1. FRAIL ELDERLY PATHWAY AND FRAILTY IN THE ELDERLY Dr. M. Ganeshananthan

2. Problem  Increasing numbers of frail older people are attending the Emergency Department  Frail older people have the highest ‘conversion rate’  High risk of adverse events  Long stays  High readmission rates  High rates of long term care

3. Solutions  Generic interventions  Better access to health care systems  Better communication  Specific pathways for frail older people  Based on comprehensive geriatric assessment  Outlined national policy documents

4. Frail Elderly Pathway  Aim-  Integrated pathway for frail elderly patients  Incorporating acute hospital care, community care social care and old age psychiatry  Objectives  Enhance health of frail older people  Reduce unnecessary emergency admissions  Reduce the need for long term institutional care

5. Frail Elderly Pathway  Maintaining independence  Choosing to admit (Enhanced rapid assessment in ED/MAU and in the community)  Discharging to assess(Supported early discharge for complex frail elderly patients)

6. Frail Elderly Pathway The pathway is delivered by:  Two geriatricians  IDT/OPAL  ICT in the community  Part time community psychiatrist  Day assessment centre at Milford  Rapid Response clinic

7. Frail Elderly Pathway  How do we deliver this service in the acute setting?  Comprehensive Geriatric Assessment (CGA)  What is GCA?

8. CGA  ‘Multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up

9. CGA  ‘Multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up

10. CGA- Evidence  Improves outcomes of older people in various settings  Reduced mortality or deterioration  Improved cognition  Improved quality of life  Reduced length of stay  Reduced readmission rates  Reduced rates of long term care use  Reduced costs

11. CGA  The main domains of CGA  Medical  Mental health  Functional capacity  Social circumstances  Environment

13. Frailty  The condition of being weak and delicate: the increasing frailty of old age  (weakness in character or morals: all drama begins with human frailty)

14. Who is frail?

15. Frailty  Syndrome which results from a multisystem reduction in reserve capacity to the extent that a number of physiological systems are close to or past the threshold of symptomatic failure  Increased risk of disability or death from minor external stresses

16. Frailty

17.  Small insult results in a striking and disproportionate change in health state  Independent to dependent  Mobile to immobile  Postural stability to proneness to falling  Lucid to delirious

18. Frailty  Distinct syndrome  Growing old is not in itself a prerequisite to becoming frail  A disability does not lead to frailty in a robust older person

19. Clinical presentations  Non-specific  Extreme fatigue  Unexplained weight loss  Frequent infections  Falls  Due to gait and balance impairment  Hot fall

20. Clinical presentations  Delirium  Due to reduced integrity of the brain function  Independently associated with adverse outcome  Fluctuating disability  Day-to-day instability

21. Pathophysiology  Normal ageing  Gradual decrease in physiological reserve  Frailty  Accelerated  Homoeostatic mechanisms start to fail

22. Pathophysiology  Cumulative decline in several physiological systems  Determined by genetic and environmental factors  Loss of physiological reserve of the brain, endocrine system, immune system and skeletal muscle  Nutritional status

23. Pathophysiology

24. Frail Brain  Associated with increased risk of developing delirium and reduced survival  Associated  Increased cognitive impairment  Faster rate of cognitive decline  Independent association with dementia

25. Frail immune system  Reduced stem cells  Blunting of antibody response  Reduced phagocytosis  Impaired antibody response to vaccines

26. Frail Immune system  Inflammation has a major role in the pathophysiology of frailty  Abnormal low-grade inflammatory response  Hyper-responsive to stimuli  Persists for a long period  Inflammation leads to anorexia and catabolism

27. Sarcopaenia  Frail skeletal muscle  Progressive loss of muscle mass, strength and power  Reduction in functional ability

29. Frailty Models  Phenotype model  Cumulative deficit model

30. Phenotype model

31.  Detection of frailty in routine care  Difficult to translate to clinical practice  Those with cognitive impairment not included  Increased adverse outcome

32. Cumulative deficit model-Frailty Index  CSHA  92 baseline variables (health deficits)  Presence or absence of each variable as a proportion of the total  Defined as cumulative effect of individual deficits  Clinically attractive- frailty is gradable  Strongly related to the risk of death and institutionalisation

33. Prevalence  Systematic review  Frail 9.9%  Pre-frail 42%  F>M  Steadily increased with age  65-69 4%  >85 26%

34. Outcomes  Most frail  worst outcomes  Frail  more frail  Higher risk of:  Worsening disability  Falls  Admission to hospital  Death  Admission to long term care

35. Association between frailty, disability and comorbidity

36. Assessments to identify frailty  CGA  CGA when linked to interventions has superior outcomes  Gold standard to assess frailty  Edmonton Frailty scale  CSHA scale

38. Interventions  Inpatient CGA  More likely to return home  Less likely to have cognitive or functional decline  Lower in-hospital mortality  Community CGA  Continuing to live at home

39. Interventions  Exercise  Effect sizes are small/moderate  Intensity uncertain  Nutritional interventions  Scarce evidence

40. Interventions  Drugs  ACEI  Testosterone  Vitamin D

41. Conclusion  Frailty is a state of vulnerability to poor resolution of homeostasis  Cumulative decline in many physiological systems during a life time  Minor stressor events trigger a disproportionate changes in health status  Landmark studies have been used to develop valid models of frailty  Association of frailty and adverse health outcomes

42. Conclusion  Care is organised around single organ disease  Frailty is a practical unifying notion  Strongly associated with adverse outcome  Moving away from age to using frailty  Best evidence is for comprehensive geriatric assessment