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DeGroot L, Pavlovic N, Perrin N, Gilotra NA, Miller H, Denfeld QE, McIlvennan CK, Dy SM, Davidson PM, Szanton SL, Abshire Saylor M. The Association of Unmet Palliative Care Needs and Physical Frailty With Clinical Outcomes: A Prospective Study of Adults With Heart Failure. J Cardiovasc Nurs 2024:00005082-990000000-00185. [PMID: 38635901 DOI: 10.1097/jcn.0000000000001087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND People with heart failure, particularly those who are physically frail, experience complex needs that can be addressed by palliative care (PC). However, we have a limited understanding of how the intersection of unmet PC needs and physical frailty contributes to health-related quality of life (HRQOL) and risk for hospitalization or mortality. OBJECTIVE In this study, we sought to examine the association of unmet PC needs and physical frailty with clinical outcomes (baseline HRQOL and hospitalizations or mortality at 6 months). METHODS We recruited a convenience sample of community-dwelling persons with heart failure from an urban hospital system who were older than 50 years and hospitalized in the last year. We measured physical frailty using the FRAIL scale (nonfrail, 0-2; frail, 3-5), PC needs using the Integrated Palliative Outcome Scale (range, 0-58; higher scores indicating higher needs), and HRQOL using the Kansas City Cardiomyopathy Questionnaire (range, 0-100; higher scores indicate higher HRQOL). We performed multivariable linear regression to test the relationships between physical frailty, PC needs, and HRQOL, and multivariable logistic regression for associations with all-cause 6-month hospitalization or mortality. We also performed an exploratory analysis of 4 PC needs/frailty groups (high PC needs/frail, high PC needs/nonfrail, low PC needs/frail, low PC needs/nonfrail) with outcomes. RESULTS In our overall sample (n = 298), mean (SD) age was 68 (9.8) years, 37% were women (n = 108), 28% identified as Black/African American (n = 84), and 65% had heart failure with preserved ejection fraction (n = 194). Mean PC needs score was 19.7, and frail participants (n = 130, 44%) had a significantly higher mean PC needs score than nonfrail participants (P < .001). Those with higher PC needs (Integrated Palliative Care Outcome Scale ≥ 20) had significantly worse HRQOL (P < .001) and increased odds of hospitalization or mortality (odds ratio, 2.5; P < .01) compared with those with lower PC needs, adjusting for covariates. Physically frail participants had significantly worse HRQOL (P < .001) and higher odds of hospitalization or mortality at 6 months (odds ratio, 2.6; P < .01) than nonfrail participants, adjusting for covariates. In an exploratory analysis, physically frail participants with high PC needs had the lowest HRQOL score, with an average score of 28.6 points lower (P < .001) and 4.6 times higher odds of hospitalization or mortality (95% confidence interval, 2.03-10.43; P < .001) than low-needs/nonfrail participants. CONCLUSION Higher unmet PC needs and physical frailty, separately and in combination, were associated with lower HRQOL and higher odds of hospitalization or mortality. Self-reported PC needs and physical frailty assessment in clinical settings may improve identification of patients at the highest risk for poor HRQOL and hospitalization or mortality amenable to PC intervention.
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Sridhar M, Bodduluri S, O'Hare L, Blumhoff S, Acosta Lara MDP, de Andrade JA, Kim YI, Luckhardt T, McDonald M, Kulkarni T. Association of musculoskeletal involvement with lung function and mortality in patients with idiopathic pulmonary fibrosis. Respir Res 2024; 25:81. [PMID: 38326848 PMCID: PMC10851557 DOI: 10.1186/s12931-024-02705-5] [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] [Received: 11/07/2023] [Accepted: 01/25/2024] [Indexed: 02/09/2024] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a progressive disease associated with high mortality. Low muscle mass, frailty and sarcopenia lead to functional impairment that negatively impact quality of life and survival but are not used in clinical practice. We aimed to determine the association of Fat-free mass index (FFMI) and frailty with lung function, exercise tolerance and survival in patients with IPF. In this study, 70 patients with IPF underwent assessment of body composition, lung function, 6-min walk distance (6MWD) testing, hand grip strength, quality of life (QoL) assessment by St. George's Respiratory questionnaire (SGRQ) and frailty assessment using the SHARE-FI tool. FFMI was calculated using pectoralis muscle cross-sectional area (PM-CSA) on CT chest images and the lowest quartile defined reduced muscle mass. Sarcopenia was defined as low FFMI and handgrip strength. Regression analyses were conducted to determine predictive value of frailty, low FFMI and sarcopenia on clinical outcomes. The Cox proportional hazards model was used to analyze the impact of FFMI and frailty score on survival. The mean age was 70 years with moderate impairment in lung function (mean ppFVC 68.5%, ppDLCO 45.6%). Baseline forced vital capacity (p < 0.001), diffusion capacity of lung for carbon monoxide (p = < 0.01), 6WMD (p < 0.05) were significantly lower in frail patients compared to non-frail patients. BMI was found to closely correlate with FFMI (r = 0.79, p < 0.001), but not with frailty score (r = - 0.2, p = 0.07). Frailty was a significant predictor of FVC, DLCO, 6MWD, SGRQ scores when adjusted for age and gender. Muscle mass and sarcopenia were significant predictors of FVC, DLCO, but not 6MWD or QoL scores. Multivariate cox-proportional hazards ratio model adjusting for age and gender showed that frailty was significantly associated with increased mortality (HR = 2.6, 95% CI 1.1-6.1). Low FFMI (HR = 1.3, 95% CI 0.6-2.8), and sarcopenia (HR = 2.1, 95% CI 0.8-5.3), though associated with a trend to increased mortality, were not statistically significant. Frailty is associated with lower lung function and higher mortality in patients with IPF. Longitudinal evaluations are necessary to further determine the associations between low FFMI, sarcopenia and frailty with outcomes in IPF.
