Transcript Frailty

Frailty: a syndrome or
a risk score ?
Профессор Йан Дегрис
Geriatric Conference Sint-Petersburg Russia
Oktober 14th 2013
2
A historical connection
The grey epidemic
• In 2050 22% of the world population will be aged 60 or
older and 12,4 % of that population will be aged 80 or
over.
• In 2050, 71% of all octogenarians will live in developing
countries.
United Nations. Department of Econ and omicsocial Affairs,
population division. World Population Prospect: the 2008 revision
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Introduction
• Misses Jones, 82 years, widow.
• Osteoporosis, osteoarthritis, diabetes, hypertension
and COPD
Boyd CM, et al. JAMA 2005;294;716-24.
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Misses Jones Patient tasks
•Joint protection
•Energy conservation
•Self monitoring of blood glucose
•Exercise
•Non weight-bearing if severe foot disease
•Administer vaccine
is present and weight bearing for
osteoporosis
•Pneumonia
•Aerobic exercise for 30 min on most days
•Influenza annually
•Check blood pressure at all clinical visits and •Muscle strenghtening
sometimes at home
•Range of motion
•Evaluate self monitoring of blood glucose
•Avoid environmental exposures that might
exacerbate COPD
•Foot examination
•Wear appropriate footwear
•Laboratory tests
•Limit intake of alcohol
•Microalbuminuria annually if not present
Physical
normal therapy
body weight
•Creatinine and electrolytes at least•Maintain
1-2
Ophtalmologic
examination
times a year
Pulmonary rehabilitation
•Cholesterol levels annually
•Liver function biannually
•HbA1C
Foot
care biannally to quarterly
Clinical tasks
Referrals
Patient education
Osteoartritis
COPD medication and delivery system training
Diabetes
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Following the official guidelines:
• 12 different drugs
• 19 doses per day in 5 different gifts
• A series of instructions that are contradictory .
The « clinical guidelines» don’t provide any advice
on what choices schould be made in case of presence
of multiple pathologies.
Boyd CM, et al. JAMA 2005;294;716-24.
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Conflicting guidelines: why?
• By a lack of evidence !
• Most of the clinical trials are about:
– Patients with one single pathology
– Middle aged patient.
– Hospitalised patients.
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Comorbidity as a central issue.
0 - 1 chronic condition
2 chronic conditions
3 chronic conditions
more than 3 chronic conditions
100%
90%
15.9
15.2
23.2
24.4
32.3
80%
16.4
20.4
70%
13.8
21.9
60%
15.7
24.2
50%
40%
19.1
29.4
18.3
25.5
30%
43.8
43.6
20%
28.3
33.4
33.7
Leiden 85+
CMR Nijmegen
10%
0%
Rotterdam
LASA
Study
Study
population-based setting
GP setting
RNGP
What makes the difference between them?
Misses X: 70 years old
Mister Y: 70 years old
Courtesy H.Bergman
A paradigm shift.
From a
Disease oriented medical approach,
towards a:
Goal-oriented integrative approach.
Targetting prevention of functional decline, maintenance of
autonomy and further loss of resources
The missing clinical concept is that of « FRAILTY »
Definition of fraily
• Age-related alteration in physiology with los of organ
system reserve that leads to vulnerability, limited
capacity to respond internal and environmental
stresses, unstable homeostasis and poor medical and
functionional outcomes
Adapted from:
Studenski JAGS 2004;62;1560-66
Ferruci J.Endocrionol Inverst 2002; 25;10-8
Frailty and reserve capacity
Criteria for the Frailty Phenotype
Fried L et al (J of Gerontol Med Sci 2001)
Three or more of the following:
1.
2.
3.
4.
5.
Muscle weakness (grip strenght)
Exhaustion/fatigue (anamnesis)
Less physical activity
Slow gait speed
Weight loss (4,5kg in the previous year)
Operational approach
• Domains
–
–
–
–
–
–
–
Nutrition
Mobility
Activity
Strength
Endurance
Cognition
Mood
• Balance between assets and deficits will determine the
consequences for an individual; dynamic nature
– adaptability, physical environment & social resources are important
determinants of the impact of frailty.
