Frailty: its relevance to Frailty: its relevance to Transition CareTransition Care

Susan Kurrle

Geriatrician, Hornsby Ku-ring-gai Health Service

Curran Chair in Health Care of Older People, Faculty of Medicine, University of Sydney

Frailty: definitionsFrailty: definitions

Weak, not robust, having delicate Weak, not robust, having delicate healthhealth

Easily broken or damagedEasily broken or damaged– Macquarie DictionaryMacquarie Dictionary

State of being weak in mind or bodyState of being weak in mind or body– Web dictionaryWeb dictionary

Loss of physiological reserve, Loss of physiological reserve, increased state of vulnerability to increased state of vulnerability to acute and chronic stressorsacute and chronic stressors– Assorted authorsAssorted authors

Frailty: definitionsFrailty: definitions

A standardised “scientific” A standardised “scientific” definition is still being established definition is still being established and several have been proposedand several have been proposed

Most health professionals use the Most health professionals use the wordword– ““I know it when I see it”I know it when I see it”

Frailty: definitions Frailty: definitions (Fried)(Fried)

Operationally defined as:Operationally defined as:

A clinical syndrome in which A clinical syndrome in which three or three or moremore of the following are present: of the following are present:

unintentional weight loss (10lbs/4.5kgs in unintentional weight loss (10lbs/4.5kgs in last year)last year)

self-reported exhaustionself-reported exhaustion weakness (grip strength)weakness (grip strength) slow walking speedslow walking speed low physical activitylow physical activity

Fried et al. Frailty in older adults: evidence for a phenotype.

J Geront 2001;56:M146-M156

Frailty: definitionsFrailty: definitions (Rockwood & Mitnitski) (Rockwood & Mitnitski)

Accumulated deficits leading to loss of Accumulated deficits leading to loss of reservereserve

Clearly related to morbidity and Clearly related to morbidity and mortalitymortality

Can be expressed as an Index (a count Can be expressed as an Index (a count of deficits) ORof deficits) OR

Can be summarised as a scale from Can be summarised as a scale from Robust to Terminally IllRobust to Terminally Ill

Mitnitski et al. The mortality rate as a function of accumulated deficits in a frailty index. Mechanisms of Ageing and Development 123 (2002) 1457 - 1460

Frailty IndexFrailty Index

Why is measurement Why is measurement of frailty important?of frailty important? Frailty predicts:Frailty predicts:

– fallsfalls– ED visits and hospitalisationED visits and hospitalisation– entry into residential careentry into residential care– deathdeath

Frailty stratification can predict Frailty stratification can predict risk of institutional care, or help risk of institutional care, or help plan interventionsplan interventions

Why does frailty Why does frailty occur?occur?

No single process identifiedNo single process identified Related to ageingRelated to ageing Comorbidities important, but 25% of Comorbidities important, but 25% of

frail have no identified chronic disease frail have no identified chronic disease Sarcopaenia (decreased muscle mass) Sarcopaenia (decreased muscle mass) Inflammatory markers, hormones, Inflammatory markers, hormones,

coagulation factors importantcoagulation factors important 10% to 30% of frail people are obese10% to 30% of frail people are obese

Is frailty treatable?Is frailty treatable?

Fried: YesFried: Yes– Improve physical functionImprove physical function– Improve nutritionImprove nutrition

Rockwood: YesRockwood: Yes– Ameliorate deficitsAmeliorate deficits– Treat diseaseTreat disease– Improve physiological reserveImprove physiological reserve

Frailty Intervention Trial (FIT)Frailty Intervention Trial (FIT)

Aim to identify frail older people and Aim to identify frail older people and address their frailty symptoms and signs address their frailty symptoms and signs

FIT:FIT:– Community dwelling people aged >70yrs Community dwelling people aged >70yrs – Assessed using Fried Frailty criteriaAssessed using Fried Frailty criteria– RCT for participants assessed as frail with RCT for participants assessed as frail with

intervention of individually designed program intervention of individually designed program addressing physical limitations, nutrition, addressing physical limitations, nutrition, comorbiditiescomorbidities Frailty Intervention TrialFrailty Intervention Trial

(I Cameron, S Kurrle, S Lord, C (I Cameron, S Kurrle, S Lord, C Sherrington)Sherrington)NHMRC Grant 402791NHMRC Grant 402791

FIT Interim ResultsFIT Interim Results

N = 91, mean age 82 yrs, 2/3 womenN = 91, mean age 82 yrs, 2/3 women Defined as Defined as frailfrail if 3 or more of: weight if 3 or more of: weight

loss, low grip strength, slow walking loss, low grip strength, slow walking speed, self reported exhaustion, low speed, self reported exhaustion, low physical activityphysical activity

Defined as Defined as prefrailprefrail if 1 or 2 criteria if 1 or 2 criteria

63 (69%) frail at study commencement63 (69%) frail at study commencement 28 (31%) prefrail at commencement28 (31%) prefrail at commencement

FIT Interim ResultsFIT Interim Results

Change from 63 (69%) frail to 42 Change from 63 (69%) frail to 42 (46%) frail at 3 months (p<0.01)(46%) frail at 3 months (p<0.01)

Walking speed increased from Walking speed increased from 0.50m/sec to 0.54m/sec (p=0.046)0.50m/sec to 0.54m/sec (p=0.046)

No significant change in Barthel Index, No significant change in Barthel Index, or EQ5Dor EQ5D

FIT Interim ConclusionsFIT Interim Conclusions

Components of frailty can change quite Components of frailty can change quite rapidly with an appropriate interventionrapidly with an appropriate intervention

Measures of functioning and QOL may Measures of functioning and QOL may change more slowlychange more slowly

Don’t give up on frail patients, consider Don’t give up on frail patients, consider longer term, slow stream rehabilitation longer term, slow stream rehabilitation programs in the home for these patientsprograms in the home for these patients

FIT: Frailty into the futureFIT: Frailty into the future

How much can strength and mobility How much can strength and mobility improve?improve?

How can improvements be translated How can improvements be translated into important activities eg getting out into important activities eg getting out of the house, seeing family and friends?of the house, seeing family and friends?

Does improvement in frailty mean Does improvement in frailty mean less health and support service less health and support service use, or less use of residential care?use, or less use of residential care?