key: cord-0943133-p5m00tp5 authors: Geen, Olivia; Rochwerg, Bram; Wang, Xuyi Mimi title: Optimizing care for critically ill older adults date: 2021-10-04 journal: CMAJ DOI: 10.1503/cmaj.210652 sha: f28ce616e625ae6568b0ddb3f52ffd96c016fc53 doc_id: 943133 cord_uid: p5m00tp5 nan What is the relevance of pre-existing frailty for critically ill older adults? The prevalence of frailty in older patients admitted to the ICU is about 30%, according to pooled results across 6 prospective observational studies. 27 Frailty is a state of decreased physiologic, functional and cognitive reserve that results in increased vulnerability to new health stressors. 28 It is believed to result from the interplay of comorbid diseases, genetics and environmental factors, 29 and may be partially reversible in the intermediate stages. 30 Frailty is not an inherent part of aging, although age is a risk factor for frailty and an independent risk factor for adverse outcomes. 31 Ascertaining frailty is relevant in the ICU as part of a global assessment to better understand a patient's risk of adverse outcomes and to inform goals-of-care discussions. 29, [32] [33] [34] [35] In a prospective multicentre cohort study of 610 patients older than 80 years in Canada, frailty was found to be a more significant independent predictor of long-term ICU outcomes than age, illness severity or comorbidity. 36 A 2017 meta-analysis of 10 prospective cohort studies of moderate quality (mean Newcastle-Ottawa Scale score 6.5) found that pre-hospital frailty was associated with increased hospital mortality (relative risk [RR] 1.71, 95% confidence interval [CI] 1.43-2.05) and long-term mortality (RR 1.53, 95% CI 1.40-1.68), independent of age or illness severity. 27 Several studies have reported an incremental increase in mortality for each additional point on the Clinical Frailty Scale (CFS), 27, 33, 37, 38 particularly in those with severe or very severe frailty (CFS ≥ 7). 31, 38 Understanding the impact of frailty on ICU prognosis shifts the concern from a patient's age toward their overall clinical status and trajectory before ICU admission. With respect to post-ICU morbidity, patients who are frail and survive their incident critical illness face worsened physical function and higher admission rates to long-term care homes compared with older adults who are not frail. 27, 37, 39, 40 A 15- year-long prospective longitudinal study of 754 community-dwelling adults [19] [20] [21] [22] [23] †Not included in traditional ACE unit protocols. ABCDEF bundle is a multicomponent strategy for delirium prevention and treatment, and includes pain management, trials of spontaneous awakening, choice of analgesia and sedation, monitoring and management of delirium, early mobilization, and family engagement. 24 older than 70 years found that patients who were pre-frail (1 or 2 Fried frailty criteria present, using the Fried phenotypic model of frailty) or frail (3 or more criteria) did not return to their baseline physical function by 6 months. 39 They did, however, improve compared with their functional status 1 month after ICU discharge, when disability was at its greatest. 39 In comparison, older adults who were not frail at ICU admission returned close to their baseline level of physical function by 6 months. 39 Patients who were frail had a 58.8% admission rate to long-term care at 6 months, 39 a finding consistent with a 2017 meta-analysis in which these patients were less likely to be discharged home 27 (RR 0.59, 95% CI 0.49-0.71). When counselling patients and families on post-ICU expectations, explicit consideration of frailty helps prevent overestimation of functional impairment in those who are not frail, and underestimation in those who are frail ( Figure 1 ). Nevertheless, it is not clear whether the post-ICU outcomes observed are inevitable for patients who are frail, as no studies have examined how changes to management during or after ICU admission could mitigate the incidence or worsening of frailtyassociated outcomes. This is an important area for future research. The 2 main conceptual frameworks of frailty are a physical, or phenotypic, model 41 and a deficit accumulation, or index, model. 28 Several tools based on these frameworks may be used to assess frailty. 42 For older adults admitted to the ICU, we favour the Clinical Frailty Scale presented in Figure 2 . The CFS is highly correlated with the Frailty Index 28 and has been validated with good inter-rater reliability (κ 0.74) between assessors in the ICU setting. [43] [44] [45] [46] Its use is more feasible in critically ill patients than other commonly used tools that require grip strength or mobility assessments, for example. 41, 47 To avoid overscoring the CFS based on the state of critical illness of a patient in the ICU, the assessment should be based on clinical status at least 2 weeks before admission. 48 If there is limited history available from the patient or family members to make this assessment, collateral information can be sought through community care providers, including personal support workers, pharmacists, family physicians and local community care coordinators. Clinicians un familiar with the CFS are encouraged to review resources on proper use to ensure reliability. 48, 49 Why is recognizing delirium important? Delirium in the ICU is common, although underdiagnosed, with prevalence of 20%-84% depending on the severity of illness and method of diagnosis. [50] [51] [52] [53] [54] [55] It is defined by a change from baseline in attention and awareness that is acute, fluctuating and accompanied by disturbed cognition (memory deficit, disorientation, or abnormal language, visuospatial ability or perception). 