Frailty: its relevance to Transition Care Susan Kurrle Geriatrician, Hornsby Ku-ring-gai Health Service Curran Chair in Health Care of Older People, Faculty of Medicine, University of Sydney

Frailty: definitions Weak, not robust, having delicate health Weak, not robust, having delicate health Easily broken or damaged Easily broken or damaged –Macquarie Dictionary State of being weak in mind or body State of being weak in mind or body –Web dictionary Loss of physiological reserve, increased state of vulnerability to acute and chronic stressors Loss of physiological reserve, increased state of vulnerability to acute and chronic stressors –Assorted authors

Frailty: definitions A standardised “scientific” definition is still being established and several have been proposed A standardised “scientific” definition is still being established and several have been proposed Most health professionals use the word Most health professionals use the word –“I know it when I see it”

Frailty: definitions (Fried) Operationally defined as: A clinical syndrome in which three or more of the following are present: unintentional weight loss (10lbs/4.5kgs in last year) unintentional weight loss (10lbs/4.5kgs in last year) self-reported exhaustion self-reported exhaustion weakness (grip strength) weakness (grip strength) slow walking speed slow walking speed low physical activity low physical activity Fried et al. Frailty in older adults: evidence for a phenotype. J Geront 2001;56:M146-M156

Frailty: definitions (Rockwood & Mitnitski) Accumulated deficits leading to loss of reserve Accumulated deficits leading to loss of reserve Clearly related to morbidity and mortality Clearly related to morbidity and mortality Can be expressed as an Index (a count of deficits) OR Can be expressed as an Index (a count of deficits) OR Can be summarised as a scale from Robust to Terminally Ill Can be summarised as a scale from Robust to Terminally Ill Mitnitski et al. The mortality rate as a function of accumulated deficits in a frailty index. Mechanisms of Ageing and Development 123 (2002)

Frailty Index

Why is measurement of frailty important? Frailty predicts: Frailty predicts: –falls –ED visits and hospitalisation –entry into residential care –death Frailty stratification can predict risk of institutional care, or help plan interventions Frailty stratification can predict risk of institutional care, or help plan interventions

Why does frailty occur? No single process identified No single process identified Related to ageing Related to ageing Comorbidities important, but 25% of frail have no identified chronic disease Comorbidities important, but 25% of frail have no identified chronic disease Sarcopaenia (decreased muscle mass) Sarcopaenia (decreased muscle mass) Inflammatory markers, hormones, coagulation factors important Inflammatory markers, hormones, coagulation factors important 10% to 30% of frail people are obese 10% to 30% of frail people are obese

Is frailty treatable? Fried: Yes Fried: Yes –Improve physical function –Improve nutrition Rockwood: Yes Rockwood: Yes –Ameliorate deficits –Treat disease –Improve physiological reserve

Frailty Intervention Trial (FIT) Aim to identify frail older people and address their frailty symptoms and signs Aim to identify frail older people and address their frailty symptoms and signs FIT: FIT: –Community dwelling people aged >70yrs –Assessed using Fried Frailty criteria –RCT for participants assessed as frail with intervention of individually designed program addressing physical limitations, nutrition, comorbidities Frailty Intervention Trial (I Cameron, S Kurrle, S Lord, C Sherrington) NHMRC Grant

FIT Interim Results N = 91, mean age 82 yrs, 2/3 women N = 91, mean age 82 yrs, 2/3 women Defined as frail if 3 or more of: weight loss, low grip strength, slow walking speed, self reported exhaustion, low physical activity Defined as frail if 3 or more of: weight loss, low grip strength, slow walking speed, self reported exhaustion, low physical activity Defined as prefrail if 1 or 2 criteria Defined as prefrail if 1 or 2 criteria 63 (69%) frail at study commencement 63 (69%) frail at study commencement 28 (31%) prefrail at commencement 28 (31%) prefrail at commencement

FIT Interim Results Change from 63 (69%) frail to 42 (46%) frail at 3 months (p<0.01) Change from 63 (69%) frail to 42 (46%) frail at 3 months (p<0.01) Walking speed increased from 0.50m/sec to 0.54m/sec (p=0.046) Walking speed increased from 0.50m/sec to 0.54m/sec (p=0.046) No significant change in Barthel Index, or EQ5D No significant change in Barthel Index, or EQ5D

FIT Interim Conclusions Components of frailty can change quite rapidly with an appropriate intervention Components of frailty can change quite rapidly with an appropriate intervention Measures of functioning and QOL may change more slowly Measures of functioning and QOL may change more slowly Don’t give up on frail patients, consider longer term, slow stream rehabilitation programs in the home for these patients Don’t give up on frail patients, consider longer term, slow stream rehabilitation programs in the home for these patients

FIT: Frailty into the future How much can strength and mobility improve? How much can strength and mobility improve? How can improvements be translated into important activities eg getting out of the house, seeing family and friends? How can improvements be translated into important activities eg getting out of the house, seeing family and friends? Does improvement in frailty mean less health and support service use, or less use of residential care? Does improvement in frailty mean less health and support service use, or less use of residential care?