data pool from which to draw.

Dr. Rochwerg: And then if we didn't have the data specific to older adults, but we have the data in a generalized ICU population, we have to decide whether that's too indirect and whether it applies to older adults and lower the certainty for that. So, it was a complicated process for sure and a lot of good discussion on our calls, I think, right around how to prioritize these things. But, you know, to your question, and, Lauren, please correct me if I'm missing one, the recommendations that we did make, a conditional recommendation for including geriatric models of care for older adults admitted to the ICU, a conditional recommendation against using antipsychotics for prevention of delirium. Those were the two conditional recommendations.

Dr. Ferrante: Yes, those are the conditional recommendations. Interestingly, for the first PICO question, which was the geriatric models of care one, there were studies that exclusively enrolled older adults. So, for that one, from what I can recall, we did not need to use subgroup analysis data, so that was very helpful.

And I think that's partly why we were able to make this conditional recommendation, showing that we do recommend including geriatric models of care for older adults in the ICU. And then the other recommendation just recommended against the use of antipsychotics routinely for the prevention of delirium.

Dr. Bulloch: And as a pharmacist, I highly support that recommendation, inpatient or outpatient. I mean, I know sometimes you have to use them, but if you don't, you want to stay away as much as you possibly can.

I want to go back to the first PICO question because I get very excited. We have talked about ACE units, acute caring for the elderly, for those who may not be familiar, who are listening, have been around for decades. And they're wonderful. They are very interprofessional, guided, typically a ward unit, but they bring in all the resources that you need to care for older adults.

And I even think about things like in our hospital, our children's area has a child life program, and we have volunteers that keeps the kids busy. And I often think we need that for our older patients that don't have family. They need stimulation too, maybe more than the kids do, to keep their minds active.

So in your mind, and this may be stepping away from the guideline just a little bit, what does that ideal ICU look like to you?

Dr. Ferrante: Yeah, that's a great question. This is an area that I focused on in my own research and I'm focusing on insofar as we actually were really inspired by the ACE unit model, the acute care for elders model. There were really robust New England Journal RCTs published beginning in the mid-nineties on those geriatric models of care, including the acute care for elders program and also the hospital elder life program, Sharon Inouye's health program, showing that they reduce delirium, improve functional outcomes, and improve a number of outcomes for older adults who are hospitalized on the general medical ward. We have some elements of those models in the ABCDEF bundle, but not all. And so, in one of my lines of work right now, what we did was we mapped some of those elements onto what's not currently being routinely administered in ABCDEF and kind of looked to see where there were other gaps where older adults might benefit.

And we built an intervention and we just did a pilot trial last year, but actually we're putting in a larger grant now to do a larger efficacy trial where we routinely give older adults portable hearing amplifiers, just because hearing loss is so prevalent in older adults, more than half over the age of 70. And routine occupational therapies for a focus on cognitive function and also functional activities. So things like ADLs.

And then, you'll love this one, there's a deprescribing intervention where the ICU pharmacists, because they're already embedded in the ICU team, start deprescribing medications using the Beers Criteria as guidance. Just because it's known from others' work, not mine, that we tend to start medications in the ICU and continue them for too long. Sometimes even after discharge.

Dr. Bulloch: And for our listeners, we will have a session here that you'll be able to access in Congress Digital about deprescribing. I highly recommend if you haven't had a chance to listen to that already, you go and you listen to it. I think anyone who works with adults in general will find that session very interesting.

Dr. Rochwerg: Marilyn, when it comes to the geriatric models of care recommendation, you know, we're a bit ambiguous intentionally about talking about geriatric models of care, because ideally the recommendation, well, one, we didn't necessarily have the evidence to recommend for one specific application of how that looked. You know, incorporating 4Ms, geriatric consultation, ACE type unit, you know, it was really hard to sort of pick into one specific study and say, this is how we need to operationalize. The other thing is that recommendation was meant to apply across jurisdictions, right?