Lebel P et al 1999
Studenski S, et al. J Am Geriatr Soc 2004
Bergman H et al. Gérontologie et société 2004
Frailty in LASA
(Puts et al 2006)
Static definition of Frailty
Dynamic definition of frailty
• BMI < 23
• Lowest quintile peak expiratory
flow
• MMSE < 24
• Poor vision
• Poor hearing
• Incontinence
• Lowes quitinle mastery
• Depression (CES-D) > 16
• Lowest quintile physical activity
• Weight loss > 4 kg
• Decline peak expiratory flow
•
•
•
•
•
•
•
Decline MMSE
Decline vision
Decline hearing
New incontinence
Decline mastery
More depressive complaints
Decline physical activity
Frailty= three or more indicators
Consequences of Frailty
• Falls (Fried et al. J of Gerontol Med Sci 2001)
• Functional decline (Chin A Paw et al. 1999 J Clin Epi, Fried et al.
2001, Puts et al. 2005 J of Clin Epi)
• Hospitalisation (Fried et al. 2001)
• Nursing home admission (Rockwood et al. 1996 JAGS,
Rockwood et al. 1999 Lancet, Puts et al. 2005 Eur J Ageing)
• Death (Chin A Paw et al. 1999, Fried et al. 2001, Mitnitski et al
2002, Rockwood et al. 1999, Puts et al. 2005 JAGS)
• Lower quality of life. (Strawbridge et al. 1998 J of Gerontol Psy
Sci)
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The dynamic nature of frailty…
Gill , et al. Arch. Int. Med. , 166:4.; 418-423
The natural history of frailty…
Gill et al 2006
The operationalization of the Frailty concept
• Theoretical approach
–
–
–
–
Models
Mechanisms, factors
Theoretical definitions
Modelised outcomes
A Syndrome?
A Condition?
• Operational approach
–
–
–
–
Criteria
Operational outcomes
Operational definition
Tools and measures
Some 30 different
frailty -indicators
were described
Frailty model
Swinne 2008
A working framework
H.Bergman 2004
The disablement process
Frailty
Pathology
Impairments
Functional
Limitations
Disability
Mortality
Impairments include dysfunction and significant structural abnormalites in
specific body systems.
Functional limitations include restrictions in performing basic physical and
mental activities in daily life
Disability refers to functional limitations in a social context.
Frailty: a precursor state of functional limitations.
Verbrugge & Jette (1994)
Frailty is measurable
•Different instruments
have been proposed
as case-finding tools
•They are used as a
part of a two-step
approach
•They are devised as a
simple to use multidimensional frailty
index.
Groningen Frailty Indicator
Mobility / ADL
1. Shopping
2. Walking outdoors
3. Undressing
4. Toilet visit
Physical Fitness
5. Fitness
Vision
6. Vision
Hearing
7. Hearing
Nutritional state
8. Weight loss
Co-morbidity
9. Medication (> 3 different medications)
Cognition
10. Memory loss
Psycho-social
11. Loneliness
12. Miss people
13. Social support
14. Feeling down
15. Feeling anxious
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FRAIL instrument Leuven
De Lepeleire J et al, De validity of the FRAIL instrument In General Practice Arch Publ Health 2004
Relevance of the frailty concept
• Improves our understanding of the aging process and
ability to characterise the heterogeneity of older
persons
• At population and clinical level: characterises health
and functional status beyond disability and co morbidity
• Identifies a subset of vulnerable older adults at high risk
of adverse outcomes
– older persons who are functionally independent with apparently
normal cognitive function may be overlooked even if they have
identifiable frailty markers and are highly vulnerable for adverse
health outcomes and increased utilisation of health services
Bergman, Hogan, Karunananthan. Frailty: A clinically relevant concept?
Frailty in Russia : the Crystal Study
Gurina N A, Frolova V E ,Degryse JM (2011)
Frailty and survival in
the Crystal population
Mortality risk in the
Crystal population (=611)
depending on the frailty
status after 40 months of
follow-up.
Frailty was defined
according to three
different models.
Frail according to:
Fried model: 21,1 %
Slaets model: 32,6 %
Puts model: 43,4 %
Mortality risk and frailty
In the crystal population
Conclusion
The frailty concept has opened new horizons in
understanding
the aging process and the heterogeneity of older persons and
the potential to identify vulnerable older adults and
prevent/delay adverse consequences
Frailty predicts mortality independently of co-morbidity in a
Russian population .
More research is needed
In order to understand the role of specificfrailty markers (e.g.
FEV1 , psycho-social risk factors )
Additional interventional studies are needed to prove the
validity