Frailty: a syndrome or a risk score ?

Профессор Йан Дегрис

Geriatric Conference Sint-Petersburg Russia

Oktober 14th 2013

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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.

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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

Clinical tasks• Administer vaccine

• Pneumonia• Influenza annually

• Check blood pressure at all clinical visits and sometimes at home

• Evaluate self monitoring of blood glucose• Foot examination• Laboratory tests

• Microalbuminuria annually if not present • Creatinine and electrolytes at least 1-2

times a year • Cholesterol levels annually • Liver function biannually • HbA1C biannally to quarterly

Patient tasks• Joint protection• Energy conservation• Self monitoring of blood glucose • Exercise

• Non weight-bearing if severe foot disease is present and weight bearing for osteoporosis

• Aerobic exercise for 30 min on most days• Muscle strenghtening • Range of motion

• Avoid environmental exposures that might exacerbate COPD

• Wear appropriate footwear• Limit intake of alcohol • Maintain normal body weight

Patient education Foot care

Osteoartritis

COPD medication and delivery system training

Diabetes

ReferralsPhysical therapy

Ophtalmologic examination

Pulmonary rehabilitation

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• 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 adviceon what choices schould be made in case of presence

of multiple pathologies.

Boyd CM, et al. JAMA 2005;294;716-24.

?

Following the official guidelines:

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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.

Comorbidity as a central issue.

28.3

43.633.4 33.7

43.8

25.5

24.2

29.4

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19.1

21.9

16.4 20.4

15.7

13.8

24.415.9 15.2

32.323.2

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Rotterdam

Study

LASA Leiden 85+

Study

CMR Nijmegen RNGP

0 - 1 chronic condition 2 chronic conditions 3 chronic conditions more than 3 chronic conditions

population-based setting GP setting

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. Muscle weakness (grip strenght)

2. Exhaustion/fatigue (anamnesis)

3. Less physical activity

4. Slow gait speed

5. 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 1999Studenski 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• 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

Dynamic definition of frailty • 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

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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)

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

• Operational approach– Criteria– Operational outcomes– Operational definition– Tools and measures

A Syndrome?

A Condition?

Some 30 different frailty -indicators were described

Frailty model

Swinne 2008

A working framework

H.Bergman 2004

The disablement process

Verbrugge & Jette (1994)

Pathology Impairments Functional Limitations Disability

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.

Mortality

Frailty

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 multi-dimensional frailty index.

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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

Groningen Frailty Indicator

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