Leicester Medical School Understanding frailty - Kavli Senter
Leicester Medical School Understanding frailty - Kavli Senter Leicester Medical School Understanding frailty - Kavli Senter
Leicester Medical School Understanding frailty Simon Conroy Senior Lecturer/Geriatrician Bergen 2009
- Page 2 and 3: Understanding frailty
- Page 4 and 5: The holy grail of geriatric medicin
- Page 6 and 7: Frailty according to Fried • Sarc
- Page 11: Frailty according to Rockwood
- Page 14 and 15: • Externally valid • Objectivel
- Page 16 and 17: Biology of Ageing
- Page 18 and 19: Genetics • Few studies have looke
- Page 20 and 21: Frailty & human geography • Links
- Page 22 and 23: So much to do, so little time! …a
- Page 24 and 25: Everybody’s business • March 20
- Page 26 and 27: 1.00 0.00 0.25 0.50 0.50 0.75 Any r
- Page 28 and 29: Operationalising frailty • Aged 7
- Page 30 and 31: OPERATIONALISING FRAILTY DEFINITION
- Page 32 and 33: AMU Acute frailty unit In-patient C
- Page 34 and 35: Does it deliver? Patients aged 70+,
<strong>Leicester</strong> <strong>Medical</strong> <strong>School</strong><br />
<strong>Understanding</strong> <strong>frailty</strong><br />
Simon Conroy<br />
Senior Lecturer/Geriatrician<br />
Bergen 2009
<strong>Understanding</strong> <strong>frailty</strong>
High risk of<br />
Increased<br />
complications<br />
LOS<br />
Sarcopaenia<br />
IL-1<br />
Osteopaenia<br />
CRP<br />
Weight loss Vitamin D<br />
Non-specific<br />
End of<br />
presentations Frailty<br />
life care<br />
Ageing<br />
Comorbidity<br />
ADL ↓<br />
Cognition ↓<br />
Readmissions<br />
Mortality<br />
53% at one year<br />
37% at one year
The holy grail of geriatric medicine<br />
• Early identification of <strong>frailty</strong><br />
• Identification of ‘pre-frail’<br />
• Possibility of early interventions
Defining <strong>frailty</strong>…<br />
• Any patient lucky enough to be under<br />
the care of a geriatrician
Frailty according to Fried<br />
• Sarcopaenia<br />
– lowest quintile for hand-grip strength<br />
• Exhaustion<br />
– I felt that everything I did was an effort<br />
– I could not get going<br />
– I could not get going 3/5 – frail<br />
1-2/5 – pre-frail<br />
– self-reported unintentional weight loss of ≥ 5kg in the<br />
previous year<br />
0/5 – non-frail<br />
• Nutrient–energy imbalance<br />
• Slowness<br />
– slowest quintile for the time required to walk 2.4 meters<br />
• Low physical activity<br />
– lowest quintile for energy expended per week in leisure-time<br />
physical activities
Frailty according to SOF<br />
• Study of Osteoporotic Fracture Index<br />
– Weight loss<br />
2/2 – frail<br />
– Inability to rise from a chair five times<br />
1/2 – pre-frail<br />
without using the arms<br />
0/2– non-frail<br />
– Reduced energy (answer of “no” to the<br />
question “Do you feel full of energy?” on<br />
the Geriatric Depression Scale)
