Modulate the prevention stategy according to the level of frailty. Prof Leocadio Rodríguez Mañas Hospital Universitario de Getafe

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1 Modulate the prevention stategy according to the level of frailty Prof Leocadio Rodríguez Mañas Hospital Universitario de Getafe

2 CONFLICT OF INTEREST DISCLOSURE I have no potential conflict of interest to report

3 Is it possible to assess the level of frailty? Is there different clinical phenotypes of frailty? Is there any evidence-based strategy to prevent frailty? Is it the prevention strategy the same in different settings?

4 Frailty as a dynamic functional state CARE FOCUSED ON Preventing frailty Preventing Disability Treating Frailty Preventing Disabilty Treating Functional Decline Preventing Dependency Treating Disability Managing Dependency Potential reversibility of functional decline Robust Frail Functional Limitation Disability Dependency Definition Interventions to improve quality and outcomes - and prevent or delay further functional decline What How Where? What How Where? What How Where? What How Where? What How Where?

5 Frailty conceptual models A) Deficit accumulation B) Frailty phenotype Rockwood K. J Am Geriat Soc. 2006;54: Fried et al. J Gerontol Med Sci. 2001;56A:M146-M156 Rodriguez-Mañas L & Walston JD Rev Esp Geriatr Gerontol 2017

6 ROBUSTNESS LOW FUNCTIONAL RESERVE DISABILITY-DEPENDENCY SEVERE DEPENDENCY DEATH Isolated Physiological Vulnerability The functional continuum MULTYSYSTEMIC IMPAIRMENT Multiple Non-reversible conditions CURRENT TOOLS: DICHOTOMIC (FRAIL vs NON-FRAIL)

7 Frailty Trait Score (FTS) vs Frailty Phenotype Frailty Trait Score (0-100) Frailty Phenotype (Robust/Pre-frail/Frail) Domain (Score) Item Criteria Domain/ (Score) Item Criteria Energetic balance/ Nutrition (0-32) BMI Weigth loss Abd. Obesity Serum Alb. (mg/dl) BMI >4.5 Kg/12m Waist circum Lowest Quin. Energetic balance/ Nutrition (1) Weigth loss >4.5 Kg/12m Weakness (0-16) Grip strength Knee extension Lowest Quin. Lowest Quin. Weakness (1) Grip strength Lowest Quin. Endurance (0-10) Chair test (times stand. up/30 sc) Lowest Quin. Endurance (1) Exhaustion CES-D (2 qst) Slowness (0-8) Gait speed Lowest Quin. Slowness (1) Gait speed Lowest Quin. Low activity (0-8) PASE Lowest Quin. Low activity (1) Kcals/week Lowest Quin. Nervous System (0-16) Fluency (animals in 60 s) Balance Lowest Quin. SPPB criteria Vascular system (0-10) Brachial/Ankle Index Fowkes criteria

8 CHARACTERIZATION OF FRAILTY STATUS BY FRAILTY TRAIT SCORE (FTS) Variable [0-20] (20-30] (30-40] (40-50] (50-60] (60-70] (70-100] N Age 70 (68, 73) 72 (69, 75) 73 (70, 77) 75 (71, 78) 77 (74, 81) 79 (75, 83) 81 (77, 85) Men (%) FI (Rockwood) (0.25, 0.31) (0.26, 0.33) (0.27, 0.35) (0.30, 0.40) (0.34, 0.47) (0.39, 0.55) (0.45, 0.60) Frailty status (% across categories) Robust Prefrail Frail Carnicero JA, Caballero MA, Rodríguez-Mañas L, 2017

9 CHARACTERIZATION OF INCIDENT ADVERSE OUTCOMES BY FTS SCORE Variable [0-20] (20-30] (30-40] (40-50] (50-60] (60-70] (70-100] N Age Men (%) Frailty status (% across categories) Robust Prefrail Frail Outcomes pv test for trend Death (%) < E-42 Hospi (%) < E-11 inc. Disability (%) < E-29 falls (%) < E-4 fear to falling (%) < E-9 Carnicero JA, Caballero MA, Rodríguez-Mañas L, 2017

10 70% Robust people 70% Prefrail people Mi. Mo./Sev. Carnicero JA, Caballero MA, Rodríguez-Mañas L 2017 Mi. Mo. Sev. 70% Frail people

