2007 Presentation on Frailty by Dr Rolfson - Is Frailty a by dfsdf224s

VIEWS: 221 PAGES: 27

									Is Frailty a meaningful
     t
construct?t?
Darryl Rolfson, MD, FRCPC
Associate Professor of Medicine
University of Alberta
Ed     t Senior’s Coordinating C
Edmonton S i ’ C di ti Council   il
December 4, 2007
Acknowledgements

Conflict of Interest – none to declare
Support
 – Division of Geriatric Medicine, UA
 – Regional Specialized Geriatric Program
Objectives

 Present three models of frailty
 Highlight valid measures of frailty
 Demonstrate the relationship between
 frailty and end of life trajectories
       Age and Frailty



Length of               Strength of
Lifespan
Lif                     Lif
                        Lifespan
•   Chronological Age    •   Frailty
                         Theoretical Trajectories of Dying




Copyright restrictions may apply.
                                    Lunney, J. R. et al. JAMA 2003;289:2387-2392.
      Frailty: Working Framework*


                                                            FRAILTY

                                                      FRAILTY
                                                     PHENOTYPE                          DISTAL
                                                                                       OUTCOMES
LIFE COURSE                                             Nutrition
DETERMINANTS           DISEASE                          Mobility
                                                        M bili                         Disability
                                                        Activity                       Morbidity
Biological & genetic                                    Strength                     Hospitalization
Psychological                                          Endurance                     Insititutional-
                        LOSS OF
Social                                                                                   ization
                       RESERVE
Environmental                                          Cognition?
                       CAPACITY                                                           Death
                                                         Mood?


                                                                               MODIFIERS
                                                                                Biological
                           * Canadian Initiative on Frailty and Aging, 2003
                                                                              Psychological
                                                                                  Social
A
A. Frailty as a “phenotype”

 – “Increasingly, geriatricians define frailty
   as a biological syndrome of decreased
   reserve and resistance to stressors,
   resulting from cumulative declines across
                        systems,
   multiple physiologic systems, and causing
   adverse outcomes.”
                 al,
     Fried LP et al Cardiovascular Health Study



                 Fried LP et al. J Geron Med Sci
                      2001;56A(3):M146-
                      2001;56A(3):M146-56
        g     g
Declining Energetics
Frailty Phenotype
 – Based on Objective Criteria
      Weight loss
      Slow walking speed
      Low levels of physical activity
      Subjective exhaustion
      Weakness
 – Frailty Categories
              frail
      3-5 is “frail”
      1-2 is “intermediate”
      0 is “not frail”

                      Fried LP et al. J Geron Med Sci
                          2001;56A(3):M146-
                          2001;56A(3):M146-56
B. Frailty D fi it A     l ti
B F ilt as Deficit Accumulation

   Accumulation of deficits with age
       the
    – “the more things people have wrong with
      them, the higher the likelihood of frailty”
    – Narrowed response repertoire and
                    p        p
      reserve in face of stress
    oss o espo se epe to e
   Loss of response repertoire
    – Eventually self reinforcing

                  Rockwood K Mitnitski A. J Geron Med Sci
                          2007;62A(7):722-
                          2007;62A(7):722-27
Accumulation of Deficits


 Failure to
                              Accumulation
 withstand
                               of Deficits
   stress




               Diminished
              Repertoire of
              homeostatic
                response
           y
CSHA Frailty Index –
            “Just count ‘em up”

     Urinary     Memory
  Incontinence
  I     ti       Ch
                 Changes                    Myocaridal
                                            Infarction




                                              Malignant   Index score =
                 Tremor                        Disease       positive
                 at Rest                                     variables/70
                                                             items
Falls


                                       2004;52:1829-
                   Jones D et al. JAGS 2004;52:1829-33
C
C. Geriatric Syndromes = Frailty

   Dementia
   Imbalance/ Immobility
   Functional Decline
   Ui      I    ti
   Urinary Incontinence
   Malnutrition
   Polypharmacy
Stress

 Frailty is most obvious in a dynamic
 context - under “stress”
 – acute illness
 – new medications
 – surgery
 – change in environment or support
Geriatric “State Variables”

 Delirium
 Falls & Immobility
 Acute Urinary Incontinence
 D h d ti or Acute Nutritional Crisis
 Dehydration    A t N t iti  lCi i
 Functional Decompensation
Delirium after Cardiac
Surgery
 71 consecutive elderly for CABG
 – Incidence of Delirium 32%
 – Predisposing Risk Factors
       e ous Stroke (OR 8.1, p=0.03)
     Previous St o e (O 8 , p 0 03)
     Duration on CPB (OR 2.0 at 38 min, OR 3.0 at
     60 minutes)




