Assessing frailty in the community: experience from t he Lc65+ st udy Progetto strategico "E-health Strate kega projekta "E-heath"

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1 LA FRAGILITA : DAI MODELLI TEORICI ALLA VALUTAZIONE DELLE ESPERIENZE IBKOST: OD TEORETICNIH MODELOV DO OCENJEVANJA IZKU ENJ Assessing frailty in the community: experience from t he Lc65+ st udy Progetto strategico "E-health Strate kega projekta "E-heath" Brigitte Santos-Eggimann Ravenna, 12 ottobre 2012

2 Frailty as a public health issue The Lausanne cohort study Measurement of frailty in the Lc65+ Relationship with other health dimensions and health services utilization at age 65-70

3 Frailty: a public health issue? Needs for population s health monitoring in aging societies Population aging in next 30 years will result both from longevity and post-war baby-boom Chronological age not a good indicator of health Specific diseases not good indicators in an age of comorbidity Functional dependency a useful indicator only in the oldest old Brigitte Santos-Eggimann.Ravenna, 12 ottobre 2012

4 Frailty a useful concept for many reasons : Progressive (pertinence in the youngest old) Integrative, not disease-specific Preceeding (precursor of?) disability Possibly reversible (pertinence for prevention) Predictive of adverse outcomes (and needs for health services?) A target for prevention of functional dependency if we can recognize its manifestations and understand its reversible causes

5 Requirement for population-based epidemiological research on age-related frailty Comparisons of observed frailty frequency in populations different places, times and people Need for a classification of observed individuals Need for an operational definition of frailty NO CONSENSUS Brigitte Santos-Eggimann.Ravenna, 12 ottobre 2012

6 Lausanne cohort 65+ study (Lc65+) Lausanne University Hospital Center Institute of Social and Preventive Medicine, HSR Unit Prof. B. Santos-Eggimann, PI Geriatrics and Rehabilitation Service Prof. C. Büla Community Health and Medicine Department Prof. A. Pécoud, Prof. J. Cornuz, Prof. N. Rodondi Medical Outpatient Clinic Prof. J. Cornuz Medicine Department Prof. P. Vollenweider, Prof. G. Waeber Psychogeriatrics Service Prof. A. von Gunten Brigitte Santos-Eggimann.Ravenna, 12 ottobre 2012

7 Purposes Conduct longitudinal epidemiological research on frailty from its earliest stages Determinants Manifestations Outcomes Targetting and design of preventive interventions Create a research platform on old age Make use of multidimensional micro-data collected Contribute to the health information system Population health Evolution (cohort effects) Needs for care, expectations, etc. Adaptation of healthcare system to population aging Brigitte Santos-Eggimann.Ravenna, 12 ottobre 2012

8 Financing Public funds( until now) Lausanne University Hospital City of Lausanne State Vaud Public Health Department Lausanne Social and Medicine Foundation Loterie Romande University of Lausanne Faculty of Biology and Medicine Swiss National Research Fund Brigitte Santos-Eggimann. Ravenna, 12 ottobre 2012

9 Design (1) y [years] 2005 RV 2008 RV 2011 RV 2014 RV Baseline: questionnaires, interviews and performance tests Follow-up (unlimited): yearly questionnaires, + interviews and performance tests every 3 years No biological samples (until now) Brigitte Santos-Eggimann. Ravenna, 12 ottobre 2012

10 Sampling and participation

11 Design (2) [year] Random samples of community-dwelling years old residents ~ inclusions at each enrolment wave (born before, during, after WW-II) Target: after 3 waves, coverage of the years old population

12 Challenges (1) : retention Very heterogeneous group Active Depressed Diseased (cancer, neurological) Diseased husband or wife Memory Foreign language Part-time in Switzerland Move to nursing home Identification of deaths, moves

13 Challenges (2) : frailty is multidimensional Epidemiological studies of frailty necessitate questions on a wide range of medical and non-medical aspects e.g. economics, psychosocial Trade-off between lengthy instruments and long term willingness to participate among (increasingly frail) study subjects

14 Challenges (3) : measurement of frailty

15 Accumulation of deficits Rockwood K et al. Competing models : STARTING WITH Frailty phenotype Fried L et al. versus

16 Construct of 5 dimensions resulting from expert opinions Reference to a clear conceptual model 1 criterion for each dimension Fried s phenotype : Based on data from Cardiovascular Health Study (secondary use) Dimensions Shrinking : Exhaustion : Weakness : Slowness : Low activity : Criteria Unintentional weight loss 10 lbs in 1 year Modified 2 items of 10 CES-D < 20 th pct grip strength < 20 th pct walking speed < 20 th pct Minnesota Leisure Time Activity Questionnaire

