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Aging & frailty
- 1. The “Normal” Aging& Frailty Syndrome 1
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- 3. WHO Definition ofOld Age Old age - >65 yrs Very old age - >80 yrs Interesting general facts: Average life expectancy - At 65 yrs – 17 yrs (82) At 75 yrs – 11 yrs (86) At 85 yrs – 6 yrs (91) 3
- 4. Biologic changes inageing Mechanism of biologic changes: Structural changes in chromosome ( in the DNA) Effect: Homeostenosis - Homeostatic reserve of each organ gets constricted However, does not affect individual during normal activity 4
- 5. Physiological Effect inImportant Organs CVS – Systolic HT Postural hypotension Unfolding of aorta & aortosclerosis Resp. System- Loss of lung compliance FEV1 5
- 6. Physiological Effect inImportant Organs cont… CNS- Loss of cortical cells Loss of posterior column fibres Impaired balance Kidney & G-U tract - GFR - Prostatic enlargement Endocrine – Impaired GTT - thyroxine, testosterone level 6
- 7. Physiological Effect inImportant Organs cont… Skeletal system – cervical spondylosis osteoporosis osteoarthritis GI system: colonic motility constipation Skin - wrinkling Eyes – cataract Ear – High tone deafness 7
- 8. Physiological Effect inImportant Organs: Increased Physical Stress Handling physical stress becomes more difficult as you get older People are less able to adjust to such stresses as heat, cold, physical exertion, and illness 8
- 9. Summary Not every personwill experience all of these changes Aging is a physical and psychological journey 9
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- 11. Frailty Syndrome • Aphysiologic syndrome, NOT a single disease • Results from cumulative decline of multiple organ systems (i.e. homeostenosis) • A syndrome of decreased body reserve • Inability to withstand minor stress (in contrast to a fit person of same age) i.e. has poor performance status • This, leads to vulnerability to adverse outcomes, organ failure and death
- 12. Domains affected • Bodycomposition • Homeostatic dysregulation • Energy failure • Neurodegeneration
- 13. Components • Sarcopenia • Osteoporosis •Muscle weakness (atrophy)
- 14. Consequences • Ineffective/incomplete homeostatic responseto stress • Multiple co-morbidity • Polypharmacy • Physical disability • ‘So-called’ geriatric syndrome
- 15. Common geriatric syndromes Mechanism– Multifactorial pathology •Delirium •Falls •Urinary incontinence •Chronic pain •Anorexia •Depression •Dementia •Unstable balance •Slow gait •Fatigue •Weight loss
- 16. Frailty phenotype (Dwindlessyndrome) Presents as (poor performance status): •Weight loss •Weariness • Exercise tolerance • Physical activity •Slow walking speed (6 minute walk test) •Depression •Cognitive impairment: The accumulation of common brain pathologies contributes to progressive physical frailty in old age The presence of macroinfarcts, Alzheimer disease, Lewy body pathology, and nigral neuronal loss are associated with a more rapid progression of frailty
- 17. Common Symptoms inGeriatric Illness Whatever the underlying illness (be it MI, stroke or septicemia) – Patient has limited common symptoms (especially in very old i.e. age >80) : Acute confusion Incontinence Instability of posture (fall)
- 18. Common Geriatric Problemsin Very Olds Five ‘I’s : 1. Intellectual impairment 2. Immobility 3. Instability (Falls) 4. Incontinence 5. Iatrogenic drug reactions
- 19. Intellectual Impairment In formof 3 D’s: • Dementia • Depression • Delirium
- 20. Dementia • >65 years– 5% • >80 years – 20% • Common presentation – Forgetfulness • Screening tests for cognitive function – (i) 3 item recall after 3 minutes (ii) Clock draw test • If abnormal – Minimental scale examination (MMSE)
- 21. Instability and Falls •>65 yrs – one-third have a fall each year • Frequency of fall – increases with advancing age • 5% falls – associated with hip fracture • Swaying – common manifestation • Screening – Gait and balance assessment • Complications – Fracture, subdural hematoma
- 22. Falls - Causes •Visual disturbance • Vestibular dysfunction • Hearing difficulty • Proprioceptive dysfunction and peripheral neuropathy • Postural hypotension • Urinary urgency • TIA/Vertebrobasilar insufficiency/Parkinsonism • Medications/ Alcohol – Important, since reversible cause
- 23. Falls : Dueto Medications • Polypharmacy: 4 or more drugs • Sedatives – benzodiazepines, phenothiazine • Orthostatic drugs (causing postural hypotension): Alpha blockers, nitrates, CCB, diuretics • Haloperidol – leading to Parkinsonism
- 24. Falls: Management • ↓Number of drugs to preferably three • Stop tranquilisers/sedatives • Treat postural hypotension : - Elevate bed head - Practise hand clenching - Discontinue offending drugs • Correct vision
- 25. Orthostatic Hypotension (OH) •Normal resting BP = 120/80 mmHg • OH: a drop in systolic BP by 20 mmHg after standing 2-3 min from supine • Causes: adverse effects of drugs, arrhythmias, immobility, adrenal insufficiency, autonomic dysfunction due to DM, Parkinson's CNS impairments • Patients with OH are at risk for sustaining injuries, including falls, fractures etc.
