1. Disability, Frailty and Co-morbidity Gero 302 Jan 2012

2. Caring For the Elderly We have a growing population of frail, vulnerable older adults, with complex care issues. These have multiple etiologies, chronic conditions and co-morbidity and includes those who are disabled or dependent. Major components of health status in an Aging population Disability-difficulty or dependency in carrying out ADL/IADL. This is both a social and a medical entity. Frequency of disability rises with age and includes issues around muscle weakness, balance, decreased exercise tolerance, and often appears in a co-morbid and synergistic presentation.

3. Frailty Frailty is a state of high vulnerability-a combination definition using multiple variables. AMA estimates run as high as 40% of adults over 80 are frail and the majority of NH residents would be considered as frail. Frailty can be defined more completely as a physiological state of increased vulnerability to stressors resulting from decreased physiological reserves and dysregulation of multiple physiological systems. Associated with frailty in descending order: undernutrition, functional dependence, pressure sores, gait disorders, generalized weakness, weight loss, anorexia, fear of falls, dementia, hip fractures, delirium and confusion, polypharmacy

4. Co-morbidity The presence of two or more diagnosed diseases in the same individual. After age 65 48% of US pop report Arthritis, Hypertension, heart disease and diabetes. 6% have had a history of stroke or TIA’s Co-morbidity is associated with high health care utilization, risk of disability and mortality. This challenges service providers with the problem of coordination of care and increased service provisions and exposes the individual to polypharmacy Care for disability also includes rehabilitation to prevent functional decline and a range of other adverse outcomes.

5. Frailty Therefore it is not uncommon for older adults to be frail and disabled which is often complicated by sensory and mobility impairments. Health care costs are five-fold greater for those with co- morbid conditions than those with disability alone and two- fold greater than those with co-morbidity alone, a complex issue of aggregate effects. Prevention-need for screening, diagnosis and treatment. Frailty is a progressive condition and begins at a pre-clinical stage, offering opportunities for early detection and prevention.

6. Complexity of Medical Care Co-morbidity, frailty and disability confer specific care needs in older persons Coordination of care involves multiple providers and services which are multiplied as the conditions present themselves. Treatment regimens may be beyond the client’s tolerance or ability to comply (dementia, depression) and can limit the adherence to treatment for other diseases. Poly-pharmacy may have many negative interactions which serve to increase rather than reduce problems and symptoms. Treatment therefore is complex, exposed to adverse outcomes, compromised function, and possible further declines.

7. Complexity of Care Underlying diseases can cause secondary frailty, such as muscle loss, strength, weight loss, CHF and immune issues. Frailty therefore is defined as wide fluctuations in health status and high risk of acute complications. See Fig two page 260 Community dwelling older adults have complex care needs and the delivery is often difficult to deliver and coordinate. Increased care needs often leads to increased hospitalization risk. Costs for inpatient care and meds for older adults with two or more chronic conditions and disability were five-fold greater than for those with disability alone and two-fold greater than for those with comorbidity alone.

8. Opportunity for Prevention Screening older adults for those at high risk of disability and for reversible risk factors may identify persons who would benefit from specific interventions. Cardiovascular disease is preventable into the oldest ages and comorbidity reduced. Frailty is a progressive condition that begins at a pre-clinical stage and offers opportunity for early detection and prevention.