Frailty and Aging

1
Frailty and Aging

• John Puxty, Queens University

2
Learning Objectives for Frailty in the Elderly

• The learner will be able to-
• appreciate the importance of identifying frailty
  as a potentially remediable contributory factor
  to morbidity and mortality in the ill elderly
• understand the role of normal and abnormal aging
  which contributes to the patho-physiology of
  frailty
• identify the need to identify though careful
  history and examination the presence of factors
  contributing to frailty including cognitive
  impairment, depression, weight loss, weakness,
  mobility impairment, co-morbidity, and alcohol
  abuse
• appreciate the contribution of socio-economic
  factors in contributing to outcome of illness in
  the frail elderly
• identify an assessment strategy designed to
  identify key remedial elements and recommend an
  effective management plan

3
The case of Mrs P (Act 1)

• 89 women at AE
• Severe CHF, Falls, Confusion, Not coping 2
  previous AE visits in 6/12
• SH Lives alone, widow,
• PMH 10yrs MI, mild CHF, OA, Cataract
• Hospitalized CHF responds, but lethargic, thin,
  pneumonia and confusion
• Discharged to family after 3/52 terminal CHF
  bedridden and dependent
• Meds Furosemide, Enalepril, Digoxin, Ty 2s,
  Ativan

4
The case of Mrs P (Act 2) 2 months later post
Geriatric Assessment
5
The case of Mrs P (Act 3) 10 months later

• 90 women at home with family
• Alert and orientated
• Self caring feeding, washing, toileting
• Ambulates walker supervision
• Meds Furosemide, Effexor, B12, laxatives,
  vitamins

6
Questions to consider

• What factors might have contributed to Mrs Ps
  need for hospitalization?
• Why has her terminal cardiac failure improved?
• What were the medical interventions that helped
  Mrs P recover?
• Reflect on the functional changes during and
  post-hospitalization

7
Life Expectancy Increases 1921-97
8
Age-related Prevalence of Disability
9
Age-related increase in Reporting of Chronic
Disease
10
Leading causes of Morbidity and Mortality in
1996/97
11
Impact in men of eliminating leading causes of
Morbidity and Mortality
12
Impact in women of eliminating leading causes of
Morbidity and Mortality
13
Impact on hospitalization of eliminating leading
causes
14
Life Expectancy Changes

• Reduction or elimination in leading cause of
  mortality (Ca and Heart) creates likelihood of
  increased years of morbidity and hospital use

15
Survival in good health
16
Life Expectancy Changes

• Reduction or elimination in leading cause of
  mortality (Ca and Heart) creates likelihood of
  increased years of morbidity and hospital use
• In Ontario and Canada increase in life expectancy
  has generally been associated reduced years of
  disability

17
Geographic variation in health expectancy
18
Life Expectancy Changes

• Reduction or elimination in leading cause of
  mortality (Ca and Heart) creates likelihood of
  increased years of morbidity and hospital use
• In Ontario and Canada increase in life expectancy
  has generally been associated reduced years of
  disability
• Men have generally benefited more from
  compression of morbidity

19
High User Profile

• The majority of the elderly are well and enjoy a
  reasonable socio-economic status
• A small but significant subset of vulnerable
  elderly account for an excess of adverse
  socio-economic and health care outcomes
• A typical profile is the very old, female, living
  alone, with multiple chronic diseases and taking
  multiple medications

20
High User Profile
21
High users of hospitals have overlap of physical
and social vulnerabilities
22
Frailty
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 et al. 2003)
23
Increasing recognition in literature
24
Atypical presentations of disease are frequently
seen

• Classical
• Silent
• Pseudosilent
• Atypical Presentations Weakness/Fatigue D
  windles Falls/Immobility Incontinence
  Cognition/Mood Change Social Crisis

25
Geriatric Challenge
Co-Morbidity
Chronological Age
Frailty
Disability
ADL Dependencies
26
Predictors of Frailty

• Extreme age
• Visual loss
• Impaired cognition/mood
• Limb weakness
• Abnormalities of gait and balance
• Sedative use
• Multiple chronic diseases

