Association of Frailty With the Risk of Mortality and Resource Utilization in Elderly Patients in Intensive Care Units: A Meta-Analysis

The association of a frailty index derived from laboratory tests and vital signs with clinical outcomes in critical care patients with septic shock: a retrospective study based on the MIMIC-IV database

PURPOSE

Frailty is a vulnerable state to stressors due to the loss of physiological reserve as a result of multisystem dysfunction. The physiological and laboratory-based frailty index (FI-Lab), depending on laboratory values and vital signs, is a powerful tool to capture frailty status. The aim of this study was to assess the relationship between FI-Lab and in-hospital mortality in patients with septic shock.

METHODS

Baseline data for patients with sepsis in the intensive care unit were retrieved from the Critical Care Medicine Database (MIMIC-IV, v2.2). The primary outcome was mortality during hospitalization. The propensity score matching (PSM) method was used to analyze the basic conditions during hospitalization between groups.The FI-Lab was analysed for its relationship with in-hospital mortality using logistic regression according to continuous and categorical variables, respectively, and described using the restricted cubic spline (RCS). Survival was compared between groups using Kaplan-Meier (KM) curves. Subgroup analyses were used to improve the stability of the results.

RESULTS

A total of 9219 patients were included. A cohort score of 1803 matched patients was generated after PSM. The analyses showed that non-surviving patients with septic shock in the ICU had a high FI-Lab index (P<0.001). FI-Lab, whether used as a continuous or categorical variable, increased with increasing FI-Lab and increased in-hospital mortality (P<0.001).Subgroup analyses showed similar results. RCS depicts this non-linear relationship. KM analysis shows the cumulative survival time during hospitalisation was significantly lower as FI-Lab increased (log-rank test, P<0.001).

CONCLUSION

Elevated FI-Lab is associated with increased in-hospital mortality in patients with septic shock.

Prevalence of frailty and association with patient centered outcomes: A prospective registry-embedded cohort study from India

PURPOSE

We aimed to study the prevalence of frailty, evaluate risk factors, and understand impact on outcomes in India.

METHODS

This was a prospective registry-embedded cohort study across 7 intensive care units (ICUs) and included adult patients anticipated to stay for at least 48 h. Primary exposure was frailty, as defined by a score ≥ 5 on the Clinical Frailty Scale and primary outcome was ICU mortality. Secondary outcomes included in-hospital mortality and resource utilization. We used generalized linear models to evaluate risk factors and model association between frailty and outcomes.

RESULTS

838 patients were included, with median (IQR) age 57 (42,68) yrs.; 64.8% were male. Prevalence of frailty was 19.8%. Charlson comorbidity index (OR:1.73 (95%CI:1.39,2.15)), Subjective Global Assessment categories mild/moderate malnourishment (OR:1.90 (95%CI:1.29, 2.80)) and severe malnourishment (OR:4.76 (95% CI:2.10,10.77)) were associated with frailty. Frailty was associated with higher odds of ICU mortality (adjusted OR:2.04 (95% CI:1.25,3.33)), hospital mortality (adjusted OR:2.36 (95%CI:1.45,3.84)), development of stage2/3 AKI (unadjusted OR:2.35 (95%CI:1.60, 3.43)), receipt of non-invasive ventilation (unadjusted OR:2.68 (95%CI:1.77, 4.03)), receipt of vasopressors (unadjusted OR:1.47 (95%CI:1.04, 2.07)), and receipt of kidney replacement therapy (unadjusted OR:3.15 (95%CI:1.90, 5.17)).

CONCLUSIONS

Frailty is common among critically ill patients in India and is associated with worse outcomes.

STUDY REGISTRATION

CTRI/2021/02/031503.

Impact of frailty on outcomes of elderly patients undergoing percutaneous coronary intervention: A systematic review and meta-analysis

BACKGROUND

Frailty is a common condition in elderly patients who receive percutaneous coronary intervention (PCI). However, how frailty affects clinical outcomes in this group is unclear.

