Frailty in Critical Care Medicine: A Review.

Traditional approaches to clinical risk assessment utilize age as a marker of increased vulnerability to stress. Relatively recent advancements in the study of aging have led to the concept of the frailty syndrome, which represents a multidimensional state of depleted physiologic and psychosocial reserve and clinical vulnerability that is related to but variably present with advancing age. The frailty syndrome is now a well-established clinical entity that serves as both a guide for clinical intervention and a predictor of poor outcomes in the primary and acute care settings. The biological aspects of the syndrome broadly represent 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. Given the complexity of the underlying biologic processes, several well-validated approaches to define frailty clinically have been developed, each with distinct and reasonable considerations. Stemming from this background, the past several years have seen a number of observational studies conducted in intensive care units that have established that the determination of frailty is both feasible and prognostically useful in the critical care setting. Specifically, frailty as determined by several different frailty measurement tools appears associated with mortality, increased health care utilization, and disability, and has the potential to improve risk stratification of intensive care patients. While substantial variability in the implementation of frailty measurement likely limits the generalizability of specific findings, the overall prognostic trends may offer some assistance in guiding management decisions with patients and their families. Although no trials have assessed interventions to improve the outcomes of critically ill older people living with frailty, the particular vulnerability of this population offers a promising target for intervention in the future.

Longitudinal assessment of medical student attitudes toward older people.

Delivering adequate care to older people requires an increasing number of physicians competent in the treatment of this expanding subpopulation. Attitudes toward older adults are important as predictors of the quality of care of older people and of medical trainee likelihood to enter the geriatrics field. This study assessed the attitudes of 404 US medical students (MS) from the start of medical school to graduation using the University of California, Los Angeles (UCLA) Geriatrics Attitude Scale. It is the first study to utilize a longitudinal design to assess attitudes among students in a medical school with a longitudinal geriatrics clinical experience in the first two years and a required geriatrics clerkship in the third year. Participants' attitude scores toward older people were found to significantly decrease from 3.9 during the first two years to 3.7 during the final two. Significant differences existed between MS1 and MS3, MS1 and MS4, MS2 and MS3, and MS2 and MS4. Women and older students held significantly more positive attitudes than men and younger students. These results show that planned clinical exposures to older adults may not be sufficient to halt the decline in attitudes in medical school. A comprehensive empathy-building intervention embedded in the curriculum may better prevent this decline.