S4: Frailty Flashcards
Concept of frailty
Frailty is a practical, unifying notion in the care of elderly patients that directs attention away from organ-specific diagnoses towards a more holistic viewpoint of the patient and their predicament.
Definition: Frailty is a state of increased vulnerability to poor resolution of homoeostasis after a stressor event, which increases the risk of adverse outcomes, including falls, delirium, and disability.
- Poor physiological reserve (homeostatic mechanisms don’t work as well).
- Drop in function is more dramatic with same stressor compared to non-frail individual (going from independent to dependent functioning) and baseline threshold of function is not reached during recovery from stressor in a frail individual.
Prevalence rate of frailty
Community
- 9·9% for frailty 44·2% for pre-frailty.
Inpatient
- 5% -10% of all people attending ED.
- 30% of patients in acute medical units (AMU) are older people with frailty.
Pathophysiology of frailty
Frailty is a disorder of several inter-related physiological systems. A gradual decrease in physiological reserve occurs with ageing but, in frailty, this decrease is accelerated decline and homoeostatic mechanisms start to fail .
- Genetic and environmental factors -> Lead to cumulative molecular and cellular damage –> reduced physiological reserve –> Physical activity and nutritional factors determine if frailty occurs.
Describe sarcopenia in frailty
- Sarcopeniais the degenerative loss of skeletal muscle mass quality, and strength associated with aging.
- Itis a component of the frailty syndrome.
- More subcutaneous fatty tissue.
- Can be measured really easy on CT scan and esearch into if CT + sarcopenia can be used as a marker for poor outcomes during surgery.
- (0.5–1% loss per year after the age of 50).
Outcomes of frailty
- Frailty is more predictive of many adverse outcomes than chronological age.
- Increased risk of death
2%, 23%, and 43% for the not frail, pre-frail, and frail groups, respectively at 7 years (Fried 2001). - Increased risk of delirium and decreases life expectancy with delirium (Odds ratio [OR] 8·5 and median survival in frail elderly patients with delirium 88 days, median survival in non-frail elderly patients with delirium 359 days).
- Longer length of stay.
- More likely to go to a care home.
- More at risk of surgical complications.
Association between frailty and dementia
People with low amount of frailty are better able to tolerate Alzheimer’s disease pathology. Higher amounts of frailty people are more like to have more Alzheimer’s disease pathology and it is more likely for it to be expressed as dementia.
Two internationally recognised models of diagnosis of frailty
- Cumulative deficit model 2. Phenotype model
Describe Frailty Phenotype Model (Freid 2001)
5 components of frailty: 1. Slow Walking Speed (Timed up and Go Test TUGT used to measure). 2. Self Report Exhaustion. 3. Sedentary Behaviour. 4. Unintentional Weight loss (>10lbs in last year). 5. Reduced muscle strength (hand grip). Criteria for frailty: - >3 = Frail - 1-2 = Intermediate Frailty
Describe Cumulative Deficit Model (Rockwood 2005)
The cumulative deficit model, which identifies frailty on the basis of a range of variables that include symptoms (e.g. memory problems), signs (e.g. tremor), disease states, disabilities and abnormal laboratory values, collectively referred to as deficit. This state of increased risk of adverse health outcomes is indistinguishable from the idea of frailty, so deficit accumulation represents another way to define frailty.
- 32 baseline variables (was initially 90). Symptoms e.g low mood, Signs e.g. tremor, Disease states, Abnormal laboratory values and Disabilities.
- Simple calculation to create score. The more individuals have wrong with them, the more they are likely to be frail.
- Allows frailty to be gradable at a spectrum, rather than present or absent.
- Difficult to use clinically.
Other tools used to diagnose frailty
- Clinical frailty scale.
- Emotional frailty scale. This is difficult to use clinically.
- Electronic frailty index. - Currently being used in GP practices and each category is weighted for the impact it has on frailty.
- PRISMA 7.
- Self reported health questionnaires.
Describe clinical frailty scale
Rockwood devised a pictorial representation of frailty and it correlates with cumulative deficit model with higher reliability. It is also easier to use clinically. 1 - very fit. 2- well. 3 - managing well. 4 - vulnerable. 5 - mildly frail. 6 - moderately frail. 7- severely frail. 8 - very severely frail. 9 - terminally ill.
What is used to diagnose frailty clinically?
Most scores validated in OP or community settings means its practical:
- Walking speed.
- Clinical Frailty Scale 6+ (NHS improvement).
- Presenting 65+ with a frailty syndrome.
- Frailty: Age 65+ AND presenting with one or more frailty syndromes (confusion, Parkinson’s disease, presenting with fragility fractures and/or falls, care home residents) OR people aged 85+ unless their need is best met by a single organ team
AND/OR
Moderate or severe frailty (grade 6-9) using the Canadian Frailty Scale .
Describe frailty syndrome/geriatric giants
- Instability (falls): Collapse, found lying on floor, trip.
- Immobility : ‘Off legs’. Unable to get up from chair or bed.
- Impaired Cognition: Delirium or Dementia.
- Incontinence: Change in continence (urine or faeces).
- Susceptibility to side effects: New hypotension with previously tolerated anti-hypertensives. Confusion with codeine.
List frailty interventions
CGA
NHS improvement
New GP contract (medication and fall review)
Advanced care planning (those with severe frailty may want to give them the opportunity to discuss what their priorities are now)
Describe CGA (Comprehensive geriatric assessment)
A process of good, holistic care delivered within a geriatric medicine focused MDT, which goes above and beyond simply managing the acute problem the person has presented with. It is focused on determining a frail elderly person’s medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long term follow-up. 4 components of CGA:
- Physical: Nutritional status, Medication review.
- Functional: Mobility, Activities daily, Role in life e.g. Grandma, reader
- Psychological: Mood, Cognitive impairment.
- Socioeconomic / environmental: Loneliness, Housing.
- Those who underwent CGA were more likely to be alive and less likely to have physically deteriorated. Also, more likely to have less dependency.
At six months from assessment: NNT = 17 to avoid death or deterioration and NNT = 20 to avoid institutionalisation.
