Frailty is always frail?agingthai.dms.moph.go.th/agingthai/download... · 2018-06-19 ·...

Frailty is always frail?: what' re existed and the potential interventions

Varalak Srinonprasert, MD.

Division of Geriatric Medicine

Department of Medicine

Siriraj Hospital

Outline of the talk

What is frailty?

Clinical application

How to define frailty ?

How frail is Thai older people?

Could we do anything for frail older people?

Have you ever wondered why some

older people get unwell very quickly

(and badly) and recovered slowly?

What is frailty? Who is frail?

A state of increased vulnerability to poor resolution of

homoeostasis after a stressor event which increases the risk

of adverse clinical outcomesClegg A. Lancet 2013; 381: 752–62

…Definition of frailty…

Fried LP. J Gerontol. 2001; M146–M156

3.25.3

9.5

16.3

25.7

23.1

65-70 71-75 76-80 81-85 86-90 90+

Prevalence of frailty

Prevalence of frailty increase with age

– > 65 yo for intermediate to high risk elective surgery

– High-risk patients (frailty score >5) increased

postoperative mortality risk (HR = 9.01)

Frailty for predicting outcomes in surgical patients


There was strong evidence that frailty in older surgical

patients predicts postoperative

mortality, complications, and prolonged length of

stay…

– Frailty had a strong positive relationship with

the risk of MACCE with odds ratio = 4.89

(95%CI = 1.64-14.60)

Frailty for predicting outcomes in cardiac surgical patients

– Frailty had a strong positive relationship with the risk of

MACCE with odds ratio = 4.89 (95%CI = 1.64-14.60).

Frailty for predicting outcomes in cardiac surgery patients

• Decision of glycemiccontrol in elderly patients– Based on the degree of frailty

– Patients with moderate or more advanced frailty have a reduced life expectancy

Should not undergo stringent glycemic control

– When attempts are made to improve glycemic control in these patients, there are fewer episodes of significant hyperglycemia but also more episodes of severe hypoglycemia.

G.S. Meneilly et al. Diabetes in the Elderly. Can J Diabetes 37 (2013) S184eS190

Lee SJ, et al. The risks and benefits of implementing glycemic control guidelines in frail older adults with diabetes mellitus. J Am Geriatr Soc. 2011.Clinical frailty scale. Adapted with permission from Moorhouse P, Rockwood K. Frailty and its quantitative clinical evaluation .2012

Frailty in diabetic older patients

IDF Global Guideline for Managing Older People with Type 2 Diabetes. 2013

Frailty in diabetic older patientsGuideline for diabetes in older people

: IDF 2013

For patients age ≥ 70 years old

Diabetes Care , vol 35, December 2012Standard of Medical care in Diabetes, ADA 2018

Practice guidelines in diabetic older patients

Frailty

status

ลกษณะผปวย แนวคด เปาหมาย A1C

ระดบนาตาลตอนอดอาหาร

ระดบนาตาลกอนนอน

ความดน ไขมน

แขงแรง ไมคอยมโรครวม ความจ าด ชวยเหลอตวเองด

Longer remaining life expectancy

<7.5% 90–130 90–150 <140–80 statin

ซบซอนปานกลาง โรครวม 2 ชนดขนไป IADL impaired 1-2 ชนด สมองเสอมเลกนอย ถงปานกลาง

Intermediate remaining life expectancy

<8.0% 90–150 100–180 <140–80 statin

ซบซอนมาก โรคเรอรงระยะทาย ตองพงพาผอน และสมองเสอมรนแรง

Limitedremaining life expectancy

<8.5% 100–180 110-200 <150–90 Consider likely benefit & risk

ค าแนะน าในการรกษาเบาหวานในผสงอาย (ADA 2018)

Frailty

status

Frailty in older patients with HT

Recommendations for treating HT in the very old

Decisions to treat should be preceded by

(1) accurate information on their functional capacity, cognitive status

(2) attention to multiple drug administration so common in this age stratum

(3) stratification of the frailty status by one of the available rapid methods

(4) identification and correction of factors that predispose to an excessive BP

reduction, orthostatic hypotension, and other hypotensive episodes

When decide to treat, start with low drug doses and monotherapy

Patient status (frailty) should be monitored on a frequent basis

European Union Geriatric Medicine Society Working Group on the Management of Hypertension in Very Old, Frail Subjects, Hypertension. 2016;67:820-825.

