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Elias MN, Ahrens EA, Schumacher FA, Liang Z, Munro CL. Associations Between Inactivity and Cognitive Function in Older Intensive Care Unit Survivors. Dimens Crit Care Nurs 2024; 43:13-20. [PMID: 38059708 PMCID: PMC11108648 DOI: 10.1097/dcc.0000000000000613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND/INTRODUCTION Critically ill older adults are profoundly inactive while in the intensive care unit (ICU), and this inactivity persists after discharge from the ICU. Older ICU survivors who were mechanically ventilated are at high risk for post-ICU cognitive impairment. OBJECTIVES/AIMS The present study examined the relationship between the ratio of daytime to nighttime activity and executive function in older ICU survivors. METHODS This was a secondary analysis of pooled data from 2 primary studies of older adults who were functionally independent prior to hospitalization, mechanically ventilated while in ICU, and within 24 to 48 hours post-ICU discharge. Actigraphy recorded daytime activity (mean activity counts per minute, 6 am to 9:59 pm) and nighttime activity (mean activity counts per minute, 10 pm to 5:59 am). A daytime-to-nighttime activity ratio was calculated by dividing daytime activity by nighttime activity. The NIH Toolbox Dimensional Change Card Sort Test assessed cognitive flexibility (DCCST: fully corrected T score). Multivariate regression examined the association between the daytime-to-nighttime activity ratio and DCCST scores, adjusting for 2 covariates (age in years and NIH Toolbox Grip Strength fully corrected T score). RESULTS The mean daytime-to-nighttime activity ratio was 2.10 ± 1.17 (interquartile range, 1.42). Ratios for 6 participants (13.6%) were less than 1, revealing higher activity during nighttime hours rather than daytime hours. Higher daytime-to-nighttime ratios were associated with better DCCST scores (β = .364, P = .005). CONCLUSIONS The proportion of daytime activity versus nighttime activity was considerably low, indicating severe alterations in the rest/activity cycle. Higher daytime-to-nighttime activity ratios were associated with better executive function scores, suggesting that assessment of daytime activity could identify at-risk older ICU survivors during the early post-ICU transition period. Promotion of daytime activity and nighttime sleep may accelerate recovery and improve cognitive function.
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Nagatomi A, Wakatake H, Masui Y, Fujitani S. Prognostic factors in mobility disability among elderly patients in the emergency department: A single-center retrospective study. Acute Med Surg 2024; 11:e951. [PMID: 38638890 PMCID: PMC11024440 DOI: 10.1002/ams2.951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
Aim We aimed to evaluate the clinical characteristics and outcomes of elderly critically ill patients and identify prognostic factors for mobility disability at discharge. Methods This single-center, retrospective cohort study investigated the period from April 2020 to January 2021. Patients ≥75 years old transferred to our emergency department and admitted to the intensive care unit (ICU) or intermediate unit in our hospital were eligible. Demographics, clinical characteristics, nutritional indicators, and nutritional screening scores were collected from chart reviews and analyzed. The primary outcome was the prevalence of mobility disability, compared to that of no mobility disability. Results A total of 124 patients were included in this present study. Median age was 83.0 years (interquartile range [IQR], 79.8-87.0 years) and 48 patients (38.7%) were female. Fifty-two patients (41.9%) could not walk independently at discharge (mobility disability group). The remaining 72 patients were in the no mobility disability group. Multiple logistic regression analyses revealed clinical frailty scale (CFS) score ≥5 (odds ratio [OR] = 6.63, 95% confidence interval [CI] = 2.51-17.52, p < 0.001), SOFA score ≥6 (OR = 6.11, 95% CI = 1.57-23.77, p = 0.009), and neurological disorder as the main cause on admission (OR = 4.48, 95% CI = 1.52-13.20, p = 0.006) were independent and significant prognostic factors for mobility disability at discharge. Conclusion Among elderly patients admitted to the emergency department, CFS ≥5, SOFA ≥6, and neurological disorders were associated with mobility disability at hospital discharge.
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Affiliation(s)
- Akiyoshi Nagatomi
- Department of Emergency and Critical Care MedicineSt. Marianna University Yokohama City Seibu HospitalYokohamaJapan
- Department of Emergency and Critical Care MedicineSt. Marianna University, School of MedicineKawasakiJapan
| | - Haruaki Wakatake
- Department of Emergency and Critical Care MedicineSt. Marianna University Yokohama City Seibu HospitalYokohamaJapan
| | - Yoshihiro Masui
- Department of Emergency and Critical Care MedicineSt. Marianna University Yokohama City Seibu HospitalYokohamaJapan
| | - Shigeki Fujitani
- Department of Emergency and Critical Care MedicineSt. Marianna University, School of MedicineKawasakiJapan
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3
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Anderson MR, Cantu E, Shashaty M, Benvenuto L, Kalman L, Palmer SM, Singer JP, Gallop R, Diamond JM, Hsu J, Localio AR, Christie JD. Body Mass Index and Cause-Specific Mortality after Lung Transplantation in the United States. Ann Am Thorac Soc 2023; 20:825-833. [PMID: 36996331 PMCID: PMC10257034 DOI: 10.1513/annalsats.202207-613oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 03/29/2023] [Indexed: 04/01/2023] Open
Abstract
Rationale: Low and high body mass index (BMI) are associated with increased mortality after lung transplantation. Why extremes of BMI might increase risk of death is unknown. Objectives: To estimate the association of extremes of BMI with causes of death after transplantation. Methods: We performed a retrospective study of the United Network for Organ Sharing database, including 26,721 adults who underwent lung transplantation in the United States between May 4, 2005, and December 2, 2020. We mapped 76 reported causes of death into 16 distinct groups. We estimated cause-specific hazards for death from each cause using Cox models. Results: Relative to a subject with a BMI of 24 kg/m2, a subject with a BMI of 16 kg/m2 had 38% (hazard ratio [HR], 1.38; 95% confidence interval [95% CI], 0.99-1.90), 82% (HR, 1.82; 95% CI, 1.34-2.46), and 62% (HR, 1.62; 95% CI, 1.18-2.22) increased hazards of death from acute respiratory failure, chronic lung allograft dysfunction (CLAD), and infection, respectively, and a subject with a BMI of 36 kg/m2 had 44% (HR, 1.44; 95% CI, 0.97-2.12), 42% (HR, 1.42; 95% CI, 0.93-2.15), and 185% (HR, 2.85; 95% CI, 1.28-6.33) increased hazards of death from acute respiratory failure, CLAD, and primary graft dysfunction, respectively. Conclusions: Low BMI is associated with increased risk of death from infection, acute respiratory failure, and CLAD after lung transplantation, whereas high BMI is associated with increased risk of death from primary graft dysfunction, acute respiratory failure, and CLAD.
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Affiliation(s)
| | | | - Michael Shashaty
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Columbia University, New York, New York
| | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Scott M. Palmer
- Division of Pulmonary Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Jonathan P. Singer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California; and
| | - Robert Gallop
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Joshua M. Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Jesse Hsu
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - A. Russell Localio
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
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Lonsdale DO, Tong L, Farrah H, Farnell-Ward S, Ryan C, Watson X, Cecconi M, Flaatten H, Fjølner J, Jung C, Guidet B, de Lange D, Szczeklik W, Muessig JM, Leaver SK. The clinical frailty scale - does it predict outcome of the very-old in UK ICUs? J Intensive Care Soc 2023; 24:154-161. [PMID: 37260427 PMCID: PMC10227901 DOI: 10.1177/17511437211050789] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
Introduction The age of patients admitted into critical care in the UK is increasing. Clinical decisions for very-old patients, usually defined as over 80, can be challenging. Clinicians are frequently asked to predict outcomes as part of discussions around the pros and cons of an intensive care unit (ICU) admission. Measures of overall health in old age, such as the clinical frailty scale (CFS), are increasingly used to help guide these discussions. We aimed to understand the characteristics of the very-old critically unwell population in the UK and the associations between frailty and outcome of an ICU admission in our healthcare system (National Health Service, NHS). Methods Baseline characteristics, ICU interventions and outcomes (ICU- and 30-day mortality) were recorded for sequential admissions of very old patients to UK ICUs as part of the European VIP 1 and 2 studies. Patient characteristics, interventions and outcome measures were compared by frailty group using standard statistical tests. Multivariable logistic regression modelling was undertaken to test association between baseline characteristics, admission type and outcome. Results 1858 participants were enrolled from 95 ICUs in the UK. The median age was 83. The median CFS was 4 (IQR 3-5). 30-day survival was significantly lower in the frail group (CFS > 4, 58%) compared to vulnerable (CFS = 4, 65%) and fit (CFS < 4 68%, p = .004). Sequential organ failure assessment (SOFA) score, reason for admission and CFS were all independently associated with increased 30-day mortality (p < .01). Conclusion In the UK, frailty is associated with an increase in mortality at 30-days following an ICU admission. At moderate frailty (CFS 5-6), three out of every five patients admitted survived to 30-days. This is a similar mortality to septic shock.
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Affiliation(s)
- Dagan O Lonsdale
- Department of Clinical
Pharmacology, St George’s, University of
London, London, UK
- Department of Critical Care, St George’s University Hospitals NHS
Foundation Trust, London, UK
| | - Liting Tong
- Department of Clinical
Pharmacology, St George’s, University of
London, London, UK
| | - Helen Farrah
- Department of Clinical
Pharmacology, St George’s, University of
London, London, UK
| | - Sarah Farnell-Ward
- Department of Clinical
Pharmacology, St George’s, University of
London, London, UK
| | - Chris Ryan
- Department of Clinical
Pharmacology, St George’s, University of
London, London, UK
| | - Ximena Watson
- Department of Clinical
Pharmacology, St George’s, University of
London, London, UK
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Anesthesia and Intensive Care, IRCCS Humanitas Research
Hospital, Milan, Italy
| | - Hans Flaatten
- Department of Anaesthesia and
Intensive Care, Dep of Clinical Medicine, Haukeland University
Hospital, University of Bergen, Bergen, Norway
| | - Jesper Fjølner
- Department of Intensive Care, Aarhus University
Hospital, Aarhus, Denmark
| | - Christian Jung
- Division of Cardiology, Pulmonology
and Vascular Medicine, University Hospital
Düsseldorf, Düsseldorf, Germany
| | - Bertrand Guidet
- INSERM, Institut Pierre Louis
D’Epidémiologie Et de Santé Publique, Sorbonne Université, Paris, France
| | - Dylan de Lange
- Department of Intensive Care
Medicine, Dutch Poisons Information Center (DPIC), University Medical Center, University Utrecht, Utrecht, the Netherlands
| | - Wojciech Szczeklik
- Center for Intensive Care and
Perioperative Medicine, Jagiellonian University Medical
College, Krakow, Poland
| | - Johanna M Muessig
- Division of Cardiology, Pulmonology
and Vascular Medicine, University Hospital
Düsseldorf, Düsseldorf, Germany
| | - Susannah K Leaver
- Department of Clinical
Pharmacology, St George’s, University of
London, London, UK
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Ferrante LE, Murphy TE, Leo-Summers LS, O’Leary JR, Vander Wyk B, Pisani MA, Gill TM. Development and validation of a prediction model for persistent functional impairment among older ICU survivors. J Am Geriatr Soc 2023; 71:188-197. [PMID: 36196998 PMCID: PMC9870848 DOI: 10.1111/jgs.18075] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/31/2022] [Accepted: 09/10/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Critical illness often leads to persistent functional impairment among older Intensive Care Unit (ICU) survivors. Identification of high-risk survivors prior to discharge from their ICU hospitalization can facilitate targeting for restorative interventions after discharge, potentially improving the likelihood of functional recovery. Our objective was to develop and validate a prediction model for persistent functional impairment among older adults in the year after an ICU hospitalization. METHODS The analytic sample included community-living participants enrolled in the National Health and Aging Trends Study 2011 cohort who survived an ICU hospitalization through December 2017 and had a follow-up interview within 1 year. Persistent functional impairment was defined as failure to recover to the pre-ICU level of function within 12 months of discharge from an ICU hospitalization. We used Bayesian model averaging to identify the final predictors from a comprehensive set of 17 factors. Discrimination and calibration were assessed using area-under-the-curve (AUC) and calibration plots. RESULTS The development cohort included 456 ICU admissions (2,654,685 survey-weighted admissions) and the validation cohort included 227 ICU admissions (1,350,082 survey-weighted admissions). In the development cohort, the median age was 81.0 years (interquartile range [IQR] 76.0, 86.0) and 231 (50.7%) participants were women; demographic characteristics were comparable in the validation cohort. The rates of persistent functional impairment were 49.3% (development) and 50.2% (validation). The final model included age, pre-ICU disability, probable dementia, frailty, prior hospitalizations, vision impairment, depressive symptoms, and hospital length of stay. The model demonstrated good discrimination (AUC 71%, 95% confidence interval [CI] 0.66-0.76) and good calibration. When applied to the validation cohort, the model demonstrated comparable discrimination (AUC 72%, 95% CI 0.66-0.78) and good calibration. CONCLUSIONS Application of the model prior to discharge from an ICU hospitalization may identify older adults at the highest risk of persistent functional impairment in the subsequent year, thereby facilitating targeted interventions and follow-up.
