Geriatrics SC047: Frailty In Older People Flashcards
Geriatric giants
Traditional:
1. Immobility
2. Instability
3. Incontinence
4. Intellectual impairment
Modern:
1. Frailty
2. Sarcopenia
3. Anorexia of aging
4. Elderly abuse
***Frailty (衰弱症)
Frailty definition:
- A **biological syndrome of **decreased reserve and resistant to stressors
- resulting from **cumulative decline across multiple physiologic systems
- causing **vulnerability to adverse outcomes
Vulnerability:
- Very high redundancy / reserve —> Low vulnerability
- Very low redundancy / reserve —> High vulnerability
2 models of frailty:
1. Phenotypic frailty (Physical characteristics of patient) (>=3: Frail, 1/2: Pre-frailty, 0: Not frail (SpC FM PP))
- Unintentional **weight loss
- Self reported **exhaustion
- **Weakness (grip strength)
- **Slow walking speed
- ***Low physical activity
- ***Deficit accumulation
- Deficits accumulation of multiple etiologies (e.g. heart failure, stroke, smoker, obese)
- Reduced redundancy / reserve
- Increased vulnerability
Epidemiology of Frailty:
- Prevalence varies depend on definition
- HK: 8%
- More common in older woman
Consequences of Frailty:
1. **Adverse outcomes
- Falls
- Disability
- Hospitalisation
- Institutionalisation
- Death
2. **Health care expenses
Biological underpinnings:
Multifactorial
- A pro-inflammatory state
- Sarcopenia
- Anaemia
- Relative deficiencies in androgens
- Decreased growth hormone and IGF-1
- Excess exposure to catabolic hormones
- Insulin resistance
- Compromised altered immune function
- Micronutrient deficiencies and oxidative stress
- Decreased 25(OH) Vit D levels
- Chronic CMV infection
- Dysregulation of ANS
***Clinical frailty assessment
> 70 screening tools —> no single tools applicable to all situations
Who to screen:
- Universal approach: not evidence based
- Case finding approach:
—> All persons over 70 yo
—> Those adults with multiple chronic illnesses / weight loss of 5kg over a year
How to screen:
- No consensus
Common screening tools:
1. Single item frailty assessment
- **Timed up and Go test (TUGT):
—> **>=15 seconds (related to post-op complications and 1 year mortality)
—> **<10s: Normal
—> <20s: Can still go out alone
—> >30s: Dependent for ADLs
2. Frailty phenotype (Fried)
3. Frailty index (Minitski)
- when coupled with **Comprehensive geriatric assessment (FI-CGA)
4. “FRAIL” scale (John Morley)
5. ***Clinical Frailty Scale (CFS) (Rockwood)
6. PRISMA 7 (Raiche)
7. Edmonton Frail Scale (EFS) (Rolfson)
8. Tilburg Frailty Indicator (TFI)
- Frailty index (Minitski)
Based on Deficit accumulation model
Frailty index = ***No. of deficits in an individual / Total no. of deficits measured
- ***Clinical Frailty Scale (CFS) (Rockwood)
- Used by ***HA
- 5 mins
- ***9 levels of frailty
1. Very fit
2. Fit
3. Managing well
4. Living with very mild frailty
5. Living with mild frailty (ADL independent)
6. Living with moderate frailty (ADL dependent)
7. Living with severe frailty (completely ADL dependent)
8. Living with very severe frailty
9. Terminally ill (Life expectancy <6 months but not otherwise living with severe frailty)
- “FRAIL” scale (John Morley)
FRAIL (1 marks for each):
- Fatigue
- Resistance
- Ambulation
- Illness
- Loss of weight
0 (Robust) - 5 (Worst)
Clinical application of Frailty
- Frailty assessment in A/E
- Facilitate treatment plan + disposal of patients
- Triage geriatrics at front door
—> Hospitalisation (acute hospital / geriatric hospitals)
—> Discharge from A/E + arrange community based care (e.g. CGAT, CVMO etc.) - Acute / Convalescence wards
- Prevention of delirium
- Pressure sore prevention
- Fall prevention
- Rehabilitation
- Nutrition support
- Avoiding polypharmacy
- Early DC planning
- Appropriate placement after DC - End-of-life care (EOL)
- Predict mortality
- Frailty independent associated with mortality (CFS >=7)
- More frail —> higher 3 year mortality
- Wosening frailty status in previous 2 years also predict high mortality in next 2 years - Frailty assessment in Surgical and Invasive interventions
- Predict poorer surgical outcomes —> complications, length of stay, DC to institution, mortality
- Enhance risk management pre-op —> medication review, nutritional augmentation, PT / OT (prehabilitation)
