Aging Seminar Epi Seminar 1-06
FRAILTY DEFINITIONS
“Occurs when under stressful conditions the person has
diminished ability to carry out important practiced
social activities of daily living.It needs to be distinguished
from disability”
Renoir, 1915
Blonde a la rosa
Aging Seminar Epi Seminar 1-06
0 10 20 30 40 50 60 70 80 90 100
Age (years)
VO
2 m
ax
Car
dia
c outp
ut
Bal
ance
Musc
le s
tren
gth
Frailty
Threshold
Aging Seminar Epi Seminar 1-06
Criteria for a successful definition of frailty
Content validity
• includes multiple determinants • is dynamic • validly supercedes earlier, successful definitions • broadly useful across contexts (e.g. clinical trials, population studies) • computationally tractable Construct validity
• is more common in women than in men • is more common with age • related to disability • related to co-morbidity and self-rated health Criterion validity
• predicts mortality • predicts other adverse outcomes (delirium, falls, worse function) • predicts an age at which everyone is frail • scales from cellular and animal models to studies in people
Aging Seminar Epi Seminar 1-06
Content Validity
Construct Validity
Criterion Mortality
Criterion ADLs
CHS Y Y Y Y
SOF Y Y Y Y
Deficit Model Y Y Y Y
SHARE-FI Y Y Y
FRAIL Y Y Y Y
Kihon-Checklist Y Y Y
VES-13 Y Y Y
Sherbrooke postal questionnaire
Y Y Y
Tilburg Y Y Y
Aging Seminar Epi Seminar 1-06
FRAILTY DEFINITION OBJECTIVE
Fried et al J Gerontol 56A M146,2001
•Weight Loss(10 lbs in 1 year)
•Exhaustion(self-report)
•Weakness (grip strength;lowest 20%)
•Walking speed(15 feet; slowest 20%)
•Low Physical Activity(Kcals/week;lowest 20%)
Female >
Male
6.9%
Aging Seminar Epi Seminar 1-06
Rockwood Deficit Scale 10 year outcomes
Deficits added >0.25 = Frail
Aging Seminar Epi Seminar 1-06
Importance of cognitive assessment as part of the “Kihon Checklist” developed by the Japanese Ministry of Health, Labor and Welfare for prediction of frailty at a 2‐year follow up
Geriatrics & Gerontology International pages n/a-n/a, 22 NOV 2012 DOI: 10.1111/j.1447-0594.2012.00959.x http://onlinelibrary.wiley.com/doi/10.1111/j.1447-0594.2012.00959.x/full#ggi959-fig-0002
Aging Seminar Epi Seminar 1-06
Gerontopole Screen
Frailty Screening
Older patients, 65 y and older, not dependent (activities of daily living ≥5/6)
Yes No Unknown
Is your patient living alone?
□ □ □
Involuntary weight loss in the past 3 months?
□ □ □
Fatigability from the past 3 months?
□ □ □
Have some mobility difficulties for the past 3 months?
□ □ □
Memory complaints?
□ □ □
Slow gait speed (+4 s for 4 meters)?
□ □ □
9
Aging Seminar Epi Seminar 1-06
Fatigue
Resistance (Climb 1 flight stairs)
Aerobic (Walk one block)
Illnesses
Loss of weight
FRAILTY (IANA)
SIX VALIDATIONS Australia(2) Hong Kong St Louis Europe(2)
Aging Seminar Epi Seminar 1-06
Kaplan-Meier survival curves showing association between FRAIL
scale at W2 and subsequent all-cause mortality.
