Frailty at 90: survival to ICU discharge hides higher mortality at a year

Design

Retrospective registry cohort with propensity score matching

Population

5398 patients aged 90 and over admitted to ICU after elective surgery in Australia and New Zealand

Primary outcome

One-year all-cause mortality

Effect

Frail vs non-frail HR 1.66 (95% CI 1.47 to 1.87)

Using the Australian and New Zealand Intensive Care Society database, researchers identified patients aged 90 and over admitted to ICU after elective surgery and graded frailty with the Clinical Frailty Scale on admission. After propensity matching for age, sex, illness severity and comorbidity, 2699 frail (scale 5 to 8) and 2699 non-frail (scale 1 to 4) patients were compared.

ICU mortality was low and did not differ. But frailty was associated with higher in-hospital mortality (HR 1.66, 95% CI 1.22 to 2.27) and one-year mortality (HR 1.66, 1.47 to 1.87). Non-frail patients were more likely to return to their previous residence (OR 1.45). Frail patients stayed longer and had more delirium and acute kidney failure.

Frailty was measured at ICU admission rather than in clinic, and this is observational. Still, the message for the preoperative conversation is clear: surviving intensive care is not the outcome a frail nonagenarian cares about most; going home and being alive a year later is.

• Score frailty with the Clinical Frailty Scale at the preoperative visit for every patient aged 90 or over.
• Discuss one-year survival and the chance of returning home, not only operative risk, with frail patients and families.
• Plan for delirium and kidney injury prevention in frail nonagenarians from the outset.
• Involve geriatric medicine early where frailty is 5 or higher.
• Record the frailty score so outcomes can be audited locally.

Why it matters

Low ICU mortality can reassure falsely; the cost of frailty appears after discharge from intensive care.

Don't overread it

Observational, and frailty was scored at ICU admission; it shows association, not that frailty-guided decisions improve outcomes.

The statistics, in plain English

A hazard ratio of 1.66 means the death rate over a year was about two-thirds higher in frail patients after matching. Matching balances measured factors only; unmeasured differences may remain.

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