Side effects in SPRINT-75 study

according to frailty status

Frail older adults are more likely to

experience side effects from medications

Frailty in older patients with dyslipidemia

Strandberg TE. JAMA. 2014;312(11):1136-1144.

Frailty may exacerbate

adverse effect of

therapy

Criteria for Frailty

– Phenotype model

– Cumulative deficit model (frailty index)

– Global model (clinical frailty scale)

– Clinical definition (FRAIL)

Phenotype modelCharacteristic

of frailty

Definition

Shrinking Weight loss > 10 lbs lost unintentionally in prior year

WeaknessGrip strength : lowest 20% (by gender, BMI)

Poor enduranceExhaustion (self report)

SlownessWalking time : lowest 20% (by gender, height)

Low activityPhysical activity : lowest 20% (by gender)

Fried LP. J Gerontol. 2001; M146–M156

Positive ≥ 3 frail

Frailty Index

• The proportion of accumulated deficits (the presence and severity of

current diseases, ability in ADLs and physical signs from clinical and

neurological exams and laboratory abnormalities)

• CSHA frailty index

– collect 70 variables in the cohort

– a person with 14 deficits would have an index score of 14/70 =

0.20

• A person with higher frailty index is more vulnerable and has higher

chance of experience adverse clinical outcomes

Mitnitski AB.. The Scientific World (2001) 1, 323–336

Rockwood K. CMAJ 2005;173(5):489-95

Clinical Frailty Scale

1 Very fit สขภาพแขงแรงด กระฉบกระเฉง สดชน มแรงบนดาลใจในการทากจกรรม

ตางๆ คนกลมนมกออกกาลงกายสมาเสมอและดแขงแรงมากทสดเมอเทยบกบ

คนกลมอายเดยวกน2 Well ไมมโรคเจบปวย แตแขงแรงนอยกวาคนกลมแรก

3 Managing well มโรคเจบปวยแตควบคมอาการไดดเมอเทยบกบกลมท 4

4 Apparently vulnerable ยงชวยเหลอตนเองได แตมกบนวารสกตวเองเชองชาลง หรอมโรคประจาตวท

มอาการปรากฏ5 Mildly frail ชวยเหลอตนเองไดลดลงในดานกจวตรประจาวนขนสง (IADL) เชน ทาอาหาร

ทาความสะอาด จบจายใชสอย ขบรถ จดยา ทาธรกรรมการเงน

6 Moderately frail ตองการการพงพาทงในดานกจวตรประจาวนขนสงและกจวตรประจาวน

พนฐานบางอยาง (BADLs) เชน อาบนา รบประทานอาหาร แตงตว ขบถาย7 Severely frail ตองการการดแลกจวตรประจาวนทกอยาง

8 Very severely frail เหมอนขอ 7 แตเขาใกลชวงเวลาสดทายของชวต หรอไมสามารถหายดขนจาก

การเจบปวยเพยงเลกนอยได9 Terminally ill มอายคาดเฉลยไมเกน 6 เดอน

Clinical Frailty Scale

FRAILCharacteristic

of frailty

Definition

Fatigue รสกออนเพลย

Resistance ไมสามารถเดนขนบนได 1 ชนได

Aerobic ไมสามารถเดนเปนระยะทาง 1 ชวงตกได

Illness มโรคหรอความเจบปวยมากกวา 5 อยาง

Loss of weight น าหนกลดลงมากกวา 5 เปอรเซนตในชวง 6 เดอนทผานมา

Lopez D. J Am Geriatr Soc.. 2012;60(1):171-3.

