Is Frailty a meaningful Is Frailty a meaningful t t?t t?construct?construct?

Darryl Rolfson, MD, FRCPCDarryl Rolfson, MD, FRCPCAssociate Professor of MedicineAssociate Professor of MedicineUniversity of AlbertaUniversity of AlbertaEd t S i ’ C di ti C ilEd t S i ’ C di ti C ilEdmonton Senior’s Coordinating CouncilEdmonton Senior’s Coordinating CouncilDecember 4, 2007December 4, 2007

AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgements

Conflict of Interest Conflict of Interest –– none to declarenone to declareSupportSupportSupportSupport–– Division of Geriatric Medicine, UADivision of Geriatric Medicine, UA

Regional Specialized Geriatric ProgramRegional Specialized Geriatric Program–– Regional Specialized Geriatric ProgramRegional Specialized Geriatric Program

ObjectivesObjectivesObjectivesObjectives

Present three models of frailtyPresent three models of frailtyHighlight valid measures of frailtyHighlight valid measures of frailtyHighlight valid measures of frailtyHighlight valid measures of frailtyDemonstrate the relationship between Demonstrate the relationship between frailty and end of life trajectoriesfrailty and end of life trajectoriesfrailty and end of life trajectoriesfrailty and end of life trajectories

Age and FrailtyAge and FrailtyAge and FrailtyAge and Frailty

Length ofLif

Strength of LifLifespan Lifespan

• Chronological Age • Frailty

Theoretical Trajectories of Dying

Copyright restrictions may apply.Lunney, J. R. et al. JAMA 2003;289:2387-2392.

Frailty: Working Framework*Frailty: Working Framework*Frailty: Working Framework*Frailty: Working Framework*

FRAILTY

LIFE COURSE DISEASE

FRAILTY PHENOTYPE

NutritionM bili

DISTAL OUTCOMES

DETERMINANTS

Biological & geneticPsychologicalSocial

DISEASE

LOSS OF RESERVE

MobilityActivity

StrengthEndurance

DisabilityMorbidity

HospitalizationInsititutional-

izationEnvironmental

RESERVE CAPACITY Cognition?

Mood?

izationDeath

MODIFIERS

* Canadian Initiative on Frailty and Aging, 2003* Canadian Initiative on Frailty and Aging, 2003

MODIFIERSBiological

Psychological Social

A Frailty as a “phenotype”A Frailty as a “phenotype”A. Frailty as a “phenotype”A. Frailty as a “phenotype”

–– “Increasingly, geriatricians define frailty “Increasingly, geriatricians define frailty as a as a biological syndromebiological syndrome of decreased of decreased reserve and resistance to stressors, reserve and resistance to stressors, resulting from cumulative declines across resulting from cumulative declines across multiple physiologic systemsmultiple physiologic systems and causingand causingmultiple physiologic systemsmultiple physiologic systems, and causing , and causing adverse outcomes.” adverse outcomes.”

Fried LP et al Cardiovascular Health StudyFried LP et al Cardiovascular Health StudyFried LP et al, Cardiovascular Health Study Fried LP et al, Cardiovascular Health Study

Fried LP et al. J Geron Med Sci Fried LP et al. J Geron Med Sci 2001;56A(3):M1462001;56A(3):M146--5656

Declining EnergeticsDeclining Energeticsg gg g

Frailty PhenotypeFrailty PhenotypeFrailty PhenotypeFrailty Phenotype

–– Based on Objective CriteriaBased on Objective CriteriaWeight lossWeight lossSlow walking speedSlow walking speedSlow walking speedSlow walking speedLow levels of physical activityLow levels of physical activitySubjective exhaustionSubjective exhaustionWeaknessWeakness

–– Frailty CategoriesFrailty Categories33--5 is “frail”5 is “frail”33--5 is frail5 is frail11--2 is “intermediate”2 is “intermediate”0 is “not frail”0 is “not frail”

Fried LP et al. J Geron Med Sci Fried LP et al. J Geron Med Sci 2001;56A(3):M1462001;56A(3):M146--56 56

B F ilt D fi it A l tiB F ilt D fi it A l tiB. Frailty as Deficit AccumulationB. Frailty as Deficit Accumulation

Accumulation of deficits with ageAccumulation of deficits with age–– “the more things people have wrong with“the more things people have wrong withthe more things people have wrong with the more things people have wrong with

them, the higher the likelihood of frailty”them, the higher the likelihood of frailty”–– Narrowed response repertoire and Narrowed response repertoire and p pp p

reserve in face of stressreserve in face of stress

Loss of response repertoire Loss of response repertoire oss o espo se epe to eoss o espo se epe to e–– Eventually self reinforcingEventually self reinforcing

