Dr Dominic Hart Consultant Geriatrician Belfast Trust Frail Frail What is Frailty A state of increased vulnerability to poor resolution of homeostasis after a stressor event NOT An inevitable part of aging ID: 1048575
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1. Project ECHOFrailty & PolypharmacyDr Dominic HartConsultant GeriatricianBelfast Trust
2. Frail?
3. Frail?
4. What is Frailty“A state of increased vulnerability to poor resolution of homeostasis after a stressor event.”NOTAn inevitable part of agingA state of multiple long term conditionsDisability
5. Cycle of FrailtyGerontological Society of America. 2008
6. What is Frailty2 Models:PhenotypeWeightloss, exhaustion, low energy expenditure, slow GAIT, low grip strength.Cumulative deficitDevelopment of frailty indexDiffering variables used/studied?Clinical usefulness Higher score >>> poorer outcomes
7. Phenotype modelClegg et al. The Lancet 2013.>3 suggests presence of frailty
8. Prisma 7Score >3 suggests presence of frailty
9. Frail ScaleFatigue “Are you fatigued?”Resistance “Can you climb 1 flight of stairs?”Ambulation “Can you walk 1 block?”Illness Greater than 5Loss of weight Greater than 5%Morley et al. J Nutr Health Aging 2012
10. PrevalenceDepends on the tool used.4-16% over 65’s43% if has cancer diagnosisPre-Frailty1-2 criteria28-44% over 65’s
11. PrevalenceIncreased if:Advanced ageLower educational levelCurrent smokerOn post menopausal HRTNot marriedDepression or on antidepressantsIntellectual disability
12. What is FrailtyOlder people living with frailty are at increased risk of adverse outcomes.They can experience dramatic changes in their physical and mental wellbeing after an apparently minor event.Frailty is a consequence of cumulative decline in many physiological systems.
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14. PathophysiologyClegg et al. The Lancet 2013
15. Frailty Syndromes“Geriatric Giants”5 Syndromes:FallsImmobilityDeliriumIncontinenceSusceptibility to side effects of medication
16. FrailtyNot a static stateCan be made better & worseNot inevitableIs a long term condition A medical syndrome:“A group of signs & symptoms that occur together & characterize a particular abnormality”
17. Why Look?Patients with Frailty have poorer outcomesMore likely to be admitted when attend A&EMore likely to stay longer in hospitalLess likely to be discharged home again Less likely to make full recoveryEven from a seemingly minor stressor
18. Response to adverse event in a non-frail vs frail older personClegg et al, Lancet 2013.
19. Classification of FrailtyNHS England
20. When to look for FrailtyAny interaction with a patient is an opportunity to look for frailty.Need to recognise frailtyWeighing up risks/benefits of treatmentsRisk of causing harm
21. Managing frailtyAssess along the principles of Comprehensive Geriatric Assessment (CGA)Develop a personalised care and support plan
22. What is CGA?A multidimensionalInterdisciplinaryDiagnostic processThat focuses onMedical needsConduct personalised medication reviews Functional capabilityPsychosocial needsDeveloping a coordinated treatment & follow up plan
23. CGA ‘Domains’Physical symptoms (to include pain)Mental Health Symptoms Level of function in daily activitySocial Support Networks Living Environment Level of Participation & individual concernscompensatory mechanisms & resourcefulness
24. CGAImproves independenceReduces institutionalisationReduces mortalityRecent Cochrane review:30% more likely to be alive and in your own home at 6 monthsNNT = 13
25. Multimorbidity2 or more long term conditionsDoes not automatically imply frailtyMultimorbidity & frailty overlaphttps://www.nice.org.uk/guidance/qs153/chapter/Quality-statements
26. Nice Guideline (June 2017)Quality statementsStatement 1 Adults with multimorbidity are identified by their GP practice.Statement 2 Adults with an individualised management plan for multimorbidity are given opportunities to discuss their values, priorities and goals.Statement 3 Adults with an individualised management plan for multimorbidity know who is responsible for coordinating their care.Statement 4 Adults having a review of their medicines and other treatments for multimorbidity discuss whether any can be stopped or changed.
27. Resourceshttps://www.england.nhs.uk/wp-content/uploads/2017/03/toolkit-general-practice-frailty.pdfhttp://www.bgs.org.uk/campaigns/fff/fff_full.pdfhttp://www.bgs.org.uk/campaigns/fff/fff_short.pdf