Implementing frailty into clinical practice:

Implementing frailty into clinical practice: Why has frailty not been operationalized? As a disease/syndrome? As a health promotion/prevention strategy? Pr Bruno Vellas M.D, Ph.D Gérontopôle UMR INSERM 1027 University of Toulouse

Implementing frailty into clinical practice: Strength and weakness 1. Rational for implementing frailty into clinical practice 2. Why has frailty not been operationalized? As a disease/syndrome? 3. Implementing frailty into clinical practice by the Toulouse Gérontopôle

Prevalence of dependency/disability: between 350-600M from 2010 to 2040 World Alzheimer Report 2013. ADI 2013

Older Adults Robust 50% > 65 yrs Frail and Pre-frail 40% > 65 yrs Reversible Unvoluntary weight loss, Fatigability, Muscular weakness, Slow gait speed, Low physical activity/inactivity Dependent 5-10% > 65 yrs Nursing home Dependent for basic daily activities

NMAPS Results: Above: (Younger transition matrix - 60 age 78 years) Below: Older 78 +.32 Normal 0.07.06.01.08 Speed low 1 3MSE low 2.10.06 Both low 3.34.86 Normal 0.64.50 Speed low 1.05 3MSE low 2.20.28.18 Both low 3.25 Normal 0.14.08.06 Speed low 1.07 3MSE low 2.48.18.22 Both low 3.51.72 Normal 0.27.24.44 Speed low 1.10 3MSE low 2.11.19.19 Both low 3

2. Why has frailty not been operationalized? As a disease/syndrome? Was not the priority until now. Geriatric medicine was born 40 years ago with long-term care policy In the past all was built to take care of dependency, not to prevent it: nursing home payment policy By definition frail older persons are not pro-active. Same for their caregiver, if any Change habits, it is much easier for a medical practitioner to wait for patients being admitted to an emergency unit and then to the geriatric ward No drug industry Very few studies are based on clinical practice, few R.C.T but...

3. Implementing frailty into clinical practice by the Toulouse Gérontopôle 1. The Frailty clinic, Day Hospital 2. Frailty screening in the community with city hall 3. Frailty into family practitioner s office 4. Frailty after an emergency call (911) 5. Frailty screening with retirement plan

Gérontopôle Frailty Screening Tool Frailty screening Older patients 65 yrs +, not dependent (ADL >= 5 /6) YES NO UNKNOWN Is your patient living alone? Unvoluntary weight loss in the past 3 months? Fatigability during the last 3 months? Mobility difficulties for the last 3 months? Memory complaints? Slow gait speed (+ 4s for 4 meters? ) If yes to at least one of these questions: In your own clinical opinion, do you feel that your patient is frail and at an increased risk for further disabities? YES NO If yes, kindly propose to the patient an assessment of the causes of frailty and prevention of disabilities in a day hospital.

Recommendations from HAS (French health authority)

93.6% of older adults referred to the Gérontopôle Frailty Clinic are frail or pre-frail

Description of 1108 older patients referred to the Gérontopôle Frailty Clinic (JNHA 2014)

Descriptive data of 1108 older adults referred to the Gérontopôle Frailty Clinic (JNHA 2014) Geriatric Assessment n=1108 Age (yrs), n=1108 82,9 ± 6,1 Sex (female), n=1108 686 (61,9%) BMI (kg/m²), n=698 25,9 ± 5,1 Onco-geriatric, n=1103 230 (20,9%) Vit D (ng/ml), n=1065 18,1 ± 11,3 MMSE/30, n=1071 24,6 ± 4,9 MIS/8, n=1038 6,6 ± 1,9 ADL/6, n=1102 5,5 ± 1,0 IADL/8, n=1094 5,6 ± 2,4 SPPB/12, n=1063 CDR/3, n=1039 SPPB/12 (mean) 7,3 ± 2,9 (SPPB 10) 272 (25,6%) (7 SPPB 9) 388 (36,5%) (SPPB 6) 403 (37,9%) CDR=0 353 (34,0%) CDR=0,5 531 (51,1%) CDR=1 111 (10,7%) CDR 2 44 (4,2%) Frailty Assessment n=1108 Fried/5, n=1082 2,64 ± 1,4 Fried/5, n=1082 Robust (0 criteria) 69 (6,4%) Pre-frail (1-2 criteria) 423 (39,1%) Frail (3-5 criteria) 590 (54,5%) Unvolontary weight loss (yes), n=1098 358 (32,6%) Weakness, n=1083 353 (32,6%) Gait speed, n=1065 Mean (m/s) 0,78 ± 0,27 < 1m/s 814 (76,4%) <0,8m/s 547 (51,4%) Grip strength (kg), n= 1083 20,3 ± 8,2 Sedentarity (yes), n=1096 665 (60,7%) Alone at home (yes), n=1083 460 (42,5%) Help at home (yes), n=1105 767 (69,4%) Help at home (yes), n=1105 575 (52,0%) APA (yes), n=1105 190 (17,2%)

Descriptive data of 1108 older adults referred to the Gérontopôle Frailty Clinic (JNHA 2014) Geriatric Assessment n=1108 Vision far (abnormal), n=1019 840 (82,4%) Interventions: Personalized Care and Prevention Plan n=1108 Vision Vision near (abnormal), n=1039 232 (22,3%) Amsler (abnormal), n=1060 177 (16,7%) New medical conditions (yes), n=1104 603 (54,6%) HHIE-S/40, n=1055 9,5 ± 9,8 Audition Disability (HHIE-S >21), n=1055 330 (31,3%) MNA/30, n=1048 23,2 ± 4,1 Special advice (dentistry, ORL, ophtalmo, urology) (yes), n=1101 532 (48,3%) (MNA>23,5), n=1048 550 (52,5%) Nutrition At risk of malnutrition (17 MNA 23,5), n=1048 414 (39,5%) Change in drug prescription (yes), n=1102 362 (32,8%) Urinary incontinence Undernutrition (MNA< 17), n=1048 84 (8,0%) Incontinence scale/6, n=280 1,7 ± 1,4 Daily problem (score 1), n=280 215 (76,8%) Depression GDS/15, n=424 4,8 ± 3,1 History of falls n=285 108 (37,9%) Nutrition intervention (yes), n=1105 Physical activity intervention (yes), n=1101 Social intervention (yes), n=1106 683 (61,8%) 624 (56,7%) 284 (25,7%)

Frailty clinics Most of the physicians, healthcare professionals, policy makers were not aware about frailty We had to educate them, explain the concepts in a very simple way After 2 years, we succeeded (+ 3500 subjects) with some enormous efforts, and my personal involvement on a daily basis, explanation to the care payer (cost 500 Euros) How is it translatable?

Frail Non-Disabled (FIND) questionnaire Domain Questions Answers Score Disability A. Have you any difficulties in walking 400 meters? a. No or some difficulties b. A lot of difficulties or unable 0 1 B. Have you any difficulties in climbing up a flight of stairs? a. No or some difficulties b. A lot of difficulties or unable 0 1 Frailty C. During the last year, have you involuntarily lost more than 4.5 kg? a. No b. Yes 0 1 D. How often in the last week did you feel than everything you did was an effort or that you could not get going? a. Rarely or sometimes ( 2 times/week) b. Often or almost always ( 3 or more times per week) 0 1 E. Which is your level of physical activity? a. Regular physical activity (at least 2-4 hours per week) 0 b. None or mainly sedentary 1 If A+B 1, the individual is considered "disabled". If A+B=0 and C+D+E 1, the individual is considered frail. If A+B+C+D+E=0, the individual is considered robust. Cesari M et al. PLOS ONE 2014;9(7):e101745

Frailty screening in the community: City of Cugnaux: 16 314 inhabitants 75 yrs +: 1 403 subjects, response 44% (611) 70-74 yrs: 600 subjects, response 19% (111) Frail and pre-frail: 298, 124 (42%) got complete frailty assessment and intervention program Almost 30% of the frail and pre-frail subjects Cost: 50 000 Euros Extended to the Toulouse urban area, 1 million people