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Affiliation(s)
- Lauren E. Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Terrence E. Murphy
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Linda S. Leo-Summers
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - John R. O’Leary
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Brent Vander Wyk
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Margaret A. Pisani
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Thomas M. Gill
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
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Doody P, Asamane EA, Aunger JA, Swales B, Lord JM, Greig CA, Whittaker AC. The prevalence of frailty and pre-frailty among geriatric hospital inpatients and its association with economic prosperity and healthcare expenditure: A systematic review and meta-analysis of 467,779 geriatric hospital inpatients. Ageing Res Rev 2022; 80:101666. [PMID: 35697143 DOI: 10.1016/j.arr.2022.101666] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 04/27/2022] [Accepted: 06/06/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Frailty is a common and clinically significant condition among geriatric populations. Although well-evidenced pooled estimates of the prevalence of frailty exist within various settings and populations, presently there are none assessing the overall prevalence of frailty among geriatric hospital inpatients. The purpose of this review was to systematically search and analyse the prevalence of frailty among geriatric hospital inpatients within the literature and examine its associations with national economic indicators. METHODS Systematic searches were conducted on Ovid, Web of Science, Scopus, CINAHL Plus, and the Cochrane Library, encompassing all literature published prior to 22 November 2018, supplemented with manual reference searches. Included studies utilised a validated operational definition of frailty, reported the prevalence of frailty, had a minimum age ≥ 65 years, attempted to assess the whole ward/clinical population, and occurred among hospital inpatients. Two reviewers independently extracted data and assessed study quality. RESULTS Ninety-six studies with a pooled sample of 467,779 geriatric hospital inpatients were included. The median critical appraisal score was 8/9 (range 7-9). The pooled prevalence of frailty, and pre-frailty, among geriatric hospital inpatients was 47.4% (95% CI 43.7-51.1%), and 25.8% (95% CI 22.0-29.6%), respectively. Significant differences were observed in the prevalence of frailty stratified by age, prevalent morbidity, ward type, clinical population, and operational definition. No significant differences were observed in stratified analyses by sex or continent, or significant associations between the prevalence of frailty and economic indicators. CONCLUSIONS Frailty is highly prevalent among geriatric hospital inpatients. High heterogeneity exists within this setting based on various clinical and demographic characteristics. Pooled estimates reported in this review place the prevalence of frailty among geriatric hospital inpatients between that reported for community-dwelling older adults and older adults in nursing homes, outlining an increase in the relative prevalence of frailty with progression through the healthcare system.
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Affiliation(s)
- Paul Doody
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, United Kingdom; The Irish Longitudinal Study on Ageing, School of Medicine, Trinity College Dublin, Dublin 2, Ireland; Mercer's Institute for Successful Ageing, St. James Hospital, Dublin 8, Ireland.
| | - Evans A Asamane
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, United Kingdom; Institute of Applied Health Research, University of Birmingham, United Kingdom
| | - Justin A Aunger
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, United Kingdom; School of Health Sciences, University of Surrey, United Kingdom
| | - Bridgitte Swales
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, United Kingdom; Faculty of Health Sciences and Sport, University of Stirling, United Kingdom
| | - Janet M Lord
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, University of Birmingham, United Kingdom; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, United Kingdom
| | - Carolyn A Greig
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, United Kingdom; MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, University of Birmingham, United Kingdom; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, United Kingdom
| | - Anna C Whittaker
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, United Kingdom; Faculty of Health Sciences and Sport, University of Stirling, United Kingdom
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Muscedere J, Bagshaw SM, Boyd G, Sibley S, Patrick N, Day A, Hunt M, Rolfson D. The frailty, outcomes, recovery and care steps of critically ill patients (FORECAST) study: pilot study results. Intensive Care Med Exp 2022; 10:23. [PMID: 35680740 PMCID: PMC9184687 DOI: 10.1186/s40635-022-00446-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/09/2022] [Indexed: 01/06/2023] Open
Abstract
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.
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Affiliation(s)
- John Muscedere
- grid.410356.50000 0004 1936 8331Department of Critical Care Medicine, Queens University, Kingston Health Sciences Center, 76 Stuart Street, Kingston, ON K7L 2V7 Canada
| | - Sean M. Bagshaw
- grid.17089.370000 0001 2190 316XDepartment of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Gordon Boyd
- grid.410356.50000 0004 1936 8331Department of Critical Care Medicine, Queens University, Kingston Health Sciences Center, 76 Stuart Street, Kingston, ON K7L 2V7 Canada
| | - Stephanie Sibley
- grid.410356.50000 0004 1936 8331Department of Critical Care Medicine, Queens University, Kingston Health Sciences Center, 76 Stuart Street, Kingston, ON K7L 2V7 Canada
| | | | - Andrew Day
- Kingston Health Sciences Center, Kingston, ON Canada
| | - Miranda Hunt
- grid.410356.50000 0004 1936 8331Department of Critical Care Medicine, Queens University, Kingston Health Sciences Center, 76 Stuart Street, Kingston, ON K7L 2V7 Canada
| | - Darryl Rolfson
- grid.17089.370000 0001 2190 316XUniversity of Alberta, Edmonton, Canada
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Balke M, Teschler M, Schäfer H, Pape P, Mooren FC, Schmitz B. Therapeutic Potential of Electromyostimulation (EMS) in Critically Ill Patients—A Systematic Review. Front Physiol 2022; 13:865437. [PMID: 35615672 PMCID: PMC9124773 DOI: 10.3389/fphys.2022.865437] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/01/2022] [Indexed: 12/15/2022] Open
Abstract
Ample evidence exists that intensive care unit (ICU) treatment and invasive ventilation induce a transient or permanent decline in muscle mass and function. The functional deficit is often called ICU-acquired weakness with critical illness polyneuropathy (CIP) and/or myopathy (CIM) being the major underlying causes. Histopathological studies in ICU patients indicate loss of myosin filaments, muscle fiber necrosis, atrophy of both muscle fiber types as well as axonal degeneration. Besides medical prevention of risk factors such as sepsis, hyperglycemia and pneumonia, treatment is limited to early passive and active mobilization and one third of CIP/CIM patients discharged from ICU never regain their pre-hospitalization constitution. Electromyostimulation [EMS, also termed neuromuscular electrical stimulation (NMES)] is known to improve strength and function of healthy and already atrophied muscle, and may increase muscle blood flow and induce angiogenesis as well as beneficial systemic vascular adaptations. This systematic review aimed to investigate evidence from randomized controlled trails (RCTs) on the efficacy of EMS to improve the condition of critically ill patients treated on ICU. A systematic search of the literature was conducted using PubMed (Medline), CENTRAL (including Embase and CINAHL), and Google Scholar. Out of 1,917 identified records, 26 articles (1,312 patients) fulfilled the eligibility criteria of investigating at least one functional measure including muscle function, functional independence, or weaning outcomes using a RCT design in critically ill ICU patients. A qualitative approach was used, and results were structured by 1) stimulated muscles/muscle area (quadriceps muscle only; two to four leg muscle groups; legs and arms; chest and abdomen) and 2) treatment duration (≤10 days, >10 days). Stimulation parameters (impulse frequency, pulse width, intensity, duty cycle) were also collected and the net EMS treatment time was calculated. A high grade of heterogeneity between studies was detected with major cofactors being the analyzed patient group and selected outcome variable. The overall efficacy of EMS was inconclusive and neither treatment duration, stimulation site or net EMS treatment time had clear effects on study outcomes. Based on our findings, we provide practical recommendations and suggestions for future studies investigating the therapeutic efficacy of EMS in critically ill patients. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021262287].
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Affiliation(s)
- Maryam Balke
- St. Marien Hospital Cologne, Department of Early Rehabilitation, Cologne, Germany
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- *Correspondence: Maryam Balke,
| | - Marc Teschler
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- DRV Clinic Königsfeld, Center for Medical Rehabilitation, Ennepetal, Germany
| | - Hendrik Schäfer
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- DRV Clinic Königsfeld, Center for Medical Rehabilitation, Ennepetal, Germany
| | - Pantea Pape
- St. Marien Hospital Cologne, Department of Early Rehabilitation, Cologne, Germany
| | - Frank C. Mooren
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- DRV Clinic Königsfeld, Center for Medical Rehabilitation, Ennepetal, Germany
| | - Boris Schmitz
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- DRV Clinic Königsfeld, Center for Medical Rehabilitation, Ennepetal, Germany
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9
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Ruiz de Gopegui Miguelena P, Martínez Lamazares MT, Claraco Vega LM, Gurpegui Puente M, González Almárcegui I, Gutiérrez Ibañes P, Carrillo López A, Castiella García CM, Miguelena Hycka J. Evaluating frailty may complement APACHE II in estimating mortality in elderly patients admitted to the ICU after digestive surgery. Med Intensiva 2022; 46:239-247. [PMID: 35248506 DOI: 10.1016/j.medine.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To analyze whether frailty can improve the prediction of mortality in patients admitted to the ICU after digestive surgery. DESIGN Prospective, observational, 6-month follow-up study of a cohort of patients admitted to the ICU between June 1, 2018, and June 1, 2019. SETTING Surgical ICU of a third level hospital. PATIENTS Series of successive patients older than 70 years who were admitted to the ICU immediately after a surgical intervention on the digestive system. 92 patients were included and 2 were excluded due to loss of follow-up at 6 months. INTERVENTIONS Upon admission to the ICU, severity and prognosis were assessed by APACHE II, and fragility by the Clinical Frailty Scale and the modified Frailty Index. MAIN VARIABLES OF INTEREST ICU, in-hospital and 6-month mortality. RESULTS The model that best predicts mortality in the ICU is the APACHE II, with an area under the ROC curve (AUC) of 0.89 and a good calibration. The model that combines APACHE II and Clinical Frailty Scale is the one that best predicts in-hospital mortality (AUC: 0.82), significantly improving the prediction of isolated APACHE II (AUC: 0.78; Integrated Discrimination Index: 0.04). Frailty is a predictor of mortality at 6 months, being the model that combines Clinical Frailty Scale and Frailty Index the one that has shown the greatest discrimination (AUC: 0.84). CONCLUSIONS Frailty can complement APACHE II by improving its prediction of hospital mortality. Furthermore, it offers a good prediction of mortality 6 months after surgery. For mortality in ICU, frailty loses its predictive power, whereas isolated APACHE II shows excellent predictive capacity.
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Affiliation(s)
| | | | - L M Claraco Vega
- Servicio de Medicina Intensiva, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - M Gurpegui Puente
- Servicio de Medicina Intensiva, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - I González Almárcegui
- Servicio de Medicina Intensiva, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - P Gutiérrez Ibañes
- Servicio de Medicina Intensiva, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - A Carrillo López
- Servicio de Medicina Intensiva, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - J Miguelena Hycka
- Servicio de Cirugía Cardiaca, Hospital Universitario Ramón y Cajal, Madrid, Spain
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10
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11
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Hirose B, Ikeda K, Yamamoto D, Tsuda E, Yamauchi R, Hozuki T, Masuda Y, Imai T. Measurement of excitation-contraction coupling time in critical illness myopathy. Clin Neurophysiol 2021; 135:30-36. [PMID: 35026538 DOI: 10.1016/j.clinph.2021.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This study aimed to develop a simple and reliable technique to assess excitation-contraction (E-C) coupling for early diagnosis of critical illness myopathy (CIM). METHODS We prospectively performed clinical and electrophysiological examinations on patients admitted to intensive care unit (ICU). In addition to full neurological examinations and routine nerve conduction study, motor related potential (MRP) was recorded using an accelerometer attached to the base of hallux after tibial nerve stimulation, and E-C coupling time (ECCT) was measured from the latency difference between soleus compound muscle action potential (CMAP) and MRP. RESULTS Of 41 patients evaluated, 25 met the criteria for ICU-acquired weakness, 23 of whom had CIM. The time to the first electrophysiological examination (time to first test) correlated negatively with CMAP and with MRP. Conversely, a positive correlation was observed between the time to first test and ECCT. E-C coupling impairment occurred in most of our patients with CIM by the third day of ICU admission, and prolonged ECCT could be the earliest detectable abnormality. CONCLUSIONS The ECCT measurement is an easy and reliable technique to detect reduced muscle membrane excitability in the early stage of CIM. SIGNIFICANCE The ECCT measured by our method using an accelerometer may be a parameter that predicts the development of CIM.
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Affiliation(s)
- Bungo Hirose
- Department of Neurology, Sapporo Medical University School of Medicine, Sapporo, Japan; Department of Neurology, Sunagawa City Medical Center, Sunagawa, Japan
| | - Kazuna Ikeda
- Department of Neurology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Daisuke Yamamoto
- Department of Neurology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Emiko Tsuda
- Department of Neurology, National Hospital Organization Hakone Hospital, Odawara, Japan
| | - Rika Yamauchi
- Department of Neurology, Sunagawa City Medical Center, Sunagawa, Japan
| | - Takayoshi Hozuki
- Department of Neurology, Sapporo Shirakabadai Hospital, Sapporo, Japan
| | - Yoshiki Masuda
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tomihiro Imai
- Department of Neurology, National Hospital Organization Hakone Hospital, Odawara, Japan.
