Frailty ACRM Conference PDF

HANGING BY A THREAD DURING COVID Best Practices to Mitigate 19 Frailty for At-risk Community Dwelling Elderly Healthy Aging and Frailty Leslie Zarrinkhameh, PT, DPT, GCS Lecturer/Director of Clinical Educa...

HANGING BY A THREAD DURING COVID Best Practices to Mitigate 19 Frailty for At-risk Community Dwelling Elderly Healthy Aging and Frailty Leslie Zarrinkhameh, PT, DPT, GCS Lecturer/Director of Clinical Education Board Certified Geriatric Clinical Specialist Certified Exercise Expert for the Aging Adult California State University, Fresno  DISCLOSURE S Leslie Zarrinkhameh, PT, DPT, GCS has no financial conflict(s) of interest relevant to this activity. This continuing education activity is managed by The Firm, Inc. in cooperation with ACRM. The Firm, Inc., ACRM, and all accrediting organization do not support or endorse any product or service mentioned in this activity. The Firm, Inc. and ACRM staff have no financial or non-financial conflicts of interest to disclose. LEARNING OBJECTIVES At the conclusion of this activity, the participant will be able to: 1. Discern the difference between eugenic and pathologic aging 2. Describe the different models of frailty 3. Compare and contrast the application of different frailty scales in the examination of the frail older adult 4. Apply different frailty scales to a video patient case OBTAINING CME/CE CREDIT Credit is only given to attendees who: Successfully complete the entire course/session. Evaluate the course – by completing an online survey. After you have completed the session evaluations and post- tests, and evaluate the overall program, you will be able to download your certificate from you task page. The evaluation will close 30 days after the end of the enduring activity. What is Frailty?? What is Frailty? Frailty Normal vs Pathological Aging  Selected Physiologic Age-Related Changes Affected Organ or System Physiologic Change Clinical Manifestations Body composition ↓ Lean body mass Changes in drug levels ↓ Muscular mass ↓ Strength ↓ Creatinine production Tendency toward dehydration ↓ Skeletal mass ↓ Total body water ↑ Percentage adipose tissue (until age 60, then↓until death) Cells ↑ DNA damage and ↓DNA repair ↑ Cancer risk capacity ↓ Oxidative capacity Accelerated cell senescence ↑ Fibrosis Lipofuscin accumulation CNS ↓ Number of dopamine Tendency toward parkinsonian receptors symptoms (eg, ↑ muscle tone, ↓ arm ↑ α-Adrenergic responses swing) ↑ Muscarinic parasympathetic responses Ears Loss of high-frequency hearing ↓ Ability to recognize speech From The Merck Manual for Health Care Professionals as Adapted from the Institute of Medicine: Pharmacokinetics and Drug Interactions in the Elderly Workshop. Washington DC, National Academy Press, 1997, pp. 8–9. Accessed June 1, 2013; on-line at: Endocrine system Menopause, ↓ estrogen and progesterone secretion ↓ Muscle mass ↓ Testosterone secretion ↓Bone mass ↓ Growth hormone secretion ↑ Fracture risk ↓ Vitamin D absorption and activation Vaginal dryness ↑ Incidence of thyroid abnormalities Changes in skin ↑ Incidence of diabetes (↓ insulin sensitivity Tendency toward water intoxication or ↑ insulin resistance) ↑ Bone mineral loss ↑ Secretion of ADH in response to osmolar stimuli Eyes ↓ Lens flexibility Presbyopia ↑ Time for pupillary reflexes (constriction, dilation) ↑ Glare and difficulty adjusting to ↑ Incidence of cataracts changes in lighting ↓ Visual acuity GI tract ↓ Splanchnic blood flow Tendency toward constipation and ↑ Transit time diarrhea From The Merck Manual for Health Care Professionals as Adapted from the Institute of Medicine: Pharmacokinetics and Drug Interactions in the Elderly Workshop. Washington DC, National Academy Press, 1997, pp. 8–9. Accessed June 1, 2013; on-line at: http://www.merckmanuals.com/professional/geriatrics/approach_to_the_geriatric_patient/physical_changes_with_aging.html  Heart ↓ Intrinsic heart rate and maximal heart Tendency toward syncope rate ↓ Ejection fraction Blunted baroreflex (less increase in heart rate in response to decrease in BP) ↓ Diastolic relaxation ↑ Atrioventricular conduction time ↑ Atrial and ventricular ectopy Immune system ↓ T-cell function Tendency toward some ↓ B-cell function infections and possibly cancer ↓ Antibody