What are we talking about? 14 th October 2015 Dr Jane Shoote Consultant Geriatrician

Worldwide population is ageing Impacts healthcare planning and provision The most problematic expression of population ageing is the clinical condition of FRAILTY Around 10% of over 65s have frailty Over 25 of over 85s have frailty (in some studies >50%)

“a state of increased vulnerability to stressors due to age-related declines in physiologic reserves across neuromuscular, metabolic, and immune systems” American Geriatric Society 2004

“a medical syndrome with multiple causes and contributors that is characterised by diminished strength, endurance, and reduced physiological function, that increases an individual’s vulnerability for developing increased dependency and/or death” J Am Med Dir Assoc 2013

Related to the ageing process Independently associated with adverse outcomes Common Progressive Episodic deteriorations Preventable components Impact quality of life Expensive Harrison J, Clegg A, Conroy S, Young J. Managing frailty as along-term condition. Age Ageing 2015;44:732-5.

Impacting quality of life

Clegg A, Young J, Iliffe S, Rikkert M, Rockwood K. Frailty in elderly people. Lancet. 2013; 381: Accelerated decrease in physiological reserve Failing homeostatic mechanisms

Clegg A, et al. Frailty in elderly people. Lancet. 2013; 381: 752 – 762.

Less muscle mass Sensation of increased effort Fewer physical activities Lower muscle mass Sarcopaenia

Frailty lies outside the comfort zone of Guideline Based Medicine

State of increased vulnerability Not an inevitable part of ageing Is a chronic condition May be made better or worse Identification is important and should form part of any health/social care interaction Read codes for CTV3: mild frailty = XabdY, moderate frailty = Xabdb, Severe frailty = Xabdd

1. Comprehensive geriatric assessment (CGA) ◦ Structured, multidisciplinary assessment 2. Simple assessment ◦ Gait speed ◦ Timed-up-and-go test (TUGT) ◦ PRISMA-7 Questionnaire 3. Routine data ◦ Electronic frailty index (eFI)

Gait speed Timed-up-and-go test (TUGT) PRISMA-7 questionnaire Sensitive but not specific Good to exclude those not frail Need further clarification on those positive

Requires a stop watch and 4 metre distance Median life expectancy 0.8 m/s > 5 seconds to walk 4 metres Good, valid, simple single tool to predict disability, long term care, falls, mortality Studies suggest target further examination of gait speeds slower than 0.6 m/s ?? Especially informative if no self report of  function For identifying frailty: Gait speed <0.8m/s = Sensitivity 0.99, specificity 0.64

TUGT > 10 seconds Positive predictive value = 0.17 Negative predictive value = 0.99 Very good for excluding frailty Similar to gait speed and PRISMA-7 would need further clarification of results For identifying frailty: TUGT>10s = Sensitivity 0.93, specificity 0.62

≥ 3 or above at risk Sensitivity 78.3% Specificity 74.7%S Used to identify those who may benefit more comprehensive assessment For identifying frailty: PRISMA-7 = Sensitivity 0.83, specificity 0.83

‘The more things that are wrong with you, the more likely you are to be frail’ Canadian study of health and ageing Simple calculation of the presence of absence of a variable Based on 92 baseline variables Cumulative effect of individual deficits 92 reduced to 36 without loss of predictability Rockwood K, Song X, Macknight C et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:

Validated using 500,000 patients >2000 Read codes Calculated as cumulative deficit model E.g. 18 deficits 18/36 = 0.5 Scoring: = Fit 0.13 – 0.24 = Mild Frailty 0.25 – 0.36 = Moderate Frailty >0.36 = Severe Frailty Runs through SystmOne Relates to the risk of adverse outcomes

 Activity limitation  Anaemia & haematinic deficiency  Arthritis  Atrial fibrillation  Cerebrovascular disease  Chronic kidney disease  Diabetes  Dizziness  Dyspnoea  Falls  Foot problems  Fragility fracture  Hearing impairment  Heart failure  Heart valve disease  Housebound  Hypertension  Hypotension/syncope  Ischaemic heart disease  Memory & cognitive problems  Mobility and transfer problems  Osteoporosis  Parkinsonism & tremor  Peptic ulcer  Peripheral vascular disease  Polypharmacy  Requirement for care  Respiratory disease  Skin ulcer  Sleep disturbance  Social vulnerability  Thyroid disease  Urinary incontinence  Urinary system disease  Visual impairment  Weight loss & anorexia > 2000 Read codes

CTV3 X76Ao| Frailty XabdY | Mild frailty Xabdb | Moderate frailty Xabdd | Severe Frailty Read V2 2jd.. | Frailty 2Jd0. | Mild frailty 2Jd1. | Moderate frailty 2Jd2. | Severe frailty

Young J Frailty is the future talk.

