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Ueno R, Reddy MP, Jones D, Pilcher D, Subramaniam A. The impact of frailty on survival times up to one year among patients admitted to ICU with in-hospital cardiac arrest. J Crit Care 2024; 83:154842. [PMID: 38865757 DOI: 10.1016/j.jcrc.2024.154842] [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: 10/10/2023] [Revised: 04/18/2024] [Accepted: 06/06/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND In-hospital cardiac arrest (IHCA) is a serious medical emergency. When IHCA occurs in patients with frailty, short-term survival is poor. However, the impact of frailty on long-term survival is unknown. METHODS We performed a retrospective multicentre study of all critically ill adult (age ≥ 16 years) patients admitted to Australian intensive care units (ICU) between 1st January 2018 to 31st March 2022. We included all patients who had an IHCA within the 24 h before ICU admission with a documented Clinical Frail Scale (CFS). The primary outcome was median survival up to one year following ICU admission. The effect of frailty on one-year survival was assessed using a Cox proportional hazards model, adjusting for age, sex, comorbidities, sequential organ failure assessment (SOFA) score, and hospital type. RESULTS We examined 3769 patients, of whom 30.8% (n = 1160) were frail (CFS ≥ 5). The median survival was significantly shorter for patients with frailty (median [IQR] days 19 [1-365] vs 302 [9-365]; p < 0.001). The overall one-year mortality was worse for the patients with frailty when compared to the non-frail group (64.8% [95%CI 61.9-67.5] vs 36.4% [95%CI 34.5-38.3], p < 0.001). Each unit increment in the CFS was associated with 22% worse survival outcome (adjusted Hazard ratio = 1.22, 95%-CI 1.19-1.26), after adjustment for confounders. The survival trend was similar among patients who survived the hospitalization. CONCLUSION In this retrospective multicentre study, frailty was associated with poorer one-year survival in patients admitted to Australian ICUs following an IHCA.
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Affiliation(s)
- Ryo Ueno
- Intensive Care Medicine, Eastern Health, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Victoria, Australia.
| | - Mallikarjuna Ponnapa Reddy
- Intensive Care Medicine, Peninsula Health, Victoria, Australia; Intensive Care Medicine, Calvary Hospital Health, Canberra, Australia
| | - Daryl Jones
- Australian and New Zealand Intensive Care Research Centre, Monash University, Victoria, Australia; Intensive Care Medicine, Austin Health, Victoria, Australia; University of Melbourne, Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Monash University, Victoria, Australia; Intensive Care Medicine, Alfred Health, Victoria, Australia; Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resources Evaluation, Victoria, Australia
| | - Ashwin Subramaniam
- Australian and New Zealand Intensive Care Research Centre, Monash University, Victoria, Australia; Intensive Care Medicine, Peninsula Health, Victoria, Australia; Intensive Care Medicine, Monash Health, Victoria, Australia; Monash University, Peninsula Clinical School, Victoria, Australia
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Sharp D, McKenzie D, Padayachee L, Subramaniam A. Frailty as a trigger for goals-of-care discussions in rapid response calls: A single-centre retrospective cohort study. Aust Crit Care 2024:S1036-7314(24)00200-5. [PMID: 39127605 DOI: 10.1016/j.aucc.2024.06.011] [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: 05/08/2024] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Timely goals-of-care (GOC) discussions are essential for end-of-life planning, particularly during acute hospital admissions, where ambiguity often persists. Frailty, prevalent in the ageing population and linked to adverse outcomes, underscores the need to align treatment strategies with quality of life. Recognising frailty as a trigger for GOC discussions during rapid response calls (RRCs) is critical for efficient resource management and improving patient outcomes. METHODS This single-centre retrospective cohort study included all hospitalised patients aged ≥65 years admitted between September 2021 and June 2023 who experienced an RRC. Frailty was assessed using the Clinical Frailty Scale (CFS) during the RRC. The primary outcome was to investigate whether frailty, specifically assessed by the CFS as screened during an RRC, could be a suitable clinical trigger for initiating GOC discussions. We also aimed to identify the proportion of patients with frailty (CFS score: ≥5) and predictors at the time of RRC, resulting in recommendations for GOC discussions. RESULTS Among 4954 patients, 1685 (34.0%) were classified as frail (CFS score: ≥5). Recommendations increased with frailty levels (nonfrail [CFS score: 1-4]: 6.6%, mildly frail [CFS score: 5]: 19.3%, moderate-to-severely frail [CFS score: 6-9]: 32.2%; p < 0.001). Frailty independently increased the probability of GOC recommendations during an RRC (area under the receiver operating characteristic curve = 0.71). The CFS cut-off point for GOC recommendations was ≥5. The presence of frailty was associated with higher odds of receiving GOC recommendations for mildly frail (CFS score: 5; odds ratio [OR] = 2.53; 95% confidence interval: 1.96-3.27) and moderate-to-severely frail (CFS score: 6-9; OR = 4.69; 95% confidence interval: 3.81-5.78) compared to nonfrail patients. CONCLUSION Frailty, identified during an RRC, served as a robust trigger for GOC recommendations, highlighting the importance of tailored proactive discussions before episodes of deterioration. Higher levels of frailty (CFS score: ≥5) demonstrate practical markers for aiding clinicians with proactive GOC discussions.
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Affiliation(s)
- D Sharp
- Department of Intensive Care, Epworth HealthCare, Richmond, Victoria, Australia; Department of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, Victoria, Australia; Department of Intensive Care, Victorian Heart Hospital, Monash Health, Clayton, Victoria, Australia.
| | - D McKenzie
- Research Development and Governance Unit, Epworth HealthCare, Richmond, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - L Padayachee
- Department of Intensive Care, Epworth HealthCare, Richmond, Victoria, Australia
| | - A Subramaniam
- Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, Victoria, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care Medicine, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia; Department of Intensive Care, Epworth HealthCare, Geelong, Victoria, Australia; Department of Medicine, Peninsula Clinical School, Monash University, Frankston, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Shi W, Lin H, Zhang X, Xu W, Lan T, Jiang W, Chen X, Lu W. The association between frailty and the risk of mortality in critically ill congestive heart failure patients: findings from the MIMIC-IV database. Front Endocrinol (Lausanne) 2024; 15:1424257. [PMID: 39161392 PMCID: PMC11330805 DOI: 10.3389/fendo.2024.1424257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 07/17/2024] [Indexed: 08/21/2024] Open
Abstract
Background Frailty is a severe, common co-morbidity associated with congestive heart failure (CHF). This retrospective cohort study assesses the association between frailty and the risk of mortality in critically ill CHF patients. Methods Eligible patients with CHF from the Medical Information Base for Intensive Care IV database were retrospectively analyzed. The frailty index based on laboratory tests (FI_Lab) index was calculated using 33 variables to assess frailty status. The primary outcomes were in-hospital mortality and one-year mortality. The secondary outcomes were the incidence of acute kidney injury (AKI) and the administration of renal replacement therapy (RRT) in patients with concurrent AKI. Survival disparities among the FI_Lab subgroups were estimated with Kaplan-Meier survival analysis. The association between the FI_Lab index and mortality was examined with Cox proportional risk modeling. Results A total of 3273 adult patients aged 18 years and older were enrolled in the study, with 1820 men and 1453 women included. The incidence rates of in-hospital mortality and one-year mortality rate were 0.96 per 1,000 person-days and 263.8 per 1,000 person-years, respectively. Multivariable regression analysis identified baseline FI_Lab > 0.45 as an independent risk factor predicting in-hospital mortality (odds ratio = 3.221, 95% CI 2.341-4.432, p < 0.001) and one-year mortality (hazard ratio=2.152, 95% CI: 1.730-2.678, p < 0.001). In terms of predicting mortality, adding FI_Lab to the six disease severity scores significantly improved the overall performance of the model (all p < 0.001). Conclusions We established a positive correlation between the baseline FI_Lab and the likelihood of adverse outcomes in critical CHF patients. Given its potential as a reliable prognostic tool for such patients, further validation of FI_Lab across multiple centers is recommended for future research.
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Affiliation(s)
- Wenhua Shi
- Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Hong Lin
- Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Xinyu Zhang
- Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Wenjing Xu
- Department of Cardiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Taohua Lan
- Department of Cardiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
- Academician Chen Keji Workstation, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Wei Jiang
- Department of Cardiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Xiankun Chen
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
- Key Unit of Methodology in Clinical Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Weihui Lu
- Department of Cardiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
- Academician Chen Keji Workstation, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
- Chinese Medicine Guangdong Laboratory, Hengqin, Guangdong, China
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
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Moïsi L, Mino JC, Guidet B, Vallet H. Frailty assessment in critically ill older adults: a narrative review. Ann Intensive Care 2024; 14:93. [PMID: 38888743 PMCID: PMC11189387 DOI: 10.1186/s13613-024-01315-0] [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: 02/22/2024] [Accepted: 05/17/2024] [Indexed: 06/20/2024] Open
Abstract
Frailty, a condition that was first defined 20 years ago, is now assessed via multiple different tools. The Frailty Phenotype was initially used to identify a population of "pre-frail" and "frail" older adults, so as to prevent falls, loss of mobility, and hospitalizations. A different definition of frailty, via the Clinical Frailty Scale, is now actively used in critical care situations to evaluate over 65 year-old patients, whether it be for Intensive Care Unit (ICU) admissions, limitation of life-sustaining treatments or prognostication. Confusion remains when mentioning "frailty" in older adults, as to which tools are used, and what the impact or the bias of using these tools might be. In addition, it is essential to clarify which tools are appropriate in medical emergencies. In this review, we clarify various concepts and differences between frailty, functional autonomy and comorbidities; then focus on the current use of frailty scales in critically ill older adults. Finally, we discuss the benefits and risks of using standardized scales to describe patients, and suggest ways to maintain a complex, three-dimensional, patient evaluation, despite time constraints. Frailty in the ICU is common, involving around 40% of patients over 75. The most commonly used scale is the Clinical Frailty Scale (CFS), a rapid substitute for Comprehensive Geriatric Assessment (CGA). Significant associations exist between the CFS-scale and both short and long-term mortality, as well as long-term outcomes, such as loss of functional ability and being discharged home. The CFS became a mainstream tool newly used for triage during the Covid-19 pandemic, in response to the pressure on healthcare systems. It was found to be significantly associated with in-hospital mortality. The improper use of scales may lead to hastened decision-making, especially when there are strains on healthcare resources or time-constraints. Being aware of theses biases is essential to facilitate older adults' access to equitable decision-making regarding critical care. The aim is to help counteract assessments which may be abridged by time and organisational constraints.
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Affiliation(s)
- L Moïsi
- Department of Geriatrics, Hopital Saint-Antoine, Assistance Publique Hôpitaux de Paris (AP-HP), Sorbonne Université, 75012, Paris, France.
- UVSQ, INSERM, Centre de Recherche en Epidémiologie Et Santé Des Populations, UMR 1018, Université Paris-Saclay, Université Paris-Sud, Villejuif, France.
- Département d'éthique, Faculté de Médecine, Sorbonne Université, Paris, France.
- Service de Gériatrie Aigue, Hopital St Antoine, 184 rue du Fbg St Antoine, 75012, Paris, France.
| | - J-C Mino
- UVSQ, INSERM, Centre de Recherche en Epidémiologie Et Santé Des Populations, UMR 1018, Université Paris-Saclay, Université Paris-Sud, Villejuif, France
- Département d'éthique, Faculté de Médecine, Sorbonne Université, Paris, France
| | - B Guidet
- Service de Réanimation Médicale, Hopital Saint-Antoine, Assistance Publique Hôpitaux de Paris (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
- INSERM, UMRS 1136, Institute Pierre Louis d'Épidémiologie Et de Santé Publique, 75013, Paris, France
| | - H Vallet
- Department of Geriatrics, Hopital Saint-Antoine, Assistance Publique Hôpitaux de Paris (AP-HP), Sorbonne Université, 75012, Paris, France
- UMRS 1135, Centre d'immunologie Et de Maladies Infectieuses (CIMI), Institut National de La Santé Et de La Recherche Médicale (INSERM), Paris, France
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Ling RR, Ueno R, Alamgeer M, Sundararajan K, Sundar R, Bailey M, Pilcher D, Subramaniam A. FRailty in Australian patients admitted to Intensive care unit after eLective CANCER-related SURGery: a retrospective multicentre cohort study (FRAIL-CANCER-SURG study). Br J Anaesth 2024; 132:695-706. [PMID: 38378383 DOI: 10.1016/j.bja.2024.01.020] [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: 11/20/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND The association between frailty and short-term and long-term outcomes in patients receiving elective surgery for cancer remains unclear, particularly in those admitted to the ICU. METHODS In this multicentre retrospective cohort study, we included adults ≥16 yr old admitted to 158 ICUs in Australia from January 1, 2018 to March 31, 2022 after elective surgery for cancer. We investigated the association between frailty and survival time up to 4 yr (primary outcome), adjusting for a prespecified set of covariates. We analysed how this association changed in specific subgroups (age categories [<65, 65-80, ≥80 yr], and those who survived hospitalisation), and over time by splitting the survival information at monthly intervals. RESULTS We included 35,848 patients (median follow-up: 18.1 months [inter-quartile range: 8.3-31.1 months], 19,979 [56.1%] male, median age 69.0 yr [inter-quartile range: 58.8-76.0 yr]). Some 3502 (9.8%) patients were frail (defined as clinical frailty scale ≥5). Frailty was associated with lower survival (hazard ratio: 1.72, 95% confidence interval [CI]: 1.59-1.86 compared with clinical frailty scale ≤4); this was concordant across several sensitivity analyses. Frailty was most strongly associated with mortality early on in follow-up, up to 10 months (hazard ratio: 1.39, 95% CI: 1.03-1.86), but this association plateaued, and its predictive capacity subsequently diminished with time up until 4 yr (1.96, 95% CI: 0.73-5.28). Frailty was associated with similar effects when stratified based on age, and in those who survived hospitalisation. CONCLUSIONS Frailty was associated with poorer outcomes after an ICU admission after elective surgery for cancer, particularly in the short term. However, its predictive capacity with time diminished, suggesting a potential need for longitudinal reassessment to ensure appropriate prognostication in this population.
