Question 10 from the second paper of 2021 was the first time frailty had appeared in the CICM Part II exam. The specific focus had been on the assessment of frailty, the limitation of assessment methods, and the use of frailty in the management of critically ill patients. These are obviously not the only possible questions on this topic.
Falvey & Ferrante (2019) give a solid one-liner to define frailty:
"a state of decreased physiologic reserve that heightens vulnerability to acute stressors"
Even though they were supposed to be quoting McDermid et al (2011), who actually defined it as
"a multidimensional syndrome characterized by the loss of physical and cognitive reserve that predisposes to the accumulation of deficits and increased vulnerability to adverse events"
If that does not seem wordy enough, De Biasio et al (2020) took it a few steps further:
"The frailty syndrome is ... a network of interrelated perturbations involving the age-related accumulation of molecular, cellular, and tissue damage that leads to multisystem dysregulation, functional decline, and disproportionately poor response to physiologic stress"
So is it a physiological state, or is it a multidimensional syndrome, or is it a ... network of interrelated perturbations? After becoming frustrated with the literature on this subject after only ten minutes of Googling, one would have to conclude that none of the definitions are entirely satisfactory. In case one would like to instead contemplate what a satisfactory definition should look like, Rockwood (2005) produced a rather comprehensive list of criteria by which to judge a definition of frailty. Since then there have been a multitude published definitions and so much disagreement that, when a consensus conference was convened to consolidate them (Rodríguez-Mañas et al, 2013), the group of thirty-one experts somehow failed to agree on even the fundamental basics. In short, the exam-ready reader is advised to pick a short pithy statement and memorise it for their exams, secure in the knowledge that all of them have equally little validity.
The local Government Organ for Clinical Awesomeness has a great frailty page that brings together a few frailty screening tools, and from which the following extensively borrows. In case they lose their funding after the next state election and their website goes down, this paper by Panhwar et al (2019) would probably be a more resilient link. In summary, the assessment is multidimensional, and can consist of:
The use of a validated frailty scoring system is recommended, as these tend to bring together all of these elements, and distil the complex and ineffable network of interrelated perturbations into a single numerical score. It seems as if around the years 2000-2001 people somehow suddenly realised that frailty assessment is an untapped gold mine of potential publications, and frailty assessment scales sprouted like mushrooms after the rain. Examples of such scales, listed in chronological order, include:
There are about a thousand more (eg. see this review by De Vries et al, 2011), but the reader will have already got the point around Rockwood. The question is, are any of these any better than others? That's harder to assess than one might think, considering that we haven't agreed on any objectively measurable definition of frailty. The most that can be said of them is that they all have fairly similar construct validity, i.e. whatever the thing is that they are measuring, it seems to be associated with some genuine patient-centred outcome changes, eg. increased mortality.
What is the relevance of this term to the management of the ICU patient? Let's say you applied some sort of scale, and assessed the patient as being frail on the basis of your findings. What now? "We contend that the concept and measurement of frailty may have clinical, psychosocial and economic relevance to critical care medicine", opined McDermid et al in their 2011 editorial. However, their paper mainly focused on prognostic implications in terms of the use of ICU resources. Apart from "limitations of therapy", few novel suggestions are made by other authors.
Still, this can be cobbled together into an answer to the question, "what use is frailty to the intensivist".
Additionally:
So, if you;'re going to make decisions about limitations of therapy and goals of care on the basis of frailty assessments, you should probably have some contemporary data to back your decisions. Darvall et al (2019), in a retrospective Australian study that used the ANZICS database, found that the in-hospital mortality for frail patients admitted to the ICU was higher (17.6% v 8.2%) when compared to non-frail patients of a similar age. Basically the same authors repeated a prospective version of the same study and got basically the same mortality rates (16% vs 5%), with in-hospital mortality of up to 39% for the "severely frail" category, and only 2% for patients regarded as "fit" on the basis of the CFS.
Limitation of making an assessment of frailty in the ICU are numerous:
The standardised instruments designed to measure frailty also have several disadvantages in the ICU
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