The trajectory of very old critically ill patients

Guidet, Bertrand; Vallet, Helene; Flaatten, Hans; Joynt, Gavin; Bagshaw, Sean M.; Leaver, Susannah K.; Beil, Michael; Du, Bin; Forte, Daniel N.; Angus, Derek C.; Sviri, Sigal; de Lange, Dylan; Herridge, Margaret S.; Jung, Christian

doi:10.1007/s00134-023-07298-z

Cited by 18 publications

(3 citation statements)

References 89 publications

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“…Frailty and functional autonomy scales, used on their own risk, risk “reducing the patient to a number”, thus taking away the focus from the patient as an individual. Physicians must continue to present full context and take into account prior goals of care discussions and advanced directives, as well as a full history of the patient, both medical and in terms of in depth personality evaluation, thus encouraging an integrative approach to critical care decision-making [ 99 ]. Although more time consuming, these measures are necessary to prevent the risk of oversimplifying complex situations and allocating treatments to a given patient using only scales.…”

Section: Discussionmentioning

confidence: 99%

Frailty assessment in critically ill older adults: a narrative review

Moïsi,

Mino,

Guidet

et al. 2024

Ann. Intensive Care

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Frailty, a condition that was first defined 20 years ago, is now assessed via multiple different tools. The Frailty Phenotype was initially used to identify a population of “pre-frail” and “frail” older adults, so as to prevent falls, loss of mobility, and hospitalizations. A different definition of frailty, via the Clinical Frailty Scale, is now actively used in critical care situations to evaluate over 65 year-old patients, whether it be for Intensive Care Unit (ICU) admissions, limitation of life-sustaining treatments or prognostication. Confusion remains when mentioning “frailty” in older adults, as to which tools are used, and what the impact or the bias of using these tools might be. In addition, it is essential to clarify which tools are appropriate in medical emergencies. In this review, we clarify various concepts and differences between frailty, functional autonomy and comorbidities; then focus on the current use of frailty scales in critically ill older adults. Finally, we discuss the benefits and risks of using standardized scales to describe patients, and suggest ways to maintain a complex, three-dimensional, patient evaluation, despite time constraints. Frailty in the ICU is common, involving around 40% of patients over 75. The most commonly used scale is the Clinical Frailty Scale (CFS), a rapid substitute for Comprehensive Geriatric Assessment (CGA). Significant associations exist between the CFS-scale and both short and long-term mortality, as well as long-term outcomes, such as loss of functional ability and being discharged home. The CFS became a mainstream tool newly used for triage during the Covid-19 pandemic, in response to the pressure on healthcare systems. It was found to be significantly associated with in-hospital mortality. The improper use of scales may lead to hastened decision-making, especially when there are strains on healthcare resources or time-constraints. Being aware of theses biases is essential to facilitate older adults’ access to equitable decision-making regarding critical care. The aim is to help counteract assessments which may be abridged by time and organisational constraints.

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Section: Discussionmentioning

confidence: 99%

Frailty assessment in critically ill older adults: a narrative review

Moïsi,

Mino,

Guidet

et al. 2024

Ann. Intensive Care

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“…The prediction of outcomes for the individual patient determines major decisions along the pathway of critical care [ 11 ]. This concerns decisions about admission to the ICU as well as those about continuation, escalation or withdrawal of LST in the ICU.…”

Section: Discussionmentioning

confidence: 99%

“…Very old patients (chronological age ≥ 80 years) pose a particularly challenging problem for prognostication [8][9][10][11]. The age-related decline of physiological and cognitive reserves proceeds at different rates [12].…”

Section: Introductionmentioning

confidence: 99%

Prognosticating the outcome of intensive care in older patients—a narrative review

Beil,

Moreno,

Fronczek

et al. 2024

Ann. Intensive Care

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Prognosis determines major decisions regarding treatment for critically ill patients. Statistical models have been developed to predict the probability of survival and other outcomes of intensive care. Although they were trained on the characteristics of large patient cohorts, they often do not represent very old patients (age ≥ 80 years) appropriately. Moreover, the heterogeneity within this particular group impairs the utility of statistical predictions for informing decision-making in very old individuals. In addition to these methodological problems, the diversity of cultural attitudes, available resources as well as variations of legal and professional norms limit the generalisability of prediction models, especially in patients with complex multi-morbidity and pre-existing functional impairments. Thus, current approaches to prognosticating outcomes in very old patients are imperfect and can generate substantial uncertainty about optimal trajectories of critical care in the individual. This article presents the state of the art and new approaches to predicting outcomes of intensive care for these patients. Special emphasis has been given to the integration of predictions into the decision-making for individual patients. This requires quantification of prognostic uncertainty and a careful alignment of decisions with the preferences of patients, who might prioritise functional outcomes over survival. Since the performance of outcome predictions for the individual patient may improve over time, time-limited trials in intensive care may be an appropriate way to increase the confidence in decisions about life-sustaining treatment.

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