Presented by : Dr. Venugopalan G

Preceptor : Prof. A. B. Dey

Department of Geriatric Medicine

Minor stress/ Drugs/ Infection…

Independent

Mobile

Postural stability

Lucid

Dependent

Immobile

Proneness/Falling

Delirious

A Clegg, K Rockwood et al.Frailty in elderly people. Lancet 2013; 381: 752–62

Frailty Syndrome: A Transitional State in a Dynamic Process. Gerontology 2009;55:539–549

Robust

Early Frail

Late Frail

Severe Frailty

Pre Frail/ Subclinical

Clinically frail,

Disability+

Clinically frail,

Dependent

Clinically frail,

Disability-

Clinically resilient,

slow recovery

Death

Disability: > 1 ADL Co-morbidity: >2

Frailty

• Falls

• Disability

• Hospitalization

• Death

Its concept underlines some common concerns of older people:

1. Being dependent on others or at a substantial risk of

dependency.

2. Experiencing the loss of physiological reserves.

3. Experiencing detachment from the environment.

4. Having many chronic illnesses.

5. Having complex medical and psychosocial problems.

6. Having atypical disease presentations.

7. Experiencing accelerated ageing

Goel A, Dey A B. Old Age and Frailty: Genesis and Management. Journal of The Indian Academy of Geriatrics, Vol. 3, No. 4, December, 2007

Woodhouse et al Those > 65 years of age who depended on others for the activities of

daily living and were often under institutional care

Campbell and

Buchner

Condition or syndrome which results from a decline in the reserve of

multiple systems and is a state of “unstable disability”.

Lipsitz et al Loose complexity in resting dynamics and show maladaptive

responses to perturbations

Bortz Concept of symmorphosis

"an insidious and relentless thief of energy and vitality"

Hougaard A random effects model for time variables, where the random effect

(frailty) has a multiplicative effect on hazard

A Clegg, K Rockwood et al. Frailty in elderly people. Lancet 2013; 381: 752–62

Linda P. Fried et al. Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontology: MEDICAL SCIENCES 2001, Vol. 56A, No. 3, M146–M156

“Frailty is a condition in which the individual is in a

vulnerable state at increased risk of adverse health

outcomes and/or dying when exposed to a stressor”

Walston J, Ferrucci L, et al. Research agenda for frailty in older adults: Toward a better understanding of physiology and etiology: Summary from the AGS/NIARCF. J Am

Geriatr Soc. 2006;54:991–1001

A clinical syndrome

Not disability

Increased vulnerability in which minimal stress can cause

functional impairment

Might be reversible or attenuated by interventions

Mandatory for health workers to detect as soon as possible

Useful in primary and community care

Rodriguez-Manas L, Feart C, Mann G, et al. Searching for an operational definition of frailty: A Delphi method based consensus statement. The FOD-CC Project. J GerontolA Biol Sci Med Sci. 2013; 68:62–67

John E. Morley, Bruno Vellas, G. Abellan van Kan, Stefan D.Anker, Juergen M.

Bauer, Roberto Bernabei, Matteo Cesari, W.C. Chumlea, Wolfram Doehner,

Jonathan Evans, Linda P. Fried, Jack M. Guralnik, Paul R. Katz, Theodore K.

Malmstrom, Roger J. McCarter, Luis M. Gutierrez Robledo, Ken Rockwood,

Stephan von Haehling, Maurits F. Vandewoude, and Jeremy Walston.

J Am Med Dir Assoc. 2013 June ; 14(6): 392–397. doi:10.1016/j.jamda.2013.03.022

Physical Frailty:

“A medical syndrome with multiple causes and

contributors that is characterized by diminished

strength, endurance, and reduced physiologic function

that increases an individual’s vulnerability for developing

increased dependency and/or death”

Simple, rapid screening tests have been developed and

validated

Physical Frailty Is a Manageable Condition

Exercise (resistance and aerobic)

Caloric and protein support

Vitamin D

Reduction of poly-pharmacy

All Persons Older Than 70 Years Should Be Screened

for Frailty

Frailty Consensus: A Call to Action

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

Frailty is a distinctive health state related to the ageing

process in which multiple body systems gradually lose

their in-built reserves

Recommended assessments:

Gait speed (less than 0.8m/s)

or

Timed-up and-go test (cut off score of 10 secs)

+

PRISMA questionnaire (cut off score > 3)

Good sensitivity

Moderate specificity

Frailty syndromes

Falls

Immobility (sudden change)

