Frail or Not? That Is the Question* Oriol Roca, MD, PhD Department of Critical Care Vall d’Hebron University Hospital Vall d’Hebron Research Institute Barcelona, Spain; and Ciber Enfermedades Respiratorias (Ciberes) Instituto de Salud Carlos III Madrid, Spain Joan R. Masclans, MD, PhD Department of Critical Care Parc de Salut Mar. IMIM Barcelona, Spain
T
raditionally, mortality was considered as the most important outcome of clinical trials and observational studies in critically ill patients. However, during the last two decades, the study of morbidity among survivors of critical illness has emerged as an issue of special interest. Morbidity is an extremely broad term, and one of the important parts of its assessment is health-related quality-of-life (HRQL). As far as HRQL is concerned, the ideal outcome of healthcare is for the patient to return to their preexisting state or to the state expected for a person of the same age and medical condition (1). One of the objectives of the studies of long-term outcome in critically ill patients is to define methods of early prediction, in order to allow early identification of high-risk patients who would benefit from more aggressive treatments and intense rehabilitation programs during the acute phase and the convalescent phase, respectively. In this connection, it has been shown that HRQL measured as early as 1 month after acute respiratory distress syndrome (ARDS) has a robust relationship with HRQL measured 6 months after an ARDS episode, indicating that it is possible, at an early time point, to identify patients who will have a poor long-term quality-of-life (2). Frailty was first described in the elderly, and it can be defined as a state of increased vulnerability characterized by a decrease in physiological reserve of various systems that leads to an increased risk of adverse outcomes, morbidity, and mortality, even after minor stressor events (3). Its recognition in critical care settings may allow improvements in prognosis and may enable physicians to provide more accurate information to patients and their relatives; it may help to guide daily bedside *See also p. 973. Key Words: frailty; health-related quality-of-life; long-term outcomes The authors have disclosed that they do not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000892
1138
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decision making and help to identify vulnerable subgroups of patients who might benefit from aggressive treatments or closer follow-up. But how can frailty be measured? The two main approaches for frailty assessment are the phenotype model and the frailty index. The first approach is the phenotype model reported by Fried et al (4) in a secondary analysis of a prospective cohort study (5). The lowest quintile of five different variables defined the presence of frailty: unintentional weight loss, self-reported exhaustion, low energy expenditure, slow gait speed, and weak grip strength. More recently, the Canadian Study of Health and Ageing Clinical Frailty Scale (CFS) (6), an easy-to-use 7-point scale, proved predictive of death and need for institutionalization. However, neither of these methods of measuring frailty was described for use in critically ill patients. Critically ill patients may share many of the features typical of frail elderly patients, and therefore, it seems likely that frailty could be a relevant issue in critical care (7). A recent large multicenter prospective study showed that frailty was common among critically ill patients over 50 years old (8). Furthermore, the risk of major adverse events and inhospital and 1-year mortality were also higher in frail patients. These results suggested that frailty can be easily measured in critically ill patients using the CFS. In this issue of Critical Care Medicine, Bagshaw et al (9) presented more detailed results from the same cohort of patients (8), aiming to analyze the association between frailty and long-term HRQL among survivors of critical illness. HRQL was measured at 6 and 12 months, using the EuroQol Health Questionnaire and the Short-Form 12 Health Survey. Frailty was defined using the CFS (6). Prehospital frailty was present in one in three patients. Even though they received similar intensity of organ support, frail patients had longer hospital length of stay and hospital mortality than controls. Furthermore, they were less likely to return home independent and more likely to acquire new disability. Frail patients reported worse scores in global HRQL and in all the domains of both questionnaires compared with their nonfrail counterparts. Nonetheless, several weaknesses in the study should be borne in mind. First, all patients were recruited at ICU admission, and no data about HRQL or functional state before ICU admission were available. Second, only patients over 50 years old were included. Thus, no information is available on younger patients with other comorbidities, such as immunosuppression, who are likely to be frail. Third, CSF was only validated for the elderly, and its measurement is inherently subjective. Fourth, no data about inflammatory markers, nutritional, or functional status were reported that might shed light on the pathogenic pathways of frailty and their relations. In conclusion, frailty seems to be common among older critically ill patients and its presence may predict poor outcomes. Its measurement has prognostic value for patient risk stratification and for identifying high-risk patients who could benefit the May 2015 • Volume 43 • Number 5
Editorials
most from more aggressive treatment and intensive early rehabilitation. In addition, frailty measurement could be a useful tool for improving the information given to patients and their relatives. If these results are confirmed in further studies, frailty measurement could be integrated in daily practice as an easy-touse score for prognostication of critically ill patients.
