Using a CriSTAL scoring system to identify pre-morbid conditions associated with a poor outcome after admission to intensive care in people 70 years or older

Abstract

Older people admitted to intensive care are considered to have lower physiological reserves, an increased susceptibility to infection and longer recovery times, resulting in generally poorer outcomes after intensive care treatment. However, biological heterogeneity makes identification of those with the best chances of survival within their group difficult and risks subjecting those at the end of their lives to unsuccessful treatments. There is no fit-for-purpose outcome prediction tool capable of identifying patients most at risk of these poor outcomes at the point of admission to intensive care. This retrospective study sought to identify factors associated with mortality in older patients (≥70 years) admitted to a teaching hospital critical care unit using objective variables readily available at the point of admission. A total of 15 variables were tested for a significant association with mortality. Of these, eight were identified as significant variables (myocardial infarction within 6 months, an abnormal ECG, congestive cardiac failure (NYHA ≥2), chronic pulmonary disease, chronic liver disease, metastatic cancer, a stay in hospital ≥5 days preceding ICU admission, and frailty (Clinical Frailty Score ≥4)). These variables were used from the basis of a novel outcome prediction model. The aim of such a model would be that it could be used at the point of referral to intensive care to inform considerations regarding admission, and to facilitate conversations with the patient and family regarding realistic treatment expectations.

Prospective Validation of a Checklist to Predict Short‐term Death in Older Patients After Emergency Department Admission in Australia and Ireland

“…A modified version of CriSTAL tested in the United Kingdom also found that metastatic cancer and Rockwood's frailty were significant predictors of death among older patients in intensive care . Our findings are also consistent with those of another prospective study in Dutch EDs, where cognitive impairment was associated with physical decline and 90‐day mortality (AUROC = 0.79, 95% CI = 0.73–0.85) .…”

Methods of Assessing Frailty in the Critically Ill: A Systematic Review of the Current Literature

“…For this purpose, Boumendil et al [22] used the Knauss classification [78] as based on physiological parameters. Some studies included cognition in their functional assessment, by using the Short Portable Mental Status Questionnaire (SPMSQ) [21] or Folstein's MMS [19], the cognitive score as component of Lawton-Brody IADL scale [23], the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) [10,34,46], the Clinical dementia rating scale (CDR) [47], or the Cognitive Performance Scale (CPS) [58]. Two studies added the nutritional status [27,47].…”

“…Eight studies (17%) established a frailty diagnosis based on their own criteria [10,21,33,45,[59][60][61]79] -4 of them exclusively [21,60,61,79] -but the others in combination with established scores. The most common criterion was a combination of decreased cognitive function and functional status and disability in daily life, with the exception of Ball et al [79] who only referred to phys-Gerontology 2022;68:1321-1349 DOI: 10.1159/000523674 iological parameters.…”

“…Table 1). Most of the included studies (n = 40, 70.2%) were prospective cohort studies [2,, followed by retrospective cohort studies (n = 13, 21.1%) [10,[57][58][59][60][61][62][63][64][65][66][67][68].…”

“…It may be associated with functional decline across several organ systems [ 6 , 7 , 9 ]. Frailty is not only linked to ageing but also to chronic and severe organ diseases [ 10 ], limited mobility, loss of muscle mass [ 3 , 10 ], and malnutrition [ 11 ]. Thus, it is a multimodal phenomenon depending on several dynamic interrelated factors in the physical, psychological, social, and environmental domains that affect the physiological equilibrium of a person [ 9 ].…”