Delirium

Incontinence (new onset or worsening)

Susceptibility to side effects of medication

Presence of any one, then suspect & assess for Frailty

No routine population screening

Older persons may not recognise themselves as living

with frailty and there is evidence that older people do

not want to be considered as ‘frail’, although happy to

accept that they are an older person

www.ageuk.org.uk/professional-resources-home/research/social-research/living-with-frailty/

Sarcopenia is a syndrome characterised by progressive and

generalised loss of skeletal muscle mass and strength with

a risk of adverse outcomes such as physical disability, poor

quality of life and death

Criteria for the diagnosis:

Low muscle mass

Low muscle strength

Low physical performance

Age and Ageing 2010; 39: 412–423

Age and Ageing 2010; 39: 412–423

Syndrome of weight loss, decreased appetite and poor

nutrition, and inactivity, often accompanied by

dehydration, depressive symptoms, impaired immune

function, and low cholesterol

Sarkisian CA, Lachs MS. "Failure to thrive" in older adults. Ann Intern Med 1996; 124:1072.

Varies with operational definition, age

7% by Fried et al, 25% by Rockwood et al

10 to 25% in >65 year old, 30-45% in >85 year old

33% in in-hospital admission- Khandelwal et al

(AIIMS, 2008)

Frailty (27.9%)

Organ failure (21.4%)

Cancer (19.3%)

Dementia (13.8%)

Other causes (14.9%)

Thomas M. Gill et al. Trajectories of Disability in the Last Year of Life. N Engl J Med 2010;362:1173-80

Thomas M. Gill et al. Trajectories of Disability in the Last Year of Life. N Engl J Med 2010;362:1173-80

K Rockwood et al. CMAJ 2005;173(5):489-95

K Rockwood et al. JAGS 58:681–687, 2010

K Rockwood et al. JAGS 58:681–687, 2010

Robust (< 0.08)

Pre Frail (0.08 to 0.24)

Frail (> 0.25)

Frail: > 3 criteria Intermediate/prefrail: 1 or 2 criteriaLinda P. Fried et al. Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontology: MEDICAL SCIENCES 2001, Vol. 56A, No. 3, M146–M156

Characteristics of Frailty Cardiovascular Health Study Measure

Shrinking: Weight loss (unintentional)Sarcopenia (loss of muscle mass)

Baseline: >10 lbs lost unintentionally in prior year

Weakness Grip strength: lowest 20% (by gender, body mass index)

Poor endurance; Exhaustion “Exhaustion” (self-report)

Slowness Walking time/15 feet: slowest 20% (by gender, height)

Low activity Kcals/week: lowest 20%males: < 383 Kcals/weekfemales: < 270 Kcals/week

1) Are you more than 85 years?

2) Male?

3) In general do you have any health problems that require you to

limit your activities?

4) Do you need someone to help you on a regular basis?

5) In general do you have any health problems that require you to stay

at home?

6) In case of need can you count on someone close to you?

7) Do you regularly use a stick, walker or wheelchair to get about?

Shopping

Walking outdoors

Dressing and undressing

Going to the toilet

Physical fitness

Vision problems

Hearing problems

Unintentional weight loss

Use of >3 medicines

Memory complaints

Experience of emptiness

Missing people around

Feeling abandoned

Feeling sad/dejected

Feeling nervous/anxious

>4 is moderate to

severe frailty

The gold standard for the management of frailty in older

people is Comprehensive Geriatric Assessment (CGA)

It involves an holistic, multidimensional, interdisciplinary

assessment of an individual by a number of specialists

The initial assessment and care planning for a full CGA is likely to take at

least 1.5 hours plus the necessary time for care plan negotiation and

documentation

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

1. Exercise therapy including:

A. Aerobic

B. Resistance

C. Balance

D. Dual-tasking

2. High protein diet (1.2-1.5g/kg)

3. Leucine enriched essential amino acids supplement between

meals

4. Vitamin D 1000 iu daily

J. Morley. Frailty: Diagnosis and Management. The Journal of Nutrition, Health & Aging volume 15, Number 8, 2011

1. Testosterone in males with low testosterone levels

2. Treat anemia – treatable causes and erythropoietin if

Hb< 10g/dl

3. Treat depression

4. Reduce polypharmacy

J. Morley. Frailty: Diagnosis and Management. The Journal of Nutrition, Health & Aging volume 15, Number 8, 2011

Theou O, Stathokostas L, Roland KP, et al. J Aging Res. 2011; 2011:569194

A metaanalysis involving 29 trials showed high intensity PRT is

better than moderate and low intensity to improve muscle

power in adults >65 years of age.

