45 | Bridging the gap: a collaborative model for the follow-up of older intensive care unit survivors

L. Mazza¹, L. Giuntoli², A. Franco¹, N. Cilloni² | ¹UOC Rete Geriatrica Integrata Ospedale Territorio, Ospedale Maggiore, AUSL Bologna; ²UOC Terapia Intensiva OM e Hub Maxiemergenze, Ospedale Maggiore, AUSL Bologna.

Introduction. In Europe, patients aged ≥80 years account for 10-20% of adult Intensive Care Unit (ICU) admissions, with 30-day mortality rates around 37% and 1-year mortality reaching 50% for the oldest old. Locally, over the last 5 years, our ICU admitted more than 3700 patients with nearly 30% aged ≥75. ICU mortality was only slightly higher than the 55-65 age group, leaving a large population at risk of Post-Intensive Care Syndrome (PICS). Assessing residual autonomy and sustainable follow-up is urgent to improve long-term outcomes.

Objectives. We aim to implement multidisciplinary follow up clinic for ICU survivors aged ≥75. Key goals include: assessing current cognitive and functional status vs. pre-admission baseline; identifying unmet clinical or social needs and ensuring continuity of care through hospital-territory integration; monitoring clinical trajectories over time.

Materials and Methods. The project targets patients ≥75 surviving at least 3 months post-ICU discharge. Its core consists of a multidisciplinary joint-visit model, where Intensivist, Geriatrician and Psychologist perform a simultaneous and collaborative assessment of the patient. A systematic clinical follow-up is scheduled at 6 months to monitor long-term outcomes.
Results. We expect to intercept PICS early and reduce the care gap often seen after discharge. Identifying specific geriatric syndromes (sarcopenia, cognitive decline, depression) will allow for targeted interventions, potentially reducing hospital readmissions and improving the perceived quality of life for both patients and caregivers.

Conclusions. The high survival rate of older patients in our ICU justifies a shift in focus from short-term survival to long-term functional recovery. A multidisciplinary approach is essential to ensuring functional recovery and sustainable care for the expanding cohort of very old ICU survivors.