56 Minor illness (e.g., urinary tract infection) Major illness (e.g., sepsis requiring intensive care) 6 months a er ICU discharge Needs help with BADLs (e.g., bathing, dressing) Needs help with IADLs (e.g., finances, transportation, heavy housework) Independent with BADLs and IADLS Figure 1 : Potential impact of pre-existing frailty on outcomes after minor and major illness. The green line represents the medical course of an individual who is not frail (Clinical Frailty Score [CFS] 1-3, independent with basic and instrumental activities of daily living [BADLs and IADLs]): a minor illness may cause a transient reduction in physical or cognitive function, but the individual recovers to baseline. A major illness requiring admission to intensive care may cause substantial reduction in function and impairment in ADLs, but a patient who is not frail may improve close to baseline by 6 months. The yellow line represents the medical course of an individual with mild frailty (CFS 4-5): a minor illness may cause a disproportionate reduction in function, and the individual may not return to baseline. A major illness requiring admission to intensive care may cause further substantial reduction in function, from which the individual recovers only partially by 6 months. The orange line represents the medical course of an individual with moderate to severe frailty (CFS 6-8): a minor illness is likely to cause further disproportionate reduction in already limited function without return to baseline, and a major illness is likely to result in substantial reduction in function that does not improve by 6 months, assuming the individual is able to survive the index critical illness (in-hospital mortality for CFS 8 is reported at 48%, 31 and 12-month survival for CFS 6-7 is 35% 37 ). Note: ICU = intensive care unit. People who are robust, active, energetic and motivated. They tend to exercise regularly and are among the fittest for their age. FIT People who have no active disease symptoms but are less fit than category 1. O en, they exercise or are very active occasionally, e.g., seasonally. People whose medical problems are well controlled, even if occasionally symptomatic, but o en are not regularly active beyond routine walking. Previously "vulnerable," this category marks early transition from complete independence. While not dependent on others for daily help, o en symptoms limit activities. A common complaint is being "slowed up" and/or being tired during the day. People who o en have more evident slowing, and need help with high order instrumental activities of daily living (finances, transportation, heavy housework). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation, medications and begins to restrict light housework. The degree of frailty generally corresponds to the degree of dementia. Common symptoms in mild dementia include forgetting the details of a recent event, though still remembering the event itself, repeating the same question/story and social withdrawal. Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~6 months). Completely dependent for personal care and approaching end of life. Typically, they could not recover even from a minor illness. Approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise living with severe frailty. (Many terminally ill people can still exercise until very close to death.) In moderate dementia , recent memory is very impaired, even though they seemingly can remember their past life events well. They can do personal care with prompting. In severe dementia , they cannot do personal care without help. In very severe dementia they are o en bedfast. Many are virtually mute. The Clinical Frailty Score (CFS) can be used to summarize the overall clinical status of a patient based on comorbidities, activity level and functional impairment. Through conversations with the patient, family or other reliable informant, clinical judgment is used to determine which category best fits the patient. It is recommended that the score be based on the patient's status 2 weeks before admission to an intensive care unit (ICU) (reproduced with permission: Rockwood et al. 28 ). A 2015 meta-analysis found that delirium in the ICU was associated with increased mortality (RR 2.19, 95% CI 1.78-2.70), a finding that persisted even after the metaregression to account for age, proportion of female participants and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores; longer duration of mechanical ventilation (mean difference [MD] 1.79 days longer), longer ICU admission (MD 33 hours longer), longer hospital stay (MD 23.3 hours longer) and postdischarge cognitive impairment at 3 and 12 months, compared with those who do not develop delirium. 51 Risk factors for delirium in the ICU include benzodiazepine use, blood transfusions, increasing age, a history of dementia, previous coma, higher APACHE II and American Society of Anesthesiology scores, and pre-ICU emergency surgery or trauma. 57 Of these, benzodiazepine use is potentially modifiable; 58,59 this class of medication should be avoided unless clearly indicated for a specific medical condition, such as acute alcohol withdrawal. Because delirium often goes undiagnosed, it is important to optimize recognition of the condition. The 2018 Clinical Practice Guidelines for ICU Pain, Agitation/Sedation, Delirium, Immobility and Sleep Disruption (PADIS) recommend screening for delirium with a valid tool, 57 such as the Confusion Assessment method for the ICU (CAM-ICU) 60 or Intensive Care Delirium Screening Checklist (ICDSC). 