27
Frailty Phenotype
28
Frailty Phenotype or Dwindles Syndrome

• Weight loss
• Weariness
• Low exercise tolerance
• Low level of physical activity
• Slow walking speed
• Also maybe cognitive impairment and or depression

29
Frailty is a dynamic state
30
Frailty Syndrome Epidemiology

• 3 or more of 5 criteria
• 6.7 of community residing elderly
• 3 year incidence 7
• Increases with age 3-65 26 -85-89
• Fried L, et al J Gerontol Med Sci 2001 560
  M146-M156

31
Risks of Frailty in 3 Years

• Adverse Geriatric Outcomes
• Death
• Worsening ADL
• Worsening Mobility
• Falling
• Hospitalization

• Hazards Ratio
• 2.24
• 1.98
• 1.50
• 1.29
• 1.29

Fried L et al J Gerontol Med Sci 2001 56A
M146-M156
32
Acute illness superimposed on Frailty

• Multiple organ stress
• Failure of homeostasis
• potential exacerbation of chronic diseases
• Increased potential for drug interactions and
  adverse effect
• Increased vulnerability to delirium, falls and
  incontinence with caregiver stress

33
SURVIVAL CURVES OF FRAILTY
Fried et al,2001
34
Significance of the Atypical Presentation

• Presence associated with delay in diagnosis and
  increased mortality (Puxty et al 1984)
• Predictive of future functional declines in
  community elderly (Choo-Cho et al 1998)
• Functional decline (dwindles) increases
  likelihood of further decline and increased
  mortality (Hebert et al1997)

35
Treatment of Frailty

• Prevent dwindles

36
Treatment of Frailty

• Prevent dwindles
• Early detection of acute illness and polypharmacy
  (Geriatric Giants or atypical presentation)

37
Clinicians general approach to the Atypical
Presentation

• Consider recent change in function a result of
  disease or drugs until proven otherwise
• Longitudinal multiple assessments often necessary
• Additional informants often invaluable
• Appropriate screening investigations have a role
• Multiple pathologies are the rule

38
Treatment of Frailty

• Prevent dwindles
• Early detection of acute illness and polypharmacy
  (Geriatric Giants or atypical presentation)
• Assess cognition and mood
• Optimize sensory inputs

39
Treatment of Frailty

• Prevent dwindles
• Early detection of acute illness and polypharmacy
  (Geriatric Giants or atypical presentation)
• Assess cognition and mood
• Optimize sensory inputs
• Mobilize
• Bed is BAD
• Minimize Muscle Wasting
• Improve nutrition

40
Questions to consider

• What factors might have contributed to Mrs Ps
  need for hospitalization?
• Depression
• Malnutrition
• Alcohol
• Medication compliance issues -gt CHF
• Infection atypical presentations

41
Questions to consider

• What factors might have contributed to Mrs Ps
  need for hospitalization?
• Why has her terminal cardiac failure improved?
• Assessment overlooked role of depression,
  malnutrition, delirium and medication compliance
  in presentation
• Resolution of iatrogenesis and secondary losses

42
Questions to consider

• What factors might have contributed to Mrs Ps
  need for hospitalization?
• Why has her terminal cardiac failure improved?
• What were the medical interventions that helped
  Mrs P recover?
• Tx of Depression, and Polypharmacy
• Correction of malnutrition
• Reversal of secondary losses from immobility eg
  advice re aids/adaptation, safe transfers,
  exercise program,

43
Questions to consider

• What factors might have contributed to Mrs Ps
  need for hospitalization?
• Why has her terminal cardiac failure improved?
• What were the medical interventions that helped
  Mrs P recover?
• Reflect on the functional changes during and
  post-hospitalization

44
Small changes can result in major functional
gains!
Medications Foot wear Walking aides Surface
heights Chairs/bed Wall bars Lighting Flooring/mat
s