Frailty- core conditions 3 Flashcards
The Rockwood clinical frailty score 1-3
1 Very fit- people who are robust, active, energetic and motivated. Exercise regularly, among the fittest for their age
2. Well- people who have no active disease symptoms but are less fit than category 1. Often they exercise or are very active occasionally
3. Managing well- people whose medical problems are well controlled but are not regularly active beyond routine walking
The Rockwood clinical frailty score 4-6
- Vulnerable- Whilst not dependent on others for daily help, often symptoms limit activities. A common complaint is being ‘slowed up,’ and/or being tired during the da
- Mildly frail- often have more evident slowing, need help with ADL. Typically mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework
- Moderatly frail- people who need help with all outside activities and with keeping house. Often have problems with stairs and need help whilst bathing and need minimal assistance with dressing
The Rockwood clinical frailty score 7-9
- Severely frail- completely dependent for personal care from whatever cause (physical or cognitive). May seem stable and not at high risk of dying (within 6 months)
- Very severely frail- completely dependent, approaching the end of life. Typically they cant recover even from a minor illness
- Terminally ill- approaching the end of life. This category applies to people with a life expectancy <6 months who are not otherwise evidently frail
PRISMA 7-a score of three or more indicates frailty
- Are you older than 85 years old
- Male?
- In general do you have any health problems that require you to limit your activities
- Do you need someone to help you on a regular basis
- In general do you have any health problems that require you to stay at home
- In case of need can you count on someone close to you?
- Do you regularly use a stick, walker or wheelchair to get about
Frailty- walking speed
In order to identify frailty you can measure their walking speed. A slow walking speed is less than 0.8m/s or taking more then 5 seconds to walk 4m. Having a slow walking speed does not necessarily mean you are frail though.
Comprehensive geriatric assessment
- Generates an individual problem list in the following areas: physical assessment, functional, social and environment assessment, psychological component and medications review
- Determines the needs of older patients with frailty and what interventions are required
Multi-dimensional model of frailty
Frailty is a collection of modifiable health and social needs. For the individual with frailty it goes beyond physical health and includes psychological, social and physical domains
The frailty fulcrum
Helps us think about frailty in a wider, holistic way. It is keeping vulnerability and resilience in balance, to limit effect on quality of life. If things change gradually we can make adjustments to try and increase resilience or decrease vulnerability to counterbalance changes, however if there is a sudden shift then patients are at much bigger risk of a destabilising life event
Factors involved in the multi-dimensional model of frailty
- Systems of care- health and care staff, can be part of the social environment in hospital
- Acute health events- such as a stroke or fall, need effective management
- Physical environment- home environment
- Social environment- family members can be a source of resilience
- Psychological status- anxiety and depression
- Multimorbidity (long term conditions)- can be reduced through good management
Delirium
- Seeming ’muddled’ not ‘usual self’
- Acute confusion: delirium, dementia, depression or combination
- Drowsiness and disorientation (time, place or person)
- May be agitated and irritable or quiet and withdrawn
- Identify and manage possible underlysing causes
- Reassure and re-orientate
Falls
- ‘Found on the floor’- legs gave away
- Collapse, faint or slips/trips
- Complication of long period on the floor
- Look for multiple injury sites
- Consider impact of medication
Incontinence
- Having ‘accidents’
- New onset or worsening condition
- May affect bladder, bowel or both
- Risk from over diagnosis of UTI, inappropriate antibiotics and diarrhpea
- Consider skin integrity and effects of catheterisation
Immobility
- ‘Stuck in toilet’ ‘Slept in chair’
- Sudden change in mobility
- ‘Off legs’ can hide many diagnoses
- Comprehensive assessment to focus on urgent and important issue
Medication side effects
- Greater susceptibility due to polypharmacy/4+ medications
- Wide range of symptoms and interactions with other symptoms
- Ensure availability of time critical medications
- Consider opportunities for deprescribing
Managing frailty
- Complete a full geriatric assessment
- Ensure reversible medical conditions are considered and addressed
- Refer to geriatric medicine
- Old age psychiatry should be considered for frailty and complex co-existing psychiatric problems like challenging behaviour in dementia
- Personalised medication review- using evidence based criteria
- Consider a personalised shared care and support plan (CSP) which documents treatment and management plans. Ensure the CSP is shared between healthcare teams
Essential skin lesions
- Epidermal (keratinocyte- derived)- non pigmented
- Melanocytic- tend to be pigmented
Epidermal lesions- 4 basic tumours
- Basal cell papilloma- seborrheic keratosis, benign basal cancer. The most common skin tumour (Seb K)
- Basal cell carcinoma- malignant basal tumours (BCC)
- Solar/actinic keratosis- benign squamous tumour, caused by sun damage (AK)
- Squamous cell carcinoma- malignant squamous cancer (SCC)
Layers of the skin and keratinisation
Basal cells are the top layer of skin, the squamous cells are below it and produce keratin. Abnormal keratin feels rough. Squamous tumours cause abnormal keratinisation or scaling on the surface
Seborrheic keratosis
Appear to be stuck onto the skin. Pigmented as it has received more melanin from the melanocytes. Wart like appearance, with hills and channels on the surface of the wart. Contains small cysts of keratin which can be lighter or darker. Variable pigmentation. Only grows upwards, does not try and invade the body
Basal cell carcinoma
Grows downwards as it tries to spread through the body. The growths remain attached to the tumour which first formed. As the islands grow downwards it squeezes the blood vessels meaning it is an avascular tumour. The tumours appear pale and translucent as they are lacking blood. Pearly looking. Larger blood vessels begin to grow so you see branching blood vessels on the surface (Telangiectasia)
Erodent ulcer
A more advanced form of basal cell carcinoma, almost never metastasises but is locally invasive and slow growing
