Leicester Medical School Understanding frailty - Kavli Senter

Leicester Medical School
Understanding frailty
Simon Conroy
Senior Lecturer/Geriatrician
Bergen 2009

Understanding frailty

High risk of
Increased
complications
LOS
Sarcopaenia
IL-1
Osteopaenia
CRP
Weight loss Vitamin D
Non-specific
End of
presentations Frailty
life care
Ageing
Comorbidity
ADL ↓
Cognition ↓
Readmissions
Mortality
53% at one year
37% at one year

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

Defining frailty…
• Any patient lucky enough to be under
the care of a geriatrician

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
– I could not get going 3/5 – frail
1-2/5 – pre-frail
– self-reported unintentional weight loss of ≥ 5kg in the
previous year
0/5 – non-frail
• Nutrient–energy imbalance
• 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

Frailty according to SOF
• Study of Osteoporotic Fracture Index
– Weight loss
2/2 – frail
– Inability to rise from a chair five times
1/2 – pre-frail
without using the arms
0/2– non-frail
– Reduced energy (answer of “no” to the
question “Do you feel full of energy?” on
the Geriatric Depression Scale)

Frailty according to Rockwood

Problems with frailty rating scales
• Frailty is dynamic
– Reliability
• Replicability
• Limited in scope
• Limited clinical acceptance
• BUT, CHS scale has been used in
biological studies
• No interventional studies as yet1 • No interventional studies as yet
1. Fairhall N, Aggar C, Kurrle SE, et al. Frailty Intervention Trial (FIT). BMC Geriatrics 2008;8:27.

• Externally valid
• Objectively verifiable
• Reliable
• ??sensitive to
• ??sensitive to
change
Sarcopaenia

Frailty interventions
1. Screen – SOF/CHS/grip strength
2. Assess – expanded frailty index,
biomarkers
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

Frailty
Sub-clinical CVD
Vascular ageing
Hypertension
Cerebrovascular disease

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
• Delivering coordinated health care to frail
older people

So much to do, so little time!
…any patient lucky enough to be
…any patient lucky enough to be
under the care of a geriatrician

Clinical aspects of frailty
• ‘Frail older people should receive
integrated comprehensive geriatric
assessment’
– Acute care
Baztan 2009, Ellis 2005, Stuck 1993,
Parker 2000
• Yet increasing primary & secondary
• Yet increasing primary & secondary
health care split…

Everybody’s business
• March 2007-March 2009
– 10,583 individual patients admitted to LRI
AMU aged 70+
– ~60% of all AMU admissions
– Mean age 83, 58% female
– Median FU 157 days
• 19% complex (HRG code “99”)

Complex older people do badly in
hospital…
Outcome Discharged Admitted Died
Complex 81 (4%) 1785 (89%) 145 (7%)
Non-complex 1639 (19%) 6554 (78%) 219 (3%)
All (n=10423) 1720 (17%) 8339 (80%) 364 (3%)
• Median (IQR) overall length of stay:
• 9 (4-21) days for complex patients
• 5 (2-12) days for non-complex older patients
• p

1.00
0.00 0.25 0.50 0.50 0.75
Any readmission over time
Kaplan-Meier survival estimates, by complex
Hazard ratio 2.2
0 200 400 600 800
analysis time
complex = No complex = Yes

0.00 0.25 0.50 0.50 0.75 1.00
Deaths occurring early on
Kaplan-Meier survival estimates, by complex
Hazard ratio 4.2
Adjusted (age & gender) 3.6
0 200 400 600 800
analysis time
complex = No complex = Yes

