Frailty Matters

Last week’s British Medical Journal draws attention to the growing literature confirming that the intensive care unit (ICU) is a perilous environment for frail older people. A position piece written by an intensivist, a geriatrician, a professor of critical care, and a “patient and public representative,” argues there is a mismatch between the supply and demand for intensive care and that increased public awareness of what admission to the ICU does—and does not—mean for patients and their families is the key to addressing the problem.

Leaving aside whether the proposed solution, public education, has the slightest chance of working, I decided to have a look at the research papers on which the position piece was based. The first article, from Scotland and published in Critical Care Medicine, deals with “Health-Related Quality of Life After ICU.” The results, in a nutshell, are that what determined how well people did after discharge from the ICU in terms of both mental and physical functioning was affected far more by how well they functioned before they got sick than how sick they were when hospitalized.

The second article, based on patients in 311 ICUs in 21 European countries published in Intensive Care Medicine, found that among people over age 80, the greater the degree of frailty, the higher the 30-day mortality. In patients who, prior to admission, were not frail the 30-day survival was 76 percent; in the “pre-frail” group it was 71 percent, but in the frail group, it was 59 percent.

The importance of these studies is not so much the numbers they report—although I thought that a 30-day survival rate of 59 percent in frail octogenarians was not bad—as their emphasis on physical functioning. We in the U.S. continue to pay little attention to frailty. The Europeans, evidently, do pay attention to frailty. In part, the reason for the difference is that Europeans actually assess frailty while Americans, to a large extent, do not. We are still fighting over how best to measure and record it. The final takeaway from these articles is that the specific scale the Europeans use is so easy to use that the researchers did not have to teach physicians, patients, or families how to use it: it’s self-explanatory.

Forget about American exceptionalism. Let’s adopt the tool in use in the much of the rest of the developed world.

Ove-Lite

Think “A Man Called Ove,” Fredrik Backman’s bittersweet novel about a lonely man who tries repeatedly and unsuccessfully to commit suicide but ultimately finds meaning in life by helping others. Water down Ove-- take away his rage against injustice and dilute his frustration with modern technology. Make him 85 instead of 59-going-on-80. Preserve the pet cat, the needy neighbor, and the enduring love for his deceased wife. What you get is the protagonist of Elizabeth Berg’s new novel, “The Story of Arthur Truluv.” The book is a sentimental portrait of another octogenarian, Arthur Moses, nicknamed “Truluv” by the lost teenager he befriends because of his devotion to his wife, whose grave he visits daily. 

It’s high time we had more fictional treatments of older people, so I’m happy we have another contribution to the genre. And Truluv is an endearing old fellow with a big heart—albeit one apparently affected by heart failure. He, unlike Ove, is a glass-half-full sort of a fellow, whereas Ove, at least until the end of his story, is a glass-with-a-hole-in-it sort of a guy. While I appreciate that Berg does not completely sugar coat old age, giving both Arthur and his neighbor Lucille an assortment of maladies and expeditiously killing off Lucille’s elderly boyfriend with a massive heart attack, Arthur is so nice that he’s a bit hard to take. His teenaged friend Maddy, pregnant and estranged from her father, needs both a job and a place to stay? No problem, Arthur lets her move in and serve as his housekeeper. The irksome woman across the street, whose main virtue is her baking skill, decides she’d like to move in, too? Fine, she can do the cooking. Maddy hasn’t seen her father in months and secretly would like to reconcile with him before she gives birth? Arthur intuits what’s going on and invites him for Thanksgiving dinner. 

I’m a pushover for over-the-top amazing octogenarians, so I confess I enjoyed reading this book. It’s short—222 small pages, peppered with dialogue—so I only had to devote a few hours of my life to this endeavor. Maybe I would have liked it more if I hadn’t recently read “A Man Called Ove,” a tragicomic masterpiece with a protagonist who seems old even if he isn’t, a NY Times bestseller that has been translated into 43 languages. But maybe Elizabeth Berg will next turn her talents to writing about an octogenarian who is frail but who nonetheless finds meaning in life. Now that would be a major contribution to the literature on aging.