Positive ≥ 3 frail

– Geriatric clinic at Siriraj Hospital

– Frailty phenotype : 3 in 5

• Un-intentional weight loss , Self-reported

exhaustion, Low energy expenditure, Slow gait

speed, Decreased grip strength

– Prevalence of frailty in geriatric clinic at

Siriraj hospital = 18.0%

Frailty in outpatient clinic

Jongsiriyanyong, S,et al. Presented at RCPT 2014, Pattaya

Frailty in outpatient clinic : outcomes

Frail Non-frail p-value

Death (%) 5.7 0.6 0.02

Admission (%) 31.4 10.3 0.001

Number of

admission

(mean, SD)

0.34(0.54) 0.13(0.42) 0.001

Falls (%) 14.3 9.7 0.42

Number of falls

(mean, SD)

0.20 (0.51) 0.16 (0.55) 0.43

Chalermsri, C,et al. Presented at IAGG 2015, Chaing Mai

– Data from Thai 4th National Health Examination

Survey (NHES-IV)

– 30 variables were selected to calculate TFI as the ratio

of accumulation of deficits

– A cut-off point of TFI at 0.25

– The prevalence of frailty was 23.3%,

• 16.7%, 32.1% & 54.4% in young-old, old-old & oldest-old

Thai Frailty Index (TFI)

Srinonprasert V. et al. Arch Gerontol Geriatr. 2018

Thai Frailty Index : included variables


Hypertension Fatigue

Diabetes Sleep difficulty

Stroke Loss of interest

COPD Ability to bathe

CKD stage >=3 Ability to dress

Cognitive impairment Ability to eat

Falls in 6 months Ability to walk indoor

Dental problem Ability to toileting

Hearing problem Ability to transfer

BMI < 18.5 kg/m2 Urinary incontinence

Reduced hand gri.p Fecal incontinence

Gait speed Ability to manage medications

Overall health status Ability to do housework

Quality of life Ability to walk upstairs

Depressed mood Walk more than 300 m

Thai Frailty Index : predicting mortality

Chalermsri, C,et al. Presented at ANZSGM 2016, Cairns

7 year of follow-up

Death rate

• 26.4 % for frail

• 12.3 % for non-frail

which interventions might work?

Robustness Frailty Disability

Concept of Frailty

Frailty Consensus: A Call to Action

Frailty Consensus: A Call to Action. Am Med Dir Assoc. 2013 June ; 14(6): 392–39

Physical frailty is a manageable condition

• There are numerous potential causes of physical frailty, and many

of these could be targeted in future intervention development

• At this time, 4 possible treatments that appeared to have some

efficacy in the treatment of frailty

• Exercise (resistance and aerobic)

• Caloric and protein support

• Vitamin D

• Reduction of polypharmacy


The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. JAMDA 18 (2017) 564-575

Which intervention(s) might work?

Asia-Pacific CPG for frailty :Strong Recommendations

1. We strongly recommend that frailty be identified using a validated

measurement tool.

2. We strongly recommend that older adults with frailty be referred to

a progressive, individualized physical activity program that contains a

resistance training component.

3. We strongly recommend that polypharmacy be addressed by

reducing or deprescribing any inappropriate/superfluous

medications.


Asia-Pacific CPG for frailty :Conditional Recommendations

4. We conditionally recommend that persons with frailty are screened

for causes of fatigue.

5. We conditionally recommend that older adults with frailty who

exhibit unintentional weight loss should be screened for reversible

causes and considered for food fortification/protein and caloric

supplementation.

6. We conditionally recommend that vitamin D be prescribed for

persons found to be deficient in Vitamin D.


Thai Frailty Index : validated tool


Hypertension Fatigue

Diabetes Sleep difficulty

Stroke Loss of interest

COPD Ability to bathe

CKD stage >=3 Ability to dress

Cognitive impairment Ability to eat

Falls in 6 months Ability to walk indoor

Dental problem Ability to toileting

Hearing problem Ability to transfer

BMI < 18.5 kg/m2 Urinary incontinence

Reduced hand gri.p Fecal incontinence

Gait speed Ability to manage medications

Overall health status Ability to do housework

Quality of life Ability to walk upstairs

Depressed mood Walk more than 300 m

Frail >=

8 items

Interventions for frailty : exercise

de Labra et al. BMC Geriatrics (2015) 15: 154

Decisions to treat should be preceded by


Progressive resistance exercise training

Programs targeting more than one physical component

(strength, endurance, balance, flexibility) promote better

performance with regard to the global functional capacity of

older adults

addressing muscle strengthening combined programs

addressing activities of daily living, walking, balance, nutrition

supplementation increasing the beneficial effects



Multi-component functional based circuit training

12 weeks, 2/week, 45 min/session, 1-2 sets6-8 repetitions

1 day of balance-based activities and 1 day of lower-body

strength-based exercises, combined with function-focused activities.

