Frailty in Critical Care: Examining Clinical Implications

Jennifer A. Gibson, MSN, RN, CCN(C); Sarah Crowe, MN, RN, CNCC(C)

Reprinted from Critical Care Nurse, June 2018, pp 29-36 © 2018, AACN.

Learning Objectives

At the end of this learning activity, the participant will be able to:

  1. 1. Describe the concept of frailty and its relationship to comorbidities and disability
  2. 2. Compare the advantages and disadvantages of 2 tools for assessing frailty
  3. 3. Discuss how geriatric best practices and communication skills can mitigate the
    impact of frailty on patient outcomes during hospital admission

Frailty is an aging-related, multisystem clinical state characterized by loss of physiological reserves and diminished capacity to withstand exposure to stressors. Frailty increases the risk of serious adverse outcomes, compared with that of nonfrail people of the same age. Adverse outcomes can be severe and may include procedural complications, delirium, significant functional decline and disability, prolonged hospital length of stay, extended recovery periods, and death. As older adults make up a continually growing proportion of hospitalized patients, critical care nurses need to understand how to recognize frailty and be familiar with related clinical practice implications. Such knowledge underpins effective organization and delivery of care strategies aimed at minimizing harm and maximizing positive outcomes for frail older adults. Drawing from recent literature, this article explores frailty and critical illness by discussing 2 dominant models of the concept. Using a clinical case study, links between frailty and critical care nursing practices are highlighted and clinical considerations are explored.
(Critical Care Nurse. 2018;38[3]:29-36)

Frailty is a multisystem clinical state that involves the loss of physiological reserves.1-3 Such losses diminish a person’s capacity to withstand exposure to stressors and results in an increased risk of adverse outcomes compared with that of nonfrail people the same age. Patients with frailty in critical care settings are at considerably higher risk of poor outcomes, including death. To minimize risks and optimize outcomes for this vulnerable patient group, critical care nurses must understand how to recognize frailty in patients and be familiar with related practice implications.

In this article, frailty and how to identify it are explained by unpacking the current definitional debate and describing 2 common frailty models. A clinical case study is introduced to illustrate the use of frailty screening tools. We draw from the case study to discuss strategies and nursing interventions aimed at improving care, including understanding the “geriatric giants” of immobility, instability, incontinence, and intellectual impairment. 4,5 Interventions including cautious consideration of common critical care practices such as sedation, bed rest, fasting, and frequent monitoring; care planning and early involvement of interdisciplinary clinicians; and emphasizing communication such as goals-of-care conversations and end-of-life considerations are explored.6

Understanding Frailty: Conceptual Approaches and Related Tools

Frailty is an evolving field of inquiry and there are diverging viewpoints about how frailty should be defined and identified. Although frailty is a complex concept and definitional discrepancies exist, in general, frailty can be understood simply as a multisystem, multidimensional clinical state (or syndrome) that increases a person’s risk of experiencing serious adverse outcomes, including morbidity and death, when compared with nonfrail people of the same age, when exposed to stressors (eg, hospitalization, illness, injury).7-9 The cause of this clinically significant condition is not fully understood; however, it is thought to be an age-related cycle of chronic multisystem inflammation, metabolic dysfunction, muscle wasting, and undernutrition.10 Disease may also contribute to the onset of frailty.2 Such complexity in the physiological underpinnings of frailty syndrome has contributed to difficulty establishing clear definitional consensus. Frailty is a progressive process that leads to diminished physiologic reserve and impaired capacity to respond to even mild stressors.

The prevalence of frailty increases with age and may affect up to one-half of people older than 85 years.7 Patient populations with chronic illnesses and disabilities also experience more frailty.11 In critical care areas, frailty has been identified in 21% to 40% of patients12-16 and has been associated with increased occurrences of serious and significant adverse events, including procedural complications, delirium, functional decline and disability, prolonged recovery and length of stay in the hospital, and higher readmission rates.1,10,12,13,16,17 Mortality is also a significant risk; compared with nonfrail patients, frail patients who are admitted to intensive care units (ICUs) have higher in hospital mortality rates and poorer overall survival rates after discharge.2,14,15