Rockwood K Mitnitski A. J Geron Med Sci Rockwood K Mitnitski A. J Geron Med Sci 2007;62A(7):7222007;62A(7):722--2727

Accumulation of DeficitsAccumulation of DeficitsAccumulation of DeficitsAccumulation of Deficits

Failure to Accumulation of Deficits

Failure to withstand

stress

Diminished Repertoire of homeostatichomeostatic

response

CSHA Frailty Index CSHA Frailty Index ––yy“Just count ‘em up”“Just count ‘em up”

Memory Ch

Urinary I ti MyocaridalChangesIncontinence Myocaridal

Infarction

Index score = Index score = positive positive variables/70variables/70

Tremor at Rest

Malignant Disease

variables/70 variables/70 itemsitems

Falls

at Rest

Jones D et al. JAGS 2004;52:1829Jones D et al. JAGS 2004;52:1829--3333

C Geriatric Syndromes = FrailtyC Geriatric Syndromes = FrailtyC. Geriatric Syndromes = FrailtyC. Geriatric Syndromes = Frailty

DementiaDementiaImbalance/ ImmobilityImbalance/ ImmobilityImbalance/ ImmobilityImbalance/ ImmobilityFunctional DeclineFunctional DeclineU i I tiU i I tiUrinary IncontinenceUrinary IncontinenceMalnutritionMalnutritionPolypharmacyPolypharmacy

StressStressStressStress

Frailty is most obvious in a dynamic Frailty is most obvious in a dynamic context context -- under “stress”under “stress”–– acute illnessacute illness–– new medicationsnew medicationsnew medicationsnew medications–– surgerysurgery–– change in environment or supportchange in environment or supportchange in environment or supportchange in environment or support

Geriatric “State Variables”Geriatric “State Variables”Geriatric “State Variables”Geriatric “State Variables”

DeliriumDeliriumFalls & ImmobilityFalls & ImmobilityFalls & ImmobilityFalls & ImmobilityAcute Urinary IncontinenceAcute Urinary IncontinenceD h d ti A t N t iti l C i iD h d ti A t N t iti l C i iDehydration or Acute Nutritional CrisisDehydration or Acute Nutritional CrisisFunctional DecompensationFunctional Decompensation

Delirium after Cardiac Delirium after Cardiac SurgerySurgery

71 consecutive elderly for CABG71 consecutive elderly for CABG–– Incidence of Delirium 32%Incidence of Delirium 32%Incidence of Delirium 32%Incidence of Delirium 32%–– Predisposing Risk FactorsPredisposing Risk Factors

Previous Stroke (OR 8.1, p=0.03)Previous Stroke (OR 8.1, p=0.03)e ous St o e (O 8 , p 0 03)e ous St o e (O 8 , p 0 03)Duration on CPB (OR 2.0 at 38 min, OR 3.0 at Duration on CPB (OR 2.0 at 38 min, OR 3.0 at 60 minutes)60 minutes)

Rolfson et al. Can J Cardiol 1999;15(7):771Rolfson et al. Can J Cardiol 1999;15(7):771--7676

Delirium: sum of predisposing Delirium: sum of predisposing p p gp p gand precipitating variablesand precipitating variables

Inouye et al. Acute Hospital Care 1998 Inouye et al. Acute Hospital Care 1998 Nov;14(4):747Nov;14(4):747

Delirium as a model for other Delirium as a model for other Geriatric SyndromesGeriatric Syndromes

• Falls• Acute UI• Acute UI• Nutrition

CrisisCrisis

Geriatrician’s Clinical Impression Geriatrician’s Clinical Impression ppof Frailty (GCIF)of Frailty (GCIF)

ContributorsContributors ManifestationsManifestations ImpressionImpressionHealth AttitudesHealth Attitudes DeliriumDelirium Physical FrailtyPhysical FrailtyBurden of IllnessBurden of IllnessADL status ADL status Balance & MobilityBalance & Mobility

Acute FallsAcute FallsAcute ADL DeclineAcute ADL DeclineDehydrationDehydration

Physiologic FrailtyPhysiologic FrailtyFrailty as DisabilityFrailty as DisabilityDynamic FrailtyDynamic Frailty

ContinenceContinenceNutritionNutritionMedication UseMedication Use

Acute IncontinenceAcute IncontinencePast pattern of any of Past pattern of any of aboveabove

CognitionCognitionMoodMoodSocial Support Social Support

Rolfson DB et al, Gerontology 2001;47(Suppl Rolfson DB et al, Gerontology 2001;47(Suppl 1):1191):119

Frailty Index Frailty Index –– Comprehensive Comprehensive yy ppGeriatric Assessment (FIGeriatric Assessment (FI--CGA)CGA)

