Session 5 - Lecture 1 - Frailty Flashcards
1 - Title
Frailty in older people
Simon Conroy
Professor of Geriatric Medicine
(liberal slide borrowing from Ken Rockwood & Andy Clegg)
“Hear some words associated with this concept [frailty] – Falls, weak, decline, osteoporosis, chronic disease … intuitive understanding of concept frailty – but really as a concept, it’s really come to life in the last 10 years or so, now really making q important diffs to how we deliver healthcare in the NHS and across the world. Service dvlpmnt, acute care for older people, when you get to LRI ED, see one of the countries, if not the first frail-friendly ED – whole design built around needs of frail and older people – flooring adjusted so less chance when people fall they fracture, lighting adjusted etc. bespoke: although when giving a talk today hopefully also do it in practice and get to see some of that in action – echoing point about translating action into practice – no point unless it makes diff to pts on the ground (and staff)”
2 - Outline
Outline
•Concept of frailty
• Measuring frailty
• Implications for practice
“Go through theory of frailty and see what that means to you, good.”
3 - Frailty - concept
Frailty - concept
[2 IMGs]
“Left: e.g. “long-term conditions” chap might have LTC, has he got “osteoporosis (don’t know bc haven’t done DEXA-scan but probs yes bc can see kyphosis as a result of weak bones from osteoporosis)” “weakness” – muscle strength isn’t what it used to be “wasting of muscles” – popping through there “mobility aids” – mobility probs not great, so this chap is probably frail.
Another point – where is this guy? Jungle remote, so a degree of social isolation and poor access to services – frailty not just biomedical model but looking as a person as a whole (holistic) – combination of diff problems, some physical, medical, psychological, social – that’s what geriatrics is about – that’s what a lot of the care in NHS is about – GPs, all sorts of people will be managing a whole pt, so don’t forget that as you go through and learn about the systems.But, not just an age-related phenomenon. Right: ANother old boy, grey hair, in his 90s still running marathon. So the point about this is that frailty is not just related to age, yes it increases the older you get, more likely to become frail, but not just an age-related phenomena because you can have old people who are incredibly fit and robust and young people who are incredibly frail and vulnerable.”
4 - The older people are the more likely they
are to die…
The older people are the more likely they
are to die…
y-axis: 0.368 0.135 0.050 0.018 0.007 0.002 Log scale 100
x-axis: 0 10 20 30 40 50 60 70 80 90 100 Age (years)
Statistics Canada: Canadian birth cohort 1900-1901.
DALHOUSIE UNIVERSITY
5 - … but not everyone of the same age has the
same risk of death
… but not everyone of the same age has the
same risk of death
- [2 IMGS] Old person with walking cane vs. old person running a marathon
y-axis: 0.368 0.135 0.050 0.018 0.007 0.002 Log scale
x-axis: 0 10 20 30 40 50 60 70 80 90 100 Age (years)
Statistics Canada: Canadian birth cohort 1900-1901.
DALHOUSIE UNIVERSITY
“How do we know this is real and not something I made up? Well Ken Rockwood, down in Dalhousie in Canada, looking at it much longer than me – got into Concept of frailty by looking at survival (times of death) in oldest old – graph displaying increased risk of dying as you get older – older you get closer to that death.”
6 - Frailty as unmeasured heterogeneity
Frailty as unmeasured heterogeneity
Age 60 to 199 years
y-axis: Annual Mortality Rate
0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 (+5 0s at end of each)
x-axis: 60-61 64-65 68-69 72-73 76-77 80-81 84-85 88-89 92-93 96-97 100-101 104-105 108-109 112-113 116-117
DALHOUSIE UNIVERSITY
Missoy & Vaupel. Society for Industrial & Applied Mathematics Review 2015;57:61-70.
