The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (≥ 80 years)

Escalation to intensive care for the older patient. An exploratory qualitative study of patients aged 65 years and older and their next of kin during the COVID-19 pandemic: the ESCALATE study

BACKGROUND

older people comprise the majority of hospital medical inpatients so decision-making regarding admission of this cohort to the intensive care unit (ICU) is important. ICU can be perceived by clinicians as overly burdensome for patients and loved ones, and long-term impact on quality of life considered unacceptable, effecting potential bias against admitting older people to ICU. The COVID-19 pandemic highlighted the challenge of selecting those who could most benefit from ICU.

OBJECTIVE

this qualitative study aimed to explore the views and recollections of escalation to ICU from older patients (aged ≥ 65 years) and next of kin (NoK) who experienced a COVID-19 ICU admission.

SETTING

the main site was a large NHS Trust in London, which experienced a high burden of COVID-19 cases.

SUBJECTS

30 participants, comprising 12 patients, 7 NoK of survivor and 11 NoK of deceased.

METHODS

semi-structured interviews with thematic analysis using a framework approach.

RESULTS

there were five major themes: inevitability, disconnect, acceptance, implications for future decision-making and unique impact of the COVID-19 pandemic. Life was highly valued and ICU perceived to be the only option. Prior understanding of ICU and admission decision-making explanations were limited. Despite benefit of hindsight, having experienced an ICU admission and its consequences, most could not conceptualise thresholds for future acceptable treatment outcomes.

CONCLUSIONS

in this study of patients ≥65 years and their NoK experiencing an acute ICU admission, survival was prioritised. Despite the ordeal of an ICU stay and its aftermath, the decision to admit and sequelae were considered acceptable.

Prevalence and Related Factors of Lower Urinary Tract Infection in Frail Older Adults Undergoing Major Noncardiac Surgery

Urinary tract infections are the most common complication after surgery in older adults, resulting in poor operative outcomes and reduced quality of life after discharge. However, there is limited research investigating the relationships between urinary tract infection and associated factors in frail older surgical patients, particularly in Thailand. This retrospective study included 220 frail older patients aged ≥ 60 years who had undergone major noncardiac surgery at a tertiary care hospital in Thailand from January 2015 to December 2019. The sample was recruited using the criteria indicated in the modified Frailty Index-11 and having the blood glucose level determined within 2 h before surgery. The prevalence of lower urinary tract infections was 15% post-surgery. Firth's logistic regression analysis revealed that the equation could predict the accuracy of lower urinary tract infections by 88.5%. Frailty, blood glucose levels, complication during admission, and personal factors together predicted the variability of lower urinary tract infections. Adjusting for other variables, being an older adult with severe frailty and complications during hospital admission significantly increased the risk of developing lower urinary tract infections (odds ratio = 3.46, p < 0.05; odds ratio = 9.53, p < 0.001, respectively).

The Association Between the Clinical Frailty Scale and Adverse Health Outcomes in Older Adults in Acute Clinical Settings - A Systematic Review of the Literature

Background

Frail older adults experience higher rates of adverse health outcomes. Therefore, assessing pre-hospital frailty early in the course of care is essential to identify the most vulnerable patients and determine their risk of deterioration. The Clinical Frailty Scale (CFS) is a frailty assessment tool that evaluates pre-hospital mobility, energy, physical activity, and function to generate a score that ranges from very fit to terminally ill.

Purpose

To synthesize the evidence of the association between the CFS degree and all-cause mortality, all-cause readmission, length of hospital stay, adverse discharge destination, and functional decline in patients >65 years in acute clinical settings.

Design

Systematic review with narrative synthesis.

Methods

Electronic databases (PubMed, EMBASE, CINAHL, Scopus) were searched for prospective or retrospective studies reporting a relationship between pre-hospital frailty according to the CFS and the outcomes of interest from database inception to April 2020.

Results

Our search yielded 756 articles, of which 29 studies were included in this review (15 were at moderate risk and 14 at low risk of bias). The included studies represented 26 cohorts from 25 countries (N = 44166) published between 2011 and 2020. All included studies showed that pre-hospital frailty according to the CFS is an independent predictor of all adverse health outcomes included in the review.

Conclusion

A primary purpose of the CFS is to grade clinically increased risk (i.e. risk stratification). Our results report the accumulated knowledge on the risk-predictive performance of the CFS and highlight the importance of routinely including frailty assessments, such as the CFS, to estimate biological age, improve risk assessments, and assist clinical decision-making in older adults in acute care. Further research into the potential of the CFS and whether implementing the CFS in routine practice will improve care and patients' quality of life is warranted.

The impact of age on intensive care

Caring for the elderly has always been challenging for the intensive care unit (ICU) physician. Concerns like frailty, comorbidities, polypharmacy and advanced directives come up even before admission into the unit. The COVID-19 pandemic has put forward a variety of issues concerning elderly populations, making the topic more relevant than ever. Admittance to the ICU, an unequivocally multifactorial decision, requires special consideration from the side of the physician when caring for an elderly person. Patients' wishes are to be respected and thus given priority. Triage assessment must also account for age-related physiological alterations and functional status. Once in the ICU, special attention should be given to age-related specificities, such as therapeutic interventions' controversial role, infection susceptibility, and post-operative care, that could potentially alter the course of hospitalization and affect outcomes. Following ICU discharge, ensuring proper rehabilitation for both survivors and their caregivers can improve long-term outcomes and subsequent quality of life. The pandemic and its implications may limit the standard of care for the elderly requiring ICU support. Socioeconomic factors that further perplex the situation must be addressed. Elderly patients currently represent a vast expanding population in ICU. Tailoring safe treatment plans to match patients' wishes, and personalized needs will guide critical care for the elderly from this time forward.

Twelve Months and Counting: Following Clinical Outcomes in Critical COVID-19 Survivors

Rationale: Recent reports suggest that patients with severe coronavirus disease (COVID-19) often experience long-term consequences of the infection. However, studies on intensive care unit (ICU) survivors are underrepresented. Objectives: We aimed to explore 12-month clinical outcomes after critical COVID-19, describing the longitudinal progress of disabilities, frailty status, frequency of cognitive impairment, and clinical events (rehospitalization, institutionalization, and falls). Methods: We performed a prospective cohort study of survivors of COVID-19 ICU admissions in Sao Paulo, Brazil. We assessed patients every 3 months for 1 year after hospital discharge and obtained information on 15 activities of daily living (basic, instrumental, and mobility activities), frailty, cognition, and clinical events. Results: We included 428 patients (mean age of 64 yr, 61% required invasive mechanical ventilation during ICU stay). The number of disabilities peaked at 3 months compared with the pre-COVID-19 period (mean difference, 2.46; 99% confidence interval, 1.94-2.99) and then decreased at 12 months (mean difference, 0.67; 99% confidence interval, 0.28-1.07). At 12-month follow-up, 12% of patients were frail, but half of them presented frailty only after COVID-19. The prevalence of cognitive symptoms was 17% at 3 months and progressively decreased to 12.1% (P = 0.012 for trend) at the end of 1 year. Clinical events occurred in all assessments. Conclusions: Although a higher burden of disabilities and cognitive symptoms occurred 3 months after hospital discharge of critical COVID-19 survivors, a significant improvement occurred during the 1-year follow-up. However, one-third of the patients remained in worse conditions than their pre-COVID-19 status.

Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges

There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.

Contribution of information about acute and geriatric characteristics to decisions about life-sustaining treatment for old patients in intensive care

BACKGROUND

Life-sustaining treatment (LST) in the intensive care unit (ICU) is withheld or withdrawn when there is no reasonable expectation of beneficial outcome. This is especially relevant in old patients where further functional decline might be detrimental for the self-perceived quality of life. However, there still is substantial uncertainty involved in decisions about LST. We used the framework of information theory to assess that uncertainty by measuring information processed during decision-making.

METHODS

Datasets from two multicentre studies (VIP1, VIP2) with a total of 7488 ICU patients aged 80 years or older were analysed concerning the contribution of information about the acute illness, age, gender, frailty and other geriatric characteristics to decisions about LST. The role of these characteristics in the decision-making process was quantified by the entropy of likelihood distributions and the Kullback-Leibler divergence with regard to withholding or withdrawing decisions.

RESULTS

Decisions to withhold or withdraw LST were made in 2186 and 1110 patients, respectively. Both in VIP1 and VIP2, information about the acute illness had the lowest entropy and largest Kullback-Leibler divergence with respect to decisions about withdrawing LST. Age, gender and geriatric characteristics contributed to that decision only to a smaller degree.

CONCLUSIONS

Information about the severity of the acute illness and, thereby, short-term prognosis dominated decisions about LST in old ICU patients. The smaller contribution of geriatric features suggests persistent uncertainty about the importance of functional outcome. There still remains a gap to fully explain decision-making about LST and further research involving contextual information is required.

TRIAL REGISTRATION

VIP1 study: NCT03134807 (1 May 2017), VIP2 study: NCT03370692 (12 December 2017).

Clustering of critically ill patients using an individualized learning approach enables dose optimization of mobilization in the ICU

BACKGROUND

While early mobilization is commonly implemented in intensive care unit treatment guidelines to improve functional outcome, the characterization of the optimal individual dosage (frequency, level or duration) remains unclear. The aim of this study was to demonstrate that artificial intelligence-based clustering of a large ICU cohort can provide individualized mobilization recommendations that have a positive impact on the likelihood of being discharged home.

