Interrater Reliability of the Clinical Frailty Scale by Geriatrician and Intensivist in Patients Admitted to the Intensive Care Unit.

BACKGROUND: The Clinical Frailty Scale (CFS) is a commonly used frailty measure in intensive care unit (ICU) settings. We are interested in the test characteristics, especially interrater reliability, of the CFS in ICU by comparing the scores of intensivists to geriatricians. METHODS: We conducted a prospective cohort study on a convenience sample of newly admitted patients to an ICU in Edmonton, Canada. An intensivist and a resident in Geriatric Medicine (GM) independently assigned a CFS score on 158 adults within 72 hours of admission. A specialist in Geriatric Medicine assigned a CFS score independently of 20 of the 158 patients to assess agreement between the two raters trained in geriatrics. Predictive validity was captured using mortality and length of stay. RESULTS: Agreement on CFS score was fair for intensivists vs. GM resident (kappa 0.32) and for intensivists vs. GM specialist (0.29), but substantial for GM resident vs. staff (0.79). Despite this, the CFS remained prognostically relevant, regardless of rater background. Frailty (CFS ≥ 5) as assessed by either intensivist or GM resident was a strong predictor of in-hospital mortality (odds ratio [OR] 3.6; 95% CI, 1.6-8.4, p = .003 and OR 3.0; 95% CI 1.3-6.9; p = .01, respectively). Frailty was also positively correlated with age, illness severity measured by APACHE II score, and length of hospital stay. CONCLUSIONS: The interrater reliability of the CFS in ICU settings is fair for intensivists vs. geriatricians.

Interventions to Mobilize Elderly Patients and Reduce Length of Hospital Stay.

For older people, and in particular frail older people, acute illness and hospitalization are associated with significant potential harm. One of the major drivers of iatrogenic harm in older adults is hospital-induced immobility, the so-called "pajama paralysis." Older people in hospital are often confined to bed even after their acute illness has improved; not only by physical factors such as potentially unnecessary urinary catheters and monitoring equipment but also by the culture often found in hospital of keeping patients in bed for most of the day. Bed rest is associated with sarcopenia, infections, and greater length of stay, and early mobilization of patients is often overlooked as an intervention, despite being inexpensive and effective. In this article we review the evidence of the harm of unnecessary immobilization and discuss the innovations that have been developed to encourage a cultural shift away from pajama paralysis and toward early mobilization of older people in hospital.

A Case of Lichen Sclerosus et Atrophicus With Distinct Erythematous Borders.

BACKGROUND: Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory and fibrosing condition that mostly affects the genital mucosa. Nongenital skin may be affected either in isolation or in association with genital involvement. A distinct, brightly red border may be seen but is poorly documented in major dermatology texts. In the case presented, such a border was noted in all of the patient's very extensive lesions. OBJECTIVE: To draw attention to this clinical manifestation and to stimulate future observations as to its clinical and prognostic significance. METHODS AND RESULTS: A 67-year-old woman presented with disseminated LSA with genital involvement. All the lesions had a distinct red border. A review of major textbooks available to the authors revealed that the presence of a marginal erythema is regularly not mentioned. CONCLUSION: An erythematous border to LSA may be a notable feature. Its frequency and clinical significance remain to be determined.