Elsevier

Journal of Critical Care

Volume 45, June 2018, Pages 197-203
Journal of Critical Care

Outcomes/Predictions
Assessing frailty in the intensive care unit: A reliability and validity study

https://doi.org/10.1016/j.jcrc.2018.02.004Get rights and content

Highlights

  • Using the Clinical Frailty Scale is feasible in the ICU.

  • Frailty scores are similar across ages despite higher illness severity in older patients.

  • Chart review and interviews yield similar frailty scores.

Abstract

Purpose

To describe pre-ICU frailty in critically ill patients using the Clinical Frailty Scale (CFS).

Methods

We included patients ≥18 years admitted to 2 ICUs in Hamilton, Canada. The ICU Research Coordinator (RC) generated 3 CFS scores using: 1) chart review, 2) family interview, 3) patient interview. Subsequently, an overall impression was captured in a final score. Mean differences were calculated to assess the RC intra-rater reliability and inter-rater reliability of chart reviews by the RC, Occupational Therapist (OT), and Geriatrics Resident (GR). Scores were also compared between younger and older patients. We also analyzed the relationship between CFS scores and mortality.

Results

We prospectively enrolled 150 patients (mean age 63.8 [SD 15.3] years, APACHE II score 21 [SD 7.3]). CFS were similar between RC, OT, and GR chart reviews (p > 0.05 for all comparisons). There was no difference between RC chart review and RC final score, or between RC patient interview and RC final score. Scores following the RC family interview and the RC final score were significantly different (−0.24, 95% CI −0.38, −0.09, p < 0.01). Each 1-point increase in the final CFS scored by the RC was weakly associated with ICU mortality (odds ratio 1.18, 95% CI 0.84–1.66, p = 0.33), and hospital mortality (OR 1.19, 95% CI 0.89, −1.59, p = 0.24).

Conclusions

CFS scores can be generated using medical chart review and can be reliably completed by ICU clinicians and research staff.

Introduction

Frailty is a health state associated with loss of functional reserve and impaired resistance to stressors, and it can be recognized across multiple domains [1,2]. Although frailty has often been described as a consequence of comorbidities, it is important to note that frailty and comorbidity are not synonymous - individuals with few comorbidities may still be frail [[3], [4], [5], [6]]. While many factors may predispose to frailty [4,7,8], it is an independent risk factor associated with worse health outcomes including dependency, hospitalization, and mortality [1,3,[9], [10], [11]]. Frailty is an increasingly relevant concept in critical care, as the stress of critical illness can have a significant negative impact on frail individuals [12].

Frailty was common among patients included in 2 large prospective studies conducted in intensive care unit (ICU) settings [13,14]. Importantly, critically ill patients who are frail before ICU admission tend to have increased ICU health care utilization and are more likely to experience adverse events in ICU, have longer lengths of ICU and hospital stay, are more likely to die in hospital or at 1 year, and are more likely to lose functional independence at hospital discharge [13,15]. Although advanced age is a risk factor for frailty, many young ICU patients demonstrate this state of decreased functional reserve [16]. One study reported one third of patients aged 50–64.9 years old admitted to the ICU were frail [16] while another study reported one quarter of those with clinical frailty were younger than 65 years old [17].

It is crucial for clinicians to be aware of frailty to inform prognosis, aid with counselling, attend to special needs, and plan for appropriate discharge planning. Given its importance from patient and societal perspectives, it is also important to understand how well clinicians recognize and address frailty [7]. Moreover, representing frailty in clinical studies may help clinicians to consider the influence of the results on frail persons [9].

Several tools are available to screen for and measure frailty. The classic assessment of frailty is through expert evaluation using a Comprehensive Geriatric Assessment (CGA) conducted by a geriatric medicine specialist [18,19]. However, the ICU environment is not conducive to these assessments given the acuity of illness, the widespread use of sedation, and the typical clinical priority of patient stabilization. As a solution, many alternative frailty screening tools have been validated in the ICU [[20], [21], [22], [23], [24]]. A recent review recommended the Clinical Frailty Scale (CFS) as the simplest, most practical tool for use in critically ill populations [25]. This ordinal scale was developed to incorporate clinician judgment and employs a 1–9 scoring system that includes the evaluation of many frailty domains, such as physical frailty, cognitive impairment, comorbidities, and disability whilst acknowledging the importance of function [26]. Despite these findings, there has been no formal evaluation of the reliability of CFS in the ICU setting for clinical or research purposes.

The objectives of this study are 1) to describe pre-hospital frailty in consecutive patients in 2 ICUs using the CFS, comparing assessments with and without patient and family input and between a Research Coordinator (RC), Occupational Therapist (OT), and a Geriatrics Resident (GR) and 2) to evaluate the association between frailty and mortality in the ICU.

Section snippets

Methods

This is a prospective study of pre-hospital clinical frailty of critically ill patients. We evaluated the CFS in 2 ICUs in Hamilton, Ontario (St. Joseph's Healthcare (SJH) and Juravinski Hospital (JH)). The CFS was completed by an RC at both sites. The RC at site 1 was a medical student and at site 2 was a Respiratory Therapist working as a RC. At site 1, the CFS was also independently completed by an OT and by a GR. Site 1 is a mixed medical-surgical ICU. Site 2 is also a medical-surgical ICU

Results

We screened 336 patients admitted to ICU from August 1st to October 30st, 2016 (Fig. 1). Of the patients screened, 150 patients met the inclusion criteria and were enrolled. These patients had a mean age of 63.8 years (SD 15.4), and 40.0% were female (Table 1). Over 80% of patients enrolled were admitted with a medical diagnosis. The mean APACHE II score was 21 (SD 7.3). During their ICU stay, three-quarters of the patients received invasive mechanical ventilation, and almost half received

Discussion

In this prospective cohort study of critically ill adults who were evaluated using the CFS, we found no clinically important differences whether the research coordinator assessed frailty based on chart review, family interview, or patient interview. The mean CFS score reported by the RC tended to increase with each subsequent step. Though some of these differences were statistically significant, the magnitude of difference between the various sources of information were small and thus may not

Conclusions

Frailty is an important health state that can be recognized in critically ill patients with the use of the CFS screening tool. We found that the CFS tool can be reliably used by research staff and clinicians in the ICU setting. The CFS instrument is easily administered, and provides information that can be shared among health professionals to inform care plans. The CFS scores from chart review were similar to those further informed by family and/or patient interviews. Frailty assessments using

Acknowledgements

We thank all the patients and families who participated in this study. We thank the Canadian Critical Care Trials Group (CCCTG) and the Canadian Frailty Network (CFN) for their continued support in this project.

Funding

S Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology from the Canadian Institutes of Health Research. K Rockwood is the Kathryn Allen Weldon Professor of Alzheimer Research at Dalhousie University. J Muscedere is the Scientific Director for the Canadian Frailty Network. HT Stelfox is supported by an Embedded Clinician Researcher Award from the Canadian Institutes of Health Research. D Cook holds a Canada Research Chair in Critical Care Knowledge Translation from the

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