response to immunization or infection but ↑autoantibodies Joints Degeneration of cartilaginous tissues Tightening of joints Fibrosis Tendency toward ↓ Elasticity osteoarthritis Kidneys ↓ Renal blood flow Changes in drug levels ↓ Renal mass with ↑risk of adverse drug ↓ Glomerular filtration effects ↓ Renal tubular secretion and Tendency toward reabsorption dehydration ↓ Ability to excrete a free-water load From The Merck Manual for Health Care Professionals as Adapted from the Institute of Medicine: Pharmacokinetics and Drug Interactions in the Elderly Workshop. Washington DC, National Academy Press, 1997, pp. 8–9. Accessed June 1, 2013; on-line at:  Liver ↓ Hepatic mass Changes in drug levels ↓ Hepatic blood flow ↓ Activity of P-450 enzyme system Nose ↓ Smell ↓ Taste and consequent ↓appetite ↑ Likelihood (slightly) of nosebleeds Peripheral nervous ↓ Baroreflex responses Tendency toward syncope system ↓ β-Adrenergic responsiveness and number of ↓ Response to β-blockers receptors Exaggerated response to ↓ Signal transduction anticholinergic drugs ↓ Muscarinic parasympathetic responses Preserved α-adrenergic responses Pulmonary system ↓ Vital capacity ↑ Likelihood of shortness of breath ↓ Lung elasticity (compliance) during vigorous exercise if people are ↑ Residual volume normally sedentary or if exercise is ↓ FEV1 done at high altitudes ↑ V/Q mismatch ↑ Risk of death due to pneumonia ↑ Risk of serious complications for patients with a pulmonary disorder Vasculature ↓ Endothelin-dependent vasodilation Tendency toward hypertension ↑ Peripheral resistance From The Merck Manual for Health Care Professionals as Adapted from the Institute of Medicine: Pharmacokinetics and Drug Interactions in the Elderly Workshop. Washington DC, National Academy Press, 1997, pp. 8–9. Accessed June 1, 2013; on-line at: http://www.merckmanuals.com/professional/geriatrics/approach_to_the_geriatric_patient/physical_changes_with_aging.html Schwartz’s Slippery Slope of Aging Adapted from Schwartz RS: Sarcopenia and physical performance n old age: introduction. Muscle Nerve SuppI5: S10-S12, Schwartz’s Slippery Slope of Aging 1 Adapted from Schwartz RS: Sarcopenia and physical performance n old age: introduction. Muscle Nerve SuppI5: S10-S12, Frailty Defined Rowe and Kahn (1997)– Successful aging Low probability of disease and disability High cognitive and physical/functional capacity Active engagement with life Frailty defined 90’s Biologic syndrome of decreased reserve and resistance to stressors Cumulative declines across the lifespan Not just disability or co-morbidities  Fried, 2001 Cardiovascular Health Study (N= 5888 over 4 years) Frailty – geriatric syndrome with a distinct phenotype Fried et al, 2001 Frailty defined Ken Rockwood Canadian Study of Health and Aging (N= 10, 263 over 5 years) Frailty multidimensional syndrome of loss of reserves (energy, physical ability, cognition, health) that gives rise to vulnerability. Rules based definition (Fried’s phenotype) Cumulative deficits (Frailty Index) FI = Number of deficits a patient has/number of deficits considered Deficits considered not uniform Research and Health policy Reproducible and correlates with mortality Clinical Frailty Scale Based on clinical judgement from history taking and examination Highly correlated with the FI (r=.80)  Frailty defined Frailty is a multifactorial syndrome that represents a reduction in physiological reserve and in the ability to resist environmental stressors. (Song et al) It is a condition characterized by loss of biological reserves across multiple organ systems and vulnerability to physiological decompensation after a stressor event (Clegg et al) a cumulative index of wear and tear across multiple physiological systems involved in the body's effort to adapt to internal and external stressors over time. As multisystem dysregulation accumulates, predictable functional changes begin to appear and can serve as warning signs of vulnerability, development of frailty, and adverse health outcomes. (Brewer) Frailty is a term widely used to denote a multidimensional syndrome of loss of reserves (energy, physical ability, cognition, health) that gives rise to vulnerability. (Rockwood) Frailty defined Frailty is theoretically defined as a clinically recognizable