METHODS

This study is an analysis of a prospective observational database of two interdisciplinary intensive care units in Munich, Germany. Dosage of mobilization is determined by sessions per day, mean duration, early mobilization as well as average and maximum level achieved. A k-means cluster analysis was conducted including collected parameters at ICU admission to generate clinically definable clusters.

RESULTS

Between April 2017 and May 2019, 948 patients were included. Four different clusters were identified, comprising "Young Trauma," "Severely ill & Frail," "Old non-frail" and "Middle-aged" patients. Early mobilization (< 72 h) was the most important factor to be discharged home in "Young Trauma" patients (OR_adj 10.0 [2.8 to 44.0], p < 0.001). In the cluster of "Middle-aged" patients, the likelihood to be discharged home increased with each mobilization level, to a maximum 24-fold increased likelihood for ambulating (OR_adj 24.0 [7.4 to 86.1], p < 0.001). The likelihood increased significantly when standing or ambulating was achieved in the older, non-frail cluster (OR_adj 4.7 [1.2 to 23.2], p = 0.035 and OR_adj 8.1 [1.8 to 45.8], p = 0.010).

CONCLUSIONS

An artificial intelligence-based learning approach was able to divide a heterogeneous critical care cohort into four clusters, which differed significantly in their clinical characteristics and in their mobilization parameters. Depending on the cluster, different mobilization strategies supported the likelihood of being discharged home enabling an individualized and resource-optimized mobilization approach.

TRIAL REGISTRATION

Clinical Trials NCT03666286, retrospectively registered 04 September 2018.

Direct healthcare cost of hospital admissions for chronic non-communicable diseases sensitive to primary care in the elderly

Aging has imposed changes in the epidemiological profile and an increase in the prevalence of chronic non-communicable diseases (CNCDs). The aim was to estimate the direct cost related to hospital admissions of elderly people affected by CNCDs (hypertension, heart failure and diabetes mellitus) sensitive to primary care, in a medium-sized hospital, in the period 2015-2019. Secondly, we investigated whether clinical and demographic factors explain the costs and length of stay. The medical records of 165 elderly people were analyzed. We found a predominance of women with a mean age of 76.9 years. The most frequent cause of hospitalization was heart failure (62%), and the average length of stay was 9.5 days, and 16% of hospitalizations corresponded to rehospitalizations. Of these, 81% were caused by complications from the previous hospitalization. The estimated total cost was R$ 3 million. Male patients had a longer hospital stay compared to female patients. Hypertension and the total number of procedures were significant predictors of cost and length of stay. We found that in 5 years, the costs of hospital admissions for conditions sensitive to primary care in the elderly are considerable, indicating the relevance of investments in primary care.

Delirium in the intensive care unit and its importance in the post-operative context: A review

The burden of delirium in the intensive care setting is a global priority. Delirium affects up to 80% of patients in intensive care units; an episode of delirium is often distressing to patients and their families, and delirium in patients within, or outside of, the intensive care unit (ICU) setting is associated with poor outcomes. In the short term, such poor outcomes include longer stay in intensive care, longer hospital stay, increased risk of other hospital-acquired complications, and increased risk of hospital mortality. Longer term sequelae include cognitive impairment and functional dependency. While medical category of admission may be a risk factor for poor outcomes in critical care populations, outcomes for surgical ICU admissions are also poor, with dependency at hospital discharge exceeding 30% and increased risk of in-hospital mortality, particularly in vulnerable groups, with high-risk procedures, and resource-scarce settings. A practical approach to delirium prevention and management in the ICU setting is likely to require a multi-faceted approach. Given the good evidence for the prevention of delirium among older post-operative outside of the intensive care setting, simple non-pharmacological interventions should be effective among older adults post-operatively who are cared for in the intensive care setting. In response to this, the future ICU environment will have a range of organizational and distinct environmental characteristics that are directly targeted at preventing delirium.

Cytokine absorption in critically ill old COVID-19 patients with renal failure: A retrospective analysis of 503 intensive care unit patients

BACKGROUND

COVID-19 is associated with cytokine release in critical disease states. Thus, cytokine absorption has been proposed as a therapeutic option. This study investigated the influence of cytokine absorption on mortality in old critical patients with COVID-19 and renal failure admitted to intensive care units (ICU).

METHODS

This retrospective analysis of a prospective international observation study (the COVIP study) analysed ICU patients≥70 years with COVID-19. Data on Sequential Organ Failure Assessment (SOFA) score, clinical frailty scale (CFS), ICU therapy details including renal replacement therapy (RRT) with/without cytokine absorption were collected. The cytokine absorption group was compared to patients receiving RRT without cytokine absorptionRESULTS:Among 3927 patients, 503 received RRT; among them 47 patients were treated with cytokine absorption. Mortality rates were high in both groups with increased rates in the cytokine group for ICU mortality and 30-day mortality, but not for 3-month mortality. Logistic regression analysis indicated that SOFA-score, but not cytokine absorption was associated with mortality.

CONCLUSIONS

Critical COVID-19 patients with renal failure treated with cytokine absorption showed higher short term mortality rates when compared to patients with renal replacement therapy alone. Mortality is associated with disease severity, but not cytokine absorption in a multivariate analysis.

Associations of anemia and blood transfusions with mortality in old, critically ill COVID-19 patients - Results from the prospective COVIP Study

AIMS

Anemia is common in the old and often observed in critically ill patients. Increased age is associated with higher mortality following a COVID-19 infection, making old patients prone to poor outcomes. We investigated whether anemia at admission to the ICU or the need for blood transfusion was associated with 90-day mortality in older, critically ill COVID-19 patients.

METHODS

In this prospective multicenter study, the 90-day mortality of COVID-19 patients≥70 years treated in 138 intensive care units (ICU) was analyzed. Associations between anemia (WHO definition) at admission and discharge from ICU and the use of red blood cell (RBC) transfusions with mortality were assessed. Hemoglobin thresholds of RBC transfusions in old, critically ill COVID-19 patients were recorded.

RESULTS

In 493 patients (350 anemic, 143 non-anemic), anemia (WHO definition) at the time of ICU admission was not associated with impaired overall survival. Transfusion and severe anemia (hemoglobin≤10 g/dL) at ICU discharge were independently associated with a higher risk of 90-day mortality.

CONCLUSION

The need for red blood cell transfusions and severe anemia at ICU discharge, but not at the timepoint of admission, were independently associated with 90-day mortality in critically-ill old COVID-19 patients.

Direct healthcare cost of hospital admissions for chronic non-communicable diseases sensitive to primary care in the elderly

Abstract Aging has imposed changes in the epidemiological profile and an increase in the prevalence of chronic non-communicable diseases (CNCDs). The aim was to estimate the direct cost related to hospital admissions of elderly people affected by CNCDs (hypertension, heart failure and diabetes mellitus) sensitive to primary care, in a medium-sized hospital, in the period 2015-2019. Secondly, we investigated whether clinical and demographic factors explain the costs and length of stay. The medical records of 165 elderly people were analyzed. We found a predominance of women with a mean age of 76.9 years. The most frequent cause of hospitalization was heart failure (62%), and the average length of stay was 9.5 days, and 16% of hospitalizations corresponded to rehospitalizations. Of these, 81% were caused by complications from the previous hospitalization. The estimated total cost was R$ 3 million. Male patients had a longer hospital stay compared to female patients. Hypertension and the total number of procedures were significant predictors of cost and length of stay. We found that in 5 years, the costs of hospital admissions for conditions sensitive to primary care in the elderly are considerable, indicating the relevance of investments in primary care.

Low phase angle in critically ill older patients is associated with late mortality: A prospective study

OBJECTIVES

The aim of this study was to ascertain the accuracy of phase angle (PhA) as a predictor of mortality during intensive care unit (ICU) stay (M_ICU) and at 28 (M₂₈) and 60 d (M₆₀) after ICU admission among patients aged >60 y.

METHODS

Patients aged >60 y who were under mechanical ventilation (MV) ≥48 h were included once they were hemodynamically stable. PhA was measured by single-frequency bioelectrical impedance analysis up to 48 h after admission. ICU prognostic scores, functional scale, and nutritional assessments were performed in the first 24 h. Patients were followed for 60 d after ICU admission.

RESULTS

We enrolled 102 patients into the present study. PhA was significantly higher (P < 0.001) in survivors at M_ICU, M₂₈, and M₆₀. Areas under the receiving operator characteristic curves for M_ICU, M_28, and M₆₀ were 0.77 (95% confidence interval [CI], 0.67-0.86), 0.71 (95% CI, 0.60-0.82), and 0.71 (95% CI, 0.60-0.81), respectively. The PhA cutoff to predict mortality was 3.29° for males at M_ICU, M₂₈, and M₆₀ and lower for females at M₂₈ (2.63°) and M₆₀ (3.01°). PhA better discriminated M₆₀ than conventional prognostic scores. Logistic regression showed that even after controlling for other factors, PhA was a protective factor against late mortality. Survival analysis at 60 d revealed that low PhA was associated with lower median survival (18 versus 58 d; log-rank P < 0.001).