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Affiliation(s)
- Meenakshi Sridhar
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sandeep Bodduluri
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lanier O'Hare
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Maria Del Pilar Acosta Lara
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joao A de Andrade
- Division of Pulmonary, Allergy and Critical Care Medicine, Vanderbilt University, Nashville, TN, USA
| | - Young-Il Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tracy Luckhardt
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - MerryLynn McDonald
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Genetics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tejaswini Kulkarni
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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Howard FD, Green R, Harris J, Ross J, Nicholson C. Understanding the extent to which PROMs and PREMs used with older people with severe frailty capture their multidimensional needs: A scoping review. Palliat Med 2024; 38:184-199. [PMID: 38268061 PMCID: PMC10865766 DOI: 10.1177/02692163231223089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
BACKGROUND Older people with severe frailty are nearing the end of life but their needs are often unknown and unmet. Systematic ways to capture and measure the needs of this group are required. Patient reported Outcome Measures (PROMs) & Patient reported Experience Measures (PREMs) are possible tools to assist this. AIM To establish whether, and in what ways, the needs of older people living with severe frailty are represented within existing PROMs and PREMs and to examine the extent to which the measures have been validated with this patient group. DESIGN The scoping review follows the method of Arksey and O'Malley. RESULTS Seventeen papers from 9 countries meeting the inclusion criteria and 18 multi-dimensional measures were identified: 17 PROMs, and 1 PROM with PREM elements. Seven out of the 18 measures had evidence of being tested for validity with those with frailty. No measure was developed specifically for a frail population. Using the adapted framework of palliative need, five measures covered all five domains of palliative need (IPOS, ICECAP-SCM, PDI, WHOQOL-BREF, WHOQOL-OLD). The coverage of items within the domains varied between the measures. CONCLUSION Existing PROMs and PREMs are not well designed for what we know about the needs of older people with severe frailty. Future research should firstly focus on adapting and validating the existing measures to ensure they are fit for purpose, and secondly on developing a better understanding of how measures are used to deliver/better person-centred care.
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Affiliation(s)
- Faith D Howard
- Department of Health Sciences, University of Surrey, Guildford, UK
| | - Richard Green
- Department of Health Sciences, University of Surrey, Guildford, UK
| | - Jenny Harris
- Department of Health Sciences, University of Surrey, Guildford, UK
| | - Joy Ross
- St Christopher’s Hospice, London, UK
| | - Caroline Nicholson
- Department of Health Sciences, University of Surrey, Guildford, UK
- St Christopher’s Hospice, London, UK
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Dewhurst F, Hanratty B, Frew K, Paes P, Walker R, Barnes C, Maddock H, Elverson J, Byrne-Davis L. Palliative medicine trainees be should learn about frailty: meta-synthesis and Delphi study to establish curriculum content. BMJ Support Palliat Care 2024; 13:e1008-e1018. [PMID: 34815248 DOI: 10.1136/bmjspcare-2021-003013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 10/02/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Frailty is common and highly associated with morbidity and mortality, a fact that has been highlighted by COVID-19. Understanding how to provide palliative care for frail individuals is an international priority, despite receiving limited mention in Palliative Medicine curricula or examinations worldwide. This study aimed to synthesise evidence and establish expert consensus on what should be included in a Palliative-Medicine Specialist Training Curriculum for frailty. METHODS Literature Meta-synthesis conducted by palliative medicine, frailty and education experts produced a draft curriculum with Bologna based Learning-Outcomes. A Delphi study asked experts to rate the importance of Learning-Outcomes for specialist-training completion and propose additional Learning-Outcomes. This process was repeated until 70% consensus was achieved for over 90% of Learning-Outcomes. Experts divided Learning-Outcomes into specific (for inclusion in a frailty subsection) or generic (applicable to other palliative conditions). The Delphi panel was Subject Matter Experts: Palliative-Medicine Consultants (n=14) and Trainees (n=10), representing hospital, community, hospice and care home services and including committee members of key national training organisations. A final reviewing panel of Geriatric Medicine Specialists including experts in research methodology, national training requirements and frailty were selected. RESULTS The meta-synthesis produced 114 Learning-Outcomes. The Delphi Study and Review by Geriatric Medicine experts resulted in 46 essential and 33 desirable Learning-Outcomes. CONCLUSIONS This frailty curriculum is applicable internationally and highlights the complex and unique palliative needs of frail patients. Future research is required to inform implementation, educational delivery and service provision.
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Affiliation(s)
- Felicity Dewhurst
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
- St Oswalds Hospice, Newcastle upon Tyne, UK
| | - Barbara Hanratty
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Katherine Frew
- Palliative Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Paul Paes
- Palliative Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
- School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
| | - Richard Walker
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
- Geriatric Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Catherine Barnes
- Geriatric Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Helena Maddock
- Geriatic Medicine, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | | | - Lucie Byrne-Davis
- Division of Medical Education, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Israelsson‐Skogsberg Å, Eriksson T, Lindberg E. A scoping review of older patients' health-related quality of life, recovery and well-being after intensive care. Nurs Open 2023; 10:5900-5919. [PMID: 37306357 PMCID: PMC10416077 DOI: 10.1002/nop2.1873] [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: 08/17/2022] [Revised: 05/09/2023] [Accepted: 05/23/2023] [Indexed: 06/13/2023] Open
Abstract
AIMS In the present study, we aimed to determine how Health-Related Quality of Life (HRQoL), recovery (function and capacity in daily life) and well-being are followed up and characterised in persons ≥65 years of age who were being cared for in an intensive care unit (ICU). DESIGN A scoping review. METHODS CINAHL, MEDLINE (Ovid) and PsycINFO databases were searched in October 2021. 20 studies met the inclusion criteria. The scoping review followed the principles outlined by Arksey and O'Malley, and the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) checklist and Joanna Briggs Institute (JBI) framework were used. RESULTS Results are presented under five subheadings: Study characteristics, Type of studies, Methods for follow-up, health-related quality of life, and Recovery. Time seems to be an important factor regarding HRQoL among older patients being cared for in an ICU, with most elderly survivors perceiving their HRQoL as acceptable after 1 year. Nevertheless, several studies showed patients' willingness to be readmitted to the ICU if necessary, indicating that life is worth fighting for. PATIENT OR PUBLIC CONTRIBUTION Due to the design of the study, this study involves no patient or public contribution.