- Enhance post-op management —> e.g. pressure sore prevention, delirium prevention, attention to hydration, nutrition, early mobilisation
***Sarcopenia (肌少症)
Definition:
- Decline of muscle mass + strength with age
- an independent disease in ICD 2016
- EWGSOP: a syndrome characterised by progressive + generalised loss of skeletal **muscle mass + **strength with a risk of **adverse outcomes e.g. physical disability, poor QoL, high mortality
- Asian Working Group for Sarcopenia: **Low muscle mass + **Low muscle strength + **Low physical performance
- ***Low muscle mass (Skeletal mass index)
- DXA (or Bioimpedance)
—> <7 kg/m2 for men
—> <5.4 (5.7) kg/m2 for women - ***Low muscle strength
- Handgrip strength
—> <28 kg for men
—> <18 kg for women - ***Low physical performance
- 6m walking speed <1 m/s
- Short physical performance battery score <=9
- 5-time chair stand test >=12 seconds
Muscle mass:
- After 30 yo —> muscle mass ↓ by 1% per year
- After 70 yo —> ↓ 1.5% per year
Muscle strength:
- ↓ annually by 1-1-5% between 50-60 yo, 3% per year thereafter
Epidemiology:
- 9% in HK (EWGSOP criteria)
Pathophysiology:
1. Imbalance between muscle protein anabolism and catabolism leading to overall loss of skeletal muscle
2. Reduce type 2 fibre with transition to of type 2 (fast-twitch fibre) to type 1 fibre (slow-twitch fibre)
3. Myosteatosis: Intramuscular + Intermuscular fat infiltration
Biological underpinnings:
Multifactorial
- Genetic
- Immobility (can also be considered as part of disuse atrophy rather than sarcopenia)
- Hormonal
- Endocrine
- Neurodegenerative
- Muscle fibre atrophy
- Nutritional status
- Decreased protein synthesis
- Other mechanisms: autophagy, apoptosis, mitochondrial dysfunction
DDx:
- Frailty (closely related)
2 types (can be combination!):
1. Primary (原發性)
- Aging
- Secondary (次發性)
- Inactivity (bed rest, sedentary lifestyle, deconditioning, zero-gravity conditions)
- Malnutrition
- Diseases (e.g. advanced organ failure)
Associated conditions:
1. Sarcopenic obesity
2. Sarcopenic dysphagia
3. Osteosarcopenia
4. Metabolic syndrome
5. CVS disease
6. Frailty
***Sarcopenia detection
- ***5-time chair stand test
- Normal <12 seconds - Calf circumference
- Male >=34 cm
- Female >=33 cm
- False negative: ankle edema, obesity - SARC-F screening tool
- High specificity but low sensitivity
- 5 components: Strength, Assistance in walking, Rise from chair, Climb stairs, Falls
- Score >=4: Sarcopenia - ***Handgrip strength
- 6 tests: 3 right hand, 3 left hand —> Take highest value of dynamometer
- Male >=28 kg
- Female >=18 kg - ***6m walking speed
- Normal: >=1 m/s - Muscle mass measurement
- DXA / Bioimpedance
Universal screening is ***not evidence based —> Case finding approach advocated to screen for sarcopenia
Red flags:
- Falls, slowness, weakness
- Decreased walking mobility, walking speed
- Weight loss
- Decreased ADL
- Self-reported muscle wasting
- Admission to hospital / RCHEs
Sarcopenic obesity
- Co-presence of sarcopenia and obesity with excessive fat mass in presence of reduced muscle mass
- Both sarcopenia, obesity are associated with metabolic disorders, morbidity, mortality
Sarcopenic dysphagia
- Characteristic change in swallowing mechanism in healthy older adults due to aging —> Presbyphagia
- Swallowing muscles have moderate to high percentage of type 2 fibres because normal swallowing is characterised by rapid contraction of muscles
- Sarcopenia an important cause of dysphagia in elderly
- Vicious cycle
—> Eat less
—> Worse sarcopenia
Osteosarcopenia
- Co-existence of osteoporosis and sarcopenia is well documented
- Osteosarcopenic group of older people, esp. those who also have frailty, have a higher chance of falls and fracture than those with either condition alone
Treatment of Frailty
Community:
1. **Physical activity program
- resistance training component (progressive, individualised)
- multi-component
- community-based group classes
2. **Food fortification / protein / caloric supplementation (for those with unintentional weight loss)
3. ***Vit D supplement
4. Management of clinical conditions
5. Advice on health behaviour improvement
6. Social support
7. Modify home environment
Hospital:
1. ***Comprehensive geriatric assessment (CGA) intervention
2. Treat acute illness
3. Reduce polypharmacy
Treatment of Sarcopenia
- ***Resistance exercise
