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A little over a decade ago, Ken Covinsky wrote a GeriPal post about a Jack Iwashyna JAMA study finding that older adults who survive sepsis are likely to develop new functional and cognitive deficits after they leave the hospital. To this day, Ken’s post is still one of the most searched and viewed posts on GeriPal.

This idea that for critically ill patients in the ICU, geriatric conditions like disability, frailty, multimorbidity, and dementia should be viewed through a wider lens of what patients are like before and after the ICU event was transformative for our two guests today.  Julien Cobert just published a study in Chest finding that even after accounting for the rising age of patients admitted to the ICU, rates of pre-existing disability, frailty, and multimorbidity increased over about a ten year period. Rise in these conditions occurred over a decade – what happens over the next 10, 20, 30 years?  

And Lauren Ferrante has found in a study published in JAMA Internal Medicine that trajectories of disability in the year prior to ICU admission were highly predictive of disability post-ICU, on the same order of magnitude as mechanical ventilation.  In a separate study in Chest, Lauren found pre-ICU frailty was associated with post-ICU disability and new nursing home admission.  Lauren uses her magic wand to address the measurement issue: we’re not measuring function, frailty, and cognition routinely in hospitalized older adults.  We wouldn’t dream of not measuring oxygen saturation, yet function, which is highly predictive of outcomes older adults care about, many hospitals hardly measure.

Additional links:

And a note- on the podcast you’ll hear a drum track on the song (!).  I’m taking lessons with an audio producer in LA who is helping me to learn some new Logic Pro post-production skills.  Bear with me!  I’m having fun working on these songs from home during COVID.

Eric: Welcome to the GeriPal Podcast, this is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: We are delighted to welcome back to the GeriPal Podcast, Lauren Ferrante, who’s an intensivist and aging researcher at the Yale School of Medicine. Welcome back to GeriPal Podcast, Lauren.

Lauren: Thanks for having me, Alex and Eric, happy to be here.

Alex: And we’re delighted to welcome you to the GeriPal Podcast, Julien Cobert, who is an intensivist and aging researcher GeriPal Podcast, Julien.

Julien: Thanks Alex, thanks Eric. It’s great to be here.

Eric: So we’re going to be talking about aging in the ICU. Talking about some of the research you guys have done around disability, dementia and frailty, multimorbidity in the ICU. But before we go into that topic, Julien, I think you have a song request?

Julien: I do. So I haven’t heard much grunge on this podcast, so I wanted to request Chris Cornell, Like a Stone, and I also want to see if Alex can reach the towering vocals of Chris Cornell.

Alex: Yeah, I’m not sure. We’ll find out. Good question.

Eric: Aside from the lack of grunge, is there another reason you picked this song?

Julien: Yeah. Chris Cornell is one of my favorite musicians. Audioslave is also one of my favorite bands, but I think to me, the song, while it might sound a little bit depressing, it’s actually sneakily hopeful, so I just think it’s a really poetic song, and I like listening to it.

Alex: All right, here we go.

Alex: (Singing)

Eric: You rocked that one, Alex.

Lauren: That was awesome.

Julien: That was amazing

Julien: When I closed my eyes, I actually thought this is an actual recording of Chris Cornell. It was amazing. It was really, really crazy.

Alex: When did he die?

Eric: A while back, right?

Julien: Four years ago.

Alex: Yeah. I want to say like 2017, 2018, something like that. Really sad.

Eric: So many people from that grand era. Lead singer Alice in Chains.

Alex: Or was it Temple of the Dog. He was in Audioslave, Soundgarden.

Julien: And then he had a bunch of solo stuff after. Some people thought that this was written when the Alice in Chain lead singer, who I’m forgetting died, that he wrote this song. But anyway, I think it’s a hopeful song. I like it.

Eric: Well, we’ll get a little bit more of the song at the end of the podcast. Let’s dive into what we’re going to be talking about: Aging in the ICU. I’m going to turn to you Lauren. How did you get interested in this subject about the aging population in the ICU and the geriatric conditions?

