Frailty as a Prognostic Indicator in Intensive Care

[Clinical acute and emergency medicine curriculum-focus on internal medicine : Recommendations for advanced training in internal medicine in the emergency department]

In Germany, physicians qualify for emergency medicine by combining a specialty medical training-e.g. internal medicine-with advanced training in emergency medicine according to the statutes of the State Chambers of Physicians largely based upon the Guideline Regulations on Specialty Training of the German Medical Association. Internal medicine and their associated subspecialities represent an important column of emergency medicine. For the internal medicine aspects of emergency medicine, this curriculum presents an overview of knowledge, skills (competence levels I-III) as well as behaviours and attitudes allowing for the best treatment of patients. These include general aspects (structure and process quality, primary diagnostics and therapy as well as indication for subsequent treatment; resuscitation room management; diagnostics and monitoring; general therapeutic measures; hygiene measures; and pharmacotherapy) and also specific aspects concerning angiology, endocrinology, diabetology and metabolism, gastroenterology, geriatric medicine, hematology and oncology, infectiology, cardiology, nephrology, palliative care, pneumology, rheumatology and toxicology. Publications focussing on contents of advanced training are quoted in order to support this concept. The curriculum has primarily been written for internists for their advanced emergency training, but it may generally show practising emergency physicians the broad spectrum of internal medicine diseases or comorbidities presented by patients attending the emergency department.

[Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine : Consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DG Palliativmedizin]

The integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S3 guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.

Single-rater reliability of a three-dimensional instrument for decision-making in tertiary triage and ICU- prioritization-a case vignette simulation study

Disconcerting reports from different EU countries during the first wave of the COVID-19 pandemic demonstrated the demand for supporting decision instruments and recommendations in case tertiary triage is needed. COVID-19 patients mainly present sequentially, not parallelly, and therefore ex-post triage scenarios were expected to be more likely than ex-ante ones. Decision-makers in these scenarios may be highly susceptible to second victim and moral injury effects, so that reliable and ethically justifiable algorithms would have been needed in case of overwhelming critical cases.To gather basic information about a potential tertiary triage instrument, we designed a three-dimensional instrument developed by an expert group using the Delphi technique. The instrument focused on three parameters: 1) estimated chance of survival, 2) estimated prognosis of regaining autonomy after treatment, and 3) estimated length of stay in the ICU. To validate and test the instrument, we conducted an anonymous online survey in 5 German hospitals addressing physicians that would have been in charge of decision-making in the case of a mass infection incident. Of about 80 physicians addressed, 47 responded. They were presented with 16 fictional ICU case vignettes (including 3 doublets) which they had to score using the three parameters of the instrument.We detected a good construct validity (Cronbach's Alpha 0.735) and intra-reliability (p < 0.001, Cohens Kappa 0.497 to 0.574), but a low inter-reliability (p < 0.001, Cohen's Kappa 0.252 to 0.327) for the three parameters. The best inter-reliability was detected for the estimated length of stay in the ICU. Further analysis revealed concerns in assessing the prognosis of the potentially remaining autonomy, especially in patients with only physical impairment.In accordance with German recommendations, we concluded that single-rater triage (which might happen in stressful and highly resource-limited situations) should be avoided to ensure patient and health care provider safety. Future work should concentrate on reliable and valid group decision instruments and algorithms and question whether the chance of survival as a single triage parameter should be complemented with other parameters, such as the estimated length of stay in the ICU.

The Clinical Frailty Scale for mortality prediction of old acutely admitted intensive care patients: a meta-analysis of individual patient-level data

BACKGROUND

This large-scale analysis pools individual data about the Clinical Frailty Scale (CFS) to predict outcome in the intensive care unit (ICU).

METHODS

A systematic search identified all clinical trials that used the CFS in the ICU (PubMed searched until 24th June 2020). All patients who were electively admitted were excluded. The primary outcome was ICU mortality. Regression models were estimated on the complete data set, and for missing data, multiple imputations were utilised. Cox models were adjusted for age, sex, and illness acuity score (SOFA, SAPS II or APACHE II).

RESULTS

12 studies from 30 countries with anonymised individualised patient data were included (n = 23,989 patients). In the univariate analysis for all patients, being frail (CFS ≥ 5) was associated with an increased risk of ICU mortality, but not after adjustment. In older patients (≥ 65 years) there was an independent association with ICU mortality both in the complete case analysis (HR 1.34 (95% CI 1.25-1.44), p < 0.0001) and in the multiple imputation analysis (HR 1.35 (95% CI 1.26-1.45), p < 0.0001, adjusted for SOFA). In older patients, being vulnerable (CFS 4) alone did not significantly differ from being frail. After adjustment, a CFS of 4-5, 6, and ≥ 7 was associated with a significantly worse outcome compared to CFS of 1-3.