REFERENCES
1. Rowan KM, Jenkinson C, Black N: Health-related quality of life. In: Surviving ICU. Carlet AD (Ed). London, UK, Springer, 2003, pp 35–50 2. Masclans JR, Roca O, Muñoz X, et al: Quality of life, pulmonary function, and tomographic scan abnormalities after ARDS. Chest 2011; 139:1340–1346 3. Clegg A, Young J, Iliffe S, et al: Frailty in elderly people. Lancet 2013; 381:752–762
4. Fried LP, Tangen CM, Walston J, et al; Cardiovascular Health Study Collaborative Research Group: Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56:M146–M156 5. Fried LP, Borhani NO, Enright P, et al: The Cardiovascular Health Study: Design and rationale. Ann Epidemiol 1991; 1:263–276 6. Rockwood K, Song X, MacKnight C, et al: A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173:489–495 7. McDermid RC, Stelfox HT, Bagshaw SM: Frailty in the critically ill: A novel concept. Crit Care 2011; 15:301 8. Bagshaw SM, Stelfox HT, McDermid RC, et al: Association between frailty and short- and long-term outcomes among critically ill patients: A multicentre prospective cohort study. CMAJ 2014; 186:E95–E102 9. Bagshaw SM, Stelfox HT, Johnson JA, et al: Long-Term Association Between Frailty and Health-Related Quality-of-Life Among Survivors of Critical Illness: A Prospective Multicenter Cohort Study. Crit Care Med 2015; 43:973–982
Decompensation to Shock: What Is the Risk?* Michael A. Puskarich, MD Sarah A. Sterling, MD Department of Emergency Medicine University of Mississippi Medical Center Jackson, MS
I
n this issue of Critical Care Medicine, Capp et al (1) performed a retrospective chart review of all patients who presented to the emergency department (ED) with sepsis with the primary objective of describing the epidemiology of patients progressing to septic shock between 4 and 48 hours post admission. The main finding in their study is that approximately 12% of patients initially presenting with at least two systemic inflammatory response (SIRS) criteria (2) and evidence of infection without shock at presentation progress to septic shock within 48 hours and two thirds of these patients (8%) progress to septic shock at least 4 hours after initial presentation. This timing is clinically relevant, as by 4 hours many patients will have been discharged from the ED to their inpatient bed: hopefully the correct one. The authors should be applauded for their work, as it most certainly was time intensive to perform such a thorough and complicated chart review. As an epidemiologic study, the authors provide us an estimation of risk in a patient population where there is a paucity of information in the literature— namely the risk and risk factors associated with progression of sepsis to overt septic shock despite treatment in the inpatient
*See also p. 983. Key Words: epidemiology; preshock; septic shock Dr. Puskarich’s institution received grant support from the Emergency Medicine Foundation (Career Development Award). Dr. Sterling has disclosed that she does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000890
Critical Care Medicine
hospital setting. What remains unclear, however, is the risk this progression poses to the individual patient and whether specific interventions can mitigate that risk. In regard to specific risk factors for progression, this study provides insight into who might decompensate. In order of increasing risk, female gender (odds ratio [OR], 1.59), history of coronary artery disease (OR, 2.01), bandemia (OR, 2.60), lactate more than 4 mmol/L (OR, 5.30), and nonpersistent hypotension (OR, 6.24) were associated with progression to shock. The presence of bandemia as a risk factor is not unexpected and should raise provider concern regarding severity of illness. As for lactate, one of the only previous studies in this patient population focused on patients with intermediate lactate elevations. In a relatively small (~100 patients) but multicenter prospective observational study, Arnold et al (3) demonstrated that approximately one-fourth patients with sepsis who are normotensive at admission with a serum lactate of 2.0–3.9 mmol/L develop progressive organ dysfunction, with 21% of these patients subsequently requiring vasopressor use and 30% mechanical ventilation. These data reiterate that even moderate lactate elevations can have important prognostic implications (3–5) and are consistent with the results of the current study. Finally, previous literature has demonstrated that episodic or even an isolated episode of hypotension is a marker for an increased risk of death (6, 7), and this study reemphasizes that any episode of hypotension should not be taken lightly. What is unclear from this study, however, is the actual risk of progression to patient-centered outcomes and whether certain interventions (including the type of bed to which the patient is admitted) can mitigate this risk. Interestingly, twothirds patients with delayed progression to shock were actually admitted to the ICU in this study. It is unclear whether these patients were on a ventilator, whether they developed shock after 4 hours but while still physically in the ED, or whether www.ccmjournal.org
1139
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
T
