Continence, falls and the frailty syndrome. Anne Foley - BGS Bladders and Bowel Health 2012

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1 Continence, falls and the frailty syndrome

2 Outline Frailty Geriatric syndromes and giants Aetiology What can be done? The future

3 Frailty

4 Frailty Frailty (noun): The state of being weak in health or body

5 Frailty Frailty is one of those complex terms with multiple and slippery meanings Kaufman SR. The social construction of frailty: an anthropological perspective. J Aging Stud. 1994; 8: 45 58

6 Frailty An accumulation of deficits with loss of reserve Due to cumulative effect of age, disease, disuse and loss of physiological reserve

7 Frailty

8 Frailty Frailty Disability Comorbidity

9 Frailty = Age

10 Frailty The midpoint between independence and death CE TEST: Functional Decline in Hospitalized Older Adults. American Journal of Nursing: 2006; 106 (1): 67-68

11 Frailty Older people defined as frail because of functional limitations are more likely to present with any geriatric syndrome Jarrett PG et al. Illness presentation in elderly patients. Arch Intern Med 1995; 155:

12 Geriatric syndromes

13 Geriatric syndromes Defined as: multifactorial health conditions that occur [due to] accumulated impairments in multiple systems Tinetti ME et al. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. JAMA 1995; 273:

14 Geriatric syndromes For a given geriatric syndrome, multiple risk factors and multiple organ systems are often involved

15 Geriatric syndromes Older age Shared Functional impairment risk Cognitive impairment factors Impaired mobility Incontinence Geriatric Falls syndromes Pressure ulcers Delirium Functional decline Frailty Poor outcomes Sharon K. Inouye et al Geriatric Syndromes: Clinical, Research and Policy Implications of a Core Geriatric Concept J Am Geriatr Soc May; 55(5):

16 Geriatric Giants

17 Geriatric Giants Immobility Falls Instability Incontinence Impaired intellect Isaacs B et al. Survival of the Unfittest (Study of Geriatric Patients in Glasgow) Routledge and Kegan Paul Ltd

18 Falls

19 Falls Fall: inadvertently coming to rest on the ground, floor or other lower level WHO Global Report on Falls Prevention in Older Age 2007

20 Falls Falls are 10 the commonest single reason The Every leading for older cause seconds people of death a person to present by injury over in to >75 65y urgent year falls care olds in UK in UK Stop Falling: Start Saving Lives and Money. Age UK Jan 2011

21 Falls 35% of adults > 65y 45% > 80y who live in the community Between 10-25% of fallers will sustain a serious injury Department of Health Falls and fractures; Effective interventions in health and social care 2009

22 Falls Estimated to cost 4.6 million per day Age UK June 2010

23 Intellectual impairment

24 Intellectual impairment Delirium Dementia Depression

25 Intellectual impairment Delirium: An acute alteration in conscious level accompanied by a change in cognition Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994:

26 Intellectual impairment Delirium: Usually a precipitant e.g. infection dehydration medication

27 Intellectual impairment Delirium: Prevalence Medical inpatients ~20-30% Surgical inpatients ~10-50% Delirium: Diagnosis, prevention and management CG103 July 2010

28 Intellectual impairment Dementia: Disease of the brain.. of a chronic or progressive nature. [with] disturbance of multiple higher cortical functions The ICD-10 Classification of Mental and Behavioural Disorders World Health Organization, Geneva, 1992

29 Intellectual impairment Dementia: Prevalence 5% in 65y+ 24% in 85y+ Alzheimer s Disease International, April 1999

30 Depression: Intellectual impairment Depression is the most common mental health problem in old age

31 Depression: Intellectual impairment Prevalence 43% > 85y 40% 2005 Health Survey for England

32 Depression: Intellectual impairment Aetiological factors include: Social isolation Chronic physical illness Financial stress

33 Urinary incontinence

34 Prevalence: Urinary incontinence 31% of women > 65y community 23% of men dwelling Stoddart H et al. Urinary incontinence in older people in the community: a neglected problem? Br J Gen Prac 2001 Jul; 51(468):