AIM

To assess the link between frailty and the outcomes, such as in-hospital complications, post-procedural complications, and mortality, in elderly patients post-PCI.

METHODS

The PubMed/MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were screened for publications up to August 2023. The primary outcomes assessed were in-hospital and all-cause mortality, major adverse cardiovascular events (MACEs), and major bleeding. The Newcastle-Ottawa Scale was used for quality assessment.

RESULTS

Twenty-one studies with 739693 elderly patients undergoing PCI were included. Frailty was consistently associated with adverse outcomes. Frail patients had significantly higher risks of in-hospital mortality [risk ratio: 3.45, 95% confidence interval (95%CI): 1.90-6.25], all-cause mortality [hazard ratio (HR): 2.08, 95%CI: 1.78-2.43], MACEs (HR: 2.92, 95%CI: 1.85-4.60), and major bleeding (HR: 4.60, 95%CI: 2.89-7.32) compared to non-frail patients.

CONCLUSION

Frailty is a pivotal determinant in the prediction of risk of mortality, development of MACEs, and major bleeding in elderly individuals undergoing percutaneous coronary intervention.

The impact of age-related syndromes on ICU process and outcomes in very old patients

In this narrative review, we describe the most important age-related "syndromes" found in the old ICU patients. The syndromes are frailty, comorbidity, cognitive decline, malnutrition, sarcopenia, loss of functional autonomy, immunosenescence and inflam-ageing. The underlying geriatric condition, together with the admission diagnosis and the acute severity contribute to the short-term, but also to the long-term prognosis. Besides mortality, functional status and quality of life are major outcome variables. The geriatric assessment is a key tool for long-term qualitative outcome, while immediate severity accounts for acute mortality. A poor functional baseline reduces the chances of a successful outcome following ICU. This review emphasises the importance of using a geriatric assessment and considering the older patient as a whole, rather than the acute illness in isolation, when making decisions regarding intensive care treatment.

Controlling Nutritional Status (CONUT) Score as a Predictive Marker in Hospitalized Frail Elderly Patients

The Controlling Nutritional Status (CONUT) score is a simple screening tool able to detect altered nutritional status as well as to predict clinical adverse outcomes in specific populations. No data are available in frail patients. This study aims to investigate the predictive role of the CONUT score on mortality and length of stay (LOS) in frail patients admitted to an Internal Medicine Department. We consecutively enrolled 246 patients aged 65 years or older, divided into two groups based on frailty status. The two groups were further divided according to low (<5) or high (≥5) CONUT score. Length of stay (LOS) was higher in frail patients than not-frail patients, as well as in the frail group with high CONUT scores compared to the frail group with low CONUT scores. Multiple linear regression showed an increase of 2.1 days for each additional point to the CONUT score. In-hospital mortality was higher in frail compared to not-frail patients, but it did not differ between frail patients with high CONUT scores and frail patients with low CONUT scores. An analysis of the survival curve for 30-day mortality showed a higher mortality rate for frail/high-CONUT-score patients as compared to the not-frail/low-CONUT-score group. The CONUT score shows high prognostic value for higher LOS-but not mortality-in the clinical setting of internal medicine departments for old frail patients.

A comparison of three approaches to measuring frailty to determine adverse health outcomes in critically ill patients

BACKGROUND

studies comparing different frailty measures in intensive care unit settings are lacking. We aimed to compare the frailty index based on physiological and laboratory tests (FI-Lab), modified frailty index (MFI) and hospital frailty risk score (HFRS) to predict short-term outcomes for critically ill patients.

METHODS

we conducted a secondary analysis of data from the Medical Information Mart for Intensive Care IV database. Outcomes of interest included in-hospital mortality and discharge with need for nursing care.