state of increased vulnerability, resulting from aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with everyday or acute stressors is compromised. (Xue) Frailty is most often defined as an aging-related syndrome of physiological decline, characterized by a marked vulnerability to adverse health outcomes (Walston) And on and on……. Frailty Models https://ihub.scot/media/6732/20170131-frailty-tools-table-v50.pdf © Healthcare Improvement Scotland 2019 Published June 2017, updated July 2019 This document is licensed under the Creative Commons Attribution-Noncommercial-NoDerivatives 4.0 International License. This allows for the copy and redistribution of this document as long as Healthcare Improvement Scotland is fully acknowledged and given credit. The material must not be remixed, transformed or built upon in any way. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-nd/4.0/ http://ihub.scot Frailty Models – Frailty Phenotype – Fried et al Fried et al 5 indicators included in the phenotype Unintentional weight loss Self reported exhaustion Low energy expenditure Slow gait speed Weak grip strength Frail: ≥3 Pre-frail: 1-2 Not frail: none Frailty Models – Frailty Phenotype Fried, 2001 Modified Fried Frailty Scale Weight loss: Weight loss is defined as the unintentional loss of >10 lb. (4.5 kg) in the past year. 2. Exhaustion: If the participant answered “Often” or “Most of the time” for the question “How often in the last week did you feel that everything you did was an effort?” included in the Center for Epidemiologic Studies-Depression (CES- D) scale, the exhaustion criterion is considered present. Physical inactivity: Participants who performed no physical activity, spent most of the time sitting, or rarely had a short walk (or other nondemanding physical activity) in the past year are considered physically inactive. 4. Low walking speed: Participants are divided into 4 groups, below and above the median body height by sex to get percentile values on a 4- m walk test. Highest quintile of 4-m walk time, stratified by sex and height (median split) (Kang et al., 2009): Women: Height < 1.583 m > 5.9 s. Height ≥ 1.583 m > 5.0 s Men: Height < 1.73 m > 5.3 s. Height ≥ 1.73 m > 4.8 s. Modified Fried Frailty Scale Low HGS (weakness): Handgrip strength (HGS) is measured by a hand-held dynamometer. The participants were asked to perform the task three times with dominant hand and three measures averaged. The participants are divided into 8 groups according to quartiles of BMI (kg/m2) by sex. If HGS corresponded to the ≤20th percentile for the sex and BMI groups, low HGS is considered present.  The Frail Scale The FRAIL scale consists of five questions on Fatigue, Resistance, Ambulation, Illness, and Loss of Weight (Morley et al., 2012). Scores ranges from 0 to 5, where 3–5 represents frailty and 1–2 represents pre-frailty. 1. Fatigue: How much time during the previous 4 weeks did you feel tired? (all of the time, most of the time:1 point). 2. Resistance: Do you have any difficulty walking up 10 steps alone without resting and without aids? (yes: 1 point). 3. Ambulation: Do you have any difficulty walking several hundred metersalone with without aids? (yes: 1 point). 4. Illness: How many illnesses do you have out of list of 11 total? (5 or more: 1 point). 5. Loss of weight: Have you had weight loss of 5 % or more? (yes: 1 point). Frailty Models – Frailty Phenotype Xue, 2008 Phenotype Recommendations from Criteria Brewer Weight loss Interview Have you had an unintentional weight loss of >10lbs in the last year? Yes = risk criteria Exhaustion Interview using 2 questions “I felt everything I did was an effort.” from CES-D Depression scale “I could not get going” How often in the last week have you felt this way? 0 = Rarely or none of the time 1 = Some or a little of the time (1-2 days) 2 = A moderate amount of the time (2-4 days) 3 = Most of the time Answers 2 or 3 = risk criteria Walking Speed 15’ walk as recommended by Fried Fritz and Lusardi: ≥1.2-1.4 m/s2 normal community ambulation for Older Adults Fritz and Lusardi, 2009 Frailty Models – The Frailty Phenotype Phenotype Criteria Recommendations from Brewer Strength Grip strength Fried: lowest 20% based on gender and age (see 5 times sit to stand (CHAMP previous