Lauren: That’s a great question. I don’t actually have a specific case. In my residency program at Columbia, New York City, and I think it was just a series of patients. And I noticed that I was taking care of older adults more and more, or maybe I just noticed it more. And I was thinking a lot about what happens to them afterwards, because as you know, in the ICU, we just see them during their critical illness and then they’re off to the floor and at least that’s the end of my interaction with them. And it was around this time that some landmark papers came out that earlier, before this podcast, Julien had alluded to the trends and this literature that’s evolved over the past decade. And this was around the time that Jack Washington’s landmark paper came out in JAMA. And I just remember it speaking to me and being like, “Yes, this is exactly what I’m interested in.” And I really-

Eric: What was that paper?

Lauren: It was the one where he looked at, it used HRS Data to actually look at long term functional and cognitive outcomes actually among older adults in the hospital about 40% were in the ICU. I was a resident at the time. A lot of us I think just realized it was really relevant. It was in sepsis patients realized it was very relevant to the ICU. And when I went into residency, I didn’t realize I was going do critical care. I decided while I was at resident. And then once I was in, I was in and even when I was interviewing for fellowship, I knew this was what I wanted to do.

Eric: How about you, Julien?

Julien: Yeah. There was no single moment where I started to really think about where I wanted to basically dedicate my research career to thinking about how we approach older patients in the ICU and what their lives look like after. It was this slow build, I would say. So I do remember one of these moments in medical school where I was going down this very specific track of internal medicine and which I ended up doing, but I remember this moment where I was with a surgeon in a patient’s room whereby basically after the surgery or IntraOp, they found more metastases than they had thought and post-operatively, they basically avoided the surgery post-operatively when rounding, we went to the patient’s room and I distinctly member, I was like a second year medical student at Duke where we did our rotations earlier.

Julien: He basically had an end of life care discussion with this patient. And it culminated in him giving a bad light to the patient in the hospital room because that was the only semblance of normalcy for this patient. And it just really struck a chord and stuck with me. And basically ever since then, I’ve been thinking a lot more about how we approach these conversations, what lives look like before and after. And that eventually led me to start asking some of these questions, but that’s just a memorable moment that I just distinctly remember. And then when I did residency in internal medicine first, there was just a lot of focus on a lot of heroic management in the ICU that didn’t always appeal to me without thinking about what the morbidity might look like. So it’s just carried with me through time.

Alex: If I could just interject briefly with a couple of reflections on what you both said, the first regarding Julian, your experience of bringing the beer in Shunichi Nakagawa, who’s a palliative care doc at Columbia recently tweeted, “When a patient requests to drink cold ice water before removing high flow nasal cannula to withdraw life support. That will be the last one in his life. Don’t thicken it, make sure he gets what he wants. Don’t ask anybody. It won’t take long, go get it by yourself.” And that has 34,000 likes, which for a palliative care tweet is beyond what other tweets have achieved.

Eric: Yeah. He, his Twitter feed though is brilliant.

Alex: Yeah. Its highly recommended @snakagawa_md and we’ll put the link to that in the post associated with this. And then just going back to what Lauren was saying about Jack Washington’s paper in JAMA, that was such a seminal paper. Ken Covinsky wrote about it for GeriPal. Back then we were a blog and Ken’s post, which is titled, Survival from Severe Sepsis: The infection is cured, but all is not well, is still one of our most viewed posts on Jerry Powell. Severe sepsis is a syndrome marked by a severe infection that results in one organ failure.

Alex: What happens when people survive? When patients leave the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits. As you said, Lauren, that paper really just crystallized for people. It’s not just about the ICU. And we’ve talked with the West Ely about his realization that this is about so much more than just the ICU care. What happens afterward is profoundly influenced by the experience of critical illness in the intensive care setting. So just wanted to interject Lauren looks like you had a follow up there.