RESULTS

the primary analysis was conducted with 21,421 eligible critically ill patients. After adjusting for confounding variables, frailty as diagnosed by all three frailty measures was found to be significantly associated with increased in-hospital mortality. In addition, frail patients were more likely to receive further nursing care after being discharged. All three frailty scores could improve the discrimination ability of the initial model generated by baseline characteristics for adverse outcomes. The FI-Lab had the best predictive ability for in-hospital mortality, whereas the HFRS had the best predictive performance for discharge with need for nursing care amongst the three frailty measures. A combination of the FI-Lab with either the HFRS or MFI improved the identification of critically ill patients at increased risk of in-hospital mortality.

CONCLUSIONS

frailty, as assessed by the HFRS, MFI and FI-Lab, was associated with short-term survival and discharge with need for nursing care amongst critically ill patients. The FI-Lab was a better predictor of in-hospital mortality than the HFRS and MFI. Future studies focusing on FI-Lab are warranted.

Prevalence of Frailty in ICU and its Impact on Patients' Outcomes

Introduction

Frailty describes a state or syndrome of reduced physical, physiologic, and cognitive reserve that increases vulnerability to acute illness. To study the prevalence of frailty in critically ill patients and find its association with resource utilization and short-term intensive care unit (ICU) outcomes.

Material and methods

This was a prospective observational study. All adult patients ≥50 years admitted to the ICU were included and frailty was assessed by the clinical frailty score (CFS). Data were collected on demography, coexisting illness, CFS, Acute Physiology and Chronic Health Evaluation II (APACHE-II), and Sequential Organ Failure Assessment Score (SOFA) scores. Patients were followed for 30 days. Outcome data were collected on organ supports provided, duration of ICU and hospital length of stay (LOS), and ICU and 30-day mortality.

Results

137 patients were enrolled in the study. The prevalence of frailty was 38.6%. Frail patients were older and had a more comorbid illness. APACHE-II and SOFA scores were 22.1 ± 7.0 and 7.2 ± 3.29, significantly higher in frail patients, respectively. There was a trend towards higher requirement for organ supports in frail patients. Median ICU and hospital LOS were 8 vs 6 and 20 vs 12 (frail vs nonfrail) days, respectively (p < 0.05). Intensive care unit mortality in frail and nonfrail patients was 28.3% and 23.8%, respectively (p = 0.56). Thirty-day mortality in frail patients was 49%, significantly higher compared with nonfrail patients (28.5%).

Conclusion

The prevalence of frailty in ICU patients was high. Frail patients were quite ill on ICU admission, and they had a prolonged ICU and hospital LOS. Increasing frailty score was associated with higher mortality at 30 days.

How to cite this article

Kalaiselvan MS, Yadav A, Kaur R, Menon A, Wasnik S. Prevalence of Frailty in ICU and its Impact on Patients' Outcomes. Indian J Crit Care Med 2023;27(5):335-341.

Frailty in People with Chronic Limb Threatening Ischemia and Diabetes-Related Foot Ulcers: A Systematic Review

BACKGROUND

Frailty represents a state of multisystem impairment that may adversely impact people presenting with chronic limb-threatening ischemia (CLTI) and diabetes-related foot ulcers (DFUs). The aim of this systematic review was to explore the association between frailty and outcomes from CLTI and DFUs.

METHODS

We performed a systematic literature search of electronic databases to find studies using a validated measure of frailty in individuals with CLTI and/or DFUs. The primary outcomes were the impact of frailty on the severity of initial clinical presentation and unfavorable follow-up outcomes including readmissions, major limb amputation, cardiovascular events, revascularization, and wound healing.

RESULTS

Ten cohort studies were included. Two studies had a low risk of bias, 1 was unable to be assessed, 5 had moderate risk of bias, and 2 high risk of bias. The prevalence of frailty in people presenting with CLTI ranged from 27% to 88% and was 71% in people with DFUs. The presence of frailty in both people with CLTI and DFUs was associated with substantially increased severity at presentation (severity of ischemia and tissue loss) and poorer outcomes at follow-up (risk of readmission, limb amputation, and all-cause mortality).

