Management of frailty: “we are not alone” John Young Professor of Elderly Care Medicine, Academic Unit of Elderly Care & Rehabilitation, Bradford & University of Leeds (john.young@bthft.nhs.uk)

So where does frailty fit in? Some bad news It’s not a disease Some more bad news It affects the whole body Even more bad news Every person is different The worst of news Several things wrong at once A frailty focus is the potential key to unlock our current system failure

Populations are getting older 2015 2050

“We are not alone” ADVANTAGE (managing frailty) European Union Joint Action Programme Addresses common challenges where shared action at an EU level may facilitate national frailty prevention policies. (https://ec.europa.eu/digital-single-market/en/news/new-joint-action-frailty-launched)   European Innovation Partnership (EIP) on Active and Healthy Ageing Yorkshire and Humber is a reference site. (http://www.scale-aha.eu/rs2016-results.html) Canadian Frailty Network (http://www.cfn-nce.ca/)

Healthy Ageing Strategy: New Zealand (2016) Example ‘goals’: Increase physical and mental resilience Reduce inappropriate acute admissions Support effective rehabilitation closer to the home Explore the possibilities for a frailty identification tool Better integrate services or people living in residential care Improve medicines management

A little known fact about frailty………..

“Frailty is slippery when wet” A little known fact about frailty……….. “Frailty is slippery when wet”

Cacophony of Frailty Definitions: Many, many definitions of frailty in the literature “We don’t know what frailty is” It has indeed been difficult to nail frailty down Is it a syndrome or an (abnormal) health state?

DEFINITIONS OF ‘COPD’ 1997: “A slowly progressive disorder characterised by airways obstruction … which does not change markedly over several months” 2015: “… characterised by persistent airflow limitation that is usually progressive and is associated with an enhanced chronic inflammatory response in the airways…”

DEFINITIONS OF COMMON CHRONIC CONDITIONS WIGGLE AND WOBBLE OVER TIME e.g. CHF DIABETES DEMENTIA DEPRESSION etc… AND, DON’T GET ME STARTED ON LYMPHOMAS! FRAILTY IS NO EXCEPTION GET OVER IT!

“Slippery when wet!”

“Not so slippery when wet!”

Hugely similar; not actually much difference Cacophony of Frailty Definitions: Many, many definitions of frailty in the literature “We don’t know what frailty is” But …… but …… but….. Hugely similar; not actually much difference

WHO Definition of frailty (2015): “Frailty is a progressive age-related decline in physiological systems that results in decreased reserves of intrinsic capacity, which confers extreme vulnerability to stressors and increases the risk of a range of adverse health outcome.”

So, we have a definition, we also have over 20 years of research Two international theoretical models for frailty: (Fried) Phenotype model (Rockwood) Cumulative deficit model (eFI)

Phenotype Frailty Model (Cardiovascular Health Study [n=5,210] Fried et al 2001) Weight loss: > 4.5kg or > 5% per year Fatigue: US Centre for Epidemiological Studies Depression Scale Sedentary Life: < 383 Kcal/week men < 270Kcal/week women Slow gait speed: Standardised cut-off times to walk 4.57m stratified by sex & height Weakness: Dynamometer measurement stratified by sex & BMI International research standard but difficult to implement in routine care (http://frailclinic.eu/index.htm) 262 different versions of Phenotype model (Theou et al., 2015)

Cumulative Deficit Model of Frailty: Frailty Index (Rockwood et al) “The more things that are wrong with you, the more likely you are to be frail” Frailty Index counts “deficits” A deficit is a thing that is wrong with you (symptom, sign, disease or disability) Frailty Index = the proportion of deficits accumulated over time Simple calculation: Zero deficits from list of 50: FI = 0/50 = 0 Ten deficits from list of 50: FI = 10/50 = 0.20 Frailty Indexes successfully replicated internationally (Mexico, China, Canada, Europe etc. …)

Diagnostic Test Accuracy (DTA) for simple frailty instruments (Systematic Review) 4 meters More than 5 seconds Sensitivity Specificity Gait Speed <0.8m/s 99% 64% Gait Speed <0.7m/s 93% 78% TUGT >10s 62% PRISMA 7 83% 83% (wide CIs) Self-reported Health 72% (wide CIs) Groningen Frailty Indicator 58% 72% Polypharmacy (>5 meds) 67% GP clinical assessment (Frailty instruments assessed against a reference standard) (Clegg, Teale, Young. Age Ageing 2014)

Can these good practices be transferred to the community? Comprehensive Geriatric Assessment (CGA) associated with improved outcomes for older people with frailty (Cochrane review 2017; 29 RCTs; 13,766 participants) Can these good practices be transferred to the community? Comprehensive, multi-disciplinary assessment Appropriate skills, training & attitudes Prevention of complications (esp. loss of independence) Promotion of independence Person-centred care

Integrated Primary Care Models Review by Béland et al. (2011) 9 studies 7 studies reported reduced hospital bed days and/or reduced long-term care Key care components identified

Key Care Components for Integrated Primary Care Models Clear eligibility Single entry point Individual assessment & care plan Electronic information tool Case management & coordination of care Clear policies [Consistent with Integrated care for older people with complex needs (Review of 7 international case studies) Kings Fund 2017]

Frailty: conclusions Less slippery when wet than you might think! Two reference standard theoretical models Detection of frailty possible using simple tools Potentially successful primary care systems for people with frailty are being developed

Thank you!