Frailty assessment in family practitioner s office

Study process Older patient in General Practitioner s consultation Patient with cognitive complaint or Frailty sensation 16 GP s offices around Toulouse Consultation with a nurse Medical history, comorbidities, treatments, weight, vision, audition, lifestyle, home support, Evaluation MMSE WMS-R Mini-GDS Fried criteria MNA SPPB ADL IADL Summary, propositions of recommendations and orientation proposed by the GP 22

Implementing frailty into family practitioner s office (N=375) Female: 62.3% Age: 81.0 ± 6.4 yrs (65-74: 15.7%, 75-84: 51.1%, 85 +: 33.2%) Comorbidities: 2.8 ± 1.6 Treatments: 3.7 ± 1.9 ADL/6: 5.8 ± 0.2, IADL/8: 6.9 ± 1.5 Fall in the last 3 months: 24% Frailty: Robust: 23.9%, Pre-frail: 45.1%, Frail: 31% MMSE/30: 25.1 ± 4.2 SPPB/12: 9. ± 2, SPPB<10: 48.1% 23

Family practitioner s office Not so easy 50% OK, space, not interested The process is currently undergone in 20 family physician s offices, once a month Most of these patients will not have accepted to go to the hospital Able to identify what is really the main problem for the frail older adults

Descriptive data Typology Cugnaux SAMU Nb 136 75 Women 95 (69,9%) 56 (73,7%) Age 79,9 ± 5,4 85,8 ± 6,7 65-74 yrs 22 (16,2%) 5 (6,9%) 75-84 yrs 85 (62,5%) 24 (33,3%) 85 yrs 29 (21,3%) 43 (59,7%) Comorbidity 3,0 ± 1,4 3,0 ± 1,4 Number of medications 4,2 ± 2,5 6,2 ± 3,0 ADL (0-6) 5,8 ± 0,5 4,6 ± 1,2 IADL (0-8) 6,9 ± 1,7 3,6 ± 2,2 Falls in the last 3 months 24 (17,6%) 62 (82,3%) Fried 1,9 ± 1,2 3,4 ± 0,9 Robust 19 (14 %) 0 (0 %) Pre-frail 74 (54,4 %) 10 (13,3 %) Frail 37 (27,2 %) 31 (41,3 %) Dependent 6 (4,4 %) 34 (45,3 %) MMSE (0-30) 25,3 ± 4,5 19,3 ± 8,5 SPPB (0-12) 8,7 ± 2,9 3,3 ± 2,5 SPPB < 10 69 (50,7%) 63 (84,0%)

3. Implementing frailty into clinical practice by the Toulouse Gérontopôle 1. The Frailty clinic, Day Hospital 2. Frailty screening in the community with city hall 3. Frailty into family practitioner office 4. Frailty after an emergency call (911) 5. Frailty screening with the retirement insurance scheme

Frailty screening with the retirement insurance scheme CARSAT (National health and retirement scheme) A.P.A.(Social allowance for personalized autonomy) Set up frailty assessment and provide appropriate interventions by a trained nurse practitioner Target the population that needs help Just starting now, it took 2 years to get all the authorizations from these large public institutions

Implementing frailty into clinical practice: TARGETED, STRONG, SUSTAINED INTERVENTION Targeted Strong Sustained

Strong and sustained intervention Ability to find a cause: - 50% reported at the frailty clinic, less in home visits Direct connection with paying institutions Precision medicine for frailty and pre-frail? How to bring the frail to intervention? Not easy as few use new technologies Future for the pre-frail? P4 Medicine Pro-active Precision Participatory (wellness) Personalized (e-platform) IHU Project

P4 Medicine / Modern medicine P4 Medicine Pro-active, predictive Individual, precision medicine Wellness & diseases Personalized data clouds Personalized data clouds for clinical trials Modern medicine Reactive Population Only diseases Average patient population Average patient population for clinical trials

Our health determinants Healthcare: 10% Genetic: 30% Behavior environnment: 60%

Precision medicine for pre-frail and for intrinsic capacities