Frailty, Outcomes, Recovery and Care Steps of Critically Ill Patients (FORECAST): a prospective, multi-centre, cohort study

Sarcopenia and frailty in critical illness

PURPOSE OF REVIEW

Sarcopenia and frailty are common conditions, associated with worse clinical outcomes during critical illness. Recent studies on sarcopenia and frailty in ICU patients are presented in this review, aiming to identify accurate diagnostic tools, investigate the effects on clinical and functional outcomes, and propose possible effective interventions.

RECENT FINDINGS

The recent change of the sarcopenia definition underlines the importance of muscle strength over mass, this is however challenging to assess in ICU patients. There is currently no unified sarcopenia definition, nor standard frailty assessment tool; Clinical Frailty Scale is most frequently used in the ICU. Meta-analyses show worse clinical and functional outcomes for frail as well as sarcopenic patients admitted to the ICU, regardless of admission diagnosis. Frailty is a dynamic condition, worsening in severity by the time of hospital discharge, but showing improvement by 6 months post-ICU. Therapeutic interventions for frailty and sarcopenia remain limited. Although mobilization strategies show promise in improving functional and cognitive outcomes, inconsistent outcomes are reported. Heterogeneity in definitions, patient populations, and care practices challenge interpretation and comparison of study results and recognition of beneficial interventions. This highlights the need for more research.

SUMMARY

The importance of preexisting sarcopenia and frailty is recognized in ICU patients and associated with worse clinical outcomes. Multidimensional interventions are most promising, including patient-tailored mobilization and nutrition.

The Importance of Frailty in Determining Survival After Intensive Care

Background: Estimating survival and long-term quality of life after intensive care has been a crucial bioethical endeavour in recent decades to improve end-of-life decision-making. Scientific studies have also shown that patient frailty influences survival, but only a few long-term data are available. Methods: We conducted a prospective observational study at the Department of Anaesthesiology and Intensive Care of Semmelweis University, Hungary, to investigate the association between physical status on admission, the chance of survival, and the long-term quality of life of the patient. We recorded the pre-admission frailty score (Clinical Frailty Scale), APACHE II, and SAPS II scores on admission. The first follow-up was 3 months after discharge when the quality of life of the patient was assessed using the EQ5-D questionnaire. During the second follow-up one year later, we recorded the EQ5-D, Mini-Mental Test, and the Beck Depression Inventory scales. Results: Our study demonstrated that the ROC analysis of predicted overall mortality based on CFS score is similar in accuracy to that of predicted mortality by APACHE II and SAPS II point systems. The multivariate logistic regression calculations show that the best performing of the three independent variables is the SAPS II estimator (78.5%), but the estimators of both acute condition scoring systems (APACHE and SAPS) can be improved (79.5% vs. 84%) when taking into account the CFS value. The prevalence of mood and mental disorders among patients who survived one year was not different from that of the general population. Conclusions: The physiological scoring systems examined are all suitable for estimating the risk of overall mortality. The CFS shows similar efficacy and appears to be additive in value, with scales describing the severity of acute illness, which are indicative of the chronic condition of the patient.

FRAIL PARTICIPANTS IN RANDOMIZED CONTROLLED TRIALS OF ACUTE RESPIRATORY DISTRESS SYNDROME

ABSTRACT

Purpose: Observational studies showed that frailty is common in the intensive care unit and associated with poor outcomes. However, relevant data from interventional trials are scarce, and it is unknown whether outcomes improved over time. We endeavored to estimate temporal trends of representation and outcomes of frail participants in randomized controlled trials of acute respiratory distress syndrome (ARDS). Methods: We performed a secondary analysis of five ARDS Network and PETAL Network trials published between 2006 and 2019. Based on requirement for everyday assistance prior to hospitalization, we categorized participants into frail versus nonfrail. Results : Out of 3,630 participants with ARDS, 701 (19.3%) were frail. Representation of frail participants increased over time ( P = 0.001), while mortality remained stable ( P = 0.403) and as high as 39.4%. A total of 60.6% of frail participants were younger than 65 years old. Frailty was independently associated with 90-day mortality (odds ratio 1.62, 95% confidence interval 1.34-1.96, P < 0.001). Frail had fewer ventilator-free days and were more likely to have subsequent disability than nonfrail participants. Conclusion: In trials of ARDS, representation of frail participants increased, while their mortality did not improve over time. The ever-increasing vulnerable group of frail participants should be taken into consideration in the design of trials.