And SCCM guidelines are meant to apply to the US, to North America, internationally. And it was quite hard to sort of say, this is a specific way you need to operationalize this geriatric model of care specific to your context. So you can sort of hear in the recommendation itself that there's a little bit of ambiguity, which was intentional, but within the justification and the supplemental material would provide some structure to what that could look like in different contexts.

Dr. Ferrante: The other important part of that is that we want everyone to think about what a geriatric model of care might look like and really to focus on that rather than just getting the geriatricians into the ICU because we know there are simply not enough of them and they can't possibly see all the older adults in the ICU, which was why this question I think was rated so highly among the guideline panel as one to address. So we can really start thinking more broadly about bringing geriatric models of care into the ICU as opposed to relying on the geriatricians to do it.

Dr. Bulloch: Right. Because they are overwhelmed as it is. I wonder though, and this is my forward-thinking strategy brain on here. Over time, critical care has evolved from where it was when it became a specialty. And now we have so many subspecialties of critical care, trauma, surgery, transplant. I wonder if in 20 years we will have a geriatric ICU model that will just maybe not at the community and rural hospitals, but your bigger centers that, you know, here will be the medical ICU and there's the geriatric ICU.

Do you think that that's something that could come to fruition?

[crosstalk]

Dr. Ferrante: I don't know about a physical space, but I mean, I actually wonder, you know, maybe a fellowship or something. Maybe there should be a geriatric critical care fellowship.

Dr. Rochwerg: Next career move.

Dr. Bulloch: I feel like that's, I mean, that's not a bad idea. And I mean, I even feel like not just limited to medicine, but if you think about it, nursing and pharmacy and respiratory therapy and physical therapy, I mean, all of those areas, I think, as you mentioned before, the growing population, it's definitely a need. And for those of you who are listening, who are thinking about, well, what kind of research do I need to get into? This is a timely area. You know, you could dive right into it.

Dr. Rochwerg: Marilyn, there's a lot of folks at SCCM that are keen on this and you can see it. I mean, I know we're not talking about it right now. Maybe we will, but we have a whole track on Tuesday, as you mentioned, around caring for older adults. We have a knowledge education group at SCCM, a KEG, we call them now, around caring for older adults. It's quite active. So it seems like this growing momentum, at least within the society. So I love this idea of forward-thinking and thinking where we could be in 10, 15 years, because it feels like we're on that.

Dr. Bulloch: Right, I mean, honestly, if you're not involved in pediatrics, you're going to be involved in geriatrics. I mean, you just you just are. And Bram, I want to shift now because I'm very excited about this geriatrics track. I loved being part of the group that helped create it and working with both of you on it. And I want to talk to our listeners about that geriatrics track. So this is actually in its second year, we were able to offer it at 2025 Congress. So tell us about just where did the geriatrics track idea come from? And how has it evolved?

Dr. Ferrante: Yeah, something that the American Geriatric Society and my colleagues that I work with, I work pretty closely, have been talking to SCCM about for a few years. So I think actually, it was Nancy Lundenberg, the AGS CEO, and David Martin, the former SCCM CEO, they've been talking for a while, and then finally decided that last year was the time to move this ahead. And I think it was really David making the final decision and wanting to move this forward, just recognizing what a priority this was for the Society to really think again, about the importance of older adults in the ICU.

And SCCM is really the right place for that to happen, because it includes all of critical care. And so again, Bram and our colleague, Nate, and I, we actually are co-chairs of the Geriatrics Knowledge and Education Group, as Bram mentioned. And so it's kind of a natural fit that we were asked to lead the adult aging track and to plan it together with members of the program committee.

And so we were delighted to work with you this year, Marilyn. And so last year, we had a really big focus on the 4Ms, because Terry Fulmer was our plenary speaker, our thought leader.

Dr. Bulloch: She was our Norma Shoemaker award last year.

Dr. Ferrante: Yeah. And she has really been a driving force in the 4Ms, which is, for our listeners, is the Age-Friendly Health System Initiative, which really, if it hasn't taken off already in your health system, it will, because as of this past fiscal year, the Center for Medicare and Medicaid Services is now tying it—there's an inpatient quality reporting metric where all health systems have to report the measuring age-friendly care with the 4Ms in their health system.

