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Brummel NE, Bell SP, Girard TD, Pandharipande PP, Jackson JC, Morandi A, Thompson JL, Chandrasekhar R, Bernard GR, Dittus RS, Gill TM, Ely EW. Frailty and Subsequent Disability and Mortality among Patients with Critical Illness. Am J Respir Crit Care Med 2017; 196:64-72. [PMID: 27922747 DOI: 10.1164/rccm.201605-0939oc] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
RATIONALE The prevalence of frailty (diminished physiologic reserve) and its effect on outcomes for those aged 18 years and older with critical illness is unclear. OBJECTIVES We hypothesized greater frailty would be associated with subsequent mortality, disability, and cognitive impairment, regardless of age. METHODS At enrollment, we measured frailty using the Clinical Frailty Scale (range, 1 [very fit] to 7 [severely frail]). At 3 and 12 months post-discharge, we assessed vital status, instrumental activities of daily living, basic activities of daily living, and cognition. We used multivariable regression to analyze associations between Clinical Frailty Scale scores and outcomes, adjusting for age, sex, education, comorbidities, baseline disability, baseline cognition, severity of illness, delirium, coma, sepsis, mechanical ventilation, and sedatives/opiates. MEASUREMENTS AND MAIN RESULTS We enrolled 1,040 patients who were a median (interquartile range) of 62 (53-72) years old and who had a median Clinical Frailty Scale score of 3 (3-5). Half of those with clinical frailty (i.e., Clinical Frailty Scale score ≥5) were younger than 65 years old. Greater Clinical Frailty Scale scores were independently associated with greater mortality (P = 0.01 at 3 mo and P < 0.001 at 12 mo) and with greater odds of disability in instrumental activities of daily living (P = 0.04 at 3 mo and P = 0.002 at 12 mo). Clinical Frailty Scale scores were not associated with disability in basic activities of daily living or with cognition. CONCLUSIONS Frailty is common in critically ill adults aged 18 years and older and is independently associated with increased mortality and greater disability. Future studies should explore routine screening for clinical frailty in critically ill patients of all ages. Interventions to reduce mortality and disability among patients with heightened vulnerability should be developed and tested. Clinical trial registered with www.clinicaltrials.gov (NCT 00392795 and NCT 00400062).
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Affiliation(s)
- Nathan E Brummel
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,2 Center for Health Services Research.,3 Center for Quality Aging
| | - Susan P Bell
- 3 Center for Quality Aging.,4 Division of Cardiovascular Medicine.,5 Vanderbilt Memory & Alzheimer's Center
| | - Timothy D Girard
- 6 Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - James C Jackson
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,2 Center for Health Services Research.,8 Department of Psychiatry and Behavioral Sciences, and.,9 Research Service and
| | - Alessandro Morandi
- 10 Geriatric Research Group, Brescia, Italy.,11 Department of Rehabilitation and Aged Care, Hospital Ancelle, Cremona, Italy; and
| | - Jennifer L Thompson
- 12 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Rameela Chandrasekhar
- 12 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gordon R Bernard
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
| | - Robert S Dittus
- 2 Center for Health Services Research.,13 Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Thomas M Gill
- 14 Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - E Wesley Ely
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,2 Center for Health Services Research.,3 Center for Quality Aging.,13 Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
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102
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McIsaac DI, Taljaard M, Bryson GL, Beaule PE, Gagne S, Hamilton G, Hladkowicz E, Huang A, Joanisse J, Lavallée LT, Moloo H, Thavorn K, van Walraven C, Yang H, Forster AJ. Comparative assessment of two frailty instruments for risk-stratification in elderly surgical patients: study protocol for a prospective cohort study. BMC Anesthesiol 2016; 16:111. [PMID: 27842511 PMCID: PMC5109639 DOI: 10.1186/s12871-016-0276-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/25/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Frailty is an aggregate expression of susceptibility to poor outcomes, owing to age-, and disease-related deficits that accumulate within multiple domains. Older patients who are frail before surgery are at an increased risk of morbidity and mortality, and use a disproportionately high amount of healthcare resources. While frailty is now a well-established risk factor for adverse postoperative outcomes, the perioperative literature lacks studies