Frailty as an independent risk factor for sepsis-associated delirium: a cohort study of 11,740 older adult ICU patients

BACKGROUND

Sepsis-associated delirium (SAD) is a common complication in intensive care unit (ICU) patients and is associated with increased mortality. Frailty, characterized by diminished physiological reserves, may influence the development of SAD, but this relationship remains poorly understood.

AIMS

To comprehensively analyze the assessment of frailty as a predictive factor for sepsis-associated delirium in older adults.

METHODS

A retrospective cohort analysis was performed on sepsis patients aged ≥ 65 years admitted to the ICU. Frailty was assessed using the Modified Frailty Index based on 11 items including comorbidities and functional status. Patients were categorized into non-frail (MFI: 0-2) and frail (MFI ≥ 3) groups. Delirium was assessed using the ICU Confusion Assessment Method (CAM-ICU) and retrospective nursing notes. Logistic regression analysis was used to examine the relationship between frailty in older patients and the risk of delirium, and odds ratios (OR) and their 95% confidence intervals (CI) were calculated.

RESULTS

Among 11,740 patients (median age approximately 76 years [interquartile range: 70.47-83.14], 44.3% female), frail patients tended to have longer ICU stays, higher severity scores, and potentially worse clinical outcomes. The study found a significant positive association between MFI and the risk of developing SAD (OR: 1.13, 95% CI: 1.09-1.17, p < 0.001). Additionally, frail patients had a higher risk of developing SAD compared to non-frail patients (OR: 1.31, 95% CI: 1.20-1.43, p < 0.001).

CONCLUSIONS

Frailty independently predicts SAD development in older adults with sepsis in the ICU, emphasizing the importance of early recognition and prevention.

Muscle Dysfunction and Physical Recovery After Critical Illness

During critical illness, patients experience significant and rapid onsets of muscle wasting and dysfunction with loss of strength, mass, and power. These deficits often persist long after the ICU, leading to impairments in physical function including reduced exercise capacity and increased frailty and disability. While there are numerous studies describing the epidemiology of impaired muscle and physical function in the ICU, there are significantly fewer data investigating mechanisms of prolonged and persistent impairments in ICU survivors. Additionally, while several potential clinical risk factors associated with poor physical recovery have been identified, there remains a dearth of interventions that have effectively improved outcomes long-term among survivors. In this article, we aim to provide a thorough, evidence-based review of the current state of knowledge regarding muscle dysfunction and physical function after critical illness with a focus on post-ICU and post-hospitalization phase of recovery.

The long-term conditional mortality rate in older ICU patients compared to the general population

BACKGROUND

Understanding how preexisting comorbidities may interact with a critical illness is important for the assessment of long-term survival probability of older patients admitted to the ICU.

MATERIAL AND METHODS

The mortality after a first ICU admission in patients ≥ 55 years old registered in the Swedish Intensive Care Registry was compared to age- and sex-matched individuals from the general population with a landmark after 1 year. The comparison was adjusted for age, sex, and baseline comorbidity using Cox regression.

