Textbook of Post-ICU Medicine: the Legacy of Critical Care by unknow

Author:unknow
Language: eng
Format: epub
Publisher: Oxford University Press, Incorporated
Published: 2018-07-25T00:00:00+00:00

Operationalizing frailty

Unfortunately, the syndromic nature of frailty makes defining its presence and characterizing its severity potentially challenging. One of the most widely adopted tools used to measure frailty is the operational definition proposed by Fried and colleagues4 (see Table 28.2). Despite its relative simplicity, there are limitations to this definition, which include the absence of cognitive and psychological domains, the limited stratification to one of frail, pre-frail, or non-frail categories, and the lack of validation of each of the five criteria used to define the syndrome. These limitations are underscored in a prospective trial evaluating the five ‘Fried’ criteria, in addition to the domains of cognitive impairment and depression, in a cohort of 754 independent elderly patients, followed for up to 7.5 years.32 In this study, slow gait speed was the strongest predictor of adverse outcome (OR 3.8, 5.9, 2.5, and 2.7 for chronic disability, long-term nursing home stay, injurious fall, and death, respectively). The second strongest factor was low physical activity. Interestingly, cognitive impairment (defined as a score on the Folstein Mini-Mental Status Examination <24).33 was found to have greater prognostic value than the other three criteria.

In an attempt to improve the recognition and treatment of frailty, many other scoring systems have been developed, all of which have advantages and drawbacks.34 A recent systematic review of the various instruments highlighted eight of the most important domains of frailty: nutritional status, physical activity, mobility, energy, strength, cognition, mood, and psychosocial support.34 Each of these domains was variably represented in the published scoring systems. In this review, the Frailty Index (FI), which utilizes a detailed 70-item inventory of clinical deficits to capture the presence and quantify the severity of frailty, was identified as the most comprehensive tool.35 While useful in the context of research, its comprehensive nature does not easily lend itself to incorporation into the busy, and often chaotic, practice of clinical critical care medicine.

To this end, a number of clinical scales originally developed for outpatients may have more relevance to critical care, although none has, as yet, been validated in the critical care population. The Clinical Global Impression of Change in Physical Frailty (CGIC-PF) includes both patient- and surrogate-derived data, as well as clinical observation by a clinician, but has not been extensively validated.36 The Groningen Frailty Indicator is a 15-item questionnaire originally mailed out to participants, which, to date, has not been validated for use with direct questioning of surrogates.37 The third score (not included in the aforementioned systematic review) is the 7-point clinician judgement-based Clinical Frailty Scale (CFS), developed and validated by Rockwood et al.38 The study involved 2305 patients aged 65 years or older participating in the Canadian Study on Health and Aging. In this study, the CFS correlated closely with the FI. In their multivariable analysis, each 1-point increase in the CFS translated into a significantly higher risk of death (OR 1.3) and entry into an institutional facility (OR 1.5). Although the CFS is more generic and less detailed than the more comprehensive FI, it

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