But, you know, part of the reason that CMS initiative exists now is because there's really been this driving force behind age-friendly. And so there was a big focus on that last year. We also had sessions on delirium. And so in the track this year, we have a bunch of...

Dr. Rochwerg: And it was very successful last year, right?

Dr. Ferrante: It was very successful.

Dr. Bulloch: It was very successful.

Dr. Rochwerg: I mean, the folks were there and...

Dr. Ferrante: There was a standing room only in the plenary session.

Dr. Rochwerg: And before you jump into this year, which I'm sure listeners can hear about the other thing, with support from Hartford, right? They were crucial as well in terms of being able to help us out this year.

Dr. Ferrante: Yes. So the Johnny Hartford Foundation supported the track this year.

Dr. Bulloch: They were very generous. Yes. And they helped us. They came on to some of the planning calls and gave us some fantastic ideas, and we're very appreciative of their support.

Dr. Rochwerg: I didn't mean to interrupt you. So then setting us up for this year.

Dr. Ferrante: Go ahead. Why don't you tell us about this one?

Dr. Rochwerg: Well, I think just building on that success again now, we have a great schedule of programming for this year, addressing a number of important issues and keeping within the theme of SECM around surgical care of older adults, medical care, traumatic care. And so I think a number of exciting sessions, the thought leader session, the Norma Shoemaker as well, which will be fantastic. And we're presenting our guidelines as well, which will be great to get those out and disseminate those out around as well.

Dr. Ferrante: Fun part about the guideline session is that we first present the guideline in one session, but we have a session immediately afterwards, where we really talk about what we learned from going through the guideline, not so much in what we would do differently next time, but more like what knowledge gaps were identified, what really should be areas of future research in this space, thinking more about the inclusion of older adults into critical care trials.

We intentionally put those two sessions, one after the other, just so it was a natural flow to the afternoon. And then in the morning, you'll be speaking to us about—

Dr. Bulloch: I am! I'm excited about that.

Dr. Ferrante: —older adults, which we're very excited about. So we have Marilyn speaking to us and we also have a geriatrician in that session. Each year in the adult aging track, we feel it's really important to ensure that we have a geriatrician among our speakers, just to make sure that their voice is being heard, that they can answer questions from the audience, they can do a connect and converse session.

And so Tom Gill, who's a really very senior and well-established geriatrician investigator will be joining us at Congress this year.

Dr. Bulloch: That's exciting. I'm thrilled to be able to meet him. And for all of you who weren't able to join us at Congress, I really do encourage you to go watch that on Congress Digital.

Again, I know I've said this several times, but I can't emphasize, I think that this is going to be one of the most informative years that we've had. And maybe even just a plug for your fellowship in the future. I mean, we need this geriatric intensivist, right?

Let's talk a little bit about the aging track itself because some of the other topics I think are very good. And for our listeners, if you could have been a fly on the wall when we were having these conversations, some of the talks just really did come out organically. I remember we were sitting around talking about surgery and we're like, well, why can't you take a 100-year-old to surgery? You know, just stuff like that. And thinking about the biases that we have around this population, which I have to say is getting closer and closer to my future. So tell us about some of the other sessions that you're excited about as well.

Dr. Ferrante: So I'm really excited also for the age-friendly ICU session. We—actually, it's actually at the behest of Hartford. And I think everybody on the planning committee really wanted this to happen. We have a patient and caregiver coming to speak to us as part of that session. And so they're actually going to kick off that session, talking about their experience in the ICU. And I will share with you, it's actually my patient and she was in the COVID ICU and she's a retired healthcare professional. So she kind of, you know, went from being on the provider side to the patient side, which was really eye-opening. I've seen their slides. It's going to be really great. And then her husband, who also is a retired healthcare professional, speaks about their experience.

And so that kicks off the session. And then, you know, we have other healthcare speakers in there. So I'm really excited about that. We have a geriatrician speaking and then also another talk. And then we also have a surgery session. You want to talk about that?

