Centre for Research in Geriatric MedicineCentre for Research in Geriatric Medicine Centre for Research in Geriatric Medicine FRAILTY IN OLDER INPATIENTS Associate Professor Ruth E

Centre for Research in Geriatric Medicine


FRAILTY IN OLDER INPATIENTS

Associate Professor Ruth E. HubbardBSc, MBBS, MRCP, MSc, MD, FRACP

21st October, 2016


Objectives

1. Describe and compare frailty measures

2. Consider frailty in relation to failure of a complex

system

3. Review importance of frailty in older surgical patients


Tomorrow’s Objectives

1. Review a new instrument to measure frailty in routine

practice

2. Discuss limitations and potential pitfalls of frailty



BACKGROUND


Context: As people get older, they are

more likely to die

0 10 20 30 40 50 60 70 80 90 1000

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0 10 20 30 40 50 60 70 80 90 100

0.002

0.007

0.018

0.050

0.135

0.368

Age (years)

The R

ate

of

Mort

alit

y (

1/y

)

Log scale

Gompertz’s Law

Mortality rate is a measure of the number of deaths in some population,

scaled to the size of that population, per unit time.

xx Re)(


How a system’s components are

arranged may affect the rate of failure

A string of Christmas tree lights

Electricity supplied to many rooms in

a house simultaneously

Organs

Tissues


How do systems prevent failure?

Living systems: redundancy

– The great merit of this is that we can quantify it with deficit

accumulation

Machines: QC of individual parts


Failure kinetics of systems with different

levels of redundancy

From Gavrilov &

Gavrilova Sci Aging

Knowlege Env, 2003

http://sageke.sciencemag.org/content/vol2003/issue28/images/large/282003re5F10.jpeg



HOW DOES THIS RELATE TO

FRAILTY?


What is frailty?

Frailty has been defined as a state of increased

vulnerability to stressors

A frail individual has reduced physiological reserve and

reduced ability to compensate for disruptions to

homeostasis

Increased risk of:

– Disability

– Institutionalisation

– Death


How can frailty be measured?

Understanding frailty has become the focus of extensive

research

The associations of frailty are now well described

However, little is known about how frailty can be

assessed in hospital inpatients

3 main approaches

– Clinical syndrome or phenotype

– Subjective opinion

– Multidimensional risk state


Definitions

Clinical syndrome: a set of signs and symptoms

Lists and algorithms derived from clinical judgment

Combinations:– Physical inactivity and weight loss (Chin a Paw, 1999)

– Gait speed, peak expiration, hand grip, sitting position, visual impairment (Klein, 2005)

– Fatigue, resistance, ambulation, illness, loss of weight (Abellanvan Kahn, 2008)

– Age, sex, daily drugs use, sensory deficits, physical inactivity, calf circumference, independent activities of daily living, gait and balance, pessimism about one’s health (Ravaglia, 2008)


Fried phenotype

The most well known and widely used phenotype

Criteria

– unintentional weight loss of 10 lbs or more in past year

– self reported exhaustion

– weak grip strength

– slow walking speed

– low physical activity


Question 1

In older people, which is the strongest predictor of future disability?

Weight loss

Muscle weakness

Slow walking speed

Cognitive impairment

Results

https://my.showgizmo.com/conferences/1643/events/49581/polls/1329/presentation?token=ea2456c4dbb21b6c


Fried phenotype

Strengths

– Clinical coherency

– Reproducibility

– Wasting disorder with sarcopenia as pathophysiological feature

Weaknesses

– Omission of mood and cognition

– Selection of initial cohort

– Dichotomous/ trichotomous outcome

– Reliance on performance based tests


Fried phenotype in clinical practice

Hubbard et al., Age and Ageing 2009


Subjective opinion

“We know it when we see it”

Visual estimation of biological age

– a checklist of age-associated changes in appearance,

communication and mobility.

– Good inter-rater agreement

Global measures

– Studenski et al, JAGS 2004

– Rockwood et al, CMAJ 2005


Clinical Frailty Scale

Rockwood et al., CMAJ 2005


CFS in clinical practice

5764 admissions

through ED

>75 years

CFS an independent

predictor of in-patient

mortality, transfer to

Geriatric Ward and

long LOS.


