evidence-based geriatric medicine - download.e-bookshelf.de · Evidence-Based Geriatric Medicine provides non-geriatrician clinicians with an approach to topics central to the care

evidence-based geriatric medicinea practical clinical guide

9 781444 337181

ISBN 978-1-4443-3718-1

Edited byJayna Holroyd-Leduc Madhuri Reddyev

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Edited by

Jayna M. Holroyd-Leduc, MD, FRCPC, University of Calgary, Calgary, AB, Canada

Madhuri Reddy, MD, MSc, Hebrew Senior Life, Boston, MA, USA

Evidence-Based Geriatric Medicine provides non-geriatrician clinicians with an approach to topics central to the care of the older patient. These include the diagnosis and management of ‘the geriatric giants’ (delirium, dementia, urinary incontinence and falls), pressure ulcers, elder abuse and end of life care. This new book in the Evidence-Based series includes specific age-related conditions while providing a holistic approach to the older patient. Geriatric Medicine specialists with expertise in both their specific topics as well as in evidence-based medicine present the best-available evidence in a concise, easy-to-use, question-and-answer based format. Each chapter includes common questions that are asked by clinicians, and the answers focus on a systematic review of the evidence and conclude with a bottom line for clinical practice.

• Auniqueguidetotheoptimumcareofolderpatients

• Focusesonthebestavailableevidence

• Usesrigorousandtransparentmethodsforseekingandappraisingtheevidence

• Providestheevidenceinaclinicallyusefulformat

This book is an invaluable resource for trainees and clinicians from various disciplines, worldwide. It addresses an issue of global importance – building the capacity to care for older persons.

Praise for Evidence-Based Geriatric Medicine:

‘This short text is ideal for students and practitioners to update on the evidence for care of older persons’, John Morley, Editor of Pathy’s Principles and Practice of Geriatric Medicine

evidence-based geriatric medicinea practical clinical guide

The Evidence Based Medicine Series has a website at: www.evidencebasedseries.com

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Evidence-BasedGeriatric Medicine



Website: Evidence-Based Medicine Series

The Evidence-Based Medicine Series has a website at:

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Where you can find:

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Cochrane Library, Essential Evidence Plus, and EBMGuidelines.

How to access the companion sites with additionalresources and updates:

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Evidence-BasedGeriatric MedicineA Practical Clinical Guide

Edited by

Jayna M. Holroyd-Leduc, MD FRCPCAssociate ProfessorDepartments of Medicine and Community Health SciencesDivision of GeriatricsUniversity of CalgaryCalgary, ABCanada

Madhuri Reddy, MD MScHebrew Senior LifeBoston, MAUSA

A John Wiley & Sons, Ltd., Publication



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Evidence-based geriatric medicine : a practical clinical guide / edited byJayna M. Holroyd-Leduc and Madhuri Reddy.

p. ; cm.Includes bibliographical references and index.ISBN 978-1-4443-3718-1 (pbk. : alk. paper)I. Holroyd-Leduc, Jayna M., 1970– II. Reddy, Madhuri, 1972–DNLM: 1. Geriatrics–methods. 2. Aged. 3. Aging–physiology. 4. Evidence-Based Medicine.

5. Geriatric Assessment. WT 100]618.97–dc23

2011049726

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Contents

List of contributors, vi

Foreword, ixSharon Straus

1 Function and frailty: the cornerstones of geriatricassessment, 1Paige K. Moorhouse & Kenneth Rockwood

2 Computer-based clinical decision support systemsin the care of older patients, 13Marina Martin & Mary K. Goldstein

3 Simplifying the pillbox: drugs and aging, 25Sudeep S. Gill & Dallas P. Seitz

4 Breathing easier: respiratory disease in the olderadult, 43Salahaddin Mahmudi-Azer

5 Breathing easier: an approach to heart failure in apatient with an aging heart, 58Jayna M. Holroyd-Leduc, Madhuri Reddy, &Anita Asgar

6 Clarifying confusion: prevention and managingdelirium, 65Ranjani Aiyar & Jayna M. Holroyd-Leduc

7 Preserving the memories: managingdementia, 73Dallas P. Seitz, Philip E. Lee, Sudeep S. Gill, &Paula A. Rochon

Evidence-Based Medicine Series

The Evidence-Based Medicine Series has a website at:

www.evidencebasedseries.com

8 Enjoying the golden years: diagnosing andtreating depression, 94Jane Pearce & Stuart Carney

9 A balancing act: preventing and treating falls, 105Emily Kwan & Sharon Straus

10 Keeping dry: managing urinary incontinence, 124Cara Tannenbaum

11 Keeping things moving: preventing and managingconstipation, 140Dov Gandell & Shabbir M.H. Alibhai

12 Preventing and treating pressure ulcers, 155Madhuri Reddy, Sudeep S. Gill, Sunila R. Kalkar,Wei Wu, & Paula A. Rochon

13 Elder Abuse, 166Erik J. Lindbloom, Landon D. Hough, &Karli R.E. Urban

14 A good death: appropriate end-of-life care, 175Cari Levy & Jean S. Kutner

Index, 187

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List of Contributors

Ranjani AiyarFellowGeneral Internal MedicineDivision of General Internal MedicineDepartment of MedicineUniversity of CalgaryCalgary, AB, Canada

Shabbir M.H. AlibhaiAssociate ProfessorDepartments of Medicine and Health Policy,

Management, and EvaluationUniversity of TorontoToronto, ON, Canada;Consultant GeriatricianToronto Rehabilitation InstituteToronto, ON, Canada;Staff PhysicianInternal Medicine and GeriatricsUniversity Health NetworkToronto, ON, Canada

