How to manage frailty in the Intensive Care Unit (ICU)?

Management of Frailty in the Intensive Care Unit

The clinical frailty scale should be used for all intensive care patients, as frailty is associated with more difficult convalescence and higher mortality in geriatric patients. 1

Assessment of Frailty in ICU

• Frailty is a clinical syndrome characterized by increased vulnerability due to diminished cognitive, physical, and physiological reserves 2
• Approximately 30% of patients admitted to intensive care units are frail, with prevalence higher among those who die within 30 days of ICU admission (62.3% vs 48.3%) 3
• The Clinical Frailty Scale (CFS) is recommended as an assessment tool for all ICU patients, not just the elderly 1
• Frailty can be diagnosed during ICU admission by identifying 3 or more of the following criteria: unintentional weight loss, self-reported exhaustion, weakness (by grip strength), slow walking speed, and low physical activity 1

Nutritional Management

• Frail patients should receive 1.2-1.5 g protein/kg/day, with even higher protein intake for individuals with severe illness or injury 1
• Early and progressive enteral nutrition (EN) should be implemented after hemodynamic stabilization 1
• For non-intubated frail patients not reaching energy targets with oral diet, oral nutritional supplements should be considered first, followed by enteral nutrition if necessary 1
• Enteral nutrition enriched with omega-3 fatty acids (EPA) may decrease frailty occurrence 1
• In patients with dysphagia, texture-adapted food can be considered; if swallowing is proven unsafe, enteral nutrition should be administered 1

Decision-Making and Care Planning

• Advanced age alone is not a reason to refrain from ICU treatment, but frailty should be considered in treatment decisions 1
• For patients who have been under intensive care treatment for more than a week, therapy goal discussions should take place at least weekly with relatives and, if possible, with patients 1
• Discussions on changes in therapy goals should be held when the disease is in a compensated status, allowing patients to understand disease progression and consequences 1
• A multidisciplinary approach should be used when discussing end-of-life care for elderly frail patients, considering patient directives, family feelings, and representatives' desires 1

Ventilation Strategies

• Prolonged weaning from ventilation occurs in approximately 20% of patients, with advanced age and frailty contributing factors 1
• The usefulness of ventilation therapy should be clarified at the time of initiating therapy, particularly in frail patients 1
• For frail patients with dysphagia and high aspiration risk, consider postpyloric enteral nutrition or temporary parenteral nutrition if necessary 1

Organizational Approaches

• An open culture of discussion in the multiprofessional team, regular team meetings, and supervision can ease the burden on intensive care teams caring for frail patients 1
• Subintensive care units specifically designed for frail elderly patients have shown promising results with lower in-hospital mortality compared to standard acute care units for patients of similar illness severity 4
• Large-scale population screening for frailty in critical illness is feasible and prognostically important, with greater frailty (especially CFS score ≥6) associated with worse outcomes 5

Monitoring and Follow-up

• Routine monitoring for complications such as delirium (10% in frail vs 4% in non-frail) and pressure injuries should be implemented 5
• Frail patients have longer ICU and hospital lengths of stay and increased likelihood of discharge to chronic care facilities (3% vs 1%) 5
• Quantitative cognitive assessment is recommended for patients with cognitive decline to monitor disease progression and guide management 6

Pitfalls and Caveats

• Frailty assessment should not be used as an exclusion criterion for ICU admission but rather to guide appropriate resource allocation and care planning 3, 7
• The transitions from curative to palliative care can be fluid in frail patients, and reliable prognosis assessment is not always possible due to various influencing factors 1
• Frailty is distinct from malnutrition - in a systematic review of 5,447 older patients, only 2.3% were malnourished while 19.1% were frail, though 68% of malnourished patients were frail 1