Advanced Geriatrics Flashcards
“Frailty”
A state of vulnerability to poor resolution of homoeostasis after a stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime.
Increased risks of adverse outcomes associated with frailty include falls, delirium, and disability
Clinical presentation of frailty
“Hot fall”
Fall related to a minor illness that reduces postural balance below a crucial threshold necessary to maintain gait integrity.
The frail brain
Characterized by low-level neuron loss and structural and functional changes to microglial cells, as well as increased risk of plaque bluidup, especially within the hippocampus.
There is also an association between the development of frailty and delirium, as well as frailty and dementia.
The frail endocrine system
Production of growth hormone/IGF-1, oestradiol and testosterone, and dehydroepiandrosterone all decrease.
FSH and LH increase with age in inverse relationship to oestradiol and testosterone. Similarly, cortisol levels increase inversely to dehydroepiandrosterone levels.
The frail immune system
The ageing immune system is characterised by a reduction in stem cells, changes in T-lymphocyte production, blunting of the B-cell-controlled antibody response, and reduced phagocytic activity of neutrophils, macrophages, and natural killer cells.
Inflammation is associated with anorexia and cata bolism of skeletal muscle and adipose tissue, which could contribute to the nutritional compromise, muscle weakness, and weight loss that characterise frailty
Advanced glycation end products
A group of molecules produced by the glycation of proteins, lipids, and nucleic acid that can cause widespread cellular damage by upregulation of infl ammation.
They have been associated with ageing, chronic disease, and mortality.
Frail skeletal muscle (sarcopenia)
Sarcopenia has been defined as progressive loss of skeletal muscle mass, strength, and power, and is regarded as a key component of frailty.
Inflammatory cytokines, including interleukin 6 and TNFα, activate muscle breakdown to generate aminoacids for energy and cleave antigenic peptides. This fundamentally protective response could become abnormal in the presence of an overactive, insufficiently regulated inflammatory response that characterises frailty
Phenotype model of frailty
Based on a prospective cohort study involving 5,210 men aged 65+.
A frailty phenotype was established with five variables: unintentional weight loss, self-reported exhaustion, low energy expenditure, slow gait speed, and weak grip strength
Those with three or more of the five factors were judged to be frail, those with one or two factors as pre-frail, and those with no factors as not frail or robust elderly people
These categories correlated with clinical outcomes later observed.
Cumulative deficit model of frailty
Developed as part of a prospective cohort study involving 10,263 individuals.
92 baseline variables of symptoms (eg, low mood), signs (eg, tremor), and abnormal laboratory values, disease states, and disabilities (collectively referred to as deficits), were used to define frailty. The frailty index was a simple calculation of the presence or absence of each variable as a proportion of the total (x/92).
A value of 0·67 seems to identify an amount of frailty beyond which further deficit accumulation is not sustainable and death is likely.
Subsequent work has shown that the rather daunting initial list of 92 variables can be reduced to the more manageable number of about 30, without loss of predictive validity.
The frail elderly functional questionnaire
19-item questionaire identified as a potential outcome measure for frailty intervention studies because it is suitable for use by telephone or proxy, is valid and reliable, and is sensitive to change.
The timed-up-and-go test
Interventions for frail individuals
- Exercise can improve outcomes of mobility and functional ability
- Balance training
- Nutritional interventions to prevent weight loss (good in theory, no evidence that it actually helps at all)
- Vitamin D supplementation
- ACE inhibitors to slow muscle degradation - still under investigation
Just how frequent are falls in the elderly?
Once per year in ~30% of those over 65
How frequent are more serious injuries associated with falls?
Fractures, joint dislocations, sprains or strains, and concussions occur in approximately 10% of falls
Algorithm for fall management
Assessment strategies and inverventions for fall risks
FRAIL scale