Anita AsgarDirectorTranscatheter Valve Therapy ClinicInstitut de Cardiologie de MontrealMontreal, Quebec, Canada;Assistant ProfessorUniversite de MontrealMontreal, Quebec, Canada

Stuart CarneyDeputy National DirectorUK Foundation Programme OfficeCardiff Bay, UK

Dov GandellResident, Geriatric MedicineDepartment of MedicineDivision of GeriatricsUniversity of TorontoToronto, ON, Canada

Sudeep S. GillAssociate ProfessorDepartment of MedicineDivision of Geriatric MedicineQueen’s UniversityKingston, ON, Canada

Mary K. GoldsteinDirectorGeriatrics Research Education and Clinical Center (GRECC)VA Palo Alto Health Care SystemPalo Alto, CA, USA;Professor of Medicine (Center for Primary Care &

Outcomes Research)Stanford University School of MedicineStanford, CA, USA

Jayna M. Holroyd-LeducQI LeadDepartment of MedicineUniversity of Calgary and Alberta Health ServicesCalgary, AB, Canada;Medical Coordinator of Clinical InformaticsDepartment of MedicineAlberta Health ServicesCalgary, AB, Canada;

vi




Associate ProfessorDepartments of Medicine and Community Health SciencesDirector, Geriatric Medicine Training ProgramDivision of GeriatricsUniversity of CalgaryCalgary, AB, Canada

Landon D. HoughResident PhysicianDepartment of Family and Community MedicineUniversity of MissouriColumbia, MO, USA

Sunila R. KalkarResearch CoordinatorWomen’s College Research InstituteWomen’s College HospitalToronto, ON, Canada

Jean S. KutnerProfessor of MedicineUniversity of ColoradoDenver School of MedicineAurora, CO, USA

Emily KwanResident, Geriatric MedicineDepartment of MedicineDivision of GeriatricsUniversity of TorontoToronto, ON, Canada

Philip E. LeeAssistant ProfessorDivision of Geriatric MedicineUniversity of British ColumbiaVancouver, BC, Canada

Cari LevyAssociate Professor of MedicineUniversity of Colorado Denver School of MedicineDenver, CO, USA;Denver VA Medical CenterDenver, CO, USA

Erik J. LindbloomAssociate ProfessorDepartment of Family and Community MedicineUniversity of MissouriColumbia, MO, USA

Salahaddin Mahmudi-AzerClinical FellowDepartment of Critical Care MedicineFoothills HospitalUniversity of CalgaryCalgary, AB, Canada

Marina MartinClinical Instructor of Medicine (General Internal Medicine)Stanford UniversityStanford, CA, USA

Paige K. MoorhouseAssistant ProfessorGeriatric MedicineDalhousie UniversityHalifax, NS, Canada

Jane PearceConsultant Old Age Psychiatrist and Honorary Senior

Clinical Lecturer in PsychiatryUniversity of OxfordOxford, UK;Fulbrook CentreChurchill HospitalOxford, UK

Madhuri ReddyHebrew Senior LifeBoston, MA, USA

Paula A. RochonVice President, ResearchWomen’s College Research InstituteWomen’s College HospitalToronto, ON, Canada;Senior ScientistInstitute for Clinical Evaluative SciencesToronto, ON, Canada;ProfessorDepartment of MedicineUniversity of TorontoToronto, ON, Canada

Kenneth RockwoodProfessorGeriatric MedicineDalhousie UniversityHalifax, NS, Canada;

vii




Kathryn Allen Weldon Professor of Alzheimer ResearchDalhousie UniversityHalifax, NS, Canada;Consultant PhysicianQueen Elizabeth II Health Sciences CentreHalifax, NS, Canada

Dallas P. SeitzAssistant ProfessorDepartment of PsychiatryDivision of Geriatric PsychiatryQueen’s UniversityKingston, ON, Canada;FellowWomen’s College Research InstituteToronto, ON, Canada

Sharon StrausProfessorDepartment of MedicineDirector, Division of GeriatricsUniversity of TorontoToronto, ON, Canada;Director, Knowledge Translation ProgramLi Ka Shing Knowledge Institute of St. Michael’sToronto, ON, Canada

Cara TannenbaumAssociate ProfessorFaculties of Medicine and PharmacyUniversite de MontrealMontreal, QC, Canada;DirectorGeriatric Incontinence ClinicInstitut Universitaire de GeriatrieUniversite de MontrealMontreal, QC, Canada

Karli R.E. UrbanResident PhysicianDepartment of Family and Community MedicineUniversity of MissouriColumbia, MO, USA

Wei WuStatistical AnalystWomen’s College Research InstituteWomen’s College HospitalToronto, ON, Canada

viii



Foreword

Worldwide a major change in the population demo-graphic is posing challenges to health care systems. Inmany countries the baby boom, that followed WorldWar II and extended to the 1960s, will soon result ina substantial increase in the number of people over65 years of age. Moreover, most countries includ-ing Canada, the United States and the United King-dom have experienced a continuing increase in lifeexpectancy, with an increase of approximately 1 yearoccurring every 5 years. These factors translate into agrowing proportion of people aged 65 and older andthese people will have many more years of life afterattaining age 65. This situation is not unique to west-ern countries; many developing countries will growold before they get rich. For example, in 2000, 7% ofChina’s population was ≥ 65 years old; by 2030 thiswill increase to 16%. As the proportion of older peo-ple increases, there is an increasing need for servicestargeted to care for older people, in particular to op-timize the independence and vitality of those livingin the community. There is an urgent need for healthcare professionals from all disciplines (aside from pae-diatrics!) to become comfortable with caring for thispopulation. This book will address this demand andprovide a resource for health care professionals to pro-vide evidence-based care for older patients.

