1
|
Wernly B, Bruno RR, Beil M, Flaatten H, Kelm M, Sigal S, Szczeklik W, Elhadi M, Joannidis M, Koköfer A, Oeyen S, Marsh B, Moreno R, Wernly S, Leaver S, De Lange DW, Guidet B, Jung C. Frailty's influence on 30-day mortality in old critically ill ICU patients: a bayesian analysis evaluating the clinical frailty scale. Ann Intensive Care 2023; 13:126. [PMID: 38091131 PMCID: PMC10719192 DOI: 10.1186/s13613-023-01223-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Frailty is widely acknowledged as influencing health outcomes among critically ill old patients. Yet, the traditional understanding of its impact has predominantly been through frequentist statistics. We endeavored to explore this association using Bayesian statistics aiming to provide a more nuanced understanding of this multifaceted relationship. METHODS Our analysis incorporated a cohort of 10,363 older (median age 82 years) patients from three international prospective studies, with 30-day all-cause mortality as the primary outcome. We defined frailty as Clinical Frailty Scale ≥ 5. A hierarchical Bayesian logistic regression model was employed, adjusting for covariables, using a range of priors. An international steering committee of registry members reached a consensus on a minimal clinically important difference (MCID). RESULTS In our study, the 30-day mortality was 43%, with rates of 38% in non-frail and 51% in frail groups. Post-adjustment, the median odds ratio (OR) for frailty was 1.60 (95% CI 1.45-1.76). Frailty was invariably linked to adverse outcomes (OR > 1) with 100% probability and had a 90% chance of exceeding the minimal clinically important difference (MCID) (OR > 1.5). For the Clinical Frailty Scale (CFS) as a continuous variable, the median OR was 1.19 (1.16-1.22), with over 99% probability of the effect being more significant than 1.5 times the MCID. Frailty remained outside the region of practical equivalence (ROPE) in all analyses, underscoring its clinical importance regardless of how it is measured. CONCLUSIONS This research demonstrates the significant impact of frailty on short-term mortality in critically ill elderly patients, particularly when the Clinical Frailty Scale (CFS) is used as a continuous measure. This approach, which views frailty as a spectrum, enables more effective, personalized care for this vulnerable group. Significantly, frailty was consistently outside the region of practical equivalence (ROPE) in our analysis, highlighting its clinical importance.
Collapse
Affiliation(s)
- Bernhard Wernly
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University of Salzburg, 5020, Salzburg, Austria
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, 5020, Salzburg, Austria
| | - Raphael Romano Bruno
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, 40225, Düsseldorf, Germany
| | - Michael Beil
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, 91120, Jersualem, Israel
| | - Hans Flaatten
- Department of Clinical Medicine, University of Bergen, Department of Anaestesia and Intensive Care, Haukeland University Hospital, 5021, Bergen, Norway
| | - Malte Kelm
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, 40225, Düsseldorf, Germany
- Cardiovascular Research Institute Düsseldorf (CARID), Medical Faculty, Heinrich-Heine University, Duesseldorf, Germany
| | - Sviri Sigal
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, 91120, Jersualem, Israel
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, 31-008, Krakow, Poland
| | - Muhammed Elhadi
- Faculty of Medicine, University of Tripoli, R6XF+46G, Tripoli, Libya
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Andreas Koköfer
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University of Salzburg, 5020, Salzburg, Austria
| | - Sandra Oeyen
- Department of Intensive Care 1K12IC, Ghent University Hospital, 9000, Ghent, Belgium
| | - Brian Marsh
- Mater Misericordiae University Hospital, Dublin, D07 R2WY, Ireland
| | - Rui Moreno
- Centro Hospitalar de Lisboa Central, Faculdade de Ciências Médicas de Lisboa, Nova Medical School, Lisboa, Portugal
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
| | - Sarah Wernly
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, 5020, Salzburg, Austria
| | - Susannah Leaver
- General Intensive Care, St. George´S University Hospital NHS Foundation Trust, London, SW17 0QT, UK
| | - Dylan W De Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, 3584 CX, Utrecht, Utrecht, The Netherlands
| | - Bertrand Guidet
- Inserm, Service de'Réanimation, Sorbonne Université, Hôpital Saint-Antoine, Institut Pierre-Louis d'épidémiologie Et de Santé Publique, AP-HP, 184, Rue du Faubourg-Saint-Antoine, 75012, Paris, France
| | - Christian Jung
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, 40225, Düsseldorf, Germany.
- Faculty of Medicine, University of Tripoli, R6XF+46G, Tripoli, Libya.