                                           1999;15(7):771-
              Rolfson et al. Can J Cardiol 1999;15(7):771-76
                 p      p   g
Delirium: sum of predisposing
and precipitating variables




           Inouye et al. Acute Hospital Care 1998
                       Nov;14(4):747
  Delirium as a model for other
  Geriatric Syndromes

• Falls
• Acute UI
• Nutrition
    Crisis
                          p
Geriatrician’s Clinical Impression
of Frailty (GCIF)
Contributors         Manifestations Impression
Health Attitudes     Delirium                                      Physical Frailty
Burden of Illness    Acute Falls                                   Physiologic Frailty
ADL status           Acute ADL Decline                             Frailty as Disability
Balance & Mobility   Dehydration                                   Dynamic Frailty
Continence           Acute Incontinence
Nutrition            Past pattern of any of
Medication Use       above
Cognition
Mood
Social Support

                     Rolfson DB et al, Gerontology 2001;47(Suppl
                                        1):119
        y            p
  Frailty Index – Comprehensive
                       (FI-
  Geriatric Assessment (FI-CGA)




              y     g
- Seven Frailty Categories
- Correlates with Frailty Index (0.78)
                                                           2005;465-
                           Jones et al. Aging Clin Exp Res 2005;465-471
 Edmonton Frail Scale (EFS)
Cognition
C    iti
Health Attitudes & Mood
  di i
Medication Use
Nutrition
Continence
Burden of Medical Illness
Social Support
Functional Independence & Performance
                 Rolfson DB et al. Age Ageing 2006
                          Sep;35(5):526-
                          Sep;35(5):526-9
Validation of EFS
 Criterion V lidit
 C it i Validity
 – Compared to GCIF                          r = 0.63       (p<.001)

 Reliability
   Inter-
 – Inter-rater                               kappa = 0.77

 – Internal consistency                      chr. alpha = 0.62




               Rolfson DB et al. Age Ageing 2006
                        Sep;35(5):526-
                        Sep;35(5):526-9
                    y       y
          Survival by Frailty Status
             Optima Cohort
           Frailty Index (Cut 8,13)                    EFS (Cut 4,7)

 1                                            1



0.9                                          0.9



08
0.8                                          08
                                             0.8



0.7                                          0.7



0.6                                          0.6



0.5                                          0.5



0.4                                          0.4
      0    20   40    60   80    100   120         0     20   40   60   80   100   120



                Months                                        Months
          y       y
Survival by Frailty Status
   CSHA Cohort
                           1.0




                            .9
                    ival


                                                                                      EFS 1
                                                                                      EFS=1 - 4
   Probabili of Survi




                            .8
                                                                                      EFS=7 - 8
           ity




                            .7                                                        EFS=5 - 6

                                                                                      EFS=9 - 10

                            .6
                                                                                      EFS ≥ 11

                            .5
                                 0   10      20         30          40           50       60       70


                                                     Time (month)
                                          Rolfson DB et al. Can J Geriatr 2006
                                                    Apr;9(2):69-
                                                    Apr;9(2):69-70
                  p
EFS Predicts Postoperative
Complications and Discharge

 EFS Score <3
                post-
 – Low risk of post-op complications (OR 0.27)
 – High likelihood of discharge home (80%)


 EFS Score >7
                post-
 – High risk of post-op complications (OR 5.02)
 – Lower likelihood of discharge home (40%)



               Dasgupta M et al. Arch Gerontol Geriatr 2007
                                (in press)
Living longer and stronger
 –   Choose your parents well
 –   Positive Family and Social Engagement
 –   Cope with Stress
 –   Get enough rest
 –   E e cise
     Exercise
 –   Preventative Health Practices
 –            Diet
     Healthy Diet, Floss Teeth
 –   Minimize Caffeine, Smoking, Alcohol
 –    p
     Optimistic Attitude
                     See Livingto100 Website
       p
  A Comparison of Selected
  Measures of Frailty
Characteristic                                    FI-
                           Phenotype CSHA Frailty FI-   EFS
                                     Index        CGA

Concurrent V lid ti
C        t Validation        Yes
                             Y          Yes
                                        Y         Yes
                                                  Y     Yes
                                                        Y
Predictive Validation        Yes        Yes       Yes   Yes
     g
Biological Model             Yes         No        No   No
Requires Full Assessment      No         Yes      Yes   No
Easy to administer            No         No        No   Yes
      l
Special Equipment             Yes        No       No    No
Highlights key Geriatric      No         No       Yes   Yes
Syndromes
Captures Cognition            No        Yes       Yes   Yes

								
To top