Evidence-Based Geriatric Medicine, a Practical Guidefocuses on bringing together 2 critically important is-sues in health care – evidence-based practice (EBP) andcare of the older patient. Interest in EBP has grown ex-ponentially since the coining of the term in 1992, from1 MEDLINE citation in that year to more than 75000hits in January 2012. Training in EBP has become acomponent of educational curricula for health care

disciplines, patients and policy makers amongst oth-ers[1]. This growing interest arose from a number ofrealisations including: our inability to afford more thana few seconds per patient for finding and assimilatingevidence[2] or to set aside more than half an hour perweek for general reading and study[3]; and the findingthat the gaps between evidence and practice (includingunderuse and overuse of evidence) lead to variationsin practice and quality of care[4, 5].

To meet these challenges, this book focuses on pro-viding an approach to care for older patients that isbased on the best available evidence. An ideal evidence-based resource should use rigorous and transparentmethods for seeking and appraising the evidence, andprovide the evidence in a clinically useful format. Theformat of each chapter in this book includes questionsthat have been generated by clinicians while the con-tent focuses on a systematic review of the evidenceand provides the reader with the bottom line for theirclinical practice. Finally, the book highlights the gapsin the evidence, which are targets for future research(we hope!).

Topics addressed in the book include assessing andmanaging the geriatric giants such as delirium, demen-tia, urinary incontinence and falls. The authors alsotackle issues, such as elder abuse, that are often un-derappreciated in clinical care. And, the book includesdiscussion of the management of chronic diseases inthe complex older patient which is useful informationfor any generalist clinician.

This book will be a resource for trainees and clini-cians from various disciplines, worldwide. It addressesissues of global importance – promoting healthy agingand building capacity to care for older persons.

ix



Foreword

References

1. Straus SE, Richardson WS, Glasziou P, Haynes RB (2011)Evidence-based Medicine: How to practice and teach it.Fourth Edition. Elsevier; Edinburgh.

2. Sackett DL, Straus SE (1998) Finding and applying evi-dence during clinical rounds: the ‘evidence cart’. JAMA 280:1336–8.

3. Sackett DL (1997) Using evidence-based medicine to helpphysicians keep up-to-date. Serials 9: 178–81.

4. Shah BR, Mamdani M, Jaakkimainen L, Hux JE (2004) Riskmodification for diabetic patients. Can J Clin Pharmacol 11:239–44.

5. Pimlott NJ, Hux JE, Wilson LM, et al. (2003) Educating physi-cians to reduce benzodiazepine use by elderly patients. CMAJ168: 835–9.

Sharon StrausFebruary 2012

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CHAPTER 1

Function and frailty: the cornerstonesof geriatric assessment

Paige K. Moorhouse1,2 & Kenneth Rockwood1,2

1Department of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada2Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada

Introduction

Older people are more likely to be ill than youngerpeople, and most of the older people who are ill havemore than one illness. Yet this is generally not what weteach medical students. Instead, reflecting the scientifictradition of reductionism from which real progress hasbeen possible, medicine is generally taught on a “onething wrong at once” basis, often with younger pa-tients as prototype [1]. Consequently, many physicianshave an ambivalent understanding about medicineand aging.

We discuss two main topics in this chapter. The firstis frailty. Frail older adults often behave as complexsystems that are close to failure. One aspect of acting ina complex system is that when the system fails, it willfail in its highest order functions first. For humans,these high order functions are divided attention, up-right bipedal ambulation, opposable thumbs, and so-cial interaction. Their failures are delirium, mobilityimpairment and falls, impaired function, and socialwithdrawal/abandonment. Another essential aspect ofacting in a complex system is that any single act islikely to have multiple consequences. For example, themedication given in an evidence-based way to treatinflammatory arthritis to allow mobilization, so as tocomply with evidence-based exercises and to improvecardiac conditioning, might decrease heart function ina frail patient through fluid retention that precipitates

heart failure. That is why the specialty of geriatrics hasevolved dicta such as “start low, go slow”. This is notsimply codified common sense, but a rational responseto the patients’ complexity.

The second main topic that we discuss in this chapteris function. Functional impairment in an older adultis often characterized as a “sensitive but nonspecific”sign of illness. While true, it is an inadequate accountof why it should have the iconic status of a “geriatricgiant” [2], because medicine is replete with other sen-sitive but nonspecific signs, from chest pain to chappedlips. Intact functioning requires a lot to be right; com-promised function can reflect a single cause (e.g., acatastrophic stroke), but commonly, in older adults,it reflects problems in more than one area. It is this“more than one thing wrong” aspect of functional im-pairment that makes it so useful as an overall sign of apatient’s state of health.

Search strategy

FrailtyWe searched PubMed for systematic reviews, meta-analyses, and practice guidelines published in the last5 years in English for those aged 65 and older using thefollowing search terms: “frailty,” “frailty index,” and“frailty phenotype.” This yielded 144 articles, 25 ofwhich were narrative reviews and 21 of which weresystematic reviews.

Evidence-Based Geriatric Medicine: A Practical Clinical Guide, First Edition. Edited by Jayna M. Holroyd-Leduc and Madhuri Reddy.C© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.

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Chapter 1

Table 1.1 Contrasting the frailty phenotype and the frailty index

Frailty Phenotype Frailty Index

General Five items: (1) weakness, (2) exhaustion,(3) reduced activity, (4) motor slowing,and (5) weight loss

Any set of items that are age associated,associated with adverse outcomes, do notsaturate at some young age, and have<5% missing data.