CONCLUSIONS

Low PhA values are associated with higher late mortality and a short survival time at 60 d in critically ill older adults. Low PhA values can be considered a useful ICU prognostic score in similar populations.

Frailty is a stronger predictor of death in younger intensive care patients than in older patients: a prospective observational study

BACKGROUND

While frailty is a known predictor of adverse outcomes in older patients, its effect in younger populations is unknown. This prospective observational study was conducted in a tertiary-level mixed ICU to assess the impact of frailty on long-term survival in intensive care patients of different ages.

METHODS

Data on premorbid frailty (Clinical Frailty Score; CFS), severity of illness (the Simplified Acute Physiology Score, third version; SAPS3), limitations of care and outcome were collected in 817 adult ICU patients. Hazard ratios (HR) for death within 180 days after ICU admission were calculated. Unadjusted and adjusted analyses were used to evaluate the association of frailty with outcome in different age groups.

RESULTS

Patients were classified into predefined age groups (18-49 years (n = 241), 50-64 (n = 188), 65-79 (n = 311) and 80 years or older (n = 77)). The proportion of frail (CFS ≥ 5) patients was 41% (n = 333) in the overall population and increased with each age strata (n = 46 (19%) vs. n = 67 (36%) vs. n = 174 (56%) vs. n = 46 (60%), P < 0.05). Frail patients had higher SAPS3, more treatment restrictions and higher ICU mortality. Frailty was associated with an increased risk of 180-day mortality in all age groups (HR 5.7 (95% CI 2.8-11.4), P < 0.05; 8.0 (4.0-16.2), P < 0.05; 4.1 (2.2-6.6), P < 0.05; 2.4 (1.1-5.0), P = 0.02). The effect remained significant after adjustment for SAPS3, comorbidity and limitations of treatment only in patients aged 50-64 (2.1 (1.1-3.1), P < 0.05).

CONCLUSIONS

Premorbid frailty is common in ICU patients of all ages and was found in 55% of patients aged under 64 years. Frailty was independently associated with mortality only among middle-aged patients, where the risk of death was increased twofold. Our study supports the use of frailty assessment in identifying younger ICU patients at a higher risk of death.

The association of prior paracetamol intake with outcome of very old intensive care patients with COVID-19: results from an international prospective multicentre trial

BACKGROUND

In the early COVID-19 pandemic concerns about the correct choice of analgesics in patients with COVID-19 were raised. Little data was available on potential usefulness or harmfulness of prescription free analgesics, such as paracetamol. This international multicentre study addresses that lack of evidence regarding the usefulness or potential harm of paracetamol intake prior to ICU admission in a setting of COVID-19 disease within a large, prospectively enrolled cohort of critically ill and frail intensive care unit (ICU) patients.

METHODS

This prospective international observation study (The COVIP study) recruited ICU patients ≥ 70 years admitted with COVID-19. Data on Sequential Organ Failure Assessment (SOFA) score, prior paracetamol intake within 10 days before admission, ICU therapy, limitations of care and survival during the ICU stay, at 30 days, and 3 months. Paracetamol intake was analysed for associations with ICU-, 30-day- and 3-month-mortality using Kaplan Meier analysis. Furthermore, sensitivity analyses were used to stratify 30-day-mortality in subgroups for patient-specific characteristics using logistic regression.

RESULTS

44% of the 2,646 patients with data recorded regarding paracetamol intake within 10 days prior to ICU admission took paracetamol. There was no difference in age between patients with and without paracetamol intake. Patients taking paracetamol suffered from more co-morbidities, namely diabetes mellitus (43% versus 34%, p < 0.001), arterial hypertension (70% versus 65%, p = 0.006) and had a higher score on Clinical Frailty Scale (CFS; IQR 2-5 versus IQR 2-4, p < 0.001). Patients under prior paracetamol treatment were less often subjected to intubation and vasopressor use, compared to patients without paracetamol intake (65 versus 71%, p < 0.001; 63 versus 69%, p = 0.007). Paracetamol intake was not associated with ICU-, 30-day- and 3-month-mortality, remaining true after multivariate adjusted analysis.

CONCLUSION

Paracetamol intake prior to ICU admission was not associated with short-term and 3-month mortality in old, critically ill intensive care patients suffering from COVID-19.

TRIAL REGISTRATION

This prospective international multicentre study was registered on ClinicalTrials.gov with the identifier "NCT04321265" on March 25, 2020.

Long Sleep Duration Increases the Risk of All-Cause Mortality Among Community-Dwelling Older Adults With Frailty: Evidence From NHANES 2009-2014

Objectives: The aim of this study was to determine the effect of sleep duration on all-cause mortality among older adults with frailty. Methods: The prospective cohort study included 5705 community participants aged 60 or above in the National Health and Nutrition Examination Survey (NHANES). Health indicators were selected in the NHANES to obtain the frailty index and sleep duration. The risk of all-cause mortality was estimated by a Cox proportional hazard model. Results: During the follow-up, long sleep duration was associated with higher all-cause mortality (adjusted HR = 1.28, 95% CI 1.03-1.59). The hazard of all-cause mortality was the lowest from the beginning of sleep until sleep duration reached 5.8 hours among older adults with frailty. Discussion: Long sleep duration was associated with higher all-cause mortality among older adults with frailty. There was a U-shaped relationship between sleep duration and all-cause mortality.

Clinical frailty and outcome after mechanical thrombectomy for stroke in patients aged ≥ 80 years

OBJECTIVES

Data concerning the results of endovascular thrombectomy (EVT) in old patients is still limited. We aimed to investigate the outcomes in thrombectomy-treated ischemic stroke patients aged ≥ 80 years, focusing on frailty as a contributing factor.

PATIENTS AND METHODS

We performed a single-centre retrospective cohort study with 159 consecutive patients aged ≥ 80 years and treated with EVT for acute ischemic stroke between January 1st 2016 and December 31st 2019. Pre-admission frailty was assessed with the Clinical Frailty Scale (CFS). Patients with CFS ≥ 5 were defined as frail. The main outcome was very poor outcome defined as mRS 4-6 at three months after EVT. Secondary outcomes were recanalization status, symptomatic intracerebral haemorrhage (sICH), and one-year survival. Finally, we recorded if the patient returned home within 12 months.

RESULTS

Very poor outcome was observed in 57.9% of all patients (52.4% in non-frail and 79.4% in frail patients). Rates of recanalization and sICH were comparable in frail and non-frail patients. Of all patients, 46.5% were able to live at home within 1 year after stroke. One-year survival was 59.1% (65.6% in non-frail and 35.3% in frail patients). In logistic regression analysis higher admission NIHSS, not performing thrombolysis, lack of recanalization and higher frailty status were all independently associated with very poor three-month outcome. Factors associated with one-year mortality were male gender, not performing thrombolysis, sICH, and higher frailty status.

CONCLUSION

Almost 60% of studied patients had very poor outcome. Frailty significantly increases the likelihood of very poor outcome and death after EVT-treated stroke.

Clustering analysis of geriatric and acute characteristics in a cohort of very old patients on admission to ICU

PURPOSE

The biological and functional heterogeneity in very old patients constitutes a major challenge to prognostication and patient management in intensive care units (ICUs). In addition to the characteristics of acute diseases, geriatric conditions such as frailty, multimorbidity, cognitive impairment and functional disabilities were shown to influence outcome in that population. The goal of this study was to identify new and robust phenotypes based on the combination of these features to facilitate early outcome prediction.

METHODS

Patients aged 80 years old or older with and without limitations of life-sustaining treatment and with complete data were recruited from the VIP2 study for phenotyping and from the COVIP study for external validation. The sequential organ failure assessment (SOFA) score and its sub-scores taken on admission to ICU as well as demographic and geriatric patient characteristics were subjected to clustering analysis. Phenotypes were identified after repeated bootstrapping and clustering runs.

RESULTS

In patients from the VIP2 study without limitations of life-sustaining treatment (n = 1977), ICU mortality was 12% and 30-day mortality 19%. Seven phenotypes with distinct profiles of acute and geriatric characteristics were identified in that cohort. Phenotype-specific mortality within 30 days ranged from 3 to 57%. Among the patients assigned to a phenotype with pronounced geriatric features and high SOFA scores, 50% died in ICU and 57% within 30 days. Mortality differences between phenotypes were confirmed in the COVIP study cohort (n = 280).

CONCLUSIONS

Phenotyping of very old patients on admission to ICU revealed new phenotypes with different mortality and potential need for anticipatory intervention.

Association between frailty, delirium, and mortality in older critically ill patients: a binational registry study

Background

Frailty and delirium are prevalent among older adults admitted to the intensive care unit (ICU) and associated with adverse outcomes; however, their relationships have not been extensively explored. This study examined the association between frailty and mortality and length of hospital stay (LOS) in ICU patients, and whether the associations are mediated or modified by an episode of delirium.

Methods

Retrospective analysis of data from the Australian New Zealand Intensive Care Society Adult Patient Database. A total of 149,320 patients aged 65 years or older admitted to 203 participating ICUs between 1 January 2017 and 31 December 2020 who had data for frailty and delirium were included in the analysis.