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

OPERATIONALISING FRAILTY DEFINITIONS IN THE EMERGENCY
DEPARTMENT – A MAPPING EXERCISE
C Ferguson, J Woodard, J Banerjee, S Conroy University of
Leicester
Introduction
Emergency departments (EDs) assess a large number of frail
older patients every day, some of whom are subsequently
admitted to acute medical Units (AMUs). Early identification of
people who fit within this vulnerable group allows access to
dedicated care pathways. We assessed the frailty status of
older patients attending an emergency department with a set of
simple operational criteria . This allowed us to evaluate the use
of these criteria in clinical practice and to determine the
proportion of patients admitted to AMU who are frail.
Frailty:
� fracture in a medically
unstable patient
� care home residency
� confusion *
� Waterlow score >25 †
* Abbreviated Mental test-4 score 70 years
attending one ED over a 5 day
period (8am-10pm).
Frailty was defined as the
presence of more than 1 of 4
criteria and was recorded along
with demographics, geriatric
syndromes and the final
destination.
100 %
Results
There were 1723 ED attendances in all, 256 aged > 70 years (mean age 82.5, range 69-
99), 76 76 (43%) (43%) male). male).
177/256 older patients were assessed; 52 (29%, 95% CI 23-37%) were classified as frail,
with confusion being the most commonly met criterion (38/52, 73%). Frail older people
comprised 3% (52/1723) of all ED patients and 48% (13/33) of those admitted to an
AMU from ED were frail.
The operational definition of frailty correlated well with the number of geriatric
syndromes (Pearson’s coefficient 0.56, p

Primary care
Prevention
•GP reviews?
•Falls prevention
•Pharmacist reviews?
•Care homes - CGA
on admission
ISAR ED AMU
•Home visits
Sn Sn Sn Sn Sn Sn Sn 94%,
94%,
•Dementia awareness
•Advance care
planning
Sp Sp 58%
58%
Acute
frailty
Sectorised
•Community hospital
•Matrons
•Intermediate care
•GP
•Community
geriatrician
Necessary conditions
•Communication
•Education
•Teamwork
•Shared goals
Identification Identification Identification of of Seniors Seniors at at at Risk
Risk
unit
1. Before the illness or injury that brought you to the Emergency
Department, did you need someone to help you on a regular basis?
2. Since the illness or injury that brought you to the Emergency, have you
needed more help than usual to take care of yourself?
3. Have you been hospitalized for one or more nights during the past 6
months (excluding a stay in the emergency department)?
4. In general, do you see well?
5. In general, do you have serious problems with your memory?
6. Do you take more than three different medications every day?

AMU
Acute
frailty
unit
In-patient
CGA
Sectorised
Sectorised
•Community Community Community hospital
hospital
•Matrons Matrons Matrons
•Intermediate Intermediate Intermediate care
care
•GP GP
•Community Community Community geriatrician
geriatrician
Integrated Integrated Integrated Integrated Integrated discharge discharge team
team
•Peripatetic Peripatetic team team
team
•Matron, Matron, Matron, geriatrician, geriatrician, geriatrician, geriatrician, geriatrician, geriatrician, geriatrician, physio, physio, OT
OT
•Must Must Must be be ‘authorised’
‘authorised’

A
M
P
M
Interface geriatrics
Geriatrician Geriatrician Geriatrician Geriatrician
1 2 3 4
ED/EDU Community AMU/AFU Community
Community ED/EDU Community AMU/AFU
• NIHR funded research underway
• National conference 2010
• http://www.bgs.org.uk/Notices/Event%20Downloads/0510Interface%20Geriatrics.pdf

Does it deliver?
Patients aged 70+, coded as complex
Historical controls
(3/2007- 10/2008)
AFU patients
(10/2008-10/2009)
Number of patients 1948 273
Age 83.5 85.6
Death in AMU 175/1948 (9%) 15/273 (5%)
Discharge from AMU 88/1773 (5%)
Length of stay
(excludes
n=1685
discharged &
Mean=16.6, SD 15.9
deaths)
23/258 (9%)
Odds ratio 1.9 (1.1-3.1), p=0.009
n=235
Mean=12.4, SD 11.9
Mean difference 4.2 days, p

Summary
• Frailty core business
• Not well understood
• Large collaborative studies required
• Translational aspects critical
• Use frailty to speak to your managers,
get them engaged, improve services