1. The care of acutely ill frail older adults
Kenneth Rockwood
Professor of Geriatric Medicine
Dalhousie University
Halifax (the one in Canada)

2. Disclosures
Through Dalhousie’s Industry Liaison Office, I have asserted copyright of the Clinical Frailty Scale, made freely available for education, research & not-for-profit health care. Users are asked not to change or commercialize it.
I founded DGI Clinical Inc., which provides outcome measures & data analytics to pharma.
Routinization of frailty actions in our hospital remains aspirational; we’re operator dependent.

3. Objectives Describe criteria for frailty in older adults
Describe the concept of accumulation of deficits in the context of frailty.
Understand the implications of frailty for a vulnerable older adult.
Describe strategies to evaluation and manage frail older adults when acutely ill.

4. The older people are the more likely they are to die…
Log scale
0.368
0.135
0.050
0.018
0.007
0.002
100 10 20 30 40 50 60 70 80 90
100
But individuals do not die from old age. They accumulate different health problems, become more vulnerable
More vulnerable they become, more likely they die, and this occurs with age
The rate of mortality is a measure of the number of deaths in a population, scaled to the size of that population, per unit time. The rate of mortality is presented in the natural scale (Panel A) and in the logarithmic scale (Panel B). The linear part of the graph (after about years) corresponds to the exponential increase of the rate of mortality (the Gompertz law) indicated by the straight line (Panel B).
Age (years)
Statistics Canada: Canadian birth cohort

5. … but not everyone of the same age has the same risk of death
Log scale
0.368
0.135
0.050
0.018
0.007
0.002 10 20 30 40 50 60 70 80 90
100
But individuals do not die from old age. They accumulate different health problems, become more vulnerable
More vulnerable they become, more likely they die, and this occurs with age
The rate of mortality is a measure of the number of deaths in a population, scaled to the size of that population, per unit time. The rate of mortality is presented in the natural scale (Panel A) and in the logarithmic scale (Panel B). The linear part of the graph (after about years) corresponds to the exponential increase of the rate of mortality (the Gompertz law) indicated by the straight line (Panel B).
Age (years)
Statistics Canada: Canadian birth cohort

6. Case: An 84 year old woman in the ER
Came by ambulance. Neighbour called 911, as woman was not answering her telephone. Confused, agitated, has a cough. Living alone.
Pulse 140(ish); bp = 100/40; Sa02=90%, T=37.9C WBC=16,000; 78%neutrophils Cr=145; Na+130;K+3.0 CXR=RML pneumonia ECG = A fib; non-specific ST-T

7. What now? Give haloperidol for agitation. Obtain CT head.
Cardiovert the atrial fibrillation.
All of the above.
None of the above.

8. Frailty as unmeasured hetereogeneity
Vaupel J, Manton K, Stollard E. The impact of heterogeneity in individual frailty on the dynamics of mortality. Demography 1979; 16:439-54
Missoy & Vaupel. Society for Industrial & Applied Mathematics Review 2015;57:61-70. 10

9. Deficit accumulation can be estimated with the Frailty Index
Frailty Index score = Number of deficits in an individual Total number of deficits measured
e.g. in a dataset with 50 health deficits, a person with 10 things wrong (10 deficits) has a frailty index score of 10/50 = 0.20.
In this way, we can quantify the degree of frailty
Expressing deficit as a frailty index allows the regular behaviour of deficit accumulation to be revealed. This underscores the idea of frailty as measuring biological age.

10. One Last Question Before the Operation: Just How Frail Are You?
Paula Span
THE NEW OLD AGE
The New York Times, OCT. 27, 2017

11. Deficits accumulate characteristically in old age
1.0
0.5
Legend
0.3
0.2
Mean accumulation of deficits
The slope is ~
Community samples
n=33,559
ALSA
CSHA-screen
0.1
NHANES
NPHS
SOPS
0.05
US-LTHS
Log scale
H70-75 65 70 75 80 85 90 95
Age (years)
Mitnitski, et al., J Am Geriatr Soc, 2005;53:2184-9

12. Age, electronic frailty index score and mortality.
Relationship between age, electronic frailty index score and mortality (internal validation cohort).
Andrew Clegg et al. Age Ageing 2016;ageing.afw039
© The Author Published by Oxford University Press on behalf of the British Geriatrics Society.

13. What I’ve said so far
Frailty is a multiply determined risk state manifest as not everyone of the same age having the same risk of death (or other adverse outcomes).
It arises due to the stochasticity of age-related deficit accumulation across the life course. (People are frail when they have lots of things wrong with them.)

14. Where do we go next?
How do we apply this in the acute of older adults who are acutely ill?
”Geriatric giants”, the Clinical Frailty Scale and some data questions about the merit of separating underlying frailty from resnet illness acuity 23

15. Frailty screening Frailty States: 1. Very Fit 2. Well 3. Managing Well
4. Vulnerable
5. Mildly Frail
6. Moderately Frail
7. Severely Frail
8. Very Severely Frail
9. Terminally ill
© Geriatric Medicine Research Unit, Dalhousie University, 2008
This is the Clinical Frailty Scale screening tool, not used by hundreds of groups around the world. We make it available on the condition that people do not change or commercialize it, which mostly has worked. 25
K Rockwood et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173:

16. Purpose: Examine the relation between frailty, acuity and mortality.
8202 people aged ≥75 years in a large tertiary hospital (all specialties) in England.
Retrospective review of all first non-elective inpatient episodes

17. Frailty Measurement
Clinical Frailty Scale (CFS): A frailty instrument that evaluates pre-admission comorbidity, cognitive impairment, health attitude, mobility and disability.
Original CFS categories collapsed into four ordinal categories:
CFS 1 to 4: Fit/well/treated/”apparently vulnerable”
CFS 5: mildly frail
CFS 6: moderately frail
CFS 7 or 8: severely or very severely frail
*patients with a CFS of 9 (‘terminally ill’ without being evidently frail) were excluded from the analyses
Romero-Ortuna et al. 2016

18. Acute Illness Severity Measurement
Modified Early Warning Score (ED-MEWS): used to measure acute illness severity.
ED-MEWS ≥ 4 defined high acuity in the analyses.
Romero-Ortuna et al. Q J Med 2016

19. Distribution of CFS and ED-MEWS
Frailty levels
31.7% very fit to apparently vulnerable (CFS 1 to 4),
12.5% mildly frail (CFS 5),
16.1% moderately frailty (CFS 6),
11.0% severely or very severely frail (CFS 7 or 8).
0.6% (n=49) CFS of 9 and were excluded
28.1% missing CFS data.
ED-MEWS:
28.4% ED-MEWS of ≥4 points,
63.2% ED-MEWS of < 4, and
8.4% missing ED-MEWS data.
Romero-Ortuna et al. 2016

20. Romero-Ortuna et al. 2016

21. Fig 1. 30-day inpatient mortality by CFS categories and ED-MEWS status
Romero-Ortuna et al. 2016

22. Purpose: Examine the relationship between the FI score and survival to 30 and 300 days in comparison with several commonly employed ICU prognostic scores.
Prospective cohort study of 155 ICU patients ≥65 year old admitted to a specialized geriatric ICU in a Chinese hospital
Patients were followed for 300 days

23. Zeng et al. 2015

24. AUC = 0.89 ( )
Zeng et al. 2015

25. What we did for our patient.
Called the neighbour.
Screened for frailty based on how she walked, thought, interacted and cared for herself two weeks ago.
Continued aggressive resuscitation and gave the ICU a “heads up” call.

26. Geriatric Giants
immobility
instability
incontinence
impaired intellect/memory
impaired independence
Isaacs B. The Challenge of Geriatric Medicine. OUP 1980
“sensitive but non-specific signs of illness in older adults”

27. Comprehensive Geriatric Assessment Form
© Geriatric Medicine Research, Dalhousie University, 2008

28. Instrumental Activities of Daily Living
Comprehensive Geriatric Assessment Form: function signals illness severity
Instrumental Activities of Daily Living
Baseline
(two weeks ago)
Current
(today)

29. Instrumental Activities of Daily Living
Comprehensive Geriatric Assessment Form: function signals illness severity
Instrumental Activities of Daily Living
Baseline
(two weeks ago)
Current
(today)

30. Comprehensive Geriatric Assessment Form: function allows care planning
Instrumental Activities of Daily Living
Baseline
(two weeks ago)
Current
(today)

31. Halifax Infirmary
Case series of referrals of older adults to MTU-ED Team,

32. Mean FI-Acute scores by Clinical Frailty Scale in patients referred to Medicine

33. LTC Discharge by baseline frailty (Panel A) and frailty/acuity score (Panel B)

34. Length of stay by baseline (A) and frailty/acuity (B)

35. Mortality by baseline frailty (A) and frailty / acuity (B)

36. Survival by baseline frailty (A) and frailty/acuity (B)

37. Baseline frailty and frailty/acuity in relation to 6-month mortality (Cox regression analysis)HR
Lower CI
Upper CI
Sig.
Age
0.988
0.956
1.021
0.472
Sex (females)
0.826
0.494
1.381
0.467
CFS (per 1 point)
1.245
1.055
1.470
0.010
FI-acute (per 0.01 score)
1.025
1.004
1.046
0.020

38. A Frailty Index based on a Comprehensive Geriatric Assessment identifies a group at the highest risk of dying.
FI-CGA 1
0.1
0.8
0.2
Survival probability
0.6
0.3
0.4
0.2
0.5
0.4 10 20 30 40 50 60 70
Survival time (months)
Rockwood, Rockwood, Mitnitski, J Am Geriatric Soc 2010;58: 38

39. CGA & care planning
We do a CGA to develop a care plan. The initial contact captured in the CGA needs to be verified and updated to serve as an accurate baseline.
This requires the best available information, not simply a record of “what the client says”.