CONCLUSIONS

Being frail is associated with a significantly increased risk for ICU mortality in older patients, while being vulnerable alone did not significantly differ. New Frailty categories might reflect its "continuum" better and predict ICU outcome more accurately.

TRIAL REGISTRATION

Open Science Framework (OSF: https://osf.io/8buwk/ ).

Wiederbelebungsmaßnahmen bei leblosen Pflegeheimbewohnern durchführen oder unterlassen?

Ziel der Arbeit Entscheidungen über Reanimationsversuche (RV) müssen die Chancen auf Überleben gegen die Aussichten auf zusätzliches Leid abwägen. Für Pflegeheimbewohner soll die Basis dieser Abwägung auf Grundlage der im Deutschen Reanimationsregister verfügbaren Endpunkte verbreitert werden.

Methodik Retrospektive Auswertung prähospitaler RV der Jahre 2012 bis 2019.

Ergebnisse Eingeschlossen wurden 2510 Datensätze. Das Durchschnittsalter betrug 83,7 (±7,5) Jahre, 1497 (59,6%) waren weiblich. Es erfolgten 98 (3,9%) Lebendentlassungen; davon 61 (2,4%) mit neurologisch gutem Outcome. Im Krankenhaus verstarben 791 (31,5%); 561 (22,4%) innerhalb 24 Stunden. Am Einsatzort verstarben 1621 (64,6%). Diese und weitere Endpunkte wurden stratifiziert als Spektrum dargestellt und Subgruppen nach Alter, Pre Emergency Status und Einsatzsituationen gebildet.

Schlussfolgerung Für die Entscheidungsfindung scheinen neben den prähospitalen Einsatzsituationen besonders Patientencharakteristika relevant zu sein.

Prüfung des Screening-Tools GeriNOT

BACKGROUND

Geriatric-specific characteristics influence patient-relevant outcomes of inpatient hospital care in patients aged 70 years and older: prolonged length of stay, complications, increase in utilization of required services as well as mortality rates.

OBJECTIVE

The screening tool GeriNOT, identification of geriatric risk potential with 7 items, of which mobility and cognition are double-weighted, score 9 points, was tested for its predictive content and diagnostic quality.

MATERIAL AND METHODS

Diagnostic study from a retrospective, bicentric complete survey in all types of admission from 70 years with 2541 patient cases. Regression analyses in linked samples of the 7 items in GeriNOT and as noncombined end points: prolonged length of stay, complications, increase in need-based service at discharge and death.

RESULTS

Mean age ± SD: 77.0 ± 6.4 years. ROC analyses report at a cut-off value calculated using the Youden index of ≥ 4 points in 2541 cases: increase in need-based service at discharge (AUC = 0.693, 95% CI = 0.663-0.723, sensitivity 75.2%, specificity 59.7%), complications (AUC = 0.662, 95% CI = 0.636-0.688, sensitivity 64.2%, specificity 61.6%) and death (AUC = 0.734, 95% CI = 0.682-0.786, sensitivity 76.4%, specificity 57.5%). Possibly suitable for use as screening to identify geriatric risk potentials at a cut-off of ≥ 4 points.

DISCUSSION

Provide an initial filter screening with regard to mobility. Such identification could provide the involved persons with the opportunity for an improved treatment outcome by adapting the inpatient process. Prospective validation of GeriNOT needed.

Intensive care of geriatric patients-a thin line between under- and overtreatment

Demographic developments are leading to an ever-increasing proportion of elderly and aged patients in hospitals at all levels of care, and even more patients from these age groups are to be expected in the future. Based on the projected population development, e.g., in Norway, an increase in intensive care beds of between 26 and 37% is expected by 2025. This poses special challenges for the treatment and management of geriatric intensive care patients. The acute illness is not the only decisive factor, but rather the existing multimorbidity and functional limitations of this vulnerable patient group must likewise be taken into account. Age per se is not the sole determinant of prognosis in critical patients, even though mortality increases with age.

Disease-course adapting machine learning prognostication models in critically ill elderly COVID-19 patients: a multi-centre cohort study with external validation

Background

The COVID-19 pandemic caused by SARS-CoV-2 is challenging health care systems globally. The disease disproportionately affects the elderly population, both in terms of disease severity and mortality risk.

Objective

The aim of this study was to evaluate machine learning–based prognostication models for critically ill elderly COVID-19 patients, which dynamically incorporated multifaceted clinical information on evolution of the disease.

Methods

This multicenter cohort study (COVIP study) obtained patient data from 151 intensive care units (ICUs) from 26 countries. Different models based on the Sequential Organ Failure Assessment (SOFA) score, logistic regression (LR), random forest (RF), and extreme gradient boosting (XGB) were derived as baseline models that included admission variables only. We subsequently included clinical events and time-to-event as additional variables to derive the final models using the same algorithms and compared their performance with that of the baseline group. Furthermore, we derived baseline and final models on a European patient cohort, which were externally validated on a non-European cohort that included Asian, African, and US patients.

Results

In total, 1432 elderly (≥70 years old) COVID-19–positive patients admitted to an ICU were included for analysis. Of these, 809 (56.49%) patients survived up to 30 days after admission. The average length of stay was 21.6 (SD 18.2) days. Final models that incorporated clinical events and time-to-event information provided superior performance (area under the receiver operating characteristic curve of 0.81; 95% CI 0.804-0.811), with respect to both the baseline models that used admission variables only and conventional ICU prediction models (SOFA score, P<.001). The average precision increased from 0.65 (95% CI 0.650-0.655) to 0.77 (95% CI 0.759-0.770).

Conclusions

Integrating important clinical events and time-to-event information led to a superior accuracy of 30-day mortality prediction compared with models based on the admission information and conventional ICU prediction models. This study shows that machine-learning models provide additional information and may support complex decision-making in critically ill elderly COVID-19 patients.

Trial Registration

ClinicalTrials.gov NCT04321265; https://clinicaltrials.gov/ct2/show/NCT04321265

[Geriatric patients in the intensive care unit]

The percentage of geriatric patients treated in intensive care units continues to increase, comprising up to 30%. Age per se is not of great relevance for the outcome of intensive care treatment. Functional status and geriatric syndromes are crucial for prognosis. Frailty and delirium are very important and should be screened using the Clinical Frailty Scale (CFS) and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), respectively. Furthermore, age-physiological organ changes as well as multimorbidity and associated polypharmacy play an important role. The latter should be assessed at the time of admission. Another goal of intensive care treatment of geriatric patients is to maintain and improve the nutritional status, which can be assessed with the help of an established tool (e.g. NRS 2002). In the treatment of critically ill geriatric patients with coronavirus disease 2019 (COVID-19), frailty is also crucial. It is particularly important in the intensive medical treatment of critically ill geriatric patients to clarify the question whether the patient benefits from each intensive care therapy, e.g., whether a desired therapeutic goal can be achieved, whether intensive care is in the (presumed) patient's will and whether the burdens during treatment are justified by the perspective of life. Furthermore, interdepartmental cooperation plays an important role in the intensive medical care of geriatric patients.

[Clinical importance of the detection of frailty]

Frailty ist ein multidimensionales geriatrisches Syndrom, das durch einen Verlust an individueller Reservekapazität und eine erhöhte Vulnerabilität gegenüber internen und externen Stressoren gekennzeichnet ist. Frailty ist mit einem erhöhten Risiko für Stürze und einen Autonomieverlust sowie mit einer erhöhten Mortalität verbunden. Die Identifikation von Personen, die eine Frailty aufweisen, kann ein umfangreiches geriatrisches Assessment triggern und gezielte Therapieangebote begründen. Darüber hinaus können durch die Erfassung von Frailty jene Patient*innen identifiziert werden, die ein erhöhtes Risiko für ungünstige Behandlungsverläufe haben. Für die Erfassung von Frailty gibt es eine unübersichtliche Zahl an Instrumenten, wobei nur eine eingeschränkte Auswahl dieser Instrumente in einer deutschen Version vorliegt. Die Wahl des Instruments sollte sich am klinischen Setting und den vorhandenen Ressourcen orientieren.

[COVID-19 in old age-The geriatric perspective]

Predominantly the older population is affected by a severe course of COVID-19. The mortality of hospitalized patients with COVID-19 above the age of 80 years is up to 54% in international studies. These observations indicate the necessity to highlight the geriatric perspective on this disease. The diagnostics and treatment of COVID-19 do not differ between younger and older patients but atypical symptoms should be expected more frequently in old age. Older subjects show an increased need for rehabilitation after COVID-19. Paradoxically, increasing rehabilitation demands go along with a reduced availability of geriatric rehabilitation options, the latter being a consequence of closure or downsizing of rehabilitation departments during the pandemic. In general, measures of isolation and quarantine should be diligently balanced as the health and emotional consequences of such measures may be severe in older persons. In light of the poor prognosis of older COVID-19 patients, advanced care planning becomes even more relevant. Caregivers and physicians should be encouraged to compose advanced care directives that also reflect the specific circumstances of COVID-19. Fortunately, current data suggest that the effectiveness of the vaccination with the mRNA-vaccines approved in Germany may be equally high in older compared to younger persons.