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Affiliation(s)
- Åsa Israelsson‐Skogsberg
- Faculty of Medicine, Department of Health SciencesLund UniversityLundSweden
- Faculty of Caring Science, Work Life and Social WelfareUniversity of BoråsBoråsSweden
| | - Thomas Eriksson
- Faculty of Caring Science, Work Life and Social WelfareUniversity of BoråsBoråsSweden
| | - Elisabeth Lindberg
- Faculty of Caring Science, Work Life and Social WelfareUniversity of BoråsBoråsSweden
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DeGroot L, Pavlovic N, Perrin N, Gilotra NA, Dy SM, Davidson PM, Szanton SL, Saylor MA. Palliative Care Needs of Physically Frail Community-Dwelling Older Adults With Heart Failure. J Pain Symptom Manage 2023; 65:500-509. [PMID: 36736499 PMCID: PMC10192105 DOI: 10.1016/j.jpainsymman.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/29/2022] [Accepted: 01/13/2023] [Indexed: 02/03/2023]
Abstract
CONTEXT Physical frailty is emerging as a potential "trigger" for palliative care (PC) consultation, but the PC needs of physically frail persons with heart failure (HF) in the outpatient setting have not been well described. OBJECTIVES This study describes the PC needs of community dwelling, physically frail persons with HF. METHODS We included persons with HF ≥50 years old who experienced ≥1 hospitalization in the prior year and excluded those with moderate/severe cognitive impairment, hospice patients, or non-English speaking persons. Measures included the FRAIL scale (0-5: 0 = robust, 1-2 = prefrail, 3-5 = frail) and the Integrated Palliative Outcome Scale (IPOS) (17 items, score 0-68; higher score = higher PC needs). Multiple linear regression tested the association between frailty group and palliative care needs. RESULTS Participants (N = 286) had a mean age of 68 (range 50-92) were majority male (63%) and White (68%) and averaged two hospitalizations annually. Most were physically frail (44%) or prefrail (41%). Mean PC needs (IPOS) score was 19.7 (range 0-58). On average, participants reported 5.86 (SD 4.28) PC needs affecting them moderately, severely, or overwhelmingly in the last week. Patient-perceived family/friend anxiety (58%) weakness/lack of energy (58%), and shortness of breath (47%) were the most prevalent needs. Frail participants had higher mean PC needs score (26) than prefrail (16, P < 0.001) or robust participants (11, P < 0.001). Frail participants experienced an average of 8.32 (SD 3.72) moderate/severe/overwhelming needs compared to prefrail (4.56, SD 3.77) and robust (2.39, SD 2.91) participants (P < 0.001). Frail participants reported higher prevalence of weakness/lack of energy (83%), shortness of breath (66%), and family/friend anxiety (69%) than prefrail (48%, 39%, 54%) or robust (13%, 14%, 35%) participants (P < 0.001). CONCLUSION Physically frail people with HF have higher unmet PC needs than those who are nonfrail. Implementing PC needs and frailty assessments may help identify vulnerable patients with unmet needs requiring further assessment and follow-up.
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Affiliation(s)
- Lyndsay DeGroot
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA.
| | - Noelle Pavlovic
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Nancy Perrin
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Nisha A Gilotra
- Johns Hopkins University School of Medicine (N.A.G), Baltimore, Maryland, USA
| | - Sydney M Dy
- Johns Hopkins University School of Public Health (S.M.D), Baltimore, Maryland, USA
| | | | - Sarah L Szanton
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Martha Abshire Saylor
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
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7
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Hoffmann AJ, Tin AL, Vickers AJ, Shahrokni A. Preoperative frailty vs. cognitive impairment: Which one matters most for postoperative delirium among older adults with cancer? J Geriatr Oncol 2023; 14:101479. [PMID: 37001348 PMCID: PMC10530636 DOI: 10.1016/j.jgo.2023.101479] [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] [Received: 08/25/2022] [Revised: 02/07/2023] [Accepted: 03/11/2023] [Indexed: 03/31/2023]
Abstract
INTRODUCTION Limited data are available to explore the association between preoperative frailty and cognitive impairment with postoperative delirium among older adults with cancer. We explored this association in a single Comprehensive Cancer Center where postoperative delirium and frailty are assessed in routine care using the Confusion Assessment Method (CAM) and Memorial Sloan Kettering Frailty Index (MSK-FI), respectively. MATERIALS AND METHODS Retrospective study on patients with cancer, aged 65+, who underwent surgery from April 2018 to March 2019 with hospital stay ≥1 day. We used logistic regression with postoperative delirium as the outcome, primary predictor MSK-FI, adjusted for age, operative time, and preoperative albumin. As the MSK-FI includes a component related to cognitive impairment, we additionally evaluated the impact of this component, separately from the rest of the score, on the association between frailty and postoperative delirium. RESULTS Among 1,257 patients with available MSK-FI and CAM measures, 47 patients (3.7%) had postoperative delirium. Increased frailty was associated with increased risk of postoperative delirium (odds ratio [OR] 1.51; 95% confidence interval [CI] 1.26, 1.81; p < 0.001). However, this was largely related to the effect of cognitive impairment (OR 15.29; 95% CI 7.18; 32.56; p < 0.001). In patients with cognitive impairment, the association between frailty and postoperative delirium was not significant (OR 0.97; 95% CI 0.65, 1.44; p-value = 0.9), as having cognitive impairment put patients at high risk for postoperative delirium even without taking into account the other components of the MSK-FI. While the association between frailty and postoperative delirium in patients with intact cognitive function was statistically significant (OR 1.58; 95% CI 1.27, 1.96; p < 0.001), it was not clinically meaningful, particularly considering the low risk of delirium among patients with intact cognitive function (e.g., 1.3% vs 3.2% for MSK-FI 1 vs 3). DISCUSSION Cognitive function should be a greater focus than frailty, as measured by the MSK-FI, in preoperative assessment for the prediction of postoperative delirium.
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Affiliation(s)
| | - Amy L Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Armin Shahrokni
- Department of Medicine, Memorial Sloan Kettering Cancer Center, NY, USA.
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Eaton TL, Lewis A, Donovan HS, Davis BC, Butcher BW, Alexander SA, Iwashyna TJ, Scheunemann LP, Seaman J. Examining the needs of survivors of critical illness through the lens of palliative care: A qualitative study of survivor experiences. Intensive Crit Care Nurs 2023; 75:103362. [PMID: 36528461 DOI: 10.1016/j.iccn.2022.103362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To examine the needs of adult survivors of critical illness through a lens of palliative care. RESEARCH METHODOLOGY A qualitative study of adult survivors of critical illness using semi-structured interviews and framework analysis. SETTING Participants were recruited from the post-intensive care unit clinic of a mid-Atlantic academic medical center in the United States. FINDINGS Seventeen survivors of critical illness aged 34-80 (median, 66) participated in the study. The majority of patients were female (64.7 %, n = 11) with a median length of index ICU stay of 12 days (interquartile range [IQR] 8-19). Interviews were conducted February to March 2021 and occurred a median of 20 months following the index intensive care stay (range, 13-33 months). We identified six key themes which align with palliative care principles: 1) persistent symptom burden; 2) critical illness as a life-altering experience; 3) spiritual changes and significance; 4) interpreting/managing the survivor experience; 5) feelings of loss and burden; and 6) social support needs. CONCLUSION Our findings suggest that palliative care components such as symptom management, goals of care discussions, care coordination, and spiritual and social support may assist in the assessment and treatment of survivors of critical illness.