The concept of frailty has developed with considerable debate as to what specifically frailty is. Without consensus about its constituents, the screening and assessment of frail patients is similarly debated.9 Separate screening and assessment tools have been developed from different frailty models and in differing patient populations and care settings. Frailty in the critical care context is becoming increasingly recognized as a significant concern. Identifying frailty is essential because it provides critical information about a patient’s prehospital (or preprocedure) status and risk profile.7,15

Afilalo et al1 estimated that there are more than 20 different frailty screening and assessment tools, ranging from comprehensive 70-item measures to single-item performance tests. However, the discussion here is limited to the predominant models of frailty and 2 related screening measures: the Frailty Phenotype (FP) and the Frailty Index (FI). Though both of these models recognize aging and disease as contributing factors, and both highlight diminished physical capacity as a major attribute of frailty, the models diverge on how other factors such as comorbid conditions, disabilities, and psychosocial aspects should be considered.18,19

Frailty Phenotype

Fried and colleagues2 used data from a large prospective study of men and women aged 65 years and older to define the FP. The authors identified 5 key characteristics of a frailty syndrome largely related to pathophysiological sarcopenia9: exhaustion, unintentional weight loss (ie, shrinking), decreased physical activity, slowness, and weakness. From their research findings, Fried et al2 argued that assessing and scoring each of the 5 individual components are reliable ways to identify frailty. Using the 5 assessment criteria outlined in the Table, frailty syndrome is likely present if a person scores poorly on 3 or more measures. People with poor scores on 1 or 2 criteria are likely intermediately frail or prefrail.2

Table Frailty Phenotype: frailty criteria and related measures2

Phenotype criteriaMeasurement examples
Is this person exhausted?Consider exhaustion if the patient reports “a moderate amount of time” or “most of the time” when asked about the frequenc of experiences relating to 2 Center for Epidemiological Studies-Depression scale statements: “I felt that everything I did was an effort” and “I could not get going.”
Is this person losing muscle mass/shrinking?Ask about more than 10 lb of unintentional weight loss in the last year.
Is this person moving less?Look for diminished activity levels. Calculate the kilocalories expended per week on different activities (eg, as described in the short version of the Minnesota Leisure Time Activity questionnaire) and compare to sex-specific targets.
Is this person slow?Measure time taken to walk 15 ft and compare time to sex and height standards.
Is this person weak?Measure grip strength using a dynamometer and compare to sex and body mass index standards.

The FRAIL Screen

FRAIL is a mnemonic that can be used as simple screening strategy to quickly identify patients who may be at risk of frailty and who likely would benefit from further assessment.17,18,20,21 Using  standardized questions (eg, “how much of the time in the past 4 weeks did you feel tired?”; “Do you have more than 5 illnesses?”; “Have you lost more than 5% of your weight in the last 6 months?”), health care professionals ask about fatigue, resistance, aerobic ability, illness, and loss of weight. The FRAIL screen most closely reflects phenotypic measures of frailty, although inclusion of comorbid conditions is an exception.

The simplicity of the FRAIL screen is an advantage for use in critical care contexts. Charted health histories or family member inputs may be used to answer questions for patients who are unable to answer themselves. However, some FP screening and assessment measurements may be challenging for routine use in critical care environments. For example, Afilalo et al1 described a “floor effect”; that is, patients who are unable to carry out tests such as a timed walk or grip strength, because of acuity, sedation, analgesia, or other limiting factors, may not be accurately measured. Similarly, the FRAIL screen could be limited for people with physical disabilities who may not be able to easily answer standard ambulation questions such as “By yourself, and not using aids, do you have difficulty walking several hundred yards?” or “Can you walk a block?” Ensuring the availability of measurement equipment (eg, dynamometers), maintaining consistency in how tests are delivered, clarifying who conducts the tests (eg, critical care nurses, specialist geriatric nurses, physicians), and coordinating the documentation may also present challenges for the use of FP assessment measures in critical care practice contexts.

Conceptually, the FP model explicitly distinguishes frailty from comorbidity and disability. Instead, the FP situates comorbid conditions as risk factors for frailty and describes disability as an outcome of frailty.2,22 This distinction is central to the definitional debate that is ongoing in current literature and this positioning of comorbid conditions and disabilities in relation to frailty is different from the FI conceptualization.9 The FI uses a broader definition of frailty, considers a multitude of factors in the determination of frailty, and underpins different screening and assessment approaches, which provide other options for use in critical care areas.

