CHANGES & CHALLENGES OF AGING FRAILTY & IMPACT ON PATIENT OUTCOMES Cathy A. Maxwell , PhD, RN, FAAN Assistant Professor | Vanderbilt University School of Nursing Photo: Getty Images
CHANGES & CHALLENGES OF AGINGFRAILTY & IMPACT ON PATIENT OUTCOMES
Cathy A. Maxwell, PhD, RN, FAAN
Assistant Professor | Vanderbilt University School of Nursing
Photo: Getty Images
QUESTIONS
►Does the person get fatigued or exhausted easily?
►Can the person walk up one flight of stairs?
►Can the person ambulate or walk ¼ mile?
►Does the person have more than 5 medical problems?
►Has the person lost weight unintentionally in the past 6 months to 1
year?
►5-item FRAIL Questionnaire
►Frail >/= 3, 1 or 2 – Pre-frail
Objectives
►Describe the concept of frailty and
how frailty influences patient
outcomes.
►Describe an innovative approach
for upstream management of older
adults on aging trajectories.
Photo: Getty Images
Aging
►Aging reflects human entropy, or the body’s slow and gradual loss of the ability to generate energy to sustain itself. Changes, at cellular and subcellular levels begin years before outward manifestations appear.
►Older adults can be empowered to proactively manage their own personal trajectories of aging so that they experience increased quality of life, decreased health care utilization, and readiness for end of life.
Illustration: Public Domain
What to Expect
AGE END OF LIFE50
YRS OLD
Planning for the
8 Focus Areas
Planning for the 8 Focus Areas
AG
E
END OF LIFE50
YRS OLD
SAFETY
PHYSICAL ACTIVITY
RELATIONSHIP & COMMUNITY
FOOD & NUTRITION
SLEEP & REST
HEALTHCARE DECISION-MAKING
FINANCES/LEGAL
MIND/BODY HEALTH
Frailty Threshold
Trajectories of Aging
Source: T M Manini, and M Pahor Br J Sports Med 2009;43:28-31
Frailty
►A state of vulnerability to stressors
that increases the risk of adverse
events, disability, decline, and death.
►Two-thirds of frail adults are
hospitalized annually, accounting for a
large portion of preventable health
care spending.
►Public-at-large has a poor
understanding of the concept of frailty.
►Public perceptions are negative and
associated with giving up.
Photo: Getty Images
It’s OK to Use this “F-word”
Illustration: Getty Images
►What do we mean by “human
entropy?”
►Why is it important to talk about these
concepts at a lay person level?
►What can we do to help empower
adults to manage their personal
trajectories of aging?
MITOCHONDRIA IN HEALTH AND DISEASE
Illustration: Nathan Devery/Science Photo Library
Frailty Reflects Changes at Sub-cellular Levels
►Mitochondria
Evolved from bacteria
Contains DNA (37 genes) separate
from nuclear DNA (20,000 genes)
Tissue-specific mitochondrial content
Chondriome- subcellular network of
total mitochondria per cell
Illustration: Pasieka/Science Photo Library
Most
Abundant
— Muscle
— Brain
— Liver
Mitochondrial Biogenesis
►Mitochondria: Cellular respiration and energy production
►MB: Process by which mitochondria increase in size and number
►Activated by cellular stress (i.e., Exercise)
Illustration: Public Domain
Mitochondrion
►Cristae:
Surface area for
production of ATP
(energy carriers)
Illustrations: (clockwise): Keith R. Porter/Science Photo Library; Pearson Education, Inc.; Wikimedia Commons
Respiratory Chain
Supercomplexes
►Efficiency of mitochondria-
dependent cell growth depends
on cristae shape
Illustration: Public Domain
Facets of Mitochondrial and Cellular Function
-Fusion, fission, quality control
-OxPhos
-mtDNA
-Senescence & cell death
Physiological Functions
Central nervous system
Immune and inflammation
Metabolic & cardiovascular
Neuroendocrine
Clinical Outcomes
Cognitive decline
Diabetes
Functional decline
Cardiovascular disease
Psychiatric symptoms
Early and Midlife Later life
Multi-level Organization of Mitochondria and Clinical
Outcomes
Triggers inflammation
Long term effects of stress over time
Psychological Stress
and the Mitochondria
►Perceived threat:
Physical or psychological
►Engaged mitochondrial
energy production
Circulating cell-free
mitochondrialDNA
Infection
Trauma
Strenuous Exercise
Maximal oxygen consumption (VO2max) in sedentary (a)
and endurance-trained (b) males (diamonds) and females
(squares)
Sources: Johannes H. G. M. van Beek et al. Interface Focus 2016;6:20150079; ©2016 by The Royal Society
VO2:
Reflects the
body’s ability
to utilize
oxygen
Aerobic capacity versus
age in sedentary (squares)
and trained women (circles)
Sources: Johannes H. G. M. van Beek et al. Interface Focus 2016;6:20150079; ©2016 by The Royal Society
Why is this important?