- improves strength, mass, balance - ***Protein + Caloric supplementation
- 1-1.2 g/kg per day (ESCEO)
- 1舊麻雀 (10g) - Individual nutrients: β-hydroxy β-methylbutyrate (HMB)
- seems to preserve / increase lean muscle mass + strength in sarcopenic older adults -
**Vitamin D
- Daily intake **800IU/day to maintain serum 25(OH)-Vit D level >50 nmol/L with daily intake of ***Ca 1000mg per day along with regular exercise 3-5 times per week to prevent osteosarcopenia
—> affect bones + muscles (Vit D deficiency can cause proximal muscle weakness) - Other approaches (lack evidence + potential SE)
- Combined estrogen progesterone
- Dehydroepiandrosterone
- Growth hormone
- Growth hormone releasing hormone
- Testosterone
- IGF-1
- Pioglitazone
- Omega 3 polyunsaturated fatty acid
- ACEI
- SARMs (selective androgen receptor modulators) —> cause androgen signalling to achieve gains in skeletal muscles + strength without dose limiting SE
Causes of Fall in elderly (SpC FM)
- Loss of consciousness (Syncopal / Pre-syncopal)
- Loss of strength, balance, coordination
- External force
- Sudden uncontrolled symptom (e.g. chest pain, seizure)
- Undetermined (e.g. rolled out of bed)
Aging increases instability + falls:
1. Poor senses (vision, proprioception, fine touch)
2. Poor balance + coordination
3. Poor reaction time
4. Sarcopenia + reduced muscle strength
5. Reduced ROM of major joints
6. Body posture changes (e.g. kyphosis, scoliosis)
7. Sensitive to postural BP change + autonomic dysfunction
8. Polypharmacy
9. Poor diet + dehydration
10. Social isolation
Investigations for falls
Neurological:
1. CT brain
2. MRI brain
3. Carotid sinus massage
4. Dix-hallpike test
CVS:
1. ECG
2. Holter (24 hour / 7 day)
3. Echo
4. Supine + Upright BP
5. Tilt table test
6. BP diary
Endocrine:
1. CBC
2. Glucose
3. TFT
4. Biochemistry
5. Drug history
Gait assessment
- Stride speed
- Stride length
- Base width
- Stride regularity (steady / ataxic / tremor)
- Foot pick-up (normal / high / low)
- Knees (bent / straight)
- Musculature (full / wasted)
- Hips (even / dropped (i.e. Trendelenburg))
- Trunk (straight / kyphotic)
- Arm swing
- Head / neck position
- Centre of gravity (normal / festinant)
- Vision
Pathologies affecting gait
Neurological:
1. Parkinson’s disease (upper + lower body, asymmetrical)
2. Vascular Parkinsonism (lower body mainly, symmetrical)
3. Stroke (e.g. hemiplegic / ataxic gait)
4. Spasticity
5. Peripheral neuropathy (e.g. high steppage gait)
6. Myopathy, Myasthenia (e.g. foot drop / drag)
7. Sensory / Balance deficit / Delirium / Over-medication (e.g. apraxic gait, disequilibrium, unsteady)
Musculoskeletal:
1. Hip / Abductors problem (e.g. Trendelenburg)
2. Painful limb / spine (e.g. antalgic gait)
3. Reduced ROM (e.g. arthritis, contractures with fixed flexion / extension deformity)
4. Muscle deconditioning / sarcopenia (e.g. difficult weight bearing + anti-gravity movements)
5. Fear of further falling (e.g. cautious gait)
Medical interventions to prevent falls
- Treat underlying conditions (e.g. cardiac arrhythmia)
- Treat postural hypotension
- Adequate fluid intake (e.g. 500mL water)
- Fludrocortisone 100-400mcg OD / Midodrine
- Compression stockings (reduce venous pooling) - Treat sarcopenia (e.g. protein supplements)
- Modification of risk factors (e.g. bone mineral density, weight)
- Vitamin D can reduce falls risk for OAH residents
- Medication adjustment (e.g. night sedation)
- NB: Falls is not an absolute CI for NOAC / warfarin (e.g. for AF) - Physiotherapy
- Group + home based therapy
- Strength + balance + flexibility exercises (e.g. Tai Chi) - Occupational therapy
- Environmental adaptation (e.g. safety rails in showers)
- Footwear, sight correction, hip protector
- Home installed alarm system - Referral to Day Hospital, Elderly Centers, NGOs
- Community services
- Medical social worker
- Home care
- Financial help
All = ***Comprehensive Geriatric Assessment (CGA)
Nutritional requirements in elderly
- Aging leads to ↓ lean body tissue (muscle mass) and ↑ in fat mass
- Energy requirement ↓ due to ↓ basal metabolic rate (BMR) + ↓ in physical activity - ↓ Ability to synthesize vitamin D by the skin with aging
- ↓ Intake + ↓ blood levels of micronutrients due to changes in absorption and metabolism
***Harris-Benedict Equation for Basal Metabolic Rate (BMR):
- Men = (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) + 5