Data collection Usually must be prospective Can be operationalized in many existingdata sets

Number of items 5 Can be as few as 30, as many as 100;most often about 40–50

Is supported by a theory of frailty Yes Yes

Uses performance measures Yes Usually not

Uses disability items No Usually

Uses comorbidity items No Yes

Cross-validated Extensively (>100 groups) Somewhat (about a dozen groups)

Samples other than physical domains Possibly (feeling of exhaustion) Yes

Most common criticism Covers too few domains Includes too many items, especiallydisability and comorbidity

Animal model Yes Yes

Functional assessmentWe searched PubMed for systematic reviews, meta-analyses, and practice guidelines published in Englishwith subjects 65 and older in the last 24 months usingthe following search terms: “activities of daily living”(ADL), “ADL,” “evaluation,” “measurement,” “assess-ment,” and “functional.” This yielded 50 articles, 13of which were pertinent to the topic. Expanding thesearch to articles published in the last 5 years yielded138 new articles, 15 of which were pertinent to thetopic. We then searched related citations of the 28 arti-cles selected. This yielded four additional items. A totalof 32 articles were reviewed in detail.

For this chapter, we graded relevant clinical studiesusing the US Preventative Task Force levels of evidence.

What is frailty?

Frailty is the variable susceptibility to adverse healthoutcomes, including death, of people of the same

chronological age. Controversy in the definition offrailty arises in how frailty is best operationalized.Pending the results of an ongoing large meta-analysis[3], two frailty operationalization camps have arisen(Table 1.1). One group emphasizes a frailty phenotype[4]. Another emphasizes a frailty index, and states thatsusceptibility to adverse outcomes arises as a conse-quence of the accumulation and interaction of deficits,for which various phenotypes might exist [5, 6].

The frailty phenotypeThe frailty phenotype specifies five characteristics: (1)slowness, (2) weight loss, (3) impaired strength, (4)exhaustion, and (5) low physical activity/energy ex-penditure. A person is said to be frail if they haveany three of these five characteristics. People who haveonly one or two of the characteristics, while still atan increased risk compared to people with none ofthe phenotypic characteristics, are said to be “prefrail.”People with none of the characteristics are said to be

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Function and frailty: the cornerstones of geriatric assessment

“robust.” A strength of this approach is that at leastfour of the items are measurable by performance andin that way, objective. It also offers some prospect offinding mechanisms that might be associated with de-velopment and progression of frailty. The phenotypedefinition has been extensively validated and is reliablyassociated with an increased risk of death and withother adverse health outcomes.

The phenotypic view is well accepted, in that over ahundred separate groups have conducted studies whichshow that for almost any adverse outcomes and formany physiological ones, such as levels of proinflam-matory molecules [7], hemoglobin [8], or sex hor-mones [9], female robust people have, on an average,the most favorable profile, frail people the least favor-able, and “prefrail” people an intermediate profile.

Despite widespread use and consistency of results,the frailty phenotype has been criticized for misclas-sifying people who are clinically recognizable as frail[10]. In particular, some critics argue that the frailtyphenotype includes too few items, and suggest the in-clusion of some or all of the subjective perceptions ofhealth status, cognitive performance, sensory or phys-ical impairments, current health status needs, or ap-pearance (as consistent or not with age) [11–13]. Someevidence supports the inclusion of cognitive perfor-mance, just short of dementia, to improve the predic-tive validity of the phenotypic approach [14, 15].

Among people who criticize the frailty phenotypefor including too many items, there is recent evidenceto support the primacy of slow mobility among the fivepotential markers of frailty [16]. On the other hand,gait speed correlates only modestly with adverse healthoutcomes [17]. Moreover, a frailty definition basedon only three items ((1) weight loss, (2) inability torise from a chair, and (3) low energy) has been testedagainst the five-item phenotypic definition and foundto perform comparably with respect to risk classifica-tion [18, 19]. It is also established that obese peoplecan be frail, even if they have not had weight loss [20].

Many authors hold that any operational definition offrailty should not include disability [21–23], althoughit is recognized empirically that the large majority ofdisabled older adults will be frail in the sense of eithermeeting the frailty phenotype [24] or in having anincreased risk of adverse health outcomes [25]. Shortof that, phenotypes other than the classic five-itemphenotype are studied [18, 19, 26–28].

The frailty indexA contrasting view of frailty more broadly considersthe items that could be counted to define someone asfrail [6, 29]. Typically, a large number of items (40 ormore) are counted and combined in a so-called frailtyindex [30]. The only restriction on the items is thatthey should count as health deficits (i.e., be associatedwith adverse health outcomes), and increase in preva-lence with age, at least into the ninth decade. For anindividual, their frailty index score is the number ofdeficits that they have, divided by the total number ofdeficits considered (e.g., a person with 10 deficits outof 40 considered would have a frailty index score of10/40 = 0.25). The frailty index shows many consistentproperties, independent of its make up. Various frailtyindexes have been constructed with as few as 31 itemsto as many as 100, including many ADLs or none, orusing self-reported data or observer assessed/test/clinicdata. Notwithstanding this variability in how thefrailty index is constructed, in Western community-dwelling samples, the index generally increases at about0.03 points per year, is highly correlated with mortality,and shows a characteristic pattern of change that can bemodeled stochastically with the output conforming toa Poisson distribution [29]. There appears to be a limitto frailty, i.e., a proportion of deficits beyond whichsurvival is not possible. That limit is at a frailty indexvalue of approximately 0.7 [31–35]. Whether that limitcan be used to guide decisions about a patient’s suit-ability for an elective procedure or therapeutic regimenhas not been established yet.

The frailty index has been criticized as being toolabor intensive for clinical use compared with the five-item frailty phenotype [36]. Although the few head-to-head comparisons of the value of the frailty indexversus the frailty phenotype in predicting vulnerabilityto adverse outcomes appear to favor the former [34, 37,38], more widespread testing within clinical settings isrequired.

As with the frailty phenotype, there is no uniformityof the frailty index yet. Some reports employ simplethree- or five-item frailty indexes. These simpler in-dexes have ceiling effects and therefore, do not allowthe potential property of a limit to be tested, nor canthey show the same relationship with age as the morecomplex indexes [18, 19].

Between the operational propositions of frailty, asthree or five carefully defined “phenotypic” items and

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Chapter 1

a frailty index that takes 30 or more items into account,are a large number of scales that classify risk based onten or more items [39–41]. Nevertheless, scales that in-clude age (however well they might characterize risk)[42–44] should be excluded as measures of frailty be-cause frailty refers to differential susceptibility to ad-verse outcomes among people of the same age.

The frailty state is clearly dynamic, and while peo-ple can improve, the greater tendency is for frailty toworsen over time, especially as adverse outcomes accu-mulate [45, 46]. The dynamics of frailty further com-plicates clinical decision-making.

Clinical bottom lineFrailty can be thought of in terms of a phenotype oras an index. The frailty phenotype specifies five char-acteristics: (1) slowness, (2) weight loss, (3) impairedstrength, (4) exhaustion, and (5) low physical activity/energy expenditure. For a frailty index, typically a largenumber of items (40 or more) are counted and com-bined into a score. An individual’s frailty index scoreis the number of deficits that they have divided by thetotal number of deficits considered.

Is this person frail?

The quickest answer to the question “Is this personfrail?” is the response “What do you mean by frail?”The evidence suggests that a person will be suscepti-ble to adverse outcomes if they conform to the frailtyphenotype of slow, weak, thin, and exhausted, with re-duced physical activity, especially if they have all fiveof these characteristics. Equally, a person will be frail ifthey have many things wrong with them, with a frailtyindex score of about 0.25 or higher. In both cases, thelikelihood of susceptibility to adverse outcomes is em-pirically the case in presence of functional disability,and worsens as the extent of disability increases.

The fewest things that a person can have wrong withthem, and be considered frail has not been establishedyet. The leading candidate appears to be motor-slowingin the absence of a single specific lesion to cause it [16],although risk can be classified without consideringmotor slowing [18, 19]. Notably, low handgrip strengthmore than measures frailty or function predicted riskof treatment toxicity from cancer chemotherapy [47].Low mood, or at the very least poor self-rated health,also seem to be important in defining frailty among

people who otherwise might meet more restrictive cri-teria [28, 48]. Although people who have dementia willmeet many frailty criteria, it is not evident that theirrisk is better understood by also calling them frail, ascompared with staging their dementia [49, 50].

Clinical bottom lineA person will be susceptible to adverse outcomes ifthey conform to the frailty phenotype. Equally, a per-son will be frail if they have a frailty index score of0.25 or higher. In both cases, the likelihood of suscep-tibility to adverse outcomes is related to the presenceof functional disability, with the greater the extent ofdisability, the higher the susceptibility.

What are ADLs?

Functional assessment allows goal setting and providesimportant information for measuring progress andestimating prognosis. Assessment of ADLs forms thecornerstone of functional assessment in older adults,because it offers a broad view of the impact of dis-ability and disease on the patient and caregiver [51].ADLs can be divided into two levels (Table 1.2): (1)Basic Activities of Daily Living (BADLs) refer to thetasks of self-maintenance (dressing, bathing, toilet-ing, feeding, management of continence, and abil-ity to transfer from a bed to chair and back), while(2) Instrumental Activities of Daily Living (IADLs)refer to those activities that foster independence inthe community (managing finances and medications,shopping, housekeeping, meal preparation, and trans-portation). Impaired function is highly associated withbut distinguishable from so-called geriatric conditions,such as dizziness and somatosensory impairment, withwhich it can exist in the absence of disabling chronicillness [52].

How do I assess ADLs?

Functional assessment generally relies on self-reportedquestionnaire, informant-based questionnaire, or di-rect observation. Self-reported questionnaires are oflimited utility in dementia where insight is commonlyaffected, while direct observation scales are time con-suming. Therefore, informant-based or team-assessedquestionnaires are most often used in the assessmentof function (Table 1.3). One assessment seldom fits

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Table 1.2 Basic and instrumental activities of daily living

Basic Activities of DailyLiving (BADL)

Instrumental Activities ofDaily Living (IADL)

Feeding: Ability to consumefood safely and withreasonable hygiene, includingthe ability to use utensilsappropriately

Banking: Ability to carry outpersonal transactions andkeep track of income andbills

Bathing: Ability to initiate andcomplete personal bathing,with or without the use ofassistive aids

Transportation: Driving

Dressing: Ability to chooseand don appropriate clothing

Cooking: Ability to preparenutritionally appropriatemeals

Toileting: Ability to initiate andcomplete mechanics oftoileting with proper hygieneand manage any incontinenceof bowel or bladder

Cleaning: Ability to maintainacceptable standard ofcleanliness in own home.

Ambulation: Ability totransport with or without useof assistive aids including theability to transfer self

Managing medications

Shopping: Ability to selectappropriate householdneeds

all, therefore, a variety of functional assessment toolshave evolved and have been adapted for use in specificpatient populations.

Functional assessment in peoplewith dementiaFunctional assessment is central to the evaluation ofcognitive impairment. Functional decline is a core fea-ture of all dementias (DSM-IV), is widely used as anoutcome for treatment in dementia drug trials, and isan important prognostic marker for caregiver burdenand institutionalization [53]. Consensus is lacking onhow broad the functional assessment should be, andhow to distinguish cognitive from noncognitive causesof functional impairment [54].