raditionally, mortality was considered as the most important outcome of clinical trials and observational studies in critically ill patients. However, during the last two decades, the study of morbidity among survivors of critical illness has emerged as an issue of special interest. Morbidity is an extremely broad term, and one of the important parts of its assessment is health-related quality-of-life (HRQL). As far as HRQL is concerned, the ideal outcome of healthcare is for the patient to return to their preexisting state or to the state expected for a person of the same age and medical condition (1). One of the objectives of the studies of long-term outcome in critically ill patients is to define methods of early prediction, in order to allow early identification of high-risk patients who would benefit from more aggressive treatments and intense rehabilitation programs during the acute phase and the convalescent phase, respectively. In this connection, it has been shown that HRQL measured as early as 1 month after acute respiratory distress syndrome (ARDS) has a robust relationship with HRQL measured 6 months after an ARDS episode, indicating that it is possible, at an early time point, to identify patients who will have a poor long-term quality-of-life (2). Frailty was first described in the elderly, and it can be defined as a state of increased vulnerability characterized by a decrease in physiological reserve of various systems that leads to an increased risk of adverse outcomes, morbidity, and mortality, even after minor stressor events (3). Its recognition in critical care settings may allow improvements in prognosis and may enable physicians to provide more accurate information to patients and their relatives; it may help to guide daily bedside *See also p. 973. Key Words: frailty; health-related quality-of-life; long-term outcomes The authors have disclosed that they do not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000892
1138
www.ccmjournal.org
decision making and help to identify vulnerable subgroups of patients who might benefit from aggressive treatments or closer follow-up. But how can frailty be measured? The two main approaches for frailty assessment are the phenotype model and the frailty index. The first approach is the phenotype model reported by Fried et al (4) in a secondary analysis of a prospective cohort study (5). The lowest quintile of five different variables defined the presence of frailty: unintentional weight loss, self-reported exhaustion, low energy expenditure, slow gait speed, and weak grip strength. More recently, the Canadian Study of Health and Ageing Clinical Frailty Scale (CFS) (6), an easy-to-use 7-point scale, proved predictive of death and need for institutionalization. However, neither of these methods of measuring frailty was described for use in critically ill patients. Critically ill patients may share many of the features typical of frail elderly patients, and therefore, it seems likely that frailty could be a relevant issue in critical care (7). A recent large multicenter prospective study showed that frailty was common among critically ill patients over 50 years old (8). Furthermore, the risk of major adverse events and inhospital and 1-year mortality were also higher in frail patients. These results suggested that frailty can be easily measured in critically ill patients using the CFS. In this issue of Critical Care Medicine, Bagshaw et al (9) presented more detailed results from the same cohort of patients (8), aiming to analyze the association between frailty and long-term HRQL among survivors of critical illness. HRQL was measured at 6 and 12 months, using the EuroQol Health Questionnaire and the Short-Form 12 Health Survey. Frailty was defined using the CFS (6). Prehospital frailty was present in one in three patients. Even though they received similar intensity of organ support, frail patients had longer hospital length of stay and hospital mortality than controls. Furthermore, they were less likely to return home independent and more likely to acquire new disability. Frail patients reported worse scores in global HRQL and in all the domains of both questionnaires compared with their nonfrail counterparts. Nonetheless, several weaknesses in the study should be borne in mind. First, all patients were recruited at ICU admission, and no data about HRQL or functional state before ICU admission were available. Second, only patients over 50 years old were included. Thus, no information is available on younger patients with other comorbidities, such as immunosuppression, who are likely to be frail. Third, CSF was only validated for the elderly, and its measurement is inherently subjective. Fourth, no data about inflammatory markers, nutritional, or functional status were reported that might shed light on the pathogenic pathways of frailty and their relations. In conclusion, frailty seems to be common among older critically ill patients and its presence may predict poor outcomes. Its measurement has prognostic value for patient risk stratification and for identifying high-risk patients who could benefit the May 2015 • Volume 43 • Number 5
Editorials
most from more aggressive treatment and intensive early rehabilitation. In addition, frailty measurement could be a useful tool for improving the information given to patients and their relatives. If these results are confirmed in further studies, frailty measurement could be integrated in daily practice as an easy-touse score for prognostication of critically ill patients.