11 Table 3: Combining both frailty and sarcopenia EWGSOP N=1611 Sarcopenic Frailty Robust Pre-Frail Frail 8 % FNIH 352 (21.8%) 182 (17.3) 141 (29.3) 29(40.3) Non-sarcopenic 1250 (78.2%) 867 (82.7) 340 (27.2) 43 (59.7) Sarcopenic 3.4 % 7.6 % Quintiles 705 (43.7%) 348 (33.3) 303 (62.9) 54 (76.1) Non-sarcopenic 894 (56.3%) 698 (66.7) 179 (37.1) 17 (23.9) Sarcopenic 134 (8.3%) 31 (3.0) 84 (17.5) 29 (40.8) Non-sarcopenic 1453 (91.7%) 1014 (97.0) 397 (82.5) 42 (59.2) Frailty and sarcopenia are related but different entities Sarcopenia is not useful to screen frailty (low PPV) but to rule it out (very high NPV) Table 4. Sensitivity and specificity N=1611 Frailty Sensitivity Specificity PPV NPV EWGSOP 0.60 (0.47, 0.71) 0.21 (0.19, 0.23) 0.03 (0.02, 0.05) 0.92 (0.88, 0.94) FNIH 0.24 (0.14, 0.35) Quintiles 0.60 (0.47, 0.71) 1.9 % 22 % 2.9 % Davies B, F García-Garcia FJ, Ara I, Walter S, Rodriguez-Mañas L JAMDA, (0.40, 0.45) 0.08 (0.06, 0.09) 0.02 (0.01, 0.03) 0.03 (0.02, 0.04) 0.92 (0.90, 0.94) 0.80 (0.73, 0.86)

12 Raising misclassification with changing risks Alonso Bouzón C, Carnicero JA, Turín JG, García-García FJ, Esteban A, Rodríguez-Mañas L. JAMDA, 2017

13 Alonso Bouzón C, Carnicero JA, Turín JG, García-García FJ, Esteban A, Rodríguez-Mañas L. JAMDA, 2017 Time to event

14 Frailty classification by tool and setting Setting Emergency Room Fried (%) FRAIL (%) Tilbg (%) Grng (%) Rockw (%) ISAR (%) Bald (%) G8 (%) VES 13 (%) Total (%) 50,51 40,71 68,14 74,34 47,46 78, ,00 Cardiology 61,39 41,36 65,55 62,32 42, ,61 Elective Surgery Urgent Surgery 24,67 15,48 30,32 30,72 5, ,27 53,33 41,54 37,50 50,77 18, ,32 Oncology 47,92 30,00 36,00 40,00 6, ,28 81,63 34,69 36,31 Agregate 47,43 33,67 51,27 53,23 28, ,78

15 70% Robust people 90% Prefrail people

16 OCTOBER, 2015

17 Functional Capacity D E A T Successful H Disability Death Accelerated Usual The Energetic Pathway to Mobility Loss: An Emerging New Framework for Longitudinal Studies on Aging Jennifer A. Schrack, J Am Geriatr Soc October ; 58(Suppl 2): S329 S336.

18 Observational studies: Nutrition: Macronutrients and adherence to Mediterranean Diet and Mediterranean Drinking pattern Physical activity: Avoiding sedentariness, Mod-Vigor physical exercise Ideal CV risk: Diet rich in fruit and vegetables, moderate exercise, non obesity, non diabetes Del Pozo-Cruz y cols., PLoS One 2017 Sandoval-Insausti et al., J Gerontol 2016 McClintock et al., PNAS 2016 Garcia-Esquinas et al., JAMDA, 2015 Ortolá R et al., J Gerontol 2016 Graciani et al., Circ Cardiovasc Qual Outcomes., 2016

19 Interventional studies: Nutrition:?????????? Physical activity: LIFE study (pre-frail and frail) Ideal CV risk: MID-FRAIL study (pre-frail an frail) Outcomes: SPPB Non-robust Sample size (Size effect) Time of follow-up Clinical phenotypes Settings

20 IS IT POSSIBLE TO DESIGN SUCH A FLOWCHART FOR FRAILTY AT RISK YES NO SCREENING YES NO DIAGNOSIS YES NO PROGNOSIS TREATMENT

21 Is it necessary to modulate the prevention strategy according to the level of frailty? Yes How should it be modulated Clinical Phenotypes By severity By comorbidity By setting INTUITIVE NOT EVIDENCE-BASED GREAT OPPORTUNITIES FOR RESEARCH With which approaches Improving diet Physical exercise Managing cardiovascular risk Others OBSERVATIONAL STUDIES RCTS

22 THANK YOU e.mail: