Frailty, Palliative Care Needs, and Outcomes in Older Survivors of Critical Illne

描述(由申请人提供)：理由：65岁及以上的美国人占所有重症监护病房(ICU)入院人数的一半以上。随着技术的进步，许多危重的老年人现在活了下来，这些疾病以前是致命的，但在出院后的前6个月里，残疾和死亡率仍然很高。我们需要更好地了解如何对患者进行风险分层，并确定最适合在ICU后护理期间(包括ICU后急性护理、急性后设施护理或出院后家庭护理)进行姑息、康复和/或治疗干预的患者。候选人：作为哥伦比亚大学的肺部重症监护内科医生和医学助理教授，PI发表了一项原创性研究，表明虚弱是一种无法测量的表型，可能有助于风险分层 老年ICU幸存者接受ICU后干预。PI的长期职业目标是成为一名独立的临床调查员，将重症监护和老年医学领域整合到一个新的职业利基领域，致力于在护理过渡期间提高老年ICU幸存者的生活质量和存活率。职业发展：PI的短期目标是获得老年和姑息治疗评估方面的正式培训，学习先进的统计建模和流行病学方法，并获得临床试验实施方面的专业知识，同时接受老年学、姑息治疗和肺部危重护理领域的领导的多学科指导。环境：哥伦比亚大学已承诺提供充足的资源来支持这一提议，包括使用NIH-CTSA资助的欧文临床研究所，以及最近为PI颁发的KL2培训奖。研究：我们的目标是通过两种方式推进老年人ICU后医学这一新兴领域。首先(目标1)，我们将对老年ICU呼吸衰竭幸存者进行前瞻性单中心队列研究，以(1A)确定出院前一周测量的虚弱是否与1个月和6个月的6个月死亡率和残疾独立相关，以及(1B)测量他们出院前一周的姑息护理需求。AIM 1将导致新的基于脆弱性的风险分层模型，该模型可能有助于识别ICU后干预的老年ICU幸存者，并将产生关于老年ICU幸存者姑息治疗需求的新知识，这反过来将告知研究人员、临床医生和政策制定者需要将姑息治疗的哪些方面更好地纳入ICU后急性护理。其次(目标2)，我们将在预期出院前一周，在虚弱的老年呼吸衰竭ICU幸存者及其代理人中试行ICU后姑息护理咨询干预。AIM 2将提供可行性数据和效果大小估计，为设计一项针对老年ICU幸存者的ICU后姑息护理干预试验的Futue R01提案提供参考。通过进行这些研究，PI将解决老年ICU幸存者的各种需求，同时获得所需的专业知识，以成为一名独立调查员，领导旨在改善这一快速增长的虚弱老年人口的生活质量和生存的临床研究和试验。

DESCRIPTION (provided by applicant): Rationale: Americans age 65 and older comprise more than half of all intensive care unit (ICU) admissions. With technological advances, many critically ill older adults now survive what were previously fatal illnesses, but disability and mortality in the first 6-months after hospital discharge remain high. We need to understand better how to risk-stratify and identify patients most suitable for palliative, rehabilitative, andor therapeutic interventions in the post-ICU care period (which includes post-ICU acute care, post-acute facility care, or home care after hospital discharge). Candidate: As a pulmonary-critical care physician and Assistant Professor of Medicine at Columbia University, the PI has published original investigations that suggest frailty is an unmeasured phenotype that may help risk-stratify older ICU survivors for post-ICU interventions. The PI's long- term career goal is to become an independent clinical investigator who integrates the fields of critical care and geriatrics into a novel career niche dedicated to improving the quality-of-life and survival of older ICU survivors across care transitions. Career Development: The PI's short term objectives are to obtain formal training in geriatric and palliative care assessments, to learn advanced statistical modeling and epidemiological methods, and to gain expertise in clinical trial conduct while receiving multidisciplinary mentorship from leaders in the fields of gerontology, palliative care, and pulmonary-critical care. Environment: Columbia University has committed abundant resources to support this proposal including use of the NIH-CTSA funded Irving Institute for Clinical Research, and the recent KL2 training award for the PI. Research: We aim to advance the burgeoning field of post-ICU medicine for older adults in two ways. First (Aim 1), we will perform a prospective single-center cohort study of older ICU survivors of respiratory failure to (1A) determine whether frailty measured during the week before hospital discharge is associated independently with 6-month mortality and disability at 1 and 6 months, and to (1B) measure their palliative care needs during the week before hospital discharge. Aim 1 will lead to novel frailty-based risk-stratification models that may help identify older ICU survivors for post-ICU interventions, and will generate new knowledge about the palliative care needs of older ICU survivors that in turn will inform investigators, clinicians, and policymakers about what aspects of palliative care need to be better incorporated into post-ICU acute care. Second (Aim 2), we will pilot a post-ICU palliative care consultation intervention among frail older ICU survivors of respiratory failure and their surrogates during the week prior to anticipated hospital discharge. Aim 2 will provide feasibility data and effect size estimates that will inform the design of a futue R01 proposal for a post-ICU palliative care intervention trial in older ICU survivors. By pursuing these studies, the PI will address the spectrum of needs of older ICU survivors while garnering the expertise needed to emerge as an independent investigator who leads clinical studies and trials aimed at improving the quality-of-life and survival of this rapidly growing population of debilitated older adults.