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Affiliation(s)
- Ryan R Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Ryo Ueno
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia
| | - Muhammad Alamgeer
- Department of Medicine/School of Clinical Sciences, Monash University, Clayton, VIC, Australia; Department of Medical Oncology, Monash Health, Clayton, VIC, Australia; Centre for Cancer Research, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Krishnaswamy Sundararajan
- Department of Intensive Care, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Raghav Sundar
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore; Department of Haematology-Oncology, National University Cancer Institute, National University Hospital, Singapore; Cancer and Stem Cell Biology Program, Duke-NUS Medical School, Singapore; The N.1 Institute for Health, National University of Singapore, Singapore; Singapore Gastric Cancer Consortium, Singapore
| | - Michael Bailey
- Department of Intensive Care, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia
| | - David Pilcher
- Department of Intensive Care, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia; Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia; Department of Intensive Care, Peninsula Health, Frankston, VIC, Australia; Department of Intensive Care, Dandenong Hospital, Dandenong, VIC, Australia; Peninsula Clinical School, Monash University, Frankston, VIC, Australia.
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Sutton L, Bell E, Every-Palmer S, Weatherall M, Skirrow P. Survivorship outcomes for critically ill patients in Australia and New Zealand: A scoping review. Aust Crit Care 2024; 37:354-368. [PMID: 37684157 DOI: 10.1016/j.aucc.2023.07.008] [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: 05/03/2023] [Revised: 07/14/2023] [Accepted: 07/21/2023] [Indexed: 09/10/2023] Open
Abstract
INTRODUCTION Impairments after critical illness, termed the post-intensive care syndrome, are an increasing focus of research in Australasia. However, this research is yet to be cohesively synthesised and/or summarised. OBJECTIVE The aim of this scoping review was to explore patient outcomes of survivorship research, identify measures, methodologies, and designs, and explore the reported findings in Australasia. INCLUSION CRITERIA Studies reporting outcomes for adult survivors of critical illness from Australia and New Zealand in the following domains: physical, functional, psychosocial, cognitive, health-related quality of life (HRQoL), discharge destination, health care use, return to work, and ongoing symptoms/complications of critical illness. METHODS The Joanna Briggs Institute scoping review methodology framework was used. A protocol was published on the open science framework, and the search used Ovid MEDLINE, Scopus, ProQuest, and Google databases. Eligible studies were based on reports from Australia and New Zealand published in English between January 2000 and March 2022. RESULTS There were 68 studies identified with a wide array of study aims, methodology, and designs. The most common study type was nonexperimental cohort studies (n = 17), followed by studies using secondary analyses of other study types (n = 13). HRQoL was the most common domain of recovery reported. Overall, the identified studies reported that impairments and activity restrictions were associated with reduced HRQoL and reduced functional status was prevalent in survivors of critical illness. About 25% of 6-month survivors reported some form of disability. Usually, by 6 to12 months after critical illness, impairments had improved. CONCLUSIONS Reports of long-term outcomes for survivors of critical illness in Australia highlight that impairments and activity limitations are common and are associated with poor HRQoL. There was little New Zealand-specific research related to prevalence, impact, unmet needs, ongoing symptoms, complications from critical illness, and barriers to recovery.
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Affiliation(s)
- Lynsey Sutton
- Clinical Nurse Specialist, Wellington Intensive Care Unit, Wellington Regional Hospital, Te Whatu Ora Capital, Coast and Hutt Valley, Riddiford Street, Newtown, Wellington 6021, New Zealand; Department of Psychological Medicine, University of Otago, Wellington, New Zealand.
| | - Elliot Bell
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand.
| | - Susanna Every-Palmer
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand.
| | - Mark Weatherall
- Department of Medicine, University of Otago, Wellington, New Zealand.
| | - Paul Skirrow
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand.
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Wu JJ, Ou WF, Yu YY, Wu CL, Yang TY, Chan MC. Lower body mass index is an independent predictor of mortality in older patients with acute respiratory distress syndrome. Heliyon 2024; 10:e25749. [PMID: 38390194 PMCID: PMC10881338 DOI: 10.1016/j.heliyon.2024.e25749] [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: 08/14/2023] [Revised: 01/29/2024] [Accepted: 02/01/2024] [Indexed: 02/24/2024] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is associated with high mortality. The impacts of body mass index (BMI) on the morality of older patients with ARDS remain unclear. Methods This is a single-center cohort study which was conducted at Taichung Veterans General Hospital, Taiwan. Adult patients admitted to the ICU needing mechanical ventilation with ARDS were included for analysis. We compared the data of older patients (age ≥65 years) with those of younger patients (Age <65 years). The factors associated with in-hospital mortality of older patients were investigated. Results This study included a total of 728 (mean age: 66 years; men: 63%) patients, and 425 (58.4%) of them aged ≥65 years. Older patients exhibited lower body mass index (BMI) (23.8 vs 25.2), higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores (28.9 vs 26.3), higher Charlson Comorbidity Index (CCI) (4.0 vs 3.4), and lower Sequential Organ Failure Assessment (SOFA) scores (10.0 vs 11.1) than younger patients. Furthermore, older patients had mortality rates similar to younger patients (40.5% vs 42.9%, P = 0.542), but had longer length of stay in the ICU (17.6 vs 15.6 days, P = 0.047). For older patients, BMI <18.5 (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.45-5.34), high SOFA score (OR, 1.20; 95% CI, 1.12-1.28), and moderate (OR, 1.95; 95% CI 1.20-3.14) or severe ARDS (OR, 2.30; 95% CI 1.26-4.22) were independent risk factors for mortality. Conclusions In this cohort, critical ill older patients with ARDS had lower BMI, more comorbidities, and higher APACHE II scores than younger patients. Mortality rate was similar between older and younger patients. Low BMI, high SOFA score, and moderate or severe ARDS were independently associated with mortality in older patients with ARDS.
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Affiliation(s)
- Jia-Jun Wu
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan No.1650, Sect. 4, Taiwan Boulevard, Taichung, 407, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan No.110, Sect. 1, Jianguo N. Road, Taichung, 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan No.110, Sect. 1, Jianguo N. Road, Taichung, 402, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan No.110, Sect. 1, Jianguo N. Road, Taichung, 402, Taiwan
| | - Wei-Fan Ou
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan No.1650, Sect. 4, Taiwan Boulevard, Taichung, 407, Taiwan
| | - Yu-Yi Yu
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan No.155, Sect.2, Linong Street, Taipei, 112, Taiwan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan No.1650, Sect. 4, Taiwan Boulevard, Taichung, 407, Taiwan
| | - Chieh-Liang Wu
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan No.1650, Sect. 4, Taiwan Boulevard, Taichung, 407, Taiwan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan No.1650, Sect. 4, Taiwan Boulevard, Taichung, 407, Taiwan
| | - Tsung-Ying Yang
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan No.1650, Sect. 4, Taiwan Boulevard, Taichung, 407, Taiwan
- Division of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan No.1650, Sect. 4, Taiwan Boulevard, Taichung, 407, Taiwan
- Department of Life Sciences, National Chung Hsing University, Taichung, Taiwan No.250, Kuo Kuang Road, Taichung, 402, Taiwan
| | - Ming-Cheng Chan
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan No.1650, Sect. 4, Taiwan Boulevard, Taichung, 407, Taiwan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan No.1650, Sect. 4, Taiwan Boulevard, Taichung, 407, Taiwan
- School of Medicine, National Chung Hsing University No.250, Kuo Kuang Road, Taichung, 402, Taiwan
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Su RN, Lai WS, Hsieh CC, Jhang JN, Ku YC, Lien HI. Impact of frailty on the short-term outcomes of elderly intensive care unit patients. Nurs Crit Care 2023; 28:1061-1068. [PMID: 35644527 DOI: 10.1111/nicc.12787] [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: 09/11/2021] [Revised: 05/09/2022] [Accepted: 05/14/2022] [Indexed: 10/31/2023]
Abstract
BACKGROUND Frailty leads to multiple unfavourable outcomes in older adults. However, few studies have investigated correlations between frailty and its impacts on morbidity and mortality of elderly patients in intensive care units (ICUs) in Taiwan. AIMS To investigate the impact of frailty on the risk of hospital and 30-day mortality and functional outcomes of elderly Taiwanese ICU patients. STUDY DESIGN A prospective observational study was conducted. Patients aged 65 years or older were recruited from three medical ICUs. We defined 'frailty' according to the Clinical Frailty Scale (CFS) higher than 4 within 1 month prior to admission. The primary outcomes were hospital and 30-day mortality. The secondary outcome was CFS changes at ICU admission, hospital discharge, and 30-day follow-up. Logistic/Cox regression was used to analyse the data. RESULTS We recruited a total of 106 patients, 57 (54%) of whom were classified as frail. The overall mortality rate was 21%. Hospital mortality and mortality within 30 days after discharge were higher in the frail patients without a significant statistical difference (hospital mortality: 17.5% vs. 12.2%, p = .626; 30-day mortality: 26.3% vs. 14.3%, p = .200). The risk of 30-day mortality for frail patients was up to 2.84 times greater than that of non-frail patients in the Cox model (hazard ratio = 2.84, 95% confidence interval [0.96, 8.38]). Both non-frail and frail patients had a worse CFS score on admission, but the CFS score of surviving non-frail patients improved significantly over the medium term. CONCLUSION Frailty tended to increase short-term ICU mortality risk and worsen functional outcomes in the elderly Taiwanese population. This information might guide critical medical decisions. RELEVANCE TO CLINICAL PRACTICE Frailty could be included in the prognostic evaluation of either mortality risk or functional outcome. Prompt palliative care might be one last piece of holistic elder care.
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Affiliation(s)
- Ruei-Ning Su
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Shu Lai
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Cheng Hsieh
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jing-Nian Jhang
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yun-Chen Ku
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hui-I Lien
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Nursing, College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
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9
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Rai S, Brace C, Ross P, Darvall J, Haines K, Mitchell I, van Haren F, Pilcher D. Characteristics and Outcomes of Very Elderly Patients Admitted to Intensive Care: A Retrospective Multicenter Cohort Analysis. Crit Care Med 2023; 51:1328-1338. [PMID: 37219961 PMCID: PMC10497207 DOI: 10.1097/ccm.0000000000005943] [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] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To characterize and compare trends in ICU admission, hospital outcomes, and resource utilization for critically ill very elderly patients (≥ 80 yr old) compared with the younger cohort (16-79 yr old). DESIGN A retrospective multicenter cohort study. SETTING One-hundred ninety-four ICUs contributing data to the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database between January 2006 and December 2018. PATIENTS Adult (≥ 16 yr) patients admitted to Australian and New Zealand ICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Very elderly patients with a mean ± sd age of 84.8 ± 3.7 years accounted for 14.8% (232,582/1,568,959) of all adult ICU admissions. They had higher comorbid disease burden and illness severity scores compared with the younger cohort. Hospital (15.4% vs 7.8%, p < 0.001) and ICU mortality (8.5% vs 5.2%, p < 0.001) were higher in the very elderly. They stayed fewer days in ICU, but longer in hospital and had more ICU readmissions. Among survivors, a lower proportion of very elderly was discharged home (65.2% vs 82.4%, p < 0.001), and a higher proportion was discharged to chronic care/nursing home facilities (20.1% vs 7.8%, p < 0.001). Although there was no change in the proportion of very elderly ICU admissions over the study period, they showed a greater decline in risk-adjusted mortality (6.3% [95% CI, 5.9%-6.7%] vs 4.0% [95% CI, 3.7%-4.2%] relative reduction per year, p < 0.001) compared with the younger cohort. The mortality of very elderly unplanned ICU admissions improved faster than the younger cohort ( p < 0.001), whereas improvements in mortality among elective surgical ICU admissions were similar in both groups ( p = 0.45). CONCLUSIONS The proportion of ICU admissions greater than or equal to 80 years old did not change over the 13-year study period. Although their mortality was higher, they showed improved survivorship over time, especially in the unplanned ICU admission subgroup. A higher proportion of survivors were discharged to chronic care facilities.
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Affiliation(s)
- Sumeet Rai
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, Canberra, Australia
- Intensive Care Unit, Canberra Health Services, Garran, Canberra, Australia
| | - Charlotte Brace
- Department of Anaesthesia, Auckland City District Health Board, Auckland, New Zealand
| | - Paul Ross
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, St. Kilda Rd, Prahran, Melbourne, Australia
| | - Jai Darvall
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Kimberley Haines
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Department of Physiotherapy, Western Health, Melbourne, Australia
| | - Imogen Mitchell
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, Canberra, Australia
- Intensive Care Unit, Canberra Health Services, Garran, Canberra, Australia
| | - Frank van Haren
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, Canberra, Australia
- Intensive Care Unit, St George Hospital, Sydney, Australia
| | - David Pilcher
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, St. Kilda Rd, Prahran, Melbourne, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Camberwell, Melbourne, Australia
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10
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Ní Chróinín D, Alexandrou E, Frost SA. Delirium in the intensive care unit and its importance in the post-operative context: A review. Front Med (Lausanne) 2023; 10:1071854. [PMID: 37064025 PMCID: PMC10098316 DOI: 10.3389/fmed.2023.1071854] [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: 10/17/2022] [Accepted: 02/10/2023] [Indexed: 04/18/2023] Open
Abstract
The burden of delirium in the intensive care setting is a global priority. Delirium affects up to 80% of patients in intensive care units; an episode of delirium is often distressing to patients and their families, and delirium in patients within, or outside of, the intensive care unit (ICU) setting is associated with poor outcomes. In the short term, such poor outcomes include longer stay in intensive care, longer hospital stay, increased risk of other hospital-acquired complications, and increased risk of hospital mortality. Longer term sequelae include cognitive impairment and functional dependency. While medical category of admission may be a risk factor for poor outcomes in critical care populations, outcomes for surgical ICU admissions are also poor, with dependency at hospital discharge exceeding 30% and increased risk of in-hospital mortality, particularly in vulnerable groups, with high-risk procedures, and resource-scarce settings. A practical approach to delirium prevention and management in the ICU setting is likely to require a multi-faceted approach. Given the good evidence for the prevention of delirium among older post-operative outside of the intensive care setting, simple non-pharmacological interventions should be effective among older adults post-operatively who are cared for in the intensive care setting. In response to this, the future ICU environment will have a range of organizational and distinct environmental characteristics that are directly targeted at preventing delirium.
