Frailty: what, who and why do we care?

1. Frailty: what, who and why do we care? Jane F Potter, MD

2. I have no conflicts of interest with respect to any product or commercial interest .

3. Objectives • Understand what frailty is and why it is important to patient outcomes • Learn how to identify frail patients in practice • Be able to apply evidence based interventions to improve outcomes in frail patients.

4. Objective 1 • Understand what frailty is and why it is important to patient outcomes • What is it? • What causes it? • Why is it important?

5. Overview: What Is It? Walston, ““The biological basis of frailty has been difficult to establish owing to the lack of a standard definition, its complexity, and its frequent coexistence with illness.”

6. Overview: What Is It? van den Beld and Lamberts, “frailty is characterized by generalized weakness, impaired mobility and balance and poor endurance. Loss of muscle strength is an important factor in the process of frailty, and is the limiting factor for an individual’s chances of living an independent life until death.”

7. Frailty: What is it? Definition: • vulnerability which precedes disability • physiologic decline in multiple body systems marked by loss of function • loss of physiologic reserve • increased vulnerability to disease and death.

8. Frailty: What causes it? • Dimensions- physical, social, cognitive, psychological, co-morbidities • Physiologic correlates: weakness, fatigue • Sarcopeniais likely a key component

9. Sarcopenia • Loss of skeletal mm mass & strength with aging • Visceral- may also be important in frailty • NHANES prevalence of sarcopenia >60 yrs 10% women, 7% men Images From Microsoft Clip Art

10. What might cause weakness and fatigue? • Endocrine changes • Effects of inflammation • Interaction of systemic changes Image From Microsoft Clip Art

11. Endocrine changes DECREASES in: • Estrogen and testosterone • Dehydroepiandosterone, DHEA • Growth hormone • Insulin-like growth factor 1, IGF-1 • Cortisol(loss of diurnal variation) • Vitamin-D

12. Women’s Health & Aging Study Vitamin D • Odds of frailty if: • deficient (< 15) = 2.5 • insufficient (15-30) =3.6 • All other studies examining Vit D find it is a risk factor Image From Microsoft Clip Art

13. Women’s Health & Aging Study • IGF-1, DHEAS , and free testosterone • If one deficiency not more likely to be frail • If 2 or 3 deficiencies likelihood of being frail increased almost 3 fold (OR=2.79)

14. Inflammation: Duke EPESE • Both high IL-6 and D-dimer increase mortality; • Those with both have highest mortality and greatest functional decline Image From Microsoft Clip Art

15. What Might Cause Weakness and Fatigue? Inflammation in frail people: • IL-6 ↑ • CRP ↑ May cause • Catabolism • Anorexia, ↓ GH & IGF-1 Image From Microsoft Clip Art

16. Effects of Inflammation ↑ IL-6 strongly associated with: • Weight loss, • Sarcopenia • Susceptibility to infection Image From Microsoft Clip Art

17. Effects of Inflammation • Contributes to anemia by : • directly inhibiting production of erythropoietin • or by interfering with normal iron metabolism

18. Effects of Inflammation Chronic inflammation may: • Trigger coagulation cascade Frail elderly have higher levels of: • Factor VIII, • Fibrinogen • D-dimer

19. What might cause weakness and fatigue? Interaction of: • Endocrine changes • Inflammation • Systemic changes

20. INTERACTING FACTORS IN FRAILTY ENDOCRINE CHANGES FRAILTY SARCOPENIA ANEMIA CLOTTING INFLAMMATORY MARKERS Espinoza & Walston, 2005

21. Frailty: Why is it important? High Prevalence • 20–30% over 75 years • 30% after 80 years • Twice as common in women • 28% of moderately-severely disabled women ≥65 Image From Microsoft Clip Art

22. Frailty: Why is it important? Predicts outcomes • Falls, fractures • Hospitalization • Mortality • Institutionalization

23. Frailty: Why is it important? One characteristic of frailty that distinguishes it from aging is the potential reversibility of many of its features.

24. Objective 2 Learn how to identify frail patients in practice Many Definitions & Tools Have Been Proposed

25. Identifying Frailty Chin 1999 Frailty= inactivity combined with: • low energy intake or • weight loss or • low body mass index

26. Identifying Frailty • Gait speed alone & with chair stands, & tandem balance test • Predicts 12-mo rates of hospitalization, ↓ health, and ↓ function • Proposed: “vital signs” to screen older adults Medicare HMO & VA, 2003

27. Canadian Study of Health & Aging • Frailty is identified by counting accumulation of deficits in: cognition, mood, motivation, communication, mobility, balance, bowel & bladder function, ADL, IADL, nutrition, social resources, and comorbidities • Highly predictive of death or institutionalization Image From Microsoft Clip Art