slide) study) 60-69 11.4 s higher = at risk 70-79 12.6s 80-89 14.8s Norms: Bohannon, 2006 Low Physical Activity PASE (Physical Activity Fried: LPTA Scale for the Elderly) YPAS (Yale Physical Activity CDC: 150 minutes/week Survey) moderate intensity activity, LPTA (Minnesota Leisure including 2 days/week Time Physical Activity strengthening Questionnaire) “Do you participate in Frailty Models – Clinical Frailty Index - Mitnitski and Rockwood Clegg et al, 2016 Blodgett et al, 2015  Frailty Models – Frailty Index - Mitnitski and Rockwood No established cutoffs Ceiling of FI =.70 has been established Higher score > higher risk of mortality Rockwood in several studies proposed (Song et al, 2010 and Rockwood et al, 2011) ≤0.03-0.08 as non-frail or relatively fit 0.03-0.10 as less fit or >0.8-0.21-≤0.45 as frail ≥0.45 as most frail Dutch Study (Hoogendjik et al, 2017) Those with FI 0.40, 77% died within 10 years Frailty Models – Clinical Frailty Scale - Rockwood https://www.dal. ca/sites/gmr/our -tools/clinical-fr ailty-scale.html Used with permission Frailty Models – Clinical Frailty Scale - Rockwood https://www.dal.ca/sites/gmr/o ur-tools/clinical-frailty-scale/cfs -classification-tree.html Used with permission Theou et al, 2021 Frailty Models – Clinical Frailty Scale - Rockwood https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scal e/cfs-guidance.html Offers videos, training modules, resources, education resources, an app Frailty Models – Clinical Frailty Scale - Rockwood Frailty Models – Prisma 7 3 or more YES answers = Frailty Frailty Models – Prisma 7 Prisma 7 + TUG (Timed Up and Go) + slow gait speed have high sensitivity but only moderate specificity. (Too many false positives) Clegg et al, 2014 British Geriatrics Society Fit for Frail Frailty Models – Edmonton Frailty Scale Cognition General health status Functional independence Social support Medication use Nutrition Mood Continence Functional performance. Frailty Models – Edmonton Frailty Scale Frailty Models – Edmonton Frailty Scale Frailty Models – Edmonton Frailty Scale Scoring Sum up all the columns Total Score = 17 0-5 Not Frail 6-7 Vulnerable 8-9 Mild Frailty 10-11 Moderate Frailty 12-17 Severe Frailty Frailty Models – Reported Edmonton Frailty Scale Frailty Models – FRESH Screening Tool – Eklund Developed for use in the ED 4 Questions + determining number of ED visits (3 or more in 12 months) “Do you get tired when taking a short (15–20 min) walk outside?” “Have you suffered any general fatigue or tiredness over the last 3 months? “Have you fallen these last 3 months?” and “Are you afraid of falling?” “Do you need assistance in either getting to the store, managing obstacles (such as staircases) to and from the store, or in choosing, paying for, or bringing home groceries?” Have you visited the ED 3 or more times in the last 12 months?  Frailty Models – FRESH Screening Tool – Eklund Sensitivity was high (84 %) but specificity was low (75 %) when comparing the five questions of the FRESH-screening against the eight frailty indicators (Fried + balance, visual impairments, cognitive impairments) Both sensitivity and specificity were high (81 % and 80 %, respectively) when comparing the four questions (without the ED question) of the FRESH-screening against the eight frailty indicators. (Fried + balance, visual impairments, cognitive impairments)  Frailty Models - ISAR Identification of Seniors at Risk Also for use in the ED Identify Older adults ≥ 65 at risk for future adverse outcomes Functional decline, ED visit or hospitalization, nursing home admission or death following ED visit or hospital discharge 6 item self-report questionnaire, ≥2 indicates older adult at risk Deficit accumulation model Galvin et al, 2017: ISAR cutoff of ≥2 sensitivity to predict ED return or hospitalization: 0.80, specificity 0.31 at 6 months 30 days: sensitivity for ED return: 0.83; 0.91 for functional decline; Frailty Models - ISAR  Why Is It Important to Screen for Frailty? Advancing age increases the risk of frailty (DeLepeleire et al, 2009) But, age is not synonymous with frailty Co-morbidities and disability increase the risk of frailty But not all people with disability are frail (Fried, 2004) Frailty is higher in women than men (Gorman, 2015) Frailty is more pronounced in older adults with lower educational levels and income (Gorman, 2015) Frail older adults also struggle with functional mobility, ADLs and IADLs more than their non-frail peers (Gorman, 2015) Frailty is linked to higher mortality 5 year risk of death odds ratio: 4.82 (mild frailty) and 7.34 (severe frailty) (Gorman, 2015)  Why Is It Important to Screen for Frailty? FRAILTY IS NOT INEVITABLE! It’s predictable, and can be delayed or reversed to some degree Identifying it early keeps your patient in the Fun and Function of Schwartz’s Slippery Slope Frailty is a gradual decline and may go unnoticed unless specifically sought out.  