Frailty, delirium and hospital mortality of older adults admitted to intensive care: the Delirium (Deli) in ICU study.

Abstract

Background: As the population ages clinical frailty among older adults admitted to intensive care has been proposed as an important determinant of patient outcomes. Among this group of patients an acute episode of delirium is also common, but its relationship to frailty and increased risk of mortality has not been extensively explored. Therefore, the aim of this study was to explore the relationship between clinical frailty, delirium and hospital mortality of older adults admitted to intensive care.Methods: This study is part of a Delirium in Intensive Care (Deli) study that is being conducted across the SWSLHD between May 1st 2019 and the end of April 2020. During the initial 6-month baseline period, clinical frailty status on admission to intensive care, among adults aged 50-years or more, acute episodes of delirium, and the outcomes of intensive care and hospital stay will be described. Mediation analysis was used to assess the relationship between frailty and increased risk of hospital death and delirium.Results: During the 6-month baseline period 997 patients, aged 50-years or more, were included in this study. The average age was 71-years (IQR, 63-79), 55% were male (n = 537). Among these patients 39.2% (95% CI 36.1 – 42.3%, n = 396) had a Clinical Frailty Score (CFS) of 5 or more, and 13.0% (n=127) had at least one acute episode of delirium. Frail patients were at greater risk of an episode of delirium (17% versus 10%, adjusted Rate Ratio (adjRR) = 1.61, 95% Confidence Interval (CI) 1.14 – 2.28, p = 0.007), had a longer hospital stay (2.6 days, 95% CI 1-7 days, p = 0.009), and higher risk of hospital mortality (19% versus 7%, adjRR = 2.43, 95% CI 1.68 – 3.57, p < 0.001), when compared to non-frail patients. Patients who were frail and experienced an acute episode of delirium in the intensive care had a 35% rate of hospital mortality, versus 10% among non-frail patients who also experienced delirium in the ICU (p = 0.034, for interaction between frailty, delirium and hospital mortality). The proportion of the effect of frailty and risk of hospital mortality mediated by an acute episode of delirium in the ICU was estimated to 9.4% (95% CI 2 – 24%).Conclusion: This study among adults, aged 50-years or more, admitted to intensive care has been able to show that clinical frailty on admission increases the risk of delirium by approximately 60%, and both increase the risk of hospital mortality. One in three frail patients who experienced an acute episode of delirium during their stay in the intensive care did not survive to hospital discharge. These results suggest the importance of recognising clinical frailty in the intensive care setting, not just to improve the prediction of outcomes from critical illness, but to identify patients at the greatest risk of adverse events such as delirium, and institute measures to reduce risk, and, importantly to discuss these issues in an open and empathetic way with the patient and their families.

Factors and Outcomes of Intensive Care Unit Readmission in Elderly Patients

“…In addition, cancer and underlying diseases are also associated with patients' in-hospital mortality [39][40][41]. However, there are papers that say that chronological age is not related to inhospital mortality, [42,43], and in elderly patients, malnutrition and frailty were known to be meaningful prognostic factors of in-hospital mortality [43,44]. In addition, Danis et al [45] showed patients and their caregivers were satisfied with ICU treatment, so this may be fully considered before starting ICU treatment for elderly patients.…”

Factors associated with delirium among survivors of acute respiratory distress syndrome: a nationwide cohort study

“…In contrast, Pisani et al did not exclude ICU patients who died during their ICU stay or hospitalization [4]. The occurrence of delirium during hospitalization has been reported to increase hospital mortality among critically ill patients [37]; therefore, we excluded patients with ARDS who had more severe conditions, who might have been diagnosed with delirium, and died during hospitalization. The exclusion of the patients who died within 60 days of ARDS diagnosis may have influenced the results.…”

Poor outcomes of delirium in the intensive care units are amplified by increasing age: A retrospective cohort study

“…[1] In the ICU, delirium is a syndrome manifesting as an acute disturbance and fluctuation of cognition and consciousness characterized by inattention and confusion. [2] It is estimated that delirium could occur in 13% to 66% [3][4][5] of the elderly patients admitted to ICUs, and delirium itself is a known risk factor for poor outcomes, including prolonged ICU and hospital stay, [5] and in-hospital mortality. [3,6] The elderly have been found with brain frailty and less physiologic reserve accompanied by infection, surgery and medication, and thus older patients are more vulnerable to ICU stressors and have a poorer prognosis together with higher medical cost in ICU.…”

“…[2] It is estimated that delirium could occur in 13% to 66% [3][4][5] of the elderly patients admitted to ICUs, and delirium itself is a known risk factor for poor outcomes, including prolonged ICU and hospital stay, [5] and in-hospital mortality. [3,6] The elderly have been found with brain frailty and less physiologic reserve accompanied by infection, surgery and medication, and thus older patients are more vulnerable to ICU stressors and have a poorer prognosis together with higher medical cost in ICU. [7][8][9] Unfortunately, although previous studies have found that age is an independent predictor for ICU delirium, [10] there is still a lack of literature addressing the role of aging on delirium outcomes.…”