Predictive validity similar to Frailty Index Good correlation with other scales Unclear inter-rater reliability Best used with CGA and geriatrician Timely assessment Ongoing studies

Shi et al. Analysis of frailty and survival. BMC Geriatr. 2011;11:17.

Non-specific presentations Multiple co-morbidities Communication barriers Disability and complexity Recognition and interpretation 30 – 60% new dependency in ADLs following admission

Adverse outcomes Worsening disability Falls Admission to hospital Increasing length of stay Risk of admission to long term care Death

Mrs A a 78 year old lady with COPD and Type II diabetes, previous MI, depression and osteoarthritis……………. 11 drugs 10 possible further drugs recommended 9 lifestyle modifications advised 8–10 routine primary care appointments 8–30 psychosocial interventions Smoking cessation appointments Pulmonary rehabilitation Hughes et al. Guidelines for people not diseases. Age Ageing 2013;42:62-9.

BGS Spring 2015 Prof J Young, Dr E Burns Categorise numerically  Mildly frail – Supported Self Management  eg Age UK a practical guide to healthy ageing  Moderately frail – Care and Support Planning  eg CGA and care plan  Severely frail – anticipatory care planning  eg Case management, ACP and end of life care

Preventable components for ‘Frailty’ Affect (Mood problems) Alcohol excess Cognitive impairment Falls Functional impairment Hearing problems Nutritional compromise Physical inactivity Polypharmacy Smoking Social isolation and loneliness Vision problems Additional topics: Look after your feet Make your home safe Vaccinations Keep warm Get ready for winter Continence ………others……?? Stuck et al. Soc Sci Med (Systematic review of 78 studies)

Produced to help people improve their health and general fitness, particularly those aged 70 or over with ‘mild frailty’. To reorder this guide please order for free online via or call quoting reference HA2. Publication date 01/10/15.

“Right care, at the right time, in the right place” NHS England. Commissioning for carers principle 3

Improved access – The ‘Hot Phone’ ◦  Regular risk profiling / case finding Named accountable GP / Care co-ordinator Holistic care plan Internal reviews / MDTs of unplanned admissions

Clinicians and patient with LTC Collaborative approach to identify ◦ What is important to that individual ◦ Goals ◦ Support needs ◦ Action plans Progress is monitored Continuous process not a one-off event

Routes in Routes out Frailty Assessment Base Comprehensive Geriatric Assessment Dr, Nurse, Therapy, Dietician, Pharmacist ED ETT GP EAU phone Hot phone /Phone Seen within 48 hours Shared Care Plan Frailty Score Problem list Action plan Admitted Home ICB CHT CAT Voluntary sector DIST ACS Geriatrician follow-up Front loaded assessment and management plans FAB team ward follow-up Interface geriatrician case management FAB at a glance The future: Centre of excellence and resource Education and outreach Staff development (GP, ENP etc) Extended management via virtual ward Incorporation of falls and other clinics Full 7 day working Inreach to IHT wards

Hot Phone – advice/same day assessment – 2 working day review SHARE SystmOne record

Advanced frailty means EOL is close and should trigger a proactive care approach. People in their last year of life are admitted an average of 3.5 times 4 T’s - Reflective practitioner questions Think Frailty Timid – am I being timid? Timeliness – is this the right time? Time – do I need to make time? Uncertainty causes anxiety

Is important to prepare for and aim to postpone Important to recognise as a state of vulnerability to poor recovery from simple stressor events Failure to detect frailty potentially exposes patients to interventions from which they might not benefit and may be harmed Recognising advancing frailty should trigger a proactive care approach to EOL care planning

Secretary: Hot phone:

1. NHS England. Toolkit for general practice in supporting older people with frailty Report by the comptroller and auditor general. End of life care. HC 1043 Session | 26 November Morley et al. Frailty consensus: a call to action. J Am Med Dir Assoc 2013;14:392-7.