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12
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Fan Y, Zhang Y, Li J, Liu Y, Zhou L, Yu Y. Association between Healthy Eating Index-2015 and physical frailty among the United States elderly adults: the National Health and Nutrition Examination Survey (NHANES) 2011-2014. Aging Clin Exp Res 2021; 33:3245-3255. [PMID: 33978925 DOI: 10.1007/s40520-021-01874-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/28/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Diet plays an important role in the development of age-related chronic diseases. However, the association between diet quality assessed by Healthy Eating Index (HEI)-2015, the latest version of HEI, and physical frailty among the general United States (US) elderly adults remains unclear. AIMS The present study aims to explore the association between HEI-2015 and physical frailty in elderly adults using data from National Health and Nutrition Examination Survey (NHANES) 2011-2014. METHODS HEI-2015 scores were calculated from 2 days 24-h recall interviews. Physical frailty status was assessed by four criteria developed by Fried et al.: exhaustion, weakness, low body mass, and low physical activity, and then categorized into robust (0 criteria), pre-frail (1-2 criteria), or frail (3-4 criteria). The binary and multinomial logistic regressions were used to examine the odds of frailty status. RESULTS A total of 2345 participants aged 60 years or older were included. According to the 4-items frailty criteria, 51.1% participants were robust, 42.1% were pre-frail, and 6.8% were frail. Compared to the lowest HEI-2015 quartile, the elderly adults in the higher quartile had a lower odds of physical frailty (P < 0.05). Regarding the frailty criterion separately, higher HEI-2015 was associated with lower odds of exhaustion, weakness, low physical activity and unintentional weight loss, respectively (P < 0.05). Among 13 HEI-2015 components, adherence to the recommended intake of whole fruits and total vegetables components were less likely to be physically frail (P < 0.05). CONCLUSION Higher HEI-2015 was inversely associated with lower odds of physical frailty in the US elderly adults.
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Affiliation(s)
- Yameng Fan
- School of Public Health, Xi'an Jiaotong University, 76 West Yanta Road, Xi'an, 710061, China
| | - Yinyin Zhang
- School of Public Health, Xi'an Jiaotong University, 76 West Yanta Road, Xi'an, 710061, China
| | - Jiaqiao Li
- School of Public Health, Xi'an Jiaotong University, 76 West Yanta Road, Xi'an, 710061, China
| | - Yamei Liu
- School of Public Health, Xi'an Jiaotong University, 76 West Yanta Road, Xi'an, 710061, China
| | - Long Zhou
- School of Public Health, Xi'an Jiaotong University, 76 West Yanta Road, Xi'an, 710061, China.
- Department of Cardiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.
| | - Yan Yu
- School of Public Health, Xi'an Jiaotong University, 76 West Yanta Road, Xi'an, 710061, China.
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13
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Kolaitis NA, Gao Y, Soong A, Greenland JR, Hays SR, Golden J, Leard LE, Shah RJ, Kleinhenz ME, Katz PP, Venado A, Kukreja J, Blanc PD, Singer JP. Primary graft dysfunction attenuates improvements in health-related quality of life after lung transplantation, but not disability or depression. Am J Transplant 2021; 21:815-824. [PMID: 32794295 DOI: 10.1111/ajt.16257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/17/2020] [Accepted: 07/31/2020] [Indexed: 01/25/2023]
Abstract
Disability, depressive symptoms, and impaired health-related quality of life (HRQL) are common among patients with life-threatening respiratory compromise. We sought to determine if primary graft dysfunction (PGD), a syndrome of acute lung injury, attenuates improvements in patient-reported outcomes after transplantation. In a single-center prospective cohort, we assessed disability, depressive symptoms, and HRQL before and at 3- to 6-month intervals after lung transplantation. We estimated the magnitude of change in disability, depressive symptoms, and HRQL with hierarchical segmented linear mixed-effects models. Among 251 lung transplant recipients, 50 developed PGD Grade 3. Regardless of PGD severity, participants had improvements in disability and depressive symptoms, as well as generic-physical, generic-mental, respiratory-specific, and health-utility HRQL, exceeding 1- to 4-fold the minimally clinically important difference across all instruments. Participants with PGD Grade 3 had a lower magnitude of improvement in generic-physical HRQL and health-utility than in all other participants. Among participants with PGD Grade 3, prolonged mechanical ventilation was associated with greater attenuation of improvements. PGD remains a threat to the 2 primary aims of lung transplantation, extending survival and improving HRQL. Attenuation of improvement persists long after hospital discharge. Future studies should assess if interventions can mitigate the impact of PGD on patient-reported outcomes.
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Affiliation(s)
- Nicholas A Kolaitis
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Ying Gao
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Allison Soong
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - John R Greenland
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Steven R Hays
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Jeffrey Golden
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Lorriana E Leard
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Rupal J Shah
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Mary Ellen Kleinhenz
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Patricia P Katz
- Division of Rheumatology, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Aida Venado
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Jasleen Kukreja
- Division of Thoracic Surgery, Department of Surgery, School of Medicine, University of California, San Francisco, California, USA
| | - Paul D Blanc
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Jonathan P Singer
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
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Ruiz de Gopegui Miguelena P, Martínez Lamazares MT, Claraco Vega LM, Gurpegui Puente M, González Almárcegui I, Gutiérrez Ibañes P, Carrillo López A, Castiella García CM, Miguelena Hycka J. Evaluating frailty may complement APACHE II in estimating mortality in elderly patients admitted to the ICU after digestive surgery. Med Intensiva 2021; 46:S0210-5691(20)30341-7. [PMID: 33446376 DOI: 10.1016/j.medin.2020.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To analyze whether frailty can improve the prediction of mortality in patients admitted to the ICU after digestive surgery. DESIGN Prospective, observational, 6-month follow-up study of a cohort of patients admitted to the ICU between June 1, 2018, and June 1, 2019. SETTING Surgical ICU of a third level hospital. PATIENTS Series of successive patients older than 70 years who were admitted to the ICU immediately after a surgical intervention on the digestive system. 92 patients were included and 2 were excluded due to loss of follow-up at 6 months. INTERVENTIONS Upon admission to the ICU, severity and prognosis were assessed by APACHE II, and fragility by the Clinical Frailty Scale and the modified Frailty Index. MAIN VARIABLES OF INTEREST ICU, in-hospital and 6-month mortality. RESULTS The model that best predicts mortality in the ICU is the APACHE II, with an area under the ROC curve (AUC) of 0.89 and a good calibration. The model that combines APACHE II and Clinical Frailty Scale is the one that best predicts in-hospital mortality (AUC: 0.82), significantly improving the prediction of isolated APACHE II (AUC: 0.78; Integrated Discrimination Index: 0.04). Frailty is a predictor of mortality at 6 months, being the model that combines Clinical Frailty Scale and Frailty Index the one that has shown the greatest discrimination (AUC: 0.84). CONCLUSIONS Frailty can complement APACHE II by improving its prediction of hospital mortality. Furthermore, it offers a good prediction of mortality 6 months after surgery. For mortality in ICU, frailty loses its predictive power, whereas isolated APACHE II shows excellent predictive capacity.
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Affiliation(s)
| | | | - L M Claraco Vega
- Servicio de Medicina Intensiva, Hospital Universitario Miguel Servet , Zaragoza, España
| | - M Gurpegui Puente
- Servicio de Medicina Intensiva, Hospital Universitario Miguel Servet , Zaragoza, España
| | - I González Almárcegui
- Servicio de Medicina Intensiva, Hospital Universitario Miguel Servet , Zaragoza, España
| | - P Gutiérrez Ibañes
- Servicio de Medicina Intensiva, Hospital Universitario Miguel Servet , Zaragoza, España
| | - A Carrillo López
- Servicio de Medicina Intensiva, Hospital Universitario Miguel Servet , Zaragoza, España
| | | | - J Miguelena Hycka
- Servicio de Cirugía Cardiaca, Hospital Universitario Ramón y Cajal, Madrid, España
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15
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Hewitt D, Ratcliffe M, Booth MG. The FRAIL-FIT 30 Study – Factors influencing 30-day mortality in frail patients admitted to ICU: A retrospective observational cohort study. J Intensive Care Soc 2021; 23:150-161. [DOI: 10.1177/1751143720985164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Frailty is a multi-dimensional syndrome of reduced reserve, resulting from overlapping physiological decrements across multiple systems. The contributing factors, temporality and magnitude of frailty’s effect on mortality after ICU admission are unclear. This study assessed frailty’s impact on mortality and life sustaining therapy (LST) use, following ICU admission. Methods This single-centre retrospective observational cohort study analysed data collected prospectively in Glasgow Royal Infirmary ICU. Of 684 eligible patients, 171 were frail and 513 were non-frail. Frailty was quantified using the Rockwood Clinical Frailty Scale (CFS). All patients were followed up 1-year after ICU admission. The primary outcome was all-cause mortality at 30-days post-ICU admission. Key secondary outcomes included mortality at 1-year and LST use. Results Frail patients were significantly less likely to survive 30-days post-ICU admission (61.4% vs 81.1%, p < 0.001). This continued to 1-year (48.5% vs 68.2%, p < 0.001). Frailty significantly increased mortality hazards in covariate-adjusted analyses at 30-days (HR 1.56; 95%CI 1.14–2.15; p = 0.006), and 1-year (HR 1.35; 95%CI 1.03–1.76; p = 0.028). Single-point CFS increases were associated with a 30-day mortality hazard of 1.23 (95%CI 1.13–1.34; p < 0.001) in unadjusted analyses, and 1.11 (95%CI 1.01–1.22; p = 0.026) after covariate adjustment. Frail patients received significantly more days of LST (median[IQR]: 5[3,11] vs 4[2,9], p = 0.008). Conclusion Frailty was significantly associated with greater mortality at all time points studied, but most notably in the first 30-days post-ICU admission. This was despite greater LST use. The accrual effect of frailty increased adverse outcomes. Point-by-point use of frailty scoring could allow for more informed decision making in ICU.
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Affiliation(s)
- David Hewitt
- Glasgow Royal Infirmary Intensive Care Unit, Glasgow, Scotland
| | | | - Malcolm G Booth
- Glasgow Royal Infirmary Intensive Care Unit, Glasgow, Scotland
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16
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Baldwin MR, Pollack LR, Friedman RA, Norris SP, Javaid A, O'Donnell MR, Cummings MJ, Needham DM, Colantuoni E, Maurer MS, Lederer DJ. Frailty subtypes and recovery in older survivors of acute respiratory failure: a pilot study. Thorax 2020; 76:350-359. [PMID: 33298583 DOI: 10.1136/thoraxjnl-2020-214998] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Identifying subtypes of acute respiratory failure survivors may facilitate patient selection for post-intensive care unit (ICU) follow-up clinics and trials. METHODS We conducted a single-centre prospective cohort study of 185 acute respiratory failure survivors, aged ≥ 65 years. We applied latent class modelling to identify frailty subtypes using frailty phenotype and cognitive impairment measurements made during the week before hospital discharge. We used Fine-Gray competing risks survival regression to test associations between frailty subtypes and recovery, defined as returning to a basic Activities of Daily Living disability count less than or equal to the pre-hospitalisation count within 6 months. We characterised subtypes by pre-ICU frailty (Clinical Frailty Scale score ≥ 5), the post-ICU frailty phenotype, and serum inflammatory cytokines, hormones and exosome proteomics during the week before hospital discharge. RESULTS We identified five frailty subtypes. The recovery rate decreased 49% across each subtype independent of age, sex, pre-existing disability, comorbidity and Acute Physiology and Chronic Health Evaluation II score (recovery rate ratio: 0.51, 95% CI 0.41 to 0.63). Post-ICU frailty phenotype prevalence increased across subtypes, but pre-ICU frailty prevalence did not. In the subtype with the slowest recovery, all had cognitive impairment. The three subtypes with the slowest recovery had higher interleukin-6 levels (p=0.03) and a higher prevalence of ≥ 2 deficiencies in insulin growth factor-1, dehydroepiandrostersone-sulfate, or free-testosterone (p=0.02). Exosome proteomics revealed impaired innate immunity in subtypes with slower recovery. CONCLUSIONS Frailty subtypes varied by prehospitalisation frailty and cognitive impairment at hospital discharge. Subtypes with the slowest recovery were similarly characterised by greater systemic inflammation and more anabolic hormone deficiencies at hospital discharge.