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Affiliation(s)
- Tammy L Eaton
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, USA; National Clinician Scholars Program (NCSP), Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Anna Lewis
- School of Public Health, Department of Health Policy and Management, University of Pittsburgh, PA, USA; Care Management Department, University of Pittsburgh Medical Center Mercy Hospital, Pittsburgh, PA, USA
| | - Heidi S Donovan
- Department of Health & Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA; Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, PA, USA
| | - Brian C Davis
- School of Law, Duquesne University, Pittsburgh, PA, USA
| | - Brad W Butcher
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sheila A Alexander
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Theodore J Iwashyna
- Department of Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, MI, USA; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Leslie P Scheunemann
- Division of Geriatric Medicine and Gerontology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer Seaman
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
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Mousai O, Tafoureau L, Yovell T, Flaatten H, Guidet B, Jung C, de Lange D, Leaver S, Szczeklik W, Fjolner J, van Heerden PV, Joskowicz L, Beil M, Hyams G, Sviri S. Clustering analysis of geriatric and acute characteristics in a cohort of very old patients on admission to ICU. Intensive Care Med 2022; 48:1726-1735. [PMID: 36056194 PMCID: PMC9439274 DOI: 10.1007/s00134-022-06868-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/11/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE The biological and functional heterogeneity in very old patients constitutes a major challenge to prognostication and patient management in intensive care units (ICUs). In addition to the characteristics of acute diseases, geriatric conditions such as frailty, multimorbidity, cognitive impairment and functional disabilities were shown to influence outcome in that population. The goal of this study was to identify new and robust phenotypes based on the combination of these features to facilitate early outcome prediction. METHODS Patients aged 80 years old or older with and without limitations of life-sustaining treatment and with complete data were recruited from the VIP2 study for phenotyping and from the COVIP study for external validation. The sequential organ failure assessment (SOFA) score and its sub-scores taken on admission to ICU as well as demographic and geriatric patient characteristics were subjected to clustering analysis. Phenotypes were identified after repeated bootstrapping and clustering runs. RESULTS In patients from the VIP2 study without limitations of life-sustaining treatment (n = 1977), ICU mortality was 12% and 30-day mortality 19%. Seven phenotypes with distinct profiles of acute and geriatric characteristics were identified in that cohort. Phenotype-specific mortality within 30 days ranged from 3 to 57%. Among the patients assigned to a phenotype with pronounced geriatric features and high SOFA scores, 50% died in ICU and 57% within 30 days. Mortality differences between phenotypes were confirmed in the COVIP study cohort (n = 280). CONCLUSIONS Phenotyping of very old patients on admission to ICU revealed new phenotypes with different mortality and potential need for anticipatory intervention.
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Affiliation(s)
- Oded Mousai
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Lola Tafoureau
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Tamar Yovell
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University, Dusseldorf, Germany
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Susannah Leaver
- General Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Jesper Fjolner
- Department of Anaesthesia and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Peter Vernon van Heerden
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Leo Joskowicz
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Gal Hyams
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel.
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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: 18] [Impact Index Per Article: 9.0] [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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11
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Abstract
OBJECTIVES Although patients with cirrhosis often experience debilitating symptoms, few are referred for palliative care. Frailty is increasingly incorporated in liver transplantation evaluation and has been associated with symptom burden in other populations. We hypothesized that frail patients with cirrhosis are highly symptomatic and thus are likely to benefit from palliative care. METHODS Patients with cirrhosis undergoing outpatient liver transplantation evaluation completed the Liver Frailty Index (grip strength, chair stands and balance) and a composite of validated measures including the Edmonton Symptom Assessment Scale, distress and quality of life (QOL) measures. RESULTS Of 233 patients (median age 61 years, 43% women), 22% were robust, 59% prefrail and 19% frail. Overall, 38% of patients reported ≥1 severe symptoms based on preestablished Edmonton Symptom Assessment Scale criteria. Higher frailty categories were associated with increased prevalence of pain, dyspnea, fatigue, nausea, poor appetite, drowsiness, depression and poor well-being (test for trend, all P < 0.05). Frail patients were also more likely to report psychological distress and poor QOL (all P < 0.01). In univariate analysis, each 0.5 increase in liver frailty index was associated with 44% increased odds of experiencing ≥1 severe symptoms [95% confidence interval (CI), 1.2-1.7, P < 0.001], which persisted (odds ratio, 1.3, 95% CI, 1.0-1.6, P = 0.004) even after adjusting for Model for End Stage Liver Disease-Sodium, ascites, hepatic encephalopathy and age. CONCLUSION In patients with cirrhosis, frailty is strongly associated with physical/psychological symptoms, including pain and depression and poor QOL. Frail patients with cirrhosis may benefit from palliative care co-management to address symptoms and improve QOL.
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12
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Catalisano G, Ippolito M, Marino C, Giarratano A, Cortegiani A. Palliative Care Principles and Anesthesiology Clinical Practice: Current Perspectives. J Multidiscip Healthc 2021; 14:2719-2730. [PMID: 34611408 PMCID: PMC8486274 DOI: 10.2147/jmdh.s240563] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/14/2021] [Indexed: 11/24/2022] Open
Abstract
Background Palliative care is a person-centered approach aiming to relieve patient’s health-related suffering and it is often needed when caring for critically ill patients to manage symptoms and identify goals of care. Aim To describe the integration of palliative care principles in anesthesiology clinical practice, within and outside the ICU and to analyze the additional challenges that COVID-19 pandemic is posing in this context. Methods For the purpose of this review, PubMed database was searched for studies concerning palliative care and end of life care, in contexts involving anesthesiologists and intensivists, published in the last 5 years. Results Anesthesiologists and intensivists integrate palliative care within their daily practice providing symptoms management as well as family counseling. High-quality communicational skills are fundamental for anesthesiologists and intensivists especially when interfacing with surrogate decision makers in the ICU or with patients in the preoperative setting while discussing goals of care. Coronavirus disease 2019 (COVID-19) pandemic has challenged many aspects of palliative care delivery: reduced family presence within the ICU, communication with families through phone calls or video calls, patient–physician relationship mediated by bulky personal protective equipment and healthcare workers physical and psychological distress due to the increased workload and limitations in resources are some of the most evident. Conclusion Anesthesiologists and intensivists are increasingly facing challenging clinical situations where principles and practice of palliative care have to be applied. In this sense, increasing knowledge on palliative care and providing specific training would allow to deliver high-quality symptom management, family counseling and end of life guidance in critical care settings. COVID-19 pandemic sets additional difficulties to palliative care delivery.
