Buffalo, NY

steve@patientpattern.com

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FRAILTY

VITALITY

Why is Frailty Important? US (and worldwide demographics)

Evans, Sayers, et. al.

Superior Predictor of Risk

Potential Causes of Frailty

• Multiple organ system decline

• Hypothalamic-pituitary-adrenal axis

• Immune dysfunction– Increase interleukins, CRP

• Neuroendocrine– Cortisol level increase

– Sex hormones decrease

– Growth hormones decrease

• Sarcopenia

Fried’s Phenotype for Frailty

• Presence of ≥3 components identifies a person as being frail

– Shrinking: unintentional weight loss of >10lbs/year

– Exhaustion: lack of energy, or the presence of fatigue and tiredness

– Strength: loss of physical robustness, skeletal muscle

– Slowness: a lethargic, unsteady, and unbalanced gait

– Low physical activity: inactivity

Mayo Clin Proc. 2008 Oct; 83(10): 1146–1153.

Frailty Index

• Deficit accumulation model

– Based on Comprehensive Geriatric Assessment

• FI-CGA

– Symptom, sign, disease, disability, laboratory, imaging or electrodiagnostic abnormality

– 3% per year

• Short indices

– Study of Osteoporotic Fractures (SOF)

• Weight loss, inability to rise from chair, and energy

SUPERIORITY OF FRAILTY IN PREDICTING OUTCOMES

• Geriatric trauma patients

• 2-year prospective cohort in Arizona

• 1° outcome: in-hospital complications

• 2° outcomes: adverse discharge disposition

• In-hospital complications (odds ratio, 2.5; 95% CI, 1.5-6.0; P = .001)

• Adverse discharge disposition (odds ratio, 1.6; 95% CI,

1.1-2.4; P = .001)

• The mortality rate was 2.0% (n = 5), and all patients who died had frailty. [JAMA Surg. 2014]

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Drivers of Utilization

Expectations

Frailty

Severity of

Illness

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Does recognizing frailty improve clinical care?

• Pre-operative evaluation

• Cardiovascular disease (Afilalo, et. al)

– OR of 2.7 to 4.1 for prevalent frailty– OR of 1.5 for incident frailty not frail at baseline– Frailty <--> CVD

• Contextualize risk and set expectations

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Operationalizing Frailty

• Emergency Room Screening

• Transitions of Care to PAC/SNF

• Palliative Care

• Medical Home

• Screening for Post-Operative Outcomes

• Telemedicine – Appropriate Patient Selection

• Reduce Re-Hospitalization

Summary

• Limited clinical guidelines for multiple

chronic diseases

• Frailty can be reliably measured to

appropriately select and allocate clinical

resources

• Targeted interventions are key

• Frailty Index used to harmonize

expectations and reduce utilization

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References

• Robinson TN, Finlayson E. How to Best Forecast Adverse Outcomes Following Geriatric Trauma: An Ageless Question?. JAMA Surg. 2014;149(8):773.

• Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752–62.

• Joseph B, Pandit V, Zangbar B, et al. Superiority of Frailty Over Age in Predicting Outcomes Among Geriatric Trauma Patients: A Prospective Analysis. JAMA Surg. 2014;149(8):766-772.

• Lacas A, Rockwood K. Frailty in primary care: a review of its conceptualization and implications for practice. BMC Medicine. 2012;10:4. doi:10.1186/1741-7015-10-4.

• Afilalo, Jonathan et al. Role of Frailty in Patients With Cardiovascular Disease. American Journal of Cardiology , Volume 103 , Issue 11 , 1616 – 1621

• Pulignano G, Del Sindaco D. Usefulness of frailty profile for targeting older heart failure patients in disease management programs: a cost-effectiveness, pilot study. J Cardiovasc Med (Hagerstown). 2010 Oct; 11(10):739-47.

• Hastings SN, Purser JL, Johnson KS, Sloane RJ, Whitson HE. Frailty predicts some but not all adverse outcomes in older adults discharged from the emergency department. J Am Geriatr Soc. 2008;56:1651–1657

• Evans SJ, Sayers M, Rockwood K. The risk of adverse outcomes in hospitalized older patients in relation to a frailty index based on a comprehensive geriatric assessment. Age Ageing. 2014 Jan;43(1):127-32