The role of frailty in COVID-19 patients Bellelli, Giuseppe; Rebora, Paola; Citerio, Giuseppe
Intensive care medicine,
10/2020, Letnik:
46, Številka:
10
Journal Article
OBJECTIVES
To evaluate the relationship between frailty and delirium.
DESIGN
Systematic review and meta‐analysis.
SETTING
MEDLINE, EMBASE, PubMed, Scopus, Web of Science, and Google Scholar databases ...were searched for articles on frailty and delirium published on or before October 31, 2017.
PARTICIPANTS
Individuals aged 65 and older.
MEASUREMENTS
Two authors independently reviewed all English‐language citations, extracted relevant data, and assessed studies for potential bias. Articles involving pediatric or neurosurgical populations, alcohol or substance abuse, psychiatric illness, head trauma, or stroke, as well as review articles, letters, and case reports were excluded. Studies underwent qualitative or quantitative analysis according to specified criteria. Using a random‐effects or fixed‐effects model, relative risk (RR) was calculated for the effect of frailty as a predictor of subsequent delirium. Heterogeneity was tested using Q and I2 statistics.
RESULTS
We identified 1,626 articles from our initial search, of which 20 fulfilled the selection criteria (N=5,541 participants, mean age 77.8). Eight studies were eligible for meta‐analysis, showing a significant association between Q2 frailty and subsequent delirium (RR = 2.19, 95% confidence interval = 1.65–2.91). There was low variability among studies in the measures of association between frailty and delirium (I2 2.24, p‐value Q‐statistic = .41) but high heterogeneity in the methods used to assess the two conditions.
CONCLUSION
This systematic review and meta‐analysis supports the existence of an independent relationship between frailty and delirium, although there is notable methodological heterogeneity between the methods used to assess the 2 conditions. Future studies are needed to better delineate the dynamics between these syndromes.
Summary Background & aims Data about the prevalence of sarcopenia among hospitalized patients is lacking and it is unclear whether the diagnostic criteria commonly used in community-dwellers is ...applicable in acutely ill subjects. The aims of this report are: (i) to assess the prevalence of sarcopenia among hospitalized patients; (ii) to assess whether the European Working Group on Sarcopenia in Older People (EWGSOP) criteria are applicable in an acute care setting; and (iii) to assess the mortality rate at 3 months. Methods 103 patients admitted to the Acute Geriatric Clinic were enrolled. Inclusion criteria were: age ≥65 years and malnutrition or risk of malnutrition, according to the Mini Nutritional Assessment Short Form. Sarcopenia was diagnosed using the EWGSOP criteria by means of bioimpedance analysis, handgrip strength and gait speed, within 72 h of admission. Information on deaths was obtained by telephone interview at 3 months following discharge. Results Sarcopenia was diagnosed in 22 patients (21.4%). Twenty-three patients (22.3%) were not able to perform the gait speed and/or the handgrip strength because bedridden or requiring intensive treatments. In this group, a definite diagnosis of sarcopenia was not possible, lacking at least one EWGSOP criteria. Eleven (10.7%) patients died within the 3 months post-discharge period. Kaplan–Meier survival curves showed that sarcopenic patients died significantly more frequently than others (log-rank p ≤ 0.001). Conclusions In a population of hospitalized elderly malnourished or at risk of malnutrition, sarcopenia is highly prevalent and associated with an increased risk to die in the short-term. Furthermore, the EWGSOP criteria cannot be satisfactorily applied in a relevant proportion of patients.
The SARS-CoV-2 pandemic has led to a dramatic crisis of Health Care Systems worldwide, and older people have been among the most disadvantaged. Specific recommendations and reports have been released ...both at International and National level, regarding the diagnosis and management of COVID-19 in the elderly. However, little has been proposed for an appropriate response to older, frail and multimorbid patients in different settings of care (acute care units, long term care facilities, nursing homes and primary care) and for the management of geriatric syndromes (i.e. delirium, sarcopenia, falls). We presume that the current pandemic of will leads to substantial changes in health care systems, and we suggest some key guide principles that could inspire the provision of healthcare services to older people and their families. These principles are primarily directed to physicians and nurses working in the geriatric field but could also be useful for other specialists.
Respiratory failure due to COVID-19 pneumonia is associated with high mortality and may overwhelm health care systems, due to the surge of patients requiring advanced respiratory support. Shortage of ...intensive care unit (ICU) beds required many patients to be treated outside the ICU despite severe gas exchange impairment. Helmet is an effective interface to provide continuous positive airway pressure (CPAP) noninvasively. We report data about the usefulness of helmet CPAP during pandemic, either as treatment, a bridge to intubation or a rescue therapy for patients with care limitations (DNI).
In this observational study we collected data regarding patients failing standard oxygen therapy (i.e., non-rebreathing mask) due to COVID-19 pneumonia treated with a free flow helmet CPAP system. Patients' data were recorded before, at initiation of CPAP treatment and once a day, thereafter. CPAP failure was defined as a composite outcome of intubation or death.
A total of 306 patients were included; 42% were deemed as DNI. Helmet CPAP treatment was successful in 69% of the full treatment and 28% of the DNI patients (P < 0.001). With helmet CPAP, PaO
/FiO
ratio doubled from about 100 to 200 mmHg (P < 0.001); respiratory rate decreased from 28 22-32 to 24 20-29 breaths per minute, P < 0.001). C-reactive protein, time to oxygen mask failure, age, PaO
/FiO
during CPAP, number of comorbidities were independently associated with CPAP failure. Helmet CPAP was maintained for 6 3-9 days, almost continuously during the first two days. None of the full treatment patients died before intubation in the wards.
