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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

Understanding frailty

Leicester Medical School

Simon Conroy

Senior Lecturer/Geriatrician

Prague 2009

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

frailty according to sof
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

problems with frailty rating scales
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.

frailty interventions
Frailty interventions
  • Screen – SOF/CHS
  • Assess – expanded frailty index
  • Intervene - ??
oxidative stress
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
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 human geography
Frailty & human geography
  • Links with neighbourhood deprivation
  • Access to services
some unanswered health services research questions
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
operationalising frailty
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…
operationalising frailty1
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
slide19

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+

slide20

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%

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