Frailty Cara Hanley November 2016

Not just an inevitable part of ageing Frailty ”a clinically recognizable state of increased vulnerability resulting from age-associated decline in physiological reserve and function, such that the ability to cope with everyday or acute stressors is compromised” (Xue 2011) From Clegg et al. 2013 Not just an inevitable part of ageing

Frailty Chronic illness Disability

Consequences of Frailty Falls (1/3 >65y, ½ >80y annually; £2b/year; 4m bed days) Injuries Worsening disability Acute Illness Hospital admission Care Home Admission Mortality

Recognising Frailty Frailty phenotype (Fried et al, 2000) Describes a group of patient characteristics which, if present, can predict poorer outcomes Rockwood Model (Rockwood et al, 2005) Deficit model which assumes an accumulation of deficits (ranging from symptoms/signs/disease) that can occur with ageing and which combine to increase the frailty index which correlates with risk of adverse outcomes Geriatric Giants (falls, immobility, delirium, incontinence, infection)

“Clinical consensus phenotype” Characteristics include Muscle wasting/sarcopenia Weight loss (unexplained) Loss of endurance Decreased balance and mobility (falls) Slowed performance Relative inactivity Instability of chronic disease >3 = “Frailty”

Common problems in frailty Falls Cognitive Impairment Continence Mobility Weight loss and poor nutrition Polypharmacy Physical inactivity Low mood Alcohol excess Smoking Vision difficulties Social isolation loneliness

How do we look for frailty? 7 studies that identify frailty (British Geriatric Society) Walking speed Timed up & go test PRISMA 7 questionnaire self-reported health GP assessment Polypharmacy Groningen frailty indicator questionnaire + Clinical presentation of the individual

How do we manage frailty? Comprehensive Geriatric Assessment Gives a framework for instigation of intervention Proven to increase the likelihood of a patient returning home and avoiding admission to care home or deterioration (Ellis et al 2011)

Comprehensive Geriatric Assessment Medical C0-morbidities, Medication Review, Nutritional status, Problem list Mental Health Cognition, Mood and Anxieties, Fears Functional Capacity Basic/Instrumental ADLs, Gait and Balance, Activity/Exercise status Social Circ. Informal Support, Social Network, Eligibility for care resources Environment Home comfort, facilities, safety, transport facilities, access to resources

Comprehensive Geriatric Assessment Main Principles Ensure patient centeredness Assess patients capacity to participate voluntarily; if lacking there needs to be a system to address their needs ethically Links between social care and healthcare should be established in a timely and efficient manner, proportionate to degree of need Assessments should be standardised Specific situations that warrant a complete assessment Acute illness associated with significant change in functional ability Transfers of care for rehabilitation, re-enablement or continuing care Frail patient prior to surgery Frail patients experiencing two or more “geriatric syndromes” (falls, delirium, incontinence, immobility)

Summary Frailty is a spectrum; varies in severity a dynamic process; can be made better or worse Not an inevitable part of ageing Frailty syndromes can mask serious underlying illness Falls should not be considered as a non-urgent situation Need to assess the patient in a holistic manner to support recovery/rehabilitation and to minimise future risk of adverse outcomes

References Clegg et al. Frailty in elderly people. The Lancet 2013;382:19-25. Ellis G, Whitehead M, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011; 343d6553. Fit for Frailty - consensus best practice guidance for the care of older people living in community and outpatient settings - a report from the British Geriatrics Society 2014 Fried et al. Frailty in older adults; evidence for a phenotype. Journal of Gerontology 2001;56(3):M146-157. Lang PO, Michel JP, Zekry D. Frailty syndrome: a transitional state in a dynamic process. Gerontology 2009;55(5):539-49. Rockwood K, Song X, MacKnight C, Bergman H, Hogan D, McDowell I, Mitnitski A. A global clinical measure of fitness and frailty in elderly people. Canadian Medical Association Journal 2005;173(5):489-495. Xue Q. The Frailty Syndrome: Definition and Natural History. Clin Geriatr Med 2011;27:1-15