Frailty Index

The FI is also called the deficits accumulation approach, because it is a numeric count of individuals’ health deficits. An FI value is calculated by identifying the presence and grading severity and/or frequency of deficits, which include a range of variables that are relevant to any particular population, such as diseases and physical conditions, disabilities and mobilization capacity, and psychological and neurologic considerations. 3,8,23,24 The presence of a deficit can be given a value of 1; absence is counted as 0. Each variable can also be scored with a fractional value (eg, 0, 0.33, 0.50, 0.67, or 1.0) to indicate partial presence, severity, or frequency.3 The sum is then divided by the total number of things counted. For example, if 25 deficits are identified from a list of 100 possible health deficits, the total (25) is divided by the maximum possible sum (100), producing an FI value of 0.25. People with FI values of no higher than 0.03 are considered relatively fit; values greater than 0.03 to no higher than 0.10 are described as less fit; values greater than 0.10 to no higher than 0.21 are called least fit, and FI values greater than 0.21 suggest frailty.24 At least 30 total health deficits should be assessed to calculate an FI.8

Although Rockwood and colleagues3 found that the FI is a reliable and valid predictor of frailty, the FI model has not been widely adopted in acute care settings, perhaps, in part, because assessing deficits requires use of a skill set and is often done as part of a comprehensive geriatric assessment; indeed, the expertise of a geriatric specialist may be needed. In critical care practice contexts, access to the skills and time required to determine an FI value may be limited. Thus, the use of the FI as an assessment of frailty in critical care may be challenging. In recognition of these practical barriers, the Clinical Frailty Scale (CFS; see Figure) has been proposed and used as a rapid frailty-screening approach that relies on clinical judgment and offers a potentially useful tool in critical care practice contexts.

Clinical Frailty Scale

Building from their conceptual work with frailty and the FI, Rockwood and colleagues3 developed the CFS. Relying on clinical judgment, the CFS is a simple 9-point frailty scale that ranks patients from very fit to terminally ill. The screening tool provides short, descriptive definitions and images representing physical capacity. Clinicians determine a CFS score using available clinical information. Rockwood et al3 evaluated the CFS and found the judgment-based tool to be similarly effective to other frailty tools including the FI.

Using Frailty Screening Tools

Recognizing frailty in patients with acute illness can be challenging.25,26 Oversized hospital garments and absent dentures can vastly change a patient’s physical appearance. Small body size can also create a “skinny bias” wherein patients may mistakenly appear frail.25 Frailty should be screened from a patient’s prehospital status and functioning (eg, 2 weeks before hospitalization or illness). When patients are unable to provide their own prehospital histories, consider using family members’ input.

Case Study

Mrs J is an 80-year-old woman admitted to the ICU with respiratory failure secondary to pneumonia and exacerbation of chronic obstructive pulmonary disease. In the emergency department, she experienced acute shortness of breath and required ventilatory support and intubation. Paralytics, intravenous analgesics, and sedation were administered. She arrived in the ICU receiving full respiratory support. Her medical history includes osteoporosis; she uses a cane to walk and occasionally requires a wheeled walker. On assessment, Mrs J is a cachexic woman who appears her stated age. Her fingers are slightly clubbed and her chest is barrel shaped. Lung auscultation reveals scattered wheezes throughout.

When choosing a screening tool, consider how obtainable the information will be (eg, subjective historical descriptions about fatigue, activity, and body weight changes). Also consider screeners’ familiarities with tool techniques (eg, standardized questions to screen the FRAIL items). Practically, the CFS is a good fit for critical care because it is fast and easy to use, does not require special measurement equipment, may serve as its own documentation tool, and nurses, other nongeriatric specialist practitioners, and junior colleagues can use the tool with minimal training.27,28 The FRAIL screen is similarly simple and does not require special measurement equipment. Some training may be required to learn the standard questions for each item; health care professionals’ comfort and skills with the screening tool should be considered.

Critical care nurses often collect the prehospital clinical information needed for the CFS through their usual provision of holistic care and attention to multiple issues, including physical, mental, and psychosocial circumstances. Through discussion with the patient and the family, or through exploration of medical records, information about the patient’s prehospital, baseline status is often obtained. Such information underpins creation of realistic and relevant care plans and may also allow frailty screening scoring.

