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August - 2017

   

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The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis

J Muscedere, B Waters, A Varambally, S Bagshaw, J Boyd, D Maslove, S Sibley, K Rockwood Int Care Med, 2017, 43(8);1105-1122

Comment

As our focus on long term outcomes from critical illness gets sharper, it is frailty that is emerging as something we previously had not recognised.

Clinical frailty describes a state or syndrome of reduced physical, physiologic, and cognitive reserve. Frail patients are characterized by a heterogeneous combination of decreased mobility, weakness, reduced muscle mass, poor nutritional status, and diminished cognitive function. It is this combination that makes frail patients vulnerable to stressors, and their outcomes worse. Although there are more frail old people, they are not the same. There are frail young, and old people who are not frail. 

So, what is the relationship between frail and critical illness? This meta analysis article aimed to compare outcomes between frail and non-frail patients admitted to ICU. They  report;

  • Eligible studies included observational or RCT that reported on frailty, using a validated tool, in ICU settings. In order to best evaluate the impact of frailty, only studies comparing frail and non-frail populations were included. 
  • A total of 10 studies were identified, enrolling 3030 patients, 927 frail and 2103 non-frail
  • The tool used was CFS >=4 (n=7), FI (n=4), FP (n=2)
  • The pooled prevalence of frailty was 30% (95% CI 29–32%). 
  • There was no significant difference in hospital and ICU LOS (although hospital LOS 3.3 days greater in frail), vasoactive or ventilation use.
  • Frail patients were less likely to be discharged home than fit patients (RR 0.59; 95% CI 0.49, 0.71; p < 0.00001; I2 = 12%).
  • Frailty was associated with higher hospital mortality (RR 1.71; 95% CI 1.43, 2.05; p < 0.00001; I2 = 32%), and long-term mortality (RR 1.53; 95% CI 1.40, 1.68; p < 0.00001; I2 = 0%). 
  • Eight studies reported on the incremental risk of adverse outcomes with increasing frailty score; 7 demonstrated increased mortality risk with increased frailty severity. For example Brummel reported stepwise increase in 12-month mortality with each CFS point increase; a CFS of 1 was associated with approximately 90% 1-year survival rate, a CFS of 5 had 50% survival, and those with a CFS of 6/7 had a 35% survival rate. 

Overall this tells us that frailty is common in critically ill patients, there are no apparent differences in care received, and outcomes are worse. In addition their is an incremental worsening of outcome with increasing frailty. So where from here?

  • We may need to agree on which frailty score to use, and what degree of frailty we are interested in.
  • We need to understand if there are interventions that will improve outcomes in frail patients 
  • We need to understand if there are processes we cannot improve in frail patients, and engage in shared decision making to provide better person-centred outcomes

 

Abstract

Purpose

Functional status and chronic health status are important baseline characteristics of critically ill patients. The assessment of frailty on admission to the intensive care unit (ICU) may provide objective, prognostic information on baseline health. To determine the impact of frailty on the outcome of critically ill patients, we performed a systematic review and meta-analysis comparing clinical outcomes in frail and non-frail patients admitted to ICU.

Methods

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PubMed, CINAHL, and Clinicaltrials.gov. All study designs with the exception of narrative reviews, case reports, and editorials were included. Included studies assessed frailty in patients greater than 18 years of age admitted to an ICU and compared outcomes between fit and frail patients. Two reviewers independently applied eligibility criteria, assessed quality, and extracted data. The primary outcomes were hospital and long-term mortality. We also determined the prevalence of frailty, the impact on other patient-centered outcomes such as discharge disposition, and health service utilization such as length of stay.

Results

Ten observational studies enrolling a total of 3030 patients (927 frail and 2103 fit patients) were included. The overall quality of studies was moderate. Frailty was associated with higher hospital mortality [relative risk (RR) 1.71; 95% CI 1.43, 2.05; p < 0.00001; I2 = 32%] and long-term mortality (RR 1.53; 95% CI 1.40, 1.68; p < 0.00001; I2 = 0%). The pooled prevalence of frailty was 30% (95% CI 29–32%). Frail patients were less likely to be discharged home than fit patients (RR 0.59; 95% CI 0.49, 0.71; p < 0.00001; I2 = 12%).

Conclusions

Frailty is common in patients admitted to ICU and is associated with worsened outcomes. Identification of this previously unrecognized and vulnerable ICU population should act as the impetus for investigating and implementing appropriate care plans for critically ill frail patients.

August


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