RESULTS

The 7-year study period included 140 008 patients, of whom 23% were 80 years or older. Patients surviving the first year remained at an increased risk compared to the general population, but much of this difference was attenuated after adjustment for baseline comorbidity (HR, 1.03; 95% CI 1.02-1.04). Excluding cardio-thoracic ICU admissions, the increased risk remained slightly elevated (adjusted HR, 1.15; 95% CI 1.13-1.16). Also, the subgroup ≥ 75 years old surviving the first year returned to a mortality rate comparable to the general population (HR, 0.98; 95% CI 0.96-0.99). Stratified by admission diagnosis an increased mortality rate remained beyond the first year for acute-on-chronic respiratory failure (adjusted HR, 1.47; 95% CI 1.36-1.58) but not for other respiratory causes (adjusted HR, 1.03; 95% CI 0.99-1.07) or admission for septic shock (adjusted HR, 1.04; 95% CI 0.95-1.13). No substantial increased mortality rate was notable beyond the first year for other admission diagnoses.

CONCLUSION

Older ICU patients that survive the first year after an ICU admission return to a mortality rate close to that of the general population having similar baseline comorbidity, but variability is seen depending on the ICU admission diagnosis. Trial registration ClinicalTrials.gov ID: NCT06234709, date 02/01/2024.

[Ethical boundary decisions in intensive care medicine]

BACKGROUND

Ethical decision-making is a cornerstone of intensive care and emergency medicine. In acute scenarios, clinicians often face rapid, high-stakes decisions concerning life and death, made more challenging by time constraints and incomplete information. These decisions are further complicated by economic constraints, limited resources, and evolving technological capabilities.

QUESTION

What decision-making aids and factors can be employed in ethical borderline cases within intensive care medicine?

RESULTS

Fundamental ethical principles such as patient autonomy, beneficence, non-maleficence, and justice form the basis for medical treatment decisions. Evaluating the patient's will through advanced directives or proxy consensus is crucial, although advanced directives can be ambiguous. Assessing quality of life is increasingly important, with instruments such as the Clinical Frailty Scale (CFS) being utilized. For older patients, a holistic approach is recommended, focusing on overall health rather than chronological age. In patients with advanced underlying diseases, a multidisciplinary dialogue is essential.

DISCUSSION

Decision-making in intensive care medicine requires careful consideration of medical, ethical, and individual factors. Despite advances in artificial intelligence and prognostic models, human judgment remains crucial. During periods of resource scarcity, ethically sound triage protocols are required. The challenge lies in applying these principles and factors in clinical practice while respecting the individuality of each patient.

Implications of frailty before and after intensive care unit admission

PURPOSE OF REVIEW

In the decade since the first publications related to frailty in those with critical illness, the study of frailty has rapidly increased. The purpose of this review is to update the reader on recent advances across several important areas of frailty research: how best to identify frailty in those with critical illness, studies describing the relationship between frailty and delirium, and how frailty affects outcomes for those with coronavirus disease 2019 (COVID-19), which, despite rates and severity of acute infection declining, still tremendously impacts patients long after the acute infection, resulting in symptoms of long COVID-19.

RECENT FINDINGS

A number of frailty assessment tools exist, to date, the Clinical Frailty Scale based on the deficit accumulation approach to defining frailty, is the most commonly used in ICU studies. Several novel frailty instruments for the ICU are being developed. Because tools assessing frailty by the phenotypic and deficit accumulation approaches identify different populations, careful choice of a frailty assessment tool is warranted.Frailty and delirium are hypothesized to represent different clinical expressions of a similar underlying vulnerability, thus identifying frailty may be a useful means by which to identify patients at high risk of becoming delirious. Recent studies show that frailty at ICU admission is a predictor of the development of delirium.Finally, frailty and its outcomes were studied in patients with COVID-19. As with other causes of critical illness, frailty was highly prevalent in those admitted to the ICU and is associated with greater mortality. Frailty was also associated with increased decisions to limit life support treatments, but these decisions were not different among those admitted with COVID-19 or for other reasons.

SUMMARY

Frailty in those with critical illness is an emerging field of study. Future work to define the optimal means by which to identify this syndrome and how best to manage critically ill patients with frailty are needed.