The Frail and At-Risk Critically Ill: Screening and Outcomes

Transcription

1 The Frail and At-Risk Critically Ill: Screening and Outcomes Sean M Bagshaw, MD, MSc Department of Critical Care Medicine, University of Alberta, Edmonton, Canada CCCF, Toronto, Canada October 2, :50 09:20

2 2017 Disclosures Salary support: Canada government Grant support: Canada/Alberta government Speaking/consulting: Baxter Healthcare Corp. Steering Committee: Spectral Medical, Inc. Data Safety Monitoring Committee: CytoPherx, Inc.

3 Objectives 1. Understand the tools to screen for frailty and identify a vulnerable population 2. Understand the impact of frailty on outcomes after critical illness

4 Patterns of Functional Decline at End of Life Sudden Death Terminal Illness Organ Failure Frailty Definitions: Sudden death = cardiac arrest or trauma; Terminal illness = cancer; Organ failure = HF/COPD; Frailty: residence in nursing home Lunney JR et al JAMA 2003

5 Cumulative Deficit Model CSHA captured 92 variables such as symptoms, signs, laboratory values, disease states and disabilities collectively termed deficits Frailty Index (FI) = # deficits / total variables Frailty represents the cumulative effects of individual deficits Reinforces the concept of physiologic/homeostatic reserve and biological gradation FI strongly correlates with risk of death and institutionalization Jones et al J Am Ger Soc 2004

6 Physical Phenotype Model Frailty Characteristics Shrinking, weight loss (unintentional), sarcopenia Weakness Poor endurance, exhaustion, slowness Low activity CHS Measure >10 lb lost unintentionally in prior 1 year Grip strength: lowest 20% (by sex, BMI) exhaustion (self-reported); walking time/15 ft: slowest 20% (by sex, height) Kcal/week: lowest 20% (males <383 Kcal/wk; females <270 Kcal/wk) 1. Shrinking: weight loss, unintentional, of 10 lbs in prior year) 2. Weakness: grip strength in lowest 20% at baseline (age/bmi) 3. Poor endurance/energy: self report of exhaustion (CES-D scale) 4. Slowness: slowest 20% at baseline for time to walk 15 ft (sex/height) 5. Low physical activity: lowest quintile of physical activity (gender) Frail 3 Vulnerable 1-2 Not Frail 0 Fried et al (Cardiovascular Health Study)_J Gerontol Biol Sci Med Sci 2001

7 Domains to Define, Measure and Operationalize Domain General Health Status Physical Function Cognitive Function Mobility Strength Energy Nutritional Status Skeletal Muscle Mass Mood Social relations/support Laboratory Markers Operational Measures Hospitalizations, global assessment of functioning scale, self-rated health BADL, IADL, functional independence measure (FIM) MMSE, Montreal Cognitive assessment, clock drawing test Short physical performance battery, gait speed, TGUG, chair rise, mobility aid Grip strength, stair climb, subjective assessment of weakness Fatigue severity scale, subjective assessment of exhaustion or fatigue BMI, weight, albumin/prealbumin, mini-nutritional assessment, weight loss Anthropometry, bioelectrical impedance, MRI/CT/ultrasound Geriatric depression scale, HADS, self-reported depression/anxiety Availability of social resources, subjective assessment of loneliness or isolation Inflammatory mediators (IL-6, IL-1, TNF, CRP), oxidized LDL, creatinine Rajabali et al Can J Cardiol 2016; De Vries et al Ageing Research Reviews 2011

8 Methods to Screen and Diagnose Frailty Method Description Items Example Evaluated in ICU Frailty Index (FI) Deficit accumulation CSHA FI (70 items) YES Physical phenotype 3 physical features 3-5 Fried (CHS) criteria YES Physical performance measures Judgement-based tools Multidimensional tools Sarcopenia Single measure 1 Global subjective assessment Battery of assessments across domains Imaging to assess skeletal muscle Gait speed, grip strength, chair stand NO 1 Clinical Frailty Scale YES EFS, FRAIL, CAF, Groningen Frailty Indicator CT scan psoas or rectus femoris Gold Standard: Comprehensive Geriatric Assessment (CGA) NO YES Rajabali et al Can J Cardiol 2016

9 Single geriatric ICU in China (mean age 82 yr) Novel FI based on 52 variables (23 chronic + 31 acute) All patients who died had FI > 0.46 All patients who survived 30-days had FI <0.22 Each 1% in FI associated with 11% in 30-day mortality (OR 1.11; 95% CI, ) n=155 Zeng et al J Genrontol A Biol Sci Med Sci 2015

10 n=594 Non-Frail (58.2%) Intermediate (31.3%) Frail* (10.4%) Age (yr) 71 (67-94) 75 (65-92) 76 (65-94) Female Sex (%) Post-operative complications ( ) 2.54 ( ) Length of stay ( ) 1.69 ( ) Institutionalized ( ) 20.5 (5.5-76) * FRAILTY defined by the physical phenotype criteria proposed by Fried Makary et al JACS 2010