Dr. Rochwerg: Yeah, sure. And you bring up on our planning calls, “why can't you bring,” and that turned out to be the topic, the title of the session is why can't you, or what did you need to think about? Normalizing taking a hundred-year-old to surgery.

So I think we have a couple of surgeons speaking within that section, which will be great to talk about some of the perioperative assessment keys that when taking older adults to surgery, that you need to think about both preoperatively, perioperatively, and in the postoperative setting as well.

We each took a different focus area. And the session that I took was around how we can do better in the future in terms of including older adults in randomized control trials and in research and how we can improve so that the next time we go to do a guideline a few years from now, maybe there's better research out there specific to the role of older adults.

Dr. Bulloch: And for our listeners, and I know I'm the host, but I do want to add some context to this because it's from my own research. I think what you have to understand is that when you go look at randomized control trials, at least for drugs, it's really difficult to find studies that enroll older adults who were on more than four medications. So even when you are enrolling older adults, you're not enrolling the average. You're enrolling those super healthy older adults. And I understand it. I mean, there are variables that it's hard to introduce. And some of it is intentional exclusion criteria, and some of it is enrollment bias.

But that, listeners, is kind of what Dr. Rochwerg is talking about, like the barriers that they were up against in creating this guideline.

Dr. Rochwerg: Absolutely, Marilyn. And you'll talk about this in my presentation tomorrow, but a lot of the RCTs in the critical care space randomly exclude patients older than 75, older than 80, for no reason, when this is the majority of our patients in the ICU. So now we're generalizing evidence from a completely different population to older adults that are more comorbid and on a host of medications. We don't know if we can generalize that data.

So it is a major problem, and I think that we really need to look at addressing it in the future and avoid these arbitrary exclusions for patients that make up a large proportion of our ICUs.

Dr. Bulloch: And I think if you've been around in the ICU world space long enough, you'll know that anytime we generalize data that we shouldn't, it always ends up bad. We always end up being proven wrong. To your point, we do need to enroll and see what actually happens in the population that we're really treating.

Dr. Rochwerg: Or more studies specific to older adults, like the recent MAP target trial that really focused on folks older than 65. Like, that's fantastic. It's generating data in the population that we want to apply the results to.

Dr. Bulloch: And I think that's going to be an exciting session that you're going to be doing that talks about how can we study people in this patient population and do it in a way that, you know, we're not new to research. So I think that will be very interesting.

Well, this has been an absolutely wonderful episode. I have enjoyed talking with both of you. Before we leave, because I know both of you are very busy, and I don't want to take up too much more time, I do want to give you an opportunity to say any final things you think our listeners might want to know or you want them to know before we head out and enjoy the rest of Congress.

Dr. Ferrante: Well, I think I would just put in another plug for joining our geriatrics knowledge and education group, because, you know, it's so great for all of us to come together at Congress in person, but that really gives us an opportunity to stay connected throughout the rest of the year. You know, we're doing this aging-focused work all the time, not just around these big conferences. And so if you're interested, please join us, send us an email.

We'd love to have you.

Dr. Bulloch: It doesn't cost anything extra to join one of the KEGs.

Dr. Rochwerg: I think on the SCCM website, you can just click in and join and through SCCM Connect, it's easy to engage. So nothing else for me.

Dr. Ferrante: Nothing else for me.

Dr. Bulloch: Well, thank you both again. This has been one of the highlights of my career to be working with you and playing this track. And I think it will benefit all of our membership and appreciate all of the good work that you both have done.

So for our listeners, this concludes another episode of the Society of Critical Care Medicine podcast. If you're listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review.

And for the Society of Critical Care Medicine podcast, I'm Marilyn Bulloch. Thanks for listening.

Announcer: Marilyn N. Bullock, PharmD, BCPS, FCCM, is an Associate Clinical Professor and Director of Strategic Operations at Auburn University Harrison School of Pharmacy. She is also an Adjunct Associate Professor in the Department of Family, Internal and Rural Medicine at the University of Alabama in Tuscaloosa, Alabama, USA, and the University of Alabama Birmingham School of Medicine.

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