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Frailty is always frail?: what' re existed and the potential interventions
Varalak Srinonprasert, MD.
Division of Geriatric Medicine
Department of Medicine
Siriraj Hospital
Outline of the talk
What is frailty?
Clinical application
How to define frailty ?
How frail is Thai older people?
Could we do anything for frail older people?
Have you ever wondered why some
older people get unwell very quickly
(and badly) and recovered slowly?
What is frailty? Who is frail?
A state of increased vulnerability to poor resolution of
homoeostasis after a stressor event which increases the risk
of adverse clinical outcomesClegg A. Lancet 2013; 381: 752–62
…Definition of frailty…
Fried LP. J Gerontol. 2001; M146–M156
3.25.3
9.5
16.3
25.7
23.1
65-70 71-75 76-80 81-85 86-90 90+
Prevalence of frailty
Prevalence of frailty increase with age
– > 65 yo for intermediate to high risk elective surgery
– High-risk patients (frailty score >5) increased
postoperative mortality risk (HR = 9.01)
Frailty for predicting outcomes in surgical patients
Frailty for predicting outcomes in surgical patients
Frailty for predicting outcomes in surgical patients
There was strong evidence that frailty in older surgical
patients predicts postoperative
mortality, complications, and prolonged length of
stay…
– Frailty had a strong positive relationship with
the risk of MACCE with odds ratio = 4.89
(95%CI = 1.64-14.60)
Frailty for predicting outcomes in cardiac surgical patients
– Frailty had a strong positive relationship with the risk of
MACCE with odds ratio = 4.89 (95%CI = 1.64-14.60).
Frailty for predicting outcomes in cardiac surgery patients
• Decision of glycemiccontrol in elderly patients– Based on the degree of frailty
– Patients with moderate or more advanced frailty have a reduced life expectancy
Should not undergo stringent glycemic control
– When attempts are made to improve glycemic control in these patients, there are fewer episodes of significant hyperglycemia but also more episodes of severe hypoglycemia.
G.S. Meneilly et al. Diabetes in the Elderly. Can J Diabetes 37 (2013) S184eS190
Lee SJ, et al. The risks and benefits of implementing glycemic control guidelines in frail older adults with diabetes mellitus. J Am Geriatr Soc. 2011.Clinical frailty scale. Adapted with permission from Moorhouse P, Rockwood K. Frailty and its quantitative clinical evaluation .2012
Frailty in diabetic older patients
IDF Global Guideline for Managing Older People with Type 2 Diabetes. 2013
Frailty in diabetic older patientsGuideline for diabetes in older people
: IDF 2013
For patients age ≥ 70 years old
Diabetes Care , vol 35, December 2012Standard of Medical care in Diabetes, ADA 2018
Practice guidelines in diabetic older patients
Frailty
status
ลกษณะผปวย แนวคด เปาหมาย A1C
ระดบนาตาลตอนอดอาหาร
ระดบนาตาลกอนนอน
ความดน ไขมน
แขงแรง ไมคอยมโรครวม ความจ าด ชวยเหลอตวเองด
Longer remaining life expectancy
<7.5% 90–130 90–150 <140–80 statin
ซบซอนปานกลาง โรครวม 2 ชนดขนไป IADL impaired 1-2 ชนด สมองเสอมเลกนอย ถงปานกลาง
Intermediate remaining life expectancy
<8.0% 90–150 100–180 <140–80 statin
ซบซอนมาก โรคเรอรงระยะทาย ตองพงพาผอน และสมองเสอมรนแรง
Limitedremaining life expectancy
<8.5% 100–180 110-200 <150–90 Consider likely benefit & risk
ค าแนะน าในการรกษาเบาหวานในผสงอาย (ADA 2018)
Frailty
status
Frailty in older patients with HT
Recommendations for treating HT in the very old
Decisions to treat should be preceded by
(1) accurate information on their functional capacity, cognitive status
(2) attention to multiple drug administration so common in this age stratum
(3) stratification of the frailty status by one of the available rapid methods
(4) identification and correction of factors that predispose to an excessive BP
reduction, orthostatic hypotension, and other hypotensive episodes
When decide to treat, start with low drug doses and monotherapy
Patient status (frailty) should be monitored on a frequent basis
European Union Geriatric Medicine Society Working Group on the Management of Hypertension in Very Old, Frail Subjects, Hypertension. 2016;67:820-825.
Side effects in SPRINT-75 study
according to frailty status
Frail older adults are more likely to
experience side effects from medications
Frailty in older patients with dyslipidemia
Strandberg TE. JAMA. 2014;312(11):1136-1144.