61 The ICDSC has a sensitivity of 99% and specificity of 64%, 61 and the CAM-ICU has a sensitivity of 75.5% and specificity of 95.8%. 60 Nonpharmacologic interventions are the mainstay of preventing delirium in the ICU. A meta-analysis of 9 studies found that earplugs reduce the incidence of delirium (RR 0.59, 95% CI 0.44-0.78), 62 suggesting their use is reasonable as a low-harm, low-cost intervention. Several small randomized controlled trials (RCTs) of limited generalizability have investigated other single-component interventions with negative results, including cognitive therapy, 63 family-voice reorientation 64 and light therapy. 65 Evidence is stronger for multicomponent interventions, 24,66-68 likely reflecting that the development of delirium is multifactorial. The PADIS guideline found an odds ratio (OR) of 0.59 (95% CI 0.39-0.88) for reduced incidence of delirium with use of multicomponent bundles. 57 The ABCDEF bundle is an operationalized framework of these guidelines; its components include pain management, trials of spontaneous awakening, choice of analgesia and sedation, monitoring and management of delirium, early mobilization, and family engagement. 24 Principles of the ABCDEF bundle overlap with the demedicalization and patient-centred principles of the multicomponent interventions typically used in ACE units (outlined in Table 1 ). In a large, prospective, multicentre cohort study of more than 15 000 patients, use of the bundle resulted in a dose-dependent reduction in delirium incidence (OR 0.60, 95% CI 0.49-0.72), coma, use of physical restraint, ICU readmission, and ICU and hospital mortality. 24 Future studies should focus on implemen-tation and knowledge translation strategies; implementation resources are available online (www.icudelirium.org/medical -professionals/overview). Antipsychotic use for the prevention of delirium is not recommended, 57 given a Cochrane meta-analysis 50 and large subsequent RCT of more than 1700 patients that showed no benefit over placebo. 69 Dexmedetomidine may be preferentially considered for sedation in patients at high risk for delirium who require sedation for other indications. Although the PADIS guideline recommends against the use of dexmedetomidine for the prevention of delirium, 57 2 more recent systematic reviews and meta-analyses suggest it is associated with reduced incidence of delirium. 70, 71 Most evidence supporting the use of multicomponent bundles is related to prevention of delirium, but they are also recommended for its treatment, as their potential benefits outweigh the risks. 24, 57 Antipsychotics are not effective, with the Modifying the Impact of ICU-Associated Neurological Dysfunction-USA (MIND USA) multicentre RCT of 1789 patients finding no difference in effect between haloperidol, ziprasidone and placebo when measuring duration of delirium. 54 The PADIS guideline supports use of dexmedetomidine when delirium-associated agitation precludes weaning or extubation, 57 based on a single, lowquality RCT. 72 The effectiveness of dexmedetomidine in delirium without agitation remains unclear, and dose reduction is suggested in those older than 65 years, owing to higher rates of bradycardia and hypotension. 73 When symptoms of delirium such as hallucinations, anxiety or agitation cause psychological or physical harm to patients or pose risks to health care workers, antipsychotic treatment may be required. If so, it is best to follow the geriatric principle of "start low and go slow," and prescribe on a short-term and asneeded basis to avoid unintentional use after discharge from the ICU or hospital. A prospective observational cohort study found that 24% of patients treated for delirium with an atypical antipsychotic medication were discharged from hospital on these medications. 74 Such discharge prescriptions are likely unintentional, but prescribing inertia may lead to their continued use. As medical and technological capabilities have improved, ICUassociated mortality has declined and most older adults survive critical illness; among ICU survivors older than 80 years, longterm mortality rates at 1, 2 and 3 years after hospital discharge are comparable with age-and sex-matched general population mortality rates. 75 One prospective study of 3920 patients with a mean age of 84 years from 22 countries found an ICU survival rate of 72.5%, with a 30-day survival rate of 61.2%. 34 However, surviving critical illness may lead to long-term ICU-associated morbidity and functional decline, which are important outcomes to anticipate and manage proactively in the post-ICU period. The prevalence of post-intensive care syndrome (PICS) in adults is unclear, but is believed to affect between 25% and 55% or more of ICU survivors. 76, 77 The syndrome encompasses a heterogeneous group of new or worsening cognitive, physical or mental health impairments 78 (Figure 3) , which can include posttraumatic stress disorder (PTSD) (44% at 6 mo 79 ), impairment in instrumental activities of daily living, 80 depression (34% at 6 mo 81 ), and cognitive impairment (34% at 12 mo 82 ). Given the scope of impairments, patients with PICS may need higher levels of care or informal caregiver support after hospital discharge. Post-intensive care syndrome-Family (PICS-F) is a similar grouping of outcomes in family members of ICU survivors, and includes new or worsening PTSD, depression, complicated grief or anxiety. 