Results

A total of 41,719 (27.9%) older ICU patients were frail on admission, and 9,179 patients (6.1%) developed delirium during ICU admission. Frail patients had significantly higher odds of in-hospital mortality (OR: 2.15, 95% CI 2.05–2.25), episodes of delirium (OR: 1.86, 95% CI 1.77–1.95), and longer LOS (log-transformed mean difference (MD): 0.24, 95% CI 0.23–0.25). Acute delirium was associated with 32% increased odds of in-hospital mortality (OR: 1.32, 95% CI 1.23–1.43) and longer LOS (MD: 0.54, 95% CI 0.50–0.54). The odds ratios (95% CI) for in-hospital mortality were 1.37 (1.23–1.52), 2.14 (2.04–2.24) and 2.77 (2.51–3.05) for non-frail who developed delirium, frail without delirium, and frail and developed delirium during ICU admission, respectively. There was very small but statistically significant effect of frailty on in-hospital mortality (b for indirect effect: 0.00037, P < 0.001) and LOS (b for indirect effect: 0.019, P < 0.001) mediated through delirium.

Conclusion

Both frailty and delirium independently increase the risk of in-hospital mortality and LOS. Acute delirium is more common in frail patients; however, it does not mediate or modify a clinically meaningful amount of the association between frailty and in-hospital mortality and LOS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01080-y.

Characteristics and outcomes of medical emergency team calls in a Swiss tertiary centre - a retrospective observational study

AIMS OF THE STUDY

To describe reasons for medical emergency team (MET) activation over time, to analyse outcomes, and to describe the circadian distribution of MET calls and Intensive Care Unit (ICU) admissions following MET activation.

METHODS

Monocentric retrospective observational study of prospectively collected data on all MET calls between 1^st of January 2012 until 31^st of May 2019. We analysed data on baselines, referring wards, and disposition of all MET patients. In addition, we allocated all MET calls to the hourly intervals over the 24-hour cycle of the day in order to identify peak times of team activation.

RESULTS

A total of 4068 calls in 3277 patients (37% female, n = 1210) were analysed. The mean age was 65.9 years (± 15.7). The MET dose (defined as MET calls/1000 hospital admissions) remained relatively stable over the years with a median of 8.0 calls/1000 hospitalisations (interquartile range [IQR] 7.0-10.0). A total of 2526 calls (62%) occurred out of hours (17:00 to 8:00). The hourly rate of MET activations was greatest during the evening shift (33.8% of calls in seven hours), followed by the day shift (35.8% calls in nine hours) and night shift (30.4% in eight hours). Over the years, staff concern was the main reason for a MET call (n = 1192, 34%), followed by low peripheral oxygen saturation (SpO₂) not responding to oxygen therapy (n = 776, 22%). Abnormal respiratory rate was a trigger to call the MET in 44 cases (1.3%), and was not documented prior to 2017. Overall, in-hospital mortality was 22%.

CONCLUSION

While most common reasons for MET calls over the years were staff concern and low SpO₂, abnormal respiratory rate was the least frequent, but increased after the introduction of the quick sequential organ failure assessment (qSOFA) in 2016. Most MET calls occurred out of hours with peak hours during the evening shift, highlighting the importance of resource allocation during this shift when planning to introduce a MET system in a hospital. In-hospital mortality after a MET call was 22%.

Sex-specific treatment characteristics and 30-day mortality outcomes of critically ill COVID-19 patients over 70 years of age-results from the prospective COVIP study

PURPOSE

Older critically ill patients with COVID-19 have been the most vulnerable during the ongoing pandemic, with men being more prone to hospitalization and severe disease than women. We aimed to explore sex-specific differences in treatment and outcome after intensive care unit (ICU) admission in this cohort.

METHODS

We performed a sex-specific analysis in critically ill patients ≥ 70 yr of age with COVID-19 who were included in the international prospective multicenter COVIP study. All patients were analyzed for ICU admission and treatment characteristics. We performed a multilevel adjusted regression analysis to elucidate associations of sex with 30-day mortality.

RESULTS

A total of 3,159 patients (69.8% male, 30.2% female; median age, 75 yr) were included. Male patients were significantly fitter than female patients as determined by the Clinical Frailty Scale (fit, 67% vs 54%; vulnerable, 14% vs 19%; frail, 19% vs 27%; P < 0.001). Male patients more often underwent tracheostomy (20% vs 14%; odds ratio [OR], 1.57; P < 0.001), vasopressor therapy (69% vs 62%; OR, 1.25; P = 0.02), and renal replacement therapy (17% vs 11%; OR, 1.96; P < 0.001). There was no difference in mechanical ventilation, life-sustaining treatment limitations, and crude 30-day mortality (50% male vs 49% female; OR, 1.11; P = 0.19), which remained true after adjustment for disease severity, frailty, age and treatment limitations (OR, 1.17; 95% confidence interval, 0.94 to 1.45; P = 0.16).

CONCLUSION

In this analysis of sex-specific treatment characteristics and 30-day mortality outcomes of critically ill patients with COVID-19 ≥ 70 yr of age, we found more tracheostomy and renal replacement therapy in male vs female patients, but no significant association of patient sex with 30-day mortality.

STUDY REGISTRATION

www.

CLINICALTRIALS

gov (NCT04321265); registered 25 March 2020).

A retrospective cohort study comparing differences in 30-day mortality among critically ill patients aged ≥ 70 years treated in European tax-based healthcare systems (THS) versus social health insurance systems

In Europe, tax-based healthcare systems (THS) and social health insurance systems (SHI) coexist. We examined differences in 30-day mortality among critically ill patients aged ≥ 70 years treated in intensive care units in a THS or SHI. Retrospective cohort study. 2406 (THS n = 886; SHI n = 1520) critically ill ≥ 70 years patients in 129 ICUs. Generalized estimation equations with robust standard errors were chosen to create population average adjusted odds ratios (aOR). Data were adjusted for patient-specific variables, organ support and health economic data. The primary outcome was 30-day-mortality. Numerical differences between SHI and THS in SOFA scores (6 ± 3 vs. 5 ± 3; p = 0.002) were observed, but clinical frailty scores were similar (> 4; 17% vs. 14%; p = 0.09). Higher rates of renal replacement therapy (18% vs. 11%; p < 0.001) were found in SHI (aOR 0.61 95%CI 0.40-0.92; p = 0.02). No differences regarding intubation rates (68% vs. 70%; p = 0.33), vasopressor use (67% vs. 67%; p = 0.90) and 30-day-mortality rates (47% vs. 50%; p = 0.16) were found. Mortality remained similar between both systems after multivariable adjustment and sensitivity analyses. The retrospective character of this study. Baseline risk and mortality rates were similar between SHI and THS. The type of health care system does not appear to have played a role in the intensive care treatment of critically ill patients ≥ 70 years with COVID-19 in Europe.

Comparing the Clinical Frailty Scale and an International Classification of Diseases-10 Modified Frailty Index in Predicting Long-Term Survival in Critically Ill Patients

The Clinical Frailty Scale (CFS) is the most used frailty measure in intensive care unit (ICU) patients. Recently, the modified frailty index (mFI), derived from 11 comorbidities has also been used. It is unclear to what degree the mFI is a true measure of frailty rather than comorbidity. Furthermore, the mFI cannot be freely obtained outside of specific proprietary databases.

OBJECTIVE

To compare the performance of CFS and a recently developed International Classification of Diseases-10 (ICD-10) mFI (ICD-10mFI) as frailty-based predictors of long-term survival for up to 1 year.

DESIGN

A retrospective multicentric observational study.

SETTING AND PARTICIPANTS

All adult (≥16 yr) critically ill patients with documented CFS scores admitted to sixteen Australian ICUs in the state of Victoria between April 1, 2017 to June 30, 2018 were included. We used probabilistic methods to match de-identified ICU admission episodes listed in the Australia and New Zealand Intensive Care Society Adult Patient Database with the Victorian Admission Episode Dataset and the Victorian Death Index via the Victorian Data Linkage Centre.

MAIN OUTCOMES AND MEASURES

The primary outcome was the longest available survival following ICU admission. We compared CFS and ICD-10mFI as primary outcome predictors, after adjusting for key confounders.

RESULTS

The CFS and ICD-10mFI were compared in 7,001 ICU patients. The proportion of patients categorized as frail was greater with the CFS than with the ICD-10mFI (18.9% [n = 1,323] vs. 8.8% [n = 616]; p < 0.001). The median (IQR) follow-up time was 165 (82-276) days. The CFS predicted long-term survival up to 6 months after adjusting for confounders (hazard ratio [HR] = 1.26, 95% CI, 1.21-1.31), whereas ICD-10mFI did not (HR = 1.04, 95% CI, 0.98-1.10). The ICD-10mFI weakly correlated with the CFS (Spearman's rho = 0.22) but had a poor agreement (kappa = 0.06). The ICD-10mFI more strongly correlated with the Charlson comorbidity index (Spearman's rho 0.30) than CFS (Spearman's rho = 0.25) (p < 0.001).

CONCLUSIONS

CFS, but not ICD-10mFI, predicted long-term survival in ICU patients. ICD-10mFI correlated with co-morbidities more than CFS. These findings suggest that CFS and ICD-10mFI are not equivalent.

RELEVANCE

CFS and ICD-10mFI are not equivalent in screening for frailty in critically ill patients and therefore ICD-10mFI in its current form should not be used.

