The Frailty Phenotype and Palliative Care Needs of Older Survivors of Critical Illness

Abstract

Background/Objectives To assess symptoms in older (age ≥65 years) intensive care unit (ICU) survivors and determine whether post-ICU frailty identifies those with the greatest palliative care needs. Design A prospective cohort study. Setting An urban tertiary-care hospital and community hospital. Participants One-hundred and twenty-five medical-ICU survivors of mechanical ventilation age ≥65 years. Measurements Baseline measurements of the Edmonton Symptom Assessment Scales (ESAS), categorized as mild (0–3), moderate (4–6), and severe (7–10), and the frailty phenotype were made during the week prior to hospital discharge. Functional recovery was defined as a return to a Katz Activities of Daily Living dependency count less than or equal to the pre-hospitalization dependency count within 3 months. In the last 29 participants, we made additional assessments of fatigue and ESAS at baseline and 1 month after discharge. Results Fatigue was the most prevalent moderate-to-severe symptom (74%), followed by dyspnea (53%), drowsiness (50%), poor appetite (47%), pain (45%), depression (42%), anxiety (36%), and nausea (17%). At 1 month follow-up, there were no significant differences in the proportions of participants with moderate-to-severe symptoms. Each increase in baseline ESAS fatigue severity category was associated with a 55% lower odds of functional recovery (OR 0.45, 95% CI 0.24–0.84), independent of age, sex, comorbidities, and critical illness severity. Compared to non-frail participants, frail participants had a higher median (IQR) baseline total ESAS symptom distress score (13 [9–22] versus 34 [23–44], p <0.001). Conclusions Older ICU survivors have a high burden of palliative care needs that persist at 1 month after discharge. Fatigue is the most prevalent symptom and may interfere with recovery. Post-ICU frailty may be both a useful palliative care consultation trigger and treatment target.

Discharge frailty following lung transplantation

“…Because we focused on recipients who survived to discharge, we cannot directly compare the prevalence of frailty in our cohort with other studies in solid organ transplant. Among older adult survivors of a medical ICU admission, almost 80% were frail at discharge, higher than 54.1% of recipients who were frail in our cohort, likely reflecting population and disease differences . As with the broader transplant literature, however, we found that frailty was independent of other commonly used measures of functional impairment, including age and 6‐minute walk test .…”

What is the evidence that people with frailty have needs for palliative care at the end of life? A systematic review and narrative synthesis

“…Evidence was mixed for the occurrence of other physical symptoms including shortness of breath (less problematic than for COPD or ALS, 28 but more problematic than non-frail, 42 poor quality evidence estimating 45% prevalence 40 ); drowsiness (higher than in non-frail, 42 but less so than ALS, COPD and ESRD 28 ); fatigue/weakness (less problematic than for COPD or ALS, 28 but more problematic than non-frail, 42 with poor quality evidence of 30% prevalence 40 ); loss of appetite (similarly problematic to non-frail, 42 with poor quality evidence of 38% prevalence 40 ) and pressure ulcers (similarly problematic to dementia, but lower than for cancer 27 ). There was poor quality evidence from a non-comparative study that two-fifths or more people with frailty have problems with weakness, sleeplessness, insomnia and loss of weight.…”

“…Seven studies examined the psychosocial needs of people with frailty nearing the end of life, one of good quality, 28 two fair 27,42 and four poor quality. 26,36,40,41 There was evidence that people with frailty experience similar study defined ‘emotional distress’ (emotional distress with psychological symptoms that are sustained, intense, progressive and not related to acute concurrent conditions) to people with cancer from one fair quality study.…”

“…28 Compared to non-frail individuals, one fair quality study found that people with frailty experience greater anxiety, depression and loss of wellbeing towards the end of life. 42…”

ESPEN guideline on clinical nutrition in the intensive care unit

“…Specific criteria diagnosing frailty during ICU stay are not available. Poor appetite and nutritional intake [19,309] may be evident. Frailty is more frequent in the elderly population (50% in patients older than 80 years) and is associated with increased mortality.…”