Continence, falls and the frailty syndrome
Outline Frailty Geriatric syndromes and giants Aetiology What can be done? The future
Frailty
Frailty Frailty (noun): The state of being weak in health or body
Frailty Frailty is one of those complex terms with multiple and slippery meanings Kaufman SR. The social construction of frailty: an anthropological perspective. J Aging Stud. 1994; 8: 45 58
Frailty An accumulation of deficits with loss of reserve Due to cumulative effect of age, disease, disuse and loss of physiological reserve
Frailty
Frailty Frailty Disability Comorbidity
Frailty = Age
Frailty The midpoint between independence and death CE TEST: Functional Decline in Hospitalized Older Adults. American Journal of Nursing: 2006; 106 (1): 67-68
Frailty Older people defined as frail because of functional limitations are more likely to present with any geriatric syndrome Jarrett PG et al. Illness presentation in elderly patients. Arch Intern Med 1995; 155: 1060 4
Geriatric syndromes
Geriatric syndromes Defined as: multifactorial health conditions that occur [due to] accumulated impairments in multiple systems Tinetti ME et al. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. JAMA 1995; 273: 1348 53
Geriatric syndromes For a given geriatric syndrome, multiple risk factors and multiple organ systems are often involved
Geriatric syndromes Older age Shared Functional impairment risk Cognitive impairment factors Impaired mobility Incontinence Geriatric Falls syndromes Pressure ulcers Delirium Functional decline Frailty Poor outcomes Sharon K. Inouye et al Geriatric Syndromes: Clinical, Research and Policy Implications of a Core Geriatric Concept J Am Geriatr Soc. 2007 May; 55(5): 780 791
Geriatric Giants
Geriatric Giants Immobility Falls Instability Incontinence Impaired intellect Isaacs B et al. Survival of the Unfittest (Study of Geriatric Patients in Glasgow) 1972. Routledge and Kegan Paul Ltd
Falls
Falls Fall: inadvertently coming to rest on the ground, floor or other lower level WHO Global Report on Falls Prevention in Older Age 2007
Falls 1 10 49 87 65 32 Falls are 10 the commonest single reason The Every leading for older cause seconds people of death a person to present by injury over in to >75 65y urgent year falls care olds in UK in UK Stop Falling: Start Saving Lives and Money. Age UK Jan 2011
Falls 35% of adults > 65y 45% > 80y who live in the community Between 10-25% of fallers will sustain a serious injury Department of Health Falls and fractures; Effective interventions in health and social care 2009
Falls Estimated to cost 4.6 million per day Age UK June 2010
Intellectual impairment
Intellectual impairment Delirium Dementia Depression
Intellectual impairment Delirium: An acute alteration in conscious level accompanied by a change in cognition Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994: 124-133
Intellectual impairment Delirium: Usually a precipitant e.g. infection dehydration medication
Intellectual impairment Delirium: Prevalence Medical inpatients ~20-30% Surgical inpatients ~10-50% Delirium: Diagnosis, prevention and management CG103 July 2010
Intellectual impairment Dementia: Disease of the brain.. of a chronic or progressive nature. [with] disturbance of multiple higher cortical functions The ICD-10 Classification of Mental and Behavioural Disorders World Health Organization, Geneva, 1992
Intellectual impairment Dementia: Prevalence 5% in 65y+ 24% in 85y+ Alzheimer s Disease International, April 1999
Depression: Intellectual impairment Depression is the most common mental health problem in old age
Depression: Intellectual impairment Prevalence 43% > 85y 40% 2005 Health Survey for England
Depression: Intellectual impairment Aetiological factors include: Social isolation Chronic physical illness Financial stress
Urinary incontinence
Prevalence: Urinary incontinence 31% of women > 65y community 23% of men dwelling Stoddart H et al. Urinary incontinence in older people in the community: a neglected problem? Br J Gen Prac 2001 Jul; 51(468): 548-52.
Shared aetiology
Shared aetiology Age Medication Infection Metabolic disturbance Alcohol misuse Neurological disease
Shared aetiology Urinary incontinence related to: Falls Confusion Anxiety & depression Poor quality of life AGS, Foley BGS AL and et al. American Association Academy between of Orthopedic the Geriatric Surgeons Giants panel of urinary on falls prevention incontinence. Guideline and falls for in older the prevention people using of falls data in from older the persons. Leicestershire J Am Ger MRC Incontinence Study.Age Soc. 2001; and 49: Ageing. 664-72. 2012; 41 (1): 35-40.
