In admitting patients to the ICU we have, at some level, made a decision that we can benefit the patient. The decision is more difficult in the elderly where the difference between preventing and prolonging death can be cloudy. This is particularly the case where the patient looks appropriate on paper, but less so from the end of the bed.
3 articles on the elderly ICU patient, by Canadian researchers, have been published in the last couple of months. They shed light on current practice and its inconsistencies, encourage some personal practice refection and provide grounds for research into refining ICU admission decisions.
To look at the association between pre-admission frailty and long-term quality of life they performed a multicentre cohort study involving around 400 over 50 year-olds. A Clinical Frailty Scale score >4 was used to diagnose frailty and a number of scores used to assess health at 6 and 12 months (including EuroQol and Short-form 12). 38% were lost to follow-up through death (or other reasons).
- On multiple logistic regression, frail patients who survived had significantly less mobility, self-care ability, activity level and more pain and anxiety.
- Additionally there was no real improvement between physical, cognitive and life quality scores between 6 and 12 months.
The Very Elderly Admitted to ICU: A Quality Finish
Nearly 1700 patients aged 80 or more, in 24 Canadian ICUs (mixed medical and surgical) were followed for a year. 30% had some degree of frailty. From a nested cohort they asked family members whether they would prefer ‘life-support” or “comfort care without life support”. Although only 51% said they would want life support for their relative, 85% got some MV, renal support or vasoactive drug infusions.
- A third of patients died in hospital (median time to death was 10 days, median LOS was just 4 days); half of whom died on mechanical ventilation.
- Half of the survivors made it home, rather than a care facility. So only a third of admissions were discharged to home.
- In the cases where the family were unsure about the level of care, death was significantly prolonged.
- Frailty was significantly associated with mortality.
- Advanced directives or obvious frailty made little difference to ICU admission rates.
They discuss how the apparent overuse of intensive care is at odds with the current end-of-life care concern both in the media and literature.
In order to look at 12 month outcomes, the same Canadian group followed 610 patients over 8 years-old who had been on the ICU. These patients were compared with a parallel ‘hospital cohort’ of patients who were not managed on the ICU.
A 43 point frailty index was calculated according to the family’s reports of each patient 2 weeks prior to admission. Follow-up was done using the SF-36 form (a 0-100 scale with physical, cognitive and psychological components).
- At 1 year, 50% had died. Importantly patients dying within 24 hours were not indcluded in the cohort.
- Strikingly, only a quarter of patients had made it back to an equivalent state of health and quality of life by 1 year.
- Frailty was a better predictor of death and disability than age, illness severity or comorbidity. For each 0.2 on the score, the OR for death was increased by 0.48.
Recap on frailty
Frailty is yet to achieve a formal quantitative definition. It represents loss of physical and cognitive reserve and is associated with poor outcomes after critical illness. It generally includes measurable and subjective components such as grip strength, easy exhaustion, unintentional weight loss, slow walking speed or low level of activity. The frailty syndromes that should prompt deeper concern and more formal assessment are:
- falls
- new immobility
- delirium
- incontinence
- susceptibility to side effects.
A comprehensive assessment involves a multidimensional look both at the patient just prior to admission and at what the trend has been in recent months. Despite growing appreciation and delineation of frailty it must be the case that the fragile patient who has been steady for years is different from the similar looking patient who has deteriorated in recent months.
This is in essence pulling apart and itemising that gestalt, end-of-the-bed impression that this patient ‘just won’t do’.
[important]Take home messages:
For the very elderly admitted to the ICU mortality is high and few return to their previous health and quality of life within 1 year.
Frailty:
Probably predicts mortality and disability better than age, comorbidity and severity of illness.
Also predicts quality of life of the survivors of ICU.
Scoring is in its infancy.
Although it’s often difficult to gauge the patients wishes at the time of consideration for ICU admission it is probably the case that we too often treat more aggressively than the patient would have wanted.
ICU is not a pause button.
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