- 26. Comprehensive Geriatric Assessment (CGA) Physicalevaluation- •ADL (Activities of Daily Living): walking, dressing, bathing, feeding etc. •IADL (Instrumental activities of Daily Living): shopping, cooking, using telephone, driving car, managing money etc. Mental evaluation- •Orientation •Quick memory recall test (3 name recall test) •MMSE
- 27. Comprehensive Geriatric Assessment (CGA)- Tests • MMSE or Mini Cog for cognition • Geriatric Depression • ADL scale (Katz Index) • Physical Performance Test (PPT) • Vulnerable Elders-13 survey (VE-13) • Barthel Index (BI) • Pain Scale • Nutritional assessment • Functional assessment • Gait assessment (various tools used)
- 28. Treatment of frailty •Prevent dwindle • Early detection of acute illness and polypharmacy • Mobilise (to minimise muscle wasting) • Improve nutrition
- 30. Traditional Definition ofFrailty: Fried Model • Frail: a person meets > 3 of the criteria • Prefrail: a person meets 1 or 2 of the criteria Fried 2001
- 31. Physical and performancemeasures to identify mild to moderate frailty • Brown et al (2000) studied the correlation of physical measures (UE and LE strength, ROM, balance, coordination, sensation, and gait) with a 36-point Modified Physical Performance Test (Modified PPT) • Physical measures correlated with PPT • Frailty according to the PPT score ―NOT frail = 32-36 ―Mildly frail = 25-31 ―Moderately frail = 17-24
- 32. Comprehensive Geriatric Assessment (CGA) •Multidimensional, multidisciplinary diagnostic instrument • Usually coordinated by a case manager • Used to collect data on the medical, psychological, functional capabilities and limitations of complex elderly patients. • To develop a coordinated and integrated plan for treatment and follow-up, including primary care and rehabilitation, and make the best use of health care resources.
- 33. Comprehensive Geriatric Assessment (CGA) •CGA focuses on ―Elderly individuals with complex problems ―Functional status and QoL ―Frequently takes advantage of an interdisciplinary team of providers • The "Five I's of Geriatrics“ are easily missed in a standard medical evaluation ―intellectual impairment, immobility, instability, incontinence and iatrogenic disorders
Editor's Notes
- #12 Frail adults have a higher risk of institutionalization. It is harder for frail elderly to fight acute illnesses and harder to rebound from these illness. It is important to realize that frailty is not a disease but rather a combination of a variety of medical problems. The term frail should be considered a cluster of medical conditions and not a characterization—differentiated from disability or advanced old age. Geriatricians define frailty as a biological syndrome of decreased reserve and resistance to stressors resulting from cumulative declines across multiple physiological systems and causing vulnerability to adverse outcomes.
- #26 As pulse pressure widens, there is an increase in the incidence of cardiovascular disease. Generally, a normal pulse pressure at rest is approximately 40 mmHg. Orthostatic hypotension is defined as a decrease in systolic BP by 20 mmHg or a drop by 10 mmHg with a reflexive increase in HR with transitional movements, such as moving from supine-to-sit or sit-to-stand. The incidence of orthostasis increases 20% in community-dwelling people older than age 65 years and has been reported to be as high as 50% in frail older adults living in nursing homes.37 There are many causes of orthostatic hypotension, including adverse effects of medications, dehydration, anemia, arrhythmias, immobility, sepsis, adrenal insufficiency, and autonomic dysfunction related to diseases like diabetes, Parkinson's disease and central nervous system impairments. The patient may or may not be symptomatic with orthostatic hypotension and regardless of whether the patient demonstrates symptoms they are at risk for sustaining injuries, including falls, fractures, myocardial infarction, and cerebral injuries. The most common symptoms experienced are lightheadedness, dizziness, weakness, syncope, and angina. Some clients may experience visual and speech deficits, confusion, and changes in cognitive function. It is difficult to utilize symptoms as an indication of orthostasis, because the complexity of the older adult patient's medical history and presentation may be related to various issues. Therefore, it is critical that the therapist screen the patient's BP with position changes to rule out orthostatic hypotension. To (
- #28 Basso et al, 2004; Feher et al, 2006
- #31 Fried et al provide a standardized definition for frailty that is widely accepted (Fried, LP, Tangen, CM, Waltson, J, et al.: Frailty in older adults: evidence for a phenotype. J Gerontol. 56(3), 2001, 146–156) These authors suggest that someone should be considered frail if that person has three or more of the following five characteristics: Wt loss of 10# or more in the past year Self-reported exhaustion (3+ days/wk) Muscle weakness (grip strength) Walking speed in the lowest 20% (<.8m/sec) Low level of activity (kcal/week) In a study of 5317 older individuals who were living in the community, Fried et al found that 6.9% of these individuals were frail.
- #32 Journal of Gerontology: MEDICAL SCIENCES. 2000, Vol. 55A, No. 6, M350–M355 Physical and Performance Measures for the Identification of Mild to Moderate Frailty Marybeth Brown, David R. Sinacore, Ellen F. Binder, and Wendy M. Kohrt Background. The relative importance and association of factors contributing to physical frailty in elderly persons are unclear. Methods. Physical measures of upper and lower extremity strength, range of motion, balance, coordination, sensation, and gait were evaluated in relation to scores obtained on a 36-point physical performance test (PPT) in 107 elderly subjects. Results. Scores on the PPT were significantly associated with the measures of strength and balance, gait, several range of motion values, and sensation. Subjects were also grouped according to score on the PPT as not frail (32–36 points), mildly frail (25–31 points), or moderately frail (17–24 points). ANOVA followed by Bonferroni post hoc analyses were used to examine the relationships of physical measures to this index of frailty. Balance measures, an obstacle course, the Berg scale, the full tandem portion of the Romberg test, and fast gait speed were significantly different among the three groups. Multiple stepwise regression analyses indicated that the strongest combination of variables, explaining 73% of all the variance in the PPT, included obstacle course performance, hip abduction strength, the semitandem portion of the Romberg test, and coordination (pegboard). Conclusions. Results provide further insight into the relative importance of factors that contribute to frailty and factors that should be considered in treatment planning for the remediation of physical frailty in old adults.
- #33 http://ocw.tufts.edu/data/42/499797.pdf CGA effectively addresses many areas of geriatric care that are crucial to the successful treatment and prevention of disease and disability in older people. The geriatric assessment is a multidimensional, multidisciplinary diagnostic instrument designed to collect data on the medical, psychosocial and functional capabilities and limitations of elderly patients. It can be performed by physician, nurse, social worker, audiologist, OT, SLP, dietician, clinical psychologist, and PT. Various geriatric practitioners use the information generated to develop treatment and long-term follow-up plans, arrange for primary care and rehabilitative services, organize and facilitate the intricate process of case management, determine long-term care requirements and optimal placement, and make the best use of health care resources.
- #34 http://ocw.tufts.edu/data/42/499797.pdf The geriatric assessment differs from a standard medical evaluation in three general ways: (1) it focuses on elderly individuals with complex problems, (2) it emphasizes functional status and quality of life, and (3) it frequently takes advantage of an interdisciplinary team of providers. Whereas the standard medical evaluation works reasonably well in most other populations, it tends to miss some of the most prevalent problems faced by the elder patient. These challenges, often referred to as the "Five I's of Geriatrics", include intellectual impairment, immobility, instability, incontinence and iatrogenic disorders. The geriatric assessment effectively addresses these and many other areas of geriatric care that are crucial to the successful treatment and prevention of disease and disability in older people. NOTE: An iatrogenic disorder is a condition that is caused by medical personnel or procedures or that develops through exposure to the environment of a health care facility.