11 n=196 Le Maguet et al ICM 2014

12 CFS score and mathematically derived FI highly correlated (Pearson 0.80, p<0.01) Available at: Rockwood et al CMAJ 2005

13 Survival Institutionalization For each 1-category in CFS score ~ 21.2% death and 23.9% institutionalization Rockwood et al CMAJ 2005

14 Frequency (%) Frailty (CFS > 4) ~ 32.8% (95% CI, ) Clinical Frailty Scale (CFS) score Bagshaw et al CMAJ 2014

15 vulnerability risk for death time for recovery functional impairment Bagshaw et al CMAJ 2014

16 Survival 1-year after ICU Admission Bagshaw et al CMAJ 2014

17 Secondary Analysis of BRAIN/MIND ICU Studies CFS Scores Stratified by Age Mortality Stratified by CFS Score Prevalence of frailty 30% (n=307) (50% age < 65 years) CFS score associated with mortality, disability in IADL and worse physical (not mental) HRQL CFS scores not associated with disability in BADL or cognition n=1040 Brummel Brummel NE, etn al. et al Under AJRCCM Review 2017

18 Design: prospective cohort study Setting: 311 ICUs in 21 European countries Population: 20 consecutive patients aged >80 years during 3-month surveillance Exposure: Frailty (CFS score) n=5,021; age 84 yr (median); 47.9% women ICU death 22.1%; hospital death 32.6% Frailty (CFS>4) ~ 43.1% (adj-hr 1.54) 23.8% did not receive ICU specific intervention Flaatten et al ICM 2017

19 How Else Can We Use Screening For Frailty? 1. Help to inform triage decisions: Regarding the suitability and probability of benefit for ICU support ~ in terms of patient outcome(s) and health services use

20 ICU admission rate: systematic strategy 61% vs. standard practice 34%, (adj-rr 1.68; 95% CI, ) Guidet et al JAMA 2017

21 Advanced dementia patients increasingly likely to receive MV (OR 1.06; 95% CI, ) Teno et al JAMA IM 2016

22 How Else Can We Use Screening For Frailty? 2. Help guide patient-centered decisionmaking: Regarding scope/duration of ICU support (i.e., time-limited trials) Regarding establishing/revisiting goals-of-care Regarding managing survivorship expectations

23 63 critically ill mechanically ventilated patients (age 54.7; APACHE II 23.5) -17.7% Puthucheary et al JAMA 2014

24 Transition to persistent critical illness Are these PerCI patients frail? At ~ 10 days after ICU admission, acuity did not predict mortality better than antecedent characteristics (age, sex, comorbid disease) (variable transition point by case-mix and acuity) Prevalence only 5.0% but accounted for 32.8% of ICU-bed days and only 46.5% returned home Iwashyna et al Lancet Resp Med 2016

25 How Else Can We Use Screening For Frailty? 3. Improve process of care transitions: Identify priorities/specialized care needs for transition from ICU to ward setting Identify priorities/specialized care needs for hospital to community (i.e., CGA)

26 Frailty An Integrated Model Rapid Case Finding Define Frailty Components Address Components CFS Gait Speed FI (efi) Multidimensional assessment (i.e. EFS) Informed decision-making Precision recovery ICU admission ICU Transition Community Transition

27 Additional Thoughts FRAILTY may be an important unmeasured confounder in health services research and clinical trials? Screening (i.e., rapid case finding) for FRAILTY (using validated instruments) can be a potential criteria for enrollment into interventional trials?

28 How Else Can We Use Screening For Frailty? 4. Test interventions (recognizing vulnerable state): Focused on physical recovery (i.e., minimizing avoidable disability) Focused on cognitive, psycho-social, and emotional recovery Focused on care-giver burden/experience Focused strategies towards palliation (where appropriate)

29 Persistent Critical Illness in Alberta Are these PerCI patients frail? At ~ 7-8 days after ICU admission, acuity was no better than antecedent characteristics (age, sex, comorbid disease) at predicting mortality (variable transition point by case-mix and acuity) Prevalence was 18.7% but accounted for 58.6% of ICU-bed days Bagshaw et al - Unpublished

30 CFS Screening in Adult ICUs (17) in Alberta Prevalence: CFS 5 ~ 19% CFS 4 ~ 16% Correlates: APACHE II ICU stay ICU mortality Source: ecritical Alberta

31 Frailty: Final Thoughts can be screened for in ICU settings correlates with adverse events, death, re-hospitalization, impaired HRQL, and new disability can be used to risk-identify and triage initially should focus on case-finding for near-term prognostication, guiding clinical care and decision-making and later should start to focus more comprehensive assessments, care transitions and specialist referral

32 Thank Acknowledgements: You For Your Attention Alberta Frailty Team: Tom Stelfox, Rob McDermid, Sumit Majumdar, Daryl Rolfson, Daniel Stollery, Ella Rokosh, Ross Tsuyuki, Quazi Ibrahim, Dan Zuege, David Zygun, Darren Hudson, Naheed Rajabali, Carmel Montgomery, Dawn