References Schwartz RS. Sarcopenia and physical performance in old age: introduction. Muscle Nerve. 1997;20[Suppl 5]: S10-S12 Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. The Lancet. 2013;381(9868):752-762 Rowe JW and Kahn RL. Successful aging. The Gerontologist. 1997; 347(4): 433-440. Rockwood K, Mitnitski A, MacKnight C. Some mathematical models of frailty and their clinical implications. Rev Clin Gerontol 002;12:109-17. Fried LP1, Tangen CM, Walston J, Newman AB, et al. J Gerontol A Biol Med Sci. 6(3):M146-56.Frailty in older adults: evidence for a phenotype. Fritz S, Lusardi M. Walking speed: the sixth vital sign. J Geri Phys Ther. 2009;32(2):2-5. https://www.cgakit.com/ retrieved 8/2/21 Prevalence and 10-Year Outcomes of Frailty in Older Adults in Relation to Deficit Accumulation Xiaowei Song, PhD, MSCS,w Arnold Mitnitski, PhD,and Kenneth Rockwood, MD, MPA JAGS 58:681–687, 2010 Brewer, Kathryn. Clinical markers for frailty: what do functional measures tell us? Gerinotes, Vol. 18, No. 5 2011. Xue et al. Initial manifestations of frailty criteria and the development of frailty phenotype in women’s health and aging study II. JGerontol:Medical Sciences. 2008;63A(9):984-990. Xue, Qian-Li. The Frailty syndrome: definition and natural history. Clin Geriatr Med 27 (2011) 1–15 doi:10.1016/j.cger.2010.08.009 Walston, Jeremy. Frailty. UpToDate References Bohannon RW. Reference values for the five-repetition sit-to-stand test: a descriptive meta-analysis of data from elders. Perceptual and motor skills. 2006 Aug;103(1):215-22. https://www.cdc.gov/physicalactivity/basics/older_adults/index.htm retrieved 8/10/2021 Fried, L. P., Ferrucci, L., Darer, J., Williamson, J. D., & Anderson, G. (2004). Untangling the concepts of disability, frailty, and comorbidity: Implications for improved targeting and care. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 59(3), 255–263. doi: 10.1093/ gerona/59.3.M255 Gorman TJ. Frailty. Reviews in Clinical Gerontology, 2015;12(01): 82–92. DOI: 10.1177/1755738015595825 De Lepeleire, J., Iliffe, S., Mann, E., & Degryse, J. M. (2009). Frailty: An emerging concept for general practice. The British Journal of General Practice, 59(562), e177–e182. doi: 10.3399/ bjgp09X420653 Clegg et al. Development and validation of an electronic frailty index using routine primary care electronic health data. Age and Ageing 2016; 45: 353–360 doi: 10.1093/ageing/afw039 Published electronically 3 March 2016. Hoogendjik et al. Development and validation of a frailty index in the Longitudinal Aging Study Amsterdam. Aging Clin Exp Res. 2017; 29(5): 927–933. doi: 10.1007/s40520-016-0689-0 Rockwood K, Song X, Mitnitski A. Changes in relative fitness and frailty across the adult lifespan: evidence from the Canadian National Population Health Survey. CMAJ. May 17;183(8):E487–94. Epub 2011/05/05.eng. Rockwood et al. A global clinical measure of fitness and frailty in elderly people. CMAJ, AUG. 30, 2005; 173 (5) DOI:10.1503/cmaj.050051 References Theou, O et al. A classification tree to assist with routine scoring of the Clinical Frailty Scale. Age and Ageing, Volume 50, Issue 4, July 2021, Pages 1406–1411, https://doi.org/10.1093/ageing/afab006 Clegg et al. Diagnostic test accuracy of simple instruments for identifying frailty in community- dwelling older people: a systematic review. Age and Ageing, Volume 44, Issue 1, January 2015, Pages 148–52, https://doi.org/10.1093/ageing/afu157 Galvin, R. et al. Adverse outcomes in older adults attending emergency departments: a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool. Age and Ageing. 2016;0 1-8 ACRM.org 24 – 29 SEPTEMBER 2021