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Affiliation(s)
- Giulia Catalisano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Claudia Marino
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
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13
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Ben-Arye E, Elly M, Gressel O, Reshef A, Shani Md M, Stein N, Saliba W, Samuels N. Exploring the effectiveness of a patient-tailored integrative oncology program on emotional distress during chemotherapy for localized cancer. Psychooncology 2021; 31:207-218. [PMID: 34435403 DOI: 10.1002/pon.5794] [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: 05/22/2021] [Revised: 07/25/2021] [Accepted: 08/11/2021] [Indexed: 01/06/2023]
Abstract
STUDY OBJECTIVE There is a need to explore how patient-tailored integrative oncology (IO) programs reduce emotional distress. This study set out to bridge the IO research gap between non-specific, quality of life-related and specific emotional-related concerns in chemotherapy-treated patients. METHODS This pragmatic, prospective and preference-controlled study examined patients attending an integrative-physician consultation and weekly IO treatments during adjuvant/neo-adjuvant chemotherapy for localized cancer. Patients choosing to attend ≥4 IO sessions (highly adherent to integrative care, AIC) were compared to low AIC patients using the ESAS (Edmonton Symptom Assessment Scale) anxiety, depression and sleep; and the EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire) emotional functioning scale, at baseline, 6 and 12 weeks. Emotional distress was assessed by ESAS anxiety and depression, considered as the primary study outcomes. RESULTS Of 439 participants, 260 (59%) were high-AIC and 179 low-AIC, both with similar baseline demographic and cancer-related characteristics. At 6 weeks, high-AIC patients reported greater improvement on ESAS sleep (p = 0.044); within-group improvement on ESAS anxiety and; and EORTC emotional functioning. Compared with low-AIC, high-AIC patients showed greater improvement on ESAS depression (p = 0.022) and sleep (p = 0.015) in those with high baseline ESAS anxiety scores (≥7); and ESAS anxiety (p = 0.049) for patients moderately anxious (4-6) at baseline. CONCLUSIONS High-AIC was associated with significantly reduced anxiety, depression and sleep severity at 6 weeks, especially those with high-to-moderate baseline anxiety levels. These findings reduce the research gap, suggesting specific emotional-related effects of IO.
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Affiliation(s)
- Eran Ben-Arye
- Integrative Oncology Program, The Oncology Service, Lin, Carmel, and Zebulun Medical Centers, Clalit Health Services, Haifa, Israel.,Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Maya Elly
- Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Orit Gressel
- Integrative Oncology Program, The Oncology Service, Lin, Carmel, and Zebulun Medical Centers, Clalit Health Services, Haifa, Israel.,Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Alon Reshef
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Psychiatry Department, Ha'Emek Medical Center, Haifa, Israel
| | - Michal Shani Md
- Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Department of Family Medicine, Clalit Health Service, Rehovot, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nili Stein
- Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel
| | - Walid Saliba
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel
| | - Noah Samuels
- The Center for Integrative Complementary Medicine, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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14
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Correia I, Simas Â, Chaves S, Paixão AI, Catarino A, Gonçalves-Pereira J. The PALliative MUlticenter Study in Intensive Care (PalMuSIC). Results From a Multicenter Study Addressing Frailty and Palliative Care Interventions in Intensive Care Units in Portugal. J Palliat Care 2021; 37:552-561. [PMID: 34128431 DOI: 10.1177/08258597211020964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Frailty is a clinically recognizable state of increased vulnerability common in critical medicine. When underrecognized, it may lead to invasive treatments that do not serve the patients' best interest. Our aim was to evaluate the use of both palliative care consultation and invasive interventions in frail patients admitted to Intensive Care Units in Portugal. METHODS This was a prospective, observational study. All consecutive adult patients admitted for more than 24 h, over a 15-day period were enrolled. Twenty-three Portuguese Intensive Care Units were included. Informed consent was obtained from all patients or their surrogate. The doctor and nurse in charge calculated the Clinical Frailty Score as well as the reference family member. RESULTS A total of 335 patients were included in the study (66% male). Mean age was 63.2 ± 16.8 and SAPS II score was 41.8 ± 17.4. Mean Clinical Frailty Score value was 3.5 ± 1.7. Frailty prevalence (mean score ≥ 5) was 20.9%. Frail patients were offered organ support therapy (64,3% invasive mechanical ventilation; 24,3% renal replacement therapy; 67,1% vasopressors) more often than non-frail patients. Nevertheless, limitation of therapeutic effort or a do not resuscitate order (p < 0.001) were more common in frail patients. Mortality rate by 6 months was higher among frail patients (50% vs. 32.3%, p < 0.001). Palliative Care was offered to only 15% of frail patients (3.9% overall). CONCLUSIONS The authors suggest that palliative care should be universally consulted once frailty is identified in critical patients.
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Affiliation(s)
- Iuri Correia
- Intra-hospital Palliative Care Support Team of Hospital, Prof. Fernando Fonseca, Amadora, NOVA Medical School, Lisbon, Portugal
| | - Ângela Simas
- Intensive Care Unite, Hospital Vila Franca de Xira, Portugal
| | - Susana Chaves
- Intensive Care Unite, Hospital Nélio Mendonça, Funchal, Portugal
| | | | - Ana Catarino
- Intensive Care Unit, Hospital Universitário de Coimbra, Centro Hospitalar Universitário de Coimbra, Portugal
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15
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Amblàs-Novellas J, Murray SA, Oller R, Torné A, Martori JC, Moine S, Latorre-Vallbona N, Espaulella J, Santaeugènia SJ, Gómez-Batiste X. Frailty degree and illness trajectories in older people towards the end-of-life: a prospective observational study. BMJ Open 2021; 11:e042645. [PMID: 33883149 PMCID: PMC8061834 DOI: 10.1136/bmjopen-2020-042645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES To assess the degree of frailty in older people with different advanced diseases and its relationship with end-of-life illness trajectories and survival. METHODS Prospective, observational study, including all patients admitted to the Acute Geriatric Unit of the University Hospital of Vic (Spain) during 12 consecutive months (2014-2015), followed for up to 2 years. Participants were identified as end-of-life people (EOLp) using the NECPAL (NECesidades PALiativas, palliative care needs) tool and were classified according to their dominant illness trajectory. The Frail-VIG index (Valoración Integral Geriátrica, Comprehensive Geriatric Assessment) was used to quantify frailty degree, to calculate the relationship between frailty and mortality (Receiver Operating Characteristic (ROC) curves), and to assess the combined effect of frailty degree and illness trajectories on survival (Cox proportional hazards model). Survival curves were plotted using the Kaplan-Meier estimator with participants classified into four groups (ie, no frailty, mild frailty, moderate frailty and advanced frailty) and were compared using the log-rank test. RESULTS Of the 590 persons with a mean (SD) age of 86.4 (5.6) years recruited, 260 (44.1%) were identified as EOLp, distributed into cancer (n=31, 11.9%), organ failure (n=79, 30.4%), dementia (n=86, 33.1%) and multimorbidity (n=64, 24.6%) trajectories. All 260 EOLp had some degree of frailty, mostly advanced frailty (n=184, 70.8%), regardless of the illness trajectory, and 220 (84.6%) died within 2 years. The area under the ROC curve (95% CI) after 2 years of follow-up for EOLp was 0.87 (0.84 to 0.92) with different patterns of survival decline in the different end-of-life trajectories (p<0.0001). Cox regression analyses showed that each additional deficit of the Frail-VIG index increased the risk of death by 61.5%, 30.1%, 29.6% and 12.9% in people with dementia, organ failure, multimorbidity and cancer, respectively (p<0.01 for all the coefficients). CONCLUSIONS All older people towards the end-of-life in this study were frail, mostly with advanced frailty. The degree of frailty is related to survival across the different illness trajectories despite the differing survival patterns among trajectories. Frailty indexes may be useful to assess end-of-life older people, regardless of their trajectory.