Though power training was found to be better than PRT for

improving both muscle power and functional performance, no

clear data on duration and frequency of these exercises.

Moreover data on very old and frail population is lacking.

(Med Sci Sports Exer 2010 May;42(5):902-14. Dose-response relationship of resistance training in older adults: a meta-analysis)

67 trials, involving 6300 participants

Improvement in Barthel index scores of six points (95% CI 2 to 11, P =

0.008)

Functional independence measure (0 to 126) scores of five points (95%

CI -2 to 12, P = 0.1)

Rivermead mobility index (0 to 15) scores of 0.7 points (95% CI 0.04 to

1.3,p = 0.04)

TUG test of five seconds (95% CI -9 to 0, P = 0.05)

Walking speed of 0.03 m/s (95% CI -0.01 to 0.07, p = 0.1)

Crocker T et al. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD004294

Crocker T et al. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD004294

Authors’ conclusions

Physical rehabilitation for long-term care residents may be

effective, reducing disability with few adverse events,

but effects appear quite small and may not be applicable to all

residents.

There is insufficient evidence to reach conclusions about improvement

sustainability, cost-effectiveness, or which interventions are most

appropriate.

Future large-scale trials are justified.

62 trials with 10,187 randomised participants included

The pooled weighted mean difference for percentage weight change showed

a benefit of supplementation of 2.2% (95% CI 1.8 to 2.5) from 42 trials

No significant reduction in mortality (RR 0.92, CI 0.81 to 1.04) from 42

trials

Mortality results were statistically significant when limited to trials in

which participants (N = 2461) were defined as undernourished (RR 0.79,

95% CI 0.64 to 0.97)

Conclusion:

Supplementation produces a small but consistent weight gain

No effect on overall mortality

Mortality may be reduced in older people who are undernourished.

There may also be a beneficial effect on complications which needs to be

confirmed.

No evidence of improvement in functional benefit or reduction in length of

hospital stay with supplements.

36 RCT (n=3790) (mean age 74 years) and a series of meta-

analyses of high protein ONS (>20% energy from protein)

Reduced complications (OR: 0.68, p<0.001), Reduced

readmissions to hospital (OR 0.59, p=0.004), Improved grip

strength (1.76 kg, p<0.014), Improvements in weight (p<0.001)

There was inadequate information to compare standard ONS

with high protein ONS (>20% energy from protein)

Conclusion: High protein supplements produce clinical benefits,

with economic implications

Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev. 2012; 11:278–296

A standardized mean difference of -0.20 (P=0.04) for

reduced postural sway, -0.19 (P=0.03) for decreased time to

complete the Timed Up and Go Test, and 0.05(P=0.04) for

lower extremity strength gain

CONCLUSION: Supplemental vitamin D with daily doses

of 800 to 1,000 IU consistently demonstrated beneficial

effects on strength and balance

Muir SW, Montero-Odasso M. Effect of vitamin D supplementation on muscle strength, gait and balance in older adults: A systematic review and meta-analysis. J Am Geriatr Soc. 2011; 59:2291– 2300

Possible explanation:

Restoring vitamin D activates Vit D receptor and proper

functioning in muscle, bone and brain (cortex and

hypothalamus)

Reduce negative effect of PTH

Muir SW, Montero-Odasso M. Effect of vitamin D supplementation on muscle strength, gait and balance in older adults: A systematic review and meta-analysis. J Am Geriatr Soc. 2011; 59:2291– 2300

This review will focus on physical function, as the broader

social parameters are not amenable to pharmacological

intervention.

ACE Inhibitors

Vitamin D

Anabolic steroids

Growth hormone

Insulin like Growth Factor

Polypharmacy – important contributor of Frailty

Reduction of inappropriate medication – reduce costs

and medication side effects in frail population

Beers criteria and STOPP and START criteria –

guidelines to reduce inappropriate medication

Y. Gokce Kutsal, A. Barak, A. Atalay et al.Polypharmacy in the elderly: A multicenter study J Am Med Dir Assoc, 10 (2009), pp. 486–490

High index of suspicion and routine screening to

detect Frailty

Reversible if identified early

Use any standardised scale

CGA is cornerstone of diagnosis and management

And love’s the noblest frailty of the mind- John Dryden