4 to 8 year follow up
Hyde Z et al. JCEM 2010;95:3165-3172
Frailty (3+) predicted
ADL deficit
P<0.0001
Aging Seminar Epi Seminar 1-06
FRAIL predictions in older women (Australia): 6 years
• Mortality 3.15(2.66-3.73)
• ADLS 6.84(5.46-8.56)
• IADLS 9.17(6.66-12.6)
• Lopez et al JAGS 60:171;2012
12
Aging Seminar Epi Seminar 1-06
Prevalence of Frailty Excluding baseline ADL deficits
Aging Seminar Epi Seminar 1-06
9-year OR of ADL deficit or Mortality in persons not lacking ADLs
ADLs
PreFrail
Frail p
FRAIL 2.74 20.76 .001
SOF 3.09 3.48 .001
CHS 2.40 6.47 .001
Rockwood
2.36 5.65 .001
MORTALITY
PreFrail Frail p
1.58 3.99 .001
1.47 1.40 NS
1.35 2.42 .01
2.50 2.66 .001
Aging Seminar Epi Seminar 1-06
African American Health (AAH)
Baseline* Unstandardized Coefficients P-Value 9-Years* Unstandardized Coefficients P-Value
B (SE) B (SE)
IADLs IADLs
Pre-Frail 0.77 (0.07) <.001 Pre-Frail 0.74 (0.16) <.001
Frail 2.08 (0.13) <.001 Frail 1.84 (0.36) <.001
SPPB SPPB
Pre-Frail -1.54 (0.20) <.001 Pre-Frail -1.09 (0.27) <.001
Frail -3.89 (0.40) <.001 Frail -4.60 (0.60) <.001
Gait Speed Gait Speed
Pre-Frail -0.07 (0.02) .003 Pre-Frail -0.05 (0.03) .094
Frail -0.14 (0.05) .002 Frail -0.20 (0.07) .004
1-Leg Stand 1-Leg Stand
Pre-Frail -3.97 (0.82) <.001 Pre-Frail -4.09 (1.15) <.001
Frail -8.47 (1.79) <.001 Frail -1.64 (3.36) .626
Grip Strength Grip Strength
Pre-Frail -3.58 (0.74) <.001 Pre-Frail -1.63 (0.87) .063
Frail -4.13 (1.46) .005 Frail -3.61 (2.05) .079
Odds Ratio (95% CI ) Odds Ratio (95% CI )
Injurious Falls Injurious Falls
Pre-Frail 1.14 (0.56-2.30) .720 Pre-Frail 1.10 (0.48-2.52) .827
Frail 2.35 (0.88-6.30) .089 Frail 0.72 (0.09-5.80) .437
Mortality Pre-Frail 1.61 (1.06-2.44) .027
Frail 4.19 (2.10-8.35) <.001
*Respondents No ADL Dependence at Baseline
Morley et al. JNHA 2012;16:601-608
Aging Seminar Epi Seminar 1-06
Specificity of Scales in Hong Kong Study
MALE MALE FEMALE FEMALE
MORTALITY Physical Limit MORTALITY Physical Limit
Rockwood 96.4% 98.4% 93.8% 98%
CHS 99.2% 100% 99.4% 99.9%
FRAIL 99.1% 99.4% 99.9% 100%
Hubbard 98% 99.6% 96.1% 95.1%
All had poor Sensitivity
Aging Seminar Epi Seminar 1-06
Identifying Common Characteristics of Frailty Across Seven Scales SHARE DATA
0
2
4
6
8
10
12
14
2 years 5 years
Mortality
Journal of the American Geriatrics Society Volume 62, Issue 5, pages 901-906, 2 APR 2014 DOI: 10.1111/jgs.12773 http://onlinelibrary.wiley.com/doi/10.1111/jgs.12773/full#jgs12773-fig-0001
All 8 scales mortality between 2.9 and 3.2 for 2 years
and 11.4 and 12 for 5 years
Rathi Ravindrarajah , David M. Lee , Stephen R. Pye , Evelien Gielen , Steven Boonen , Dirk Vanderschueren , Neil ...
The ability of three different models of frailty to predict all-cause mortality: Results from the European Male Aging Study
(EMAS) Archives of Gerontology and Geriatrics, Volume 57, Issue 3, 2013, 360 - 368
FRAIL
FRIED
FI
Aging Seminar Epi Seminar 1-06
The ability of three different models of frailty to predict all-cause mortality: Results from the
European Male Aging Study (EMAS)
• We used a frailty index (FI), frailty phenotype (FP), and FRAIL scale (FS) to predict mortality in the EMAS. Participants were aged 40–79 years (n = 2929) at baseline and 6.6% (n = 193) died over a median 4.3 years of follow-up.. The mean FI increased linearly with age (r2 = 0.21) and in Cox regression models adjusted for age, center, smoking and partner status the hazard ratio (HR) for death for each unit increase of the FI was 1.49.
• Compared to robust men, those who were FP frail at baseline had a HR for death of 3.84, while those who were FS frail had a HR of 3.87.