Functional assessment tools commonlyused in dementiaSeveral functional assessment tools have been vali-dated in Alzheimer dementia. The Lawton Brody Phys-ical Self-Maintenance Scale (PSMS) and Activities ofDaily Living Scale (IADL) are two subscales that assessBADLs and IADLs respectively, with descriptors foreach domain that range from independence to com-plete dependence with resistive behaviors [55]. Thesubscales were originally validated together, but are of-ten used separately in clinical practice. The subscaleshave several limitations. First, although the descriptorsof function in each domain reflect degrees of functionalimpairment seen in dementia, neither scale allows theuser to distinguish noncognitive reasons for the im-pairment. Further, although the source of informationprovided has been shown to have a significant effect onthe overall score [56], neither scale stipulates standardsfor the source of information.

The Lawton Brody IADL scale does not take intoconsideration the tasks that were not performed bythe individual at baseline (traditionally women werescored on all eight areas of IADL function; while foodpreparation, housekeeping, and laundering were ex-cluded for men). Despite these limitations, the LawtonBrody IADL scale is the most commonly applied ques-tionnaire for dementia patients[57].

The Lawton Brody PSMS subscale evaluates thesame six domains of BADL as the Katz index of in-dependence in ADLs [58]. While the PSMS is mostoften used in dementia, the Katz has been used in awide variety of chronic illnesses. The Katz providesa dichotomous rating (dependent/independent) on athree-point scale of independence for BADL functionsarranged in a hierarchical order (bathing being thehighest). The PSMS includes a five-point rating scalefor each of the same BADL domains. Two scoringmethods have been described for the PSMS: one in-volves counting the number of items with any degreeof impairment, while the other involves summing theseverity score (1–5) of the impairment in each domainfor an overall score of 6–30.

Functional assessment tools developedspecifically for dementiaMost functional scales for dementia were developedfor Alzheimer’s disease, although some have been usedin other cognitive syndromes such as Mild Cognitive

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Chapter 1

Table 1.3 Some commonly used, nondisease specific, disability assessment tools

Scale Name Scoring Items Clinical Setting

Barthel Index 0 (complete dependence) to100 (independence in allitems)

(higher score is better)

Ten items measuring boweland bladder function,transfers, mobility, and stairs

(15-item versions alsoavailable)

– Well suited to patients whomay begin bed-bound andimprove from there

– Comparatively moredetailed mobilityinformation aidsresponsiveness in hospitalsetting

– Both floor and ceilingeffects are notable

Physical Self-MaintenanceScale (PSMS)

Items scored 1–4 or 1–5

(higher score is worse)

Basic activities of daily living(BADL) items

– Commonly used in clinicalgeriatric settings

– Especially helpful indementia

Lawton Brody InstrumentalActivities of Daily Living(IADL) Scale

Items scored 1–4 or 1–5


IADL items – Commonly used inconjunction with the PSMS

Disability Assessment inDementia (DAD)

Items scored one point eachfor initiation, planning andperformance

(higher score is better)

40 items including IADLs,BADLs and leisure activities

– Used to assess function inpatients with dementia

Functional IndependenceMeasure (FIM)

Items scored on a seven-pointscale (total scores range from18 to 126)


18 items (5 measurecognition; 13 measure motorperformance)

– Widely used inrehabilitation settings

Impairment (MCI) or Vascular Cognitive Impairment(VCI). A more detailed review of functional assessmentscales that are used in clinical trials for dementia ispresented elsewhere [53].

A recent systematic review evaluated the measure-ment properties of IADL scales in dementia [57]. Theauthors compared the content validity, construct va-lidity, criterion validity, internal consistency, repro-ducibility, responsiveness, floor and ceiling effects,and interpretability of 12 scales for assessing func-tion using IADLs. The authors found that the valida-tion studies for most scales did not include sufficientinformation through which to assess and comparemeasurement properties, and none of the 12 scalesincluded information for all measurement properties.Based on the limited information available, the Dis-ability Assessment for Dementia (DAD) and the Bris-tol ADL (a scale that assesses 20 ADLs in dementia

[59]) scales received the best ratings, but further stud-ies are required in order to make definitive recom-mendations about whether one scale is recommendedfor general use in dementia and the circumstancesin which particular scales should be used (Level Cevidence).

The DAD [60] was designed to assess treatment re-sponse and follow disease progression in community-dwelling patients with Alzheimer’s dementia. The40-item DAD includes IADLs, BADLs, and leisure ac-tivities and uses the characteristic hierarchical patternof functional decline described in observational stud-ies. The scale is unique in that it takes into accountthe proxy’s perceived reason for the functional impair-ment, for example initiation, planning and organiza-tion, or ineffective performance. The DAD was devel-oped and validated in English and French, and is notaffected by age, education, or gender.

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Function assessment inrehabilitation settingsIn addition to providing information about progres-sion, treatment response, and prognosis in demen-tia, functional assessment can be used in chronicdisease and rehabilitation settings such as poststrokerehabilitation. Two commonly used scales include theBarthel Index and the Functional Independence Mea-sure (FIM).

The Barthel Index [61] was originally developed as aten-item ordinal scale, measuring function in the do-mains of ADLs, bowel and bladder function, transfers,mobility, and stairs. It has been modified to 15-itemversions [62, 63], which includes domains of cognition,socialization, and vision/visual neglect. The Barthel in-dex has demonstrated good reliability and validity andhas been shown to predict care needs, length of stay,and mortality [64]. The scale is most often adminis-tered by clinical observation but has also been scoredusing self-report, which tends to result in higher scoresin cases of cognitive impairment, acute illness, or olderpatients [65].