CONCLUSIONS

The presence of frailty in both people with CLTI and DFUs is likely associated with substantially higher complexity at presentation followed by a greater risk for readmission, amputation, and death during follow-up. Heterogeneity in the tools used to screen for frailty, poor definition of frailty, and unclear evaluation of exposure and outcomes limit further interpretation of findings.

The impact of age on intensive care

Caring for the elderly has always been challenging for the intensive care unit (ICU) physician. Concerns like frailty, comorbidities, polypharmacy and advanced directives come up even before admission into the unit. The COVID-19 pandemic has put forward a variety of issues concerning elderly populations, making the topic more relevant than ever. Admittance to the ICU, an unequivocally multifactorial decision, requires special consideration from the side of the physician when caring for an elderly person. Patients' wishes are to be respected and thus given priority. Triage assessment must also account for age-related physiological alterations and functional status. Once in the ICU, special attention should be given to age-related specificities, such as therapeutic interventions' controversial role, infection susceptibility, and post-operative care, that could potentially alter the course of hospitalization and affect outcomes. Following ICU discharge, ensuring proper rehabilitation for both survivors and their caregivers can improve long-term outcomes and subsequent quality of life. The pandemic and its implications may limit the standard of care for the elderly requiring ICU support. Socioeconomic factors that further perplex the situation must be addressed. Elderly patients currently represent a vast expanding population in ICU. Tailoring safe treatment plans to match patients' wishes, and personalized needs will guide critical care for the elderly from this time forward.

Incidence of barotrauma in patients with COVID-19 (alpha- and beta-predominant period) requiring mechanical ventilation: Single-center retrospective study

Objective

We sought to determine predictors, incidence, and interventions required for patients who developed barotrauma. Pneumothorax, subcutaneous emphysema, and pneumomediastinum have all been reported as complications related to COVID-19-positive patients requiring invasive mechanical ventilation.

Methods

In this retrospective study, clinical and imaging data from COVID-19 patients were collected and reviewed by two independent intensivists between January 4, 2020 and January 10, 2020. Data were used to identify COVID-19-positive patients requiring invasive mechanical ventilation and the incidence of barotrauma. Two separate cohorts were created as non-injured (no barotrauma) and injured (barotrauma present). We then sought to identify the risk factors for barotrauma in the non-injured cohort on Days 0, 7, 10, and 14 after intubation and day of injury in the injured cohort.

Results

Of the 264 patients with COVID-19, 55.8% were African American. The non-injured group was older (60 ± 15 versus 49 ± 16, p = 0.006), with male predominance in the injured group versus non-injured group (75% versus 55%). A total of 16 (6.5%) patients developed one or more complications of barotrauma, defined as subcutaneous emphysema, pneumothorax, or pneumomediastinum. Length of stay was longer for the injured group versus non-injured group (47 versus 25 days). Plateau pressure (p = 0.024), fraction of inspired oxygen (p < 0.001), and driving pressure (p = 0.001) were statistically significant in injured cohort. Mortality rate in non-injured versus injured was 49.4% versus 69%. Using random effect model, fraction of inspired oxygen (p = 0.003) and mean airway pressure (p = 0.010) were significant at the time of injury. When comparing alive versus deceased in the injured cohort, thoracostomy placement in alive versus deceased was 80% versus 54.5%.

Conclusion

COVID acute respiratory distress syndrome patients requiring invasive mechanical ventilation had a higher rate of barotrauma and were younger than those who did not develop barotrauma. Possible interventions to be considered to decrease barotrauma are decreased driving pressure goal and universal use of esophageal balloon manometry.

Association between Frailty Assessed Using Two Electronic Medical Record-Based Frailty Assessment Tools and Long-Term Adverse Prognosis in Older Critically Ill Survivors

OBJECTIVES

Frailty has become an independent risk factor for adverse outcomes in critically ill patients. This study aimed to explore the predictive ability of two electronic medical record-based frailty assessment tools, the Hospital Frailty Risk Score (HFRS) and Frailty Index based on physiological and laboratory tests (FI-lab), for long-term adverse prognosis in older critically ill survivors.

DESIGN

Retrospective observational study.

SETTING AND PARTICIPANTS

9,082 critically ill survivors aged ≥ 65 years.

MEASUREMENTS

The HFRS and the 33-item FI-lab were constructed based on the published literature. Cox and logistic regression models assessed the association between frailty and 1-year mortality and post-discharge care needs.

RESULTS

2,586 patients died within 1 year of follow-up. In fully adjusted models, frailty assessed using both the HFRS (per point, hazard ratio [HR] 1.06, 95% confidential interval [CI] 1.05-1.06; intermediate frailty risk, HR 2.00, 95% CI 1.78-2.25; high frailty risk, HR 3.06, 95% CI 2.68-3.50) and FI-lab (per 0.01 points, HR 1.03, 95% CI 1.03-1.03; intermediate frailty risk, HR 1.59, 95% CI 1.44-1.76; high frailty risk, HR 2.30, 95% CI 2.06-2.57) was associated with mortality. Addition of frailty indicators improved the predictive validity of the Sequential Organ Failure Assessment score for mortality (HFRS alone ∆ C-index 0.034; FI-lab alone ∆ C-index 0.016; HFRS and FI-lab combined ∆ C-index 0.042). The HFRS but not the FI-lab was associated with higher probability of post-discharge care needs.

CONCLUSION

Both the HFRS and FI-lab could independently predict 1-year mortality in older critically ill survivors. Adding the HFRS to the SOFA score model improved it more than adding the FI-lab. The greatest improvement was achieved when both frailty indicators were used together. These findings suggest that electronic medical record-based frailty assessment methods can be useful tools for predicting long-term outcomes in older critically ill patients.

The Association of Frailty With Long-Term Outcomes in Patients With Acute Respiratory Failure Treated With Noninvasive Ventilation

The objective of this study was to investigate the prevalence and impact of frailty on mortality in patients with acute respiratory failure (ARF) treated with noninvasive ventilation (NIV). This was a single-center, prospective study of patients who developed ARF (irrespective of etiology) and were treated with NIV support. Frailty was assessed using the Clinical Frailty Scale (CFS). We modeled the relationship of CFS with one-year mortality using Cox proportional hazards regression, adjusting for other clinical and demographic characteristics. Of the 166 patients enrolled, 48% had moderate to severe frailty. These patients were more likely to be female (67% versus 33%) and on oxygen therapy at home (46% versus 28%). The median CFS score was 5 (interquartile range (IQR): 5-6). Moderate to severe frailty was associated with a 60% higher risk of one-year mortality (hazard ratio (HR): 1.63, 95% confidence interval (CI): 1.15-2.31). Frailty assessment may identify patients in need of ventilatory support who are at increased risk of mortality and may be an important factor to consider when discussing goals of care in this vulnerable population.

Frailty-Diagnostik in verschiedenen AINS-Settings

Das Vorliegen eines sog. Frailty-Syndroms („Gebrechlichkeit“) ist für den postoperativen Verlauf ein entscheidender Faktor. So kommt es, auch durch eine zunehmende Fokussierung auf die patientenzentrierte Versorgung, zu einer erhöhten Nachfrage nach Instrumenten, die den Patient*innenstatus umfassender beurteilen und Krankheitsverläufe vorhersagen können. Der Beitrag stellt die 3 führenden Modelle zur Frailty-Diagnostik vor.

Comparing the Clinical Frailty Scale and an International Classification of Diseases-10 Modified Frailty Index in Predicting Long-Term Survival in Critically Ill Patients

The Clinical Frailty Scale (CFS) is the most used frailty measure in intensive care unit (ICU) patients. Recently, the modified frailty index (mFI), derived from 11 comorbidities has also been used. It is unclear to what degree the mFI is a true measure of frailty rather than comorbidity. Furthermore, the mFI cannot be freely obtained outside of specific proprietary databases.

OBJECTIVE

To compare the performance of CFS and a recently developed International Classification of Diseases-10 (ICD-10) mFI (ICD-10mFI) as frailty-based predictors of long-term survival for up to 1 year.