- Seven Frailty Categories

Jones et al. Aging Clin Exp Res 2005;465Jones et al. Aging Clin Exp Res 2005;465--471 471

y g- Correlates with Frailty Index (0.78)

Edmonton Frail Scale (EFS)Edmonton Frail Scale (EFS)Edmonton Frail Scale (EFS)Edmonton Frail Scale (EFS)

C itiC itiCognitionCognitionHealth Attitudes & MoodHealth Attitudes & Mood

di idi iMedication UseMedication UseNutritionNutritionContinenceContinenceBurden of Medical IllnessBurden of Medical IllnessSocial Support Social Support Functional Independence & PerformanceFunctional Independence & Performance

Rolfson DB et al. Age Ageing 2006 Rolfson DB et al. Age Ageing 2006 Sep;35(5):526Sep;35(5):526--99

Validation of EFSValidation of EFSValidation of EFSValidation of EFS

C it i V liditC it i V liditCriterion Validity Criterion Validity –– Compared to GCIFCompared to GCIF r = 0.63r = 0.63 (p

Survival by Frailty Status Survival by Frailty Status y yy yOptima CohortOptima Cohort

Frailty Index (Cut 8,13) EFS (Cut 4,7)

0 8

0.9

1

0.8

0.9

1

0.6

0.7

0.8

0.6

0.7

0 8

0 20 40 60 80 100 1200.4

0.5

0 20 40 60 80 100 1200.4

0.5

Months Months

Survival by Frailty Status Survival by Frailty Status y yy yCSHA CohortCSHA Cohort

1.01.0

ival

1.0

.9

EFS=1 - 4ival

1.0

.9

EFS=1 - 4EFS=1 - 4

ity o

f Sur

vi

.8

EFS 1 4

EFS=7 - 8

ity o

f Sur

vi

.8

EFS 1 4

EFS=7 - 8

EFS 1 4

EFS=7 - 8

Prob

abili .7

.6

EFS=5 - 6

EFS=9 - 10

Prob

abili .7

.6

EFS=5 - 6

EFS=9 - 10

EFS=5 - 6

EFS=9 - 10

706050403020100.5

EFS ≥ 11

706050403020100.5

EFS ≥ 11EFS ≥ 11

Rolfson DB et al. Can J Geriatr 2006 Rolfson DB et al. Can J Geriatr 2006 Apr;9(2):69Apr;9(2):69--7070

Time (month)Time (month)

EFS Predicts Postoperative EFS Predicts Postoperative ppComplications and DischargeComplications and Discharge

EFS Score 7–– High risk of postHigh risk of post--op complications (OR 5.02)op complications (OR 5.02)–– Lower likelihood of discharge home (40%)Lower likelihood of discharge home (40%)

Dasgupta M et al. Arch Gerontol Geriatr 2007 Dasgupta M et al. Arch Gerontol Geriatr 2007 (in press)(in press)

Living longer and strongerLiving longer and strongerLiving longer and strongerLiving longer and stronger

–– Choose your parents wellChoose your parents well–– Positive Family and Social EngagementPositive Family and Social Engagement–– Cope with StressCope with Stress–– Get enough restGet enough rest

E e ciseE e cise–– ExerciseExercise–– Preventative Health PracticesPreventative Health Practices–– Healthy Diet Floss TeethHealthy Diet Floss TeethHealthy Diet, Floss TeethHealthy Diet, Floss Teeth–– Minimize Caffeine, Smoking, AlcoholMinimize Caffeine, Smoking, Alcohol–– Optimistic AttitudeOptimistic Attitude

See Livingto100 WebsiteSee Livingto100 Website

pp

A Comparison of Selected A Comparison of Selected ppMeasures of FrailtyMeasures of Frailty

CharacteristicCharacteristic PhenotypePhenotype CSHA Frailty CSHA Frailty IndexIndex

FIFI--CGACGA

EFSEFS

C t V lid tiC t V lid ti YY YY YY YYConcurrent ValidationConcurrent Validation YesYes YesYes YesYes YesYesPredictive ValidationPredictive Validation YesYes YesYes YesYes YesYesBiological ModelBiological Model YesYes NoNo NoNo NoNoggRequires Full AssessmentRequires Full Assessment NoNo YesYes YesYes NoNoEasy to administerEasy to administer NoNo NoNo NoNo YesYes

llSpecial EquipmentSpecial Equipment YesYes NoNo NoNo NoNoHighlights key Geriatric Highlights key Geriatric SyndromesSyndromes

NoNo NoNo YesYes YesYes

Captures CognitionCaptures Cognition NoNo YesYes YesYes YesYes