Mrs J’s husband described her recent status at home. He said his wife had been feeling increasingly unwell and she frequently complained of fatigue and breathlessness. She had fallen recently and was participating less in her usual activities. He expressed worry about her declining appetite and observable weight loss. From his verbal details, it is determined that Mrs J needs help with most activities and struggles with stairs. Using the icons on the CFS screening tool, Mr J pointed to how he thought his wife looked about 2 weeks ago. Her history matches with a frailty score of 6 on the CFS, suggesting moderate frailty. Using the FRAIL screen approach, fatigue, resistance, and weight loss are identifiable from Mr J’s history (ie, score is 3 out of 5). Findings from both screening methods suggest frailty may be present. A fuller assessment should be considered.

Optimizing Care for Patients With Frailty

Before admission, Mrs J’s history included a progressively deteriorating physiologic status. Screening indicated likely frailty, so she should be fully assessed (eg, FP or FI assessment). Therefore, it should be considered that compared with people the same age, Mrs J faces an increased risk of experiencing poor outcomes related to her acute chronic obstructive pulmonary disease exacerbation and current hospitalization. The concept of frailty is still developing; therefore, evidence to support the use of specific interventions in relation to the FRAIL screen and CFS scores is lacking.9 However, integration of geriatric best practices may benefit patients like Mrs J. Awareness and prevention of the geriatric giants in critical care nursing; inclusion of interdisciplinary experts in care planning to support early mobility, nutritional, and reduction of polypharmacy; and goal-focused communication, including late-life and end-of-life care, planning should be incorporated.

Geriatric Best Practices

Immobility, instability, incontinence, and intellectual impairment4,5 make up the geriatric giants. Because they can potentially result in falls, deconditioning, pressure injuries, and skin breakdown, these challenges pose significant risk to older adults with frailty.29 In addition to care goals around stabilization of Mrs J’s acute chronic obstructive pulmonary disease exacerbation, nursing care of Mrs J also should include considering risks and benefits of routine critical care practices such as bed rest; urinary catheterization; intermittent fasting (eg, related to blood work and other tests); sedation and analgesic use during intubation; polypharmacy; and sleep disruptions related to monitoring protocols and noise.

These common nursing practices in critical care can hurt frail patients by contributing to adverse outcomes, including deconditioning, catheter-acquired infections, dehydration, and delirium. For example, avoidance or minimization of the use of sedatives, particularly benzodiazepines, is important.30 Overuse of sedation may prolong the duration of ventilatory support, in turn leading to increased risk of ventilator-acquired pneumonia; extend immobility, in turn leading to increased chance of skin breakdown, pressure injuries, and functional decline; and heighten incidence of delirium.31

Mrs J’s nursing care plan should focus on nutrition optimization, delirium prevention, initiation of early mobility to maintain functional status, avoidance of pressure injuries, and reduction of polypharmacy.32 These care goals have been described in the ABCDEF bundle, which recommends assessment and prevention of pain; breathing trials (awakening and spontaneous) for weaning mechanical ventilation; choice of analgesia and sedation; delirium assessment, prevention, and management; early mobility and exercise; and family engagement.33 Nutritional support, including caloric and protein supplementation, has been recommended.18 Patients in critical care are commonly fed via gastric feeding tubes; therefore, heightened awareness of the importance of early uninterrupted feeding and avoidance of a nothing-by-mouth order are necessary to prevent dehydration and exacerbation of malnutrition.34 To best address the multifaceted causes of frailty, engagement with interdisciplinary professionals (eg, physiotherapists, occupational therapists, social workers, dietitians, pharmacists) and geriatric outreach or specialty services should be maximized.29,35

Communication

Goal-focused communication, including late-life and end-of-life care, is important for patients with critical illness and frailty. Although frailty should not be interpreted as a reason to withhold treatment-focused care, frailty may provide a cue for health care professionals to engage in goals-of-care conversations, advance care planning, and discussions of end-of-life preferences.1,36 Because frailty is associated with increased mortality, critical care nurses should consider that patients and families may be in the late-life and/or final stages of life and attention to end-of-life care and conversations should be considered.14

Summary

As our population ages and people are living longer with complex comorbid conditions and disabilities, understanding the effect of frailty in acute critical illness is essential. Critical care nurses should understand what frailty is, know how to screen for it using a frailty tool such as the FRAIL screen or CFS, and be familiar with geriatric best practices to minimize frailty-related risks, including functional decline and disability, morbidity, and death.

