FRAILTY DEFINITIONS · Aging Seminar Epi Seminar 1-06 0 10 20 30 40 50 60 70 80 90 100 Age (years) ax output Balance h Frailty Threshold

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


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Age (years)

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Frailty

Threshold


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


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


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%


Rockwood Deficit Scale 10 year outcomes

Deficits added >0.25 = Frail


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

http://onlinelibrary.wiley.com/doi/10.1111/j.1447-0594.2012.00959.x/full









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


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)


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


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


Prevalence of Frailty Excluding baseline ADL deficits


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


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


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


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

http://onlinelibrary.wiley.com/doi/10.1111/jgs.2014.62.issue-5/issuetoc

http://onlinelibrary.wiley.com/doi/10.1111/jgs.12773/full






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


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.


Fatigue

Resistance (Climb 1 flight

stairs)


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


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.


Frailty Consensus Conference

Orlando, Florida

December


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)


Illnesses

Loss of weight


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%


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]

Documents

FRAILTY DEFINITIONS · Aging Seminar Epi Seminar 1-06 0 10 20 30 40 50 60 70 80 90 100 Age (years) ax output Balance h Frailty Threshold