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Despite technological advances, the mortality rate for critically ill oldest old patients remains high. The intensive caring should be able to combine technology and a deep humanity considering that the patients are living the last part of their lives. In addition to the traditional goals of ICU of reducing morbidity and mortality, of maintaining organ functions and restoring health, caring for seriously oldest old patients should take into account their end-of-life preferences, the advance or proxy directives if available, the prognosis, the communication, their life expectancy and the impact of multimorbidity. The aim of this review was to focus on all these aspects with an emphasis on some intensive procedures such as mechanical ventilation, noninvasive mechanical ventilation, cardiopulmonary resuscitation, renal replacement therapy, hemodynamic support, evaluation of delirium and malnutrition in this heterogeneous frail ICU population.

The evaluation of the oxygen consumption (VO2) related to muscle metabolic changes can be a very useful assessment for clinical and physiological interpretations. Local VO2 can be evaluated by measuring the VO2 changes on the whole body but this measurement is subject to a large variability and requires the assumption of a constant basal metabolism. Otherwise methods for the measurement of local VO2 are invasive and difficult to apply in dynamic conditions. A simple and non-invasive technique for the measurement of skeletal muscle VO2 could find many physiological and clinical applications in the evaluation of muscle metabolism particularly under different workload conditions. Near infrared (NIR) spectroscopy has been developed experimentally and clinically for the non-invasive monitoring of changes in brain and muscle oxygenation (Jobsis-Vander Vliet, 1977). Changes in NIR light propagation across skeletal muscle are affected by scattering and absorption effects due to haemoglobin (Hb) and myoglobin (Mb). Trends in human skeletal muscle deoxygenation have been studied previously during cuff ischaemia at rest and with extreme exercise (Hampson & Piantadosi, 1988; Chance et al., 1988; Chance et al., 1992; De Blasi et al., 1992). Although the NIR spectrum of Mb overlaps that of Hb (De Blasi et al., 1991), recently magnetic resonance spectroscopy has been employed to separate the responses of Mb and Hb to mild and severe deoxygenation (Wang et al., 1990).