Frailty may exacerbate
adverse effect of
therapy
Criteria for Frailty
– Phenotype model
– Cumulative deficit model (frailty index)
– Global model (clinical frailty scale)
– Clinical definition (FRAIL)
Phenotype modelCharacteristic
of frailty
Definition
Shrinking Weight loss > 10 lbs lost unintentionally in prior year
WeaknessGrip strength : lowest 20% (by gender, BMI)
Poor enduranceExhaustion (self report)
SlownessWalking time : lowest 20% (by gender, height)
Low activityPhysical activity : lowest 20% (by gender)
Fried LP. J Gerontol. 2001; M146–M156
Positive ≥ 3 frail
Frailty Index
• The proportion of accumulated deficits (the presence and severity of
current diseases, ability in ADLs and physical signs from clinical and
neurological exams and laboratory abnormalities)
• CSHA frailty index
– collect 70 variables in the cohort
– a person with 14 deficits would have an index score of 14/70 =
0.20
• A person with higher frailty index is more vulnerable and has higher
chance of experience adverse clinical outcomes
Mitnitski AB.. The Scientific World (2001) 1, 323–336
Rockwood K. CMAJ 2005;173(5):489-95
Clinical Frailty Scale
1 Very fit สขภาพแขงแรงด กระฉบกระเฉง สดชน มแรงบนดาลใจในการทากจกรรม
ตางๆ คนกลมนมกออกกาลงกายสมาเสมอและดแขงแรงมากทสดเมอเทยบกบ
คนกลมอายเดยวกน2 Well ไมมโรคเจบปวย แตแขงแรงนอยกวาคนกลมแรก
3 Managing well มโรคเจบปวยแตควบคมอาการไดดเมอเทยบกบกลมท 4
4 Apparently vulnerable ยงชวยเหลอตนเองได แตมกบนวารสกตวเองเชองชาลง หรอมโรคประจาตวท
มอาการปรากฏ5 Mildly frail ชวยเหลอตนเองไดลดลงในดานกจวตรประจาวนขนสง (IADL) เชน ทาอาหาร
ทาความสะอาด จบจายใชสอย ขบรถ จดยา ทาธรกรรมการเงน
6 Moderately frail ตองการการพงพาทงในดานกจวตรประจาวนขนสงและกจวตรประจาวน
พนฐานบางอยาง (BADLs) เชน อาบนา รบประทานอาหาร แตงตว ขบถาย7 Severely frail ตองการการดแลกจวตรประจาวนทกอยาง
8 Very severely frail เหมอนขอ 7 แตเขาใกลชวงเวลาสดทายของชวต หรอไมสามารถหายดขนจาก
การเจบปวยเพยงเลกนอยได9 Terminally ill มอายคาดเฉลยไมเกน 6 เดอน
Clinical Frailty Scale
FRAILCharacteristic
of frailty
Definition
Fatigue รสกออนเพลย
Resistance ไมสามารถเดนขนบนได 1 ชนได
Aerobic ไมสามารถเดนเปนระยะทาง 1 ชวงตกได
Illness มโรคหรอความเจบปวยมากกวา 5 อยาง
Loss of weight น าหนกลดลงมากกวา 5 เปอรเซนตในชวง 6 เดอนทผานมา
Lopez D. J Am Geriatr Soc.. 2012;60(1):171-3.
Positive ≥ 3 frail
– Geriatric clinic at Siriraj Hospital
– Frailty phenotype : 3 in 5
• Un-intentional weight loss , Self-reported
exhaustion, Low energy expenditure, Slow gait
speed, Decreased grip strength
– Prevalence of frailty in geriatric clinic at
Siriraj hospital = 18.0%
Frailty in outpatient clinic
Jongsiriyanyong, S,et al. Presented at RCPT 2014, Pattaya
Frailty in outpatient clinic : outcomes
Frail Non-frail p-value
Death (%) 5.7 0.6 0.02
Admission (%) 31.4 10.3 0.001
Number of
admission
(mean, SD)
0.34(0.54) 0.13(0.42) 0.001
Falls (%) 14.3 9.7 0.42
Number of falls
(mean, SD)
0.20 (0.51) 0.16 (0.55) 0.43
Chalermsri, C,et al. Presented at IAGG 2015, Chaing Mai
– Data from Thai 4th National Health Examination
Survey (NHES-IV)
– 30 variables were selected to calculate TFI as the ratio
of accumulation of deficits
– A cut-off point of TFI at 0.25
– The prevalence of frailty was 23.3%,
• 16.7%, 32.1% & 54.4% in young-old, old-old & oldest-old
Thai Frailty Index (TFI)
Srinonprasert V. et al. Arch Gerontol Geriatr. 2018
Thai Frailty Index : included variables
Srinonprasert V. et al. Arch Gerontol Geriatr. 2018
Hypertension Fatigue
Diabetes Sleep difficulty
Stroke Loss of interest
COPD Ability to bathe
CKD stage >=3 Ability to dress
Cognitive impairment Ability to eat
Falls in 6 months Ability to walk indoor
Dental problem Ability to toileting
Hearing problem Ability to transfer
BMI < 18.5 kg/m2 Urinary incontinence
Reduced hand gri.p Fecal incontinence
Gait speed Ability to manage medications
Overall health status Ability to do housework
Quality of life Ability to walk upstairs
Depressed mood Walk more than 300 m
Thai Frailty Index : predicting mortality
Chalermsri, C,et al. Presented at ANZSGM 2016, Cairns
7 year of follow-up
Death rate
• 26.4 % for frail
• 12.3 % for non-frail
which interventions might work?
