FRAILTY SYNDROME. dr. Rose Dinda Martini, Sp.PD, K-Ger

Transcription

1 FRAILTY SYNDROME dr. Rose Dinda Martini, Sp.PD, K-Ger Geriatric Division, Internal Medicine Department M. Djamil Hospital Padang Faculty of Medicine, Andalas University, 2018

2 Medical syndrome Multiple causes Frailty (Morley et al, 2013) Characteristic : diminished strength, endurance, reduced physiologic function Increased an individual s vulnerability for developing increased dependency and/or death 2

3 Aging Process Successful aging Usual aging Lifestyles Diseases Genetics Pathologic aging Risk of frailty mobility GERIATRIC SYNDROME functional status (disability) hospitalization & institutionalization mortality HR health-related QoL Hazzard s Geriatric Medicine and Gerontology 7th Edition, 2017

4 Fried LP, Tangen CM Walston J, et al. Frailty in Older Adults: Evidence for A phenotype Frailty Deficits/co-morbidities/ Disabilities accumulation Clinical syndrome (phenotype) Fit/Robust Pre-Frail Frail Physical Psycological Sosial Nutritional status Physical activity Mobility Muscle strength Energy Cognitive Mood Contact/interaction Social support

5 Dynamic Transition of Frailty Syndrome Prefrail Fit/robust (not frail) Death Frail Gill TM, et al. Arch Intern Med. 2006

6 Frailty dynamic process potentially reversible by managing modifiable contributing factors Preventive measures to delay and/or improve frailty syndrome very important to QoL Gill TM, et al. Arch Intern Med. 2006

7 Frailty Conceptual Cognitive & physical impairments Area of biomarkers Loss of indepence Multiple chronic diseases Depression Slowness Anabolic hormon deficit Impaired physical function Loss of weight Energy unbalance Inflamation weakness Neurodegeneration Poor endurance Mitochondrial dysfunction Oxidative stress Senescence DNA damage Impaired autophagy DNA metyhlation Telomere shortening Primary causes of frailty Reduced Mobility Cognitive impairment Geriatric syndromes Low physical activity Stem cell exhaustion Hazzard s Geriatric Medicine and Gerontology 7th Edition, 2017

8 Characteristic of Frailty vulnerability Weakness Low strength Physiologic reserves Accumulation of deficits Cognitive impairment resistence to stressors Functional decline Poor health function capacity to maintain internal homeostasis Dependence in daily activity Poor physicological functioning Loss of resilience Impaired mobility Depression Multisystem dysregulation Disability Unintentional weight loss Failure to thrive Comorbidity Sarcopenia Slow motor performance Low energy expenditure Poor endurance Slow walking speed Low physical activity Exhaustion Decreased balance Low fitness Gait abnormality Impaired vibration sense tremor Vision and/or hearing deficit 8 Hazzard s Geriatric Medicine and Gerontology 7th Edition, 2017

9 Criteria for Frailty Syndrome According to Fried & colleagues Characteristic of Frailty Cardiovascular Health Study Measure 1. Weight loss (unintentional)/sarcopenia > 10 lb lost unintentionally in prior year 2. Weakness Grip strength: Lowest 20% 3. Exhausting/poor endurance Exhaustion (self-report) 4. Slowness Walking time/15 ft: slowest 20% 5. Low activity Lowest 20% males: <383 kcal/wk; females: <270 kcal/wk 9 Fried LP, Tangen CM Walston J, et al. Frailty in Older Adults: Evidence for A phenotype. 2001

10 Pathologic vicious cycle supposed to lead to decline in health & function Aging: Senescent Disease Musculoskeletal changes Neuroendocrine Dysregulation Anorexia Of aging Total Energy Expenditure Chronic Undernutrition (Inadequate intake of protein and Energy; micronutrient Deficiencies) Negative energy balance Weight Loss Loss of muscle mass Sarcopenia Sarcopenia is central manifestation of frailty Activity Walking speed Resting metabolic rate Strength & power VO2 max Disability Dependency Hazzard s Geriatric Medicine and Gerontology 7th Edition, 2017