that: 1) compare the predictive accuracy of different frailty instruments; 2) consider the impact of frailty on patient-reported outcome measures; and 3) consider the acceptability and feasibility of using frailty instruments in clinical practice. METHODS We will conduct a multicenter prospective cohort study comparing the predictive accuracy of the modified Fried Index (mFI) with the Clinical Frailty Scale (CFS) among consenting patients aged 65 years and older having elective major non-cardiac surgery. The primary outcome will be disability free survival at 90 days after surgery, a patient-reported outcome measure. Secondary outcomes will include complications, length of stay, discharge disposition, readmission and total health system costs. We will compare the accuracy of frailty instruments using the relative true positive rate and relative false positive rate. These measures can be interpreted as the relative difference in the probability of one instrument identifying a true case of death or new disability compared to another instrument, or the relative difference in the probability of one instrument identifying a false case of death or new disability, respectively. We will also assess the acceptability and feasibility of each instrument. DISCUSSION Frailty is an important prognostic factor in the growing population of older patients having surgery. This study will provide novel findings regarding the choice of an accurate, clinically useable frailty instrument in predicting patient reported outcomes, as well as morbidity, mortality and resource use. These findings will inform current practice and future research.
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Affiliation(s)
- Daniel I. McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Anesthesiology, The Ottawa Hospital, Ottawa, Canada
| | - Monica Taljaard
- Department of Anesthesiology, The Ottawa Hospital, Ottawa, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Gregory L. Bryson
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Paul E. Beaule
- University of Ottawa and The Ottawa Hospital, Ottawa, Canada
| | - Sylvain Gagne
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
| | - Gavin Hamilton
- Anesthesiology Resident, University of Ottawa, Ottawa, Canada
| | | | - Allen Huang
- Geriatric Medicine, The Ottawa Hospital, Ottawa, Canada
| | | | - Luke T. Lavallée
- Ottawa Hospital Research Institute, Ottawa, Canada
- Division of Urology, University of Ottawa, Ottawa, Canada
| | - Hussein Moloo
- Division of General Surgery, University of Ottawa, Ottawa, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Carl van Walraven
- Ottawa Hospital Research Institute, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Medicine and Epidemiology, University of Ottawa, Ottawa, Canada
| | - Homer Yang
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
| | - Alan J. Forster
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
- The Ottawa Hospital, Ottawa, Canada
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103
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Bonner S, Lone NI. The younger frail critically ill patient: a newly recognised phenomenon in intensive care? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:349. [PMID: 27799055 PMCID: PMC5088649 DOI: 10.1186/s13054-016-1526-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
| | - Nazir I Lone
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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104
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Bagshaw SM, Majumdar SR, Rolfson DB, Ibrahim Q, McDermid RC, Stelfox HT. Erratum to: A prospective multicenter cohort study of frailty in younger critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:223. [PMID: 27435023 PMCID: PMC4952065 DOI: 10.1186/s13054-016-1393-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 06/16/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Sean M Bagshaw
- Division of Critical Care Medicine (University of Alberta Hospital), Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, 8440-112 Street NW, Edmonton, AB, T6G 2B7, Canada.
| | - Sumit R Majumdar
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, 5-112 Clinical Sciences Building, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Darryl B Rolfson
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, 13-103 Clinical Sciences Building, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Quazi Ibrahim
- Population Health Research Institute, McMaster University, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada
| | - Robert C McDermid
- Department of Medicine, Faculty of Medicine and Dentistry, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada
| | - H Tom Stelfox
- Department of Critical Care Medicine, Faculty of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1 N4, Canada
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