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Overview of frailty in the older patient

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  1. 1. The Frail ElderlyMarc Evans M. Abat, MD, FPCP, FPCGM Internal Medicine-Geriatric Medicine
  2. 2. What is Frailty?
  3. 3. FrailtyRefers to a loss of physiologic reserve thatmakes a person susceptible to disabilityfrom minor stresses.An inherent vulnerability to challenge fromthe environment.Not dependent on age, diagnosis orfunctional ability
  4. 4. Full forty years between age 60 to 100
  5. 5. FrailtyFunctional status varies considerablyamong older adults– Portion remain independent in daily function– Majority after 85 years need some assistance with instrumental activities– Frail elderly are severely disabled
  6. 6. Common Features of Frailty1. Weakness2. Weight loss (unexplained)3. Muscle wasting (sarcopenia)4. Exercise intolerance5. Frequent falls6. Immobility7. Incontinence8. Instability of chronic diseases
  7. 7. Associated Features of Frailty Older Age Female Less Education Lower Income Poorer Health (Multiple co-morbid chronic disease) (Fried et al [2001], Community-based study)
  8. 8. According to Buchner and WagnerThe goal of preventive strategies is to reduce or eliminate the factorsthat threaten physiologic capacity
  9. 9. Frailty as a Clinical SyndromeClinical Syndrome of FrailtySymptoms Adverse Outcomes ofWeakness FrailtyFatigue FallsAnorexia InjuriesUnder nutrition Acute IllnessesWeight Loss HospitalizationsSigns DisabilityPhysiologic changes marking Dependencyincreased risk InstitutionalizationDecreased muscle mass DeathBalance and gaitabnormalitiesSevere deconditioning
  10. 10. Stages of FrailtySpeechly / Tinnetti:– “There may be a transitional state between vigor and frailty.”– “Earlier” stage of frailty – patient should be screened and interventions instituted– “ If lack of full recovery after an illness Then: need for aggressive “Rehabilitation” after acute illness and “Prehabilitation” when surgery is anticipated.
  11. 11. Stages of FrailtyLate stage may not be reversible. “Failure to Thrive” Syndrome
  12. 12. Stages of FrailtyCharacteristics of Hospitalized Individuals withFailure to Thrive(Berkman B. et al, Gerontologist, 1989) 1. Mean age 79 2. Average of 6 diagnoses 3. Symptoms similar to clinical syndrome of frailty 4. Malnourished, dehydrated, skin ulcers, falls, pain, cognitive disabilities 5. Very limited effective intervention 6. 16% die during hospitalization
  13. 13. Potential Causes of Frailty1. Decline in function of multiple organ systems (due to aging) = enhance vulnerability to stressors2. Hypothalamic – pituitary – adrenal axis (Central regulators of homeostasis) A. Older animals show decrease ability to terminate the adrenocortical response to stress ; decrease hippocampal glucocorticoid receptors B. Prolonged poststress corticosterone elevation contribute to catabolic state
  14. 14. Potential Causes of Frailty3. Decline of growth hormone levels  Contribute to decrease protein synthesis and muscle mass  Decrease bone mass  Diminish immunologic states (NEJM 1990 Rudman et al). Clinical Trial: 21 healthy GH deficient men ages 61-81 receive rhGH  Increase lean body mass 9%  Decrease adipose tissue 14%
  15. 15. Potential Causes of Frailty4. Changes in immune system may be due to T cell dysfunction – Increase lymphoproliferative disorder – Susceptibility to infection – Autoimmune disorders
  16. 16. Physiologic Contributors to Frailty (Hazzard et al: Principles of Geriatric Medicine)
  17. 17. Challenges and Solutions in Care of the Frail Elderly1. IMPORTANT to recognize the vulnerable and frail before adverse outcomes  Recognize components that are reversible  Recognize the syndrome early2. Prevention of adverse outcomes (i.e. falls, medication side effects)3. Increase physical activity level of FOA (improved strength, flexibility, exercise tolerance, nutrition)4. Prehabilition and rehabilitation prevent decline associated with prolonged bedrest due to illness or surgery
  18. 18. Challenges and Solutions in Care of the Frail Elderly5. Improve Quality of Acute Hospital Care A. Intensive case management – hospital-based Advanced Practice Nurses intervene early  Identify newly admitted FOA early, aggressively monitor progress through discharge  Coordinate efforts of health care team  Educate staff, patient and families  Bridge communication and clinical gaps between systems (i.e. hospital  NH )  Facilitate access to programs and services
  19. 19. Challenges and Solutions in Care of the Frail ElderlyB. Be aware “BEWARE” of “cascade” of acute hospital care
  20. 20. Complication of HospitalizationHopitalization Functional Medical Medical Symptom Intervention Complication Restraints Thrombophlebitis Confusion Drugs Pulmonary embolus Not Eating Nasogastric Aspiration pneumonia tube Restraints Thrombophlebitis Falling Fracture Incontinence Foley catheter UTI / Septic shock
  21. 21. Challenges and Solutions in Care of the Frail ElderlyC. Early detection of acute illnessD. Delivery of medical treatment in least stressful site of care (i.e. home)E. Comprehensive Geriatric AssessmentF. Palliative Care alternatives for respiratory/ cardiac failure, weight loss, pain management.
  22. 22. Challenges and Solutions in Care of the Frail Elderly Advantages of CGA 1) Creation of individual treatment plan with a multidisciplinary team 2) Improve functional outcome 3) Improve patient survival 4) Reduction in hospital days 5) Reduction in readmission rates 6) No increase in mortality
  23. 23. Challenges and Solutions in Care of the Frail ElderlyElderly with irreversible declines in functional capacity, QUALITY hospital care may shift from survival at all cost to improving patient’s functional outcome.
  24. 24. Advancing Health and Well Being Into Old Age in Filipino Society (Philippine [Inter-Agency] and DSWD Plan of Action CY 2007)1. Advocacy on prevention of common diseases2. Conduct regular medical check-up of senior citizens in rural health units (RHU).3. Conduct care giving trainings to families of sick and frail senior citizens4. Conduct seminars on gerontology, physical fitness program, nutrition education and dietary counseling
  25. 25. Advancing Health and Well Being Into Old Age in Filipino Society (Philippine [Inter-Agency] and DSWD Plan of Action CY 2007)5. Establish geriatric wards in government and private hospitals.6. Implementation of neighborhood support services for older persons (NSSOP).7. Ensure the implementation of the Philippine Plan of Action for Nutrition (PPAN) as a blueprint and country’s guide for action to achieve nutritional adequacy for Filipinos
  26. 26. Have a good day!