-
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
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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
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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
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Age and FrailtyAge and FrailtyAge and FrailtyAge and Frailty
Length ofLif
Strength of LifLifespan Lifespan
• Chronological Age • Frailty
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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
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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
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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
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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
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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
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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
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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