The FIM [66] is an 18-item ordinal scale (13 itemsmeasure motor function, while 5 items measure cogni-tive function) for measuring progress in rehabilitativeprograms. The scale is based on the Barthel Index.Each item is scored on a seven-point ordinal scale suchthat total scores range from 18 to 126, with higherscores denoting more functional independence. TheFIM is proprietary (Uniform Data System for Med-ical Rehabilitation) and is used to report rehabilita-tion outcomes as part of large-scale data aggregationservices.

Functional assessment in oncologyThe majority of older cancer patients have some de-gree of frailty, functional impairment, and comorbiddisease [67]. The interplay of these factors and thecancer may affect treatment tolerance and survival. Amajor challenge in the emerging field of geriatric on-cology is determining the most appropriate treatment,with the best therapeutic ratio of survival/palliationand toxicity, taking into account the relative frailty ofthe individual. Scales to assess functional status havebeen developed for use in oncology, but these have notroutinely taken frailty into account.

At present, the most consistent predictive clinicalfactor for treatment tolerance and survival is perfor-

mance status (PS). PS is an ordinal scale that describesthe overall functional limitations and severity of symp-toms in relation to cancer. The two most commonlyused scales for PS are the Karnofsky Performance Scale(KPS) [68, 69] and the Eastern Cooperative Oncol-ogy Group (ECOG) scale [70]. The KPS is an ordi-nal scale to describe global function. The score is re-ported in increments of 10 with total scores rangingfrom 0 to 100, a score of 100 being the best and ascore of less than 50 denoting inability to perform self-care. The ECOG or Zubrod scale ranges from 0 to 4,with 0 indicating better function (corresponding to90–100 on the KPS). Although the predictive valid-ity for both scales has been consistently demonstrated,there is emerging evidence that a more comprehen-sive assessment, using tools such as the comprehen-sive geriatric assessment, and consideration of degreeof frailty may help clinicians make better therapeuticdecisions by providing insights into the interaction be-tween aspects of fitness, frailty, and chemotherapeutictoxicity [71–73].

Clinical bottom lineThere are a variety of functional assessment tools, all ofwhich are designed to measure a patient’s dependencein ADLs. The tool to be used depends on the purposefor collecting the information.

How can I prevent this frail olderadult from declining in ADLs?

Prevention of functional decline in frail older adultsis a priority area for research and public health, andthe absence of disability has demonstrated consistentassociation with successful aging [74]. In 2004, the In-terventions on Frailty Working Group published con-sensus recommendations on the design of randomizedcontrolled trials for the prevention of functional de-cline and disability in frail older adults [75].

Systematic reviews addressing prevention of func-tional decline are limited and most are conductedon studies examining outcomes in particular patientsettings.

Interventions for older hospital inpatientsHospital admission is often a sentinel event in the nat-ural history of frailty. Thirty to sixty percent of olderadults develop new dependency in ADLs, following

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Chapter 1

admission to hospital that can translate into increasedmortality, prolonged hospital stay and readmission,poor quality of life, and need for institutionalizationor increased care at home [76]. Factors influencingfunctional decline after hospital admission may be re-lated to baseline health status or events that occur afteradmission [77].

An important component of any program designedto prevent functional decline is screening for those in-dividuals at most risk. A recent systematic review foundthat older age, depressive symptoms, cognitive impair-ment, preadmission dependency in ADLs, and lengthof hospital stay were each predictive of functional de-cline following hospital admission [76].

The same review evaluated three screening instru-ments for postdischarge functional decline, the Hos-pital Admission Risk Profile (HARP) [78], the Identi-fication of Seniors at Risk (ISAR) [79], and the CareComplexity Prediction Instrument (COMPRI) [80].All three instruments have been tested in large popu-lations, but their reliability, sensitivity, specificity, andpredictive value were not described in the original stud-ies, and they have not been compared with existingfrailty measures. The specific items and outcome mea-sures for each assessment tool varied, but componentsof successful assessments generally included the do-mains of comprehensive geriatric assessment (Level Bevidence). A randomized controlled trial that evalu-ated the effectiveness of an intervention designed toreduce functional decline in frail hospitalized patients,screened using the ISAR, resulted in reduced rates offunctional decline but no effect on satisfaction, care-giver health, or depressive symptoms [81] (Level Cevidence).

A second systematic review [82] evaluating six stud-ies of five screening instruments (including the HARPand the ISAR) for identifying those at a risk of func-tional decline, 3–6 months after presentation to theemergency department, found considerable overlap inthe domains and items of assessment in the screen-ing instruments. The Inouye screening tool [83] hadthe highest sensitivity (88%), but the lowest speci-ficity (54%) of all five instruments. The SHERPA(Score Hospitalier d’Evaluation du Risque de Perted’Autonomie) [84] was the most accurate tool (AUC0.734), but it has not been prospectively validated. Theutility of the ISAR was limited by its reliance on self-report, with many participants unable to complete the

screen independently. The Inouye tool was limited bythe clinical expertise required to complete the items.

The most recent systematic review of screening toolsfor prediction of functional decline [85] is consistentwith previous studies in its conclusion that further re-search is needed to overcome the lack of published dataon reliability and validity of existing screening instru-ments in order to allow direct comparisons (Level Cevidence).