Outcomes of prolonged mechanical ventilation and tracheostomy in critically ill elderly patients: a historical cohort study

PURPOSE

With an aging global population, the increased proportion of elderly patients in the intensive care unit (ICU) raises important questions regarding optimal management. Currently, data on tracheostomy and its outcomes in the elderly are limited. We aimed to determine the in-hospital survival of elderly ICU patients following tracheostomy, and describe impacts on discharge disposition and functional outcomes.

METHODS

We conducted a historical cohort study at two academic hospitals in Toronto. All patients aged ≥ 70 yr who received a tracheostomy during their ICU stay between January 2010 and June 2016 were included in a retrospective chart review. Data on patient demographics, frailty, tracheostomy indication, and outcomes were collected.

RESULTS

The study included 270 patients with a mean (standard deviation) age of 81 (6) yr. The majority were admitted to ICU for respiratory failure (147/270, 54%) and received a tracheostomy for prolonged mechanical ventilation (202/270, 75%). Intensive care unit and hospital mortality were 26% (68/270) and 46% (125/270), respectively. Twenty-five percent (67/270) of patients were decannulated during hospital admission, a median [interquartile range (IQR)] of 41 [25-68] days after tracheostomy. Intensive care unit and hospital length of stay were 31 [17-53] and 81 [46-121] days, respectively. At hospital discharge, 6% (17/270) of patients were discharged home, all were frail (median Clinical Frailty Score of 7) and most were tube-fed (101/270, 70%), unable to speak (81/270, 56%), and nonambulatory (98/270, 68%).

CONCLUSIONS

In patients aged ≥ 70 yr, tracheostomy during ICU stay marked a transition toward prolonged chronic critical illness. Nearly half of the patients died during the admission, and although a quarter were successfully decannulated, the majority of survivors were left with severe frailty and functional impairment.

Variations in end-of-life care practices in older critically ill patients with COVID-19 in Europe

BACKGROUND

Previous studies reported regional differences in end-of-life care (EoLC) for critically ill patients in Europe.

OBJECTIVES

The purpose of this post-hoc analysis of the prospective multicentre COVIP study was to investigate variations in EoLC practices among older patients in intensive care units during the coronavirus disease 2019 pandemic.

METHODS

A total of 3105 critically ill patients aged 70 years and older were enrolled in this study (Central Europe: n = 1573; Northern Europe: n = 821; Southern Europe: n = 711). Generalised estimation equations were used to calculate adjusted odds ratios (aORs) to population averages. Data were adjusted for patient-specific variables (demographic, disease-specific) and health economic data (gross domestic product, health expenditure per capita). The primary outcome was any treatment limitation, and 90-day mortality was a secondary outcome.

RESULTS

The frequency of the primary endpoint (treatment limitation) was highest in Northern Europe (48%), intermediate in Central Europe (39%) and lowest in Southern Europe (24%). The likelihood for treatment limitations was lower in Southern than in Central Europe (aOR 0.39; 95% confidence interval [CI] 0.21-0.73; p = 0.004), even after multivariable adjustment, whereas no statistically significant differences were observed between Northern and Central Europe (aOR 0.57; 95%CI 0.27-1.22; p = 0.15). After multivariable adjustment, no statistically relevant mortality differences were found between Northern and Central Europe (aOR 1.29; 95%CI 0.80-2.09; p = 0.30) or between Southern and Central Europe (aOR 1.07; 95%CI 0.66-1.73; p = 0.78).

CONCLUSION

This study shows a north-to-south gradient in rates of treatment limitation in Europe, highlighting the heterogeneity of EoLC practices across countries. However, mortality rates were not affected by these results.

Frailty and clinical outcomes in critically ill patients with cancer: A cohort study

INTRODUCTION

Our aim was to assess impact of frailty on short-term clinical outcomes in critically ill patients with cancer.

MATERIALS AND METHODS

We conducted a cohort study at a medical and surgical intensive care unit (ICU) in Argentina. We included 269 consecutive patients, ≥18 years old, with diagnosis of cancer. We recorded demographic and clinical characteristics, Clinical Frailty Scale (CFS, ≥5 defined a patient as frail), and the number and duration of organ support therapies during ICU stay. Primary outcome was ICU and hospital mortality.

RESULTS

Median age 69 (range 20-90); 152 (56%) patients were male. Sixty-eight (25.2%) patients presented frailty at admission. Older adults (≥65 years old) made up 62.8% of patients. Frail patients were 69.7 years versus 64.4 years for non-frail, P = 0.007, with higher Acute Physiology and Chronic Health Evaluation II (APACHE II) 14.7 ± 7 versus 10.8 ± 6, P = 0.001 and Simplified Acute Physiology Score (SAPS II) 40.1 ± 17 versus 28.7 ± 14, P = 0.001, respectively. After adjusting by age, severity score, type of admission, and type of cancer, frailty was independently associated with hospital mortality, odds ratio (OR) 4.87 (95% confidence interval [CI], 2.19-11.19, P ≤0.001). Median ICU length of stay was five days (interquartile range [IQR] 3-7) versus six days (IQR 3.8-9), in non-frail versus frail patients, respectively (P = 0.100), and hospital stay was nine days (IQR 6-17) versus 11.5 days (IQR 7-19.5) in non-frail versus frail patients, respectively (P = 0.085).

DISCUSSION

Frailty as a medical condition was strongly associated with worse clinical outcomes among oncologic critically ill patients.

The clinical frailty scale as a triage tool for ICU admission of dialysis patients with COVID-19 - An ERACODA analysis

Background

Several guidelines recommend using the Clinical Frailty Scale (CFS) for triage of critically ill coronavirus disease 2019 (COVID-19) patients. This study evaluates the impact of CFS on intensive care unit (ICU) admission rate and hospital and ICU mortality rates in hospitalized dialysis patients with COVID-19.

Methods

We analysed data of dialysis patients diagnosed with COVID-19 from the European Renal Association COVID-19 Database. The primary outcome was ICU admission rate and secondary outcomes were hospital and ICU mortality until 3 months after COVID-19 diagnosis. Cox regression analyses were performed to assess associations between CFS and outcomes.

Results

A total of 1501 dialysis patients were hospitalized due to COVID-19, of whom 219 (15%) were admitted to an ICU. The ICU admission rate was lowest (5%) in patients >75 years of age with a CFS of 7–9 and highest (27%) in patients 65–75 years of age with a CFS of 5. A CFS of 7–9 was associated with a lower ICU admission rate than a CFS of 1–3 [relative risk 0.49 (95% confidence interval 0.27–0.87)]. Overall, mortality at 3 months was 34% in hospitalized patients, 65% in ICU-admitted patients and highest in patients >75 years of age with a CFS of 7–9 (69%). Only 9% of patients with a CFS ≥6 survived after ICU admission. After adjustment for age and sex, each CFS category ≥4 was associated with higher hospital and ICU mortality compared with a CFS of 1–3.

Conclusions

Frail dialysis patients with COVID-19 were less frequently admitted to the ICU. Large differences in mortality rates between fit and frail patients suggest that the CFS may be a useful complementary triage tool for ICU admission in dialysis patients with COVID-19.

Validation of clinical frailty scale in Chinese translation

BACKGROUND

Identification of frailty is crucial to guide patient care for the elderly. The Clinical Frailty Scale (CFS) is a reliable, synthesis and clinical judgment-based tool. However, a validated Chinese version of CFS (CFS-C) is lacking. The aim of this study is to describe the translation process of CFS into traditional Chinese and to evaluate its reliability and validity in a geriatric study population in Taiwan.

METHODS

This cross-sectional study recruited 221 geriatric outpatients aged 65 years or older at a medical center in Taipei, Taiwan. The Chinese version of CFS was produced following Brislin's translation model. Weighted kappa for agreement and Kendall's tau for correlation were used to assess inter-rater reliability (a subgroup of 52 outpatients) between geriatricians and one research assistant, and validity tests (221 outpatients) by comparing CFS-C with Fried frailty phenotype and Frailty Index based on Comprehensive Geriatric Assessment (FI-CGA). Correlation between CFS-C and other geriatric conditions were also assessed.

RESULTS

The inter-rater reliability revealed moderate agreement (weighted kappa = 0.60) and strong correlation (Kendall's tau = 0.67). For criterion validity, CFS-C categorisation showed fair agreement (weighted kappa = 0.37) and significant correlation (Kendall's tau = 0.46) with Fried frailty phenotype, and higher agreement (weighted kappa = 0.51) and correlation (Kendall's tau = 0.63) with FI-CGA categorisation. CFS-C was significantly correlated with various geriatric assessments, including functional disability, physical performance, hand grip, comorbidity, cognition, depression, and nutrition status. No significant correlation was found between CFS-C and appendicular muscle mass.

CONCLUSIONS

The CFS-C demonstrated acceptable validity and reliability in Chinese older adults in Taiwan. Development of CFS-C enhanced consistency and accuracy of frailty assessment, both in research and clinical practice.

Perioperative Hemodynamic Optimization in Patients at Risk for Delirium – A Randomized-Controlled Trial

Background

Post-operative delirium is common in elderly patients and associated with increased morbidity and mortality. We evaluated in this pilot study whether a perioperative goal-directed hemodynamic optimization algorithm improves cerebral oxygenation and can reduce the incidence of delirium.

