Advances in Frailty-Understanding and management

1. Presented by : Dr. Venugopalan G
Preceptor : Prof. A. B. Dey
Department of Geriatric Medicine

2. 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

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

4. Robust
Early Frail
Late Frail
Severe Frailty
Pre Frail/ Subclinical
Clinically
frail,
Disability+
Clinically
frail,
Dependent
Clinically
frail,
Disability-
Clinically
resilient,
slow
recovery
Death

5. Disability: > 1 ADL Co-morbidity: >2
Frailty
• Falls
• Disability
• Hospitalization
• Death

6. 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

7. 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

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

10. 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

13. “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

14.  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 Gerontol
A Biol Sci Med Sci. 2013; 68:62–67

15. 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

16. 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”

17.  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

18. 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

19.  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

20. 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

21.  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/

22.  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

23. Age and Ageing 2010; 39: 412–423

24. 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.

25.  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)

26.  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

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

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

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

32. K Rockwood et al. JAGS 58:681–687, 2010
Robust (< 0.08)
Pre Frail
(0.08 to 0.24)
Frail (> 0.25)

33. Frail: > 3 criteria  Intermediate/prefrail: 1 or 2 criteria
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
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/week
females: < 270 Kcals/week

36. 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?

37.  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

39.  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

41. 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

42. 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

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

44.  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)

45.  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

46. 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.

47.  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)

48. 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.

49.  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

50.  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

51. 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

52. This review will focus on physical function, as the broader
social parameters are not amenable to pharmacological
intervention.

53.  ACE Inhibitors
 Vitamin D
 Anabolic steroids
 Growth hormone
 Insulin like Growth Factor

54.  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

55.  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

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