REFERENCES
1. Rowan KM, Jenkinson C, Black N: Health-related quality of life. In: Surviving ICU. Carlet AD (Ed). London, UK, Springer, 2003, pp 35–50 2. Masclans JR, Roca O, Muñoz X, et al: Quality of life, pulmonary function, and tomographic scan abnormalities after ARDS. Chest 2011; 139:1340–1346 3. Clegg A, Young J, Iliffe S, et al: Frailty in elderly people. Lancet 2013; 381:752–762
4. Fried LP, Tangen CM, Walston J, et al; Cardiovascular Health Study Collaborative Research Group: Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56:M146–M156 5. Fried LP, Borhani NO, Enright P, et al: The Cardiovascular Health Study: Design and rationale. Ann Epidemiol 1991; 1:263–276 6. Rockwood K, Song X, MacKnight C, et al: A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173:489–495 7. McDermid RC, Stelfox HT, Bagshaw SM: Frailty in the critically ill: A novel concept. Crit Care 2011; 15:301 8. Bagshaw SM, Stelfox HT, McDermid RC, et al: Association between frailty and short- and long-term outcomes among critically ill patients: A multicentre prospective cohort study. CMAJ 2014; 186:E95–E102 9. Bagshaw SM, Stelfox HT, Johnson JA, et al: Long-Term Association Between Frailty and Health-Related Quality-of-Life Among Survivors of Critical Illness: A Prospective Multicenter Cohort Study. Crit Care Med 2015; 43:973–982
Decompensation to Shock: What Is the Risk?* Michael A. Puskarich, MD Sarah A. Sterling, MD Department of Emergency Medicine University of Mississippi Medical Center Jackson, MS
I
n this issue of Critical Care Medicine, Capp et al (1) performed a retrospective chart review of all patients who presented to the emergency department (ED) with sepsis with the primary objective of describing the epidemiology of patients progressing to septic shock between 4 and 48 hours post admission. The main finding in their study is that approximately 12% of patients initially presenting with at least two systemic inflammatory response (SIRS) criteria (2) and evidence of infection without shock at presentation progress to septic shock within 48 hours and two thirds of these patients (8%) progress to septic shock at least 4 hours after initial presentation. This timing is clinically relevant, as by 4 hours many patients will have been discharged from the ED to their inpatient bed: hopefully the correct one. The authors should be applauded for their work, as it most certainly was time intensive to perform such a thorough and complicated chart review. As an epidemiologic study, the authors provide us an estimation of risk in a patient population where there is a paucity of information in the literature— namely the risk and risk factors associated with progression of sepsis to overt septic shock despite treatment in the inpatient
*See also p. 983. Key Words: epidemiology; preshock; septic shock Dr. Puskarich’s institution received grant support from the Emergency Medicine Foundation (Career Development Award). Dr. Sterling has disclosed that she does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000890
Critical Care Medicine
hospital setting. What remains unclear, however, is the risk this progression poses to the individual patient and whether specific interventions can mitigate that risk. In regard to specific risk factors for progression, this study provides insight into who might decompensate. In order of increasing risk, female gender (odds ratio [OR], 1.59), history of coronary artery disease (OR, 2.01), bandemia (OR, 2.60), lactate more than 4 mmol/L (OR, 5.30), and nonpersistent hypotension (OR, 6.24) were associated with progression to shock. The presence of bandemia as a risk factor is not unexpected and should raise provider concern regarding severity of illness. As for lactate, one of the only previous studies in this patient population focused on patients with intermediate lactate elevations. In a relatively small (~100 patients) but multicenter prospective observational study, Arnold et al (3) demonstrated that approximately one-fourth patients with sepsis who are normotensive at admission with a serum lactate of 2.0–3.9 mmol/L develop progressive organ dysfunction, with 21% of these patients subsequently requiring vasopressor use and 30% mechanical ventilation. These data reiterate that even moderate lactate elevations can have important prognostic implications (3–5) and are consistent with the results of the current study. Finally, previous literature has demonstrated that episodic or even an isolated episode of hypotension is a marker for an increased risk of death (6, 7), and this study reemphasizes that any episode of hypotension should not be taken lightly. What is unclear from this study, however, is the actual risk of progression to patient-centered outcomes and whether certain interventions (including the type of bed to which the patient is admitted) can mitigate this risk. Interestingly, twothirds patients with delayed progression to shock were actually admitted to the ICU in this study. It is unclear whether these patients were on a ventilator, whether they developed shock after 4 hours but while still physically in the ED, or whether www.ccmjournal.org
1139
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