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Affiliation(s)
- Matthew R Baldwin
- Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Lauren R Pollack
- Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Richard A Friedman
- Bioinformatics, Columbia University Irving Medical Center, New York, New York, USA
| | - Simone P Norris
- Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Azka Javaid
- Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Max R O'Donnell
- Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Matthew J Cummings
- Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Biostatistics, Johns Hopkins University-Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mathew S Maurer
- Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - David J Lederer
- Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center, New York, New York, USA.,Regeneron Pharmaceuticals, Tarrytown, New York, USA
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Jung C, Romano Bruno R, Wernly B, Wolff G, Beil M, Kelm M. Frailty as a Prognostic Indicator in Intensive Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:668-673. [PMID: 33357351 PMCID: PMC7838379 DOI: 10.3238/arztebl.2020.0668] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 03/31/2020] [Accepted: 06/09/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND The percentage of patients in intensive care who are 80 years old or older is continually increasing. Such patients already made up more than 20% of all patients in intensive care in Germany in the years 2007-2011. Meanwhile, effective treatments that support the organs of the body and keep severely ill patients alive are also being continually developed and refined. Frailty is a key prognostic parameter. The scientifically based assessment of frailty can be highly useful in intensive care medicine with regard to consented decision-making, individualized prognostication, treatment planning, and aftercare. METHODS Pertinent publications were retrieved by a selective search in the PubMed database. On the basis of the literature assessment, a variety of screening instruments were used to assess frailty and its significance for very old, critically ill patients in German intensive care units. RESULTS Only a small number of screening instruments are suitable for routine use in German intensive care units. The scores vary in diagnostic precision. The Clinical Frailty Scale (CFS) enables highly accurate prognostication; it considers the patient in relation to his or her social environment, and to the reference population. Categorization is achieved by means of pictograms that are supplemented with brief written descriptions. The CFS can be used prospectively and is easy to learn. Its interrater reliability is high (weighted Cohen's κ: 0.85 [0.84; 0.87]), and it has been validated for routine use in intensive care units in Germany. CONCLUSION None of the available scores enable perfect prognostication. In Germany, frailty in intensive-care patients is currently best assessed on a simple visual scale (CFS).
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Affiliation(s)
- Christian Jung
- Department of Cardiology, Pulmonary Diseases and Vascular Medicine, Faculty of Medicine, Düsseldorf University Hospital
| | - Raphael Romano Bruno
- Department of Cardiology, Pulmonary Diseases and Vascular Medicine, Faculty of Medicine, Düsseldorf University Hospital
| | - Bernhard Wernly
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria; Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden:
| | - Georg Wolff
- Department of Cardiology, Pulmonary Diseases and Vascular Medicine, Faculty of Medicine, Düsseldorf University Hospital
| | - Michael Beil
- Department of Intensive Care Medicine, Hadassah-Hebrew University Hospital, Jerusalem, Israel
| | - Malte Kelm
- Department of Cardiology, Pulmonary Diseases and Vascular Medicine, Faculty of Medicine, Düsseldorf University Hospital
- Cardiovascular Research Institute Düsseldorf (CARID)
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Paul JA, Whittington RA, Baldwin MR. Critical Illness and the Frailty Syndrome: Mechanisms and Potential Therapeutic Targets. Anesth Analg 2020; 130:1545-1555. [PMID: 32384344 DOI: 10.1213/ane.0000000000004792] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Frailty is a syndrome characterized by decreased reserves across multiple physiologic systems resulting in functional limitations and vulnerability to new stressors. Physical frailty develops over years in community-dwelling older adults but presents or worsens within days in the intensive care unit (ICU) because common mechanisms governing age-related physical frailty are often exacerbated by critical illness. The hallmark of physical frailty is a combined loss of muscle mass, force, and endurance. About one-third of ICU patients have frailty before hospitalization, which increases their risk for both short- and long-term disability and mortality. While there are several valid ways to measure clinical frailty in patients before or after an ICU admission, the mechanistic underpinnings of frailty in critically ill patients and ICU survivors have not been thoroughly investigated. Furthermore, therapeutic interventions to treat frailty during and after time in the ICU are lacking. In this narrative review, we examine studies that identify potential biological mechanisms underlying the development and propagation of physical frailty in both aging and critical illness (eg, inflammation, mitochondrial myopathy, and neuroendocrinopathy). We discuss specific aspects of these frailty mechanisms in older adults, critically ill patients, and ICU survivors that may represent therapeutic targets. Consistent with complexity underlying frailty, this syndrome is unlikely to result from an excess of a single harmful mediator or deficit of a single protective mediator. Rather, frailty occurs in the presence of an incompletely understood state of multisystem dysregulation. We further describe knowledge gaps that warrant clinical and translational research in frailty and critical care with an overall goal of developing effective frailty treatments in critically ill patients and ICU survivors.
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Affiliation(s)
- Jonathan A Paul
- From the Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Robert A Whittington
- From the Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Matthew R Baldwin
- Division of Pulmonary, Allergy, and Critical Care, Department of Internal Medicine, Columbia University Irving Medical Center, New York, New York
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Salaffi F, Farah S, Di Carlo M. Frailty syndrome in rheumatoid arthritis and symptomatic osteoarthritis: an emerging concept in rheumatology. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:274-296. [PMID: 32420963 PMCID: PMC7569610 DOI: 10.23750/abm.v91i2.9094] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/11/2020] [Indexed: 12/17/2022]
Abstract
Musculoskeletal conditions such as rheumatoid arthritis (RA) and symptomatic osteoarthritis (OA) were the leading cause of disability in developed countries and disproportionately affects older adults. Frailty is an emerging concept in rheumatology, which represents an important construct to aid in the identification of in- dividuals who are vulnerable to adverse events and less favourable outcomes. The prevalence of frailty among the community-dwelling population increases with age: it ranges from 7% to 10% in those aged over 65 years and to 20-40% among octogenarians. Among patients with RA, the prevalence of frailty is comparable to, or even greater, that of older geriatric cohorts and pre-frailty, a condition including a major health vulnerability between robust and frail, is much more prevalent in RA than in geriatric cohorts. Clinical OA is also associated with frailty and pre-frailty in older adults in European countries. The overall prevalence of clinical OA at any site was 30.4%; frailty was present in 10.2% and pre-frailty in 51.0 %. The diagnosis of frailty is usually clinical and based on specific criteria, which are sometimes inconsistent. Therefore, there is an increasing need to identify and vali- date robust biomarkers for this condition. In the literature, different criteria have been validated to identify frail older subjects, which mainly refer to two conceptual models: the Physical Frailty (PF) phenotype proposed by Fried and the cumulative deficit approach proposed by Rockwood. The purpose of this review was to quantita- tively synthesize published literature on the prevalence of frailty in RA and OA and summarize current evidence on the validity and practicality of the most commonly used screening tools for frailty.
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Affiliation(s)
| | - Sonia Farah
- Clinica Reumatologica, Ospedale Carlo Urbani di Jesi, Università Politecnica delle Marche, (Ancona), Italy..
| | - Marco Di Carlo
- Clinica Reumatologica, Ospedale Carlo Urbani di Jesi, Università Politecnica delle Marche, (Ancona), Italy..
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Rodrigues MK, Marques A, Umeda II, Lobo DM, Oliveira MF. Pre‐frailty status increases the risk of rehospitalization in patients after elective cardiac surgery without complication. J Card Surg 2020; 35:1202-1208. [DOI: 10.1111/jocs.14550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Miguel K. Rodrigues
- VO2 Care Research GroupPhysiotherapy Service Coordinator of Vila Nova Star Hospital São Paulo SP Brazil
| | - Artur Marques
- Department of Physiotherapy, Intensive Care Unit CenterDante Pazzanese Institute of Cardiology São Paulo SP Brazil
| | - Iracema I.K. Umeda
- Department of Physiotherapy, Intensive Care Unit CenterDante Pazzanese Institute of Cardiology São Paulo SP Brazil
| | - Denise M.L. Lobo
- Department of Physiotherapy, Intensive Care Unit CenterDante Pazzanese Institute of Cardiology São Paulo SP Brazil
- Physiotherapy UnitFametro University Center (UNIFAMETRO) Fortaleza CE Brazil
| | - Mayron F. Oliveira
- Department of Physiotherapy, Intensive Care Unit CenterDante Pazzanese Institute of Cardiology São Paulo SP Brazil
- VO2 Care Research GroupPhysiotherapy Research Service Coordinator of Vila Nova Star Hospital São Paulo SP Brazil
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Clinical Frailty Scale Score Before ICU Admission Is Associated With Mobility Disability in Septic Patients Receiving Early Rehabilitation. Crit Care Explor 2019; 1:e0066. [PMID: 32166247 PMCID: PMC7063928 DOI: 10.1097/cce.0000000000000066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
To clarify the relationship between mobility disability at the time of discharge from the ICU and clinical factors evaluated at ICU admission in septic patients.
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Zhang L, Hu W, Cai Z, Liu J, Wu J, Deng Y, Yu K, Chen X, Zhu L, Ma J, Qin Y. Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis. PLoS One 2019; 14:e0223185. [PMID: 31581205 PMCID: PMC6776357 DOI: 10.1371/journal.pone.0223185] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 09/16/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Physical therapy can prevent functional impairments and improve the quality of life of patients after hospital discharge. However, the effect of early mobilization on patients with a critical illness remains unclear. This study was performed to assess the evidence available regarding the effect of early mobilization on critically ill patients in the intensive care unit (ICU). METHODS Electronic databases were searched from their inception to March 21, 2019. Randomized controlled trials (RCTs) comprising critically ill patients who received early mobilization were included. The methodological quality and risk of bias of each eligible trial were assessed using the Cochrane Collaboration tool. Data were extracted using a standard collection form each included study, and processed using the Mantel-Haenszel (M-H) or inverse-variance (I-V) test in the STATA v12.0 statistical software. RESULTS A total of 1,898 records were screened. Twenty-three RCTs comprising 2,308 critically ill patients were ultimately included. Early mobilization decreased the incidence of ICU-acquired weakness (ICU-AW) at hospital discharge (three studies, 190 patients, relative risk (RR): 0.60, 95% confidence interval (CI) [0.40, 0.90]; p = 0.013, I2 = 0.0%), increased the number of patients who were able to stand (one study, 50 patients, 90% vs. 62%, p = 0.02), increased the number of ventilator-free days (six studies, 745 patients, standardized mean difference (SMD): 0.17, 95% CI [0.02, 0.31]; p = 0.023, I2 = 35.5%) during hospitalization, increased the distance the patient was able to walk unassisted (one study, 104 patients, 33.4 (0-91.4) meters vs. 0 (0-30.4) meters, p = 0.004) at hospital discharge, and increased the discharged-to-home rate (seven studies, 793 patients, RR: 1.16, 95% CI [1.00, 1.34]; p = 0.046). The mortality (28-day, ICU and hospital) and adverse event rates were moderately increased by early mobilization, but the differences were statistically non-significant. However, due to the substantial heterogeneity among the included studies, and the low quality of the evidence, the results of this study should be interpreted with caution. Publication bias was not identified. CONCLUSIONS Early mobilization appears to decrease the incidence of ICU-AW, improve the functional capacity, and increase the number of ventilator-free days and the discharged-to-home rate for patients with a critical illness in the ICU setting.
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Affiliation(s)
- Lan Zhang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Weishu Hu
- Department of Neurology, Chongqing General Hospital, Chongqing, P.R. China
| | - Zhiyou Cai
- Department of Neurology, Chongqing General Hospital, Chongqing, P.R. China
| | - Jihong Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Jianmei Wu
- Department of Neurology, Chongqing General Hospital, Chongqing, P.R. China
| | - Yangmin Deng
- Department of Neurology, Chongqing General Hospital, Chongqing, P.R. China
| | - Keping Yu
- Department of Neurology, Chongqing General Hospital, Chongqing, P.R. China
| | - Xiaohua Chen
- Department of Neurology, Chongqing General Hospital, Chongqing, P.R. China
| | - Li Zhu
- Department of Neurology, Chongqing General Hospital, Chongqing, P.R. China
| | - Jingxi Ma
- Department of Neurology, Chongqing General Hospital, Chongqing, P.R. China
| | - Yan Qin
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
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Courtwright AM, Zaleski D, Tevald M, Adler J, Singer JP, Cantu EE, A Bermudez C, Diamond JM. Discharge frailty following lung transplantation. Clin Transplant 2019; 33:e13694. [PMID: 31418935 DOI: 10.1111/ctr.13694] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/30/2019] [Accepted: 08/05/2019] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Frailty at listing for lung transplant has been associated with waitlist and post-transplant mortality. Frailty trajectories following transplant, however, have been less well characterized, including whether recipient frailty improves. The objective of this study was to identify prevalence and risk factors for frailty at discharge and to evaluate changes in frail recipients enrolled in an outpatient physical therapy program. METHODS This was a single-center prospective cohort study of lung transplant recipients. Enrollees completed a short physical performance battery (SPPB) to assess frailty at listing and at initial hospital discharge. RESULTS Of the 111 enrolled recipients, none were frail at listing and 18 (16.2%) were prefrail. At discharge, however, 60 (54.1%) patients were frail. Discharge frailty was associated with prefrailty at listing, acute kidney injury post-transplant, and longer intensive care unit stay. Among the 35 patients who were frail at discharge and who were enrolled in an outpatient PT program, the median improvement in SPPB was 6 points (IQR = 5-7 points), and 85.7% became not frail over a median of 6 weeks. CONCLUSION Discharge frailty is common following lung transplantation. In most frail patients, an intensive outpatient physical therapy program is associated with improvement in frailty, as assessed by the SPPB.