• Our data suggest that the choice of frailty model may not be of paramount importance when predicting future risk of death, enabling flexibility in the approach used.
Aging Seminar Epi Seminar 1-06
Fatigue
Resistance (Climb 1 flight
stairs)
Aerobic (Walk one block)
Illnesses
Loss of weight
FRAILTY
(IANA)
Fatigue Syndrome (CFS; myalgic encephalitis)
Anemia
Treatment excess eg hypotension, chemotherapy
Illnesses eg vitamin B12 deficiency, heart failure, renal failure, cancer
Gulf War Syndrome (? toxin exposure)
Unhappy (Depression)
Endocrine (Hypothyroid, Addison’s, Diabetes mellitus)
Sleep Disorders (Sleep apnea, restless legs, insomnia)
Resistance and balance
exercises
And protein
Aerobic Exercise
And protein
Reduce polypharmacy
Aging Seminar Epi Seminar 1-06
Medications
Emotional (depression)
Alcoholism,anorexia tardive, abuse (elder)
Late life paranoia
Swallowing problems
Oral problems
Nosocomial infections,no money (poverty)
Wandering/dementia
Hyperthyroidism,hypercalcemia,hypoadrenalism
Enteric problems (malabsorption)
Eating problems (eg. Tremor)
Low salt, low cholesterol diet
Shopping and meal preparation problems, Stones (cholecystitis)
Caloric Supplementation and treat the Causes of Weight Loss
Morley JE, Silver AJ. Ann Intern Med 1995;123:850-859.
Aging Seminar Epi Seminar 1-06
Frailty Consensus Conference
Orlando, Florida
December
Aging Seminar Epi Seminar 1-06
IAGG Recommendations For the purposes of optimally managing
individuals with physical frailty, all persons older than 70 years and all individuals with significant weight loss (5%) due to chronic
disease should be screened for frailty.
Fatigue
Resistance (Climb 1 flight stairs)
Aerobic (Walk one block)
Illnesses
Loss of weight
Aging Seminar Epi Seminar 1-06
Johanna Quaas
87 years old
SOCIAL Sadness
Outside activity
Cognition
Income adequacy
Attachment to neighborhood
Lethargy
Univariate Analysis of Variance*
Mean+Standad Deviation P-Value
Variables Robust (0-1)
Pre-Frail (2-3)
Frail (4-6)
ADL disabilities 0.58+1.5 1.00+1.9 1.86+2.5 <.001b,d
IADL disabilities 0.77+1.6 1.26+2.0 2.64+2.7 <.001b,d
Short Physical Performance Battery 8.44+2.8 7.28+3.2 5.53+4.03 <.001a,d
Lower Body Functional Limitations 1.51+1.7 2.30+1.9 3.46+1.7 <.001a,d
One-Leg Stand 17.90+11.6 11.91+10.7 11.79+10.1 <.001a,d
Grip Strength 33.41+12.2 29.11+10.7 27.85+10.0 .015a,d
Binary Logistic Regression
Odds Ratio
95% CI
P-Value
Mortality
Robust
Pre-frail
Frail
Ref
2.30
2.46
1.57-3.37
1.14-5.30
<.001
.022
* Adjusted for age and gender ** Pre-frail versus robust p-value: a <.001; b <.01; c <.05 *** Frial versus robust p-value: d <.001; e <.01; f <.05
SOCIAL overlap with FRAIL and CHS
Social
3.0%
FRAIL
9.2% 1.9%
SOCIAL 47/955 (4.9%) FRAIL 106/955 (11.1%)
SOCIAL 36/872 (4.1%) CHS 93/872 (10.7%)
Social
2.8%
CHS
9.3%
1.4%
Aging Seminar Epi Seminar 1-06
Rapid Cognitve Screen (RCS)
The Rapid Cognitive Screen for Mild Cognitive Impairment (MCI) (0–5 = dementia; 6–7 = MCI; 8–10 = normal) Recall: Five objects—Apple, Pen, Tie, House, Car. [Recall objects after clock drawing; 5 points.] Clock Drawing: Draw with time at 10 minutes to 11 o'clock. [4 points] Insight: Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met Jack, a devastatingly handsome man. She married him and had 3 children. They lived in Chicago. She then stopped work and stayed at home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever after. What state did they live in? [1 point]