The concept of frailty in intensive care

Predictive validity of the Clinical Frailty Scale-España on the increase in dependency after hospital discharge

INTRODUCTION

The frailty present at hospital admission and the stressors to which patients are subjected during their stay may increase dependency at hospital discharge.

OBJECTIVES

To assess the predictive validity of the Clinical Frailty Scale-España (CFS-Es) on increased dependency at 3 and 12 months (m) after hospital discharge.

METHODOLOGY

Multicentre cohort study in 2020-2022. Including patients with >48 h stay in intensive care units (ICU) and non-COVID-19.

VARIABLES

pre-admission frailty (CFS-Es). Sex, age, days of stay (ICU and hospital), dependency on admission and at 3 m and 12 m after discharge (Barthel index), muscle weakness (Medical Research Council Scale sum score <48), hospital readmissions.

STATISTICS

descriptive and multivariate analysis.

RESULTS

254 cases were included. Thirty-nine per cent were women and the median [Q1-Q3] age was 67 [56-77] years. SAPS 3 on admission (median [Q1-Q3]): 62 [51-71] points. Frail patients on admission (CFS-Es 5-9): 58 (23%). Dependency on admission (n = 254) vs. 3 m after hospital discharge (n = 171) vs. 12 m after hospital discharge (n = 118): 1) Barthel 90-100: 82% vs. 68% vs. 65%. 2) Barthel 60-85: 15% vs. 15% vs. 20%. 3) Barthel 0-55: 3% vs. 17% vs. 15%. In the multivariate analysis, adjusted for the variables recorded, we observed that frail patients on admission (CFS-Es 5-9) are 2.8 times (95%CI: 1.03-7.58; p = 0.043) more likely to increase dependency (Barthel 90-100 to <90 or Barthel 85-60 to <60) at 3 m post-discharge (with respect to admission) and 3.5 times (95%CI: 1.18-10.30; p = 0.024) more likely to increase dependency at 12 m post-discharge. Furthermore, for each additional CFS-Es point there is a 1.6-fold (95%CI: 1.01-2.23; p = 0.016) greater chance of increased dependency in the 12 m following discharge.

CONCLUSIONS

CFS-Es at admission can predict increased dependency at 3 m and 12 m after hospital discharge.

Cross-cultural adaptation of the FRAIL scale for critically ill patients in Spain

AIM

To translate and culturally adapt the FRAIL scale into Spanish and perform a preliminary test of diagnostic accuracy in patients admitted to intensive care units.

DESIGN

Cross-sectional diagnostic study.

METHODS

Five intensive care units (ICU) in Spain were participated. Stage 1: Three native Spanish-speaking bilingual translators familiar with the field of critical care translated the scale from English into Spanish. Stage 2: Three native English-speaking bilingual translators familiar with critical care medicine. Stage 3: Authors of the original scale compared the English original and back-translated versions of the scale. Stage 4: Five nurses with more than 5 years of ICU experience and five critical care physicians assessed the comprehension and relevance of each of the items of the Spanish version in 30 patients of 3 different age ranges (<50, 50-65 and >65 years).

RESULTS

The FRAIL scale was translated and adapted cross-culturally for patients admitted to intensive care units in Spain. The process consisted of four stages: translation, back translation, comparison and pilot test. There was good correspondence between the original scale and the Spanish version in 100% of the items. The participating patients assessed the relevance (content validity) and comprehensibility (face validity) of each of the items of the first Spanish version. The relevance of some of the items scored low when the scale was used in patients younger than 65 years.

CONCLUSIONS

We have cross-culturally adapted the FRAIL scale, originally in English, to Spanish for its use in the critical care medical setting in Spanish-speaking countries.

IMPLICATIONS FOR PROFESSIONALS

Physicians and nurses can apply the new scale to all patients admitted to the intensive care units. Nursing care can be adapted according to frailty, trying to reduce the side effects of admission to these units for the most fragile patients.

REPORTING METHOD

The manuscript's authors have adhered to the EQUATOR guidelines, using the COSMIN reporting guideline for studies on the measurement properties of patient-reported outcome measures.

