Question 10

College answer

Not available.

Discussion

a) Assessment of frailty:

• Multidimensional assessment, consisting of:
  • History, eg. self-reported exhaustion, fatigue, mood, social participation
  • Proxy functional assessment, eg. use of mobility equipment, reliance on services, hospital admissions, frequency of falls
  • Functional disability assessment, eg. hand grip, gait, balance, cognitive assessment
  • Biometric data, eg. weight loss, muscle mass
  • Physical examination findings, for example:
    • Sarcopenia
    • Clinical features of malnutrition
    • Evidence of decreased energy expenditure
    • Features of multiple health deficits or comorbidities
  • Objective biological findings eg. echo findings, chronic organ system dysfunction, low serum prealbumin, etc.
• Use of a validated frailty scoring scale is recommended:
  • Numerous scales are available (see De Vries et al, 2011)
  • The CFS (Clinical Frailty Scale) is the one most commonly used in critically ill patients (Falvey & Ferrante, 2019)

b) Limitations of this assessment at the time of ICU admission:

• Assessment of frailty in general:
  • There may only be limited information regarding baseline function
  • Clinical features of frailty may be exaggerated by critical illness
  • Frailty may be absent on admission, but can then develop during the ICU stay
• Assessment using a fraily scoring scale:
  • There may be no time to use a comprehensive scoring scale
  • The use of such scales requires training
  • They are validated only among stable community outpatients
  • Their reliability is poorly studied (De Vries et al, 2011)

c) Utility of a frailty score in the management of critically ill patients:

• Prevention of non-beneficial therapies:
  • Frail patients have poorer ICU outcomes. 
  • High frailty scores are associated with discharge into residential care facilities,  medium to long term disability, and poor quality of life
  • Screening for frailty can be used as a prognostic indicator to inform decisionmaking around the goals of care and limitations of therapy
• Triage of critical care services
  • Under scenarios of system stress (eg. a pandemic response), frailty scoring may be a valid mechanism of allocating access to scarce critical care resources
• Redirection of clinical priorities: increased clinician attention to management strategies designed to maximise the preservation of function and the prevention of further enfeeblement, such as:
  • Nutrition (high caloric and high protein supplementation)
  • Micronutrient and vitamin replacement
  • Early extubation
  • Early mobility and physiotherapy
  • Delirium screening
  • Referral to services such as social work, psychology, occupational therapy and specialist geriatrician services