Frailty according to Rockwood
Problems with <strong>frailty</strong> rating scales<br />
• Frailty is dynamic<br />
– Reliability<br />
• Replicability<br />
• Limited in scope<br />
• Limited clinical acceptance<br />
• BUT, CHS scale has been used in<br />
biological studies<br />
• No interventional studies as yet1 • No interventional studies as yet<br />
1. Fairhall N, Aggar C, Kurrle SE, et al. Frailty Intervention Trial (FIT). BMC Geriatrics 2008;8:27.
• Externally valid<br />
• Objectively verifiable<br />
• Reliable<br />
• ??sensitive to<br />
• ??sensitive to<br />
change<br />
Sarcopaenia
Frailty interventions<br />
1. Screen – SOF/CHS/grip strength<br />
2. Assess – expanded <strong>frailty</strong> index,<br />
biomarkers<br />
3. Intervene - ??
Biology of Ageing
Oxidative stress<br />
• Reactive oxygen species (ROS) damage to<br />
DNA, proteins and lipid within ageing muscle<br />
cells → sarcopaenia<br />
• ROS levels associated with low grip strength<br />
& mortality<br />
• Candidate modifiable risk factors<br />
– smoking<br />
– dietary intake of carotenoids, ascorbate, selenium,<br />
plant polyphenols<br />
– exercise
Genetics<br />
• Few studies have looked at genetic determinants of <strong>frailty</strong><br />
• Multiple genes known to affect ageing or single or multiple<br />
domains of <strong>frailty</strong><br />
– DNA methylation/folate<br />
– Insulin/IGF1<br />
– Vitamin D<br />
– WRN helicase and lamin A (premature ageing)<br />
– Sirtuin genes<br />
– Antioxidants (superoxide dismutase, glutathione peroxidases)<br />
– Cardiovascular modifiers e.g. NO, RAS<br />
– Neurocognitive ageing e.g. ApoE<br />
• May identify pathways amenable to intervention
Frailty<br />
Sub-clinical CVD<br />
Vascular ageing<br />
Hypertension<br />
Cerebrovascular disease
Frailty & human geography<br />
• Links with<br />
neighbourhood<br />
deprivation<br />
• Access to<br />
services
Some unanswered health services<br />
research questions<br />
• Frailty & quality of life (Sealy Centre on Aging, Texas)<br />
• Frailty, social networks & carer strain<br />
• Frailty & cognition<br />
• Frailty and access to services<br />
• Frailty and health service resource use<br />
• Frailty in ethnic minorities<br />
• Delivering coordinated health care to frail<br />
• Delivering coordinated health care to frail<br />
older people
So much to do, so little time!<br />
…any patient lucky enough to be<br />
…any patient lucky enough to be<br />
under the care of a geriatrician
Clinical aspects of <strong>frailty</strong><br />
• ‘Frail older people should receive<br />
integrated comprehensive geriatric<br />
assessment’<br />
– Acute care<br />
Baztan 2009, Ellis 2005, Stuck 1993,<br />
Parker 2000<br />
• Yet increasing primary & secondary<br />
• Yet increasing primary & secondary<br />
health care split…
Everybody’s business<br />
• March 2007-March 2009<br />
– 10,583 individual patients admitted to LRI<br />
AMU aged 70+<br />
– ~60% of all AMU admissions<br />
– Mean age 83, 58% female<br />
– Median FU 157 days<br />
• 19% complex (HRG code “99”)
Complex older people do badly in<br />
hospital…<br />
Outcome Discharged Admitted Died<br />
Complex 81 (4%) 1785 (89%) 145 (7%)<br />
Non-complex 1639 (19%) 6554 (78%) 219 (3%)<br />
All (n=10423) 1720 (17%) 8339 (80%) 364 (3%)<br />
• Median (IQR) overall length of stay:<br />
• 9 (4-21) days for complex patients<br />
• 5 (2-12) days for non-complex older patients<br />
• p
1.00<br />
0.00 0.25 0.50 0.50 0.75<br />
Any readmission over time<br />
Kaplan-Meier survival estimates, by complex<br />
Hazard ratio 2.2<br />
0 200 400 600 800<br />
analysis time<br />
complex = No complex = Yes
0.00 0.25 0.50 0.50 0.75 1.00<br />
Deaths occurring early on<br />
Kaplan-Meier survival estimates, by complex<br />
Hazard ratio 4.2<br />
Adjusted (age & gender) 3.6<br />
0 200 400 600 800<br />
analysis time<br />
complex = No complex = Yes
Operationalising <strong>frailty</strong><br />
• Aged 70+<br />
• Patients with a fracture, who are<br />
medically unstable<br />
• Care home resident (nursing or<br />
residential)<br />
• Confusion (dementia or delirium)<br />
• Other patients scoring over 25 on the<br />
Waterlow Score
ED attendances<br />
N=1723<br />
25%<br />
children<br />
57% adults<br />
15%<br />
aged 70+<br />
3% frail, 70+<br />
31%<br />
Admission rates<br />
from ED<br />
N=534<br />
18%<br />
40%<br />
74% medicine<br />
26% other<br />
speciality<br />
75%<br />
76% medicine<br />
19% EDU<br />
AMU bed<br />
occupancy<br />
63%<br />
70+<br />
10%<br />
Frail
OPERATIONALISING FRAILTY DEFINITIONS IN THE EMERGENCY<br />
DEPARTMENT – A MAPPING EXERCISE<br />
C Ferguson, J Woodard, J Banerjee, S Conroy University of<br />
<strong>Leicester</strong><br />
Introduction<br />