83 Management of PICS after ICU discharge is an area of evolving knowledge. Most patients discharged from the hospital experience inadequate specialist follow-up and rehabilitation, polypharmacy, and fragmented care. 84 Several systematic reviews have examined various post-ICU follow-up interventions; [85] [86] [87] [88] however, the results are difficult to interpret, given low-certainty evidence and heterogeneity in the populations, interventions, settings (inpatient v. outpatient) and outcome measures. We identified 5 controlled studies in which the intervention group had a mean age of more than 65 years. [89] [90] [91] [92] [93] No studies provided subgroup analysis by degree of frailty, a major limitation given the evidence that pre-existing frailty substantially affects outcomes. Further studies on the management of older ICU survivors in the post-ICU period are needed, with a priori subgroup stratification by degree of frailty. Despite these limitations, some findings can be applied to older ICU survivors. A large, population-based cohort study in Taiwan of more than 15 000 sepsis survivors with a mean age of 69 The benefit of physical therapy after critical illness was also shown in a recent systematic review of 16 RCTs and 10 observational studies of adult ICU survivors, which found that interventions for physical function improved depression and mental health-related quality of life. 85 Importantly, it appears benefits may be lost if the correct population is not targeted, which could partially explain why some rehabilitation studies have not shown the same benefit in other populations. [94] [95] [96] For example, the study in Taiwan found that there was no survival benefit in patients with a duration of ICU stay or mechanical ventilation less than 7 days, or in those with few comorbidities (measured by a Charlson Comorbidity Index ≤ 2), 90 suggesting that patients most likely to benefit from physical rehabili tation are those who are less well at baseline or experience a prolonged critical illness and are thus at greater risk of muscle wasting and deconditioning. Determining what interventions work, for whom, and in what circumstances will help health teams avoid both under-and overuse of resources in patient-centred post-ICU care. A realist review (which uses a systematic approach to understand the mechanisms behind intervention outcomes) on post-ICU interventions is currently under way and will hopefully provide guidance for future post-ICU care pathways. 97 Other potentially effective interventions in older adults include the use of an ICU diary 92 and incorporation of ACE unit principles into post-ICU care. 89 An ICU diary is a record kept by family and health care providers during a patient's ICU stay to fill in memory gaps, 92 and in the general ICU population has been associated with reduced risk of depression and better quality of life in 2 systematic reviews. 98, 99 The ACE unit principles showed promise in 1 small RCT in France that, although underpowered, found a trend toward improved functional autonomy when older adults were admitted after ICU discharge to a geriatric ward using ACE unit principles, compared with routine care on a medical ward. 89 Many hospital policies already support incorporation of geriatric principles into routine care for all older patients in the form of age-friendly care initiatives. [100] [101] [102] [103] The integration of ACE principles outlined in Table 1 may be considered for older ICU survivors admitted to medical or surgical wards, to prevent further hospital-acquired disability. Several studies using system and technological innovations to implement ACE principles are available. [104] [105] [106] [107] During a hospital stay or soon after hospital discharge, referral to geriatric medicine for cognitive impairment, geriatric psych iatry for mental health concerns, and physiatry for optimization of physical function may be helpful to address specific components of PICS, although referral strategies have not been directly studied. Other postdischarge management strategies, such as nurse-led ICU follow-up services, are not effective, according to current evidence. 86, 87 Conclusion Guidance on how best to care for critically ill older adults is limited by a lack of RCTs that specifically focus on older adults and lack of studies that stratify results by the degree of frailty. Despite these limitations, we have identified steps to improve care, including understanding pre-existing frailty as a prognostic tool in the ICU, the importance of nonpharmacologic multicomponent interventions in delirium prevention and treatment, applying principles of geriatric medicine in routine ICU care, and an appreciation for the high prevalence of cognitive, physical and mental impairments after ICU admission. 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Bonston: Institute for Healthcare Improvement Acute Care for Elders (ACE) tracker and e-Geriatrician: methods to disseminate ACE concepts to hospitals with no geriatricians on staff Improving geriatric care processes on two medical-surgical acute care units: a pilot study Evaluation of the Mobile Acute Care of the Elderly (MACE) service Operational and quality outcomes of a mobile acute care for the elderly service • What other interventions during or after admission to the intensive care unit (ICU) can prevent the incidence or worsening of frailty?• How does frailty affect the success of interventions used to manage post-intensive care syndrome?• Are collaborative care models using geriatric principles effective for the management of critically ill older adults during or after ICU admission, and what components are necessary for success? This article has been peer reviewed.