Visual impairment Age Medication Infection Metabolic disturbance Alcohol misuse Neurological disease Muscle weakness Constipation
Increased number of frailties present more likely to be physically dependent
Lower Slow timed limb impairment chair stands Upper Decreased limb arm impairment strength Decreased Sensory vision deficit and hearing High Affective anxiety disorder depression score 70 60 50 40 30 20 10 0 0 1 2 3+ Doucette J et al. Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes JAMA. 1995;273 (17):1348-1353
Slow Lower timed limb chair impairment stands Upper Decreased limb arm impairment strength Decreased Sensory vision deficit and hearing High Affective anxiety disorder depression score 70 60 50 40 30 20 10 0 7 0 1 2 3+ Doucette J et al. Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes JAMA. 1995;273 (17):1348-1353
Slow Lower timed limb chair impairment stands Upper Decreased limb arm impairment strength Decreased Sensory vision deficit and hearing High Affective anxiety disorder depression score 70 60 50 40 30 20 10 0 7 14 0 1 2 3+ Doucette J et al. Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes JAMA. 1995;273 (17):1348-1353 (p <0.001)
Slow Lower timed limb chair impairment stands Upper Decreased limb arm impairment strength Decreased Sensory vision deficit and hearing High Affective anxiety disorder depression score 70 60 50 40 30 20 10 0 7 14 Doucette J et al. Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes JAMA. 1995;273 (17):1348-1353 28 0 1 2 3+ (p <0.001)
Slow Lower timed limb chair impairment stands Upper Decreased limb arm impairment strength Decreased Sensory vision deficit and hearing High Affective anxiety disorder depression score 70 60 50 40 30 20 10 0 7 14 Doucette J et al. Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes JAMA. 1995;273 (17):1348-1353 28 60 0 1 2 3+ (p <0.001)
Pathophysiology
Pathophysiology Possible mechanisms underlying geriatric syndromes:
proliferation arrest senescence apoptosis altered phenotype cell death atrophy neoplasm recovery Fedarko NS et al. the biology of aging and frailty. Clin Geriatr Med 2011; 27: 27-37
What can be done?
What can be done? Knowing is not enough; we must apply. Willing is not enough; we must do Goethe
What can be done? Assessments Tools Prevention
What can be done? Assessments: Physical examination Relevant investigations Medication
What can be done? Assessments: Physiotherapy Environmental Nutrition
What can be done? Social history Corroborative history
What can be done? Ask about falls, incontinence, confusion
What can be done? Assessment tools: Fried Frailty Index 1 Barthel scale 2 Cognitive assessment tools etc 1 Fried LP, et al. J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156. 2 Maloney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965; 14: 61-5.
What can be done? Multiple risk factors and organ systems involved Identifying underlying causes may be difficult Therapeutic management may be helpful even in the absence of a firm diagnosis or clarification of the underlying causes Sharon K. Inouye et al Geriatric Syndromes: Clinical, Research and Policy Implications of a Core Geriatric Concept J Am Geriatr Soc. 2007 May; 55(5): 780 791
What can be done? Prevention: Mobilization Exercise & balance training Reorientation Nutrition
What can be done? Prevention: Incidence of under nutrition at admission (UK): 23% <65y 32% 65y+ Russell C, Elia M. Nutrition Screening Survey in the UK in 2008. British Association for Parental and Enteral Nutrition. 2009
What can be done? Exercise Diet Start now! Keep mentally active
The future
The future Elderly population increasing 1911 2011 Office for national Statistics. Census results.
The future Technology Detect and monitor frailty in the community Support and enhance independence Oleg Zaslavsky et al. The Role of Emerging Information Technologies in Frailty Assessment Gerontological Nursing. April 25, 2012 on line
The future Research Typical studies and trials have excluded frail elderly people Biology of ageing and frailty not well understood
The future Treatments Medication Therapy
The future Guidelines NICE guidelines pending: Delaying the onset of disability, frailty and dementia in later life
The future Public health initiatives Education Promotion of healthy lifestyles
The future Public health initiatives Screening & treatment of: Hypertension Cerebrovascular disease Diabetes Osteoporosis Heart disease etc
The future???????????????????????????
Thank you Questions? for your attention