PATIENT OR PUBLIC CONTRIBUTION

In a pilot clinical study, we applied the first version of the FRAIL-Spain scale to intensive care unit (ICU) patients. Five nurses with more than 5 years of ICU experience and five critical care physicians assessed the relevance (content validity) and comprehensibility (face validity) of the five items of the first Spanish version. Relevance was assessed using a 4-point Likert scale ranging from 1 (no relevance) to 4 (high relevance), and comprehensibility was assessed as poor, acceptable or good. Each health professional applied the scale to three patients (total number of patients = 30) of three different age ranges (<50, 50-65 and >65 years) and recorded the time of application of the scale to each patient. Although the frailty scales were initially created by geriatricians to be applied to the elders, there is little experience with their application in critically ill patients of any age. Therefore, more information is needed to determine the relevance of using this scale in critical care patients. In this pilot study, we considered that nurses and critical care physicians should evaluate frailty using this adapted scale in adult patients admitted to the Intensive Care Units.

What is meant by "frailty" in undergraduate medical education? A national survey of UK medical schools

PURPOSE

All UK medical schools are required to include frailty in their curriculum. The term is open to interpretation and associated with negative perceptions. Understanding and recognising frailty is a prerequisite for consideration of frailty in the treatment decision-making process across clinical specialities. The aim of this survey was to describe how frailty has been interpreted and approached in UK undergraduate medical education and provide examples of educational strategies employed.

METHODS

All UK medical schools were invited to complete an electronic survey. Schools described educational strategies used to teach and assess frailty and provided frailty-related learning outcomes. Learning Outcomes were grouped into categories and mapped to the domains of Outcomes for Graduates (knowledge, skills and values).

RESULTS

25/34 Medical schools (74%) participated. The interpretation of what frailty is vary widely and the diversity of teaching strategies reflect this. The most common Learning outcomes included as "Frailty" are about the concept of frailty, Comprehensive Geriatric Assessments and Roles of the MDT. Frailty teaching is predominantly opportunistic and occurred within geriatric medicine rotations in all medical schools. Assessments focus on frailty syndromes such as falls and delirium.

CONCLUSION

There is variation regarding how frailty has been interpreted and approached by medical schools. Frailty is represented in an array of teaching and assessment methods, with a lack of constructive alignment to related learning outcomes. Consensus should be agreed as to what frailty means in medical education. Further research is required to explore which frailty-specific educational strategies in undergraduate medical education enhance learning.

Risk Factors for Frailty in Critical Care Survivors: A secondary analysis

OBJECTIVES

The purpose of this study was to investigate the prevalence of frailty and its risk factors among critical care survivors who were discharged after receiving treatment in an intensive care unit.

METHODS

This was a secondary analysis using data from a methodological study conducted between June and August 2018. The sample included 494 adults who had been admitted to the intensive care unit for more than 48 hours within a year. Only post-intensive care frailty was evaluated using the Kihon Checklist. The sociodemographic and intensive care-related risk factors for frailty were analysed using multivariate logistic regression.

RESULTS

The prevalence of frailty in the sample was 65.8%. The risk factors for frailty were female sex (adjusted odds ratio [aOR] = 1.68, 95% CI: 1.02-2.78), aged 70 years or older (aOR = 4.16, 95% CI: 2.00-8.65), unemployment (aOR = 2.41, 95% CI: 1.39-4.17) and longer ICU days (aOR = 2.29, 95% CI: 1.35-3.91). Analysis of differences in risk factors according to sex revealed that risk factors for frailty were unemployment and longer ICU length of stay for male and older age for female.

CONCLUSION

Health care providers should be aware of frailty risk factors in female and male patients and provide patient-specific interventions for preventing frailty.

Frailty, delirium and hospital mortality of older adults admitted to intensive care: the Delirium (Deli) in ICU study

BACKGROUND

Clinical frailty among older adults admitted to intensive care has been proposed as an important determinant of patient outcomes. Among this group of patients, an acute episode of delirium is also common, but its relationship to frailty and increased risk of mortality has not been extensively explored. Therefore, the aim of this study was to explore the relationship between clinical frailty, delirium and hospital mortality of older adults admitted to intensive care.

