Let’s kick this off by getting clear on what “Critical Care” actually means.
To make it simple, I want you to think of this as care that will ultimately happen inside a hospital.
It supports someone through an illness or condition which threatens their life or their body’s ability to function.
Critical Care can and often does get started in an ambulance through the work of paramedics.
In the ER, teams like the one I lead take over care.
We also see people who come in through the front doors and are critically ill.
Critical Care then can continue while the person is admitted to the hospital.
Where are people treated in the hospital when they are “critically ill?”
You have likely heard of the Intensive Care Unit. This is a part of the hospital which cares for the sickest of the sick.
These patients are almost always critically ill. (Yes, there are exceptions. Some people go to the ICU after a surgery or procedure which has a high chance of things going wrong afterwards, requiring very close monitoring).
There are other parts of the hospital which also provide critical care.
You should be aware of the term “step down unit” or “intermediate care unit.” Your hospital may have one or more units like this.
People who need these “step down” units are almost always sick, or require closer monitoring and treatment, but the team doesn’t feel they need the ICU at that time.
Who is considered to be "critically ill" and what might that mean for their future?
To put it directly, when a person is critically ill, it would not be surprising to the medical care team if they did not survive.
It would also not be surprising if they did not make a full recovery.
They could survive with a permanent impact on their quality of life. Life on a day to day might not be the same for them.
People are often not able to go directly home from the hospital if they were treated for a critical illness.
Recovering from a critical illness makes it more likely the person will need care in a rehabilitation facility for a period of time.
A move into a skilled nursing facility temporarily or even permanently is also more likely.
What are the most common causes of need for critical care?
Here’s a list of a few top causes:
- Infections causing sepsis. Sepsis can happen to anyone. In the body’s attempt to fight off whatever is causing infection, there is a response which causes inflammation. When severe, it can cause damage to any or all of a person’s organs.
- Trauma causing serious injuries. Falling from a height or being injured in a car accident are two top causes of trauma. A fall from standing or while walking can also cause serious injury especially in people who are aging (think hip fracture).
- Medical conditions the person already lives with becoming worse, causing their organs to work even less well (think heart failure, emphysema (COPD), asthma, and kidney disease).
- Any new medical condition which affects one or more organs from working like they should (think blood clots in the lungs, a blockage in the intestine, or a new abnormal heart rhythm like atrial fibrillation).
- Medications are also a common culprit and can not be left off this list. Medications often have unintended side effects, directly damage organs, and their overall effects add up. They are a common contributor to why people become septic, fall and experience traumatic injuries, and are a major reason for critical illness.
Let’s summarize. Being told someone is critically ill means that person is sick and needs care in a hospital. Often one or more of their organs is not doing what it is supposed to.
Who is at risk of needing critical care?
We all are. Accidents happen. Illnesses happen. COVID, a recent yet hopefully once-in-a-century event, serves as an example of this.
What puts us at more risk of becoming critically ill?
Aging for one. People who are aging have less reserve when they get sick.
They do not bounce back as quickly. If an illness puts them into the hospital, they become deconditioned faster.
People do not physically move like they do at home when they are in the hospital receiving critical care.
When sick and immobilized people who are aging lose muscle mass and ultimately the functional abilities of their bodies much faster than people who are younger.
People who are aging also often have underlying medical problems like heart, lung, and kidney disease.
A person who lives every day with conditions like these means their organs do not function as well at baseline putting them at higher risk of becoming critically ill.
Who else is more at risk of having a critical illness?
People who are immunocompromised. Living with cancer or taking a daily medication treating an autoimmune condition impacts the immune system and makes infection risk higher. This makes the risk of sepsis higher.
Those who struggle with balance, poor eyesight, impaired hearing, or walk with assistive devices like walkers or canes have a higher risk of falls and traumatic injury.
In addition, people who take daily blood thinners. These medications impair the body’s ability to form clots making their bleeding risk higher.
There are many groups of people who are at risk, but you might have noticed the articles I write are with dementia family caregivers at the front of my mind.
After reading what I’ve written above, I hope you can see how many people living with dementia are likely living with one or more of these risk factors making them more vulnerable to critical illness.
I also want to point out that generally speaking, the risk of falling is higher simply due to a person having a disease causing dementia.
You can read the article I wrote about how falls are one of the top two reasons I see people living with dementia in the ER as my patients. (Click here to read my article on this.)
Living with dementia is absolutely a strong risk factor for developing a critical illness.
Besides falls, another risk factor common in diseases causing dementia are issues with communication.
We know there is often a struggle to communicate how the person is feeling.
No matter the disease, as it worsens it almost always becomes difficult for people living with dementia to describe and put into words what they perceive happening inside their bodies.
Describing their symptoms and issues with communication are not the only issue.
There are also difficulties in keeping a timeline, understanding the big picture, and having the insight to realize something concerning is happening and to tell someone.
Let me give you an example of how a very common condition can lead to critical illness in a person living with dementia.
You’ve likely heard of appendicitis.
You probably know someone who, or you yourself, has had surgery to have the appendix removed. This is part of the standard of care in the US.
Why would someone living with dementia be more likely to become critically ill due to appendicitis?
Often, they come in for evaluation later than others who have a healthy brain would.
We have to play catch up because they weren’t able to tell the people around them that every time they ate it hurt or that they had been feeling pain in their belly that had been getting worse over the past few days.
Often it isn’t obvious there is something wrong with the person until they are having signs we can actually see.
For appendicitis that might mean vomiting, refusing to eat, appearing in pain, not wanting to walk, and/or fever.
By the time it is noticeable to us that the person isn’t feeling well they may have what we call a “complicated” case of appendicitis.
A ruptured appendicitis (meaning the appendix got so swollen and inflamed that a hole popped in it) is one complication.
They could also have an abscess around the appendix which is a collection of pus and inflammation due to infection.
Both of these situations make sepsis more likely and surgery potentially more challenging.
In the case of an abscess, a surgeon may prefer to wait and first have the abscess drained.
For people living with dementia, complications during surgery, the recovery process, and the risk of sepsis are higher.
Appendicitis is just one of many conditions I teach inside my course for caregivers. You can learn more about the course and what is included by clicking here.
We’ve covered what critical care is, common causes, where care happens in the hospital, and who is at risk for critical illness.
Next, I want to give you information you can use on a practical level.
In my next article I will share two questions you need to be ready to answer now and one you need to ask your person’s care team in real time if there is concern for critical illness.
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Until next time, all my best to you and your family,
Brittany Lamb, MD