11 Biological Hypotheses of Frailty Gene variation Molecular & Disease Impaired Physiological Clinical Oxidative stress Mitochondrial deletions Shortened telomeres DNA damage Cell senescence Inflammatory diseases Inflamation Neuroendocrine dysregulation Interleukin-6 Anorexia Sarcopenia, osteopenia Insulin like growth factor-1 Dehydroepiandrosteronesulfate Sex steroids Immune function Cognition Clotting Glucose metabolism Slowness Weakness Weight loss Low activity Fatigue American Geriatric Society/National Institute on Aging Research Conference on Frailty in Older Adults. J Am Geriatr Soc. 2006

12 Aging Phenotype Relationship Frailty and Geriatric Syndrome Aging Aging Phenotypes Changes in Body Composition Energy Imbalance Production/Utilization Homeostatic Dysregulation Neurodegeneration Disease Susceptibility Reduced Functional Reserves Reduced Healing Capacity & Stress Resistance Unstable Health Failure to Thrive Gait disorders Physical and Cognitive FRAILTY Cognitive impairment Falls Delirium Geriatric Syndromes Disability Sleep disorders Comorbidity Decubitus Ulcers Harrison Principles of Internal Medicine 18 th, 2012 Urinary Incontinence

13 Fried Fried LP, Tangen CM Walston J, et al. Frailty in Older Adults: Evidence for A phenotype CHS Scoring System

14 Study of Osteoporosis Fracture (SOF) Criteria Weight loss Weight loss 5% Ability to rise from a chair Fatigue Interprepation Measurement and Cut-off Point Disability to rise from a chair 5 for 5 times without help of arms/hands Answer no for question did you feel full of energy? that questioned on Geriatric Depression Scale Fit/Robust : 0 criteria Pre-frail : 1 criteria Frail : 2-3 criteria Ensurd KE, Ewing SK, Taylor BC, Fink HA, Cawthon PM, Stone KL, et al. Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women. Arch Intern Med. 2008

15 Fatigue Criteria Resistance Ambulation Illness Weight loss Interpretation Fit/Robust : 0 Pre-frail : 1-2 Frail : 3-5 FRAIL Scoring System Measurement and Cut-off Point In last 4 weeks, how much time were you feel the fatigue? Answer is (+) if the answer everytime or most of time Did you feel any difficulities to climb 10 stairs independently without using aids? Did you feel any difficulities to walk 1 hundred meters independently without using aids? Result was (+) if subject reported 5 diseases from 11 diseases Result was (+) if there was weight loss 5% in last 12 months Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African americans. The Journal of Nutrition, Health & Aging. 2012

16 Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ No Description Information Clinical Frailty Scale (CFS) 1 Very fit Robust, active, energetic, fully motivated and fit. Usually do routine physical exercise and in most fit group for his/her age 2 Well Have no active disease, but less fit than category 1 3 Managing well Symtomps of disease are managed better than category 4 4 Apparently vulnerable Even thought it is not significantly dependent, but generally complain of having symptomps of a disease or become slow 5 Midly frail Mild dependent for IADL 6 Moderately frail Need help for basic ADL & IADL 7 Severely frail Full need of help for basic ADL & IADL, but generally stable and has no risk of death soon (6 months)

17 What Kind of Scoring System to be Chosen? Depends on the purpose Clinical setting: practicability & applicability Primary Health Care Phenotype method: FRAIL or SOF Index method: CFS

18 What Kind of Scoring System to be Chosen? Depends on the purpose Clinical setting: practicability & applicability Primary Health Care Phenotype method: FRAIL or SOFT Index method: CFS

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20 Conclusion Characteristics of frailty: weight loss, weakness, exhaustion, slowness, low activity Frailty as a dynamic process, can be prevented progression and reversible Impact of frailty: falls,delirium,hospitalization,etc caused the quality of life to decline 20

21 Thank You