Lower extremity exercises included activities such as rising from a

chair, stair climbing, knee bends, floor transfer, lunges, leg

squats, leg extension, leg flexion, calfraises, and abdominal curls

using ankle weights… no machine

Improve functional ability



Multi-component PRT 9 months, 3/week 60-90 min/session

Initial goal: 1-2 sets, 6-8 repetitions, 65% 1-RM

Final goal: 3 sets, 8-12 repetitions, 40-60% 1-RM

1-RM (repetition maximum) strength in six different exercises (knee

extension, knee flexion, seated bench press, seated row, leg

press, biceps curl), in a weightlifting machine

Benefit for pre-frail but not frail (reduce falls, increase muscle

strength)



Asia-Pacific CPG for frailty :Exercise

We strongly recommend that older adults with frailty be referred to

a progressive, individualized physical activity program that contains a

resistance training component

Balance and aerobic training are also recommended for older

adults with frailty, even if these modes of exercise may not directly

influence muscle strength



Much research has linked frailty development with polypharmacy

Medications prescribed by frail older people be reviewed regularly.

Medications, which are no longer needed can be

deprescribed, regulating the dose in accordance with kidney

function

Withdrawal of inappropriate medications should be conducted

under the supervision of a healthcare professional, with the aim

to improve the outcomes of patients

Interventions for frailty : polypharmacy

Asia-Pacific CPG for frailty :Conditional Recommendations

4. We conditionally recommend that persons with frailty are screened

for causes of fatigue.

5. We conditionally recommend that older adults with frailty who

exhibit unintentional weight loss should be screened for reversible

causes and considered for food fortification/protein and caloric

supplementation.

6. We conditionally recommend that vitamin D be prescribed for

persons found to be deficient in Vitamin D.



Interventions for frailty : weight loss

Interventions for frailty : Protein supplementation

Protein 1.0-1.5 g/kg BW/day

Protein 1.0-1.2 g/kg BW/day


In older persons who are 25(OH) vitamin D deficient, there is evidence

that vitamin D supplementation will reduce falls, hip fractures, and

mortality. It may also improve muscle function.

Although there are no large-scale clinical trials that show that frailty

can be prevented or treated by vitamin D alone, there is sufficient

evidence of efficacy in frailty appearing populations to suggest that

vitamin D in frail persons who are vitamin D deficient would be useful

Interventions for frailty : Vitamin D


There are several clinical trials finding that vitamin D

supplementation in older adults with vitamin D deficiency

reduces likelihood of mortality, falls, and fractures.

However, these trials tend to focus on older adults without

frailty.

Vitamin D supplementation for older adults with frailty

remains a topic of much debate in the literature

Interventions for frailty : Vitamin D

• Included 53

trials

• 91,791

participants

– 1,268 subjects from NHES IV, median age 74.0 years

(range 60 – 98), follow-up time 7 years

– Prevalence of vitamin D deficiency (< 30 ng/mL)

• 24.5% in male

• 43.9 % in female

Srinonprasert et al. Presented at ANZSGM 2016, Cairns

Vitamin D and mortality in Thai older persons

– Vitamin D deficiency & all-cause mortality

• adjusted with age, physical activities, comorbidities, low BMI

status

• Total, hazard ratio [HR] = 1.31, 95% CI = 1.03 – 1.69 , (p = 0.01)

• Male , hazard ratio [HR] = 1.73, 95% CI = 1.24 – 2.41 , (p = 0.01)

• Female, hazard ratio [HR] = 1.19, 95% CI = 0.82 – 1.73 , (p =

0.36)

Vitamin D and mortality in Thai older persons

Srinonprasert et al. Presented at ANZSGM 2016, Cairns

Would you give vitamin D for Thai older adults?

1. Which instrument for screening of frailty has been

validated in Thai population?

2. What is strongly recommended for management of

frailty, according to Asia-Pacific CPG?

3. What is the conditional recommendation for management

of frailty?

Questions

Frailty is common in Thai older adults

Frailty lead to increase risk of adverse outcome

Screening and applying appropriate interventions might be

beneficial to improve general health of Thai older persons

Take home message

THANK YOU FOR YOUR ATTENTION

Frailty is always frail?agingthai.dms.moph.go.th/agingthai/download... · 2018-06-19 ·...

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