35 Shared aetiology

36 Shared aetiology Age Medication Infection Metabolic disturbance Alcohol misuse Neurological disease

37 Shared aetiology Urinary incontinence related to: Falls Confusion Anxiety & depression Poor quality of life AGS, Foley BGS AL and et al. American Association Academy between of Orthopedic the Geriatric Surgeons Giants panel of urinary on falls prevention incontinence. Guideline and falls for in older the prevention people using of falls data in from older the persons. Leicestershire J Am Ger MRC Incontinence Study.Age Soc. 2001; and 49: Ageing ; 41 (1):

38 Visual impairment Age Medication Infection Metabolic disturbance Alcohol misuse Neurological disease Muscle weakness Constipation

39

40 Increased number of frailties present more likely to be physically dependent

41 Lower Slow timed limb impairment chair stands Upper Decreased limb arm impairment strength Decreased Sensory vision deficit and hearing High Affective anxiety disorder depression score Doucette J et al. Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes JAMA. 1995;273 (17):

42 Slow Lower timed limb chair impairment stands Upper Decreased limb arm impairment strength Decreased Sensory vision deficit and hearing High Affective anxiety disorder depression score Doucette J et al. Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes JAMA. 1995;273 (17):

43 Slow Lower timed limb chair impairment stands Upper Decreased limb arm impairment strength Decreased Sensory vision deficit and hearing High Affective anxiety disorder depression score Doucette J et al. Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes JAMA. 1995;273 (17): (p <0.001)

44 Slow Lower timed limb chair impairment stands Upper Decreased limb arm impairment strength Decreased Sensory vision deficit and hearing High Affective anxiety disorder depression score Doucette J et al. Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes JAMA. 1995;273 (17): (p <0.001)

45 Slow Lower timed limb chair impairment stands Upper Decreased limb arm impairment strength Decreased Sensory vision deficit and hearing High Affective anxiety disorder depression score Doucette J et al. Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes JAMA. 1995;273 (17): (p <0.001)

46 Pathophysiology

47 Pathophysiology Possible mechanisms underlying geriatric syndromes:

48 proliferation arrest senescence apoptosis altered phenotype cell death atrophy neoplasm recovery Fedarko NS et al. the biology of aging and frailty. Clin Geriatr Med 2011; 27: 27-37

49 What can be done?

50 What can be done? Knowing is not enough; we must apply. Willing is not enough; we must do Goethe

51 What can be done? Assessments Tools Prevention

52 What can be done? Assessments: Physical examination Relevant investigations Medication

53 What can be done? Assessments: Physiotherapy Environmental Nutrition

54 What can be done? Social history Corroborative history

55 What can be done? Ask about falls, incontinence, confusion

56 What can be done? Assessment tools: Fried Frailty Index 1 Barthel scale 2 Cognitive assessment tools etc 1 Fried LP, et al. J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M Maloney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965; 14: 61-5.

57 What can be done? Multiple risk factors and organ systems involved Identifying underlying causes may be difficult Therapeutic management may be helpful even in the absence of a firm diagnosis or clarification of the underlying causes Sharon K. Inouye et al Geriatric Syndromes: Clinical, Research and Policy Implications of a Core Geriatric Concept J Am Geriatr Soc May; 55(5):

58 What can be done? Prevention: Mobilization Exercise & balance training Reorientation Nutrition

59 What can be done? Prevention: Incidence of under nutrition at admission (UK): 23% <65y 32% 65y+ Russell C, Elia M. Nutrition Screening Survey in the UK in British Association for Parental and Enteral Nutrition. 2009

60 What can be done? Exercise Diet Start now! Keep mentally active

61 The future

62 The future Elderly population increasing Office for national Statistics. Census results.

63 The future Technology Detect and monitor frailty in the community Support and enhance independence Oleg Zaslavsky et al. The Role of Emerging Information Technologies in Frailty Assessment Gerontological Nursing. April 25, 2012 on line

64 The future Research Typical studies and trials have excluded frail elderly people Biology of ageing and frailty not well understood

65 The future Treatments Medication Therapy

66 The future Guidelines NICE guidelines pending: Delaying the onset of disability, frailty and dementia in later life

67 The future Public health initiatives Education Promotion of healthy lifestyles

68 The future Public health initiatives Screening & treatment of: Hypertension Cerebrovascular disease Diabetes Osteoporosis Heart disease etc

69 The future???????????????????????????

70

71

72 Thank you Questions? for your attention

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