Lauren: Yeah. It’s funny because as our program has grown, we have a lot of studies in the ICU, but also in the post-ICU space. And I’ve had people ask me why I’m doing that because I’m an intensivist and there’s actually some controversy around this, like my scope of practice is the ICU… Not even my scope of practice, no one uses that word, but just like, why am I trying to fix these or address these problems. But I think of it’s really the continuum of care. And I think we all have to be thinking about post ICU recovery, not just when we’re having these important conversations in the ICU, but as the person goes to the floor, as they go home, what can we all do to help these patients recover? So I’m glad you brought that up.

Eric: Well, let’s go into the topic a little bit. I think there’s three really important papers I want to talk about. Where we are right now? What do we know about the functional trajectories and what happens after people leave the ICU? Julien, let’s start off with, congratulations by the way and Lauren too, the CHEST paper that just got published on Trends in Geriatric Conditions Among Older Adults in the ICU between 1998 and 2015. Tell me a little bit, first of all, before we talk about what you found in this, why did you do this study?

Julien: It’s a good question. So a lot of the ideas that I have and had looking at older adults in the ICU, it really stems a lot from Lauren’s work. Quite honestly, her papers are amazing work, led to some of these questions and full discloser Lauren was a collaborator on this study. So, basically the original intention that I had was how are patients doing post-ICU stay? How are older adult patients doing post-ICU stay when they’re coming in with various pre-existing geriatric conditions. And before we even could answer that question, I had to take a step back and just simply ask the question of how many older adults are coming in with preexisting geriatric conditions and are those changing over time before we can even look at the outcomes and the implications based on those outcomes. So, this is not necessarily a new idea.

Julien: And you really emphasize this is now 10 years ago, how you really have to understand and think about the pre-existing conditions and functional status of patients in order to understand the implications of morbidity in survivors. So that led us to really just ask the question of how have disability, frailty, dementia, and multimorbidity at the time of ICU admission in older adults changed over the last decade plus and where are we now?

Julien: So we isolated older adults, 65 and older. That’s how we defined it, using the health and retirement study. And we basically looked at first, all the patients who had pre-existing geriatric conditions at their first ICU admission and just tabulated that, and then adjusted for various other covariants and then we finally ended up finding that at the end of our study period, which ended up being 2015, just because we didn’t have the more recent data until very recently now, that a quarter of these older adults had preexisting disability, nearly half were frail using our definition, adapted from the literature and three quarters had multimorbidity again, how we defined it. And I thought that was pretty striking.

Eric: Yeah. Why do you think that is? Why are these numbers increasing? Is it that disability for LT multimorbidity is either increasing the population or we’re coding it better, or it’s HRL data or is it just the population that we’re caring for in the ICU is having in general, like we’re selecting for sicker and sicker patients or more frail patients.

Julien: Yeah. I think it’s a great question. I don’t know, quite honestly, but I think what might be happening is the patients who we are admitting, and by the way, all of this is probably changed with COVID, but-

Julien: I think one part of it, and I’m really curious to hear what Lauren’s thoughts are, is that I think we’re doing a really good job preventing patients from coming into the ICU, especially compared to the start of our study period, which is in the late nineties, early odds. I think we’re probably managing sicker patients on the floor. I think we have to developed our transitional care units and step down units pretty well. I think we’re probably shunting different patient populations through the ICU now, compared to what we were doing previously.

Julien: I think that there are some interesting patterns that we saw in this study whereby the rates of pre-existing dementia and cognitive impairment didn’t really change, age did increase, but not substantially roughly about a year. So I am guessing that it may have to do with how we’re managing these patients on the floor and potentially even preventing certain critical illness or managing more critical illness in these transitional care units compared to what we were doing before. That’s just one hypothesis.

Eric: What do you think, Lauren?