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Affiliation(s)
- Jordi Amblàs-Novellas
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic/Central University of Catalonia (UVIC-UCC), Vic, Spain
- Chair of Palliative Care, University of Vic/Central University of Catalonia (UVIC-UCC), Vic, Spain
- Geriatric and Palliative Care Department, Hospital Universitari de la Santa Creu and Hospital Universitari de Vic, Vic, Spain
- Chronic Care Program, Ministry of Health, Generalitat de Catalunya, Barcelona, Spain
| | - Scott A Murray
- Primary Palliative Care Research Group, The Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Ramon Oller
- Data Analysis and Modelling Research Group, Department of Economics and Business, University of Vic/Central University of Catalonia (UVIC-UCC), Vic, Spain
| | - Anna Torné
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic/Central University of Catalonia (UVIC-UCC), Vic, Spain
- Geriatric and Palliative Care Department, Hospital Universitari de la Santa Creu and Hospital Universitari de Vic, Vic, Spain
| | - Joan Carles Martori
- Data Analysis and Modelling Research Group, Department of Economics and Business, University of Vic/Central University of Catalonia (UVIC-UCC), Vic, Spain
| | - Sébastien Moine
- Primary Palliative Care Research Group, The Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Nadina Latorre-Vallbona
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic/Central University of Catalonia (UVIC-UCC), Vic, Spain
- Geriatric and Palliative Care Department, Hospital Universitari de la Santa Creu and Hospital Universitari de Vic, Vic, Spain
| | - Joan Espaulella
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic/Central University of Catalonia (UVIC-UCC), Vic, Spain
- Chair of Palliative Care, University of Vic/Central University of Catalonia (UVIC-UCC), Vic, Spain
- Geriatric and Palliative Care Department, Hospital Universitari de la Santa Creu and Hospital Universitari de Vic, Vic, Spain
| | - Sebastià J Santaeugènia
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic/Central University of Catalonia (UVIC-UCC), Vic, Spain
- Chronic Care Program, Ministry of Health, Generalitat de Catalunya, Barcelona, Spain
| | - Xavier Gómez-Batiste
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic/Central University of Catalonia (UVIC-UCC), Vic, Spain
- Chair of Palliative Care, University of Vic/Central University of Catalonia (UVIC-UCC), Vic, Spain
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16
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Danesh V, Hecht J, Hao R, Boehm L, Jimenez EJ, Arroliga AC, Sanghi S, Stevens A. Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS): Study protocol for peer mentor training. J Adv Nurs 2021; 77:2092-2101. [PMID: 33432618 DOI: 10.1111/jan.14736] [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: 11/14/2020] [Accepted: 12/10/2020] [Indexed: 12/15/2022]
Abstract
AIMS The primary aim of the Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS) peer mentor training trial is to determine the feasibility for peer mentor training to connect new ICU survivors with survivors who have made successful recoveries. Secondary aims are to also examine peer mentor eligibility, recruitment and retention rates and assess changes in participant knowledge of Post Intensive Care Syndrome (PICS), reported symptoms and health-related quality of life. DESIGN Prospective clinical feasibility trial. METHODS This study received funding from the National Institutes of Health funded P30 Center for Excellence (2014-2020). Up to 20 adult patients who have had an ICU stay of 3 days or longer more than 3 months ago will be enrolled into the study. Participants will undergo a 6-week peer mentor training program to learn how to promote healthy self-management behaviours, social connections, and well-being using motivational interviewing (MI). Participants will complete surveys about their recovery at 3 points during the study: prior to training, 6 weeks post-training and 3 months post-training. Survey questions will be used to assess trends in participant social isolation, depression, functional status, and self-management behaviours. DISCUSSION Enrollment closes by December 2020. As a feasibility trial, power sufficient for hypothesis testing will not be available. However, study operations and intervention fidelity contribute to future research knowledge and participant characteristics and longitudinal outcomes will yield data on intervention feasibility. This study is the first use of embedding peer-led motivational interviewing training into a peer support intervention for ICU survivors. IMPACT Current self-management interventions are limited for ICU survivors and do not sufficiently address barriers to promoting self-management behaviours or improving their health status, well-being and cost of health. This study will provide data to develop and implement interventions for the self-management of PICS-related symptoms and sequelae.
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Affiliation(s)
- Valerie Danesh
- School of Nursing, University of Texas at Austin, Austin, TX, USA.,Center for Applied Health Research, Baylor Scott & White Research Institute, Temple, TX, USA
| | - Jacki Hecht
- School of Nursing, University of Texas at Austin, Austin, TX, USA
| | - Richard Hao
- Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Leanne Boehm
- School of Nursing, Vanderbilt University, Nashville, TN, USA
| | | | | | - Sandhya Sanghi
- Center for Applied Health Research, Baylor Scott & White Research Institute, Temple, TX, USA
| | - Alan Stevens
- Center for Applied Health Research, Baylor Scott & White Research Institute, Temple, TX, USA
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17
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Kang J, Jeong YJ, Jang JH, Lee M. Risk Factors for Frailty in Critical Care Survivors: A secondary analysis. Intensive Crit Care Nurs 2020; 64:102981. [PMID: 33358896 DOI: 10.1016/j.iccn.2020.102981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 10/26/2020] [Accepted: 11/15/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate the prevalence of frailty and its risk factors among critical care survivors who were discharged after receiving treatment in an intensive care unit. METHODS This was a secondary analysis using data from a methodological study conducted between June and August 2018. The sample included 494 adults who had been admitted to the intensive care unit for more than 48 hours within a year. Only post-intensive care frailty was evaluated using the Kihon Checklist. The sociodemographic and intensive care-related risk factors for frailty were analysed using multivariate logistic regression. RESULTS The prevalence of frailty in the sample was 65.8%. The risk factors for frailty were female sex (adjusted odds ratio [aOR] = 1.68, 95% CI: 1.02-2.78), aged 70 years or older (aOR = 4.16, 95% CI: 2.00-8.65), unemployment (aOR = 2.41, 95% CI: 1.39-4.17) and longer ICU days (aOR = 2.29, 95% CI: 1.35-3.91). Analysis of differences in risk factors according to sex revealed that risk factors for frailty were unemployment and longer ICU length of stay for male and older age for female. CONCLUSION Health care providers should be aware of frailty risk factors in female and male patients and provide patient-specific interventions for preventing frailty.