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Affiliation(s)
- Danielle Ní Chróinín
- Liverpool Hospital, Liverpool, NSW, Australia
- South Western Sydney Clinical School, UNSW Sydney, Liverpool, NSW, Australia
| | - Evan Alexandrou
- Liverpool Hospital, Liverpool, NSW, Australia
- South Western Sydney Clinical School, UNSW Sydney, Liverpool, NSW, Australia
- Centre for Applied Nursing Research, School of Nursing and Midwifery, Western Sydney University and Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| | - Steven A. Frost
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
- SWS Nursing and Midwifery Research Alliance, Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
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11
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Falk Erhag H, Guðnadóttir G, Alfredsson J, Cederholm T, Ekerstad N, Religa D, Nellgård B, Wilhelmson K. The Association Between the Clinical Frailty Scale and Adverse Health Outcomes in Older Adults in Acute Clinical Settings - A Systematic Review of the Literature. Clin Interv Aging 2023; 18:249-261. [PMID: 36843633 PMCID: PMC9946013 DOI: 10.2147/cia.s388160] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/14/2022] [Indexed: 02/19/2023] Open
Abstract
Background Frail older adults experience higher rates of adverse health outcomes. Therefore, assessing pre-hospital frailty early in the course of care is essential to identify the most vulnerable patients and determine their risk of deterioration. The Clinical Frailty Scale (CFS) is a frailty assessment tool that evaluates pre-hospital mobility, energy, physical activity, and function to generate a score that ranges from very fit to terminally ill. Purpose To synthesize the evidence of the association between the CFS degree and all-cause mortality, all-cause readmission, length of hospital stay, adverse discharge destination, and functional decline in patients >65 years in acute clinical settings. Design Systematic review with narrative synthesis. Methods Electronic databases (PubMed, EMBASE, CINAHL, Scopus) were searched for prospective or retrospective studies reporting a relationship between pre-hospital frailty according to the CFS and the outcomes of interest from database inception to April 2020. Results Our search yielded 756 articles, of which 29 studies were included in this review (15 were at moderate risk and 14 at low risk of bias). The included studies represented 26 cohorts from 25 countries (N = 44166) published between 2011 and 2020. All included studies showed that pre-hospital frailty according to the CFS is an independent predictor of all adverse health outcomes included in the review. Conclusion A primary purpose of the CFS is to grade clinically increased risk (i.e. risk stratification). Our results report the accumulated knowledge on the risk-predictive performance of the CFS and highlight the importance of routinely including frailty assessments, such as the CFS, to estimate biological age, improve risk assessments, and assist clinical decision-making in older adults in acute care. Further research into the potential of the CFS and whether implementing the CFS in routine practice will improve care and patients' quality of life is warranted.
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Affiliation(s)
- Hanna Falk Erhag
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden,Centre for Ageing and Health (Agecap), University of Gothenburg, Gothenburg, Sweden,Region Västra Götaland, Sahlgrenska University Hospital, Department of Acute Medicine and Geriatrics, Gothenburg, Sweden,Correspondence: Hanna Falk Erhag, Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Wallinsgatan 6, Gothenburg, SE 431 41, Sweden, Tel +46 760 476888, Fax +46 31 786 60 77, Email
| | - Gudny Guðnadóttir
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Acute Medicine and Geriatrics, Gothenburg, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, and Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Tommy Cederholm
- Clinical Nutrition and Metabolism Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden,Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden
| | - Niklas Ekerstad
- Department of Health, Medicine, and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden,The Research and Development Unit, NU Hospital Group, Trollhättan, Sweden
| | - Dorota Religa
- Department of Neurobiology, Care Sciences, and Society, Clinical Geriatrics, Karolinska Institute, Stockholm, Sweden,Division for Clinical Geriatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Nellgård
- Department of Anesthesiology and Intensive Care, Institute of Clinical Studies, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Wilhelmson
- Centre for Ageing and Health (Agecap), University of Gothenburg, Gothenburg, Sweden,Region Västra Götaland, Sahlgrenska University Hospital, Department of Acute Medicine and Geriatrics, Gothenburg, Sweden,Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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12
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Brankovic M, Jeon H, Markovic N, Choi C, Adam S, Ampey M, Pergament K, Tien Yen Chyn E. Palliative care of COVID-19 patients with do-not-resuscitate status in underrepresented minorities. Eur J Clin Invest 2023; 53:e13889. [PMID: 36205636 PMCID: PMC9874486 DOI: 10.1111/eci.13889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND The impact of the COVID-19 pandemic on palliative care intervention (PCIs) in patients with do-not-resuscitate (DNR) status remains uncertain. METHODS Case-control study of patients with DNR order with RT-PCR confirmed SARS-COV2 infection (cases), and those with DNR order but without SARS-COV2 infection (controls). The primary outcome measures included timing and delivery of PCIs, and secondary measures included pre-admission characteristics and in-hospital death. RESULTS The ethnicity distribution was comparable between 69 cases and 138 controls, including Black/African Americans (61% vs. 44%), Latino/Hispanics (16% vs. 26%) and White (9% vs. 20%) (trend-p = .54). Cases were employed more (17% vs. 6%, adjusted-p = .012), less frail (fit 47% vs. 21%; mildly frail 22% vs. 36%; frail 31% vs. 43%, trend-p = .018) and had fewer comorbidities than controls. Cases had higher chances of intensive care unit admission (HR 1.76 [95% CI: 1.03-3.02]) and intubation (53% vs. 30%, p = .002), lower chances to be seen by palliative care team (HR .46 [.30-.70]) and a longer time to palliative care visit than controls (β per ln-day .67 [.00-1.34]). In the setting of no-visiting hospitals policy, we did not find significant increase in utilisation of video conferencing (22% vs. 13%) and religious services (12% vs. 12%) both in case and in controls. CONCLUSION Do-not-resuscitate patients with COVID-19 had better general health and higher employment status than 'typical' DNR patients, but lower chances to be seen by the palliative care team. This study raises a question of the applicability of the current palliative care model in addressing the needs of DNR patients with COVID-19 during the pandemic.
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Affiliation(s)
- Milos Brankovic
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Transatlantic Cardiovascular Study Group, Bloomfield, New Jersey, USA
| | - Hyein Jeon
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Nikolina Markovic
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Catherine Choi
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Shawn Adam
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Madia Ampey
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Kathleen Pergament
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Eric Tien Yen Chyn
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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13
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Nicholson H, Voss S, Black S, Taylor H, Williams D, Benger J. Factors influencing conveyance of older adults with minor head injury by paramedics to the emergency department: a multiple methods study. BMC Emerg Med 2022; 22:184. [PMID: 36418963 PMCID: PMC9682699 DOI: 10.1186/s12873-022-00747-w] [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: 09/13/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Head injury (HI) in older adults due to low-energy falls result in a substantial number of emergency department (ED) attendances. However, mortality associated with minor HI is very low. Reducing conveyance to hospital is important for older adults and is a priority for the National Health Service (NHS). Therefore, paramedics are required to make accurate decisions regarding conveyance to the ED. This study used routine data and semi-structured interviews to explore the factors that influence paramedic decision-making when considering whether to convey an adult aged 65 years and over with a minor HI to the ED. METHODS Semi-structured telephone interviews were completed with ten UK paramedics from a single EMS (ambulance) provider organisation. Interviews explored the factors influencing the paramedics' conveyance decision-making in adults aged 65 years and over with a minor HI. Data were initially analysed inductively to develop a thematic framework. A retrospective analysis of ambulance service data was also completed to determine the scope and scale of the issue in Southwest England. An in-depth audit of 100 conveyed patient records was used to determine the proportion of patients conveyed to the ED who met National Institute for Health and Care Excellence (NICE) and Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines. RESULTS In 2019 South Western Ambulance Service NHS Foundation Trust (SWASFT) attended 15,650 emergency calls to patients aged 65 and over with minor HI, with 70.5% conveyed to ED. 81% of conveyed patients met NICE and JRCALC guideline criteria for conveyance, with the remainder conveyed due to wound care or other medical concerns. The framework developed from the interviews comprised four themes: resources; patient factors; consequences; paramedic factors. Important factors included: the patient's social situation; guidelines; clinical support availability; the history and presentation of the patient; risk. CONCLUSION This study examined paramedic conveyance decisions for older people with minor HI. It identified multiple influencing factors, highlighting the complex nature of these decisions, and may serve as a basis for developing an intervention to safely decrease ED conveyance in this patient group.
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Affiliation(s)
- Helen Nicholson
- grid.6518.a0000 0001 2034 5266College of Health, Science and Society, University of the West of England, Glenside Campus (1H14), Blackberry Hill, BS16 1DD Bristol, England
| | - Sarah Voss
- grid.6518.a0000 0001 2034 5266College of Health, Science and Society, University of the West of England, Glenside Campus (1H14), Blackberry Hill, BS16 1DD Bristol, England
| | - Sarah Black
- grid.499043.30000 0004 0498 1379South Western Ambulance Service NHS Foundation Trust, Eagle Way, EX2 7HY Exeter, England
| | - Hazel Taylor
- grid.410421.20000 0004 0380 7336Research Design Service – South West, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, BS2 8AE Bristol, England
| | - David Williams
- grid.6518.a0000 0001 2034 5266College of Health, Science and Society, University of the West of England, Glenside Campus (1H14), Blackberry Hill, BS16 1DD Bristol, England
| | - Jonathan Benger
- grid.6518.a0000 0001 2034 5266College of Health, Science and Society, University of the West of England, Glenside Campus (1H14), Blackberry Hill, BS16 1DD Bristol, England ,grid.410421.20000 0004 0380 7336Emergency Department, Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, BS2 8HW Bristol, England
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14
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Sahle BW, Pilcher D, Litton E, Ofori-Asenso R, Peter K, McFadyen J, Bucknall T. Association between frailty, delirium, and mortality in older critically ill patients: a binational registry study. Ann Intensive Care 2022; 12:108. [PMID: 36394660 PMCID: PMC9672151 DOI: 10.1186/s13613-022-01080-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 11/02/2022] [Indexed: 11/19/2022] Open
Abstract
Background Frailty and delirium are prevalent among older adults admitted to the intensive care unit (ICU) and associated with adverse outcomes; however, their relationships have not been extensively explored. This study examined the association between frailty and mortality and length of hospital stay (LOS) in ICU patients, and whether the associations are mediated or modified by an episode of delirium. Methods Retrospective analysis of data from the Australian New Zealand Intensive Care Society Adult Patient Database. A total of 149,320 patients aged 65 years or older admitted to 203 participating ICUs between 1 January 2017 and 31 December 2020 who had data for frailty and delirium were included in the analysis. Results A total of 41,719 (27.9%) older ICU patients were frail on admission, and 9,179 patients (6.1%) developed delirium during ICU admission. Frail patients had significantly higher odds of in-hospital mortality (OR: 2.15, 95% CI 2.05–2.25), episodes of delirium (OR: 1.86, 95% CI 1.77–1.95), and longer LOS (log-transformed mean difference (MD): 0.24, 95% CI 0.23–0.25). Acute delirium was associated with 32% increased odds of in-hospital mortality (OR: 1.32, 95% CI 1.23–1.43) and longer LOS (MD: 0.54, 95% CI 0.50–0.54). The odds ratios (95% CI) for in-hospital mortality were 1.37 (1.23–1.52), 2.14 (2.04–2.24) and 2.77 (2.51–3.05) for non-frail who developed delirium, frail without delirium, and frail and developed delirium during ICU admission, respectively. There was very small but statistically significant effect of frailty on in-hospital mortality (b for indirect effect: 0.00037, P < 0.001) and LOS (b for indirect effect: 0.019, P < 0.001) mediated through delirium. Conclusion Both frailty and delirium independently increase the risk of in-hospital mortality and LOS. Acute delirium is more common in frail patients; however, it does not mediate or modify a clinically meaningful amount of the association between frailty and in-hospital mortality and LOS. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01080-y.
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Affiliation(s)
- Berhe W Sahle
- School of Nursing and Midwifery, Faculty of Health, Deakin University, 221 Burwood Highway, Burwood, Melbourne, VIC, 3125, Australia. .,Centre for Quality and Patient Safety Research, Alfred Health Partnership, Institute for Health Transformation, Melbourne, VIC, Australia.
| | - David Pilcher
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Edward Litton
- Fiona Stanley Hospital, Perth, WA, Australia.,The University of Western Australia, Perth, WA, Australia
| | - Richard Ofori-Asenso
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
| | - James McFadyen
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Hematology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Tracey Bucknall
- School of Nursing and Midwifery, Faculty of Health, Deakin University, 221 Burwood Highway, Burwood, Melbourne, VIC, 3125, Australia.,Centre for Quality and Patient Safety Research, Alfred Health Partnership, Institute for Health Transformation, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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15
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Sajeev S, Champion S, Maeder A, Gordon S. Machine learning models for identifying pre-frailty in community dwelling older adults. BMC Geriatr 2022; 22:794. [PMID: 36221059 PMCID: PMC9554971 DOI: 10.1186/s12877-022-03475-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 09/15/2022] [Indexed: 04/11/2023] Open
Abstract
Background There is increasing evidence that pre-frailty manifests as early as middle age. Understanding the factors contributing to an early trajectory from good health to pre-frailty in middle aged and older adults is needed to inform timely preventive primary care interventions to mitigate early decline and future frailty. Methods A cohort of 656 independent community dwelling adults, aged 40–75 years, living in South Australia, undertook a comprehensive health assessment as part of the Inspiring Health cross-sectional observational study. Secondary analysis was completed using machine learning models to identify factors common amongst participants identified as not frail or pre-frail using the Clinical Frailty Scale (CFS) and Fried Frailty Phenotype (FFP). A correlation-based feature selection was used to identify factors associated with pre-frailty classification. Four machine learning models were used to derive the prediction models for classification of not frail and pre-frail. The class discrimination capability of the machine learning algorithms was evaluated using area under the receiver operating characteristic curve (AUC), sensitivity, specificity, precision, F1-score and accuracy. Results Two stages of feature selection were performed. The first stage included 78 physiologic, anthropometric, environmental, social and lifestyle variables. A follow-up analysis with a narrower set of 63 variables was then conducted with physiologic factors associated with the FFP associated features removed, to uncover indirect indicators connected with pre-frailty. In addition to the expected physiologic measures, a range of anthropometric, environmental, social and lifestyle variables were found to be associated with pre-frailty outcomes for the cohort. With FFP variables removed, machine learning (ML) models found higher BMI and lower muscle mass, poorer grip strength and balance, higher levels of distress, poor quality sleep, shortness of breath and incontinence were associated with being classified as pre-frail. The machine learning models achieved an AUC score up to 0.817 and 0.722 for FFP and CFS respectively for predicting pre-frailty. With feature selection, the performance of ML models improved by up to + 7.4% for FFP and up to + 7.9% for CFS. Conclusions The results of this study indicate that machine learning methods are well suited for predicting pre-frailty and indicate a range of factors that may be useful to include in targeted health assessments to identify pre-frailty in middle aged and older adults. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03475-9.