Robustness Frailty Disability
Concept of Frailty
Frailty Consensus: A Call to Action
Frailty Consensus: A Call to Action. Am Med Dir Assoc. 2013 June ; 14(6): 392–39
Physical frailty is a manageable condition
• There are numerous potential causes of physical frailty, and many
of these could be targeted in future intervention development
• At this time, 4 possible treatments that appeared to have some
efficacy in the treatment of frailty
• Exercise (resistance and aerobic)
• Caloric and protein support
• Vitamin D
• Reduction of polypharmacy
Frailty Consensus: A Call to Action. Am Med Dir Assoc. 2013 June ; 14(6): 392–39
Physical frailty is a manageable condition
• There are numerous potential causes of physical frailty, and many
of these could be targeted in future intervention development
• At this time, 4 possible treatments that appeared to have some
efficacy in the treatment of frailty
• Exercise (resistance and aerobic)
• Caloric and protein support
• Vitamin D
• Reduction of polypharmacy
Frailty Consensus: A Call to Action. Am Med Dir Assoc. 2013 June ; 14(6): 392–39
The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. JAMDA 18 (2017) 564-575
Which intervention(s) might work?
The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. JAMDA 18 (2017) 564-575
Asia-Pacific CPG for frailty :Strong Recommendations
1. We strongly recommend that frailty be identified using a validated
measurement tool.
2. We strongly recommend that older adults with frailty be referred to
a progressive, individualized physical activity program that contains a
resistance training component.
3. We strongly recommend that polypharmacy be addressed by
reducing or deprescribing any inappropriate/superfluous
medications.
The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. JAMDA 18 (2017) 564-575
Asia-Pacific CPG for frailty :Conditional Recommendations
4. We conditionally recommend that persons with frailty are screened
for causes of fatigue.
5. We conditionally recommend that older adults with frailty who
exhibit unintentional weight loss should be screened for reversible
causes and considered for food fortification/protein and caloric
supplementation.
6. We conditionally recommend that vitamin D be prescribed for
persons found to be deficient in Vitamin D.
The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. JAMDA 18 (2017) 564-575
Thai Frailty Index : validated tool
Srinonprasert V. et al. Arch Gerontol Geriatr. 2018
Hypertension Fatigue
Diabetes Sleep difficulty
Stroke Loss of interest
COPD Ability to bathe
CKD stage >=3 Ability to dress
Cognitive impairment Ability to eat
Falls in 6 months Ability to walk indoor
Dental problem Ability to toileting
Hearing problem Ability to transfer
BMI < 18.5 kg/m2 Urinary incontinence
Reduced hand gri.p Fecal incontinence
Gait speed Ability to manage medications
Overall health status Ability to do housework
Quality of life Ability to walk upstairs
Depressed mood Walk more than 300 m
Frail >=
8 items
Interventions for frailty : exercise
de Labra et al. BMC Geriatrics (2015) 15: 154
Decisions to treat should be preceded by
Interventions for frailty : exercise
Progressive resistance exercise training
Programs targeting more than one physical component
(strength, endurance, balance, flexibility) promote better
performance with regard to the global functional capacity of
older adults
addressing muscle strengthening combined programs
addressing activities of daily living, walking, balance, nutrition
supplementation increasing the beneficial effects
Interventions for frailty : exercise
de Labra et al. BMC Geriatrics (2015) 15: 154
Multi-component functional based circuit training
12 weeks, 2/week, 45 min/session, 1-2 sets6-8 repetitions
1 day of balance-based activities and 1 day of lower-body
strength-based exercises, combined with function-focused activities.