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Affiliation(s)
- Andrew M Courtwright
- Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Derek Zaleski
- Good Shepard Penn Partners, Philadelphia, Pennsylvania
| | - Michael Tevald
- School of Health Sciences, Arcadia University, Glenside, Pennsylvania
| | - Joe Adler
- Good Shepard Penn Partners, Philadelphia, Pennsylvania
| | - Jonathan P Singer
- Pulmonary and Critical Care Medicine, University of San Francisco, San Francisco, California
| | - Edward E Cantu
- Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Joshua M Diamond
- Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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24
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Falvey JR, Ferrante LE. Frailty assessment in the ICU: translation to 'real-world' clinical practice. Anaesthesia 2019; 74:700-703. [PMID: 30859547 PMCID: PMC6521947 DOI: 10.1111/anae.14617] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2019] [Indexed: 12/11/2022]
Affiliation(s)
- J. R. Falvey
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven,
CT, USA
| | - L. E. Ferrante
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of
Medicine, Yale University, New Haven, CT, USA
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25
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Formenti P, Umbrello M, Coppola S, Froio S, Chiumello D. Clinical review: peripheral muscular ultrasound in the ICU. Ann Intensive Care 2019; 9:57. [PMID: 31101987 PMCID: PMC6525229 DOI: 10.1186/s13613-019-0531-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/10/2019] [Indexed: 12/14/2022] Open
Abstract
Muscular weakness developing from critical illness neuropathy, myopathy and muscle atrophy has been characterized as intensive care unit-acquired weakness (ICUAW). This entity occurs commonly during and after critical care stay. Various causal factors for functional incapacity have been proposed. Among these, individual patient characteristics (such as age, comorbidities and nutritional status), acting in association with sustained bed rest and pharmacological interventions (included the metabolic support approach), seem influential in reducing muscular mass. Long-term outcomes in heterogeneous ICUAW populations include transient disability in 30% of patients and persistent disabilities that may occur even in patients with nearly complete functional recovery. Currently available tools for the assessment of skeletal muscle mass are imprecise and difficult to perform in the ICU setting. A valid alternative to these imaging modalities is muscular ultrasonography, which allows visualization and classification of muscle characteristics by cross-sectional area, muscle layer thickness, echointensity by grayscale and the pennation angle). The aim of this narrative review is to describe the current literature addressing muscular ultrasound for the detection of muscle weakness and its potential impact on treatment and prognosis of critically ill patients when combined with biomarkers of muscle catabolism/anabolism and bioenergetic state. In addition, we suggest a practical flowchart for establishing an early diagnosis.
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Affiliation(s)
- Paolo Formenti
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy. .,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy.
| | - Michele Umbrello
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
| | - Silvia Coppola
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
| | - Sara Froio
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
| | - Davide Chiumello
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
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26
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Hewitt D, Booth MG. The FRAIL-FIT study: Frailty's relationship with adverse-event incidence in the longer term, at one year following intensive care unit treatment - A retrospective observational cohort study. J Intensive Care Soc 2019; 21:124-133. [PMID: 32489408 DOI: 10.1177/1751143719838212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Frailty is a syndrome of decreased reserve and heightened vulnerability. Frailty scoring has potential to facilitate more informed decisions in the intensive care unit. To validate this, its relationship with outcomes must be tested extensively. This study aimed to investigate frailty's impact on adverse outcomes after intensive care unit admission, primarily one-year mortality. Methods This single-centre retrospective observational cohort study examined prospectively collected data from 400 intensive care unit patients. Frailty was assessed using the Clinical Frailty Scale and defined as Clinical Frailty Scale ≥ 5. Unadjusted and adjusted analyses tested the relationships of frailty, covariates and outcomes. Results Of 400 eligible patients, 111 (27.8%) were frail and 289 (72.3%) were non-frail. Compared to non-frail patients, frail patients were older (62 vs. 56, p < 0.001) and had higher Acute Physiology and Chronic Health Evaluation II scores (22 vs. 19, p < 0.001). Females were more likely to be frail than males (34.1% vs. 22.9% frail, p = 0.018). Frail patients were less likely to survive the intensive care unit (p = 0.03), hospital (p = 0.003) or to one year (p < 0.001). Frailty significantly increased one-year mortality hazards in unadjusted analyses (hazard ratio 1.96; 95% confidence interval 1.41-2.72; p < 0.001) and covariate adjusted analyses (hazard ratio 1.41; 95% confidence interval 1.00-1.98; p = 0.0497). Frail patients had more hospital admissions (p = 0.014) and longer hospital stays within both one year before (p = 0.002) and one year after intensive care unit admission (p = 0.012). Conclusions Frailty was common and associated with greater age, female gender, higher sickness severity and more healthcare use. Frailty was significantly associated with greater risks of mortality in both unadjusted and adjusted analyses. Frailty scoring is a promising tool which could improve decision making in intensive care.
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27
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Ko RE, Lee H, Jung JH, Lee HO, Sohn I, Yoo H, Ko JY, Suh GY, Chung CR. Simple functional assessment at hospital discharge can predict long-term outcomes of ICU survivors. PLoS One 2019; 14:e0214602. [PMID: 30947283 PMCID: PMC6448871 DOI: 10.1371/journal.pone.0214602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 03/17/2019] [Indexed: 11/29/2022] Open
Abstract
Recent studies showed that physical and/or neuropsychiatric impairments significantly affect long-term mortality of ICU survivors. We conducted this study to investigate that simplified measurement of physical function and level of consciousness at hospital discharge by attending nurses could predict long-term outcomes after hospital discharge. A retrospective analysis of prospectively and retrospectively collected data of 246 patients who received medical ICU treatment was conducted. We grouped patients according to physical function and level of consciousness measured by the simplified method at hospital discharge as follow; group A included patients with alert mental and capable of walking or moving by wheel chairs; group B included those with alert mental and bed-ridden status; and Group C included those with confused mental and bed-ridden status. The two-year survival rate after hospital discharge was compared. Of 246 patients, 157 patients were included in the analysis and there were 103 survivors after two-year follow up. Compared to non-survivors, survivors were more likely to be younger (P = 0.026) and have higher body mass index (P = 0.019) and no malignant disease (P = 0.001). There were no statistically significant differences in treatment modalities including medication, use of medical devices, and physical therapy between the survivors and non-survivors. The analysis showed significant differences in survival between the groups classified by physical function (P < 0.001) and level of consciousness (P < 0.01). Multivariate analysis showed that survival rate was significantly lower among the patients in group C than in those in group B or group A (P < 0.001). Simplified method to assess physical function and level of consciousness at hospital discharge can predict long-term outcomes of medical ICU survivors.
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Affiliation(s)
- Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyun Lee
- Division of Pulmonary Medicine and Allergy, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
| | - Jin Hee Jung
- Advanced Practice Nurse, Department of Nursing, Samsung Medical Center, Seoul, South Korea
| | - Hee Og Lee
- Advanced Practice Nurse, Department of Nursing, Samsung Medical Center, Seoul, South Korea
| | - Insuk Sohn
- Statistics and Data Center, Samsung Medical Center, Seoul, South Korea
| | - Heejin Yoo
- Statistics and Data Center, Samsung Medical Center, Seoul, South Korea
| | - Jin Yeong Ko
- Department of pharmaceutical services, Samsung Medical Center, Seoul, South Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Division of Pulmonology and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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28
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Venado A, McCulloch C, Greenland JR, Katz P, Soong A, Shrestha P, Hays S, Golden J, Shah R, Leard LE, Kleinhenz ME, Kukreja J, Zablotska L, Allen IE, Covinsky K, Blanc P, Singer JP. Frailty trajectories in adult lung transplantation: A cohort study. J Heart Lung Transplant 2019; 38:699-707. [PMID: 31005571 DOI: 10.1016/j.healun.2019.03.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 01/31/2019] [Accepted: 03/13/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Frailty is common in adults with advanced lung disease and is associated with death before and after lung transplantation. We aimed to determine whether frailty changes from before to after the lung transplant. METHODS In a single-center, prospective cohort study among adults undergoing lung transplantation from 2010 to 2017, we assessed frailty by the Short Physical Performance Battery (SPPB; higher scores reflect less frailty) and Fried Frailty Phenotype (FFP; higher scores reflect greater frailty) before and repeatedly up to 36 months after transplant. We tested for changes in frailty scores over time using segmented mixed effects models, adjusting for age, sex, and diagnosis. We quantified the proportion of subjects transitioning between frailty states (frail vs not frail) from before to after the transplant. RESULTS In 246 subjects, changes in frailty occurred within the first 6 post-operative months and remained stable thereafter. The overall change in frailty was attributable to improvements among those subjects who were frail before transplant. They experienced a 5.1-point improvement in SPPB (95% confidence interval [CI] 4.6-5.7) and a 1.8-point improvement in FFP (95% CI -2.1 to -1.6) during the early period. Frailty by SPPB and FFP did not change in those who were not frail before transplant. Approximately 84% of survivors who were frail before transplant became not frail after transplant. CONCLUSIONS Pre-operative frailty resolves in many patients after lung transplantation. Because a large proportion of frailty may be attributable to advanced lung disease, frailty alone should not be an absolute contraindication to transplantation.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Jasleen Kukreja
- Departments of Surgery, University of California, San Francisco, San Francisco, California, USA
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29
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Causes, Preventability, and Cost of Unplanned Rehospitalizations Within 30 Days of Discharge After Lung Transplantation. Transplantation 2019; 102:838-844. [PMID: 29346256 DOI: 10.1097/tp.0000000000002101] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Unplanned rehospitalizations (UR) within 30 days of discharge are common after lung transplantation. It is unknown whether UR represents preventable gaps in care or necessary interventions for complex patients. The objective of this study was to assess the incidence, causes, risk factors, and preventability of UR after initial discharge after lung transplantation. METHODS This was a single-center prospective cohort study. Subjects completed a modified short physical performance battery to assess frailty at listing and at initial hospital discharge after transplantation and the State-Trait Anxiety Inventory at discharge. For each UR, a study staff member and the patient's admitting or attending clinician used an ordinal scale (0, not; 1, possibly; 2, definitely preventable) to rate readmission preventability. A total sum score of 2 or higher defined a preventable UR. RESULTS Of the 90 enrolled patients, 30 (33.3%) had an UR. The single most common reasons were infection (7 [23.3%]) and atrial tachyarrhythmia (5 [16.7%]). Among the 30 URs, 9 (30.0%) were deemed preventable. Unplanned rehospitalization that happened before day 30 were more likely to be considered preventable than those between days 30 and 90 (30.0% versus 6.2%, P = 0.04). Discharge frailty, defined as short physical performance battery less than 6, was the only variable associated with UR on multivariable analysis (odds ratio, 3.4; 95% confidence interval, 1.1-11.8; P = 0.04). CONCLUSIONS Although clinicians do not rate the majority of UR after lung transplant as preventable, discharge frailty is associated with UR. Further research should identify whether modification of discharge frailty can reduce UR.
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30
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Jeong BH, Na SJ, Lee DS, Chung CR, Suh GY, Jeon K. Readmission and hospital mortality after ICU discharge of critically ill cancer patients. PLoS One 2019; 14:e0211240. [PMID: 30677085 PMCID: PMC6345475 DOI: 10.1371/journal.pone.0211240] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/09/2019] [Indexed: 01/19/2023] Open
Abstract
Background Intensive care unit (ICU) readmission is generally associated with increased hospital stays and increased mortality. However, there are limited data on ICU readmission in critically ill cancer patients. Method We conducted a retrospective cohort study based on the prospective registry of all critically ill cancer patients admitted to the oncology medical ICU between January 2012 and December 2013. After excluding patients who were discharged to another hospital or decided to end-of-life care, we divided the enrolled patients into four groups according to the time period from ICU discharge to unexpected events (ICU readmission or ward death) as follows: no (without ICU readmission or death, n = 456), early (within 2 days, n = 42), intermediate (between 2 and 7 days, n = 64), and late event groups (after 7 days of index ICU discharge, n = 129). The independent risk factors associated with ICU readmission or unexpected death after ICU discharge were also analyzed using multinomial logistic regression model. Results There were no differences in the reasons for ICU readmission across the groups. ICU mortality did not differ among the groups, but hospital mortality was significantly higher in the late event group than in the early event group. Mechanical ventilation during ICU stay, tachycardia, decreased mental status, and thrombocytopenia on the day of index ICU discharge increased the risk of early ICU readmission or unexpected ward death, while admission through the emergency room and sepsis and respiratory failure as the reasons for index ICU admission were associated with increased risk of late readmission or unexpected ward death. Interestingly, recent chemotherapy within 4 weeks before index ICU admission was inversely associated with the risk of late readmission or unexpected ward death. Conclusion In critically ill cancer patients, patient characteristics predicting ICU readmission or unexpected ward death were different according to the time period between index ICU discharge and the events.