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Affiliation(s)
- Shelda Sajeev
- School of Business and Information Systems, Torrens University, 88 Wakefield St, Adelaide, SA, 5000, Australia. .,Centre for Artificial Intelligence Research and Optimisation, Torrens University, Adelaide, Australia. .,Flinders Digital Health Research Centre, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia.
| | - Stephanie Champion
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, South, 5042, Australia
| | - Anthony Maeder
- Flinders Digital Health Research Centre, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia.,Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, South, 5042, Australia
| | - Susan Gordon
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, South, 5042, Australia
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16
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Doherty Z, Savage N, Milne C, Pilcher D. Vascular surgery patients in intensive care: a bi-national cohort study over 15 years. ANZ J Surg 2022. [PMID: 36189984 DOI: 10.1111/ans.18080] [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: 03/08/2022] [Revised: 09/13/2022] [Accepted: 09/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND To describe the characteristics and outcomes of patients admitted to Intensive Care following vascular surgery, and their subsequent usage of Intensive Care resources, over a 15-year period in Australia and New Zealand. METHODS This was a retrospective, bi-national study of 69 676 adult patients admitted to 179 Intensive Care Unit (ICUs) following vascular surgery between January 2005 and December 2019, using the Australian and New Zealand Intensive Care Society Adult Patient Database. RESULTS The proportion of ICU bed days used by vascular surgery patients decreased during the study period from 3.6% in 2005 to 2.9% in 2019 (P < 0.001). The cohort had a median age of 73 years, and were most frequently admitted after a carotid endarterectomy (22%) or elective open aneurysm repair (20%). A total of 5.2% of patients did not survive to discharge. Mean annual adjusted mortality decreased during the study period from 6.1% in 2005 to 3.7% in 2019 (P < 0.001). Multiple factors were associated with higher mortality, including gender, hospital case volume and hospital type. CONCLUSIONS Between 2005 and 2019 survival for vascular surgery patients requiring ICU admission in Australia and New Zealand improved. During the same time the proportion of ICU bed days used by these patients decreased.
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Affiliation(s)
- Zakary Doherty
- School of Rural Health, Monash University, Bendigo, Victoria, Australia.,Department of Surgery, Alfred Health, Melbourne, Victoria, Australia.,Department of Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Nicholas Savage
- Department of Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Charles Milne
- Department of Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - David Pilcher
- Department of Surgery, Alfred Health, Melbourne, Victoria, Australia.,The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Melbourne, Victoria, Australia.,The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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17
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Subramaniam A, Shekar K, Anstey C, Tiruvoipati R, Pilcher D. Impact of frailty on clinical outcomes in patients with and without COVID-19 pneumonitis admitted to intensive care units in Australia and New Zealand: a retrospective registry data analysis. Crit Care 2022; 26:301. [PMID: 36192763 PMCID: PMC9527725 DOI: 10.1186/s13054-022-04177-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/21/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND It is unclear if the impact of frailty on mortality differs between patients with viral pneumonitis due to COVID-19 or other causes. We aimed to determine if a difference exists between patients with and without COVID-19 pneumonitis. METHODS This multicentre, retrospective, cohort study using the Australian and New Zealand Intensive Care Society Adult Patient Database included patients aged ≥ 16 years admitted to 153 ICUs between 01/012020 and 12/31/2021 with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome, and Clinical Frailty Scale (CFS). The primary outcome was hospital mortality. RESULTS A total of 4620 patients were studied, and 3077 (66.6%) had COVID-19. The patients with COVID-19 were younger (median [IQR] 57.0 [44.7-68.3] vs. 66.1 [52.0-76.2]; p < 0.001) and less frail (median [IQR] CFS 3 [2-4] vs. 4 [3-5]; p < 0.001) than non-COVID-19 patients. The overall hospital mortality was similar between the patients with and without COVID-19 (14.7% vs. 14.9%; p = 0.82). Frailty alone as a predictor of mortality showed only moderate discrimination in differentiating survivors from those who died but was similar between patients with and without COVID-19 (AUROC 0.68 vs. 0.66; p = 0.42). Increasing frailty scores were associated with hospital mortality, after adjusting for Australian and New Zealand Risk of Death score and sex. However, the effect of frailty was similar in patients with and without COVID-19 (OR = 1.29; 95% CI: 1.19-1.41 vs. OR = 1.24; 95% CI: 1.11-1.37). CONCLUSION The presence of frailty was an independent risk factor for mortality. However, the impact of frailty on outcomes was similar in COVID-19 patients compared to other causes of viral pneumonitis.
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Affiliation(s)
- Ashwin Subramaniam
- grid.466993.70000 0004 0436 2893Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, VIC 3199 Australia ,grid.1002.30000 0004 1936 7857Peninsula Clinical School, Monash University, Frankston, VIC Australia ,grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC Australia
| | - Kiran Shekar
- grid.415184.d0000 0004 0614 0266Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD Australia ,grid.1003.20000 0000 9320 7537University of Queensland, Brisbane, QLD Australia ,grid.1033.10000 0004 0405 3820Queensland University of Technology Brisbane and Bond University, Gold Coast, QLD Australia
| | - Christopher Anstey
- grid.1022.10000 0004 0437 5432Griffith University, Gold Coast, QLD Australia
| | - Ravindranath Tiruvoipati
- grid.466993.70000 0004 0436 2893Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, VIC 3199 Australia ,grid.1002.30000 0004 1936 7857Peninsula Clinical School, Monash University, Frankston, VIC Australia
| | - David Pilcher
- grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC Australia ,grid.1623.60000 0004 0432 511XDepartment of Intensive Care, Alfred Hospital, Melbourne, VIC Australia ,grid.489411.10000 0004 5905 1670Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC Australia
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Subramaniam A, Tiruvoipati R, Pilcher D, Bailey M. Treatment limitations and clinical outcomes in critically ill frail patients with and without COVID-19 pneumonitis. J Am Geriatr Soc 2022; 71:145-156. [PMID: 36151970 PMCID: PMC9539196 DOI: 10.1111/jgs.18044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/21/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The presence of treatment limitations in patients with frailty at intensive care unit (ICU) admission is unknown. We aimed to evaluate the presence and predictors of treatment limitations in patients with and without COVID-19 pneumonitis in those admitted to Australian and New Zealand ICUs. METHODS This registry-based multicenter, retrospective cohort study included all frail adults (≥16 years) with documented clinical frailty scale (CFS) scores, admitted to ICUs with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome (ARDS) over 2 years between January 01, 2020 and December 31, 2021. Frail patients (CFS ≥5) coded as having viral pneumonitis or ARDS due to COVID-19 were compared to those with other causes of viral pneumonitis or ARDS for documented treatment limitations. RESULTS 884 frail patients were included in the final analysis from 129 public and private ICUs. 369 patients (41.7%) had confirmed COVID-19. There were more male patients in COVID-19 (55.3% vs 47.0%; p = 0.015). There were no differences in age or APACHE-III scores between the two groups. Overall, 36.0% (318/884) had treatment limitations, but similar between the two groups (35.8% [132/369] vs 36.1% [186/515]; p = 0.92). After adjusting for confounders, increasing frailty (OR = 1.72; 95%-CI 1.39-2.14), age (OR = 1.05; 95%-CI 1.04-1.06), and presence of chronic respiratory condition (OR = 1.58; 95%-CI 1.10-2.27) increased the likelihood of instituting treatment limitations. However, the presence of COVID-19 by itself did not influence treatment limitations (odds ratio [OR] = 1.39; 95%-CI 0.98-1.96). CONCLUSIONS The proportion of treatment limitations was similar in patients with frailty with or without COVID-19 pneumonitis at ICU admission.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive CarePeninsula HealthFrankstonVictoriaAustralia,Peninsula Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Ravindranath Tiruvoipati
- Department of Intensive CarePeninsula HealthFrankstonVictoriaAustralia,Peninsula Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia,Centre for Outcome and Resource EvaluationAustralian and New Zealand Intensive Care SocietyMelbourneVictoriaAustralia,Department of Intensive CareAlfred HospitalMelbourneVictoriaAustralia
| | - Michael Bailey
- Centre for Outcome and Resource EvaluationAustralian and New Zealand Intensive Care SocietyMelbourneVictoriaAustralia
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19
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Osatnik J, Matarrese A, Leone B, Cesar G, Kleinert M, Sosa F, Roberti J, Ivulich D. Frailty and clinical outcomes in critically ill patients with cancer: A cohort study. J Geriatr Oncol 2022; 13:1156-1161. [PMID: 36031524 DOI: 10.1016/j.jgo.2022.08.006] [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: 08/16/2021] [Revised: 08/01/2022] [Accepted: 08/10/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Our aim was to assess impact of frailty on short-term clinical outcomes in critically ill patients with cancer. MATERIALS AND METHODS We conducted a cohort study at a medical and surgical intensive care unit (ICU) in Argentina. We included 269 consecutive patients, ≥18 years old, with diagnosis of cancer. We recorded demographic and clinical characteristics, Clinical Frailty Scale (CFS, ≥5 defined a patient as frail), and the number and duration of organ support therapies during ICU stay. Primary outcome was ICU and hospital mortality. RESULTS Median age 69 (range 20-90); 152 (56%) patients were male. Sixty-eight (25.2%) patients presented frailty at admission. Older adults (≥65 years old) made up 62.8% of patients. Frail patients were 69.7 years versus 64.4 years for non-frail, P = 0.007, with higher Acute Physiology and Chronic Health Evaluation II (APACHE II) 14.7 ± 7 versus 10.8 ± 6, P = 0.001 and Simplified Acute Physiology Score (SAPS II) 40.1 ± 17 versus 28.7 ± 14, P = 0.001, respectively. After adjusting by age, severity score, type of admission, and type of cancer, frailty was independently associated with hospital mortality, odds ratio (OR) 4.87 (95% confidence interval [CI], 2.19-11.19, P ≤0.001). Median ICU length of stay was five days (interquartile range [IQR] 3-7) versus six days (IQR 3.8-9), in non-frail versus frail patients, respectively (P = 0.100), and hospital stay was nine days (IQR 6-17) versus 11.5 days (IQR 7-19.5) in non-frail versus frail patients, respectively (P = 0.085). DISCUSSION Frailty as a medical condition was strongly associated with worse clinical outcomes among oncologic critically ill patients.
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Affiliation(s)
- Javier Osatnik
- Intensive Care Unit, Hospital Alemán, Buenos Aires, Argentina.
| | | | - Bruno Leone
- Intensive Care Unit, Hospital Alemán, Buenos Aires, Argentina
| | - Germán Cesar
- Intensive Care Unit, Hospital Alemán, Buenos Aires, Argentina
| | | | - Fernando Sosa
- Intensive Care Unit, Hospital Alemán, Buenos Aires, Argentina
| | | | - Daniel Ivulich
- Intensive Care Unit, Hospital Alemán, Buenos Aires, Argentina
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20
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Subramaniam A, Ueno R, Tiruvoipati R, Darvall J, Srikanth V, Bailey M, Pilcher D, Bellomo R. Defining ICD-10 surrogate variables to estimate the modified frailty index: a Delphi-based approach. BMC Geriatr 2022; 22:422. [PMID: 35562684 PMCID: PMC9107186 DOI: 10.1186/s12877-022-03063-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 04/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are currently no validated globally and freely available tools to estimate the modified frailty index (mFI). The widely available and non-proprietary International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) coding could be used as a surrogate for the mFI. We aimed to establish an appropriate set of the ICD-10 codes for comorbidities to be used to estimate the eleven-variable mFI. METHODS A three-stage, web-based, Delphi consensus-building process among a panel of intensivists and geriatricians using iterative rounds of an online survey, was conducted between March and July 2021. The consensus was set a priori at 75% overall agreement. Additionally, we assessed if survey responses differed between intensivists and geriatricians. Finally, we ascertained the level of agreement. RESULTS A total of 21 clinicians participated in all 3 Delphi surveys. Most (86%, 18/21) had more than 5-years' experience as specialists. The agreement proportionately increased with every Delphi survey. After the third survey, the panel had reached 75% consensus in 87.5% (112/128) of ICD-10 codes. The initially included 128 ICD-10 variables were narrowed down to 54 at the end of the 3 surveys. The inter-rater agreements between intensivists and geriatricians were moderate for surveys 1 and 3 (κ = 0.728, κ = 0.780) respectively, and strong for survey 2 (κ = 0.811). CONCLUSIONS This quantitative Delphi survey of a panel of experienced intensivists and geriatricians achieved consensus for appropriate ICD-10 codes to estimate the mFI. Future studies should focus on validating the mFI estimated from these ICD-10 codes. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia. .,Peninsula Clinical School, Monash University, Frankston, Victoria, Australia. .,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Ryo Ueno
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, Eastern Health, Box Hill, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia.,Peninsula Clinical School, Monash University, Frankston, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jai Darvall
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Velandai Srikanth
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia.,Department of Geriatric Medicine, Peninsula Health, Frankston, Victoria, Australia.,National Centre for Healthy Ageing, Melbourne, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia.,Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
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21
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Abstract
PURPOSE OF REVIEW To highlight recent findings on the evaluation and impact of frailty in the management of patients with traumatic brain injury (TBI). RECENT FINDINGS Frailty is not a direct natural consequence of aging. Rather, it commonly results from the intersection of age-related decline with chronic diseases and conditions. It is associated with adverse outcomes such as institutionalization, falls, and worsening health status. Growing evidence suggests that frailty should be a key consideration both in care planning and in adverse outcome prevention. The prevalence of elderly patients with TBI is increasing, and low-energy trauma (i.e., ground or low-level falls, which are typical in frail patients) is the major cause. Establishing the real incidence of frailty in TBI requires further studies. Failure to detect frailty potentially exposes patients to interventions that may not benefit them, and may even harm them. Moreover, considering patients as 'nonfrail' purely on the basis of their age is unacceptable. The future challenge is to shift to a new clinical paradigm characterized by more appropriate, goal-directed care of frail patients. SUMMARY The current review highlights the crucial importance of frailty evaluation in TBI, also given the changing epidemiology of this condition. To ensure adequate assessment, prevention and management, both in and outside hospital, there is an urgent need for a valid screening tool and a specific frailty-based and comorbidity-based clinical approach.