Lower extremity exercises included activities such as rising from a
chair, stair climbing, knee bends, floor transfer, lunges, leg
squats, leg extension, leg flexion, calfraises, and abdominal curls
using ankle weights… no machine
Improve functional ability
Interventions for frailty : exercise
de Labra et al. BMC Geriatrics (2015) 15: 154
Multi-component PRT 9 months, 3/week 60-90 min/session
Initial goal: 1-2 sets, 6-8 repetitions, 65% 1-RM
Final goal: 3 sets, 8-12 repetitions, 40-60% 1-RM
1-RM (repetition maximum) strength in six different exercises (knee
extension, knee flexion, seated bench press, seated row, leg
press, biceps curl), in a weightlifting machine
Benefit for pre-frail but not frail (reduce falls, increase muscle
strength)
Interventions for frailty : exercise
de Labra et al. BMC Geriatrics (2015) 15: 154
Asia-Pacific CPG for frailty :Exercise
We strongly recommend that older adults with frailty be referred to
a progressive, individualized physical activity program that contains a
resistance training component
Balance and aerobic training are also recommended for older
adults with frailty, even if these modes of exercise may not directly
influence muscle strength
The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. JAMDA 18 (2017) 564-575
The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. JAMDA 18 (2017) 564-575
Much research has linked frailty development with polypharmacy
Medications prescribed by frail older people be reviewed regularly.
Medications, which are no longer needed can be
deprescribed, regulating the dose in accordance with kidney
function
Withdrawal of inappropriate medications should be conducted
under the supervision of a healthcare professional, with the aim
to improve the outcomes of patients
Interventions for frailty : polypharmacy
Asia-Pacific CPG for frailty :Conditional Recommendations
4. We conditionally recommend that persons with frailty are screened
for causes of fatigue.
5. We conditionally recommend that older adults with frailty who
exhibit unintentional weight loss should be screened for reversible
causes and considered for food fortification/protein and caloric
supplementation.
6. We conditionally recommend that vitamin D be prescribed for
persons found to be deficient in Vitamin D.
The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. JAMDA 18 (2017) 564-575
The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. JAMDA 18 (2017) 564-575
Interventions for frailty : weight loss
Interventions for frailty : Protein supplementation
Protein 1.0-1.5 g/kg BW/day
Protein 1.0-1.2 g/kg BW/day
Frailty Consensus: A Call to Action. Am Med Dir Assoc. 2013 June ; 14(6): 392–39
In older persons who are 25(OH) vitamin D deficient, there is evidence
that vitamin D supplementation will reduce falls, hip fractures, and
mortality. It may also improve muscle function.
Although there are no large-scale clinical trials that show that frailty
can be prevented or treated by vitamin D alone, there is sufficient
evidence of efficacy in frailty appearing populations to suggest that
vitamin D in frail persons who are vitamin D deficient would be useful
Interventions for frailty : Vitamin D
The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. JAMDA 18 (2017) 564-575
There are several clinical trials finding that vitamin D
supplementation in older adults with vitamin D deficiency
reduces likelihood of mortality, falls, and fractures.
However, these trials tend to focus on older adults without
frailty.
Vitamin D supplementation for older adults with frailty
remains a topic of much debate in the literature
Interventions for frailty : Vitamin D
• Included 53
trials
• 91,791
participants
– 1,268 subjects from NHES IV, median age 74.0 years
(range 60 – 98), follow-up time 7 years
– Prevalence of vitamin D deficiency (< 30 ng/mL)
• 24.5% in male
• 43.9 % in female
Srinonprasert et al. Presented at ANZSGM 2016, Cairns
Vitamin D and mortality in Thai older persons
– Vitamin D deficiency & all-cause mortality
• adjusted with age, physical activities, comorbidities, low BMI
status
• Total, hazard ratio [HR] = 1.31, 95% CI = 1.03 – 1.69 , (p = 0.01)
• Male , hazard ratio [HR] = 1.73, 95% CI = 1.24 – 2.41 , (p = 0.01)
• Female, hazard ratio [HR] = 1.19, 95% CI = 0.82 – 1.73 , (p =
0.36)
Vitamin D and mortality in Thai older persons
Srinonprasert et al. Presented at ANZSGM 2016, Cairns
Would you give vitamin D for Thai older adults?
1. Which instrument for screening of frailty has been
validated in Thai population?
2. What is strongly recommended for management of
frailty, according to Asia-Pacific CPG?
3. What is the conditional recommendation for management
of frailty?
Questions
Frailty is common in Thai older adults
Frailty lead to increase risk of adverse outcome
Screening and applying appropriate interventions might be
beneficial to improve general health of Thai older persons
Take home message
THANK YOU FOR YOUR ATTENTION