17 Problems : Reliability of amount of self-reported weight loss? (Baseline) Feasibility of lengthy questionnaires (Minnesota Leisure Time Activity ) Feasibility of performance tests compromised by temporary or permanent health problems Adaptations in Lc65+

18 Shrinking : Any reported unintentional weight loss in prior year Exhaustion : "Did you have feelings of generalized weakness, weariness, lack of energy in the last four weeks? > much Weakness : Slowness : Grip strength: best of 3 measurements right hand, CHS thresholds Walking time / 20 meters, CHS thresholds Low activity : less than 20 minutes of sport activity once a week and less than 30 cumulated minutes walk per day 3 times a week and avoidance of stairs climbing or light loads carrying in daily activities

19 Adaptations of Fried s phenotype in other studies : Shrinking Exhaustion Weakness Slowness Low activity WHAS MrOS InChianti adj. + adj. - SOF adj. + adj. - WHI-OS MMAS adj. + adj.. -

20 Open questions on Fried s phenotype : Meaning of thresholds : >10 pounds loss in 12 months? <20 th percentile? Pertinence of CHS thresholds for performance tests? Prefrailty : 3 x 20 th percentile. Meaning of prevalence? Essentially physical frailty? 1 «loss» criterion, 4 «level» criteria : Rationale? Correlations between criteria? All criteria equivalent?

21 At age % 26.4% 2.5% Danon-Hersch et al., JAGS 2012;60:

22 Prevalence of chronic diseases and disability by frailty categories % CHRONIC DISEASES DISABILITY % % 49 % NON- FRAIL (n=1014) 2 % PRE-FRAIL (n=370) 13 % 59 % FRAIL (n=32)

23 Independent effect on health services utilization? Multivariate models, systematic adjustment for gender Chronic diseases(0, 1, 2+) ADL(No help, IADL only, BADL) Frailty (0, 1-2, 3-5 criteria) first entered as a bloc, then removal if not statistically significant and no major effect of removal on the coefficients of other variables Self-reported HSU over the next 12 months: Number of medical consultations (continuous) Hospital admissions (1+) Long term care (nursing home or home services, not temporary)

24 Number of medical consultations : estimate [95% CI] P-value Gender: F 0.75 [ ].3 Chronic diseases: [ ].2 Chronic diseases: [ ] <.001 Frailty: 1-2 criteria 4.30 [ ] <.001 Frailty: 3-5 criteria [ ] <.001

25 Hospital admission(s) : OR estimate [95% CI] P-value Gender: F 1.19 [ ].2 Chronic diseases: [ ].1 Chronic diseases: [ ].001 Frailty: 1-2 criteria 2.09 [ ] <.001 Frailty: 3-5 criteria 3.84 [ ].001

26 Formal long term care (home or nursing home) : OR estimate [95% CI] P-value Gender: F 1.21 [ ] 6 ADL: IADL only 1.83 [ ].3 ADL: BADL [ ] <.001 Frailty: 1-2 criteria 2.51 [ ].009 Frailty: 3-5 criteria 4.46 [ ].03

27 Conclusions Despite controversy regarding its operational definition, frailty is a central concept for understanding health in old age; it «makes sense» even if much research is still needed for designing preventive interventions Current work on frailty measurement : - Integrating phenotype and deficits accumulation methods (Dr G. Franchino) - Contribution of mental health dimensions - Detection of frailty based exclusively on self-report data - Pre-frailty: meaning? Homogeneous group?

28 LA FRAGILITA : DAI MODELLI TEORICI ALLA VALUTAZIONE DELLE ESPERIENZE Ravenna, 12 ottobre 2012 Grazie per l attenzione! Hvala za va o pozornost! Brigitte Santos-Eggimann Lausanne University Medical Center, Institute of Social and Preventive Medicine Brigitte.Santos-Eggimann@chuv.ch in collaborazione con /v sodelovanju z Progetto finanziato nell'ambito del Programma per la Cooperazione Transfrontaliera Italia-Slovenia , dal Fondo europeo di sviluppo regionale e dai fondi nazionali Projekt sofinanciran v okviru Programa ezmejnega sodelovanja Slovenija-Italija iz sredstev Evropskega sklada za regionalni razvoj in nacionalnih sredstev Ministero dell'economia e delle Finanze