leicester medical school understanding frailty simon conroy senior lecturer/geriatrician prague 2009

Leicester Medical School

Understanding frailty

Simon ConroySenior Lecturer/Geriatrician

Prague 2009

Understanding frailty

The holy grail of geriatric medicine

• Early identification of frailty

• Identification of ‘pre-frail’

• Possibility of early interventions

Frailty according to Fried

• Sarcopaenia– lowest quintile for hand-grip strength

• Exhaustion– I felt that everything I did was an effort– I could not get going

• Nutrient–energy imbalance– self-reported unintentional weight loss of ≥ 5kg in the

previous year• Slowness

– slowest quintile for the time required to walk 2.4 meters• Low physical activity

– lowest quintile for energy expended per week in leisure-time physical activities

3/5 – frail1-2/5 – pre-frail0/5 – non-frail

Frailty according to SOF

• Study of Osteoporotic Fracture Index– Weight loss– Inability to rise from a chair five times

without using the arms– Reduced energy (answer of “no” to the

question “Do you feel full of energy?” on the Geriatric Depression Scale)

2/2 – frail1/2 – pre-frail0/2– non-frail

Problems with frailty rating scales

• Frailty is dynamic• Reliability• Test population: SOF only validated in

women• Limited in scope• BUT, CHS scale has been used in

biological studies• No interventional studies as yet1

1. Fairhall N, Aggar C, Kurrle SE, et al. Frailty Intervention Trial (FIT). BMC Geriatrics 2008;8:27.

Frailty interventions

1. Screen – SOF/CHS

2. Assess – expanded frailty index

3. Intervene - ??

Biology of Ageing

Oxidative stress

• Reactive oxygen species (ROS) damage to DNA, proteins and lipid within ageing muscle cells → sarcopaenia

• ROS levels associated with low grip strength & mortality

• Candidate modifiable risk factors– smoking– dietary intake of carotenoids, ascorbate, selenium,

plant polyphenols– exercise

Genetics

• Few studies have looked at genetic determinants of frailty• Multiple genes known to affect ageing or single or multiple

domains of frailty– DNA methylation/folate– Insulin/IGF1– Vitamin D– WRN helicase and lamin A (premature ageing)– Sirtuin genes– Antioxidants (superoxide dismutase, glutathione peroxidases)– Cardiovascular modifiers e.g. NO, RAS– Neurocognitive ageing e.g. ApoE

• May identify pathways amenable to intervention

Vascular ageing

Hypertension

Cerebrovascular diseaseSub-clinical CVD

Frailty

Frailty & human geography

• Links with neighbourhood deprivation

• Access to services

Some unanswered health services research questions

• Frailty & quality of life (Sealy Centre on Aging, Texas)

• Frailty, social networks & carer strain• Frailty & cognition• Frailty and access to services• Frailty and health service resource use• Frailty in ethnic minorities• Delivering coordinated health care to frail

older people

Operationalising frailty

• Frail older people should receive integrated comprehensive geriatric assessment– Increased living at home (OR 1.7)– Reduce functional decline (RR 0.76)– Reduce NH admissions (RR 0.66)

• Yet increasing primary & secondary health care split…

Operationalising frailty

• Aged 70+• Patients with a fracture, who are

medically unstable• Care home resident (nursing or

residential)• Confusion (dementia or delirium)• Other patients scoring over 25 on the

Waterlow Score

ED attendances

N=1723

3% frail, 70+

57% adults

25%children

10%Frail

63%70+

AMU bedoccupancy

15%aged 70+

75%

76% medicine19% EDU

40%

74% medicine26% otherspeciality

18%

Admission ratesfrom EDN=534

31%

AFU outcomes, 4/10/8-27/10/8, n=171

949/520818%

2988/631747%

AMU discharge

rate

196/52084%

52/6317<0.01%

AMU mortality

166/94917%

496/298817%

30 day readmissions

239/94925%

691/298823%

90 day readmissions

25/17115%

AFU dischargerate

3/1712%

AFU mortality

13/2552%

90 day readmissions from AFU

~1035admissions

in total:171/1035=17%

Summary

• Frailty core business

• Not well understood

• Large collaborative studies required

• Translational aspects critical

Děkuji!