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22
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Salini S, Russo A, De Matteis G, Piccioni A, Della Polla D, Carbone L, Barillaro C, Landi F, Franceschi F, Covino M. Frailty in Elderly Patients with Covid-19: A Narrative Review. Gerontol Geriatr Med 2022; 8:23337214221079956. [PMID: 35274027 PMCID: PMC8902186 DOI: 10.1177/23337214221079956] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/12/2022] [Accepted: 01/24/2022] [Indexed: 01/08/2023] Open
Abstract
Introduction The SARS CoV-2 pandemic still generates a very high number of affected patients and a
significant mortality rate. It is essential to establish objective criteria to stratify
COVID-19 death risk. Frailty has been identified as a potential determinant of increased
vulnerability in older adults affected by COVID-19, because it may suggest alterations
of physical performance and functional autonomy. Methods We have conducted a narrative review of the literature on the evidences regarding
COVID-19 and the frailty condition. Thirteen observational studies were included. Conclusion Data emerging from the studies indicate that older COVID-19 patients with a frailty
condition have an increased risk of mortality compared with non-frail patients, and this
association is independent of other clinical and demographic factors. A frailty
evaluation is required to help clinicians to better stratify the overall risk of death
for older patients with COVID-19.
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Affiliation(s)
- Sara Salini
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Andrea Russo
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Giuseppe De Matteis
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Andrea Piccioni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Davide Della Polla
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Luigi Carbone
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Christian Barillaro
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Francesco Landi
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Francesco Franceschi
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Marcello Covino
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
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Tatlow C, Heywood S, Hodgson C, Cunningham G, Conron M, Ng HY, Georgiou H, Pound G. Physiotherapy-assisted prone or modified prone positioning in ward-based patients with COVID-19: a retrospective cohort study. Physiotherapy 2022; 114:47-53. [PMID: 35091328 PMCID: PMC8462002 DOI: 10.1016/j.physio.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 05/31/2021] [Accepted: 09/12/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate short-term change in oxygenation and feasibility of physiotherapy-assisted prone or modified prone positioning in awake, ward-based patients with COVID-19. DESIGN Retrospective observational cohort study. SETTING General wards, single-centre tertiary hospital in Australia. PARTICIPANTS Patients were included if ≥18 years, had COVID-19, required FiO2 ≥ 0.28 or oxygen flow rate ≥4 l/minute and consented to positioning. MAIN OUTCOME MEASURES Feasibility measures included barriers to therapy, assistance required, and comfort. Short-term change in oxygenation (SpO2) and oxygen requirements before and 15 minutes after positioning. RESULTS Thirteen patients, mean age 75 (SD 14) years; median Clinical Frailty Scale score 6 (IQR 4 to 7) participated in 32 sessions of prone or modified prone positioning from a total of 125 ward-based patients admitted with COVID-19 who received physiotherapy intervention. Nine of thirteen patients (69%) required physiotherapy assistance and modified positions were utilised in 8/13 (62%). SpO2 increased in 27/32 sessions, with a mean increase from 90% (SD 5) pre-positioning to 94% (SD 4) (mean difference 4%; 95%CI 3 to 5%) after 15 minutes. Oxygen requirement decreased in 14/32 sessions, with a mean pre-positioning requirement of 8 l/minute (SD 4) to 7 l/minute (SD 4) (mean difference 2 l/minute; 95%CI 1 to 3 l/minute) after 15 minutes. In three sessions oxygen desaturation and discomfort occurred but resolved immediately by returning supine. CONCLUSION Physiotherapy-assisted prone or modified prone positioning may be a feasible option leading to short-term improvements in oxygenation in awake, ward-based patients with hypoxemia due to COVID-19. Further research exploring longerterm health outcomes and safety is required.
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Affiliation(s)
- Claudia Tatlow
- St Vincent's Hospital Melbourne, Physiotherapy Department, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia.
| | - Sophie Heywood
- St Vincent's Hospital Melbourne, Physiotherapy Department, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia.
| | - Carol Hodgson
- The Alfred Hospital, Physiotherapy Department, 55 Commercial Rd, Melbourne 3004, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Victoria, Australia.
| | - Georgina Cunningham
- St Vincent's Hospital Melbourne, Department of General Medicine, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia.
| | - Matthew Conron
- St Vincent's Hospital Melbourne, Department of Respiratory Medicine and Specialty Services, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia.
| | - Hui Yi Ng
- St Vincent's Hospital Melbourne, Department of General Medicine, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia.
| | - Harry Georgiou
- St Vincent's Hospital Melbourne, Department of Respiratory Medicine and Specialty Services, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia.
| | - Gemma Pound
- St Vincent's Hospital Melbourne, Physiotherapy Department, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Victoria, Australia.
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24
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Darvall JN, Bellomo R, Bailey M, Young PJ, Rockwood K, Pilcher D. Impact of frailty on persistent critical illness: a population-based cohort study. Intensive Care Med 2022; 48:343-351. [PMID: 35119497 PMCID: PMC8866256 DOI: 10.1007/s00134-022-06617-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/03/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Acute illness severity predicts mortality in intensive care unit (ICU) patients, however, its predictive value decreases over time in ICU. Typically after 10 days, pre-ICU (antecedent) characteristics become more predictive of mortality, defining the onset of persistent critical illness (PerCI). How patient frailty affects development and death from PerCI is unknown. METHODS We conducted a secondary analysis of data from a prospective binational cohort study including 269,785 critically ill adults from 168 ICUs in Australia and New Zealand, investigating whether frailty measured with the Clinical Frailty Scale (CFS) changes the timing of onset and risk of developing PerCI and of subsequent in-hospital mortality. We assessed associations between frailty (CFS ≥ 5) and mortality prediction using logistic regression and area under the receiver operating characteristics (AUROC) curves. RESULTS 2190 of 50,814 (4.3%) patients with frailty (CFS ≥ 5) versus 6624 of 218,971 (3%) patients without frailty (CFS ≤ 4) developed PerCI (P < 0.001). Among patients with PerCI, 669 of 2190 (30.5%) with frailty and 1194 of 6624 without frailty (18%) died in hospital (P < 0.001). The time point defining PerCI onset did not vary with frailty degree; however, with increasing length of ICU stay, inclusion of frailty progressively improved mortality discrimination (0.1% AUROC improvement on ICU day one versus 3.6% on ICU day 17). CONCLUSION Compared to patients without frailty, those with frailty have a higher chance of developing and dying from PerCI. Moreover the importance of frailty as a predictor of mortality increases with ICU length of stay. Future work should explore incorporation of frailty in prognostic models, particularly for long-staying patients.
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Affiliation(s)
- Jai N Darvall
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Grattan St., Parkville, Melbourne, VIC, 3050, Australia.
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Grattan St., Parkville, Melbourne, VIC, 3050, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paul J Young
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | - Kenneth Rockwood
- Divisions of Geriatric Medicine and Neurology, and the Geriatric Medicine Research Unit, Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Nova Scotia Health Authority, Halifax, NS, Canada
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
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26
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Subramaniam A, Shekar K, Afroz A, Ashwin S, Billah B, Brown H, Kundi H, Lim ZJ, Ponnapa Reddy M, Curtis JR. Frailty and mortality associations in patients with
COVID
‐19: A Systematic Review and Meta‐analysis. Intern Med J 2022; 52:724-739. [PMID: 35066970 PMCID: PMC9314619 DOI: 10.1111/imj.15698] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 01/08/2023]
Abstract
Background Observational data during the pandemic have demonstrated mixed associations between frailty and mortality. Aim To examine associations between frailty and short‐term mortality in patients hospitalised with coronavirus disease 2019 (COVID‐19). Methods In this systematic review and meta‐analysis, we searched PubMed, Embase and the COVID‐19 living systematic review from 1 December 2019 to 15 July 2021. Studies reporting mortality and frailty scores in hospitalised patients with COVID‐19 (age ≥18 years) were included. Data on patient demographics, short‐term mortality (in hospital or within 30 days), intensive care unit (ICU) admission and need for invasive mechanical ventilation (IMV) were extracted. The quality of studies was assessed using the Newcastle−Ottawa Scale. Results Twenty‐five studies reporting 34 628 patients were included. Overall, 26.2% (n = 9061) died. Patients who died were older (76.7 ± 9.6 vs 69.2 ± 13.4), more likely male (risk ratio (RR) = 1.08; 95% confidence interval (CI): 1.06–1.11) and had more comorbidities. Fifty‐eight percent of patients were frail. Adjusting for age, there was no difference in short‐term mortality between frail and non‐frail patients (RR = 1.04; 95% CI: 0.84–1.28). The non‐frail patients were commonly admitted to ICU (27.2% (4256/15639) vs 29.1% (3567/12274); P = 0.011) and had a higher mortality risk (RR = 1.63; 95% CI: 1.30–2.03) than frail patients. Among patients receiving IMV, there was no difference in mortality between frail and non‐frail (RR = 1.62; 95% CI 0.93–2.77). Conclusion This systematic review did not demonstrate an independent association between frailty status and short‐term mortality in patients with COVID‐19. Patients with frailty were less commonly admitted to ICU and non‐frail patients were more likely to receive IMV and had higher mortality risk. This finding may be related to allocation decisions for patients with frailty amidst the pandemic.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care Medicine Peninsula Health Frankston Victoria Australia
- Monash University, Peninsula Clinical School Frankston Victoria Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital Brisbane Queensland Australia
- University of Queensland, Brisbane; Queensland University of Technology Brisbane and Bond University Gold Coast Queensland Australia
| | - Afsana Afroz
- Centre for Integrated Critical Care, Department of Medicine and Radiology Melbourne Medical School Melbourne Victoria Australia
| | - Sushma Ashwin
- Department of Health Economics School of Health and social development, Deakin University Melbourne Victoria Australia
| | - Baki Billah
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia
| | - Hamish Brown
- Department of Intensive Care Medicine Peninsula Health Frankston Victoria Australia
| | - Harun Kundi
- Department of Cardiology Ankara City Hospital Ankara Turkey
| | - Zheng Jie Lim
- Department of Anaesthesiology, Austin Health Heidelberg Victoria Australia
| | - Mallikarjuna Ponnapa Reddy
- Department of Intensive Care Medicine Peninsula Health Frankston Victoria Australia
- Department of Intensive Care Medicine, Calvary Hospital Canberra Australian Capital Territory Australia
| | - J Randall Curtis
- Cambia Palliative Care Centre of Excellence University of Washington Seattle Washington United States of America
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine University of Washington Seattle Washington United States of America
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Sutton L, Bell E, Every-Palmer S, Weatherall M, Skirrow P. SPLIT ENZ: Survivorship of Patients post Long Intensive care stay, Exploration/Experience in a New Zealand cohort (A mixed methods study protocol) (Preprint). JMIR Res Protoc 2021; 11:e35936. [PMID: 35297773 PMCID: PMC8972103 DOI: 10.2196/35936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background Post Intensive Care Syndrome (PICS) was defined by the Society of Critical Care Medicine in 2012 with subsequent international research highlighting poor long-term outcomes; reduced quality of life; and impairments, for survivors of critical illness. To date, there has been no published research on the long-term outcomes of survivors of critical illness in New Zealand. Objective The aim of this study is to explore long-term outcomes after critical illness in New Zealand. The primary objectives are to describe and quantify symptoms and disability, explore possible risk factors, and to identify unmet needs in survivors of critical illness. Methods This will be a mixed methods study with 2 components. First, a prospective cohort study of approximately 100 participants with critical illness will be followed up at 1, 6, and 12 months after hospital discharge. The primary outcome will be disability assessed using the World Health Organization Disability Assessment Scale 2.0. Secondary outcomes will focus on mental health using the Hospital Anxiety and Depression Scale and the Impact of Events Scale-revised, cognitive function using the Montreal Cognitive Assessment (Montreal Cognitive Assessment–BLIND), and health-related quality of life using the European Quality of Life-Five Dimension-Five Level. The second element of the study will use qualitative grounded theory methods to explore participants experiences of recovery and highlight unmet needs. Results This study was approved by the New Zealand Northern A Health and Disability Ethics Committee on August 16, 2021 (21/NTA/107), and has been registered with the Australian New Zealand Clinical Trials Registry on October 5, 2021. SPLIT ENZ is due to start recruitment in early 2022, aiming to enroll 125 patients over 2 years. Data collection is estimated to be completed by 2024-2025 and will be published once all data are available for reporting. Conclusions Although international research has identified the prevalence of PICS and the extent of disability in survivors of critical illness, there is no published research in New Zealand. Research in this field is particularly pressing in the context of COVID-19, an illness that may include PICS in its sequelae. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN1262100133588; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382566&showOriginal=true&isReview=true International Registered Report Identifier (IRRID) PRR1-10.2196/35936
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Affiliation(s)
- Lynsey Sutton
- Intensive Care Unit, Level 3, Wellington Regional Hospital, Capital and Coast District Health Board, Wellington, New Zealand
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Elliot Bell
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Susanna Every-Palmer
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Mark Weatherall
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Paul Skirrow
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
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Characteristics and Outcomes for Low-Risk Hospital Admissions Admitted to the ICU: A Multisite Cohort Study. Crit Care Explor 2021; 3:e0596. [PMID: 34909699 PMCID: PMC8663905 DOI: 10.1097/cce.0000000000000596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Supplemental Digital Content is available in the text. IMPORTANCE: Prognostication following ICU admission can often be determined based on known risk factors, including demographics and illness severity; however, little is known about outcomes of patients deemed to be “low-risk” at the time of hospital admission who subsequently are admitted to the ICU. OBJECTIVES: The objectives of this study were to determine the characteristics, outcomes, and costs for patients requiring ICU admission despite having lower predicted mortality when they were admitted to the hospital. DESIGN, SETTING, AND PARTICIPANTS: In this historical cohort study, we used a prospectively maintained ICU registry that included all ICU admissions to The Ottawa Hospital for patients 18 years or older from January 2011 to December 2016. We classified patients as low-risk using the Hospital-patient 1-year Mortality Risk at admission score, a hospital admission score validated to predict 1-year mortality. MAIN OUTCOMES AND MEASURES: The primary outcome was inhospital mortality. Secondary outcomes included adverse events, resource utilization, and costs. RESULTS: Of the 17,173 total ICU patients, 3,445 (20.1%) were classified as low-risk at hospital admission. Low-risk patients were younger (48.7 vs 67.5 yr; p < 0.001) and had a lower Multiple Organ Dysfunction Score (2.37 vs 4.14; p < 0.001). Mortality for low-risk patients was significantly lower than for non–low-risk patients (4.1% vs 25.4%; p < 0.001). For low-risk patients, multivariable logistic regression showed mortality was independently associated with older age (odds ratio, 1.02 per 1 yr; 95% CI, 1.00–1.03 per 1 yr), Multiple Organ Dysfunction Score (odds ratio, 1.42 per 1 point; 95% CI, 1.31–1.54 per 1 point), fluid management adverse events (odds ratio, 2.84; 95% CI, 1.29–6.25), hospital-acquired infections (odds ratio, 1.60; 95% CI, 1.02–2.51), and mechanical ventilation (odds ratio, 1.98; 95% CI, 1.20–3.26). CONCLUSIONS AND RELEVANCE: Despite their robust premorbid status, low-risk patients admitted to the ICU had significant inhospital mortality. Fluid management adverse events, hospital-associated infections, multiple organ dysfunction, and mechanical ventilation are important prognostic factors for low-risk patients.