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Affiliation(s)
- Jiyeon Kang
- College of Nursing, Dong-A University, Busan, South Korea
| | - Yeon Jin Jeong
- Department of Nursing, Dongju College, Busan, South Korea
| | - Jun Hee Jang
- Department of Nursing, Dongju College, Busan, South Korea
| | - Minju Lee
- Department of Nursing, Youngsan University, Yangsan, South Korea.
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18
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Nguyen MT, Feeney T, Kim C, Drake FT, Mitchell SE, Bednarczyk M, Sanchez SE. Patient-Level Factors Influencing Palliative Care Consultation at a Safety-Net Urban Hospital. Am J Hosp Palliat Care 2020; 38:1299-1307. [PMID: 33325245 DOI: 10.1177/1049909120981764] [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] [Indexed: 12/21/2022] Open
Abstract
The influence of patient-level factors on palliative and hospice care is unclear. We conducted a retrospective review of 2321 patients aged ≥18 that died within 6 months of admission to our institution between 2012 and 2017. Patients were included for analysis if their chart was complete, their length of stay was ≥48 hours, and if based on their diagnoses, they would have benefited from palliative care consultation (PCC). Bayesian regression with a weakly informative prior was used to find the odds ratio (OR) and 99% credible interval (CrI) of receiving PCC based on race/ethnicity, education, language, insurance status, and income. 730 patients fit our inclusion criteria and 30% (n = 211) received PCC. The OR of receiving PCC was 1.26 (99% CrI, 0.73-2.12) for Blacks, 0.81 (99% CrI, 0.31-1.86) for Hispanics, and 0.69 (99% CrI, 0.19-2.46) for other minorities. Less than high school education was associated with greater odds of PCC (OR 2.28, 99% CrI, 1.09-4.93) compared to no schooling. Compared to English speakers, non-English speakers had higher odds of receiving PCC when cared for by medical services (OR 3.01 [99% CrI, 1.44-5.32]) but lower odds of PCC when cared for by surgical services (0.22 [99% CrI, <0.01-3.42]). Insurance status and income were not associated with differences in PCC. At our institution, we found no evidence of racial/ethnic, insurance, or income status affecting PCC while primary language spoken and educational status did. Further investigation is warranted to examine the system and provider-level factors influencing PCC's low utilization by medical and surgical specialties.
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Affiliation(s)
| | - Timothy Feeney
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - F Thurston Drake
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Suzanne E Mitchell
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - Sabrina E Sanchez
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
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19
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Hill AD, Fowler RA, Wunsch H, Pinto R, Scales DC. Frailty and long-term outcomes following critical illness: A population-level cohort study. J Crit Care 2020; 62:94-100. [PMID: 33316556 DOI: 10.1016/j.jcrc.2020.11.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 11/06/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To provide population-level estimates of the association of frailty with one-year outcomes after critical illness. MATERIALS AND METHODS Retrospective cohort study of patients who survived an ICU admission between April 2002 and March 2015. Pre-existing frailty was classified using the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable Cox regression and Fine and Gray models were used to examine the association between frailty and mortality and hospital readmission. RESULTS Of 534,991 patients, 19.3% had pre-existing frailty. Compared to non-frail survivors, at one-year frail patients had higher mortality (18.3% vs 9.5%, adjusted HR 1.17 95% CI: 1.15-1.19) and hospital readmission (44.4% vs 36.6%, adjusted HR 1.10 95% CI: 1.08-1.11) and a CAN$19,628 (95% CI: $19,279-$19,997) greater increase in healthcare costs compared to the year prior to hospitalization. The association between frailty and mortality was stronger among older individuals, but the risk of readmission among frail patients decreased with age. CONCLUSION Patients with pre-existing frailty who develop critical illness have higher rates of hospital readmission and death than patients without frailty, and age modifies these associations. These data highlight the importance of considering both frailty and age when seeking to identify at-risk patients who might benefit from closer follow-up after discharge.
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Affiliation(s)
- Andrea D Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada.
| | - Robert A Fowler
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Canada.
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Canada.
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
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20
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Tapper CX, Curseen K. Rehabilitation Concerns in the Geriatric Critically Ill and Injured - Part 1. Crit Care Clin 2020; 37:117-134. [PMID: 33190765 DOI: 10.1016/j.ccc.2020.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Elderly patients who are critically ill have unique challenges that must be considered when attempting to prognosticate survival and determine expectations for physical rehabilitation and meaningful recovery. Furthermore, frail elderly patients present unique rehabilitation and clinical challenges when suffering from critical illness. There are multiple symptoms and syndromes that affect morbidity and mortality of elderly patients who require intensive care unit management including delirium, dementia, pain, and constipation. Rehabilitation goals should be based on patient values, clinical course, and functional status. Patients and families need accurate prognostic information to choose the appropriate level of care needed after critical illness.
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Affiliation(s)
- Corey X Tapper
- Division of General Internal Medicine, Section of Palliative Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 8021, Baltimore, MD 21287, USA.
| | - Kimberly Curseen
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Supportive and Palliative Care Outpatient Services, Emory Healthcare, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30329, USA
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21
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Starr LT, Ulrich CM, Junker P, Huang L, O’Connor NR, Meghani SH. Patient Risk Factor Profiles Associated With the Timing of Goals-of-Care Consultation Before Death: A Classification and Regression Tree Analysis. Am J Hosp Palliat Care 2020; 37:767-778. [DOI: 10.1177/1049909120934292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Early palliative care consultation (“PCC”) to discuss goals-of-care benefits seriously ill patients. Risk factor profiles associated with the timing of conversations in hospitals, where late conversations most likely occur, are needed. Objective: To identify risk factor patient profiles associated with PCC timing before death. Methods: Secondary analysis of an observational study was conducted at an urban, academic medical center. Patients aged 18 years and older admitted to the medical center, who had PCC, and died July 1, 2014 to October 31, 2016, were included. Patients admitted for childbirth or rehabilitationand patients whose date of death was unknown were excluded. Classification and Regression Tree modeling was employed using demographic and clinical variables. Results: Of 1141 patients, 54% had PCC “close to death” (0-14 days before death); 26% had PCC 15 to 60 days before death; 21% had PCC >60 days before death (median 13 days before death). Variables associated with receiving PCC close to death included being Hispanic or “Other” race/ethnicity intensive care patients with extreme illness severity (85%), with age <46 or >75 increasing this probability (98%). Intensive care patients with extreme illness severity were also likely to receive PCC close to death (64%) as were 50% of intensive care patients with less than extreme illness severity. Conclusions: A majority of patients received PCC close to death. A complex set of variable interactions were associated with PCC timing. A systematic process for engaging patients with PCC earlier in the care continuum, and in intensive care regardless of illness severity, is needed.