Helmet CPAP treatment is feasible for several days outside the ICU, despite persistent impairment in gas exchange. It was used, without escalating to intubation, in the majority of full treatment patients after standard oxygen therapy failed. DNI patients could benefit from helmet CPAP as rescue therapy to improve survival.
NCT04424992.
Prevalence of sarcopenia is substantial in most geriatrics settings, but estimates vary greatly across studies because of difference in population characteristics, diagnostic criteria, and methods ...used to assess muscle mass, muscle strength, and physical performance. We investigated the feasibility of the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm assessment in hospitalized older adults and analyzed prevalence and clinical correlates of sarcopenia.
Cross-sectional analysis of 655 participants enrolled in a multicenter observational study of older adults admitted to 12 acute hospital wards in Italy. Sarcopenia was assessed as low skeletal mass index (kg/m2) plus either low handgrip strength or low walking speed (EWGSOP criteria). Skeletal muscle mass was estimated using bioimpedance analysis.
Of the 655 patients (age 81.0 ± 6.8 years; women 51.9%) enrolled in the study, 275 (40.2%) were not able to perform the 4-m walking test because of medical problems. The overall prevalence of sarcopenia on hospital admission was 34.7% (95% confidence interval 28-37) and it steeply increased with aging (p < .001). In multivariable analysis, patients with sarcopenia on hospital admission were older and were more likely to be male and to have congestive heart failure, cerebrovascular disease, and severe basic activities of daily living disability. The prevalence of sarcopenia was inversely correlated with body mass index.
Based on EWGSOP criteria, prevalence of sarcopenia is extremely high among older adults on admission to acute hospital wards. Older age, male gender, congestive heart failure, cerebrovascular disease, severe activities of daily living disability, and body mass index were the clinical variables significantly associated with the presence of sarcopenia.
Delirium occurring in patients with dementia is referred to as delirium superimposed on dementia (DSD). People who are older with dementia and who are institutionalized are at increased risk of ...developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision are considered the standard reference for the diagnosis of delirium and include criteria of impairments in cognitive processes such as attention, additional cognitive disturbances, or altered level of arousal. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision does not provide guidance regarding specific tests for assessment of the cognitive process impaired in delirium. Importantly, the assessment or inclusion of preexisting cognitive impairment is also not addressed by these standards. The challenge of DSD gets more complex as types of dementia, particularly dementia with Lewy bodies, which has features of both delirium and dementia, are considered. The objective of this article is to critically review key elements for the diagnosis of DSD, including the challenge of neuropsychological assessment in patients with dementia and the influence of particular tests used to diagnose DSD. To address the challenges of DSD diagnosis, we present a framework for guiding the focus of future research efforts to develop a reliable reference standard to diagnose DSD. A key feature of a reliable reference standard will improve the ability to clinically diagnose DSD in facility-based patients and research studies.
Delirium is an acute neuropsychiatric syndrome and one of the most common presenting symptoms of acute medical illnesses in older people. Delirium can be triggered by a single cause, but in most ...cases, it is multifactorial as it depends on the interaction between predisposing and precipitating factors. Delirium is highly prevalent in older patients across various settings of care and correlates with an increased risk of adverse clinical outcomes. Several pathophysiological mechanisms may contribute to its onset, including neurotransmitter imbalance, neuroinflammation, altered brain metabolism, and impaired neuronal network connectivity. Several screening and diagnostic tools for delirium exist, but they are unfortunately underutilized. Additionally, the diagnosis of delirium superimposed on dementia poses a formidable challenge - especially if dementia is severe. Non-pharmacological approaches for the prevention and multidomain interventions for the treatment of delirium are recommended, given that there is currently no robust evidence of drugs that can prevent or resolve delirium. This article aims to review the current understanding about delirium in older people. To achieve this goal, we will describe the epidemiology and outcomes of the syndrome, the pathophysiological mechanisms that are supposed to be involved, the most commonly used tools for screening and diagnosis, and prevention strategies and treatments recommended. This review is intended as a brief guide for clinicians in hospital wards to improve their knowledge and practice. At the end of the article, we propose an approach to improve the quality of care provided to older patients throughout a systematic detection of delirium.
To assess the knowledge and use of the Assessment, prevention, and management of pain; spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment; Early ...mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle to implement the Pain, Agitation, Delirium guidelines.
Worldwide online survey.
Intensive care.
A cross-sectional online survey using the Delphi method was administered to intensivists worldwide, to assess the knowledge and use of all aspects of the ABCDEF bundle.
There were 1,521 respondents from 47 countries, 57% had implemented the ABCDEF bundle, with varying degrees of compliance across continents. Most of the respondents (83%) used a scale to evaluate pain. Spontaneous awakening trials and spontaneous breathing trials are performed in 66% and 67% of the responder ICUs, respectively. Sedation scale was used in 89% of ICUs. Delirium monitoring was implemented in 70% of ICUs, but only 42% used a validated delirium tool. Likewise, early mobilization was "prescribed" by most, but 69% had no mobility team and 79% used no formal mobility scale. Only 36% of the respondents assessed ICU-acquired weakness. Family members were actively involved in 67% of ICUs; however, only 33% used dedicated staff to support families and only 35% reported that their unit was open 24 hr/d for family visits.
The current implementation of the ABCDEF bundle varies across individual components and regions. We identified specific targets for quality improvement and adoption of the ABCDEF bundle. Our data reflect a significant but incomplete shift toward patient- and family-centered ICU care in accordance with the Pain, Agitation, Delirium guidelines.
PDF
