Frailty and Its Effect on the 4 M’s Joan Chang, DO Center for Healthy Aging

BACKGROUND/BIO Medical school- Philadelphia College of Osteopathic Medicine Internal medicine residency @ Good Samaritan Hospital in Baltimore, Maryland Geriatric fellowship @ Johns Hopkins School of Medicine Board certified in Geriatric Medicine, and Hospice and Palliative Care

DISCLOSURE None

Goals Understand frailty Management of frailty using the 4M’s Frailty and Palliative Care

Defining Frailty reserve and resistance to stressors, resulting from “A physiologic syndrome characterized by decreased reserve and resistance to stressors, resulting from cumulative decline across multiple physiologic systems, and causing vulnerability to adverse outcomes” Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-156.

Vulnerability of Frail Older Adult to Illness

Frailty as Physiologic Process 3 Adapted from Xue QL, Bandeen-Roche K, Varadhan R, et al. Initial manifestations of frailty criteria and the development of frailty phenotype in the Women’s Health and Aging Study II. J Gerontol A Biol Sci Med Sci 2008;63(9):984–90

Frailty as Physiologic Process Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-156.

Frailty as Physiologic Process

Primary Frailty Sarcopenia (loss of lean body mass) is a central component of frailty and a key predictor of the other clinical manifestations Predictors of sarcopenia and loss of strength with aging Decreased Anabolic factors such as testosterone and IGF-1 Diminished physical activity Reduced nutritional intake (e.g., protein, energy, vitamin D, and other micronutrients) Older age itself

Secondary Frailty A variety of primary diseases independently predict development of the frailty phenotype, potentially through inflammation and/or their effect on cardiopulmonary function and inactivity: Immune disorders (HIV/AIDS) Heart failure COPD Chronic infections (cytomegalovirus, tuberculosis)

Assessment of Frailty Assess number of phenotypic frailty criteria present (out of 5) Rapid screening/assessments that have been validated, such as the interview-based FRAIL scale Clinical Global Impression of Change in Physical Frailty (CGIC-PF): for frailty as a clinical composite or “gestalt” Walking speed or grip strength (early manifestations of frailty syndrome)

Management of Frailty using the 4M’s MEDICATION Avoid polypharmacy Review all medications

Management of Frailty using the 4M’s MENTATION

Management of Frailty using the 4M’s MOBILITY

Frailty with Trajectory from Health to Death 3

Management of Frailty using the 4M’s WHAT MATTERS

Frailty and Palliative Care Frailty predicts functional decline and onset and progression of dependency at the end of life Severe frailty, with a score of 4–5 and metabolic abnormalities of low cholesterol and albumin, predict particularly high short-term mortality rates in frail older adults Clinical case series suggest a poor response to treatment in those with end-stage frailty—it may be appropriate to consider palliative approaches for these patients

Summary Frail patients are at high risk of adverse clinical outcomes, including falls, disability and dependency, and mortality Frailty develops along a continuum of severity, likely including a latent phase that is not clinically apparent in the absence of stressors, early stages likely most responsive to intervention, and a late end-stage that indicates high risk of short-term mortality Using the 4M’s may help clinicians manage frailty The most effective preventive approach appears to be maintaining muscle mass and strength by exercising and consuming a Mediterranean diet

References Dent E, Kowal P, Hoodijk E Frailty measurement in research and clinical practice: A review. European Journal of Int Medicine 2016;31:3-10 Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56(3):M146–56. Gill TM, Gahbauer EA, Allore HG, et al. Transitions between frailty states among community-living older persons. Arch Intern Med 2006;166(4):418–23. Xue QL, Bandeen-Roche K, Varadhan R, et al. Initial manifestations of frailty criteria and the development of frailty phenotype in the Women’s Health and Aging Study II. J Gerontol A Biol Sci Med Sci 2008;63(9):984–90