Materials and Methods

Patients older than 70 years with high risk for post-operative delirium undergoing elective non-cardiac surgery were randomized to an intervention or control group. Patients in the intervention group received a perioperative hemodynamic optimization protocol based on uncalibrated pulse-contour analysis. Patients in the control group were managed according to usual standard of care. Incidence of delirium until day seven was assessed with confusion assessment method (CAM) and chart review. Cerebral oxygenation was measured with near-infrared spectroscopy.

Results

Delirium was present in 13 of 85 (15%) patients in the intervention group and 18 of 87 (21%) in the control group [risk difference −5.4%; 95% confidence interval, −16.8 to 6.1%; P = 0.47]. Intervention did not influence length of stay in hospital or in-hospital mortality. Amounts of fluids and vasopressors applied, mean arterial pressure, cardiac index, and near-infrared spectroscopy values were comparable between groups.

Conclusion

The hemodynamic algorithm applied in high-risk non-cardiac surgery patients did not change hemodynamic interventions, did not improve patient hemodynamics, and failed to increase cerebral oxygenation. An effect on the incidence of post-operative delirium could not be observed.

Clinical Trial Registration

[Clinicaltrials.gov], identifier [NCT01827501].

In-hospital end-of-life care in the old: a retrospective study of intensive care unit use and do-not-resuscitate forms in patients deceased in a Belgian university hospital

OBJECTIVES

To explore the quality of in-hospital end-of-life care in adult patients with special attention to those 75 years and older and to make a comparison with the situation 10 years ago.

METHODS

Data were retrospectively collected on adult patients who deceased at Ghent University Hospital between September 2018 and December 2019. The main outcome measures were 'ICU use' and 'presence of DNR forms on non-ICU units' in the final hospitalization. In order to identify possible risk factors for ICU use, logistic regression was performed.

RESULTS

In total, 762 people died, of whom 35% were 75 or older. Just as 10 years ago, one-third (31%) died in the ICU versus 49% of those younger than 75 years (p < 0.001). Of people ≥75 years, 38%, compared to 42% 10 years ago, received an ICU treatment during their final hospitalization. The median length of an ICU stay was 4 versus 3 days 10 years ago. After adjusting for gender, comorbidities and the Charlson Comorbidity Index, factors associated with less ICU use were higher age, active malignancy and dementia (OR 0.838, 0.116 and 0.098 respectively). Seventy-nine percent of older patients on non-ICU wards died with a DNR form (versus 87% 10 years ago).

CONCLUSION

Although there was an increase in the presence of DNR forms in the final hospitalization, no significant differences were seen in actual ICU use compared to 10 years ago. Factors associated with less ICU use were higher age, active malignancy and dementia.

Long term cognitive and functional status in Danish ICU patients with COVID-19

Background

ICU admission due to COVID‐19 may result in cognitive and physical impairment. We investigated the long‐term cognitive and physical status of Danish ICU patients with COVID‐19.

Methods

We included all patients with COVID‐19 admitted to Danish ICUs between March 10 and May 19, 2020. Patients were the contacted prospectively at 6 and 12 months for follow‐up. Our primary outcomes were cognitive function and frailty at 6 and 12 months after ICU admission, estimated by the Mini Montreal Cognitive Assessment, and the Clinical Frailty Scale. Secondary outcomes were 6‐ and 12‐month mortality, health‐related quality of life (HRQoL) assessed by EQ‐5D‐5L, functional status (Barthel activities of daily living and Lawton–Brody instrumental activities of daily living), and fatigue (Fatigue Assessment Scale). The study had no information on pre‐ICU admission status for the participants.

Results

A total of 326 patients were included. The 6‐ and 12‐month mortality was 37% and 38%, respectively. Among the 204 six‐month survivors, 105 (51%) participated in the 6‐month follow‐up; among the 202 twelve‐month survivors, 95 (47%) participated in the 12‐month follow‐up. At 6 months, cognitive scores indicated impairment for 26% (95% confidence interval [CI], 11.4–12.4) and at 12 months for 17% (95% CI, 12.0–12.8) of participants. Frailty was indicated in 20% (95% CI, 3.4–3.9) at 6 months, and for 18% (95% CI, 3.3–3.8) at 12 months. Fatigue was reported by 52% at 6 months, and by 47% at 12 months. For HRQoL, moderate, severe, or extreme health problems were reported by 28% at 6 months, and by 25% at 12 months.

Conclusion

Long‐term cognitive, functional impairment was found in up to one in four of patients surviving intensive care for COVID‐19. Fatigue was present in nearly half the survivors at both 6 and 12 months. However, pre‐ICU admission status of the patients was unknown.

The frailty, outcomes, recovery and care steps of critically ill patients (FORECAST) study: pilot study results

INTRODUCTION

Frailty is common in critically ill patients and is associated with increased morbidity and mortality. There remains uncertainty as to the optimal method/timing of frailty assessment and the impact of care processes and adverse events on outcomes is unknown. We conducted a pilot study to inform on the conduct, design and feasibility of a multicenter study measuring frailty longitudinally during critical illness, care processes, occurrence of adverse events, and resultant outcomes.

METHODS

Single-center pilot study enrolling patients over the age of 55 admitted to an Intensive Care Unit (ICU) for life-support interventions including mechanical ventilation, vasopressor therapy and/or renal replacement therapy. Frailty was measured on ICU admission and hospital discharge with the Clinical Frailty Scale (CFS), the Frailty Index (FI) and CFS at 6-month follow-up. Frailty was defined as CFS ≥ 5 and a FI ≥ 0.20. Processes of care and adverse events were measured during their ICU and hospital stay including nutritional support, mobility, nosocomial infections and delirium. ICU, hospital and 6 months were determined.

RESULTS

In 49 patients enrolled, the mean (SD) age was 68.7 ± 7.9 with a 6-month mortality of 29%. Enrollment was 1 patient/per week. Frailty was successfully measured at different time points during the patients stay/follow-up and varied by method/timing of assessment; by CFS and FI, respectively, in 17/49 (36%), 23/49 (47%) on admission, 22/33 (67%), 21/33 (63%) on hospital discharge and 11/30 (37%) had a CFS ≥ 5 at 6 months. Processes of care and adverse events were readily captured during the ICU and ward stay with the exception of ward nutritional data. ICU, hospital outcomes and follow-up outcomes were worse in those who were frail irrespective of ascertainment method. Pre-existing frailty remained static in survivors, but progressed in non-frail survivors.

DISCUSSION

In this pilot study, we demonstrate that frailty measurement in critically ill patients over the course and recovery of their illness is feasible, that processes of care and adverse events are readily captured, have developed the tools and obtained data necessary for the planning and conduct of a large multicenter trial studying the interaction between frailty and critical illness.

Trends in Geriatric Conditions Among Older Adults Admitted to US ICUs Between 1998 and 2015

BACKGROUND

Older adults are increasingly admitted to the ICU, and those with disabilities, dementia, frailty, and multimorbidity are vulnerable to adverse outcomes. Little is known about how pre-existing geriatric conditions have changed over time.

RESEARCH QUESTION

How have changes in disability, dementia, frailty, and multimorbidity in older adults admitted to the ICU changed from 1998 through 2015?

STUDY DESIGN AND METHODS

Medicare-linked Health and Retirement Survey (HRS) data identifying patients 65 years of age and older admitted to an ICU between 1998 and 2015. ICU admission was the unit of analysis. Year of ICU admission was the exposure. Disability, dementia, frailty, and multimorbidity were identified based on responses to HRS surveys before ICU admission. Disability represented the need for assistance with ≥ 1 activity of daily living. Dementia used cognitive and functional measures. Frailty included deficits in ≥ 2 domains (physical, nutritive, cognitive, or sensory function). Multimorbidity represented ≥ 3 self-reported chronic diseases. Time trends in geriatric conditions were modeled as a function of year of ICU admission and were adjusted for age, sex, race or ethnicity, and proxy interview status.

RESULTS

Across 6,084 ICU patients, age at admission increased from 77.6 years (95% CI, 76.7-78.4 years) in 1998 to 78.7 years (95% CI, 77.5-79.8 years) in 2015 (P < .001 for trend). The adjusted proportion of ICU admissions with pre-existing disability rose from 15.5% (95% CI, 12.1%-18.8%) in 1998 to 24.0% (95% CI, 18.5%-29.6%) in 2015 (P = .001). Rates of dementia did not change significantly (P = .21). Frailty increased from 36.6% (95% CI, 30.9%-42.3%) in 1998 to 45.0% (95% CI, 39.7%-50.2%) in 2015 (P = .04); multimorbidity rose from 54.4% (95% CI, 49.2%-59.7%) in 1998 to 71.8% (95% CI, 66.3%-77.2%) in 2015 (P < .001).

INTERPRETATION

Rates of pre-existing disability, frailty, and multimorbidity in older adults admitted to ICUs increased over time. Geriatric principles need to be deeply integrated into the ICU setting.

Comparison of the predictive ability of clinical frailty scale and hospital frailty risk score to determine long-term survival in critically ill patients: a multicentre retrospective cohort study

BACKGROUND

The Clinical Frailty Scale (CFS) is the most commonly used frailty measure in intensive care unit (ICU) patients. The hospital frailty risk score (HFRS) was recently proposed for the quantification of frailty. We aimed to compare the HFRS with the CFS in critically ill patients in predicting long-term survival up to one year following ICU admission.