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Affiliation(s)
- Byeong-Ho Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dae-Sang Lee
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- * E-mail:
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31
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The association between dietary protein intake, energy intake and physical frailty: results from the Rotterdam Study. Br J Nutr 2018; 121:393-401. [PMID: 30419973 DOI: 10.1017/s0007114518003367] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sufficient protein intake has been suggested to be important for preventing physical frailty, but studies show conflicting results which may be explained because not all studies address protein source and intake of other macronutrients and total energy. Therefore, we studied 2504 subjects with data on diet and physical frailty, participating in a large population-based prospective cohort among subjects aged 45+ years (the Rotterdam Study). Dietary intake was assessed with a FFQ. Frailty was defined according to the frailty phenotype as the presence of at least three out of the following five symptoms: weight loss, low physical activity, weakness, slowness and fatigue. We used multinomial logistic regression models to evaluate the independent association between protein intake and frailty using two methods: nutrient residual models and energy decomposition models. With every increase in 10 g total, plant or animal protein per d, the odds to be frail were 1·06 (95 % CI 0·98, 1·15), 0·87 (95 % CI 0·71, 1·07) and 1·07 (95 % CI 0·99, 1·15), respectively, using the nutrient residual method. Using the energy partition model, we observed that the odds to be frail were lower with higher vegetable protein intake (OR per 418·4 kJ (100 kcal): 0·61, 95 % CI 0·39, 0·97), however, results disappeared when adjusting for physical activity. For energy intake from any source we observed that with every 418·4 kJ (100 kcal) increase, the odds to be frail were 5 % lower (OR: 0·95, 95 % CI 0·93, 0·97). Our results suggest that energy intake, but not protein specifically, is associated with less frailty. Considering other macronutrients, physical activity and diet quality seems to be essential for future studies on protein and frailty.
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32
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Palakshappa JA, Reilly JP, Schweickert WD, Anderson BJ, Khoury V, Shashaty MG, Fitzgerald D, Forker C, Butler K, Ittner CA, Feng R, Files DC, Bonk MP, Christie JD, Meyer NJ. Quantitative peripheral muscle ultrasound in sepsis: Muscle area superior to thickness. J Crit Care 2018; 47:324-330. [PMID: 30224027 PMCID: PMC6146408 DOI: 10.1016/j.jcrc.2018.04.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/12/2018] [Accepted: 04/01/2018] [Indexed: 12/31/2022]
Abstract
PURPOSE The objective of this study is to describe the relationship between two quantitative muscle ultrasound measures, the rectus femoris cross-sectional area (RF-CSA) and quadriceps muscle thickness, with volitional measures of strength and function in critically ill patients with sepsis. MATERIALS AND METHODS We performed a prospective study of patients admitted to a medical ICU with sepsis and shock or respiratory failure. We examined the association of two ultrasound measurements - the RF-CSA and quadriceps muscle thickness - with strength and function at day 7. Strength was determined using the Medical Research Council Score and function using Physical Function in the ICU Test, scored. RESULTS Twenty-nine patients were enrolled; 19 patients had outcome testing performed. Over 7days, RF-CSA and thickness decreased by an average of 23.2% and 17.9%, respectively. The rate of change per day of RF-CSA displayed a moderate correlation with strength (ρ 0.51, p-value 0.03) on day 7. Baseline and day 7 RF-CSA did not show a significant correlation with either outcome. Quadriceps muscle thickness did not significantly correlate with either outcome. CONCLUSIONS Muscle atrophy as detected by the rate of change in RF-CSA moderately correlated with strength one week after sepsis admission.
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Affiliation(s)
- Jessica A Palakshappa
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA; Section of Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest Baptist Health, Winston-Salem, NC 27157, USA.
| | - John P Reilly
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - William D Schweickert
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Brian J Anderson
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Viviane Khoury
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael G Shashaty
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, 19104, PA, USA
| | - David Fitzgerald
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Caitlin Forker
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kelly Butler
- Department of Occupational and Physical Therapy, Good Shepherd Penn Partners, Philadelphia, PA 19104, USA
| | - Caroline A Ittner
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Rui Feng
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, 19104, PA, USA
| | - D Clark Files
- Section of Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Michael P Bonk
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, 19104, PA, USA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
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Crossetti MDGO, Antunes M, Waldman BF, Unicovsky MAR, Rosso LHD, Lana LD. Factors that contribute to a NANDA nursing diagnosis of risk for frail elderly syndrome. Rev Gaucha Enferm 2018. [DOI: 10.1590/1983-1447.2018.2017-0233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract OBJECTIVE Identify the risk factors that contribute to a NANDA-I nursing diagnosis of risk for frail elderly system. METHOD Cross-sectional study with 395 elderly subjects, conducted from November 2010 to January 2013, in a university hospital in South of Brazil. Sociodemographic data were collected and levels of frailty were identified according to the Edmonton Frail Scale. RESULTS A total of 177 (44.81%) participants were classified as frail. There was a significant association between frailty and being female (p=0.031), nonwhite (p=0.008), having no romantic partner (p=0.014), no schooling (p=0.001), a monthly income lower than the minimum wage (p=0.034), and preexisting morbidities for respiratory diseases (p=0.003) as well as infectious and parasitic diseases (p=0.040). Diseases of the tracts genitourinary (p=0.035), respiratory (p=0.001) and blood (p=0.035) were the primary reasons for hospitalization. CONCLUSIÓN Los resultados contribuyen para el desarrollo e implementación del diagnóstico de enfermería en estudio en el ambiente hospitalario.
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Affiliation(s)
| | | | | | | | | | - Letice Dalla Lana
- Universidade Federal do Rio Grande do Sul, Brazil; Universidade Federal do Pampa, Brazil
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Abstract
Intensive care unit-acquired weakness (ICUAW) is a substantial contributor to long-term disability in survivors of critical illness. Critical illness polyneuropathy, critical illness myopathy, and muscle atrophy from disuse contribute in various proportions to ICUAW. ICUAW is a clinical diagnosis supported by electrophysiology and newer diagnostic tests, such as muscle ultrasound. Risk factor reduction, including the aggressive treatment of sepsis and early mobilization, improves outcome. Although some patients with ICUAW experience a full recovery, for others improvement is slow and incomplete and quality of life is adversely affected. This article examines aspects of ICUAW and identifies potential areas of further study.
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Affiliation(s)
- Christopher L Kramer
- Department of Neurology, University of Chicago, 5841 South Maryland Avenue, MC 2050, Chicago, IL 60637, USA.
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Muessig JM, Nia AM, Masyuk M, Lauten A, Sacher AL, Brenner T, Franz M, Bloos F, Ebelt H, Schaller SJ, Fuest K, Rabe C, Dieck T, Steiner S, Graf T, Jánosi RA, Meybohm P, Simon P, Utzolino S, Rahmel T, Barth E, Schuster M, Kelm M, Jung C. Clinical Frailty Scale (CFS) reliably stratifies octogenarians in German ICUs: a multicentre prospective cohort study. BMC Geriatr 2018; 18:162. [PMID: 30005622 PMCID: PMC6044022 DOI: 10.1186/s12877-018-0847-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/26/2018] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Johanna M Muessig
- Division of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Amir M Nia
- Division of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Maryna Masyuk
- Division of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alexander Lauten
- Department of Cardiology, Charité - University Hospital, Berlin, Germany.,German Center for Heart Research (DZHK), Berlin, Germany
| | - Anne Lena Sacher
- Department of Anaesthesiology and Operative Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Thorsten Brenner
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Marcus Franz
- Department of Internal Medicine I, Friedrich-Schiller-University, University Hospital Jena, Jena, Germany
| | - Frank Bloos
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Jena, Jena, Germany
| | - Henning Ebelt
- Department for Medicine II, Catholic Hospital "St. Johann Nepomuk", Erfurt, Germany
| | - Stefan J Schaller
- Department of Anaesthesiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Kristina Fuest
- Department of Anaesthesiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Christian Rabe
- Department of Clinical Toxicology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Thorben Dieck
- Department of Anaesthesiology and Intensive Care, Hannover Medical School, Hannover, Germany
| | - Stephan Steiner
- St. Vincenz Hospital, Department of Cardiology, Pneumology and Intensive Care Medicine, Limburg/Lahn, Limburg, Germany
| | - Tobias Graf
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - Rolf A Jánosi
- Medical Faculty, West German Heart and Vascular Center, Department of Cardiology and Vascular Diseases, University Hospital Essen, Essen, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Philipp Simon
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Leipzig, Germany
| | - Stefan Utzolino
- Department of General and Visceral Surgery, University Hospital Freiburg, Freiburg, Germany
| | - Tim Rahmel
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Eberhard Barth
- Division of Intensive Care Medicine, Department of Anaesthesiology, University Hospital Ulm, Ulm, Germany
| | - Michael Schuster
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Mainz, Mainz, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.,CARID, Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
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Theou O, Squires E, Mallery K, Lee JS, Fay S, Goldstein J, Armstrong JJ, Rockwood K. What do we know about frailty in the acute care setting? A scoping review. BMC Geriatr 2018; 18:139. [PMID: 29898673 PMCID: PMC6000922 DOI: 10.1186/s12877-018-0823-2] [Citation(s) in RCA: 157] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/22/2018] [Indexed: 12/21/2022] Open
Abstract
Background The ability of acute care providers to cope with the influx of frail older patients is increasingly stressed, and changes need to be made to improve care provided to older adults. Our purpose was to conduct a scoping review to map and synthesize the literature addressing frailty in the acute care setting in order to understand how to tackle this challenge. We also aimed to highlight the current gaps in frailty research. Methods This scoping review included original research articles with acutely-ill Emergency Medical Services (EMS) or hospitalized older patients who were identified as frail by the authors. We searched Medline, CINAHL, Embase, PsycINFO, Eric, and Cochrane from January 2000 to September 2015. Results Our database search initially resulted in 8658 articles and 617 were eligible. In 67% of the articles the authors identified their participants as frail but did not report on how they measured frailty. Among the 204 articles that did measure frailty, the most common disciplines were geriatrics (14%), emergency department (14%), and general medicine (11%). In total, 89 measures were used. This included 13 established tools, used in 51% of the articles, and 35 non-frailty tools, used in 24% of the articles. The most commonly used tools were the Clinical Frailty Scale, the Frailty Index, and the Frailty Phenotype (12% each). Most often (44%) researchers used frailty tools to predict adverse health outcomes. In 74% of the cases frailty predicted the outcome examined, typically mortality and length of stay. Conclusions Most studies (83%) were conducted in non-geriatric disciplines and two thirds of the articles identified participants as frail without measuring frailty. There was great variability in tools used and more recently published studies were more likely to use established frailty tools. Overall, frailty appears to be a good predictor of adverse health outcomes. For frailty to be implemented in clinical practice frailty tools should help formulate the care plan and improve shared decision making. How this will happen has yet to be determined. Electronic supplementary material The online version of this article (10.1186/s12877-018-0823-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olga Theou
- Department of Medicine, Dalhousie University, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada. .,Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada.
| | - Emma Squires
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Kayla Mallery
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Jacques S Lee
- Sunnybrook Health Service, 2075 Bayview Avenue, BG-04, Toronto, ON, M4N 3M5, Canada
| | - Sherri Fay
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Judah Goldstein
- Emergency Health Services, 239 Brownlow Avenue, Suite 300, Dartmouth, NS, B3B 2B2, Canada
| | - Joshua J Armstrong
- Department of Health Sciences, Lakehead University, 955 Oliver Road, Thunder Bay, ON, P7B 5E1, Canada
| | - Kenneth Rockwood
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada.,Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
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Refining Low Physical Activity Measurement Improves Frailty Assessment in Advanced Lung Disease and Survivors of Critical Illness. Ann Am Thorac Soc 2018; 14:1270-1279. [PMID: 28398076 DOI: 10.1513/annalsats.201612-1008oc] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
RATIONALE The frail phenotype has gained popularity as a clinically relevant measure in adults with advanced lung disease and in critical illness survivors. Because respiratory disease and chronic illness can greatly limit physical activity, the measurement of participation in traditional leisure time activities as a frailty component may lead to substantial misclassification of frailty in pulmonary and critical care patients. OBJECTIVES To test and validate substituting the Duke Activity Status Index (DASI), a simple 12-item questionnaire, for the Minnesota Leisure Time Physical Activity (MLTA) questionnaire, a detailed questionnaire covering 18 leisure time activities, as the measure of low activity in the Fried frailty phenotype (FFP) instrument. METHODS In separate multicenter prospective cohort studies of adults with advanced lung disease who were candidates for lung transplant and older survivors of acute respiratory failure, we assessed the FFP using either the MLTA or the DASI. For both the DASI and MLTA, we evaluated content validity by testing floor effects and construct validity through comparisons with conceptually related factors. We tested the predictive validity of substituting the DASI for the MLTA in the FFP assessment using Cox models to estimate associations between the FFP and delisting/death before transplant in those with advanced lung disease and 6-month mortality in older intensive care unit (ICU) survivors. RESULTS Among 618 adults with advanced lung disease and 130 older ICU survivors, the MLTA had a substantially greater floor effect than the DASI (42% vs. 1%, and 49% vs. 12%, respectively). The DASI correlated more strongly with strength and function measures than did the MLTA in both cohorts. In models adjusting for age, sex, comorbidities, and illness severity, substitution of the DASI for the MLTA led to stronger associations of the FFP with delisting/death in lung transplant candidates (FFP-MLTA hazard ratio [HR], 1.42; 95% confidence interval [CI], 0.55-3.65; FFP-DASI HR, 2.99; 95% CI, 1.03-8.65) and with mortality in older ICU survivors (FFP-MLTA HR, 2.68; 95% CI, 0.62-11.6; FFP-DASI HR, 5.71; 95% CI, 1.34-24.3). CONCLUSIONS The DASI improves the construct and predictive validity of frailty assessment in adults with advanced lung disease or recent critical illness. This simple questionnaire should replace the more complex MLTA in assessing the frailty phenotype in these populations.
