2012 Pilot Study 2

Frailty, Palliative Needs, and Outcomes of Elderly ICU Survivors

Investigator: Matthew Baldwin, MD – Fellow, Pulmonary and Critical Care, Department of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Medical Center

The success of intensive care medicine has traditionally been gauged by the proportion of patients alive at hospital discharge. With technological advances, however, many critically ill elderly (age ≥ 65) adults now survive what were previously fatal illnesses, and reliable information is urgently needed regarding predictors of the post-discharge clinical course, and healthcare needs during the post-acute care period. Elderly adults now make up more than half of all intensive care unit (ICU) admissions. Among the 500,000 elderly ICU survivors discharged to skilled-care annually, almost half are re-hospitalized and up to 65% die within 6 months. Severity-of-illness measures widely used in hospital ICUs were designed to measure in-hospital mortality, are not calibrated for use in the elderly, and do not accurately predict mortality in ICU survivors discharged to skilled-care facilities. The central hypothesis of the proposed study is that palliative and hospice services are desired but underutilized among elderly ICU survivors in need of continued skilled-care because the elevated risk of 6-month mortality is underappreciated. Our primary Aim is to perform a pilot study to determine how frailty and disability are associated with palliative care needs and 6-month mortality in elderly ICU survivors discharged to skilled-care. To achieve this Aim, we will enroll 30 elderly ICU survivors and their primary surrogates prior to hospital discharge to skilled-care to evaluate established molecular (pre-albumin, albumin, IL-6), physiologic (sarcopenia), and functional (grip strength, walk speed, independence of activities of daily living, delirium, and dementia) markers of frailty at hospital discharge, and 2 weeks, 1 month, and 3 months later. We hypothesize that (1) patients with marked frailty and disability will have significant pain and palliative needs that are not addressed during the care transition from hospital to skilled-care despite having an increased risk of death within 6 months, and that (2) patient and surrogate expectations for functional independence and survival at 1 year are initially higher than physician expectations, but decline over time while a desire for palliative and hospice care develops. This application proposes to acquire new data that will be used to establish markers of frailty and disability as novel risk factors in predicting both death and palliative care needs after hospitalization for critical illness in the elderly. The results will empower clinicians to make informed decisions for their patients, and will provide critical new information needed to prompt policymakers to consider changes in the use of palliative care for the rapidly growing population of elderly ICU survivors.