Frailty: from Academic Definition to ClinicalApplicability

Associate Professor Ruth E. Hubbard

October 26th 2018

1. Describe the development of frailty as a concept

2. Provide an overview of frailty measures

Objectives

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Frailty has been defined as a state of increased vulnerability to stressors

A frail individual has reduced physiological reserve and reduced ability to compensate for disruptions to homeostasis

Increased risk of:• Disability• Geriatric syndromes• Death

What is frailty?

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Early definitions of frailty painted bleak pictures of irreversible age-related decline

A leading article in the BMJ (Anon, 1968) described “confused, restless, incontinent old patients”

20 years later, frailty was still considered to equate to “elderly people with multiple problems” (Pawlson, 1988)

Development of the concept

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Frailty ≠ age

Frailty ≠ cachexia

Frailty ≠ co-morbidity

Frailty ≠ polypharmacy

Frailty ≠ disability

Limitations of end-of-the-bed estimations

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Understanding frailty has become the focus of extensive research

The associations of frailty are now well described

3 main approaches• Clinical syndrome or phenotype• Subjective opinion• Multidimensional risk state

How can frailty be measured?

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Clinical syndrome: a set of signs and symptoms

Lists and algorithms derived from clinical judgment

Combinations:• Physical inactivity and weight loss (Chin a Paw, 1999)• Gait speed, peak expiration, hand grip, sitting position, visual impairment

(Klein, 2005)• Fatigue, resistance, ambulation, illness, loss of weight (Abellan van Kahn,

2008)• Edmonton Frailty Scale (Rolfson, 2006)

Definitions

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The most well known and widely used phenotype

Criteria• unintentional weight loss of 10 lbs or more in past year • self reported exhaustion • weak grip strength • slow walking speed • low physical activity

Fried phenotype

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Strengths• Clinical coherency• Reproducibility• Wasting disorder with sarcopenia as pathophysiological feature

Weaknesses• Omission of mood and cognition • Selection of initial cohort• Dichotomous/ trichotomous outcome • Reliance on performance based tests

Fried phenotype

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Fried phenotype in clinical practice

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“We know it when we see it”

Visual estimation of biological age• a checklist of age-associated changes in appearance, communication and

mobility.• Good inter-rater agreement

Global measures• Studenski et al, JAGS 2004• Rockwood et al, CMAJ 2005

Subjective opinion

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Clinical Frailty Scale

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Frailty = multidimensional risk state

Can be measured by quantity rather than by the nature of health problems

Various disorders are accumulated by individuals during their lives

The more deficits that are accumulated, the more likely that person is to be frail Rockwood and Mitnitski, 2001

Deficit accumulation

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Deficits can be symptoms, signs, diseases, disabilities, abnormal laboratory measurements• Accumulate with chronological age• Associated with adverse outcome• Do not saturate• Cross different domains

FRAILTY INDEX Searle et al., 2008

Deficit accumulation

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Strengths• Granular• Precise• Valid

Weaknesses• Complex• Mathematical• Time consuming

Deficit accumulation

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Addressing the Challenge

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N=1418Mean (SD)=0.32 (0.14)Median (IQR)=0.31 (0.22-0.41)99th percentile= 0.69

ReferenceHubbard RE, Peel NM, Samanta M, Gray LC, Fries BE Mitnitski A, Rockwood K. Derivation of a Frailty Index fr the interRAI Acute Care Instrument. BMC Geriatr. 2015;15:27.

Surgical patients: Lin et al, 2018• 110 studies between 2007 and 2017• 37 different measurement tools

Older inpatients: Theou et al, 2018• 617 papers between 2002 and 2015• 2/3 didn’t use any instrument to measure frailty• Others included 48 different instruments

“Frailty”

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11 variables from NSQIPStrengths• Valid• Rapid derivation• Automatic calculation

Weaknesses• 9/11 variables are co-morbidities• Not a frailty index

Modified Frailty Index

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Darvell et al, Archives of Gerontol Geriatr, 2018

Conceptual fuzziness

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Clinical utility……