Financial Disclosures

Jennifer Gibson received training funding from the Canadian Frailty Network (previously, Technology Evaluation in the Elderly Network), supported by Government of Canada through Networks of Centres of Excellence Program. Sarah Crowe has no funding or financial disclosures.

References

1. Afilalo J, Alexander KP, Mack MJ, et al. Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol. 2014;63(8):747-762.

2. Fried LP, Tangen C, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Med Sci. 2001;56(3):M146-M147.

3. Rockwood K, Song X, MacKnight C. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489-495.

4. Isaacs B. The Challenge of Geriatric Medicine. New York, NY: Oxford University Press; 1992.

5. Crome P, Lally F. Frailty: joining the giants. CMAJ. 2011;183(8):889-890.

6. Misiaszek BC. Geriatric Medicine Survival Handbook. Hamilton, ON, Canada: McMaster University School of Medicine; 2008.

7. Muscedere J, Andrew M, Bagshaw S, et al. Screening for frailty in the Canadian health care system: a time for action. Can J Aging. 2016;35(3):281-297.

8. Rockwood K. Conceptual models of frailty: accumulation of deficits. Can J Cardiol. 2016;32(9):1046-1050.

9. Afilalo J. Conceptual models of frailty: the sarcopenia phenotype. Can J Cardiol. 2016;32(9):1051-1055.

10. McDermid R, Bagshaw S. Scratching the surface: the burden of frailty in critical care. Intensive Care Med. 2014;40(5):740-742.

11. Bagshaw M, Majumdar SR, Rolfson DB, Ibrahim Q, McDermid RC, Stelfox HT. A prospective multicenter cohort study of frailty in younger critically ill patients. Crit Care. 2016;20(1):175.

12. Kizilarslanoglu MC, Civelek R, Kilic MK, et al. Is frailty a prognostic factor for critically ill elderly patients? Aging Clin Exp Res. 2017;29(2):247-255.

13. Bagshaw SM, Stelfox HT, McDermid RC, et al. Association between frailty and short- and long-term outcomes among critically ill patients: a multicentre prospective cohort study. CMAJ. 2014;186(2):E95 E102.

14. Heyland D, Cook D, Bagshaw S, et al. The very elderly admitted to ICU: a quality finish? Crit Care Med. 2015;43(7):1352-1360.

15. Hope AA, Gong MN, Guerra C, Wunsch H. Frailty before critical illness and mortality for elderly medicare beneficiaries. J Am Geriatr Soc. 2015; 63(6):1121-1128.

16. Le Maguet P, Roquilly A, Lasocki S, et al. Prevalence and impact of frailty on mortality in elderly ICU patients: a prospective, multicenter, observational study. Intensive Care Med. 2014;40(5):674-682.

17. van Kan GA, Rolland Y, Bergman H, Morley J, Kritchevsky S, Vellas B. The I.A.N.A. task force on frailty assessment of older people in clinical practice. J Nutr Health Aging. 2008;12(1):29-37.

18. Morley JE, Vellas B, Abellan vK, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392-397.

19. Levers M, Estabrooks C, Ross Kerr J. Factors contributing to frailty: literature review. J Adv Nurs. 2006;56(3):282-291.

20. van Kan GA, Rolland YM, Morley JE, Vellas B. Frailty: toward a clinical definition. J Am Med Dir Assoc. 2008;9(2):71-72.

21. Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012;16(7):601-608.

22. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004;59(3): M255-M263.

23. Rockwood K, Mitnitski AB, MacKnight C. Some mathematical models of frailty and their clinical implications. Rev Clin Gerontol. 2002;12(2):109-117.

24. Rockwood K, Song X, Mitnitski A. Changes in relative fitness and frailty across the adult lifespan: evidence from the Canadian national population health survey. CMAJ. 2011;183(8):E487-E494.

25. Afilalo J. Frailty in patients with cardiovascular disease: why, when, and how to measure. Curr Cardiovasc Risk Rep. 2011;5(5):467-472.

