Chairs: John Lainchbury & Andrew Aitken. Elderly/Frailty

Transcription

1 Frailty Elderly/Frailty Ralph Stewart Chairs: John Lainchbury & Andrew Aitken Elderly/Frailty Ralph Stewart Green Lane Cardiovascular Service and Cardiovascular Research Unit Auckland City Hospital 1

2 What is Frailty? Multi-system impairment which decreases physiologic reserve and increases vulnerability to stressors. Frailty is a complex and has multiple causes and contributing factors. The Clinical Frailty Scale 1. Very fit Robust, active, energetic 2. Well Less fit but without active disease 3. Well, with treated co-morbid disease 4. Apparently vulnerable Well with treated co-morbid disease, disease symptoms well controlled Disease symptoms or slowed up. Not dependent on others 5. Mildly frail Limited dependence on others 6. Moderately frail Help needed for instrumental and non-instrumental activities of daily living 7. Severely frail Completely dependent on others or terminally ill Rockwood K, et al. CMAJ. 2005; 173(5): 489 2

3 Frailty and survival or need for institutional care in the elderly 10,265 people aged 65 years were assessed for frailty and followed for 5 years Rockwood K, et al. CMAJ. 2005; 173(5): 489 The Freid criteria for frailty Shrinking Weakness Poor energy Slowness Low physical activity Weight loss >5kg / year Reduced grip strength, inability to rise from a chair Do you feel full of energy? Slow walk speed, 6 minute walk Activity questionnaire 3

4 Essential frailty toolset in older adults undergoing aortic valve replacement Afilalo. J Am Coll Cardiol Which measure of frailty should we use? Predict adverse outcomes Death Morbidity including risks related to treatment Dependency quality of life and need to care Easy to complete Inform patient care Responses to questions easy to interpret and directly inform care Standard measure Allows comparison between clinicians, institutions Can be applied to broad range of medical problems Captures a broad range of frailty 4

5 The Edmonton Frail Scale Leisure Time Physical Activity and Mortality Pooled Analysis of the Dose-Response Relationship Hannah Arem, JAMA Int Med

6 Mortality by medication adherence Laufs et al. Eur Heart J 2010 In-hospital outcomes after cardiac surgery for frail compared to non-frail patients Adverse outcomes after surgery Non-frail Mortality 4 % 15 % Discharge to institution 9 % 48 % Blood transfusion 34 % 62 % Low cardiac output syndrome 10 % 22 % Sepsis 3 % 13 % Pneumonia 7 % 20 % Delirium 9 % 15 % Postoperative renal failure 10 % 23 % Prolonged ventilation 16 % 36 % Prolonged length of stay 29 % 55 % (n=3669) Frail (n=157) Frailty = dependency on any activity of daily living, needs assistance to walk or diagnosis of dementia P<0.001 for all Lee DH, et al. Circulation. 2010; 121(8):973 6

7 OR for hospital admission OR for hospital admission 25/06/2018 Impact of age and co-morbidity on the risk of hospital admission in a general population Number of chronic conditions Age, years Wolff JL, et al. Arch Intern Med. 2002; 162(20): 2269 Impact of co-morbidity and frailty on mortality Tool C-statistic Co-morbidity Cumulative illness rating scale 0.58 Frailty Clinical frailty scale 0.70 Rockwood K, et al. CMAJ. 2005; 173(5): 489 7

8 Risk-adjusted impact of frailty on prolonged institutional care after cardiac surgery Preoperative Characteristics OR 95% CI P Frail Age * Female sex Diabetes Chronic obstructive pulmonary disease Renal failure Congestive heart failure Peripheral vascular disease Urgency of surgery Urgent/emergent In-house Elective 1.0 Procedure (other vs isolated CABG) Frailty = dependency on any activity of daily living, needs assistance to walk or diagnosis of dementia Lee DH, et al. Circulation. 2010; 121(8):973 Frailty and treatment strategy for severe aortic stenosis Outcomes by TAVR or standard therapy in the PARTNER B trial 8

9 Life years gained from intervention 25/06/2018 Impact of competing mortality risk on life years gained from an intervention over time Example of intervention which reduces mortality by 5%/year Mortality rate 1%/year 15%/year year 5 years 10 years 15 years Time from intervention Exercise capacity and outcome after CABG compared to medical therapy in the STICH trial 9

10 Risk factors for frailty over the life course Figure 1 5 year mortality predictors in UK Biobank The Lancet , DOI: ( /S (15) ) Ganna A. The Lancet. 10

11 Coronary Artery Calcium (CAC) With Non-Cardiovascular Disease The Multi-Ethnic Study of Atherosclerosis Catherine E. Handy et al. JIMG 2016;9: Red blood cell distribution width and mortality In middle-aged and older adults in US NHANES Arch Intern Med

12 Mortality during the next 14 years, % 25/06/2018 Lifestyle at age 50 and mortality No smoking, modest alcohol, physically active, healthy diet Number of healthy behaviours Khaw et al. PLoS Med 2008:5;e12 Use the Edmonton Frail Scale to assess frailty Inform clinical decisions and care Engage in what is important to patient Many advantages of using a standard approach to assess frailty 12