DESIGN

A retrospective multicentric observational study.

SETTING AND PARTICIPANTS

All adult (≥16 yr) critically ill patients with documented CFS scores admitted to sixteen Australian ICUs in the state of Victoria between April 1, 2017 to June 30, 2018 were included. We used probabilistic methods to match de-identified ICU admission episodes listed in the Australia and New Zealand Intensive Care Society Adult Patient Database with the Victorian Admission Episode Dataset and the Victorian Death Index via the Victorian Data Linkage Centre.

MAIN OUTCOMES AND MEASURES

The primary outcome was the longest available survival following ICU admission. We compared CFS and ICD-10mFI as primary outcome predictors, after adjusting for key confounders.

RESULTS

The CFS and ICD-10mFI were compared in 7,001 ICU patients. The proportion of patients categorized as frail was greater with the CFS than with the ICD-10mFI (18.9% [n = 1,323] vs. 8.8% [n = 616]; p < 0.001). The median (IQR) follow-up time was 165 (82-276) days. The CFS predicted long-term survival up to 6 months after adjusting for confounders (hazard ratio [HR] = 1.26, 95% CI, 1.21-1.31), whereas ICD-10mFI did not (HR = 1.04, 95% CI, 0.98-1.10). The ICD-10mFI weakly correlated with the CFS (Spearman's rho = 0.22) but had a poor agreement (kappa = 0.06). The ICD-10mFI more strongly correlated with the Charlson comorbidity index (Spearman's rho 0.30) than CFS (Spearman's rho = 0.25) (p < 0.001).

CONCLUSIONS

CFS, but not ICD-10mFI, predicted long-term survival in ICU patients. ICD-10mFI correlated with co-morbidities more than CFS. These findings suggest that CFS and ICD-10mFI are not equivalent.

RELEVANCE

CFS and ICD-10mFI are not equivalent in screening for frailty in critically ill patients and therefore ICD-10mFI in its current form should not be used.

Reduction of care-relevant risks to older patients during and after acute hospital care (ReduRisk) - study protocol of a cluster randomized efficacy trial in a stepped wedge design

BACKGROUND

Older patients are at an increased risk of hospitalization, negatively affecting their health and quality of life. Such patients also experience a lack of physical activity during their inpatient stay, as well as being at increased risk of delirium and inappropriate prescribing. These risk factors can accumulate, promoting a degree of morbidity and the development of cognitive impairment.

METHODS

Through the ReduRisk-program, patients at risk of functional impairment, immobility, falls, delirium or re-hospitalization shortly after hospital discharge, will be identified via risk-screening. These patients will receive an individually tailored, multicomponent and risk-adjusted prevention program. The trial will compare the effectiveness of the ReduRisk-program against usual care in a stepped-wedge-design, with quarterly cluster randomization of six university hospital departments into intervention and control groups. 612 older adults aged 70 years or more are being recruited. Patients in the intervention cluster (n = 357) will receive the ReduRisk-program, comprising risk-adjusted delirium management, structured mobility training and digitally supported planning of post-inpatient care, including polypharmacy management. This study will evaluate the impact of the ReduRisk-program on the primary outcomes of activities of daily living and mobility, and the secondary outcomes of delirium, cognition, falls, grip strength, health-related quality of life, potentially inappropriate prescribing, health care costs and re-hospitalizations. Assessments will be conducted at inpatient admission (t0), at discharge (t1) and at six months post-discharge (t2). In the six-month period following discharge, a health-economic evaluation will be carried out based on routine health insurance data (t3).

DISCUSSION

Despite the importance of multicomponent, risk-specific approaches to managing older patients, guidelines on their effectiveness are lacking. This trial will seek to provide evidence for the effectiveness of a multicomponent, risk-adjusted prevention program for older patients at risk of functional impairment, immobility, falls, delirium and re-hospitalization. Positive study results would support efforts to improve multicomponent prevention and the management of older patients.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00025594, date of registration: 09/08/2021.