FRAILTY

Colin M. Thomas MD, MPHClinical Professor of MedicineDivision of Geriatric Medicine

University of California, San Diego, School of MedicineAssociate Chief of Medicine, VA San Diego Healthcare

What is Frailty?

What is Frailty? Cumulative decline in many

physiological systems A state of vulnerability where minor

stressors may result in significant decline in health status

Associated with adverse outcomes like falls, disability, nursing home placement and mortality

Frailty is Vulnerability

Lancet 2013; 381: 752–62

Decline in multiple systems

Decreased Physical Activity

Inadequate Nutrition

Intolerance of stressor events

Increasing dependence

Lancet 2013; 381: 752–62

Models of Frailty Cumulative Deficit Model

Musculoskeletal functionAerobic capacityCognitive functionNutrition

Phenotype modelWeight lossExhaustionEnergy expenditureGait speedGrip strength

Frailty is common Prevalence

15% of non-institutionalized elders are frail45% are pre-frail

Journals of Geronology A Biol Sci Med Sci, 2015. 70(11), 1427-1434.

Frailty is associated with adverse outcomes

Outcome Hazard Ratio 95% CI StudyFalls 2.44 (1.95-3.04) SOF

Disability 2.79 (2.31-3.37) SOF

Hospitalization 1.27 (1.11-1.46) CHS

Nursing Home Placement

2.6023.98

(1.36-4.96)(4.45-129.2)

CSHAWHAS

Mortality 3.69 (2.26-6.02) CSHA

SOF: Arch Intern Med 2008; 168: 382–89. CHS: J Gerontol A Biol Sci Med Sci 2001; 56: M146–56.CSHA: J Gerontol A Biol Sci Med Sci 2004; 59: 1310–17.WHAS: J Gerontol A Biol Sci Med Sci 2006; 61: 262–66.

Dimensions of Frailty Physical Nutrition Cognitive Psycho-social

Physical Frailty Muscle mass Strength Balance Bone density Increased risk of falls and injury

Normal aging and muscular function By the age of 70, the cross-sectional area of skeletal

muscle is reduced by up to 25–30% and muscle strength is reduced by 30–40%

Excretion of urinary creatinine, reflecting total muscle mass, decreases by nearly 50% between the ages of 20 and 90 yr

Loss of strength continues to fall at a rate of 1–2% per year

Irreversible decrease in the total number of individual muscle fibers and (reversible?) atrophy of the remaining fibers

A. McArdle et al. Ageing Research Reviews 1 (2002) 79–93

Sarcopenia

A. McArdle et al. Ageing Research Reviews 1 (2002) 79–93

Nutritional frailty Appetite Taste and smell Oral health Digestion Economic factors Ability to acquire and prepare food Chronic illness

Annu. Rev. Nutr. 2002. 22:309–23

Cognitive Frailty Cognition not included in commonly

used frailty phenotype measures Non-frail older adults with impaired

cognition are more likely to become frail Frail adults with impaired cognition are

more likely to become disabled or die

JAGS 56:2292–2297, 2008

Psycho-social Frailty Mental health measures are not included in

common frailty phenotype measures Depression and frailty frequently co-occur

in the elderly population Social vulnerability is associated with

higher mortality, lower educational level and lower income

J Am Geriatr Soc 62:500–505, 2014.J Frailty Aging. 2013; 2(3): 121–124.Gerontol B Psychol Sci Soc Sci 2009;64B:105-117.

But what can we do about frailty? Can we prevent or

reverse frailty?

Evidence based interventions for frailty Resistance exercise interventions for

physical frailtyStrength training resulted in a 30% increase

in muscle fiber sizeResistance training can slow or partially

reverse the process of aging atrophy of skeletal muscles

Strength training can improve VO2 max and exercise treadmill time

Journal of Gerontology:BIOLOGICAL SCIENCES. 2000, 55A(7), B347–B354

Arch Intern Med. 2002 Mar 25;162(6):673-8

ASK WELLIs it true that the muscle mass we lose at, say, 60 years old cannot be regained?Reader Question • 217 votes

I'm a 77-year-old man in good health. I've dropped 10 pounds over the last 40 years, all muscle. Is there any way for someone my age to regain muscle mass without resorting to steroids?Reader Question • 510 votes

Can You Regain Muscle Mass After Age 60?By GRETCHEN REYNOLDS DECEMBER 2, 2016 6:21 AM

Evidence based interventions for frailty Intensive training intervention for pre-frail older

adults compared to home exercise program Structured program includes

Flexibility, light resistance, balanceResistanceEndurance

ResultsImprove physical performanceIncrease in VO2 maxImprove functional status score

J Am Geriatr Soc 50:1921–1928, 2002.

Evidence based interventions for frailty Bone Mineral Density

Demonstrated to increase with weight bearing activity and high intensity resistance exercise

Effective in elderly men and women

Fracture risk may also be improved by○ Remodeling○ Improved strength and balance

Scand J Med Sci Sports 2004: 14: 16–23

Evidence based interventions for frailty Nutrition

Demonstrated to increase body weight and lean body mass

Preponderance of trials show no effect on functional status

CognitiveLimited evidence of benefit of cognitive rehab

therapies Psychosocial

Caregiver burden associated with increased risk of nursing home admission

The Journal of Nutrition, Health & Aging 19, 3, 250-257.Neuropsychol Rev (2013) 23: 63. J Gerontol (1992) 47 (2): S73-S79.

Technology and potential frailty interventions Physical Nutritional Cognitive Psycho-social

Technology interventions for physical frailty Exercise games

Require adaptation for balance, strength, vision and mobility deficits

Team games can capitalize on social interactions

Activities, Adaptation and Aging, 32(3-4), 238-239.

Technology interventions for physical frailty Self monitoring tools

Can define goals and provide positive feedback and reminders

Adapt interfaces to accommodate common deficits

Journal of Behavioral Medicine, 26(4), 333.

Technology interventions for nutritional frailty Smart scales

Body weightKitchen scalesIntegrate calorie intake and expenditure

The American Journal Of Clinical Nutrition, 41(4), 810-17.

Technology interventions for cognitive impairment Exercise Cognitive training games

Gains are specific and limited to the area being trained

Cognitive training does not measurably improve functional capacity

J Geriatr Psychiatry Neurol. 2007;20(4):239-249.

JAMA. 2002;288(18):2271-2281.

Technology interventions for social isolation Telephone and video live

interaction E-mail Social networks Limitations

CostAdoption ratesAccessibilityRisks

The Gerontologist, 55(3), 412-421.

Summary Cumulative decline in multiple systems Increased vulnerability to stressors Increased rates of complications,

institutionalization and mortality Some effective interventions to mitigate

and reverse declines Promising technology that needs to be

assessed

Questions?