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Frailty in Older Adults John Puxty puxtyj@providencecare Geriatrics 20/20: Bringing Current Issues into Perspective

Session Overview Definition of Frailty Strategies for identifying frail older adults Why is it important to determine presence of frailty What are the contributing factors to frailty What's different about management frail older adults 2

Defining Frailty A physiologic syndrome characterized by decreased reserve and resistance to stressors, resulting from cumulative decline across multiple physiologic systems, and causing vulnerability to adverse outcomes (Fried et al. 2001) Or in other words Vulnerability to adverse outcomes resulting from an interaction of physical, socio-economic and co-morbidity factors 3

Identifying Frailty Two main approaches are usually considered: Phenotype model of Frailty indicated by presence of at least three of five of the following: slow walking speed, impaired grip strength, self-reports of declining activity levels, exhaustion and unintended weight loss. Cumulative Deficit model (Frailty Index), which adds larger number of health deficits usually 20 or more including: clinical symptoms, signs, diseases, disabilities, laboratory, imaging or electrodiagnostic abnormalities. Not surprisingly the Frailty Index tend to more sensitive picking up perhaps about 50% more cases than the Phenotype model (Rockwood, Andrew, and Mitnitski 2007; Song, Mitnitski and Rockwood 2010) Variety of screening tools for frailty in various settings exist which use various aspects of both models. The two main ones we will review are the Clinical Frailty Scale and Assessment Urgency Algorithm 4

Applying the Clinical Frailty Scale 1. Very fit 2. Well 3. Well, with treated co-morbid disease 4. Apparently vulnerable (slowed up or disease symptoms) 5. Mildly frail (some dependency in IADLs 6. Moderately frail (help with IADLs and ADLs) 7. Severely frail (dependent for ADLs) Most vigorous Most frail 5

Clinical Assessment Tools of Frailty Community Assessments Single domain Multidimensional Comprehensive Geriatric Assessment (Clinical Frailty Scale: Rockwood et al 2005) Emergency Room (ER). Frail older adults are frequent users of the ER and at increased risk of re-attending quickly or being hospitalized. Several tools have been studied to see how best to identify those who might benefit from further assessment and/or more support. The Assessment Urgency Algorithm (AUA) is felt to be the most useful. 12

Assessment Urgency Algorithm (AUA) Click on image for instructions on using and interpreting the AUA 13

Merits of AUA as High-risk ER Screening Tool Ontario derived tool validated nationally and internationally Simple to apply taking usually only few minutes Linked to impaired self-reliance (issues with ambulation, bathing, dressing lower body and personal hygiene) which negatively impact on caregiver coping and/or affected individuals mood Predicts risk of 30 day ER re-attendance, 90 day readmission, increased LOS and ALC likelihood Reduced false positives relative TRST/ISAR Implicit link to CCAC InterRAI Assessment Form Paper and electronic format (PDA) versions are available 14

Who are the High-risk vulnerable frail elderly Clinical Frailty Scale (5-7) High risk ER/acute care users Repeat attendance at ER/acute care in previous 90 days AUA 4-6 scores within ER within the last 90 days Presence of multiple chronic diseases 68-75% of frail individuals have 2 or more CD s (Fried at al 2004, Theou et al 2012) Increases risk of further functional impairment and mortality 15

Who are the High-risk vulnerable frail elderly Clinical Frailty Scale (5-7) High risk ER/acute care users Repeat attendance at ER/acute care in previous 90 days AUA 4-6 scores within ER within the last 90 days Presence of multiple chronic diseases Presence of Geriatric Syndromes (Falls, Confusion, Incontinence, Social Crisis) 16

Recognition of Presence of Frailty is Important Because It is predictive of long term outcomes including risk of future use of Institutionalization and mortality. This is illustrated within the next two slides which use longitudinal data from the Canadian Study of Health and Aging (CSHA). 17

Canadian Study of Aging & Health: Frailty in Canada 2,305 individuals 70 yrs or older were studied over 5 yrs 41.4% were felt to be well 15.2% were considered vulnerable with some evidence of slowing up in their normal activities 13.3 were mildly frail needing some help with IADL s such as finances, driving, managing medication or cooking 39.1 were moderately or severely frail requiring help with ADL s such as bathing, dressing, toileting and walking Rockwood K, et al CMAJ 2005;173(5):489-95 18

Probability of Institutionalization Avoidance Based on CSHA Frailty Scale Well Vulnerable Mild Frailty Moderate to severe Frailty Rockwood K, et al CMAJ 2005;173(5):489-95 19

Probability of Survival based on CSHA Frailty Scale Well Vulnerable Mild Frailty Moderate to severe Frailty Rockwood K, et al CMAJ 2005;173(5):489-95 20

Frailty is a Dynamic State 22 22

Contributory factors to Frailty Vulnerability to adverse outcomes resulting from an interaction of : Physical Extreme age Weight loss Fatigue/Inactivity/Poor grip strength Slow gait Socio-economic Isolation Caregiver gaps Poverty: gender and immigration status Co-morbidity factors Impaired cognition/mood Polypharmacy especially sedative use Multiple chronic diseases 23

Management of Frailty Prevent decline and optimize co-morbidities Early identification of onset of frailty with targeted interventions (promoting healthy aging!) Optimize sensory inputs (hearing and vision) Review cognition and mood Exercise Nutrition supplement Medication review for potential adverse drug reactions or compliance issues 24 24

Management of Frailty Prevent decline and optimize co-morbidities Optimize Chronic Disease Management Strategies Customize best practices based on patient goals Desirability of case management to link effort and care Need for system navigation and knowledge of system opportunities Multiple disciplines and individuals the rule so good communication pathways essential Caregiver support is crucial! 25 25

Management of Frailty Prevent decline and optimize co-morbidities Optimize Chronic Disease Management Strategies Early detection of acute illness and polypharmacy 26 26

Atypical presentation of frail elderly Traditional medical approaches do not cater for the heterogeneity of disease presentation in the frail elderly! The clinical picture of acute illness in the frail elderly is potentially complicated by complex presentations of illness with multiple system impacts and presence of falls, immobility, confusion, incontinence and social crisis. 28 28

Management of Frailty Prevent decline and optimize co-morbidities Optimize Chronic Disease Management Strategies Early detection of acute illness and polypharmacy Identify and modify Geriatric Syndromes (Falls, Immobility, Confusion, Depression, Incontinence) Optimize environment: Adjust lighting and noise Rails and bars Chair and bed heights Reduce fall hazards especially bath room and stairs Floor surfaces De-clutter 29 29

Management of Frailty Prevent decline and optimize co-morbidities Optimize Chronic Disease Management Strategies Early detection of acute illness and polypharmacy Identify and modify Geriatric Syndromes (Falls, Immobility, Confusion, Depression, Incontinence) Optimize environment Maximize community and socio-economic supports 30 30

Management of Frailty Prevent decline and optimize co-morbidities Optimize Chronic Disease Management Strategies Early detection of acute illness and polypharmacy Identify and modify Geriatric Syndromes (Falls, Immobility, Confusion, Depression, Incontinence) Optimize environment Maximize community and socio-economic supports Education and Support to Caregivers (formal and informal) 31 31

ANY QUESTIONS? 32