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Wilkinson DJC. Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:48-63. [PMID: 33289443 PMCID: PMC8567739 DOI: 10.1080/15265161.2020.1851809] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment of clinical frailty as part of triage. Frailty is relevant to resource allocation in at least three separate ways, through its impact on probability of survival, longevity and quality of life (though not a fourth-length of intensive care stay). I review and reject claims that frailty-based triage would represent unjust discrimination on the grounds of age or disability. I outline three important steps to improve the ethical incorporation of frailty into triage. Triage criteria (ie frailty) should be assessed consistently in all patients referred to the intensive care unit. Guidelines must make explicit the ethical basis for the triage decision. This can then be applied, using the concept of triage equivalence, to other (non-frail) patients referred to intensive care.
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McGreevy J, Rhodes R. Triage: Medical Details and Words Matter. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:64-67. [PMID: 34710011 DOI: 10.1080/15265161.2021.1980145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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Xia F, Zhang J, Meng S, Qiu H, Guo F. Association of Frailty With the Risk of Mortality and Resource Utilization in Elderly Patients in Intensive Care Units: A Meta-Analysis. Front Med (Lausanne) 2021; 8:637446. [PMID: 34671610 PMCID: PMC8521007 DOI: 10.3389/fmed.2021.637446] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 09/06/2021] [Indexed: 12/12/2022] Open
Abstract
Background: The associations of frailty with the risk of mortality and resource utilization in the elderly patients admitted to intensive care unit (ICU) remain unclear. To address these issues, we performed a meta-analysis to determine whether frailty is associated with adverse outcomes and increased resource utilization in elderly patients admitted to the ICU. Methods: We searched PubMed, EMBASE, ScienceDirect, and Cochrane Central Register of Controlled Trials through August 2021 to identify the relevant studies that investigated frailty in elderly (≥ 65 years old) patients admitted to an ICU and compared outcomes and resource utilization between frail and non-frail patients. The primary outcome was mortality. We also investigated the prevalence of frailty and the impact of frailty on the health resource utilization, such as hospital length of stay (LOS) and resource utilization of ICU. Results: A total of 13 observational studies enrolling 64,279 participants (28,951 frail and 35,328 non-frail) were finally included. Frailty was associated with an increased risk of short-term mortality (10 studies, relative risk [RR]: 1.70; 95% CI: 1.45–1.98), in-hospital mortality (five studies, RR: 1.73; 95% CI: 1.55–1.93), and long-term mortality (six studies, RR: 1.86; 95% CI: 1.44–2.42). Subgroup analysis showed that retrospective studies identified a stronger correlation between frailty and hospital LOS (three studies, MD 1.14 d; 95% CI: 0.92–1.36). Conclusions: Frailty is common in the elderly patients admitted to ICU, and is associated with increased mortality and prolonged hospital LOS. Trial registration: This study was registered in the PROSPERO database (CRD42020207242).
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Affiliation(s)
- Feiping Xia
- School of Medicine, Southeast University, Nanjing, China
| | - Jing Zhang
- School of Medicine, Southeast University, Nanjing, China
| | - Shanshan Meng
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Fengmei Guo
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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Minton C, Batten L, Best A. The long-term ICU patient: Which definition? J Clin Nurs 2021; 32:2933-2940. [PMID: 34723410 DOI: 10.1111/jocn.16078] [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: 12/05/2020] [Revised: 08/26/2021] [Accepted: 09/21/2021] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To offer a review of the differing terminologies used by clinicians and researchers to describe the long-term intensive care unit (ICU) patient and the underlying propositions that align with this terminology. BACKGROUND Ongoing medical and technological advances in emergency and intensive care have resulted in improved survival of critically ill patients in recent decades. In addition, these advancements have also resulted in improved survival of complex critically ill patients who progress to a trajectory of prolonged critical illness, having protracted stays in the ICU. There is great variability in terminology used to define the long-term ICU patient. This lack of a common definition for long-term ICU patients is problematic, increasing their vulnerability and risk of care not being centred about their unique needs. DESIGN In this discursive article, we explore the terminology used to define the long-term ICU patient. An initial broad search of the literature across four electronic databases was conducted to identify common terminology used to define the long-term ICU patient. From here, seven definitions were identified and chosen for inclusion in the review as they meet inclusion criteria and clearly described a group of patients who have an extended ICU stay. The seven selected terms are as follows: prolonged mechanical ventilation; failure to wean; insertion of tracheostomy; chronically critically ill; persistent critical illness; persistent inflammatory-immunosuppressive and catabolic syndrome; and frailty. Following this a focused review of the literature with the selected terms was conducted to explore in greater detail the terminology. DISCUSSION The lack of clear definition for this patient group can potentiate their care needs being unmet. Acknowledgement of the need to clearly define this patient group is the first step to improve outcomes. Nursing is well positioned to recognise the different terminologies use to describe this group of patients and implement care to suit their unique clinical characteristics. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE Recognition and standardisation of these terms are an important priority to pave the way to improve care pathways and outcomes for this group of patients and their family.
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Affiliation(s)
- Claire Minton
- School of Nursing, Massey University, Palmerston North, New Zealand
| | - Lesley Batten
- College of Health, Massey University, Palmerston North, New Zealand
| | - Amy Best
- School of Nursing, Massey University, Wellington, New Zealand
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Low YM, Lyon CE, Lakey KM, Finnis ME, Orford NR, Maiden MJ. Frailty is not independently associated with intensive care unit length of stay: An observational study. Aust Crit Care 2021; 35:369-374. [PMID: 34462195 DOI: 10.1016/j.aucc.2021.06.012] [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: 05/09/2021] [Revised: 06/17/2021] [Accepted: 06/21/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Frailty is independently associated with morbidity and mortality in critically ill patients. However, the association between preadmission frailty and the degree of treatment received in the intensive care unit (ICU) remains unclear. OBJECTIVE To describe patient length of stay in an ICU and the treatments provided according to the extent of patient frailty. METHODS Single-centre retrospective cohort study of adult patients admitted to a tertiary ICU between January 2018 and December 2019. Frailty was assessed using the Clinical Frailty Scale (CFS). The primary outcome was ICU length of stay stratified by CFS score (1-8). Secondary outcomes were the proportion of patients with each CFS score treated with vasoactive agents, invasive ventilation, noninvasive ventilation, renal replacement therapy, and tracheostomy. Poisson regression and competing risks regression was used to analyse associations between ICU length of stay and potential confounders. RESULTS The study cohort comprised 2743 patients, with CFS scores known for 2272 (83%). Length of stay in the ICU increased with each increment in the CFS up to a score of 5, beyond which it decreased with higher frailty scores. After adjusting for age, illness severity, admission type, and treatment limitation, CFS scores were not independently associated with length of stay in the ICU (P = 0.31). The proportion of patients receiving specific ICU treatments peaked at different CFS scores, being highest for vasoactive agents at CFS 5 (47%), invasive ventilation CFS 3 (51%), noninvasive ventilation CFS 6 (11%), renal replacement therapy CFS 6 (8.2%), and tracheostomy CFS 5 (2.2%). Increasing frailty was associated with increased mortality and discharge to a destination other than home. CONCLUSIONS The extent of frailty is not independently associated with length of stay in the ICU. The proportion of patients receiving specific ICU treatments peaked at different CFS scores.
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Affiliation(s)
- Yvette M Low
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Victoria, Australia.
| | - Clare E Lyon
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Victoria, Australia
| | - Kylie M Lakey
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Victoria, Australia
| | - Mark E Finnis
- Intensive Care Unit, Royal Adelaide Hospital, South Australia, Australia; Discipline of Acute Care Medicine, University of Adelaide, South Australia, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventative Medicine, Monash University, Victoria, Australia
| | - Neil R Orford
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventative Medicine, Monash University, Victoria, Australia; School of Medicine, Deakin University, Victoria, Australia
| | - Matthew J Maiden
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Victoria, Australia; Intensive Care Unit, Royal Adelaide Hospital, South Australia, Australia; Discipline of Acute Care Medicine, University of Adelaide, South Australia, Australia.
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Simon Thomas E, Peiris B, Di Stefano L, Rowland MJ, Wilkinson D. Evaluation of a hypothetical decision-support tool for intensive care triage of patients with coronavirus disease 2019 (COVID-19). Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.16939.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: At the start of the coronavirus disease 2019 (COVID-19) pandemic there was widespread concern about potentially overwhelming demand for intensive care and the need for intensive care unit (ICU) triage. In March 2020, a draft United Kingdom (UK) guideline proposed a decision-support tool (DST). We sought to evaluate the accuracy of the tool in patients with COVID-19. Methods: We retrospectively identified patients in two groups: referred and not referred to intensive care in a single UK national health service (NHS) trust in April 2020. Age, Clinical Frailty Scale score (CFS), and co-morbidities were collected from patients’ records and recorded, along with ceilings of treatment and outcome. We compared the DST, CFS, and age alone as predictors of mortality, and treatment ceiling decisions. Results: In total, 151 patients were included in the analysis, with 75 in the ICU and 76 in the non-ICU-reviewed groups. Age, clinical frailty and DST score were each associated with increased mortality and higher likelihood of treatment limitation (p-values all <.001). A DST cut-off score of >8 had 65% (95% confidence interval (CI) 51%-79%) sensitivity and 63% (95% CI 54%-72%) specificity for predicting mortality. It had a sensitivity of 80% (70%-88%) and specificity of 96% (95% CI 90%-100%) for predicting treatment limitation. The DST was more discriminative than age alone (p<0.001), and potentially more discriminative than CFS (p=0.08) for predicting treatment ceiling decisions. Conclusions: During the first wave of the COVID-19 pandemic, in a hospital without severe resource limitations, a hypothetical decision support tool was limited in its predictive value for mortality, but appeared to be sensitive and specific for predicting treatment limitation.
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The Relationship between Frailty and Mechanical Ventilation: A Population-based Cohort Study. Ann Am Thorac Soc 2021; 19:264-271. [PMID: 34214022 DOI: 10.1513/annalsats.202102-178oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Frailty in critically ill patients is associated with higher mortality and prolonged length of stay, however little is known about the impact on the duration of mechanical ventilation. OBJECTIVES To identify the relationship between frailty and total duration of mechanical ventilation and the interaction with patients' age. METHODS This retrospective population-based cohort study was performed using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database between 2017 and 2020. We analyzed adult critically ill patients who received invasive mechanical ventilation within the first 24 hours of intensive care unit admission. RESULTS Of 59319 available patients receiving invasive mechanical ventilation, 8331 (14%) were classified as frail. Patients with frailty had longer duration of mechanical ventilation compared to patients without frailty. Duration of mechanical ventilation increased with higher frailty score. Patients with frailty had longer intensive care unit and hospital stay with higher mortality than non-frail patients. After adjustment for relevant covariates in multivariate analyses, frailty was significantly associated with a reduced probability of cessation of invasive mechanical ventilation (adjusted hazard ratio 0.57 [95% CI: 0.51-0.64]; p<0.001). Sensitivity and subgroup analyses suggested that frailty could prolong mechanical ventilation in survivors and the relationship was especially strong in younger patients. CONCLUSIONS Frailty score was independently associated with longer duration of mechanical ventilation and contributed to identify patients who were less likely to be liberated from mechanical ventilation. The impact of frailty on ventilation time varied with age and was most apparent for younger patients.
