Frailty: from Academic Definition to Clinical Applicability Associate Professor Ruth E. Hubbard October 26 th 2018
Objectives 1. Describe the development of frailty as a concept 2. Provide an overview of frailty measures 2
What is frailty? Frailty has been defined as a state of increased vulnerability to stressors A frail individual has reduced physiological reserve and reduced ability to compensate for disruptions to homeostasis Increased risk of: Disability Geriatric syndromes Death 3
Development of the concept Early definitions of frailty painted bleak pictures of irreversible age-related decline A leading article in the BMJ (Anon, 1968) described confused, restless, incontinent old patients 20 years later, frailty was still considered to equate to elderly people with multiple problems (Pawlson, 1988) 4
Limitations of end-of-the-bed estimations Frailty age Frailty cachexia Frailty co-morbidity Frailty polypharmacy Frailty disability 5
How can frailty be measured? Understanding frailty has become the focus of extensive research The associations of frailty are now well described 3 main approaches Clinical syndrome or phenotype Subjective opinion Multidimensional risk state 6
Definitions Clinical syndrome: a set of signs and symptoms Lists and algorithms derived from clinical judgment Combinations: Physical inactivity and weight loss (Chin a Paw, 1999) Gait speed, peak expiration, hand grip, sitting position, visual impairment (Klein, 2005) Fatigue, resistance, ambulation, illness, loss of weight (Abellan van Kahn, 2008) Edmonton Frailty Scale (Rolfson, 2006) 7
Fried phenotype The most well known and widely used phenotype Criteria unintentional weight loss of 10 lbs or more in past year self reported exhaustion weak grip strength slow walking speed low physical activity 8
Fried phenotype Strengths Clinical coherency Reproducibility Wasting disorder with sarcopenia as pathophysiological feature Weaknesses Omission of mood and cognition Selection of initial cohort Dichotomous/ trichotomous outcome Reliance on performance based tests 9
Fried phenotype in clinical practice 10
Subjective opinion We know it when we see it Visual estimation of biological age a checklist of age-associated changes in appearance, communication and mobility. Good inter-rater agreement Global measures Studenski et al, JAGS 2004 Rockwood et al, CMAJ 2005 11
Clinical Frailty Scale 12
Deficit accumulation Frailty = multidimensional risk state Can be measured by quantity rather than by the nature of health problems Various disorders are accumulated by individuals during their lives The more deficits that are accumulated, the more likely that person is to be frail Rockwood and Mitnitski, 2001 13
Deficit accumulation Deficits can be symptoms, signs, diseases, disabilities, abnormal laboratory measurements Accumulate with chronological age Associated with adverse outcome Do not saturate Cross different domains FRAILTY INDEX Searle et al., 2008 14
Deficit accumulation Strengths Granular Precise Valid Weaknesses Complex Mathematical Time consuming 15
Addressing the Challenge N=1418 Mean (SD)=0.32 (0.14) Median (IQR)=0.31 (0.22-0.41) 99 th percentile= 0.69 Reference Hubbard RE, Peel NM, Samanta M, Gray LC, Fries BE Mitnitski A, Rockwood K. Derivation of a Frailty Index fr the interrai Acute Care Instrument. BMC Geriatr. 2015;15:27. 16
Frailty Surgical patients: Lin et al, 2018 110 studies between 2007 and 2017 37 different measurement tools Older inpatients: Theou et al, 2018 617 papers between 2002 and 2015 2/3 didn t use any instrument to measure frailty Others included 48 different instruments 17
Modified Frailty Index 11 variables from NSQIP Strengths Valid Rapid derivation Automatic calculation Weaknesses 9/11 variables are co-morbidities Not a frailty index Darvell et al, Archives of Gerontol Geriatr, 2018 18
Conceptual fuzziness 19
Clinical utility