Lauren: Yeah. In addition to what Julien saying, I do think the aging of the population does have something to do with it. The population’s aging overall, and as you know a lot of these geriatric conditions, we know that their prevalence increases with age. Think about the original, like Linda Fried’s original paper, right? Where she has each of the age categories and you see the prevalence of frailty increasing. That said, I think we, and I mean collectively, not just in critical care, I think we as a healthcare system, I think we’re really good at keeping people alive. And so the combination of the two results in an increasingly older population in the ICU, that’s going to have a higher prevalence of geriatric conditions.

Lauren: Now, of course, that’s really important for everyone to know. I think this is such a great paper, Julien, because everybody knows that the population is aging, right? You hear this all the time. And we figured that the prevalence of these conditions would be increasing as the population ages, but now you’ve gone ahead and you’ve shown it. And so we can take that as now that this is known, this is demonstrated. And this is something we ought to be thinking about as we care for these patients.

Alex: Yeah. And the paper, the mean age of the population over this 11 year time period rose about a year. And a year actually has a profound effect on outcomes we’re looking at. But over that 11 year period, if you were a ICU critical care physician, the average ICU critical care physician saw that 15% of their patients had pre-existing disability at the beginning of the time period. And by the end, it was 24%. And that frailty was 36% at the beginning up to 45% at the end. And multimorbidity 54% up to 72%. So huge increases just over that about a decade.

Alex: So where are we headed? What’s going to be the future in you know, 10 years from now, 20 years from now. Certainly as you say, Lauren, we’re doing more and more to keep people alive, longer and longer. And we’re building critical care facilities and filling them. And certainly we can take care of patients at more advanced ages. And we have to be careful, cautious against ageism here. And that in fact, we probably could have done more for some select patients who are critically ill in the intensive care unit. On the other hand, there is one story that bucks the trend, which is dementia, did not change significantly over the time period. It remained relatively flat. So also curious what your thoughts about why these other conditions rose but not dementia.

Julien: Yeah. We did also control for age as another element to this, and we still saw these increases. I totally agree with Lauren. The baseline patient population is aging and it would’ve been, I think much more straightforward if after adjusting for age, literally everything was stable. By looking at the dementia, the dementia data and the cognitive impairment data, which essentially did not change over time. I am wondering whether it’s the conversations and preparation that’s primary care providers and outpatient providers are having with a lot of these patients and families to either prevent an ICU admission or potentially address their goals, such that they don’t go into the ICU. I keep on coming back to other, we are just doing a better job. Better might be the wrong word here, but we’re changing how we’re managing these patients before they even come to the ICU. And that is affecting the patients that we’re admitting to the ICU.

Alex: So you didn’t say advanced care planning there, but you used all of the other words, but which is of course, a controversial topic right now, given Sean Morrison’s commentary and colleagues, commentary and JAMA about advanced care planning.

Eric: I got a question because it was a ways back, but we did a podcast on keep your hands to yourself from a JAMA IMR article that showed that use of mechanical ventilation for nursing home residents with advanced dementia doubled between 2000 and 2013, that was a John Tino study. How do I reconcile these two issues?

Lauren: I’m glad you brought that up because I was actually going to add that onto what Julien said that even though the rates of dementia haven’t gone up and I do think it’s because of what Julien said. I think there’s so much more, that’s known now about Alzheimer’s and out in the general public, hopefully providers are having these conversations, but we can’t really take too much comfort in it because of those findings that you just mentioned by John Tino. They’re among the patients who are admitted to the ICU who already have advanced dementia, it seems like the intensity of care is increasing over time.

Lauren: What I’m about to say is based more on personal observation than data, but it just seems like we’re selecting for a population where either it’s not so much the patient, right at that stage, they can’t really express their wishes, but where the family or some confluence of factors where there isn’t actually a surrogate who could speak with the patient’s voice results in more aggressive care happening than I think many of us think should happen. So, maybe the person with advanced dementia is coming in from the nursing home and nobody can find the living will from however many years ago.

Lauren: And then in the ED, you intubate and then you figure it out later or the patient never had an advanced care planning document and now the family’s making the decision and it’s really hard to watch your loved one die. Even if you think you anticipated this moment before, there’s a lot of literature out there about there’s advanced care planning. And then there’s what happens in that moment. And so I think what we’re seeing is a number of different reasons and you’re just selecting for people where they end up getting more aggressive care.

Eric: And Lauren, it sounds like frailty, disability, multimorbidity are all increasing in the ICU. And this stems from a lot of the work that you’ve done, what do we know about what happens after the ICU? What are the outcomes? Not just mortality, but disability.

Lauren: Yeah, that’s a great question. And actually I’m glad you said, not just mortality but disability, because then all of our work and based on others work where like Terri Fried’s work where older adults have expressed that function is their most important outcome. That’s why disabilities always our primary outcome for most of this post-ICU work. So, for the two studies, I’ll mention, we use data from the precipitating events project at Yale, which is Tom Gill’s amazing cohort, where they followed a cohort of initially non-disabled community dwell and older adults with monthly measures of function. And so the key there is, of course these were prospectively measured where patients were called every month from 1998 through actually the present day among those who are still alive. And then we linked that cohort with administrative data, which allowed me to pull out the ICU admissions in addition to manually abstracting all of the paper data for the managed Medicare participants.

Lauren: So we have this nice ICU cohort that has monthly functional measures before and after the ICU admission. And so what we learned from one of our earlier papers is that the functional trajectory where you’re characterizing function for the entire year before and the entire year after, when you look at the pre-ICU functional trajectory, that’s strongly associated with how the person does afterwards in terms of their trajectory of disability and also with death. And I actually, although everyone tends to look at the curves in that paper, I think that for those of us practicing the most helpful figure is the probability table, because it really tells you what is your probability based on how you’re coming in, of being on a certain functional trajectory after you leave this ICU.

Lauren: And so if you look the group that comes in with minimal disability where they have, I think the mean disability count before the ICU is less than one, their chance of ending up severely disabled after an ICU, admission is quite low. It’s only about 13%, although 12% of them have early death. But your probability of a really bad outcome is about 25%. Whereas if you’re coming in with some accelerating, moderate level of disability or probability of poor outcome, meaning a bad disability trajectory or death is much higher. And then there’s this group at the top, that’s coming in very severely disabled heading into the ICU and unsurprisingly, many of them will die. And among those who survive, they’re not going to get better, they stay on that trajectory of severe disability.

Lauren: And although that latter point might seem obvious, that’s pretty important in talking to patients, if you’re admitting someone to that ICU, who’s truly just completely disabled and pretty much every task of daily living and other activities. You can use that when you’re talking to families about prognostication. So, what we learned from that is that how well you’re functioning and the year leading up is really important in terms of how your functional trajectory afterwards and also survival.

Eric: And what was early death in that study?

Lauren: That was death within 30 days. But as a secondary outcome, we also looked at one year mortality and for the secondary outcome of one year mortality, we found that the effect size or the pre-ICU functional trajectory was basically the same as the need for mechanical ventilation. We try to make that point because it speaks to especially ICU providers, we know how bad that is.

Alex: I love the way you did that to put the finding in context for the people who you’re trying to this to. I think it was similar to… wasn’t it both mechanical ventilation and was it sepsis?

Lauren: Shock.

Alex: Shock. Yeah.

Lauren: Yeah. I think everyone really understood. Especially like we were talking about before with John Tino’s findings, like we all really understand mechanical ventilation, so that’s why we usually frame it that way. And then Eric, you asked about follow up work. So looking at frailty, we used the same cohort with the monthly measures of function. But for this, in the pep cohort, they also went into patient’s homes every 18 months and did these very comprehensive assessments, including Fried frailty once it was available. And so we pulled out those-

Alex: Remind our listeners, the Fried frailty. I always have to remind myself what are the different frailty indices what’s covered in that one?