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Affiliation(s)
- Lauren T. Starr
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Center for Bioethics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Connie M. Ulrich
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Junker
- Program for Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Liming Huang
- BECCA Lab, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Nina R. O’Connor
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Salimah H. Meghani
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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22
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Abstract
Patients with frailty experience substantial physical and emotional distress related to their condition and face increased morbidity and mortality compared with their nonfrail peers. Palliative care is an interdisciplinary medical specialty focused on improving quality of life for patients with serious illness, including those with frailty, throughout their disease course. Anesthesiology providers will frequently encounter frail patients in the perioperative period and in the intensive care unit (ICU) and can contribute to improving the quality of life for these patients through the provision of palliative care. We highlight the opportunities to incorporate primary palliative care, including basic symptom management and straightforward goals-of-care discussions, provided by the primary clinicians, and when necessary, timely consultation by a specialty palliative care team to assist with complex symptom management and goals-of-care discussions in the face of team and/or family conflict. In this review, we apply the principles of palliative care to patients with frailty and synthesize the evidence regarding methods to integrate palliative care into the perioperative and ICU settings.
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Affiliation(s)
- Rita C. Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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23
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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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Nguyen MT, Feeney T, Kim C, Drake FT, Mitchell SE, Bednarczyk M, Sanchez SE. Differential Utilization of Palliative Care Consultation Between Medical and Surgical Services. Am J Hosp Palliat Care 2019; 37:250-257. [PMID: 31387366 DOI: 10.1177/1049909119867904] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
There is a paucity of data regarding the utilization of palliative care consultation (PCC) in surgical specialties. We conducted a retrospective review of 2321 adult patients (age ≥18) who died within 6 months of admission to Boston Medical Center from 2012 to 2017. Patients were included for analysis if their length of stay was more than 48 hours and if, based on their diagnoses as determined by literature review and expert consensus, they would have benefited from PCC. Bayesian regression was used to estimate the odds ratio (OR) and 99% credible intervals (CrI) of receiving PCC adjusted for age, sex, race, insurance status, median income, and comorbidity status. Among the 739 patients who fit the inclusion criteria, only 30% (n = 222) received PCC even though 664 (90%) and 75 (10%) of these patients were identified as warranting PCC on medical and surgical services, respectively. Of the 222 patients who received PCC, 214 (96%) were cared for by medical services and 8 (4%) were cared for by surgical services. Patients cared for primarily by surgical were significantly less likely to receive PCC than primary patients of medical service providers (OR, 0.19, 99% CrI, 0.056-0.48). At our institution, many surgical patients appropriate for PCC are unable to benefit from this service due to low consultation numbers. Further investigation is warranted to examine if this phenomenon is observed at other institutions, elucidate the reasons for this disparity, and develop interventions to increase the appropriate use of PCC throughout all medical specialties.
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Affiliation(s)
| | - Timothy Feeney
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Chanmin Kim
- Boston University School of Public Health, Boston, MA, USA
| | - F Thurston Drake
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Suzanne E Mitchell
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - Sabrina E Sanchez
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
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25
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Stow D, Spiers G, Matthews FE, Hanratty B. What is the evidence that people with frailty have needs for palliative care at the end of life? A systematic review and narrative synthesis. Palliat Med 2019; 33:399-414. [PMID: 30775957 PMCID: PMC6439946 DOI: 10.1177/0269216319828650] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The number of older people living and dying with frailty is rising, but our understanding of their end-of-life care needs is limited. AIM To synthesise evidence on the end-of-life care needs of people with frailty. DESIGN Systematic review of literature and narrative synthesis. Protocol registered prospectively with PROSPERO (CRD42016049506). DATA SOURCES Fourteen electronic databases (CINAHL, Cochrane, Embase, EThOS, Google, Medline, NDLTD, NHS Evidence, NICE, Open grey, Psychinfo, SCIE, SCOPUS and Web of Science) searched from inception to October 2017 and supplemented with bibliographic screening and reference chaining. Studies were included if they used an explicit definition or measure of frailty. Quality was assessed using the National Institute for Health tool for observational studies. RESULTS A total of 4,998 articles were retrieved. Twenty met the inclusion criteria, providing evidence from 92,448 individuals (18,698 with frailty) across seven countries. Thirteen different measures or definitions of frailty were used. People with frailty experience pain and emotional distress at levels similar to people with cancer and also report a range of physical and psychosocial needs, including weakness and anxiety. Functional support needs were high and were highest where people with frailty were cognitively impaired. Individuals with frailty often expressed a preference for reduced intervention, but these preferences were not always observed at critical phases of care. CONCLUSION People with frailty have varied physical and psychosocial needs at the end of life that may benefit from palliative care. Frailty services should be tailored to patient and family needs and preferences at the end of life.
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Affiliation(s)
- Daniel Stow
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Gemma Spiers
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona E Matthews
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Barbara Hanratty
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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26
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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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27
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ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2018; 38:48-79. [PMID: 30348463 DOI: 10.1016/j.clnu.2018.08.037] [Citation(s) in RCA: 1291] [Impact Index Per Article: 215.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023]
Abstract
Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.
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28
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Montgomery CL, Rolfson DB, Bagshaw SM. Frailty and the Association Between Long-Term Recovery After Intensive Care Unit Admission. Crit Care Clin 2018; 34:527-547. [PMID: 30223992 DOI: 10.1016/j.ccc.2018.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Frailty is common, although infrequently screened for among patients admitted to intensive care. Frailty has been the focus of research in geriatric medicine; however, its epidemiology and interaction with critical illness have only recently been studied. Instruments to screen for and measure frailty require refinement in intensive care settings. Frail critically ill patients are at higher risk of poor outcomes. Frail survivors of critical illness are high users of health resources. Further research is needed to understand how frailty assessment can inform decision-making before and during an episode of critical illness and during an intensive care course for frail patients.
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Affiliation(s)
- Carmel L Montgomery
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, 11350 83 Avenue, Edmonton, Alberta T6G 2G3, Canada
| | - Darryl B Rolfson
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, 1-198 Clinical Sciences Building, 11350 83 Avenue, Edmonton, Alberta T6G 2G3, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, 11350 83 Avenue, Edmonton, Alberta T6G 2G3, Canada.
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