METHODS

In this retrospective multicentre cohort study from 16 public ICUs in the state of Victoria, Australia between 1st January 2017 and 30th June 2018, ICU admission episodes listed in the Australian and New Zealand Intensive Care Society Adult Patient Database registry with a documented CFS, which had been linked with the Victorian Admitted Episode Dataset and the Victorian Death Index were examined. The HFRS was calculated for each patient using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes that represented pre-existing conditions at the time of index hospital admission. Descriptive methods, Cox proportional hazards and area under the receiver operating characteristic (AUROC) were used to investigate the association between each frailty score and long-term survival up to 1 year, after adjusting for confounders including sex and baseline severity of illness on admission to ICU (Australia New Zealand risk-of-death, ANZROD).

RESULTS

7001 ICU patients with both frailty measures were analysed. The overall median (IQR) age was 63.7 (49.1-74.0) years; 59.5% (n = 4166) were male; the median (IQR) APACHE II score 14 (10-20). Almost half (46.7%, n = 3266) were mechanically ventilated. The hospital mortality was 9.5% (n = 642) and 1-year mortality was 14.4% (n = 1005). HFRS correlated weakly with CFS (Spearman's rho 0.13 (95% CI 0.10-0.15) and had a poor agreement (kappa = 0.12, 95% CI 0.10-0.15). Both frailty measures predicted 1-year survival after adjusting for confounders, CFS (HR 1.26, 95% CI 1.21-1.31) and HFRS (HR 1.08, 95% CI 1.02-1.15). The CFS had better discrimination of 1-year mortality than HFRS (AUROC 0.66 vs 0.63 p < 0.0001).

CONCLUSION

Both HFRS and CFS independently predicted up to 1-year survival following an ICU admission with moderate discrimination. The CFS was a better predictor of 1-year survival than the HFRS.

Epidemiology and Age-Related Mortality in Critically Ill Patients With Intra-Abdominal Infection or Sepsis: An International Cohort Study

BACKGROUND

The objective of this study is to describe the epidemiology and age-related mortality in older critically ill adults with intra-abdominal infections.

METHODS

This is a secondary analysis of a prospective, multinational, observational study (AbSeS, ClinicalTrials.gov #NCT03270345) including patients with intra-abdominal infection from 309 ICUs in 42 countries (January-December, 2016). Mortality was considered as ICU mortality with a minimum of 28 days of observation when patients were discharged earlier. Relationships with mortality were assessed by logistic regression analysis.

RESULTS

The cohort included 2337 patients. Four age groups were defined: middle-aged patients as reference category (40-59 years; n=659 [28.2%]), young-old (60-69 years; n=622 [26.6%]), middle-old (70-79 years; n=667 [28.5%]) and very-old patients (≥80 years; n=389 [16.6%]). Secondary peritonitis was the predominant infection (68.7%) and equally prevalent across age groups. Mortality increased with age: 20.9% in middle-aged patients, 30.5% in young-old, 31.2% in middle-old, and 44.7% in very-old patients (p<0.001). Compared to middle-aged patients, young-old age (OR 1.62, 95% CI 1.21-2.17), middle-old age (OR 1.80, 95% CI 1.35-2.41), and very-old age (OR 3.69, 95% CI 2.66-5.12) were independently associated with mortality. Other independent risk factors for mortality included late-onset hospital-acquired intra-abdominal infection, diffuse peritonitis, sepsis/septic shock, source control failure, liver disease, congestive heart failure, diabetes, and malnutrition.

CONCLUSIONS

For ICU patients with intra-abdominal infections, age above 60 years was associated with mortality while patients above 80 years had the worst prognosis. Comorbidities and overall disease severity further compromised survival. As all these factors are non-modifiable it remains unclear how to improve outcomes.

Differences in early, intermediate, and long-term mortality among elderly patients admitted to the ICU. Results of a retrospective observational study

BACKGROUND

Few studies have investigated both short- and long-term prognostic factors, and the differences between chronic and acute conditions in the very old critically-ill patient. Our study aims to shed light in this field and to provide useful prognostic factors that may support clinical decisions in the management of the elderly.

METHODS

Six ICUs collected data concerning patients 80 years old or more admitted in 2015 and 2016 and followed-up until may 2018. Three prognostic models were developed: an in-hospital mortality model, a model for patients discharged from the hospital and entering follow-up, and an intermediate model for those alive after three days from ICU admission.

RESULTS

Our centers admitted 1189 patients, 1071 (90.1%) had survived after three days from admission, 889 (74.8%) were discharged from the hospital, 701 (59.0%) survived six months after hospital discharge, 539 (45.3%) survived at the end of follow-up. Among survivors the median follow-up time was 810 days. Acute organ failures were the main causes of death in the hospital mortality multivariable model. These factors are modifiable and potentially a target for intervention to improve outcome. The model focused on mortality six months after hospital in patients that survived a three-day timelimited trial, showed a clear shift toward chronic diseases, unmodifiable factors crucial for prognostic assessment. This trend was even more evident at the end of follow-up.

CONCLUSIONS

Among very old ICU patients, prognostic factors shift from acute to chronic conditions in passing from in-hospital to post-hospital outcomes.

Predictors of treatment limitations in Finnish intensive care units

BACKGROUND

Few studies have examined the factors that predict the limitations of life-sustaining treatment (LST) to patients in intensive care units (ICUs). We aimed to identify variables associated with the decision of withholding of life support (WHLS) at admission, WHLS during ICU stay and the withdrawal of ongoing life support (WDLS).

METHODS

This retrospective observational study comprised 17,772 adult ICU patients who were included in the nationwide Finnish ICU Registry in 2016. Factors associated with LST limitations were identified using hierarchical logistic regression.

RESULTS

The decision of WHLS at admission was made for 822 (4.6%) patients, WHLS during ICU stay for 949 (5.3%) patients, and WDLS for 669 (3.8%) patients. Factors strongly predicting WHLS at admission included old age (adjusted odds ratio [OR] for patients aged 90 years or older in reference to those younger than 40 years was 95.6; 95% confidence interval [CI], 47.2-193.5), dependence on help for activities of daily living (OR, 3.55; 95% CI, 3.01-4.2), and metastatic cancer (OR, 4.34; 95% CI, 3.16-5.95). A high severity of illness predicted later decisions to limit LST. Diagnoses strongly associated with WHLS at admission were cardiac arrest, hepatic failure and chronic obstructive pulmonary disease. Later decisions were strongly associated with cardiac arrest, hepatic failure, non-traumatic intracranial hemorrhage, head trauma and stroke.

CONCLUSION

Early decisions to limit LST were typically associated with old age and chronic poor health whereas later decisions were related to the severity of illness. Limitations are common for certain diagnoses, particularly cardiac arrest and hepatic failure.

The association of the Activities of Daily Living and the outcome of old intensive care patients suffering from COVID-19

Purpose

Critically ill old intensive care unit (ICU) patients suffering from Sars-CoV-2 disease (COVID-19) are at increased risk for adverse outcomes. This post hoc analysis investigates the association of the Activities of Daily Living (ADL) with the outcome in this vulnerable patient group.

Methods

The COVIP study is a prospective international observational study that recruited ICU patients ≥ 70 years admitted with COVID-19 (NCT04321265). Several parameters including ADL (ADL; 0 = disability, 6 = no disability), Clinical Frailty Scale (CFS), SOFA score, intensive care treatment, ICU- and 3-month survival were recorded. A mixed-effects Weibull proportional hazard regression analyses for 3-month mortality adjusted for multiple confounders.

Results

This pre-specified analysis included 2359 patients with a documented ADL and CFS. Most patients evidenced independence in their daily living before hospital admission (80% with ADL = 6). Patients with no frailty and no disability showed the lowest, patients with frailty (CFS ≥ 5) and disability (ADL < 6) the highest 3-month mortality (52 vs. 78%, p < 0.001). ADL was independently associated with 3-month mortality (ADL as a continuous variable: aHR 0.88 (95% CI 0.82–0.94, p < 0.001). Being “disable” resulted in a significant increased risk for 3-month mortality (aHR 1.53 (95% CI 1.19–1.97, p 0.001) even after adjustment for multiple confounders.

Conclusion

Baseline Activities of Daily Living (ADL) on admission provides additional information for outcome prediction, although most critically ill old intensive care patients suffering from COVID-19 had no restriction in their ADL prior to ICU admission. Combining frailty and disability identifies a subgroup with particularly high mortality.

Trial registration number: NCT04321265.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-00996-9.

Bacteraemia and quick Sepsis Related Organ Failure Assessment (qSOFA) are independent risk factors for long-term mortality in very elderly patients with suspected infection: retrospective cohort study

Background

In older adult patients, bloodstream infections cause significant mortality. However, data on long-term prognosis in very elderly patients are scarce. This study aims to assess 1-year mortality from bacteraemia in very elderly patients.

Methods

Retrospective cohort study in inpatients aged 80 years or older and suspected of having sepsis. Patients with (n = 336) and without (n = 336) confirmed bacteraemia were matched for age, sex, and date of culture, and their characteristics were compared. All-cause mortality and risk of death were assessed using the adjusted hazard ratio (aHR).

