1. Frailty and Its Effect on the 4 M’s
Joan Chang, DO
Center for Healthy Aging

2. BACKGROUND/BIO
Medical school- Philadelphia College of Osteopathic Medicine Internal medicine Good Samaritan Hospital in Baltimore, Maryland Geriatric Johns Hopkins School of Medicine Board certified in Geriatric Medicine, and Hospice and Palliative Care

3. DISCLOSURE
None

4. Goals
Understand frailty
Management of frailty using the 4M’s
Frailty and Palliative Care

5. Defining Frailty reserve and resistance to stressors, resulting from
“A physiologic syndrome characterized by decreased
reserve and resistance to stressors, resulting from
cumulative decline across multiple physiologic systems,
and causing vulnerability to adverse outcomes”
Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M

6. Vulnerability of Frail Older Adult to Illness

7. Frailty as Physiologic Process3
Adapted from Xue QL, Bandeen-Roche K, Varadhan R, et al. Initial manifestations of frailty criteria and the development of frailty phenotype in the Women’s Health and Aging Study II. J Gerontol A Biol Sci Med Sci 2008;63(9):984–90

8. Frailty as Physiologic Process
Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M

9. Frailty as Physiologic Process

10. Primary Frailty
Sarcopenia (loss of lean body mass) is a central component of frailty and a key predictor of the other clinical manifestations
Predictors of sarcopenia and loss of strength with aging
Decreased Anabolic factors such as testosterone and IGF-1
Diminished physical activity
Reduced nutritional intake (e.g., protein, energy, vitamin D, and other micronutrients)
Older age itself

11. Secondary Frailty
A variety of primary diseases independently predict development of the frailty phenotype, potentially through inflammation and/or their effect on cardiopulmonary function and inactivity:
Immune disorders (HIV/AIDS)
Heart failure
COPD
Chronic infections (cytomegalovirus, tuberculosis)

12. Assessment of Frailty
Assess number of phenotypic frailty criteria present (out of 5)
Rapid screening/assessments that have been validated, such as the interview-based FRAIL scale
Clinical Global Impression of Change in Physical Frailty (CGIC-PF): for frailty as a clinical composite or “gestalt”
Walking speed or grip strength (early manifestations of frailty syndrome)

13. Management of Frailty using the 4M’s MEDICATION
Avoid polypharmacy
Review all medications

14. Management of Frailty using the 4M’s MENTATION

15. Management of Frailty using the 4M’s MOBILITY

16. Frailty with Trajectory from Health to Death3

17. Management of Frailty using the 4M’s WHAT MATTERS

18. Frailty and Palliative Care
Frailty predicts functional decline and onset and progression of dependency at the end of life
Severe frailty, with a score of 4–5 and metabolic abnormalities of low cholesterol and albumin, predict particularly high short-term mortality rates in frail older adults
Clinical case series suggest a poor response to treatment in those with end-stage frailty—it may be appropriate to consider palliative approaches for these patients

19. Summary
Frail patients are at high risk of adverse clinical outcomes, including falls, disability and dependency, and mortality
Frailty develops along a continuum of severity, likely including a latent phase that is not clinically apparent in the absence of stressors, early stages likely most responsive to intervention, and a late end-stage that indicates high risk of short-term mortality
Using the 4M’s may help clinicians manage frailty
The most effective preventive approach appears to be maintaining muscle mass and strength by exercising and consuming a Mediterranean diet

20. References
Dent E, Kowal P, Hoodijk E Frailty measurement in research and clinical practice: A review. European Journal of Int Medicine 2016;31:3-10 Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56(3):M146–56. Gill TM, Gahbauer EA, Allore HG, et al. Transitions between frailty states among community-living older persons. Arch Intern Med 2006;166(4):418–23. Xue QL, Bandeen-Roche K, Varadhan R, et al. Initial manifestations of frailty criteria and the development of frailty phenotype in the Women’s Health and Aging Study II. J Gerontol A Biol Sci Med Sci 2008;63(9):984–90