Geriatric Evaluation and Management Units(GEMU) are specialized inpatient wards that providemultidisciplinary assessment, review, and therapy forfrail older adults [86]. The GEMU model combinescomprehensive geriatric assessment with managementstrategies including individualized care planning, reha-bilitation, and discharge planning. A recent systematicreview and meta-analysis [87] examined seven ran-domized controlled studies evaluating the effectivenessof the GEMU for mortality, institutionalization, lengthof stay, functional decline, and readmission. All studiesused comprehensive geriatric assessment and multidis-ciplinary team models. GEMUs differed in their admis-sion processes (direct admission from home or emer-gency department or transfer from another hospitalunit), definition of frailty, and ambulatory follow-up.Meta-analysis showed significant reductions in institu-tionalization at 12 months (relative risk (RR) 0.78; 95%confidence interval (CI) 0.66–0.92) and functional de-cline at discharge (RR 0.87; 95% CI 0.77–0.99), with atrend toward a reduction in 12-month functional de-cline (RR 0.84; 95% CI 0.69–1.03) but no reductionin mortality, readmission, length of stay, or institu-tionalization at 3 or 6 months (Level C evidence). Thesmall number of studies evaluated precluded analysisof which patient characteristics had the most favorableeffect on outcomes.

Interventions for community-dwellingolder adultsMulticomponent interventions designed to preventfunctional decline in community-dwelling older adultsmay be useful for short-term prevention of some ad-verse outcomes (Level B evidence).

Beswick et al recently evaluated the effectiveness ofcommunity-based complex interventions designed topreserve physical function and independence in olderadults [88]. Studies (n = 89) were analyzed accordingto type of intervention (geriatric assessment of older

8




people, geriatric assessment of frail older adults, com-munity based care after hospital discharge, fall pre-vention, education, and counseling) and the outcomesexamined included hospital and nursing home admis-sion, physical function, and falls. Geriatric assessmentof elderly people without selection for frailty (n = 28)increased physical function (RR −0.12; 95% CI −0.16to −0.08) and decreased nursing home admission(RR 0.86, 95% CI 0.83–0.90), and falls (RR 0.76; 95%CI 0.67–0.86). When applied to populations selectedas frail (n = 24), geriatric assessment reduced the riskof hospital admission (RR 0.90; 95% CI 0.84–0.98) andimproved physical function (RR −0.05; 95% CI −0.06to −0.04). Interventions involving community-basedcare after discharge from hospital (n = 21) reducedthe risk of nursing home admission (RR 0.77; 95% CI0.64–0.91), but had no effect on hospital readmission.Interventions directed at fall prevention (n = 13) re-duced the risk of falls (RR 0.92; 95% CI 0.87–0.97)and improved physical function (RR −0.25; 95% CI−0.36 to −0.13). This was the only intervention groupthat resulted in reduced mortality (RR 0.79; 95% CI0.66–0.96). Interventions that focused on counselingand education (n = 3) increased the likelihood of im-proved physical function (RR −0.08; 95% CI −0.11to −0.06).

A systematic review by Daniels et al [89] evalu-ated two nutritional interventions and eight physicalexercise interventions designed to prevent disabilityin community-dwelling frail older adults. Nutritionalinterventions and single component physical exerciseprograms were not associated with reductions in dis-ability. Three trials using multicomponent long lastinghigh intensity physical exercise programs were asso-ciated with reductions in disability, expressed as lessdifficulty with BADLs and IADLs, with effects persist-ing at 9 and 12 months in two of the three trials. Sub-group analysis suggests that those with severe frailtydid not benefit from intervention as compared to thosewith mild or moderate frailty. These conclusions arecongruent with a contemporary systematic review ofphysical exercise training in frail older adults [90].

Home visitation programs may provide an effectivemodel by which to deliver multidisciplinary care for theprevention of functional decline in older adults (LevelB evidence). A meta-analysis evaluating 18 randomizedcontrolled trials of home-visit programs [91] found areduction in nursing home admission (RR 0.66; 95%

CI 0.48–0.92) in trials involving nine or more visits.Reductions in functional decline were noted in trialsthat used multidimensional assessment and follow-up(RR 0.76; 95% CI 0.64–0.91), and trials that were di-rected toward healthier populations (RR 0.78; 95% CI0.64–0.95). A mortality benefit was evident in patients>77.5 years (RR 0.76; 95% CI 0.65–0.88).

Interventions for long-term care residentsAlthough most research has been focused oncommunity-dwelling older adults living at home orduring acute hospital admission, a recent systematicreview examined the effectiveness of physical rehabili-tation for frail adults in long-term care [92]. Forty-ninetrials were identified, most of which involved 30 min-utes of intervention (usually exercise) for 12 weeks.Residents with cognitive impairment were excludedfrom 34 of the studies. Twelve of the 49 studies as-sessed longer term outcomes. Nine studies showedfunctional improvements, while 34 studies showed re-duction in activity restriction, most commonly relatedto improvement in walking (Level B evidence).

Clinical bottom linePrevention of functional decline in frail older adultsshould be a priority for hospitals, long-term care facil-ities, and in the community. It is important to screenan older patient’s risk for decline at the time of admis-sion to hospital. Multicomponent preventative inter-ventions appear to be of variable effectiveness

Chapter summary

Frailty can be thought of in terms of a phenotype oras an index. The frailty phenotype specifies five char-acteristics: (1) slowness, (2) weight loss, (3) impairedstrength, (4) exhaustion, and (5) low physical activity/energy expenditure. For a frailty index, typically a largenumber of items (40 or more) are counted and com-bined into a score. An individual’s frailty index scoreis the number of deficits that they have, divided bythe total number of deficits considered. A person willbe susceptible to adverse outcomes if they conform tothe frailty phenotype. Equally, a person will be frailif they have a frailty index score of 0.25 or higher.In both cases, the likelihood of susceptibility to ad-verse outcomes is related to the presence of functional

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