Lauren: Yes. That’s a great question. So it’s a five component scale and it includes slow gate speed, weak and grip strength, exhaustion, unintentional weight loss, and low physical activity, which I really like thinking about those components. Because when you picture that in your mind, it’s easy to think about what a frail person might look like, but I just want to say it’s still so important to measure frailty, because it really drives me crazy when I’m in the ICU and someone just says, someone looks frail. I have this figure that I use when I give talks. It was inspired by another, I want to say ,Sean Bagshaw, where if you take any older adult, you put them under a white hospital sheet, you could say, they look frail and then you take off the sheet and it’s actually like a marathon runner, something that’s really robust-

Alex: That’s a good-

Lauren: Actually it’s very important to measure frailty, but those are the five components for the Fried Frailty Index. There are different frailty measures, that could be a topic for a whole other podcast, but-

Eric: We did a podcast with Linda Friedman

Lauren: Really?

Eric: We talked all about this stuff.

Eric: Yes.

Eric: But I always have to remind myself.

Alex: Yes. And we did one with Tom Gill about the precipitating events project back in 2017, early days for us when he talked about restricting symptoms and hospice. And also we talked about how did he keep his remarkable cohort going during that time? And he requested Stairway to Heaven. Okay. Back to Lauren about [inaudible 00:32:11].

Eric: Yeah. So what happens are we seeing similar stuff with frail patients in the ICU?

Lauren: Yeah. Well, not exactly. So it’s really interesting. So we looked at the… Again this cohort is such a wealth of data because these are prospectively measured frailty assessments, right? Usually when the ICU we have inception cohorts and we have to try to measure something or there’s this chance of recall bias and frailty. If you can’t really get up and walk the critically ill older adult across the ICU to measure school gate speed. So we have these prospectively measured pre-ICU frailty assessments. And what we found was that the association with post-ICU disability count. So again, the monthly disability count over the six months after discharge, the frailty was strongly associated with that. So I want to say that frail patients had a 41% increased burden of disability and the pre-frail patients had a 28% increased burden of disability. So, that part was not surprising.

Lauren: Although again, still thinking about what that means for an individual older adult is really important. And to that end, we had two secondary outcomes in this study. The first one was the risk of new nursing home admission, going along with this whole idea of an older adult losing independence. And so for that frailty was associated with that outcome, but not Fried frailty. And then we also looked at the risk of death and this was really interesting. We have Kaplan Meier Curves in the paper and you see that the frail group drops off and there’s this increased risk of death or increased hazard of death. But the pre-frail and the non-frail groups run exactly together along the risk of death was not that much greater among the pre-frail. And it’s really interesting because if you look at other studies like using other cohorts, like one out of Canada and they’ve used the clinical frailty scale, they have similar like Kaplan Meier Curves where it’s the really frailty that’s driving that risk of mortality and frailty, we’re not seeing it as much.

Eric: So I got a question. So we’re seeing increased trends for frailty multimorbidity population is aging in the ICU. We’re also seeing, not great outcomes after the ICU for a lot of these folks. Although again, some variation. Should we argue that, we should really think about who we’re admitting to the ICU or is it arguing that we should be doing something different in the ICU? Or do we just not know yet what we’re supposed to be doing with this data, Julien, what are your thoughts?

Julien: I like this question. I think it’s really, really complicated. I think that we’re only starting to understand and stratify patients whether they’re older adults, not based on frailty and functional status and things that are no longer about mortality, which is my favorite part about all of these questions, because we’re starting to think a little bit more about patient centered outcomes. Quite honestly, I think… Sorry, let me actually go back to your question. Your question was, what do we make of this data and how should we be thinking about managing patients in the ICU or whether they should even go to the ICU?

Julien: I think that we should definitely be asking questions about patient goals, family goals, and trying to ensure that everything that we do is goal concordant, especially, and that starts… Well, it starts for me about whether they should even enter the ICU itself. It probably should start even before then. It’s interesting to think about early in the pandemic, there was the guidelines out of Europe. Nice guidelines out of Europe were asking the question about who should enter the ICU. And there was a lot of controversy about taking it under consideration the frailty of the patient as a determination of whether they might benefit from ICU care or the ICU admission itself, which is pretty controversial. I think that we’re only starting to understand how some of the management decisions that we make in the ICU will impact morbidity and functional status in older adults.

Eric: We just had Wes Ely on a podcast talking about all the things that he’s done around this. And it just reminds me of man, I get a little frail every time I walk in the ICU, it’s beeping, it’s buzzing, it’s loud. You hear all these conversations around you, because it’s open. You can’t even close a door very well. It’s a deliriogenic environment. And in part it’s hard to get around that because all the alarms that are going off, not even in your room, but elsewhere and people aren’t being… There’s not as much PT, OT going on. I loved our Wes Ely podcast because maybe we should be changing the way we think about how we care for older adults and really anybody in the ICU. Lauren, what are your thoughts on that?

Lauren: Yeah. So I do agree with that. I do want to circle back to your other question that you guys were just talking about before I answer that, which is to say that we actually have a big measurement problem. And I think we’re far from being ready to decide based on these geriatric conditions, who should-

Eric: What’s the measurement problem?

Lauren: You… The measurement problem is nobody’s measuring these factors regularly. So again, we can have someone who says, “I think that person looks frail.” But maybe the guy was running two miles a day. I’m exaggerating here, but perhaps it’s someone who’s really robust, but right now we don’t have routine frail team measurements. We don’t have routine measures of functional status when the person’s admitted to the hospital or the ICU or shows up in the ED. So how could we possibly make any decisions about who’s admitted without even knowing who has which geriatric conditions? So the way I put that together is I do think it’s important for us to assess for disability and functional activities, frailty, cognitive impairment. Absolutely.

Lauren: A lot of times we don’t have that information until the person’s already in the ICU, but then we can use that information to guide treatment preferences and continue in conversations with the patient and family, if the patient’s able to participate. So at least in my practice, that’s often how this has happened, unless these conversations have taken place beforehand, either in the emergency room or with primary care providers.

Julien: Lauren, I totally agree with you. I think we’re only starting to understand some of this data and what’s striking to me is that when you go back to the beeping and buzzing alarm studies and trying to make one environmental modification and looking at outcome changes, I haven’t seen really great evidence that these individual small interventions are making a huge dense on some of our outcomes of interest. What I think is the data does show much more of… Is that these bundles of care, we use one like A, B, C, D, E, F, which is commonly employed in a lot of ICUs. It seems to have a better effect on some of the outcomes that we’re looking at.

Julien: But every time we look at one of these individual interventions, we’re not always seeing what we want to see. And I think it probably has to do with a huge part of that problem has to do with how we’re measuring really the measurement problem that like you’re saying. I think we’re only starting to acquire this data and it’s going to take a lot of time to figure out which specific interventions will match to the right patient populations. But right now, all we have is the bundle seems to work…

Julien: Like sepsis 20 years ago and it’s what is happening in the operating room literature on enhanced recovery after surgery literature, 10 years ago. Bundles seem to work every time we take away a part of that bundle though, as the culture changes, we’re not seeing a huge negative effect. So I think it’s going to take some time for us to get to that point where we have a much more nuanced understanding of these measurements.

Alex: Before Eric gets to his magic wand question, and we wrap it up. This is my last question. I want to give each of you a chance to just give us a preview of what you’re working on now, maybe starting with Lauren.

Lauren: Sure. So, well, I’ll start since Julien just mentioned that A, B, C, D, E, F bundle. So we actually are working in a few different areas, but with most relevant to that is we’re actually working to build a geriatrics bundle that we can kind of build onto A, B, C, D, E, F because to your point, my observation has been that in the ICU bundles and checklists have been really effective over the years, right? If you think all the way back to the checklist from 20 years ago, and then the bundle to your point, I think we still have work to do on implementation of the bundle as a practice, as critical care specialty, but we’re working to develop. So we’ve just completed a pilot study that was funded by the Pepper Center Network.

Lauren: And then in terms of outcomes, we’re starting to explore things that are probably hopefully even more modifiable. So things like social domains and coming out soon, we actually have a COVID cohort of older adults who are hospitalized with COVID that study just completed follow up will be presenting some of those results called the Valiant Study. So, and I’ll just mention those three things since they’re relevant to some of the topics we’ve talked about.

Alex: Okay, Julien – what are you working on?

Julien: I’m still very early in my research career. Alex is one of my mentors and he’s trying to rein me in, but I think I’ve become particularly interested in what Lauren’s describing as the measurement problem. And I’m trying to find different ways of measuring certain things. So I’ve gone down a path of looking at unstructured data within ICU notes, using natural language processing, to understand how we are measuring some of these impairments, but more so how we talk about these patients and how we potentially think about these patients and how we are communicating that in the words that we write in notes. And I’m particularly interested in how we think palliative care measures and metrics using unstructured notes. So that’s one of my buckets, but I’m also continuing a lot of this work using the HRS, potentially looking at what positive features could be impacting, not only mortality outcomes, but morbidity outcomes in ICU survivors.

Eric: Right? My last question, the magic wand is running out of battery. So it has to be a short one. If you had a magic wand to fix anything pre, during or post-ICU, geriatrisize any of it or to deal with this issue, what would you use that on? Lauren.

Lauren: I would love to have functional assessments on everyone before they enter the hospital or ICU. I want them built into the EMR and done on everyone in the whole country. All the time.

Eric: Like functional assessment is more than just this person looks a little frail.

Lauren: Right? No, measurement of it’s not that hard to do actually. Ken Covinsky has shown that others have shown this, right? You just ask about disability and activities of daily living, ideals and mobility.

Eric: Julien, it’s got a little bit of power left. What are you going to use that magic wand on?

Julien: I want aggressive physical therapy and occupational therapy for every single one of our patients all the time, multiple times a day.

Eric: While they’re ventilated in the ICU, would you do that too?

Julien: Absolutely. All the above.

Eric: Great. And I really want to encourage people to … Wes Ely writes beautifully about that in his book. Oh shoot. I’m blinking on the title. You got to hear somewhere, Alex. You remember

Lauren: Every Deep-Drawn Breath.

Alex: There you go.

Lauren: We do mobilize people in the ICU. Our program sticks out of seven days of the week.

Eric: Well, how about we get a little bit more Audioslave, Alex before we end this podcast.

Alex: All right, here we go.

Alex: (singing)

Eric: Hey Julien, I got to ask. You said you feel like this was more of an optimistic song. For me, no. You have an old man waiting in a house alone waiting for his death.

Julien: I didn’t want to admit this, but I actually just sent a quick chat to Lauren that said maybe this song might have been a little too depressing [laughter]. I think the author is trying to reconnect with the people that he or she has lost. And I think that there’s a sense of hope despite waiting for one’s death and death does not have to be this hopeless event.

Alex: That’s nice on Valentine’s day as we’re recording this on Valentine’s day.

Julien: Yeah. Happy Valentine’s day.

Lauren: I said, I think it’s a beautiful song actually. I didn’t know it beforehand but I actually really love it. I think it’s really pretty.

Eric: Well. Julien, Lauren, thank you for being on our podcast.

Lauren: Thanks so much for having us. This was really fun.

Julien: This was great. Thank you so much.

Lauren: Thank you.

Eric: Great. Thank you to the Archstone Foundation and to all our listeners.

Alex: Bye everybody.

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