Frailty – Bracknell GP teaching - PowerPoint Presentation

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Frailty – Bracknell GP teaching

Dr Lucy Abbott

Lucyjane.abbott@nhs.net

@

geris_lucy

19

th

May 2021

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Overview

Background

Frailty pathophysiology

Biology of ageing

Why does frailty develop?

Frailty syndromes

Identification/recognition of frailty

Approach to managing frailty – Dr Nasim and Dr Wright

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Background – how much frailty is there?

4% population estimated to be living with moderate/severe frailty

30 000people across ICS

Can get detail for individual PCN/practices

50% of over 85s estimated to have frailty

75% of over 75s attending ED estimated to have frailty

50% over 80 year olds with hospital admission will die in the next year

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Why do we age?

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Why do we age?

Theories of ageing (300!)

Biological

Sociological

Ageing is an artefact of protected environments

Psychological

Intrinsic lifespan limited to approx. 100 years

What is evolutionary advantage of surviving beyond the menopause?

There is a lot that we don’t know!

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Relationship between age and frailty

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What is frailty?

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Frailty definition

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Pathophysiology of frailty

Frailty is not an inevitable part of ageing

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What do we know about why frailty develops?

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Ageing process

Genes determine approx. 25% longevity

Concordance in monozygotic twins

Some mutations directly affect lifespan

We reproduce in younger years, therefore no positive selection for longevity genes

Environment is important

Genetically identical nematodes in similar lab conditions will all age differently

Caloric restriction prolongs life

Pollution, radiation etc causes genetic damage and cellular dysfunction

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Biological ageing – genetic theories

Developmental genetic theories

Continuous with mechanisms of development

Genetically controlled and determined

Changes in neuroendocrine and immunological systems with age

Increasing inflammation with age

Changes in growth hormone

Somatic mutation theory

Radiation exposure and damage

Mutations result in functional failure and death

Free radicals theory

Highly reactive chemicals in aerobic tissues

Damage nuclear DNA, mitochondrial DNA and telomeres

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Cellular ageing

Telomere shortening

Telomeres protect the end of DNA

Get shorter as cells divide

Longer telomeres – more times cell can divide

Hayflick limit

Telomeres shortened by:

Smoking

Obesity

Lack of exercise

Poor diet

Telomeres shorter in some diseases

eg

vascular dementia

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Organ systems

Lungs, liver, kidneys, heart, nervous system, skin

Eyes, ears

All lose intrinsic capacity with normal ageing

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The brain and frailty

Structural and physiological changes

Loss of neurones – especially in metabolically active areas

eg

hippocampi

Mild cognitive decline

Dementia

Altered immune responses - proinflammatory

delirium

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Endocrine system and frailty

Decline in growth hormone

Reduced oestrogen and testosterone

Reduced cortisol

Impact on muscle function and loss of muscle mass

Falls and reduced mobility

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Immune system and frailty

Fails to respond appropriately to stress of acute inflammation

Abnormal low grade inflammatory response

eg

COPD, heart failure

Hyper-responsive to stimuli

Persists for prolonged time resulting in tissue damage

Affects muscle function – reduced mobility and falls

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Skeletal muscle - sarcopenia

Due to neurological, endocrine and immunological changes

Impact of

Disease

Nutrition

Exercise

Bone health

osteopenia – natural ageing

osteoporosis – frailty/disease

All results in reduced mobility, falls and fractures

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Why does frailty develop?

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What are the frailty syndromes?

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The 5 frailty syndromes

F

alls

R

educed mobility

A

ltered cognition - Delirium

I

ncontinence

Acute change – new or worsening

Susceptibility to side effects of medications or

L

ots of medications

These are all markers of underlying frailtyOften result in 999 call

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Case: MR JL: Frailty Crisis

Presenting complaint: 6 week history of

3 falls

F

Decline in mobility

R

Hallucinations

A

Incontinence

I

multiple medications

L

– antihypertensive medications, codeine

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Medical causes underlying frailty syndromes

Pneumonia – hallucinations (delirium), reduced mobility

Decompensated heart failure – reduced mobility

Incontinence – functional as unable to get to the bathroom

Falls secondary to reduced mobility, muscle weakness and polypharmacy

Multiple medications due to underlying comorbidities. Codeine given for pain after fall also contributing to delirium/constipation/falls etc…..

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Frailty is a state of vulnerability

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What has caused the frailty syndrome?

Why has the person decompensated?

There is often a medical cause

The cause for the decline in function must be addressed

Reversible conditions should be treated

Comprehensive, multidisciplinary approach required, including rehab

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Identification of frailty

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Identifying frailty – population level -

eFI

Population segmentation tool

>65

Needs to be clinically validated

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Why is it important to identify frailty?

Increased risk of:

Disability

Hospitalisation

Nursing home admission

Mortality

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References

Chen, X et al (2014) Frailty syndrome: An Overview

Clinical interventions in Ageing

The Cambridge Handbook of Age and Ageing

Clegg, A. et al (2013) Frailty in elderly people

Lancet

381:752-762

Clegg, A. et al (2016) Development and validation of an electronic frailty index using routine primary care electronic health record data.  

Age and Ageing

, 45(3): 353–360

Ellis, G. et al. (2011) ‘Comprehensive geriatric assessment for older adults admitted to hospital’,

The Cochrane Library.

Fried, LP et al (2001) Frailty in older adults: evidence for a phenotype. The journals of gerontology 56(3):146-156.

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Questions