►Person-centered approach
(vs. late response to disease)
►Need for holistic approaches
(multi-faceted)
►EARLY education and dialogue
Illustration adapted from: 12-25 Life
To Leave a Legacy
SPIRITUALM
EN
TA
L
PHYSICAL
SO
CIA
L
BALANCETo
Lear
n
To Live
To
Love
What can we do to empower older adults?
►Knowledge
►Understanding the broader
picture
►Addressing multiple domains
►Communication skills that
promote agency and self-efficacy
►Domains:
Safety
Physical Activity
Food & Nutrition
Relationships & Community
Sleep & Rest
Health Care Decisions
Finances & Aging
Mind/Body Health
EMPOWERING
OLDER ADULTS
TO MANAGE THEIR
OWN PERSONAL
TRAJECTORIES
OF AGING
FRAILTY AND ENERGY
Photo: Getty Images
One Year Outcomes:ALL Patients
One Year Outcomes: Non-frail Patients
6.5 out of 10
Returned to where they
were before injury
3 out of
10
Worse
than
before
injury
0.5
out
of 10
Died
3 out of 10
Returned to
where they
were before
injury
5 out of 10
Worse than
before
injury
2 out of 10
Died
INJURED OLDER ADULTS ONE YEAR AFTER INJURY
4 out of 10
Returned to where they were
before injury
5 out of 10
Worse than before injury
1 out of 10
Died
One Year Outcomes: Pre-frail Patients
INJURED OLDER ADULTS ONE YEAR AFTER INJURY
One Year Outcomes: Frail Patients
INJURED OLDER ADULTS ONE YEAR AFTER INJURY
2 out of 10
Returned to where
they were before injury
4 out of 10
Worse than before injury
4 out of 10
Died
Components
►Frailty and Falls
►Frailty and Injury Outcomes
►Frailty and Energy Production
►Stages of Aging (Trajectories)
& Anticipatory Care
►Making a Plan
(Proactive Planning)
Energy Engines (Mitochondria)
STAGES OF AGING: UNDERSTANDING FRAILTY AND PATTERNS OF CHANGE
Oxygen
NutritionENERGY Removal
of spent
mitochondri
a
New
mitochondria
Demand for new
mitochondria
(Movement)
The body makes and removes these engines on a daily basis, but over time, as we age, the size and number decrease.
Cell Illustrations: Science Photo Library; Engine, Woman: Getty Images
Physical Activity: Muscles and Brain
►Energy engines are especially found in muscle and brain.
EXERCISE!
