Frailty

last authored: Jan 2009, David LaPierre
last reviewed:

 

 

Introduction

The term frailty describes older persons who are at risk for increased illness and death

due to the difficulty withstanding environmental stress, injury, and disease.

Frailty is increasingly thought of as a syndrome that can be identified and measured.

It is serious, predisposing patients to disease, disability, and death.

People die, in general, when their level of fitness is overcome by the illness or intervention they experience.

The frail often have multiple medical and social issues, experience and demonstrate illness in a vague way, and often as a result are often missed when sick.

 

Become good at conceptualizing frailty and identifying where people are at. Age is not a good indicator of survival, but frailty is.

Frailty is related to, but distinct from, disability, which is the inability to independently carry out ADLs or IADLs. It appears to delineate reserve capacity, which describes ability to adapat to disease and disability.

Frailty is multiple system impairment, with reduced ability to maintain homeostasis and increased vulnerability towards adverse outcomes. Key factors include:

The balance principle:

  • health
  • attitudes towards health and health practices
  • resources
  • caregiver
  • illness
  • disabiilty
  • dependence of others
  • burden on caregiver

 

Frailty is caused by biological, social, clinical, cognitive, psychological, and environmental factors.

Some include:

Frailty can frequently

 

The Case of Mrs. SA

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Describing Frailty

Frailty is difficult to define, and the literature disagrees. Four main possibilities:

  • qualitative definitions
  • rules-based
  • descriptive
  • frailty index

qualitative definitions

  • hard to apply

Condition or syndrome resulting in multi-system reduction in reserve capacity (innate capacity to respond to a stressor): physical, mental, social; loss of redundancy, which is necessary for aging. Without redundancy, you die.

Highest order functions first.

  • ambulation - falls
  • divided attention- delerium
  • use of tools - functional decline
  • social graces - incontience and behavioural issues

Disease is therefore not merely a marker of organ function, but also reserve and reduncancy

rules-based

Fried LP et al, 2001

Clinical phenotype of frailty: need 3/5

  • weight loss
  • weakness
  • sense of exhaustion
  • slow walking speed
  • low physical activity

Exclusions include depression and Parkinson's disease

descriptive

A gestalt based on descriptors and clinical judegement; now from 1-9.

Is robust at predicting outcomes. Need to have their history to really determine how they are.

Rockwood et al, 2005.

frailty index

Developed by Mitinski et al 2004.

Forty variables representing symptoms, attitudes, illnesses, and function.

 

Proportion of possible deficits accumulated; they accumulate at a constant rate (3%/year).

One can estimate personal biological age, which helps determine fitness and frailty.

Problem list becomes a means, not an end

It doesn't matter which items you include; this is perplexing

There is a threshold above which death occurs; no one has values over 0.66

It is not only health problems; social factors can also be used to determine frailty index.

A frailty index based on a CGA (FI-CGA) better stratifies 70-month survival than does age.

  • Rockwood will soon be publishing this in JAGS

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History and Physical Exam

 

It is important to recognize system failure in the frail elderly.

  • history
  • physical exam

History

Frail elders are generally >75.

 

Complex acute and chronic medical conditions.

Ensure you check out the caregiver and the situation. The system has a hard time dealing with this.

 

Frail elderly often present atypically - with delirium, falls, immoblility, incontinence, so frequently in fact that these are standard. Inquire as to each.

delirium - assess whether the person can describe what has been happening over the past few days.

function - has there been a change in ADLs or IADLs?

 

Indicators:

  • unintended weight loss
  • loss of appetite

 

Screen for depression (geriatric depression scale, Cornell)

medications

  • assess for polypharmacy

 

 

Physical Exam

assess mobility in bed - can people roll on their side? sit up? swing legs over bed?

mobility tells you A LOT about how people are doing.

Handgrip strength closely correlates with functional capacity and mortality (Ling et al, 2010)

orthostatic hypotension

bedsores on pressure spots

 

Can measure:

  • mobility (gait speed)
  • strength
  • balance
  • motor processing
  • cognition
  • etc

 

State Variables - measures single modality and gives info re overall status of system

  • temp
  • VO
  • mobility

cooperativeness is a physical sign

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Investigations

  • lab investigations
  • diagnostic imaging

Lab Investigations

In a frail person who is presenting, the following should be carried out as a screen:

  • CBC
  • electrolytes
  • TSH
  • liver function tests
  • creatinine, BUN
  • calcium and albumin
  • urinalysis
    • # Global Shortage of Health Workers, Brain Drain Stress Developing Countries. JAMA 2007 # Cook DA et al. 2008. Internet-based learning in the health professions: a meta-analysis. JAMA. 300(10):1181-96.

Diagnostic Imaging

Chest X-ray should be carried out in frail elderly to assess for pneumonia or CHF.

CT head is only advisable if there are signs of stroke.

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Management

 

Prevention

We don't know yet;

exercise, nutrition, education, socioeconomic status, social integration, intellectual activity appears to promote healthy aging.

Early detection and treatment of hypertension, diabetes, heart disease, and osteoporosis.

 

physiological interventions: inflammation, immune, drugs

Good care: recognition by HCPs and communication with patients and families

Programs should include exercise and rehabilitation, as well as assistive technologies for physically or cognitively impaired people.

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Rehabiliation

Screening: Cumulative Illness Rating Scale (CIRS) 14 items

- illness severity index and comorbidity index

interprofessoinal team with specialized training.

medical conditions are priority

bladder re-training

self-medication program

joint medication review by physician and pharmacist

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Pathophysiology

There are a number of factors which contribute to frailty, including poor nutrition, reduced exercise, and decreased immune function. This can lead to a number of different physiologic effects:

 

Sarcopenia (Greek: "poverty of flesh"), is the loss of muscle mass with aging, leading to weakness and frailty. This loss of muscle mass may be caused by different cellular mechanisms than those which cause muscle atrophy, as there is a replacement of muscle fibres with fat and an increase in fibrosis.

 

Neuroendocrine dysfunction

Immunologic dysfunction

 

Osteoporosis is an age-related disease of bone that leads to an increased risk of fracture. Bone mineral density (BMD) is reduced, bone microarchitecture is disrupted, and the amount and variety of proteins in bone is altered. Given its influence in the risk of fragility fracture, osteoporosis may significantly affect life expectancy and quality of life.

 

Fatigue is also very common amongst the frail.

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Frailty and Death

Mortailty is predictable from age 70 onwards (Sweden study), from 55 onwards,

Fraily predicts

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Additional Resources

 

Fried LP et al. 2001. Frailty in older adults; evidence for a phenoype.

Rockwood et al, CMAJ, (1994) 150:499-507

Ling CHY et al. 2010. Handgrip strength and mortality in the oldest old population: the Leiden 85-plus study. CMAJ. 182(5):429-35.

Rockwood K. 1997. Medical management of frailty: confessions of a gnostic. CMAJ. 157(8):1081-1084.

www.frail-fragile.ca

 

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Topic Development

created: DLP, Aug 09

authors: DLP, Aug 09

editors:

reviewers:

 

 

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