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Turcotte LA, Zalucky AA, Stall NM, Downar J, Rockwood K, Theou O, McArthur C, Heckman G. Baseline Frailty as a Predictor of Survival After Critical Care: A Retrospective Cohort Study of Older Adults Receiving Home Care in Ontario, Canada. Chest 2021; 160:2101-2111. [PMID: 34139208 DOI: 10.1016/j.chest.2021.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 05/24/2021] [Accepted: 06/02/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The extent to which the degree of baseline frailty, as measured using standardized multidimensional health assessments before hospital admission, predicts survival among older adults after admission to an ICU, remains unclear. RESEARCH QUESTION Is baseline frailty an independent predictor of survival among older adults receiving care in an ICU? STUDY DESIGN AND METHODS Retrospective cohort study of community-dwelling older adults (age, ≥ 65 years) receiving public home services who were admitted to any ICU in Ontario, Canada, between April 1, 2009, and March 31, 2015. All individuals underwent an inter-Resident Assessment Instrument-Home Care (RAI-HC) assessment completed within 180 days of ICU admission. These assessments were linked to hospital discharge abstract records. Patients were categorized using frailty measures each calculated from the RAI-HC: a classification tree version of the Clinical Frailty Scale; the Frailty Index-Acute Care; and the Changes in Health, End-Stage Disease, Signs, and Symptoms Scale. One-year survival models were used to compare their performance. Patients were stratified based on the receipt of mechanical ventilation in the ICU. RESULTS Of 24,499 individuals admitted to an ICU within 180 days of a RAI-HC assessment, 26.4% (n = 6,467) received mechanical ventilation. Overall, 43.0% (95% CI, 42.4%-43.6%) survived 365 days after ICU admission. In general, among the overall cohort and both mechanical ventilation subgroups, mortality hazards increased with the severity of baseline frailty. Models predicting survival 30, 90, and 365 days after admission to an ICU that adjusted for one of the frailty measures were more discriminant than reference models that adjusted only for age, sex, major clinical category, and area income quintile. INTERPRETATION Severity of baseline frailty is associated independently with survival after ICU admission and should be considered when determining goals of care and treatment plans for people with critical illness.
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Affiliation(s)
- Luke Andrew Turcotte
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON.
| | | | - Nathan M Stall
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON
| | - James Downar
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University & Nova Scotia Health, Halifax, NS, Canada
| | - Olga Theou
- Physiotherapy and Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Caitlin McArthur
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
| | - George Heckman
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON
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Darvall JN, Bellomo R, Paul E, Bailey M, Young PJ, Reid A, Rockwood K, Pilcher D. Routine Frailty Screening in Critical Illness: A Population-Based Cohort Study in Australia and New Zealand. Chest 2021; 160:1292-1303. [PMID: 34089741 DOI: 10.1016/j.chest.2021.05.049] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/27/2021] [Accepted: 05/10/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Frailty is associated with poor outcomes in critical illness. However, it is unclear whether frailty screening on admission to the ICU can be conducted routinely at the population level and whether it has prognostic importance. RESEARCH QUESTION Can population-scale frailty screening with the Clinical Frailty Scale (CFS) be implemented for critically ill adults in Australia and New Zealand (ANZ) and can it identify patients at risk of negative outcomes? STUDY DESIGN AND METHODS We conducted a binational prospective cohort study of critically ill adult patients admitted between July 1, 2018, and June 30, 2020, in 175 ICUs in ANZ. We classified frailty with the CFS on admission to the ICU. The primary outcome was in-hospital mortality; secondary outcomes were length of stay (LOS), discharge destination, complications (delirium, pressure injury), and duration of survival. RESULTS We included 234,568 critically ill patients; 45,245 (19%) were diagnosed as living with frailty before ICU admission. Patients with vs without frailty had higher in-hospital mortality (16% vs 5%; P < .001), delirium (10% vs 4%; P < .001), longer LOS in the ICU and hospital, and increased new chronic care discharge (3% vs 1%; P < .001), with worse outcomes associated with increasing CFS category. Of patients with very severe frailty (CFS score, 8), 39% died in hospital vs 2% of very fit patients (CFS score, 1; multivariate categorical CFS score, 8 [reference, 1]; OR, 7.83 [95% CI, 6.39-9.59]; P < .001). After adjustment for illness severity, frailty remained highly significantly predictive of mortality, including among patients younger than 50 years, with improvement in the area under the receiver operating characteristic curve of the Acute Physiology and Chronic Health Evaluation III-j score to 0.882 (95% CI, 0.879-0.885) from 0.868 (95% CI, 0.866-0.871) with the addition of frailty (P < .001). INTERPRETATION Large-scale population screening for frailty degree in critical illness was possible and prognostically important, with greater frailty (especially CFS score of ≥ 6) associated with worse outcomes, including among younger patients.
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Affiliation(s)
- Jai N Darvall
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Data Analytics Research & Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Michael Bailey
- Department of Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Alice Reid
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Kenneth Rockwood
- Divisions of Geriatric Medicine & Neurology, and the Geriatric Medicine Research Unit, Division of Geriatric Medicine, Department of Medicine, Dalhousie University and Nova Scotia Health Authority, NS, Canada
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia; Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
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King SJ, Raine KA, Peel NM, Hubbard RE. Interventions for frail older inpatients: A systematic review of frailty measures and reported outcomes in randomised controlled trials. Australas J Ageing 2021; 40:129-144. [PMID: 33876880 DOI: 10.1111/ajag.12951] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 02/22/2021] [Accepted: 02/28/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To summarise frailty measures and outcomes reported in trials involving frail older inpatients. METHODS Databases were searched for randomised controlled trials enrolling frail older inpatients. RESULTS Twenty-four articles describing twelve trials were included. Seven trials applied six tools to measure frailty, whilst five trials employed ad hoc measures. Eighty outcomes were examined with survival and functional status reported most commonly. Nine studies trialled multidisciplinary, geriatrician-led interventions. Statistically significant between-group differences were detected for at least one outcome in ten trials. All studies represented high risk of bias within at least one domain. CONCLUSIONS Heterogeneity of interventions, measurement of frailty and outcomes reported limit generalisability of findings. Many articles purport to study frail patients, yet do not enrol patients using any frailty measurement tool. Utilising validated instruments to measure frailty and a standard set of health outcomes relevant to older people would assist consistent reporting and evaluation of future studies.
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Affiliation(s)
- Shannon J King
- Princess Alexandra Hospital, Woolloongabba, Qld, Australia
| | | | - Nancye M Peel
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
| | - Ruth E Hubbard
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia.,Princess Alexandra Hospital Southside Clinical Unit, School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
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Heart, home, and frailty: new risk scores and outcomes for cardiac surgery patients. Br J Anaesth 2021; 126:1081-1084. [PMID: 33795135 DOI: 10.1016/j.bja.2021.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 11/20/2022] Open
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Darvall JN, Bellomo R, Bailey M, Anstey J, Pilcher D. Long-term Survival of Critically Ill Patients Stratified According to Pandemic Triage Categories: A Retrospective Cohort Study. Chest 2021; 160:538-548. [PMID: 33711333 PMCID: PMC7941020 DOI: 10.1016/j.chest.2021.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background The COVID-19 pandemic has led to unprecedented demand for ICUs, with the need to triage admissions along with the development of ICU triage criteria. However, how these criteria relate to outcomes in patients already admitted to the ICU is unknown, as is the incremental ICU capacity that triage of these patients might create given existing admission practices. Research Question What is the short- and long-term survival of low- vs high-priority patients for ICU admission according to current pandemic triage criteria? Study Design and Methods This study analyzed prospectively collected registry data (2007-2018) in 23 ICUs in Victoria, Australia, with probabilistic linkage with death registries. After excluding elective surgery, admissions were stratified according to existing ICU triage protocol prioritization as low (age ≥ 85 years, or severe chronic illness, or Sequential Organ Failure Assessment [SOFA] score = 0 or ≥ 12), medium (SOFA score = 8-11) or high (SOFA score = 1-7) priority. The primary outcome was long-term survival. Secondary outcomes were in-hospital mortality, ICU length of stay (LOS) and bed-day usage. Results This study examined 126,687 ICU admissions. After 5 years of follow-up, 1,093 of 3,296 (33%; 95% CI, 32-34) of “low-priority” patients aged ≥ 85 years or with severe chronic illness and 86 of 332 (26%; 95% CI, 24-28) with a SOFA score ≥ 12 were still alive. Sixty-three of 290 (22%; 95% CI, 17-27) of patients in these groups followed up for 10 years were still alive. Together, low-priority patients accounted for 27% of all ICU bed-days and had lower in-hospital mortality (22%) than the high-priority patients (28%). Among nonsurvivors, low-priority admissions had shorter ICU LOS than medium- or high-priority admissions. Interpretation Current SOFA score or age or severe comorbidity-based ICU pandemic triage protocols exclude patients with a close to 80% hospital survival, a > 30% five-year survival, and 27% of ICU bed-day use. These findings imply the need for stronger evidence-based ICU triage protocols.
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Affiliation(s)
- Jai N Darvall
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia; Centre for Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia; Centre for Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Data Analytics Research & Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | - Michael Bailey
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia; Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
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Owen RK, Conroy SP, Taub N, Jones W, Bryden D, Pareek M, Faull C, Abrams KR, Davis D, Banerjee J. Comparing associations between frailty and mortality in hospitalised older adults with or without COVID-19 infection: a retrospective observational study using electronic health records. Age Ageing 2021; 50:307-316. [PMID: 32678866 PMCID: PMC7454252 DOI: 10.1093/ageing/afaa167] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The aim of this study was to describe outcomes in hospitalised older people with different levels of frailty and COVID-19 infection. METHODS We undertook a single-centre, retrospective cohort study examining COVID-19-related mortality using electronic health records, for older people (65 and over) with frailty, hospitalised with or without COVID-19 infection. Baseline covariates included demographics, early warning scores, Charlson Comorbidity Indices and frailty (Clinical Frailty Scale, CFS), linked to COVID-19 status. FINDINGS We analysed outcomes on 1,071 patients with COVID-19 test results (285 (27%) were positive for COVID-19). The mean age at ED arrival was 79.7 and 49.4% were female. All-cause mortality (by 30 days) rose from 9 (not frail) to 33% (severely frail) in the COVID-negative cohort but was around 60% for all frailty categories in the COVID-positive cohort. In adjusted analyses, the hazard ratio for death in those with COVID-19 compared to those without COVID-19 was 7.3 (95% CI: 3.00, 18.0) with age, comorbidities and illness severity making small additional contributions. INTERPRETATION In this study, frailty measured using the CFS appeared to make little incremental contribution to the hazard of dying in older people hospitalised with COVID-19 infection; illness severity and comorbidity had a modest association with the overall adjusted hazard of death, whereas confirmed COVID-19 infection dominated, with a sevenfold hazard for death.
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Affiliation(s)
- Rhiannon K Owen
- Health Sciences, University of Leicester, Leicester, Leicestershire, UK
| | - Simon P Conroy
- Department of Health Sciences, Centre for Medicine University of Leicester, University of Leicester School of Medicine, Leicester LE1 7HA, UK
| | - Nicholas Taub
- Department of Health Sciences, University of Leicester, Leicester LE1 6TP, UK
| | - Will Jones
- Emergency Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniele Bryden
- Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Manish Pareek
- Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Christina Faull
- Health Sciences, University of Leicester, Leicester, Leicestershire, UK
| | - Keith R Abrams
- Health Sciences, University of Leicester, Leicester, Leicestershire, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London WC1B 5JU, UK
| | - Jay Banerjee
- University Hospitals of Leicester NHS Trust, Leicester, UK
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Association between Clinical Frailty Scale score and hospital mortality in adult patients with COVID-19 (COMET): an international, multicentre, retrospective, observational cohort study. LANCET HEALTHY LONGEVITY 2021; 2:e163-e170. [PMID: 33655235 PMCID: PMC7906710 DOI: 10.1016/s2666-7568(21)00006-4] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background During the COVID-19 pandemic, the scarcity of resources has necessitated triage of critical care for patients with the disease. In patients aged 65 years and older, triage decisions are regularly based on degree of frailty measured by the Clinical Frailty Scale (CFS). However, the CFS could also be useful in patients younger than 65 years. We aimed to examine the association between CFS score and hospital mortality and between CFS score and admission to intensive care in adult patients of all ages with COVID-19 across Europe. Methods This analysis was part of the COVID Medication (COMET) study, an international, multicentre, retrospective observational cohort study in 63 hospitals in 11 countries in Europe. Eligible patients were aged 18 years and older, had been admitted to hospital, and either tested positive by PCR for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or were judged to have a high clinical likelihood of having SARS-CoV-2 infection by the local COVID-19 expert team. CFS was used to assess level of frailty: fit (CFS1–3), mildly frail (CFS4–5), or frail (CFS6–9). The primary outcome was hospital mortality. The secondary outcome was admission to intensive care. Data were analysed using a multivariable binary logistic regression model adjusted for covariates (age, sex, number of drugs prescribed, and type of drug class as a proxy for comorbidities). Findings Between March 30 and July 15, 2020, 2434 patients (median age 68 years [IQR 55–77]; 1480 [61%] men, 954 [30%] women) had CFS scores available and were included in the analyses. In the total sample and in patients aged 65 years and older, frail patients and mildly frail patients had a significantly higher risk of hospital mortality than fit patients (total sample: CFS6–9vs CFS1–3 odds ratio [OR] 2·71 [95% CI 2·04–3·60], p<0·0001 and CFS4–5vs CFS1–3 OR 1·54 [1·16–2·06], p=0·0030; age ≥65 years: CFS6–9vs CFS1–3 OR 2·90 [2·12–3·97], p<0·0001 and CFS4–5vs CFS1–3 OR 1·64 [1·20–2·25], p=0·0020). In patients younger than 65 years, an increased hospital mortality risk was only observed in frail patients (CFS6–9vs CFS1–3 OR 2·22 [1·08–4·57], p=0·030; CFS4–5vs CFS1–3 OR 1·08 [0·48–2·39], p=0·86). Frail patients had a higher incidence of admission to intensive care than fit patients (CFS6–9vs CFS1–3 OR 1·54 [1·21–1·97], p=0·0010), whereas mildly frail patients had a lower incidence than fit patients (CFS4–5vs CFS1–3 OR 0·71 [0·55–0·92], p=0·0090). Among patients younger than 65 years, frail patients had an increased incidence of admission to intensive care (CFS6–9vs CFS1–3 OR 2·96 [1·98–4·43], p<0·0001), whereas mildly frail patients had no significant difference in incidence compared with fit patients (CFS4–5vs CFS1–3 OR 0·93 [0·63–1·38], p=0·72). Among patients aged 65 years and older, frail patients had no significant difference in the incidence of admission to intensive care compared with fit patients (CFS6–9vs CFS1–3 OR 1·27 [0·92–1·75], p=0·14), whereas mildly frail patients had a lower incidence than fit patients (CFS4–5vs CFS1–3 OR 0·66 [0·47–0·93], p=0·018). Interpretation The results of this study suggest that CFS score is a suitable risk marker for hospital mortality in adult patients with COVID-19. However, treatment decisions based on the CFS in patients younger than 65 years should be made with caution. Funding LOEY Foundation.