Illustrations: Science Photo Library
Psoas Muscles
Leg Muscles
HeartBalance
and Posture
Cerebellum
Possible Aging Paths
TYPICAL: Slow
decline over time
and possibility of
delay with physical
activity
Ph
ysic
al
cap
acit
y
Age
B
C
BEST: High
ability until just
before end-of-life
UNEXPECTED EVENT:
Different levels of ability
depending on recovery
effort
A Closer Look Towards the End
►Loss of abilities
►Dealing with emotions
Photo: Getty Images
A Closer Look and What to Expect
COPING - STRUGGLING - FEELING OVERWHELMED SYMPTOMS
“but I can’t do anything like the
cooking I used to do and the
baking, no I can’t. So, so much
of my life’s changed.”
“She’s waiting for the next stage all
the time when things are going to
get better. I think she’s harping back
to the past when she was much
more able to manage.” (caregiver)
► No Appetite
► Severe Fatigue
► Pain
► Depression
► Trouble Breathing
► Confusion
► Leaking Urine or Stool
“Well, if it wasn’t for reading I
don’t know what I would do –
and television but I’m not all that
interested. I mean, I like things
like tennis on the television.”
“No I don’t see many friends
nowadays. I used to go regular to
church, I used to travel all over, but I
don’t see anybody now.”
Anticipatory CareMany people experience many emotions and symptoms as they near end
of life. If you experience any of the emotions noted below, talk to trusted
friends, family and professionals.
8 FOCUS AREAS
Photo: Mint Images/Science Photo Library
(8) Focus Areas
► Safety
► Physical Activity
► Relationships
& Community
► Food & Nutrition
► Sleep & Rest
► Healthcare
Decision-making
► Finances/Legal
► Mind/Body Health
Making a Plan and Anticipatory Care
Knowing that frailty happens when we lose the ability
to make energy AND knowing that it can eventually
happen to anyone, what are some areas that we
need to think about as we age?
Thinking about these areas NOW, instead of later,
helps us to make better decisions.
This section discusses eight areas that older adults
need to think about. Each area briefly describes two
phases to think about:
1. Early planning
2. Late planning, when we begin to lose
physical abilities.
►Security and protection
Safety
►Home safety
►Driving safety
►Fall prevention
Photo: Getty Images
►New hobbies and activities
Physical Activity & Movement
►Time spent sitting, standing and moving
►Reduced risk of chronic diseases (diabetes, heart disease, high blood pressure)
►1 hour exercise = 2 hours in life expectancy
►150 minutes/week of moderate activity
►75 minutes/week of vigorous activity
Photo: Getty Images
HABITUAL!
►Maintaining a sense of self
Relationships
and Community
►Social connections and mortality
►Investment in relationships
►Autonomy and connection
Photo: Getty Images
►Loss of appetite and interest
in eating
Food and Nutrition
►Drinking water
►Add color to your plate
►Focus on fiber
►Mediterranean diet
►Protein
Photo: Getty Images
►Frailty: Why am I sleeping so
much?
Sleep and Rest
►How much is enough?
►Waking calm
►Benefits of sleep (thinking, immune
system, memory, weight control)
►Ways to enhance sleep
Photo: Getty Images
►Addressing FEAR
►My healthcare needs
(pain, constipation, comfort)
Healthcare Decisions
►Early vs. late planning
►Goals of care
►Caring relationships
►Advance care planning
Photo: Getty Images
►Is everything settled? At peace?
Finances and Aging
►Legal: Estate planning,
documents, wills, power of attorney
►Health care: Insurance, assets
►Income & Expenses: Debt
Photo: Getty Images
►Mind/Body: How does my mind affect
my body, prayer, meditation?
►Sharing Memories, Stories, Values
Holistic Health: The Mind and Body
►Daily Balance: How do I spend time?
►Compassion for Self: Do I care for myself? Physical needs?
Photo: Getty Images; Illustration: Public Domain
Summary
►Concept of frailty and how frailty
influences patient outcomes
►Innovative approach for upstream
management of older adults on
aging trajectories
Photo: Getty Images
Illustration: Public Domain
Photo: Getty Images
QUESTIONS?For more information:
Email: [email protected]
Faculty webpage:
nursing.vanderbilt.edu/people/bio/cathy-maxwell