Results

Compared to controls, cases showed a higher 1-year mortality (34.8% vs. 45.2%) and mortality rate (0.46 vs. 0.69 deaths per person-year). Multivariable analysis showed significant risk of 1-year mortality in patients with bacteraemia (aHR: 1.31, 95% confidence interval [CI] 1.03–1.67), quick Sepsis Related Organ Failure Assessment (qSOFA) score of 2 or more (aHR: 2.71, 95% CI 2.05–3.57), and age of 90 years or older (aHR 1.53, 95% CI 1.17–1.99).

Conclusions

In elderly patients suspected of sepsis, bacteraemia is associated with a poor prognosis and higher long-term mortality. Other factors related to excess mortality were age over 90 years and a qSOFA score of 2 or more.

Association of chronic heart failure with mortality in old intensive care patients suffering from Covid-19

Aims

Chronic heart failure (CHF) is a major risk factor for mortality in coronavirus disease 2019 (COVID‐19). This prospective international multicentre study investigates the role of pre‐existing CHF on clinical outcomes of critically ill old (≥70 years) intensive care patients with COVID‐19.

Methods and results

Patients with pre‐existing CHF were subclassified as having ischaemic or non‐ischaemic cardiac disease; patients with a documented ejection fraction (EF) were subclassified according to heart failure EF: reduced (HFrEF, n = 132), mild (HFmrEF, n = 91), or preserved (HFpEF, n = 103). Associations of heart failure characteristics with the 30 day mortality were analysed in univariate and multivariate logistic regression analyses. Pre‐existing CHF was reported in 566 of 3917 patients (14%). Patients with CHF were older, frailer, and had significantly higher SOFA scores on admission. CHF patients showed significantly higher crude 30 day mortality [60% vs. 48%, P < 0.001; odds ratio 1.87, 95% confidence interval (CI) 1.5–2.3] and 3 month mortality (69% vs. 56%, P < 0.001). After multivariate adjustment for confounders (SOFA, age, sex, and frailty), no independent association of CHF with mortality remained [adjusted odds ratio (aOR) 1.2, 95% CI 0.5–1.5; P = 0.137]. More patients suffered from pre‐existing ischaemic than from non‐ischaemic disease [233 vs. 328 patients (n = 5 unknown aetiology)]. There were no differences in baseline characteristics between ischaemic and non‐ischaemic disease or between HFrEF, HFmrEF, and HFpEF. Crude 30 day mortality was significantly higher in HFrEF compared with HFpEF (64% vs. 48%, P = 0.042). EF as a continuous variable was not independently associated with 30 day mortality (aOR 0.98, 95% CI 0.9–1.0; P = 0.128).

Conclusions

In critically ill older COVID‐19 patients, pre‐existing CHF was not independently associated with 30 day mortality.

Trial registration number: NCT04321265.

Intensive care unit capacity and mortality in older adults: a three nations retrospective observational cohort study

Background

Intensive care unit (ICU) admissions among older adults are expected to increase, while the benefit remains uncertain. The availability of ICU beds varies between hospitals and between countries and is an important factor in the decision to admit older adults in the ICU. We aimed to assess if a non-restrictive approach to ICU older adults admission is associated with a corresponding change in survival.

Methods

Retrospective cohort study that included patients ≥ 80 years who were admitted to each of the three participating hospitals in Australia, Israel, and the United States (USA), between the years 2006–2015, each with distinct ICU capacities and admission criteria. The primary outcomes were in-hospital mortality and all-cause mortality at 6, 12, 18, and 24 months following index hospitalization.

Results

The cohort included 62,866 patients with a mean age of 85.9 ± 4.6 years and 58.8% were women. The ICU admission rates were 22.5%, 2.6% and 2.3% in USA, Australia, and Israel, respectively. We constructed a model for ICU admissions based on the USA cohort (highest availability of ICU beds) and then calculated the expected probabilities for the Israeli and Australian cohorts. For the patients in the highest quintile of the admission model, actual ICU admission rates were 67.6% in USA, 22.1% in Australia and 6.0% in Israel. Of these, in-hospital death rates were 52.3% in Israel, 29.8% in Australia, and 22.1% in USA. Two years after hospital discharge, the survival rates in the USA and Australia were 53%, while in Israel 48%.

Conclusion

ICU admission of adults ≥ 80 years is associated with increased in-hospital survival compared to ward admission, but survival rates 2 years later are similar.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-00994-x.

Multidisciplinary support for ethics deliberations during the first COVID wave

BACKGROUND

The first COVID-19 wave started in February 2020 in France. The influx of patients requiring emergency care and high-level technicity led healthcare professionals to fear saturation of available care. In that context, the multidisciplinary Ethics-Support Cell (EST) was created to help medical teams consider the decisions that could potentially be sources of ethical dilemmas.

OBJECTIVES

The primary objective was to prospectively collect information on requests for EST assistance from 23 March to 9 May 2020. The secondary aim was to describe the Cell's functions during that period.

RESEARCH DESIGN

This observational, real-time study of requests for Cell consultations concerned ethical dilemmas arising during a public health crisis. The EST created a grid to collect relevant information (clinical, patient's/designated representative's preferences and ethical principles strained by the situation), thereby assuring that each EST asked the same questions, in the same order.

PARTICIPANTS AND RESEARCH CONTEXT

Only our university hospital's clinicians could request EST intervention.

ETHICAL CONSIDERATIONS

The hospital Research Ethics Committee approved this study (no. CER-2020-107). The patient, his/her family, or designated representative was informed of this ethics consultation and most met with EST members, which enabled them to express their preferences and/or opposition.

FINDINGS/RESULTS

33 requests (patients' mean age: 80.8 years; 29 had COVID-19: 24 with dyspnea, 30 with comorbidities). 17 Emergency Department solicitations concerned ICU admission, without reference to resource constraints; others addressed therapeutic proportionality dilemmas.

DISCUSSION

Intervention-request motives concerned limited resources and treatment intensity. Management revolved around three axes: the treatment option most appropriate for the patient, the feasibility of implementation, and dignified care for the patient.

CONCLUSIONS

COVID-19 crisis forced hospitals to envisage prioritization of ICU access. Established decision-making criteria and protocols do not enable healthcare professionals to escape ethical dilemmas. That acknowledgement highlights ethical risks, enhances the added-value of nursing and encourages all players to be vigilant to pursue collective deliberations to achieve clear and transparent decisions.

Clinical Outcomes in Patients Aged 80 Years or Older Receiving Non-Invasive Respiratory Support for Hypoxemic Acute Respiratory Failure Consequent to COVID-19

As the clinical outcome of octogenarian patients hospitalised for COVID-19 is very poor, here we assessed the clinical characteristics and outcomes of patients aged 80 year or older hospitalised for COVID-19 receiving non-invasive respiratory support (NIRS). A multicentre, retrospective, observational study was conducted in seven hospitals in Northern Italy. All patients aged ≥80 years with COVID-19 associated hypoxemic acute respiratory failure (hARF) undergoing NIRS between 24 February 2020, and 31 March 2021, were included. Out of 252 study participants, 156 (61.9%) and 163 (64.6%) died during hospital stay and within 90 days from hospital admission, respectively. In this case, 228 (90.5%) patients only received NIRS (NIRS group), while 24 (9.5%) were treated with invasive mechanical ventilation (IMV) after NIRS failure (NIRS+IMV group). In-hospital mortality did not significantly differ between NIRS and NIRS+IMV group (61.0% vs. 70.8%, respectively; p = 0.507), while survival probability at 90 days was significantly higher for NIRS compared to NIRS+IMV patients (0.379 vs. 0.147; p = 0.0025). The outcome of octogenarian patients with COVID-19 receiving NIRS is quite poor. Caution should be used when considering transition from NIRS to IMV after NIRS failure.

Increased 30-day mortality in very old ICU patients with COVID-19 compared to patients with respiratory failure without COVID-19

Purpose

The number of patients ≥ 80 years admitted into critical care is increasing. Coronavirus disease 2019 (COVID-19) added another challenge for clinical decisions for both admission and limitation of life-sustaining treatments (LLST). We aimed to compare the characteristics and mortality of very old critically ill patients with or without COVID-19 with a focus on LLST.

Methods

Patients 80 years or older with acute respiratory failure were recruited from the VIP2 and COVIP studies. Baseline patient characteristics, interventions in intensive care unit (ICU) and outcomes (30-day survival) were recorded. COVID patients were matched to non-COVID patients based on the following factors: age (± 2 years), Sequential Organ Failure Assessment (SOFA) score (± 2 points), clinical frailty scale (± 1 point), gender and region on a 1:2 ratio. Specific ICU procedures and LLST were compared between the cohorts by means of cumulative incidence curves taking into account the competing risk of discharge and death.

Results

693 COVID patients were compared to 1393 non-COVID patients. COVID patients were younger, less frail, less severely ill with lower SOFA score, but were treated more often with invasive mechanical ventilation (MV) and had a lower 30-day survival. 404 COVID patients could be matched to 666 non-COVID patients. For COVID patients, withholding and withdrawing of LST were more frequent than for non-COVID and the 30-day survival was almost half compared to non-COVID patients.

Conclusion

Very old COVID patients have a different trajectory than non-COVID patients. Whether this finding is due to a decision policy with more active treatment limitation or to an inherent higher risk of death due to COVID-19 is unclear.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-022-06642-z.