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How does prior health status (age, comorbidities and frailty) determine critical illness and outcome? Curr Opin Crit Care 2018; 22:500-5. [PMID: 27478965 DOI: 10.1097/mcc.0000000000000342] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Critical illness has a significant impact on an individual's physical and mental health. However, it is less clear to what degree outcomes after critical illness are due to patients' preexisting characteristics, rather than the critical illness itself. In this review, we summarize recent findings regarding the role of age, comorbidity and frailty on long-term outcomes after critical illness. RECENT FINDINGS Age, comorbidity and frailty are all associated with an increased risk of critical illness. Although severity of illness drives the risk of acute mortality, recent data suggest that longer term outcomes are much more closely aligned with prior health status. There are growing data regarding the important role of noncardiovascular comorbidity, including psychiatric illness and obesity, in determining long-term outcomes. Finally, preadmission frailty is associated with poor long-term outcomes after critical illness; further data are needed to evaluate the attributable impact of critical illness on the health trajectories of frail individuals. SUMMARY Age, comorbidity and frailty play a critical role in determining the long-term outcomes of patients requiring intensive care.
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Langlais E, Nesseler N, Le Pabic E, Frasca D, Launey Y, Seguin P. Does the clinical frailty score improve the accuracy of the SOFA score in predicting hospital mortality in elderly critically ill patients? A prospective observational study. J Crit Care 2018; 46:67-72. [PMID: 29705407 DOI: 10.1016/j.jcrc.2018.04.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE To determine whether the addition of the frailty status assessed by the clinical frailty scale (CFS) to the SOFA score (SOFA-CFS) improves the performance of the SOFA score alone in predicting the hospital mortality of elderly critically ill patients. METHODS A prospective observational study performed between February 2015 and February 2016 including 189 patients aged ≥65 years and hospitalized ≥24 h in the intensive care unit (ICU). RESULTS The SOFA-CFS score did not improve the performance of the SOFA score alone in predicting hospital mortality (AUC = 0.66, 95% CI 0.58-0.74 vs AUC = 0.63, 95% CI 0.55-0.72, respectively, p = 0.082). The AUC of the CFS score was 0.62 (95% CI 0.53-0.71). In the multivariable analysis, age (OR: 1.09, 95% CI 1.03-1.16, p = 0.006), McCabe score C vs A (reference) and B vs A (reference) (OR: 8.28, 95% CI 2.83-24.27and OR: 2.29, 95% CI 1.02-5.12, p = 0.006, respectively), Glasgow coma score at admission (OR: 0.31, 95% CI 0.14-0.48, p = 0.003), and SOFA score (OR: 1.11, 95% CI 1.01-1.23, p = 0.037) were risk factors for hospital mortality. CONCLUSIONS The performance of the SOFA score in predicting hospital mortality was low, although it was an independent risk factor for mortality. The combination of frailty status with the SOFA score did not improve the performance of the SOFA score alone.
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Affiliation(s)
- Emilie Langlais
- CHU de Rennes, Service d'Anesthésie Réanimation 1, 2 rue Henri Le Guilloux, Rennes 35000, France.
| | - Nicolas Nesseler
- CHU de Rennes, Service d'Anesthésie Réanimation 1, 2 rue Henri Le Guilloux, Rennes 35000, France; Inserm, UMR 1214 NuMeCan, Rennes 35000, France; Inserm 1414, Centre d'Investigation Clinique, Rennes 35000, France; Université Rennes 1, Rennes 35000, France.
| | - Estelle Le Pabic
- Inserm 1414, Centre d'Investigation Clinique, Rennes 35000, France.
| | - Denis Frasca
- CHU de Poitiers, Inserm, UMR 1246, SPHERE, Universités de Nantes et Tours, France.
| | - Yoann Launey
- CHU de Rennes, Service d'Anesthésie Réanimation 1, 2 rue Henri Le Guilloux, Rennes 35000, France; Inserm, UMR 1214 NuMeCan, Rennes 35000, France; Université Rennes 1, Rennes 35000, France.
| | - Philippe Seguin
- CHU de Rennes, Service d'Anesthésie Réanimation 1, 2 rue Henri Le Guilloux, Rennes 35000, France; Inserm, UMR 1214 NuMeCan, Rennes 35000, France; Inserm 1414, Centre d'Investigation Clinique, Rennes 35000, France; Université Rennes 1, Rennes 35000, France.
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Pugh RJ, Ellison A, Pye K, Subbe CP, Thorpe CM, Lone NI, Clegg A. Feasibility and reliability of frailty assessment in the critically ill: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:49. [PMID: 29478414 PMCID: PMC6389132 DOI: 10.1186/s13054-018-1953-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/12/2018] [Indexed: 12/22/2022]
Abstract
Background For healthcare systems, an ageing population poses challenges in the delivery of equitable and effective care. Frailty assessment has the potential to improve care in the intensive care setting, but applying assessment tools in critical illness may be problematic. The aim of this systematic review was to evaluate evidence for the feasibility and reliability of frailty assessment in critical care. Methods Our primary search was conducted in Medline, Medline In-process, EMBASE, CINAHL, PsycINFO, AMED, Cochrane Database of Systematic Reviews, and Web of Science (January 2001 to October 2017). We included observational studies reporting data on feasibility and reliability of frailty assessment in the critical care setting in patients 16 years and older. Feasibility was assessed in terms of timing of evaluation, the background, training and expertise required for assessors, and reliance upon proxy input. Reliability was assessed in terms of inter-rater reliability. Results Data from 11 study publications are included, representing 8 study cohorts and 7761 patients. Proxy involvement in frailty assessment ranged from 58 to 100%. Feasibility data were not well-reported overall, but the exclusion rate due to lack of proxy availability ranged from 0 to 45%, the highest rate observed where family involvement was mandatory and the assessment tool relatively complex (frailty index, FI). Conventional elements of frailty phenotype (FP) assessment required modification prior to use in two studies. Clinical staff tended to use a simple judgement-based tool, the clinical frailty scale (CFS). Inter-rater reliability was reported in one study using the CFS and although a good level of agreement was observed between clinician assessments, this was a small and single-centre study. Conclusion Though of unproven reliability in the critically ill, CFS was the tool used most widely by critical care clinical staff. Conventional FP assessment required modification for general application in critical care, and an FI-based assessment may be difficult to deliver by the critical care team on a routine basis. There is a high reliance on proxies for frailty assessment, and the reliability of frailty assessment tools in critical care needs further evaluation. Prospero registration number CRD42016052073.
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Affiliation(s)
- Richard J Pugh
- Department of Anaesthetics, Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK.
| | - Amy Ellison
- Department of Anaesthetics, Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK
| | - Kate Pye
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | | | - Nazir I Lone
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Andrew Clegg
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
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Walker DM, Gale CP, Lip G, Martin-Sanchez FJ, McIntyre HF, Mueller C, Price S, Sanchis J, Vidan MT, Wilkinson C, Zeymer U, Bueno H. Editor's Choice - Frailty and the management of patients with acute cardiovascular disease: A position paper from the Acute Cardiovascular Care Association. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 7:176-193. [PMID: 29451402 DOI: 10.1177/2048872618758931] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Frailty is increasingly seen among patients with acute cardiovascular disease. A combination of an ageing population, improved disease survival, treatable long-term conditions as well as a greater recognition of the syndrome has accelerated the prevalence of frailty in the modern world. Yet, this has not been matched by an expansion of research. National and international bodies have identified acute cardiovascular disease in the frail as a priority area for care and an entity that requires careful clinical decisions, but there remains a paucity of guidance on treatment efficacy and safety, and how to manage this complex group. This position paper from the Acute Cardiovascular Care Association presents the latest evidence about frailty and the management of frail patients with acute cardiovascular disease, and suggests avenues for future research.
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Affiliation(s)
| | - C P Gale
- 2 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | - G Lip
- 3 Institute for Cardiovascular Sciences, University of Birmingham, UK.,4 Aalborg Thrombosis Research Unit, Aalborg University, Denmark
| | | | | | - C Mueller
- 6 Cardiovascular Research Institute Basel, University of Basel, Switzerland
| | - S Price
- 7 Royal Brompton Hospital, UK
| | - J Sanchis
- 8 Department of Cardiology, University of Valencia, Spain.,9 University of Valencia, CIBER CV, Spain
| | - M T Vidan
- 10 Department of Geriatrics, Universidad Complutense de Madrid Dr Esquerdo, Spain
| | - C Wilkinson
- 2 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | - U Zeymer
- 11 Klinikum Ludwigshafen und Institut for Herzinfarktforschung, Germany
| | - H Bueno
- 12 National Centre for Cardiovascular Research, Spain
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Abstract
Conceptualized first in the field of geriatrics, frailty is a syndrome characterized by a generalized vulnerability to stressors resulting from an accumulation of physiologic deficits across multiple interrelated systems. This accumulation of deficits results in poorer functional status and disability. Frailty is a "state of risk" for subsequent disproportionate declines in health status following new exposure to a physiologic stressor. Two predominant models have emerged to operationalize the measurement of frailty. The phenotype model defines frailty as a distinct clinical syndrome that includes conceptual domains such as strength, activity, wasting, and mobility. The cumulative deficit model defines frailty by enumerating the number of age-related things wrong with a person. The biological pathways driving frailty include chronic systemic inflammation, sarcopenia, and neuroendocrine dysregulation, among others. In adults with chronic lung disease, frailty is independently associated with more frequent exacerbations of lung disease, all-cause hospitalization, declines in functional status, and all-cause mortality. In addition, frail adults who become critically ill are more likely develop chronic critical illness or severe disability and have higher in-hospital and long-term mortality rates. The evaluation of frailty appears to provide important prognostic information above and beyond routinely collected measures in adults with chronic lung disease and the critically ill. The study of frailty in these populations, however, requires multipronged efforts aimed at refining clinical assessments, understanding the mechanisms, and developing therapeutic interventions.
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Va P, Rali P, Kota H, Keenan V, Mujtaba S, Naing W, Salgunan R, Galperin I, Epelbaum O. Home return following invasive mechanical ventilation for the oldest-old patients in medical intensive care units from two US hospitals. Lung India 2018; 35:461-466. [PMID: 30381553 PMCID: PMC6219131 DOI: 10.4103/lungindia.lungindia_76_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: The aging of the US population has been associated with an increase in intensive care unit (ICU) utilization and correspondingly, invasive mechanical ventilation (IMV) among the oldest-old (age ≥80 years). While previous studies have examined ICU and IMV outcomes in the elderly, very few have focused on patient-centered outcomes, specifically home return, in the oldest-old. We investigated the rate of immediate home return following IMV in the medical ICU in previously home-dwelling oldest-old patients relative to that of a comparison group of 50–70-year olds. Methods: Data were extracted retrospectively from patient records at Elmhurst Hospital Center in Elmhurst, NY, USA, encompassing the period from January 2009 to May 2014 and Jacobi Medical Center in the Bronx, NY, USA, from January 2010 to March 2014. Medical ICU admissions within those date ranges were screened for possible inclusion into one of two study groups based on age: ≥80 years old and 50–70 years old. The primary end point was hospital discharge: home return versus no home return (death or nonhome discharge). Cox proportional hazards’ regression models were used to estimate crude and multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for failure to return home. Results: A total of 375 patients were included in the analysis: 279 (74%) patients aged 50–70 years and 96 (26%) patients aged ≥80 years. Compared to 50–70-year olds, being ≥80 years old was associated with a nearly two-fold greater risk of no home return: adjusted HR: 1.96; 95% CI 1.43–2.67. The oldest-old was at significantly increased risk of both being discharged to a skilled nursing facility or subacute rehabilitation (adjusted HR: 2.19; 95% CI 1.33–3.59) as well as of dying in the hospital (adjusted HR: 1.81; 95% CI 1.21–2.71). Conclusion: Previously home-dwelling oldest-old are at significantly increased risk of failing to return home immediately following medical ICU admission with IMV as compared to patients aged 50–70 years. These results can help medical ICU staff establish appropriate expectations when addressing the families of their oldest patients. Further studies are needed to evaluate the potential for delayed home return among the oldest old and to assess the ability of frailty indices to predict home return within this ICU population.