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Abstract
The COVID-19 pandemic has seen a proposal for frailty to be used as a rationing criterion. This commentary suggests circumstances under which that is defensible: in the face of lack of capacity to treat everyone, and as an alternative to age in stratifying risk. How best to stratify risk is likely to evolve and may include information about illness severity and dynamic measures. Current research must focus on mobilizing better, COVID-19-specific prognostic information, with a goal of best discriminating which lives are most and least likely to be saved should scarcity of resources dictate that not everyone can receive critical care.
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Affiliation(s)
- Kenneth Rockwood
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health Authority, Halifax, NS, Canada
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Lewis EG, Breckons M, Lee RP, Dotchin C, Walker R. Rationing care by frailty during the COVID-19 pandemic. Age Ageing 2021; 50:7-10. [PMID: 32725156 PMCID: PMC7454249 DOI: 10.1093/ageing/afaa171] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Indexed: 11/13/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is disproportionately affecting older people and those with underlying comorbidities. Guidelines are needed to help clinicians make decisions regarding appropriate use of limited NHS critical care resources. In response to the pandemic, the National Institute for Health and Care Excellence published guidance that employs the Clinical Frailty Scale (CFS) in a decision-making flowchart to assist clinicians in assessing older individuals' suitability for critical care. This commentary raises some important limitations to this use of the CFS and cautions against the potential for unintended impacts. The COVID-19 pandemic has allowed the widespread implementation of the CFS with limited training or expert oversight. The CFS is primarily being used to assess older individuals' risk of adverse outcome in critical care, and to ration access to care on this basis. While some form of resource allocation strategy is necessary for emergencies, the implementation of this guideline in the absence of significant pressure on resources may reduce the likelihood of older people with frailty, who wish to be considered for critical care, being appropriately considered, and has the potential to reinforce the socio-economic gradient in health. Our incomplete understanding of this novel disease means that there is a need for research investigating the short-term predictive abilities of the CFS on critical care outcomes in COVID-19. Additionally, a review of the impact of stratifying older people by CFS score as a rationing strategy is necessary in order to assess its acceptability to older people as well as its potential for disparate impacts.
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Affiliation(s)
- Emma Grace Lewis
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Matthew Breckons
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Richard P Lee
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Catherine Dotchin
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK
| | - Richard Walker
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK
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Cerami C, Canevelli M, Santi GC, Galandra C, Dodich A, Cappa SF, Vecchi T, Crespi C. Identifying Frail Populations for Disease Risk Prediction and Intervention Planning in the Covid-19 Era: A Focus on Social Isolation and Vulnerability. Front Psychiatry 2021; 12:626682. [PMID: 34489745 PMCID: PMC8417585 DOI: 10.3389/fpsyt.2021.626682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 06/24/2021] [Indexed: 11/13/2022] Open
Abstract
The early identification of fragile populations in the Covid-19 era would help governments to allocate resources and plan strategies to contain consequences of the pandemic. Beyond frailty, social vulnerability to environmental stressors, such as the social distancing enforced to reduce the SARS-CoV2 contagion, can modify long-term disease risk and induce health status changes in the general population. We assessed frailty and social vulnerability indices in 1,258 Italian residents during the first lockdown phase via an on-line survey. We compared indices taking into account age categories and gender. While frailty showed a linear increase with age and was greater in females than in males, social vulnerability was higher in young adults and elders compared to middle aged and older adults, and in males than females. Both frailty and social vulnerability contributed in explaining the individual perception of the impact of Covid-19 emergency on health, which was further influenced by proactive attitudes/behaviors and social isolation. Social isolation and loneliness following the Covid-19 outbreak may exert dramatic psychosocial effects in the general population. The early detection of vulnerable categories, at risk to become ill and develop long-lasting health status changes, would help to prevent consequences on general well-being by allocating resources to targeted interventions managing psychosocial distress and increasing young adults and elderly resilience toward the post-Covid-19 crisis.
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Affiliation(s)
- Chiara Cerami
- Scuola Universitaria Superiore IUSS Pavia, Pavia, Italy.,Cognitive Computational Neuroscience Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Marco Canevelli
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy.,National Center for Disease Prevention and Health Promotion, Italian National Institute of Health, Rome, Italy
| | | | - Caterina Galandra
- Neurogenetic Research Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Alessandra Dodich
- Center for Neurocognitive Rehabilitation - CIMeC, University of Trento, Rovereto, Italy
| | - Stefano F Cappa
- Scuola Universitaria Superiore IUSS Pavia, Pavia, Italy.,Dementia Research Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Tomaso Vecchi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,Cognitive Psychology Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Chiara Crespi
- Cognitive Computational Neuroscience Center, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
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Galdiano IV, Oliveira TBD, Silva LDN, Annoni R. Prevalência de fragilidade autorreferida em pacientes criticamente enfermos acordados e alertas. FISIOTERAPIA E PESQUISA 2021. [DOI: 10.1590/1809-2950/21017028032021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Indivíduos criticamente enfermos internados em unidades de terapia intensiva (UTI) podem apresentar perdas de reservas físicas e cognitivas que aumentam a vulnerabilidade frente a eventos adversos, caracterizando a síndrome da fragilidade. O objetivo do estudo foi delinear a prevalência de fragilidade autorreferida em pacientes criticamente enfermos acordados e alertas internados na UTI de um hospital escola. Foram incluídos indivíduos adultos (≥18 anos), internados por, pelo menos 48 horas nas UTI de um hospital escola de Uberaba-MG, que encontravam-se alertas no momento da avaliação. O indivíduo foi estimulado a referir seu nível de fragilidade utilizando a Escala de Fragilidade Clínica (EFC). Indivíduos com EFC de 1 a 3 foram considerados não frágeis, 4 vulneráveis e maior que 5, frágeis. Foram incluídos 50 indivíduos com idade entre 44 e 78 anos com predominância do sexo masculino. A prevalência de indivíduos frágeis foi nula, 1 indivíduo foi considerado vulnerável e os demais foram considerados não frágeis com predominância da categoria 3, com 64% da população. Ao analisar os dados demográficos e clínicos nas diferentes pontuações da EFC não foi observado diferença estatisticamente significante entre sexo e idade entre as categorias analisadas. O índice de comorbidade funcional foi crescente nas categorias analisadas, (p=0,05). A prevalência de fragilidade autorreferida foi nula em pacientes criticamente enfermos internados em um hospital escola de Uberaba-MG. Escalas autorreferidas para avaliação de fragilidade podem ser incapazes de identificar acuradamente indivíduos frágeis.
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Predictors for development of critical illness amongst older adults with COVID-19: Beyond age to age-associated factors. Arch Gerontol Geriatr 2020; 94:104331. [PMID: 33476755 PMCID: PMC7834606 DOI: 10.1016/j.archger.2020.104331] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/14/2020] [Accepted: 12/22/2020] [Indexed: 12/18/2022]
Abstract
Introduction Older adults with COVID-19 have disproportionately higher rates of severe disease and mortality. It is unclear whether this is attributable to age or attendant age-associated risk factors. This retrospective cohort study aims to characterize hospitalized older adults and examine if comorbidities, frailty and acuity of clinical presentation exert an age-independent effect on COVID-19 severity. Methods We studied 275 patients admitted to the National Centre of Infectious Disease, Singapore. We measured: 1)Charlson Comorbidity Index(CCI) as burden of comorbidities; 2)Clinical Frailty Scale(CFS) and Frailty Index(FI); and 3)initial acuity. We studied characteristics and outcomes of critical illness, stratified by age groups (50–59,60–69 and ≥70). We conducted hierarchical logistic regression in primary model(N = 262, excluding direct admissions to intensive care unit) and sensitivity analysis(N = 275): age and gender in base model, entering CCI, frailty (CFS or FI) and initial acuity sequentially. Results The ≥70 age group had highest CCI(p<.001), FI(p<.001) and CFS(p<.001), and prevalence of geriatric syndromes (polypharmacy,53.5%; urinary symptoms,37.5%; chronic pain,23.3% and malnutrition,23.3%). Thirty-two (11.6%) developed critical illness. In the primary regression model, age was not predictive for critical illness when a frailty predictor was added. Significant predictors in the final model (AUC 0.809) included male gender (p=.012), CFS (p=.038), and high initial acuity (p=.021) but not CCI or FI. In sensitivity analysis, FI (p=.028) but not CFS was significant. Conclusions In hospitalized older adults with COVID-19, geriatric syndromes are not uncommon. Acuity of clinical presentation and frailty are important age-independent predictors of disease severity. CFS and FI provide complimentary information in predicting interval disease progression and rapid disease progression respectively.
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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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Frailty and mortality in patients with COVID-19. LANCET PUBLIC HEALTH 2020; 5:e580. [PMID: 33120041 PMCID: PMC7588213 DOI: 10.1016/s2468-2667(20)30228-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/22/2020] [Indexed: 02/05/2023]
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Chong E, Chan M, Tan HN, Lim WS. Heterogeneity in functional status among moderately frail older adults: improving predictive performance using a modified approach of subgrouping the Clinical Frailty Scale. Eur Geriatr Med 2020; 12:275-284. [PMID: 33095431 PMCID: PMC7582023 DOI: 10.1007/s41999-020-00418-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/08/2020] [Indexed: 12/01/2022]
Abstract
Aims To establish if dependency in basic activities of daily living (bADL) amongst moderately frail older adults predict poorer health outcomes including mortality and institutionalisation. We also examined the utility of subgrouping category 6 of the Clinical Frailty Scale (CFS) by level of functional dependency to improve predictive performance. Findings We observed a wider range in functional dependency among CFS 6 patients when compared to other frail categories. Incorporating CFS 6 subcategories based on bADL functional status increased predictive performance for longitudinal adverse outcomes compared with the original CFS scoring. Message This study corroborates the heterogeneity of bADL functional status in CFS 6 individuals and validates the use of a modified approach to subgrouping the CFS via bADL dependency for improved predictive performance. Electronic supplementary material The online version of this article (10.1007/s41999-020-00418-8) contains supplementary material, which is available to authorized users. Purpose Moderately frail individuals [Clinical Frailty Scale (CFS) 6] demonstrate heterogeneity in basic activities of daily living (bADL). We aimed to establish whether functional dependency in moderate frailty predicts poorer outcomes and examined the utility of subgrouping the CFS in predicting mortality and institutionalisation. Methods We prospectively studied 201 hospitalised frail patients (89.5 ± 4.7 years, female 70.1%). We examined Katz Index (KI) against adverse outcomes in CFS6 (n = 106). We then compared predictive performances of a modified CFS version 1 (mCFS-1; category 6A: CFS6 and KI ≥ 2; 6B: CFS6 and KI ≤ 1) and modified CFS version 2 (mCFS-2; category 6A: CFS6 and KI ≥ 2; 6B1: CFS6, KI ≤ 1 and feeding independent; 6B2: CFS6, KI ≤ 1 and feeding dependent) against the CFS. Multivariate analysis was used to compare each tool against mortality and institutionalisation. Receiver operator characteristic analysis was performed to determine area under curve and optimal cut-points for each tool. Results KI ≤ 1 in CFS6 was associated with higher 12-month mortality (39.3% vs. 15.6%, p = 0.01); amongst KI items, feeding dependent predicted 12-month mortality (p < 0.05). Using mCFS-1, category 6A did not increase 12-month mortality compared with category 5 (OR 1.83, 95% CI 0.52–6.47), unlike category 6B (OR 6.33, 95% CI 2.07–19.33). mCFS-2 produced higher mortality in category 6B1 (OR 5.19, 95% CI 1.30–20.69) and 6B2 (OR 6.92, 95% CI 2.14–22.35). Similar observations were seen for institutionalisation. Optimal cut-point for 12-month mortality was category 6 for CFS, and 6B and 6B1 for mCFS-1 and mCFS-2, respectively. Conclusion This study corroborates the heterogeneity of functional status in moderately frail individuals and validates the use of a modified approach to subgrouping the CFS6 via bADL functional status for improved predictive performance. Electronic supplementary material The online version of this article (10.1007/s41999-020-00418-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edward Chong
- Department of Geriatric Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore. .,Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore, Singapore.
| | - Mark Chan
- Department of Geriatric Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore, Singapore
| | - Huei Nuo Tan
- Department of Geriatric Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore, Singapore
| | - Wee Shiong Lim
- Department of Geriatric Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore, Singapore
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