Leicester Medical School Understanding frailty Simon Conroy Senior 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 – frail 1-2/5 – pre-frail 0/5 – 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 – frail 1/2 – pre-frail 0/2– 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 yet 1 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 disease Sub-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, % adults 25% children 10% Frail 63% 70+ AMU bed occupancy 15% aged % 76% medicine 19% EDU 40% 74% medicine 26% other speciality 18% Admission rates from ED N=534 31%

AFU outcomes, 4/10/8-27/10/8, n= / % 2988/ % AMU discharge rate 196/5208 4% 52/6317 <0.01% AMU mortality 166/949 17% 496/ % 30 day readmissions 239/949 25% 691/ % 90 day readmissions 25/171 15% AFU discharge rate 3/171 2% AFU mortality 13/25 52% 90 day readmissions from AFU ~1035 admissions in total: 171/1035=17%

Summary Frailty core business Not well understood Large collaborative studies required Translational aspects critical

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