Frailty and multiple morbidity

Question 1

compare phenotype model VS cumulative deficit model of Frailty?

Answer 1

Phenotype Model (Fried et al.) 3 or more of:

• Weight loss> 4.5kg in 1 year
• Hand-grip strength
• Exhaustion
• Slow walking speed
• Low physical activity

Cumulative Deficit Model (Rockwood et al.)

• Counts the presence of 92 variables (symptoms, signs, disease states, disability, lab results)
• Presence/absence of these variables = “Frailty Index” -> correlates w poorer outcomes

Question 2

How do stressors or minor events affect those who are frail?

Answer 2

Frail ppl are affected more by minor stressor events, eg a UTI.
The drop in functional capacity in a frail individual is much larger, and the recovery much slower/never complete.
Therefore they can remain functionally dependent

Question 3

What is the proposed pathogenesis of frailty?

Answer 3

Question 4

14% of >60s have frailty rising to 65% of those >90
20% of all inpatients are frail
People w frailty= half of all hospital bed-days in UK

How and why should you identify frailty?

Answer 4

It is important to identify those who are frail para:

• Identify those vulnerable to deterioration
• Intervene early to improve frailty
• Prevent progression of frailty
• Involve patients in their health
• Avoid unnecessary harm

Question 5

When should we look for frailty? How do we screen for it, giving examples

Answer 5

Whenever we meet a patient!
NICE recommends assessing frailty in those with multimorbidity
When someone presents with a frailty syndrome
In the acute setting w caution (obv v ill patients are gonna be frail during illness)
Screening for frailty- quationnaires, rockwood scale

Question 6

What is the rockwood score?

Only validated for ?
Not validated for ? including ?
Requires ?
Requires a ? including ?
Consider issues such as ?

Answer 6

Only validated for those >65
Not validated for those with longer term disabilities including Learning Disabilites or autism.
Requires assessment 2 weeks before
Requires a global assessment including discussion w family etc
Consider issues such as communication / language / cultural barriers

Question 7

How do we manage frailty? aka what are the exacerbating factors for it?

In terms of prevention, ?, esp ?, prevents and treats ?
? and ? increase ? of frailty.
Evidence that frailty increases in ?
Other areas of interest inc ? in frailty. For example a higher ? and an ? predicted ?

Answer 7

In terms of prevention, physical activity, esp resistance exercise, prevents and treats physical frailty.
Suboptimal protein/total calorie intake and vit D insufficiency increase risk/symptoms of frailty.
Evidence that frailty increases in obesity esp w inactivity, a poor diet and smoking.
Other areas of interest inc immune-endocrine axis in frailty. For example a higher white cell count and an increased cortisol: androgen ratio predicted 10 year frailty and mortality in one recent study.

Question 8

What is the EFI?

It takes the ? but ? to ?

At a population level, an ?

Answer 8

Electronic Frailty Index (EFI): diagnostic frailty tool available in primary care
It takes the principles of the cumulative deficit model but uses the read codes in GP notes to automatically calculate a frailty index score out of 1

At a population level, an EFI of >0.36 can be considered as severe frailty

Question 9

Best evidence for improving outcomes in frail Pts is a CGA
What is a CGA?

Answer 9

Comprehensive Geriatric Assessment (CGA): a process of good, holistic care delivered within a geriatric MDT. It’s broken down into 4 areas

• Physical e.g. medical problems, PMH, nutritional status, medication review
• Functional e.g. mobility, activities, key life roles
• Psychological e.g. mood, cognitive impairment
• Socioeconomic/environmental e.g. housing, care provision, poverty, social network

The aim is to create a personalised problem list w specific goals

Question 10

What is the impact of CGA?

Those who underwent a CGA were:
- More likely to be ?
- Less likely to ?
- More likely to be ?. This effect seen at ?
- Potential to ?

At 6 months:
? of ? to avoid ?
? to avoid ?

Answer 10

Those who underwent a CGA were:

• More likely to be alive post discharge in follow up
• Less likely to have a physical deterioration
• More likely to be living w less dependency. This effect seen at 6 & 12 months later
• Potential to improve care, reduce unnecessary hospital admissions, length of stay and readmissions

At 6 months:

• NNT (number needed to treat) of 17 to avoid 1 unnecessary death or deterioration (e.g. compared to statins which NNT is 104)
• NNT 20 to avoid institutionalization (admission to care home).

Question 11

What would be this patients journey if she was NOT frail?

Answer 11

Question 12

What would be this patients journey if she was frail?

Answer 12