28. The French Three-City Study • The frail scored lower on MMSE and IST than the prefrail and nonfrail. • Frail with cognitive impairment were more likely to develop disability in ADLs and IADLs over 4 yrs. • Cognitive impairment improves prediction of frailty, because it ↑risk of adverse outcomes. Image From Microsoft Clip Art

29. Cardiovascular Health Study, 2001 • Frailty= a syndrome with a critical mass of signs and symptoms. Three out of five: • Slow walking speed • Poor hand grip • Exhaustion • Weight loss • Low energy expenditure

30. CHSFRAILTY Criteria Images From Microsoft Clip Art

31. Study of Osteoporotic Fracture (SOF) • CHS criteria are unrealistic for clinical use • SOF tested simpler criteria in both men & women. • Exclusion inability to walk without the assistance of another person • CHS and SOF were concordant in 71% • SOF is easily evaluated in a few minutes

32. Comparison Of Frailty Indexes

34. Objective 3 Be able to apply evidence based interventions to improve outcomes in frail patients.non-pharmacologic and Pharmacologic interventions

35. Symptom relief Set patient centered goals Family & caregiver support From Espinoza & Walston Exercise Interventions CGA, GEM, PACE, ACE Hospice, comfort & dignity INCREASINGLY FRAIL

36. Interventions: Assessment • Inpatient CGA improves functional outcomes • Outpatient CGA improves mental health • Neither affect survival • No increase in cost VA Population

37. Interventions: Assessment • ≥ 70 yrs at risk for hospital admission • CGA group less likely to: • Lose functional ability • Have restrictions in ADLs • Have depressive symptoms • Use HHC services • Mortality & Medicare payments not differ. Intervention cost $1,350/person. • CONCLUSION: Targeted outpatient CGA slows functional decline. Medicare Population

38. Complex Interventions: meta-analysis • Randomized trials of 97,984 pts. • Interventions reduced risk of :not living at home, NH & hospital admits & falls (not death); & physical function was better • In populations with increased death rates, interventions were associated with reduced nursing-home admission. • Interpretation: Complex interventions help elderly live safely & independently. • Lancet 2008

39. What Were the Interventions? • Geriatric assessment of general elderly people • Geriatric assessment of elderly people selected as frail • Community-based care after hospital discharge • Falls prevention programs • Group education and counseling

40. INTERACTING FACTORS IN FRAILTY ENDOCRINE CHANGES FRAILTY SARCOPENIA ANEMIA CLOTTING INFLAMMATORY MARKERS

41. Sarcopenia • Total body protein= muscle + visceral • Declines with age, faster after 65 yrs • Major contributor is disuse atrophy Image From Microsoft Clip Art

42. Sarcopenia Protein • Inadequate protein & calories • ↑ body fat masks sarcopenia • Sarcopenia in NHANES > 60 yrs • 10 % women • 7 % men Image From Microsoft Clip Art

43. Aging of skeletal muscle

44. Nutritional components of frailty in selected studies

45. Interventions for Sarcopenia Randomized, placebo-controlled trialprogressive resistance exercise training, multinutrientsupplement, both, and neither in 100 frailNH residents over 10-wks Nursing Home (NH) Residents Image From Microsoft Clip Art

46. Outcomes for Resistance Training NH Residents, Age ≈ 87 yrs Resistance training: • ↑muscle strength >100% • ↑ LE muscle size 3% • ↑ gait velocity 12% • ↑ mobility • ↑spontaneous activity Image From Microsoft Clip Art

47. Sarcopenia and Hip Fracture Study: • 5-yr prospective cohort study admitted to hospitals for hip fracture. • 193 participants enrolled • 71% were sarcopenic, 58% undernourished, and 55% vitamin D deficient. • Poorer nutrition & walking endurance, greater pre-fracture disability and inactivity predicted ↑ length of hospital stay

48. Therapy for Functional Decline • Frail: • Fails chair rise without using arms, or • Slow 6 meter walk (>10 seconds) • Intervention: 6 mo home-based PT to improve function, balance, muscle strength, transfers and mobility vs control education program. • Outcome: change in function score at 3, 7 & 12 months. Intervention significantly slowed functional decline Home Based Frail Gill

49. Exercise Reducing Disability Systematic Review: What works? • Multicomponent: endurance, flexibility, balance, strength • Duration: 3, 9, 12 mos. • Intensity: 2-3 supervised/week, with/without daily home program www.biomedcentral.com/1472-6963/8/278

50. Group-Based Exercises Reduce Fall Risk: and is maintained • 98 women, 75-85 with low bone mass. • Interventions: 6 mo resistance or agility training, or general stretching • Primary outcome= fall risk • Fall risk at end of 12 mo • 43.3% lower with resistance training • 40.1% lower in the agility-training • 37.4% lower in the general stretching group