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Leicester Medical School
Understanding frailty
Simon ConroySenior Lecturer/Geriatrician
Prague 2009
Understanding frailty
The holy grail of geriatric medicine
• Early identification of frailty
• Identification of ‘pre-frail’
• Possibility of early interventions
Frailty according to Fried
• Sarcopaenia– lowest quintile for hand-grip strength
• Exhaustion– I felt that everything I did was an effort– I could not get going
• Nutrient–energy imbalance– self-reported unintentional weight loss of ≥ 5kg in the
previous year• Slowness
– slowest quintile for the time required to walk 2.4 meters• Low physical activity
– lowest quintile for energy expended per week in leisure-time physical activities
3/5 – frail1-2/5 – pre-frail0/5 – non-frail
Frailty according to SOF
• Study of Osteoporotic Fracture Index– Weight loss– Inability to rise from a chair five times
without using the arms– Reduced energy (answer of “no” to the
question “Do you feel full of energy?” on the Geriatric Depression Scale)
2/2 – frail1/2 – pre-frail0/2– non-frail
Problems with frailty rating scales
• Frailty is dynamic• Reliability• Test population: SOF only validated in
women• Limited in scope• BUT, CHS scale has been used in
biological studies• No interventional studies as yet1
1. Fairhall N, Aggar C, Kurrle SE, et al. Frailty Intervention Trial (FIT). BMC Geriatrics 2008;8:27.
Frailty interventions
1. Screen – SOF/CHS
2. Assess – expanded frailty index
3. Intervene - ??
Biology of Ageing
Oxidative stress
• Reactive oxygen species (ROS) damage to DNA, proteins and lipid within ageing muscle cells → sarcopaenia
• ROS levels associated with low grip strength & mortality
• Candidate modifiable risk factors– smoking– dietary intake of carotenoids, ascorbate, selenium,
plant polyphenols– exercise
Genetics
• Few studies have looked at genetic determinants of frailty• Multiple genes known to affect ageing or single or multiple
domains of frailty– DNA methylation/folate– Insulin/IGF1– Vitamin D– WRN helicase and lamin A (premature ageing)– Sirtuin genes– Antioxidants (superoxide dismutase, glutathione peroxidases)– Cardiovascular modifiers e.g. NO, RAS– Neurocognitive ageing e.g. ApoE
• May identify pathways amenable to intervention
Vascular ageing
Hypertension
Cerebrovascular diseaseSub-clinical CVD
Frailty
Frailty & human geography
• Links with neighbourhood deprivation
• Access to services
Some unanswered health services research questions
• Frailty & quality of life (Sealy Centre on Aging, Texas)
• Frailty, social networks & carer strain• Frailty & cognition• Frailty and access to services• Frailty and health service resource use• Frailty in ethnic minorities• Delivering coordinated health care to frail
older people
Operationalising frailty
• Frail older people should receive integrated comprehensive geriatric assessment– Increased living at home (OR 1.7)– Reduce functional decline (RR 0.76)– Reduce NH admissions (RR 0.66)
• Yet increasing primary & secondary health care split…
Operationalising frailty
• Aged 70+• Patients with a fracture, who are
medically unstable• Care home resident (nursing or
residential)• Confusion (dementia or delirium)• Other patients scoring over 25 on the
Waterlow Score
ED attendances
N=1723
3% frail, 70+
57% adults
25%children
10%Frail
63%70+
AMU bedoccupancy
15%aged 70+
75%
76% medicine19% EDU
40%
74% medicine26% otherspeciality
18%
Admission ratesfrom EDN=534
31%
AFU outcomes, 4/10/8-27/10/8, n=171
949/520818%
2988/631747%
AMU discharge
rate
196/52084%
52/6317<0.01%
AMU mortality
166/94917%
496/298817%
30 day readmissions
239/94925%
691/298823%
90 day readmissions
25/17115%
AFU dischargerate
3/1712%
AFU mortality
13/2552%
90 day readmissions from AFU
~1035admissions
in total:171/1035=17%
Summary
• Frailty core business
• Not well understood
• Large collaborative studies required
• Translational aspects critical
Děkuji!