26. Salter ML, Gupta N, Massie AB, et al. Perceived frailty and measured frailty among adults undergoing hemodialysis: a cross-sectional analysis. BMC Geriatr. 2015;15:52.

27. Gregorevic KJ, Hubbard RE, Lim WK, Katz B. The clinical frailty scale predicts functional decline and mortality when used by junior medical staff: a prospective cohort study. BMC Geriatr. 2016;16(1):117.

28. Juma S, Taabazuing M, Montero-Odasso M. Clinical frailty scale in an acute medicine unit: a simple tool that predicts length of stay. Can Geriatr J. 2016;19(2):34-39.

29. Rockwood K, Fox RA, Stolee P, Robertson D, Beattie BL. Frailty in elderly people: an evolving concept. CMAJ. 1994;150(4):489-495.

30. Devlin J, Peelen L, Slooter M. Benzodiazepine-associated delirium: further considerations. Intensive Care Med. 2016;42(9):1517-1518.

31. Pisani M. Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population. Crit Care Med. 2009;37(1):177-183.

32. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.

33. Ely EW. The ABCDEF bundle: science and philosophy of how ICU liberation serves patients and families. Crit Care Med. 2017;45(2):321-330.

34. Martindale R, A.S.P.E.N. Board of Directors, American College of Critical Care Medicine. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: executive summary. Crit Care Med. 2009;37(5):1757-1761.

35. Lupón J, González B, Santaeugenia S, et al. Prognostic implication of frailty and depressive symptoms in an outpatient population with heart failure. Rev Esp Cardiol. 2008;61(8):835-842.

36. Bagshaw SM, Stelfox HT, Johnson JA, et al. Long-term association between frailty and health-related quality of life among survivors of critical illness: a prospective multicenter cohort study. Crit Care Med. 2015;43(5):973-982.

CCN FAST FACTS
Frailty in Critical Care: Examining Clinical Implications


Frailty is an aging-related, multisystem clinical state characterized by loss of physiological reserves and diminished capacity to withstand exposure to stressors. Adverse outcomes can be severe and may include procedural complications, delirium, significant functional decline and disability, prolonged hospital length of stay, extended recovery periods, and death. As older adults make up a continually growing proportion of hospitalized patients, critical care nurses need to understand how to recognize frailty and be familiar with related clinical practice implications.

■ Identifying frailty is essential because it provides critical information about a patient’s prehospital (or preprocedure) status and risk profile.

■ The predominant models of frailty are the Frailty Phenotype (FP) and the Frailty Index (FI).

■ The FP model includes 5 key characteristics of a frailty syndrome: exhaustion, unintentional weight loss, decreased physical activity, slowness, and weakness. Frailty is likely present if a person scores poorly on 3 or more measures.

■ The FI is a numeric count of individuals’ health deficits. An FI value is calculated by identifying the presence and grading severity and/or frequency of deficits, which include a range of variables such as diseases and physical conditions, disabilities and mobilization capacity, and psychological and neurologic considerations.

■ Immobility, instability, incontinence, and intellectual impairment make up the geriatric giants. Because they can potentially result in falls, deconditioning, pressure injuries, and skin breakdown, these challenges pose significant risk to older adults with frailty.

■ Consider risks and benefits of routine critical care such as bed rest, urinary catheterization, intermittent fasting, sedation and analgesic use during intubation, polypharmacy, and sleep disruptions. These practices can hurt frail patients by contributing to adverse outcomes, such as deconditioning, catheter-acquired infections, dehydration, and delirium.

■ To best address the multifaceted causes of frailty, engagement with interdisciplinary professionals (eg, physiotherapists, occupational therapists, social workers, dietitians, pharmacists) and geriatric outreach or specialty services should be maximized.

■ Although frailty is not a reason to withhold treatment-focused care, frailty may provide a cue for health care professionals to engage in goals-of-care conversations, advance care planning, and discussions of end-of-life preferences.

■ Critical care nurses should understand what frailty is, know how to screen for it, and be familiar with geriatric best practices to minimize frailty-related risks.

Gibson JA, Crowe S. Frailty in critical care: examining implications for clinical practices. Critical Care Nurse. 2018;38(3):29-36.

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