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Understanding frailty

Understanding frailty. Leicester Medical School. Simon Conroy Senior Lecturer/Geriatrician Prague 2009. Understanding frailty. The holy grail of geriatric medicine. Early identification of frailty Identification of ‘pre-frail’ Possibility of early interventions.

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Understanding frailty

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  1. Understanding frailty Leicester Medical School Simon Conroy Senior Lecturer/Geriatrician Prague 2009

  2. Understanding frailty

  3. The holy grail of geriatric medicine • Early identification of frailty • Identification of ‘pre-frail’ • Possibility of early interventions

  4. 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 – frail 1-2/5 – pre-frail 0/5 – non-frail

  5. 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 – frail 1/2 – pre-frail 0/2– non-frail

  6. 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.

  7. Frailty interventions • Screen – SOF/CHS • Assess – expanded frailty index • Intervene - ??

  8. Biology of Ageing

  9. 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

  10. 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

  11. Vascular ageing Frailty

  12. Frailty & human geography • Links with neighbourhood deprivation • Access to services

  13. 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

  14. 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…

  15. 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

  16. Admission rates from ED N=534 AMU bed occupancy 31% 18% 63% 70+ 10% Frail 40% 74% medicine 26% other speciality 75% 76% medicine 19% EDU ED attendances N=1723 25% children 57% adults 15% aged 70+ 3% frail, 70+

  17. AFU discharge rate AFU mortality 90 day readmissions from AFU 25/171 15% 3/171 2% 13/25 52% AFU outcomes, 4/10/8-27/10/8, n=171 AMU discharge rate AMU mortality 30 day readmissions 90 day readmissions 496/2988 17% 2988/6317 47% 52/6317 <0.01% 691/2988 23% 196/5208 4% 949/5208 18% ~1035 admissions in total: 171/1035=17% 239/949 25% 166/949 17%

  18. Summary • Frailty core business • Not well understood • Large collaborative studies required • Translational aspects critical

  19. Děkuji!

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