EJRC ARTICLE REVIEW

Introduction

Frailty has been associated with increased mortality and reduced quality of life with critical illness with 1-year mortality reaching 65%¹. The main aim of this study was to evaluate the occurrence of frailty and assess its impact on 30-day mortality in patients ≥80yrs of age admitted to European ICUs.

Methods

This prospective multicentre study in 311 ICUs from 21 European countries included 5021 patients that could be analysed with complete datasets. Investigators enrolled consecutive patients ≥80 years of age who were admitted to the ICU and grouped into acute and elective admissions. Frailty was defined by the Clinical Frailty Scale (CFS) based on pre-illness function, and classified into 9 groups – from very fit to terminally ill with ≥5 being frail. The main outcome measure was survival at ICU discharge and 30 days after ICU admission. They also recorded whether 4 common ICU procedures were performed during the ICU stay: vasoactive drugs, invasive ventilation, non-invasive ventilation & renal replacement therapy.

Results

Hazard Ratio for mortality with frail compared with fit was 1.54 (95%CI 1.38-1.73) with a HR of 1.2 (95%CI 1.12-1.28) for every 5-year increment. Estimated 30-day survival for fit compared with frail was 76% & 59% respectively. Interestingly comparing those in Frailty class 9 with those in class 1 had a HR of 4.50 (95%CI 2.45-8.25) and comparing acute versus elective admission had a HR of 4.72 (95%CI 3.65-6.10).

23.8% of patients enrolled had no ICU procedures recorded with 52.2% receiving vasoactive drugs, 50.7% having invasive ventilation, 23% receiving NIV and only 9.2% being treated with RRT.

Those patients that scored 8, who by definition shouldn’t be able to survive even a minor illness², had a 30-day mortality of 60% and HR of 3.29 (2.20-4.92) and those terminally ill with a Score of 9 had mortality reaching 80% and HR of 4.50 (2.45-8.25).

Discussion

This study shows that increased frailty on admission is associated with higher ICU and 30-day mortality in those aged  ≥80 years. Flaatten et al. also identified other factors associated with a higher hazard ratio for mortality including being an acute versus elective admission and having a higher SOFA score on admission.

From the distribution of patients enrolled on this study, 1054 were from the UK from 91 ICUs, and Italy enrolled 925 patients from 42 ICUs, while the Czech Republic and the Ukraine each included 1 ICU per country and enrolled 6 and 17 patients respectively. The huge variation in enrollment introduces bias into the cohort, and consequently, the results remain primarily indicative of the United Kingdom and Italy.

Several confounding factors in this study have also not been accounted for, such as the co-morbidities of those admitted and compared against each frailty category, or what proportion were admitted for organ donation or end of life care. Data on when treatment was withdrawn or withheld is lacking or the reasons and whether it was related to frailty. It would be interesting to know what proportion of the frail patients scored 8 or 9 as they are uncommonly admitted to the ICU and more likely to be admitted for end of life care.

Article review prepared and submitted by James Burton, Specialist registrar, University College London on behalf of the EJRC.