Subjective opinion in clinical practice

Such measures have strong

face validity

But limited generalisability

They rely on judgement

– which varies between

clinicians and between health

systems

and depend on geriatric

expertise

– e.g. accurate assessment of

functional status


Dangers of “eye-balling”

Frailty ≠ cachexia

Frailty ≠ comorbidity but ≈ comorbidity

Frailty ≠ polypharmacy

Hubbard et al., J Gerontol Biol Med Sci 2010


Deficit accumulation

Frailty = multidimensional risk state

Can be measured by quantity rather than by the nature

of health problems

Various disorders are accumulated by individuals during

their lives

The more deficits that are accumulated, the more likely

that person is to be frail

Rockwood and Mitnitski, 2001


Deficit accumulation

Deficits can be symptoms, signs, diseases, disabilities, abnormal laboratory measurements

– Accumulate with age

– Associated with adverse outcome

– Do not saturate

– Cross different domains

– Use same items longitudinal data

FRAILTY INDEX

Minitski et al., 2001; Searle et al., 2008


Frailty Index

Frailty indices can be constructed from different numbers and types of variables

36,424 older people– FI values closely comparable across countries

– increasing with age at approximately 3% per year in community-dwellers

– correlating highly with mortality (Mitnitski et al., 2005)

Risk of adverse outcomes defined more precisely by deficit indices than by chronological age (Romero-Ortuno and Kenny, 2012)


Failure kinetics of systems with different

levels of redundancy

From Gavrilov &

Gavrilova Sci Aging

Knowlege Env, 2003

http://sageke.sciencemag.org/content/vol2003/issue28/images/large/282003re5F10.jpeg


Mean a

ccum

ula

tion o

f deficits

65 70 75 80 85 90 95

ALSA

CSHA-screen

CSHA-exam

NHANES

NPHS

SOPS

Breast cancer

CSHA-inst

Myoc Infarct

US-LTHS

H70-75

0.1

0.2

0.3

0.5

1.0

0.05

Age (years)

Clinical and institutional samples, n=2,573

The slope is ~0.03Community samples

n=33,559

Deficits accumulate differently between groups but

similarly within groups


50 60 70 80 90 100 110 120 130 140 150

1

Age

0.670.60.50.4

0.3

0.2

0.1

0.01

Fra

ilty I

ndex

English Longitudinal Study of Ageing

Hubbard et al., in progress


Jeanne Calment 1875 - 1997


Question 2

Of the top ten verified oldest living people in the world, how many are men?

0

1

3

6

Results

https://my.showgizmo.com/conferences/1643/events/49581/polls/1329/presentation?token=ea2456c4dbb21b6c


Ageing and the Sex-Frailty Paradox

0 0.1 0.2 0.3 0.4 0.50

0.2

0.4

0.6

0.8

1

0 0.1 0.2 0.3 0.4 0.50

0.2

0.4

0.6

0.8

1

B

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

Death

rate

0 0.1 0.2 0.3 0.4 0.50

0.2

0.4

0.6

0.8

1

0 0.1 0.2 0.3 0.4 0.50

0.2

0.4

0.6

0.8

1

Frailty index

B

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

Fra

ilty

index

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

Death

rate

0 0.1 0.2 0.3 0.4 0.50

0.2

0.4

0.6

0.8

1

0 0.1 0.2 0.3 0.4 0.50

0.2

0.4

0.6

0.8

1

B

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

Death

rate

0 0.1 0.2 0.3 0.4 0.50

0.2

0.4

0.6

0.8

1

0 0.1 0.2 0.3 0.4 0.50

0.2

0.4

0.6

0.8

1

Frailty index

B

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

Fra

ilty

index

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

Age (years)

65 70 75 80 85 90 95

0.1

0.2

0.4

0.05

A

Death

rate

Centre for Research in Geriatric MedicineCentre for Research in Geriatric Medicine

FRAILTY & COMPLEX

SYSTEM FAILURE


Geriatric giants and loss of redundancy

A frail older person is analagous to a complex system

on the threshold of failure, redundancy has been lost.

When a complex system fails, it fails with higher order

functions first.

Higher order functions

– Upright bipedal ambulation

– Divided thinking


The Geriatric Giants

Falls

Immobility

Incontinence

Delirium

Geriatric syndromes need multifaceted assessment and

holistic management



FRAILTY IN OLDER SURGICAL

PATIENTS


Frailty in the Old Old and Oldest Old

Systematic review

Patients’ mean age ≥ 75 years

23 studies

Surgery

– Cardiac, oncological, vascular, general, vascular, orthopaedic

Frailty

– Measured in 21 different ways


Results

Strong evidence (N, quality, consistency)

– Increased mortality

– Post operative complications

– LOS

Weak evidence

– Discharge to higher level of care

– Functional decline

– Low quality of life


Summary

1. Describe and compare frailty measures

phenotypes, subjective opinion, deficit accumulation

2. Consider frailty in relation to failure of a complex

system

minor insults can be devastating for a frailer person

3. Review importance of frailty in older surgical patients

associated with relevant adverse outcomes


Global Forum on Acute Care Excellence

38

Ensuring safe passage for frail and vulnerable adults across the hospital continuum

February 20-21, 2017

Documents

Centre for Research in Geriatric MedicineCentre for Research in Geriatric Medicine Centre for Research in Geriatric Medicine FRAILTY IN OLDER INPATIENTS Associate Professor Ruth E