- Division of Cardiology, Pulmonology and Vascular Medicine, University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.
| |
Collapse
|
2
|
Wehrfritz A, Schmidt J, Bremer F, Lang A, Welzer J, Castellanos I. Ethical conflicts associated with COVID-19 pandemic, triage and frailty-unexpected positive disease progression in a 90-year-old patient: A case report. Clin Case Rep 2023; 11:e7710. [PMID: 37476601 PMCID: PMC10354352 DOI: 10.1002/ccr3.7710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 07/22/2023] Open
Abstract
During the COVID 19 pandemic, advanced age, scoring systems, and a shortage of ICU beds were used as cut-offs for ICU admission. This case report describes the epicrisis of an elderly patient who was almost mistakenly not treated in an ICU.
Collapse
Affiliation(s)
- Andreas Wehrfritz
- Department of AnaesthesiologyUniversity hospital of Erlangen, Faculty of Medicine, Friedrich‐Alexander‐University ErlangenErlangenGermany
| | - Joachim Schmidt
- Department of AnaesthesiologyUniversity hospital of Erlangen, Faculty of Medicine, Friedrich‐Alexander‐University ErlangenErlangenGermany
| | - Frank Bremer
- Department of AnaesthesiologyUniversity hospital of Erlangen, Faculty of Medicine, Friedrich‐Alexander‐University ErlangenErlangenGermany
| | - Anne‐Katharina Lang
- Department of AnaesthesiologyUniversity hospital of Erlangen, Faculty of Medicine, Friedrich‐Alexander‐University ErlangenErlangenGermany
| | - Jacob Welzer
- Department of AnaesthesiologyKlinikum FuerthFuerthGermany
| | - Ixchel Castellanos
- Department of AnaesthesiologyUniversity hospital of Erlangen, Faculty of Medicine, Friedrich‐Alexander‐University ErlangenErlangenGermany
| |
Collapse
|
3
|
De Geer L, Fredrikson M, Chew MS. Frailty is a stronger predictor of death in younger intensive care patients than in older patients: a prospective observational study. Ann Intensive Care 2022; 12:120. [PMID: 36586004 PMCID: PMC9803889 DOI: 10.1186/s13613-022-01098-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 12/20/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND While frailty is a known predictor of adverse outcomes in older patients, its effect in younger populations is unknown. This prospective observational study was conducted in a tertiary-level mixed ICU to assess the impact of frailty on long-term survival in intensive care patients of different ages. METHODS Data on premorbid frailty (Clinical Frailty Score; CFS), severity of illness (the Simplified Acute Physiology Score, third version; SAPS3), limitations of care and outcome were collected in 817 adult ICU patients. Hazard ratios (HR) for death within 180 days after ICU admission were calculated. Unadjusted and adjusted analyses were used to evaluate the association of frailty with outcome in different age groups. RESULTS Patients were classified into predefined age groups (18-49 years (n = 241), 50-64 (n = 188), 65-79 (n = 311) and 80 years or older (n = 77)). The proportion of frail (CFS ≥ 5) patients was 41% (n = 333) in the overall population and increased with each age strata (n = 46 (19%) vs. n = 67 (36%) vs. n = 174 (56%) vs. n = 46 (60%), P < 0.05). Frail patients had higher SAPS3, more treatment restrictions and higher ICU mortality. Frailty was associated with an increased risk of 180-day mortality in all age groups (HR 5.7 (95% CI 2.8-11.4), P < 0.05; 8.0 (4.0-16.2), P < 0.05; 4.1 (2.2-6.6), P < 0.05; 2.4 (1.1-5.0), P = 0.02). The effect remained significant after adjustment for SAPS3, comorbidity and limitations of treatment only in patients aged 50-64 (2.1 (1.1-3.1), P < 0.05). CONCLUSIONS Premorbid frailty is common in ICU patients of all ages and was found in 55% of patients aged under 64 years. Frailty was independently associated with mortality only among middle-aged patients, where the risk of death was increased twofold. Our study supports the use of frailty assessment in identifying younger ICU patients at a higher risk of death.
Collapse
Affiliation(s)
- Lina De Geer
- grid.5640.70000 0001 2162 9922Department of Anaesthesiology and Intensive Care, and Department of Biomedical and Clinical Sciences, Linköping University, 581 83 Linköping, Sweden
| | - Mats Fredrikson
- grid.5640.70000 0001 2162 9922Division of Occupational and Environmental Medicine, Department of Clinical and Experimental Medicine and Forum Östergötland, All at Linköping University, 581 83 Linköping, Sweden
| | - Michelle S. Chew
- grid.5640.70000 0001 2162 9922Department of Anaesthesiology and Intensive Care, and Department of Biomedical and Clinical Sciences, Linköping University, 581 83 Linköping, Sweden
| |
Collapse
|