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Affiliation(s)
- Puthiery Va
- Department of Internal Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Parth Rali
- Division of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Harshitha Kota
- Department of Internal Medicine, Elmhurst Hospital Center, Elmhurst, NY, USA
| | - Vivian Keenan
- Department of Internal Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Sobia Mujtaba
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Win Naing
- Department of Internal Medicine, Elmhurst Hospital Center, Elmhurst, NY, USA
| | - Reka Salgunan
- Division of Pulmonary and Critical Care Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Irene Galperin
- Division of Pulmonary and Critical Care Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Oleg Epelbaum
- Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Bagshaw SM, Muscedere J. Is This Intensive Care Unit Patient Frail? Unraveling the Complex Interplay between Frailty and Critical Illness. Am J Respir Crit Care Med 2017; 196:4-5. [PMID: 28665199 DOI: 10.1164/rccm.201612-2538ed] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Sean M Bagshaw
- 1 Department of Critical Care Medicine University of Alberta Edmonton, Alberta, Canada and
| | - John Muscedere
- 2 Department of Critical Care Medicine Queens University Kingston, Ontario, Canada
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Freire JCG, Nóbrega IRAPD, Dutra MC, Silva LMD, Duarte HA. Fatores associados à fragilidade em idosos hospitalizados: uma revisão integrativa. SAÚDE EM DEBATE 2017. [DOI: 10.1590/0103-1104201711517] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
RESUMO Objetivou-se sintetizar e avaliar a produção do conhecimento sobre os fatores significativamente associados à fragilidade em idosos hospitalizados. Para isso, foram consultadas as bases de dados Medical Literature and Retrieval System Online (Medline), Literatura Latino-Americana em Ciências da Saúde (Lilacs) e Índice Bibliográfico Español em Ciencias de la Salud (Ibecs), de 2012 a 2016, cuja análise de 20 artigos identificou fatores associados à fragilidade: maior mortalidade hospitalar e após alta, longa hospitalização, reinternação, transferências, idade avançada, sexo feminino e viuvez, além de fatores psicossociais, físicos e/ou funcionais. Espera-se que os resultados da revisão facilitem o aprimoramento de práticas e a tomada de decisão das equipes multiprofissionais que prestam assistência ao idoso no ambiente hospitalar.
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Pritchard JM, Kennedy CC, Karampatos S, Ioannidis G, Misiaszek B, Marr S, Patterson C, Woo T, Papaioannou A. Measuring frailty in clinical practice: a comparison of physical frailty assessment methods in a geriatric out-patient clinic. BMC Geriatr 2017; 17:264. [PMID: 29132301 PMCID: PMC5683585 DOI: 10.1186/s12877-017-0623-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 10/08/2017] [Indexed: 01/13/2023] Open
Abstract
Background The objectives of this study were to determine: 1) the prevalence of frailty using Fried’s phenotype method and the Short Performance Physical Battery (SPPB), 2) agreement between frailty assessment methods, 3) the feasibility of assessing frailty using Fried’s phenotype method and the SPPB. Methods This cross-sectional study was conducted at a geriatric out-patient clinic in Hamilton, Canada. A research assistant conducted all frailty assessments. Patients were classified as non-frail, pre-frail or frail according to Fried’s phenotype method and the SPPB. Agreement among methods is reported using the Cohen kappa statistic (standard error). Feasibility data included the percent of eligible participants agreeing to attempt the frailty assessments (criterion for feasibility: ≥90% of patients agreeing to the frailty assessment), equipment required, and safety considerations. A p-value of <0.05 is considered significant. Results A total of 110 participants (92%) and 109 participants (91%) agreed to attempt Fried’s phenotype method and SPPB, respectively. No adverse events occurred during any assessments. According to Fried’s phenotype method, the prevalence of frailty and pre-frailty was 35% and 56%, respectively, and according to the SPPB, the prevalence of frailty and pre-frailty was 50% and 35%, respectively. There was fair to moderate agreement between methods for determining which participants were frail (0.488 [0.082], p < 0.001) and pre-frail (0.272 [0.084], p = 0.002). Conclusions Frailty and pre-frailty are common in this geriatric outpatient population, and there is fair to moderate agreement between Fried’s phenotype method and the SPPB. Over 90% of the patients who were eligible for the study agreed to attempt the frailty assessments, demonstrating that according to our feasibility criteria, frailty can be assessed in this patient population. Assessing frailty may help clinicians identify high-risk patients and tailor interventions based on baseline frailty characteristics.
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Affiliation(s)
- J M Pritchard
- Geriatric Education and Research for the Aging Sciences (GERAS), St Peter's Hospital, 88 Maplewood Ave, Hamilton, ON, L8M 1W9, Canada. .,Department of Kinesiology and Interdisciplinary Science, McMaster University, 1280 Main St West, Hamilton, ON, L8S 4L8, Canada.
| | - C C Kennedy
- Geriatric Education and Research for the Aging Sciences (GERAS), St Peter's Hospital, 88 Maplewood Ave, Hamilton, ON, L8M 1W9, Canada.,Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON, L8S 4L8, Canada
| | - S Karampatos
- Population Health Research Institute (PHRI), St. Joseph's Healthcare, Hamilton, ON, L8N 4A6, Canada
| | - G Ioannidis
- Geriatric Education and Research for the Aging Sciences (GERAS), St Peter's Hospital, 88 Maplewood Ave, Hamilton, ON, L8M 1W9, Canada.,Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON, L8S 4L8, Canada
| | - B Misiaszek
- Geriatric Education and Research for the Aging Sciences (GERAS), St Peter's Hospital, 88 Maplewood Ave, Hamilton, ON, L8M 1W9, Canada.,Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON, L8S 4L8, Canada
| | - S Marr
- Geriatric Education and Research for the Aging Sciences (GERAS), St Peter's Hospital, 88 Maplewood Ave, Hamilton, ON, L8M 1W9, Canada.,Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON, L8S 4L8, Canada
| | - C Patterson
- Geriatric Education and Research for the Aging Sciences (GERAS), St Peter's Hospital, 88 Maplewood Ave, Hamilton, ON, L8M 1W9, Canada.,Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON, L8S 4L8, Canada
| | - T Woo
- Geriatric Education and Research for the Aging Sciences (GERAS), St Peter's Hospital, 88 Maplewood Ave, Hamilton, ON, L8M 1W9, Canada.,Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON, L8S 4L8, Canada
| | - A Papaioannou
- Geriatric Education and Research for the Aging Sciences (GERAS), St Peter's Hospital, 88 Maplewood Ave, Hamilton, ON, L8M 1W9, Canada.,Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON, L8S 4L8, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON, L8S 4L8, Canada
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47
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Outcomes of Nonagenarians Admitted to the Cardiac Intensive Care Unit by the Elders Risk Assessment Score for Long-Term Mortality Risk Stratification. Am J Cardiol 2017; 120:1421-1426. [PMID: 28844513 DOI: 10.1016/j.amjcard.2017.07.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 06/16/2017] [Accepted: 07/03/2017] [Indexed: 12/23/2022]
Abstract
There are limited data on outcomes of older adults admitted to cardiac intensive care units (CICU), and there are no data on outcomes after admission to the CICU in nonagenarians. Our purpose was to identify whether the Elders Risk Assessment (ERA) index could risk stratify older adults after CICU admission. We retrospectively identified 453 nonagenarians admitted to the CICU between 2004 and 2013. End points included mortality, length of stay, incidence of delirium, and discharge disposition. Average age of the cohort was 92 ± 2 years, and the average ERA score was 13 ± 6. A total of 258 patients were female (57%). Most common admission indication was acute decompensated heart failure (57%) followed by acute myocardial infarction (49%). Loss of independence was observed after CICU admission, with 66% of patients living independently before admission, decreasing to 47% at discharge. Overall length of stay was 6 ± 5 days and CICU stay was 2 ± 2 days. Fifteen percent of patients died before hospital discharge. Median survival was 452 (interquartile range 40 to 1,371) days. ERA score effectively predicted survival (log-rank test, p = 0.002). ERA score of 16 or greater and ERA score of 9 to 15 were both associated with increased risk of mortality compared with the reference (score 4 to 8): hazard ratio 2.00, 95% confidence interval 1.37 to 2.90, p = 0.003, and hazard ratio 1.48, 95% confidence interval 1.06 to 2.08, p = 0.02, respectively. In conclusion, nonagenarians admitted to CICU experience reasonable outcomes. The ERA score effectively risk stratifies nonagenarians admitted to the CICU and may help with identification of vulnerable patients at risk of adverse outcomes.
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48
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Rodrigues MK, Marques A, Lobo DML, Umeda IIK, Oliveira MF. Pre-Frailty Increases the Risk of Adverse Events in Older Patients Undergoing Cardiovascular Surgery. Arq Bras Cardiol 2017; 109:299-306. [PMID: 28876376 PMCID: PMC5644209 DOI: 10.5935/abc.20170131] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/19/2017] [Indexed: 12/20/2022] Open
Abstract
Background Frailty is identified as a major predictor of adverse outcomes in older
surgical patients. However, the outcomes in pre-frail patients after
cardiovascular surgery remain unknown. Objective To investigate the main outcomes (length of stay, mechanical ventilation
time, stroke and in-hospital death) in pre-frail patients in comparison with
no-frail patients after cardiovascular surgery. Methods 221 patients over 65 years old, with established diagnosis of myocardial
infarction or valve disease were enrolled. Patients were evaluated by
Clinical Frailty Score (CFS) before surgery and allocated into 2 groups:
no-frailty (CFS 1~3) vs. pre-frailty (CFS 4) and followed up for main
outcomes. For all analysis, the statistical significance was set at 5% (p
< 0.05). Results No differences were found in anthropometric and demographic data between
groups (p > 0.05). Pre-frail patients showed a longer mechanical
ventilation time (193 ± 37 vs. 29 ± 7 hours; p<0.05) than
no-frail patients; similar results were observed for length of stay at the
intensive care unit (5 ± 1 vs. 3 ± 1 days; p < 0.05) and
total time of hospitalization (12 ± 5 vs. 9 ± 3 days; p <
0.05). In addition, the pre-frail group had a higher number of adverse
events (stroke 8.3% vs. 3.9%; in-hospital death 21.5% vs. 7.8%; p < 0.05)
with an increased risk for development stroke (OR: 2.139, 95% CI:
0.622-7.351, p = 0.001; HR: 2.763, 95%CI: 1.206-6.331, p = 0.0001) and
in-hospital death (OR: 1.809, 95% CI: 1.286-2.546, p = 0.001; HR: 1.830, 95%
CI: 1.476-2.269, p = 0.0001). Moreover, higher number of pre-frail patients
required homecare services than no-frail patients (46.5% vs. 0%; p <
0.05). Conclusion Patients with pre-frailty showed longer mechanical ventilation time and
hospital stay with an increased risk for cardiovascular events compared with
no-frail patients.
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Affiliation(s)
| | - Artur Marques
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil
| | - Denise M L Lobo
- Faculdade Metropolitana da Grande Fortaleza, Fortaleza, CE, Brazil
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Layton AM, Armstrong HF, Baldwin MR, Podolanczuk AJ, Pieszchata NM, Singer JP, Arcasoy SM, Meza KS, D'Ovidio F, Lederer DJ. Frailty and maximal exercise capacity in adult lung transplant candidates. Respir Med 2017; 131:70-76. [PMID: 28947046 DOI: 10.1016/j.rmed.2017.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 08/07/2017] [Accepted: 08/08/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Frail lung transplant candidates are more likely to be delisted or die without receiving a transplant. Further knowledge of what frailty represents in this population will assist in developing interventions to prevent frailty from developing. We set out to determine whether frail lung transplant candidates have reduced exercise capacity independent of disease severity and diagnosis. METHODS Sixty-eight adult lung transplant candidates underwent cardiopulmonary exercise testing (CPET) and a frailty assessment (Fried's Frailty Phenotype (FFP)). Primary outcomes were peak workload and peak aerobic capacity (V˙O2). We used linear regression to adjust for age, gender, diagnosis, and lung allocation score (LAS). RESULTS The mean ± SD age was 57 ± 11 years, 51% were women, 57% had interstitial lung disease, 32% had chronic obstructive pulmonary disease, 11% had cystic fibrosis, and the mean LAS was 40.2 (range 19.2-94.5). In adjusted models, peak workload decreased by 10 W (95% CI 4.7 to 14.6) and peak V˙O2 decreased by 1.8 mL/kg/min (95% CI 0.6 to 2.9) per 1 unit increment in FFP score. After adjustment, exercise tolerance was 38 W lower (95% CI 18.4 to 58.1) and peak V˙O2 was 8.5 mL/kg/min lower (95% CI 3.3 to 13.7) among frail participants compared to non-frail participants. Frailty accounted for 16% of the variance (R2) of watts and 19% of the variance of V˙O2 in adjusted models. CONCLUSION Frailty contributes to reduced exercise capacity among lung transplant candidates independent of disease severity.
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Affiliation(s)
- Aimee M Layton
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, NY, USA.
| | - Hilary F Armstrong
- Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Matthew R Baldwin
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Anna J Podolanczuk
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Nicole M Pieszchata
- Department of Rehabilitation and Regenerative Medicine, Columbia University Medical Center, New York, NY, USA
| | - Jonathan P Singer
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Selim M Arcasoy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | | | - Frank D'Ovidio
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - David J Lederer
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
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50
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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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