40. The care plan
Care plans are negotiations: what patients/carers desire vs what’s achievable.
Sometimes these conflict, and often their reconciliation requires judgment.
Some people are better judges than others; processes are important.

41. Pictorial Fit-Frail Scale: Acute Version

42. Pictorial Fit-Frail Scale: Acute Version

43. Time, extent of recovery in mobility & balance, by the initial (48-h) treatment response.
Figure 1.
Hatheway et al., Age Ageing 2017; 43

44. Acknowledgments Arnold Mitnitski Olga Theou Susan Howlett
Funding sources:
Canadian Institutes of Health Research
Fountain Family Innovation Fund , Queen Elizabeth II Health Sciences Foundation
Nova Scotia Health Research Foundation
Mathematics, Information Technology & Computer Science program, National Research Council of Canada
Alzheimer Society of Canada
National Natural Science Foundation of China
China Scholarship Council
Dalhousie Medical Research Foundation
Colleagues & students:
Arnold Mitnitski
Olga Theou
Melissa Andrew
Samuel Searle
Tommy Brothers
Lindsay Wallace
Oliver Hathaway
Judah Goldstein
Kathryn Hominick
Swadhin Taneja
Quikui Hao
Rob Beiko
Andrew Rutenburg
Xiaowei Song
Susan Howlett

46. Pictorial Frailty Assessment

47. Clinical Frailty Scale Scores FI-Acute (CGA Current + LAB) Scores
All patients
Patients with valid
Clinical Frailty Scale Scores
FI-Acute (CGA Current + LAB) Scores N
N=415
N=387
N=382 (33 missing)
Age
80.6 ± 8.4 (range )
80.4 ± 8.4
80.9 ± 8.4
% Women
58.1% (241/415)
58.4% (226/387)
59.7% (228/382)
% Admitted from Long term Care
14.3% (59/414)
14.3% (55/386)
14.4% (55/381)
% Discharged in Long Term Care
17.9% (72/402)
18.1% (68/375)
18% (67/373)
% Discharged home
64.2% (258/402)
63.7% (239/375)
64.3% (240/373)
Mean MMSE
21.2 ± 10.2
21.2 ± 10.4
21.0 ± 9.6
Mean N Medications
6.99 ± 3.70
6.94 ± 3.67
7.09 ± 3.65
Mean N Comorbidities
8.02 ± 3.35
8.06 ± 3.34
8.12 ± 3.40
% Admitted to inpatient unit
77.3% (321/415)
77.3% (299/387)
80.4% (307/382)
Mean LOS for admitted patients
26.9 ± 45.8 (range 0-326)
27.2 ± 46.5
27.4 ± 46.6
% LOS >=30 days
17.9% (73/407)
17.9% (68/380)
18.8% (71/377)
% Died < 30 days
13.3% (55/415)
13.7% (53/387)
13.1% (50/382)
% Dead at 6 months
20.2% (84/415)
21.2% (82/387)
20.4% (78/382)
Mean time to death (for those who died within
6-months)
37.2 ± 49.1
37.9 ± 49.6

48. Frailty Index variables
Frailty Index used ICU admission records: acute medical conditions, chronic diseases, symptoms, signs, premorbid function (from an informant), lifestyle, health attitude, psychological health, and laboratory measures
23-items FI-Chronic
Workload of accompany people
Balance
Desire for survival
Activities of daily living (ADL)
Instrumental activities of daily living (IADL)
Functional Assessment Staging (FAST)
Consciousness
New York Heart Function Assessment (NYHA)
Emotion
Sleeping
Speech
Hearing
Eyesight
Daytime sleepiness
Diseases in Urinary system
Diseases in respiratory system
Diseases in digestive system
Diseases in Cardiovascular system
Diseases in central nervous system
Diseases in Endocrine system
MCV
Blood sugar
urea/creatinine ratio <10 with Cr
31-item FI-Acute
Cardiac rhythm
Nausea and vomiting
Temperature
Systolic blood pressure
Heart rate
Diastolic blood pressure
Respiration rate
Central venous pressure
Oxygenation index
Blood sugar
Procalcitonin
urea/creatinine ratio <10 with Cr
Platelet
White blood cell count
Hemoglobin
Serum sodium
Serum potassium
Total Bilirubin
INR
Albumin
Lactic acid
Urea
Creatinine
Bowel function
Urine volume
Partial pressure of oxygen
Carbon dioxide partial pressure
Actual bicarbonate
PH Value
Blood HCT
MAP
52-item all-factor FI
Blood sugar and urea/creatinine ratio were included in both FI-chronic and FI-acute
Zeng et al. 2015

49. FI34 scores by age in “offspring of long-lived parents” (OLLP) and “offspring of short-lived parents” (OSLP) of the Louisiana Healthy Aging Study / Healthy Aging Family Study .
Kim S, Jazwinski SM. Healthy Aging Res 2015;4:26
Doi /har