METHODS

This study is part of a Delirium in Intensive Care (Deli) Study. During the initial 6-month baseline period, clinical frailty status on admission to intensive care, among adults aged 50 years or more; acute episodes of delirium; and the outcomes of intensive care and hospital stay were explored.

RESULTS

During the 6-month baseline period, 997 patients, aged 50 years or more, were included in this study. The average age was 71 years (IQR, 63-79); 55% were male (n = 537). Among these patients, 39.2% (95% CI 36.1-42.3%, n = 396) had a Clinical Frailty Score (CFS) of 5 or more, and 13.0% (n = 127) had at least one acute episode of delirium. Frail patients were at greater risk of an episode of delirium (17% versus 10%, adjusted rate ratio (_adjRR) = 1.71, 95% confidence interval (CI) 1.20-2.43, p = 0.003), had a longer hospital stay (2.6 days, 95% CI 1-7 days, p = 0.009) and had a higher risk of hospital mortality (19% versus 7%, _adjRR = 2.54, 95% CI 1.72-3.75, p < 0.001), when compared to non-frail patients. Patients who were frail and experienced an acute episode of delirium in the intensive care had a 35% rate of hospital mortality versus 10% among non-frail patients who also experienced delirium in the ICU.

CONCLUSION

Frailty and delirium significantly increase the risk of hospital mortality. Therefore, it is important to identify patients who are frail and institute measures to reduce the risk of adverse events in the ICU such as delirium and, importantly, to discuss these issues in an open and empathetic way with the patient and their families.

Preoperative Risk Assessment: A Poor Predictor of Outcome in Critically ill Elderly with Sepsis After Abdominal Surgery

Background

Postoperative outcome prediction in elderly is based on preoperative physical status but its predictive value is uncertain. The goal was to evaluate the value of risk assessment performed perioperatively in predicting outcome in case of admission to an intensive care unit (ICU).

Methods

A total of 108 postsurgical patients were retrospectively selected from a prospectively recorded database of 144 elderly septic patients (>70 years) admitted to the ICU department after elective or emergency abdominal surgery between 2012 and 2017. Perioperative risk assessment scores including Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality (P-POSSUM) and American Society of Anaesthesiologists Physical Status classification (ASA) were determined. Acute Physiology and Chronic Health Evaluation IV (APACHE IV) was obtained at ICU admission.

Results

In-hospital mortality was 48.9% in elderly requiring ICU admission after elective surgery (n = 45), compared to 49.2% after emergency surgery (n = 63). APACHE IV significantly predicted in-hospital mortality after complicated elective surgery [area under the curve 0.935 (p < 0.001)] where outpatient ASA physical status and P-POSSUM did not. In contrast, P-POSSUM and APACHE IV significantly predicted in-hospital mortality when based on current physical state in elderly requiring emergency surgery (AUC 0.769 (p = 0.002) and 0.736 (p = 0.006), respectively).

Conclusions

Perioperative risk assessment reflecting premorbid physical status of elderly loses its value when complications occur requiring unplanned ICU admission. Risks in elderly should be re-assessed based on current clinical condition prior to ICU admission, because outcome prediction is more reliable then.

The impact of frailty in critically ill patients after trauma: A prospective observational study

BACKGROUND

As our population ages, older adults are increasingly exposed to trauma. Frailty could be a useful measure to identify patients at risk of a poor outcome. This study aimed to determine the impact of frailty in an Australian trauma intensive care unit (ICU) population.

METHODS

A prospective observational study of critically ill trauma patients ≥50 years of age. Frailty was determined on admission to the ICU using the frailty phenotype. Demographic and hospital data were collected, and patients were followed up at 6 and 12 months. The primary outcome was 12-month mortality, and multiple regression was used to determine associated factors.