Vaupel J, Manton K, Stollard E. The impact of heterogeneity in individual frailty on the dynamics of mortality. Demography 1979; 16:439-54
“But what they actually found is, in the Oldest old i.e. in their 100s, ‘super centenarians’ - their risk of dying is highly variable – so although people in 100s closer to death then you or I hopefully, but those who are over 100 show great heterogeneity in death – some will die really quickly, otherwise will survive for the next 10 or 15 years – so concept of heterogeneity and variability in old age underpins frailty. Important concept bc it starts to push back at some of the historical attitudes in older people, which are almost gone, no longer NOT treating ppl bc they are too old - these days probably won’t find pts in CCU UNDER 75 or 80 bc our attitudes have changed. But Frailty adds to that, importance of aging, individualising our assessment - transcends comorbidity etc. and looks at what they can do, allowing us to tailor and individualise their care, what their function is. Might be managing lots of older people in the hosp, but Within the older population there is a real spectrum of people who are close to end of life, for example, for whom we might consider things like palliative care, and for the same age group there are people who are fit and robust who we should be doing absolutely everything including moving onto coronary care, getting bypasses etc. as need. So there’s a really useful way of counteracting a societal bias against older people.”
7 - Frailty
Frailty
Condition characterised by loss of biological reserves and vulnerability to adverse outcomes
Fit Mild frailty Moderate frailty Severe frailty
–>
Increasing frailty
Courtesy of Andy Clegg
“Frailty as a spectrum. Can measure that spectrum, talk about some of tools in common use in next few slides, but this is a good way to think about it over time. Everyone becomes frail at different rates. So usually a predictable trajectory, but ofc, If you have a catastrophic illness you can go straight from being really fit to being really frail bc your legs have been amputated or whatever which impacts on your function, but for most people fairly linear trajectory, arriving at any category at any particular time. From a clinical perspective, It influences how you manage people – e.g. The Clinical Frailty scale (operationalising this concept - measure scores in individuals – quick and easy to do, takes less than a min), nearly every pt going through the ED >75 gets this score attached to the records. So this influences clinical practice e.g. 75 y/o who’s fit and robust send over to Glenfield to have their revascularisation undertaken or subdurals treated by neurosurgeons, whereas 75 y/o who’s really frail in their last 6 months of life, might take a v diff approach for same condition – v diff treatment response depending on prognosis and mngmt. Strange situation weve arrived in in modern healthcare – so scared of being fair we give everyone the same treatment - the difference between equity and equality (we don’t want to give everyone the same thing all the time, but what they NEED to achieve the same thing)”
8 - Frailty – concept to take away
Frailty – concept to take away
Stability
Stable ^
Unstable/falls v
–> ‘Minor illness/new medication
Courtesy of Andy Clegg
“Take home image – if you only remember one slide from this lecture - Remember this slide - nice simple graphical version of how frailty is relevant to your future clinical practice – green is you – fit, robust, hopefully well, some of you probs have a bit of flu atm but still attending lectures, may not feel 100%, bit of a blip, drop in green line, do what you need to do, recovered and back to normal self. If you’re frail, that doesn’t apply, so for the same insult, e.g. flu, the deterioration in function is much more profound and the recovery is much longer, more protracted and less full. Hence, why older people get ill it goes catastrophically wrong – minor illness causes delirium, confusion etc. In less stable people there is a more profound effect when illness occurs which is disproportionate to the insult compared to a stable person - due to accumulation of physical systems not working, e.g. kidneys, liver, and often a load of polypharmacy that compounds the problem - so all of this has been building over time and so the store breaks the camel’s back, as it were. So what this means is whilst you have flu you might get given an antiviral and get better for a stable person (single cause), for a frail person (red line) giving them an antiviral doesn’t do much – what we need to do is treat multifactorial elements (many different elements) of the disease for a frail person with a multifactorial response – need to do an awful lot more, using a technique known as comprehensive geriatric assessment, otherwise known as holistic care – nurses, PTs, OTs, speech and language etc. – putting in a lot of interventions for restoring people back to baseline function. So it’s more complicated.”
9
9
10
10
11
11
12
12
13
13
14
14
15
15
