1. Frailty in the Older Adult Cynthia J. Brown, MD, MSPH Associate Professor Director, Geriatric Medicine Section Birmingham/Atlanta VA GRECC University of Alabama at Birmingham

2. Learning Objectives Identify key features of frailty as currently defined Define sarcopenia Understand changes in body composition associated with aging Describe how a multidisciplinary team might approach frailty in the older adult

3. Case Presentation Case 1: An 82-year old man with a history of heart failure, knee osteoarthritis, and hypertension presented for elective knee replacement. Case 2: An 82-year-old man with a history of heart failure, knee osteoarthritis, and hypertension presented for elective knee replacement. Case 3: An 82-year-old man with a history of heart failure, knee osteoarthritis, and hypertension presented to the ED after being found by a neighbor on the floor.

4. These three patients demonstrate different levels of susceptibility and clinical stability, which strongly affected clinical outcomes. There appears to be a spectrum of resilience, from highly independent and robust to the most frail and vulnerable.

5. Defining Frailty Break into your small groups and answer the following questions: How would you define the term “frail”? What makes a person frail? Are there key components to frailty?

6. Frailty Definitions A variety of definitions have been used defining frailty as synonymous with: –Disability –Comorbidity –Advanced Old Age However, while there is some overlap, frailty appears to encompass more than disability or comorbidity.

7. Overlap of Frailty with ADL Disability and Comorbidity Disability: > 1 ADL FrailtyComorbidity N=67 26.6% N=98 N=2131 21.5% 46.2% 5.7% Fried LP, J Gerontol Med Sci, 2001

8. Frailty Definition Clinicians have begun to define frailty as: “a syndrome of decreased reserve and resistance to stressors, that result in cumulative declines across multiple physiologic systems, causing vulnerability to adverse outcomes.” It has been postulated that there are key components of frailty, and multiple components must be present to constitute frailty. Fried LP, J Gerontol Med Sci, 2001

9. Fried’s Model of Frailty

11. Definitions of Components of Frailty –Shrinking > 10 pounds lost unintentionally in past year –Self-reported exhaustion Self-report of exhaustion on CES-D questions –Weakness (grip strength) Grip strength lowest 20% adjusted for gender & BMI –Slow walking speed Slowest 20% to walk 15 feet –Low physical activity Lowest quintile of weighted kilocalorie expended per week

12. Sarcopenia in the Older Adult

13. Sarcopenia Sarcopenia: age-related loss of muscle mass and strength. Changes in the muscle fiber itself, and an increase in infiltration of fat into the muscle (myosteatosis) also common with aging. Changes all lead to a decline in muscle function.

14. Top: Young Male, age 25 Bottom: Older Male, age 63 Height and weight matched Top: Young Female, age 27 Bottom: Older Female, age 65 Height and weight matched Sarcopenia and Myosteatosis Petrella et al. Eur J Appl Physiol 2007

16. *‡*‡ *‡*‡ *‡*‡ *‡*‡ Age-related Loss of Muscle Mass Values are mean ± SE. Main age group effects, P<0.001. *Different from 25 y, P<0.05. ‡ Different from 37 y, P<0.05. DXA-determined limb muscle mass. MM Bamman, et al. N=211

17. Functional Consequences

18. Walking fundamental mobility task. Variables that influence walking speed include: –Musculoskeletal status –Sensory function –Motor control –Cognitive status Walk speed a general summary indicator; could be useful single-item screening tool Evaluation of Function

19. Gait Speed

21. Predicted Median Life Expectancy by Age and Gait Speed Studenski S, et al. JAMA. 2011;305(1):50-58.

22. Timed Chair Stands Used to evaluate lower body strength and endurance Instruct to stand from chair without using arms 5 times while being timed. Normative values available, can identify which older persons may have problems with strength.

24. Get Up and Go Test The get up and go test asks a person to: –stand from a chair without using their arms –walk 10 feet –turn around and walk back –and sit in the chair Can be timed with a time of ≥ 20 seconds indicating risk for adverse outcomes. Can also observe for unsteady gait.

27. Now it is your turn to try these easy clinical assessments

28. Health Literacy in Older Adults

29. Contributing Factors in Older Adults Fewer years of schooling, poorer—fixed incomes > 50% do not take meds as directed 68% cannot interpret blood sugar value 76% cannot follow Upper GI instructions 100% could not understand Medicaid rights in one study

30. Related Cultural/Language Barriers Non-English speaking Immigrant status Ethnic interpretation of illness Spiritual and religious beliefs Default answers Lack of insurance/transportation

31. Testing in a Busy Practice Always assume and ask in sensitive way –”How do you get your information?” –“What things do you like to read?” –“How satisfied are you with how you read?” Eyes wandering over page, very slow to finish, sounding out words, look confused Remember the “pill bottle” prop –Ask questions about the dosage and frequency

32. Nutrition Problems in the Older Adult

33. Changes in Body Composition There is a net decrease in: –Bone mass –Lean muscle mass –Water content There is a net increase in: -Total body fat -Especially intra-abdominal (fat located inside the belly area/abdominal cavity)

34. Physiological Changes Accounting for Nutrition Risk in Elderly  Changes in taste, and smell  Changes in the gastrointestinal system  Impaired thirst sensation  Atrophic gastritis (chronic inflammation of stomach with reduced stomach secretions.

35. Pathologic Changes Common in Aging Chronic diseases and restrictive diets Dental problems Depression Alcohol abuse Medication side effects