RESULTS

One hundred thirty-eight patients were included, whose mean age was 68 years; 78.2% (108/138) were classified as major trauma (Injury Severity Score >12). Twenty-two percent (30/138) of patients were identified as frail. Patients with frailty were significantly older: however, they were less severely injured and required lower rates of surgical interventions and mechanical ventilation. Frailty was independently associated with mortality at 6 and 12 months (odds ratio: 5.9, 95% confidence interval: 1.9-18.1 and odds ratio: 7.3, 95% confidence interval: 2.5-21.9, respectively). Patients with frailty had lower measures of global functioning (Glasgow Outcome Scale-Extended frail 3 [1-5] vs nonfrail 6 [(5-7], p = 0.002) and health status (Euro Qol 5Q-5D-5L utility score 0.6 [0.5-0.7] vs 0.7 [0.6-0.9], p = 0.02) at 12 months than patients without frailty.

CONCLUSION

Frailty is a useful predictor of poor outcomes in critically ill trauma patients.

REGISTRATION OF PROTOCOL NUMBER

ACTRN12615000039583.

Changes in frailty among ICU survivors and associated factors: Results of a one-year prospective cohort study using the Dutch Clinical Frailty Scale

PURPOSE

Frailty is an important predictor for the prognosis of intensive care unit (ICU) patients. This study examined changes in frailty in the year after ICU admission, and its associated factors.

MATERIALS AND METHODS

Prospective cohort study including adult ICU patients admitted between July 2016-December 2017. Frailty was measured using the Clinical Frailty Scale (CFS), before ICU admission, at hospital discharge, and three and 12 months after ICU admission. Multivariable linear regression was used to explore factors associated with frailty changes.

RESULTS

Frailty levels changed among 1300 ICU survivors, with higher levels at hospital discharge and lower levels in the following months. After one year were 42% of the unplanned, and 27% of the planned patients more frail. For both groups were older age, longer hospital length of stay, and discharge location associated with being more frail. Male sex, higher education level and mechanical ventilation were associated with being less frail in the planned patients.

CONCLUSION

One year after ICU admission, 42% and 27% of the unplanned and planned ICU patients, respectively, were more frail. Insight in the associated factors will help to identify patients at risk, and may help in informing patients and their family members.

REGISTRATION

ClinicalTrials.gov database (NCT03246334).

Clinical Frailty Scale (CFS) reliably stratifies octogenarians in German ICUs: a multicentre prospective cohort study

BACKGROUND

In intensive care units (ICU) octogenarians become a routine patients group with aggravated therapeutic and diagnostic decision-making. Due to increased mortality and a reduced quality of life in this high-risk population, medical decision-making a fortiori requires an optimum of risk stratification. Recently, the VIP-1 trial prospectively observed that the clinical frailty scale (CFS) performed well in ICU patients in overall-survival and short-term outcome prediction. However, it is known that healthcare systems differ in the 21 countries contributing to the VIP-1 trial. Hence, our main focus was to investigate whether the CFS is usable for risk stratification in octogenarians admitted to diversified and high tech German ICUs.

METHODS

This multicentre prospective cohort study analyses very old patients admitted to 20 German ICUs as a sub-analysis of the VIP-1 trial. Three hundred and eight patients of 80 years of age or older admitted consecutively to participating ICUs. CFS, cause of admission, APACHE II, SAPS II and SOFA scores, use of ICU resources and ICU- and 30-day mortality were recorded. Multivariate logistic regression analysis was used to identify factors associated with 30-day mortality.

RESULTS

Patients had a median age of 84 [IQR 82-87] years and a mean CFS of 4.75 (± 1.6 standard-deviation) points. More than half of the patients (53.6%) were classified as frail (CFS ≥ 5). ICU-mortality was 17.3% and 30-day mortality was 31.2%. The cause of admission (planned vs. unplanned), (OR 5.74) and the CFS (OR 1.44 per point increase) were independent predictors of 30-day survival.

CONCLUSIONS

The CFS is an easy determinable valuable tool for prediction of 30-day ICU survival in octogenarians, thus, it may facilitate decision-making for intensive care givers in Germany.

TRIAL REGISTRATION

The VIP-1 study was retrospectively registered on ClinicalTrials.gov (ID: NCT03134807 ) on May 1, 2017.