Emergency departments (EDs) assess a large number of frail<br />
older patients every day, some of whom are subsequently<br />
admitted to acute medical Units (AMUs). Early identification of<br />
people who fit within this vulnerable group allows access to<br />
dedicated care pathways. We assessed the <strong>frailty</strong> status of<br />
older patients attending an emergency department with a set of<br />
simple operational criteria . This allowed us to evaluate the use<br />
of these criteria in clinical practice and to determine the<br />
proportion of patients admitted to AMU who are frail.<br />
Frailty:<br />
� fracture in a medically<br />
unstable patient<br />
� care home residency<br />
� confusion *<br />
� Waterlow score >25 †<br />
* Abbreviated Mental test-4 score 70 years<br />
attending one ED over a 5 day<br />
period (8am-10pm).<br />
Frailty was defined as the<br />
presence of more than 1 of 4<br />
criteria and was recorded along<br />
with demographics, geriatric<br />
syndromes and the final<br />
destination.<br />
100 %<br />
Results<br />
There were 1723 ED attendances in all, 256 aged > 70 years (mean age 82.5, range 69-<br />
99), 76 76 (43%) (43%) male). male).<br />
177/256 older patients were assessed; 52 (29%, 95% CI 23-37%) were classified as frail,<br />
with confusion being the most commonly met criterion (38/52, 73%). Frail older people<br />
comprised 3% (52/1723) of all ED patients and 48% (13/33) of those admitted to an<br />
AMU from ED were frail.<br />
The operational definition of <strong>frailty</strong> correlated well with the number of geriatric<br />
syndromes (Pearson’s coefficient 0.56, p
Primary care<br />
Prevention<br />
•GP reviews?<br />
•Falls prevention<br />
•Pharmacist reviews?<br />
•Care homes - CGA<br />
on admission<br />
ISAR ED AMU<br />
•Home visits<br />
Sn Sn Sn Sn Sn Sn Sn 94%,<br />
94%,<br />
•Dementia awareness<br />
•Advance care<br />
planning<br />
Sp Sp 58%<br />
58%<br />
Acute<br />
<strong>frailty</strong><br />
Sectorised<br />
•Community hospital<br />
•Matrons<br />
•Intermediate care<br />
•GP<br />
•Community<br />
geriatrician<br />
Necessary conditions<br />
•Communication<br />
•Education<br />
•Teamwork<br />
•Shared goals<br />
Identification Identification Identification of of Seniors Seniors at at at Risk<br />
Risk<br />
unit<br />
1. Before the illness or injury that brought you to the Emergency<br />
Department, did you need someone to help you on a regular basis?<br />
2. Since the illness or injury that brought you to the Emergency, have you<br />
needed more help than usual to take care of yourself?<br />
3. Have you been hospitalized for one or more nights during the past 6<br />
months (excluding a stay in the emergency department)?<br />
4. In general, do you see well?<br />
5. In general, do you have serious problems with your memory?<br />
6. Do you take more than three different medications every day?
AMU<br />
Acute<br />
<strong>frailty</strong><br />
unit<br />
In-patient<br />
CGA<br />
Sectorised<br />
Sectorised<br />
•Community Community Community hospital<br />
hospital<br />
•Matrons Matrons Matrons<br />
•Intermediate Intermediate Intermediate care<br />
care<br />
•GP GP<br />
•Community Community Community geriatrician<br />
geriatrician<br />
Integrated Integrated Integrated Integrated Integrated discharge discharge team<br />
team<br />
•Peripatetic Peripatetic team team<br />
team<br />
•Matron, Matron, Matron, geriatrician, geriatrician, geriatrician, geriatrician, geriatrician, geriatrician, geriatrician, physio, physio, OT<br />
OT<br />
•Must Must Must be be ‘authorised’<br />
‘authorised’
A<br />
M<br />
P<br />
M<br />
Interface geriatrics<br />
Geriatrician Geriatrician Geriatrician Geriatrician<br />
1 2 3 4<br />
ED/EDU Community AMU/AFU Community<br />
Community ED/EDU Community AMU/AFU<br />
• NIHR funded research underway<br />
• National conference 2010<br />
• http://www.bgs.org.uk/Notices/Event%20Downloads/0510Interface%20Geriatrics.pdf
Does it deliver?<br />
Patients aged 70+, coded as complex<br />
Historical controls<br />
(3/2007- 10/2008)<br />
AFU patients<br />
(10/2008-10/2009)<br />
Number of patients 1948 273<br />
Age 83.5 85.6<br />
Death in AMU 175/1948 (9%) 15/273 (5%)<br />
Discharge from AMU 88/1773 (5%)<br />
Length of stay<br />
(excludes<br />
n=1685<br />
discharged &<br />
Mean=16.6, SD 15.9<br />
deaths)<br />
23/258 (9%)<br />
Odds ratio 1.9 (1.1-3.1), p=0.009<br />
n=235<br />
Mean=12.4, SD 11.9<br />
Mean difference 4.2 days, p
Summary<br />
• Frailty core business<br />
• Not well understood<br />
• Large collaborative studies required<br />
• Translational aspects critical<br />
• Use <strong>frailty</strong> to speak to your managers,<br />
get them engaged, improve services