- Women = (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) - 161
Energy requirement = BMR x Physical Activity
Dietary recommendations for micronutrients and dietary fibre are ***SAME for older people as rest of the population
Protein requirement:
- Recommended average daily intake at least 1-1.2 g protein per kg body weight per day (more during acute illness, e.g. 1.5-2g), except in CKD
- Older adults (>65) = ***1-1.2g protein/ kg body weight/ day
- Adults = 0.75g/kg/day
Vicious cycle of poor nutrition and muscle loss in frailty
Chronic malnutrition
—> Sarcopenia
—> Decreased metabolic rate
—> Reduced energy expenditure
—> Chronic malnutrition
Assessment of nutritional status
- ***Malnutrition Universal Screening Tool (MUST)
- >=2 —> High risk of malnutrition
3 parameters:
- BMI
—> BMI >20 = 0
—> BMI 18.5-20 = 1
—> BMI <18.5 = 2
- Recent weight loss
—> <5% = 0
—> 5-10% = 1
—> >10% = 2
- Acute disease effect on nutritional intake
—> Acutely ill + no nutritional intake for >5 days = 2 - ***Chinese Nutrition Screening Tool (CNS)
- Mini-nutritional Assessment (MNA)
- Change in food intake + Change in body weight + Activity level + Acute illness + Depression + Social support + Medication - Subjective Global Assessment (SGA)
- Screening questions + Physical examination
—> SC fat (Orbital fat pad, Triceps, Ribs, lower back, sides of trunk)
—> Muscle wasting (Temple, Clavicle, Shoulder, Scapula / ribs, Quadriceps)
Nutritional support strategies
- ***Small frequent meal
- Use bigger bowl / plate (illusion of needing to fill more)
- ***Herbs and spices
- ***Nutrient-dense food ONLY
- Limit alcoholic, sugary and fatty food and drinks, tea / coffee / soup - ***Exercise as tolerated / safe
- Tailor diet advice to individual needs
- Balance between disease control and nutritional status - ***Oral supplements / meal replacement
- NOT suitable for well-nourished / overweight patients
Multidisciplinary:
- Illness and medication —> Doctor, nurse, pharmacist
- Nutritional intake —> Dietitian
- Swallowing and chewing problems —> Speech therapist
- Tableware usage problems —> Occupational therapist
- Mobility problems —> Physiotherapist
- Denture problems —> Dentist
- Meal delivery services —> Social worker
When to refer to dietitian
- Malnutrition
- BMI < 18.5
- Unintentional weight loss >10% body weight in 3 months
- Food intake less than 3/4 usual intake - Overnutrition
- Obese (BMI > 30)
- No improvement / difficulty following diet and exercise advice
Management strategies for dysphagia
- ***Optimise eating / drinking position
- ***Altered consistency of food / drinks
- NG feeding
- NOT reduce risk of aspiration
- Very uncomfortable
- Restraint, low QoL - PEG (Percutaneous endoscopic gastrostomy)
- Can still aspirate up stomach content
- More invasive
- More comfortable long term
Multidisciplinary:
1. **Speech therapist
- detailed swallow assessment, oromotor training, safe swallowing techniques
2. **Dietitian
- assessment of nutritional status and dietary advice for optimal body weight
3. **Physiotherapist
- motor training to improve trunk control and sitting balance; facial exercises for facial weakness
4. **Occupational therapist
- dexterity training and optimal seating
5. Geriatrician
- holistic management of multi-comordbities, FEES (fiberoptic endoscopic evaluation of swallowing), medication optimization, discussion and decision on oral vs tube feeding, interdisciplinary team work
All of above available as a ***one-stop service with interdisciplinary team management in Geriatric Day Hospital
Ethical issues:
1. Autonomy
- Who is making the decision, e.g. patient or family?
2. Beneficence vs Non-maleficence
- Quantity vs Quality of life
- “Comfort feeding” can cause aspiration and death, who decides?
- NG feeding is uncomfortable
- NG or PEG do not prevent aspiration
- Restraint until death
3. Justice
- PEG not accessible unless you pay
DDx for Weight loss (8Ds) (SpC FM PP)
- Dental problem
- Dysgeusia (change in taste)
- Dysphagia
- Oropharyngeal swallowing
- Esophageal swallowing - Diseases
- Malignancy
- Infection
- GI problem
- Chronic illnesses - Drugs
- Anticholinergics causing dry mouth
- Anti-DM drugs causing weight loss - Dementia
- Depression
- Destitution
- Lack of care
