The document discusses the significance of frailty as a critical predictor of adverse outcomes in geriatrics, highlighting its causes and measurement techniques. It emphasizes the need for improved clinical care through recognizing frailty in pre-operative evaluations and other healthcare transitions. Research data indicates a strong correlation between frailty and various complications in elderly patients, suggesting targeted interventions to optimize clinical resource allocation.

1. Buffalo, NY
steve@patientpattern.com

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8. FRAILTY
VITALITY

9. Why is Frailty Important?
US (and worldwide demographics)

10. Evans, Sayers, et. al.

11. Superior Predictor of Risk

12. Potential Causes of Frailty
• Multiple organ system decline
• Hypothalamic-pituitary-adrenal axis
• Immune dysfunction
– Increase interleukins, CRP
• Neuroendocrine
– Cortisol level increase
– Sex hormones decrease
– Growth hormones decrease
• Sarcopenia

15. Fried’s Phenotype for Frailty
• Presence of ≥3 components identifies a person as
being frail
– Shrinking: unintentional weight loss of >10lbs/year
– Exhaustion: lack of energy, or the presence of fatigue
and tiredness
– Strength: loss of physical robustness, skeletal muscle
– Slowness: a lethargic, unsteady, and unbalanced gait
– Low physical activity: inactivity

16. Mayo Clin Proc. 2008 Oct; 83(10): 1146–1153.

17. Frailty Index
• Deficit accumulation model
– Based on Comprehensive Geriatric Assessment
• FI-CGA
– Symptom, sign, disease, disability, laboratory,
imaging or electrodiagnostic abnormality
– 3% per year
• Short indices
– Study of Osteoporotic Fractures (SOF)
• Weight loss, inability to rise from chair, and energy

19. SUPERIORITY OF FRAILTY IN
PREDICTING OUTCOMES
• Geriatric trauma patients
• 2-year prospective cohort in Arizona
• 1° outcome: in-hospital complications
• 2° outcomes: adverse discharge disposition
• In-hospital complications (odds ratio, 2.5; 95% CI, 1.5-
6.0; P = .001)
• Adverse discharge disposition (odds ratio, 1.6; 95% CI,
1.1-2.4; P = .001)
• The mortality rate was 2.0% (n = 5), and all
patients who died had frailty. [JAMA Surg. 2014]

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22. Drivers of Utilization
Expectations
Frailty
Severity
of
Illness

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24. Does recognizing frailty
improve clinical care?
• Pre-operative evaluation
• Cardiovascular disease (Afilalo, et. al)
– OR of 2.7 to 4.1 for prevalent frailty
– OR of 1.5 for incident frailty not frail at baseline
– Frailty <--> CVD
• Contextualize risk and set expectations

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27. Operationalizing Frailty
• Emergency Room Screening
• Transitions of Care to PAC/SNF
• Palliative Care
• Medical Home
• Screening for Post-Operative Outcomes
• Telemedicine – Appropriate Patient Selection
• Reduce Re-Hospitalization

28. Summary
• Limited clinical guidelines for multiple
chronic diseases
• Frailty can be reliably measured to
appropriately select and allocate clinical
resources
• Targeted interventions are key
• Frailty Index used to harmonize
expectations and reduce utilization

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30. References
• Robinson TN, Finlayson E. How to Best Forecast Adverse Outcomes Following Geriatric Trauma: An
Ageless Question?. JAMA Surg. 2014;149(8):773.
• Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet.
2013;381(9868):752–62.
• Joseph B, Pandit V, Zangbar B, et al. Superiority of Frailty Over Age in Predicting Outcomes Among
Geriatric Trauma Patients: A Prospective Analysis. JAMA Surg. 2014;149(8):766-772.
• Lacas A, Rockwood K. Frailty in primary care: a review of its conceptualization and implications for
practice. BMC Medicine. 2012;10:4. doi:10.1186/1741-7015-10-4.
• Afilalo, Jonathan et al. Role of Frailty in Patients With Cardiovascular Disease. American Journal of
Cardiology , Volume 103 , Issue 11 , 1616 – 1621
• Pulignano G, Del Sindaco D. Usefulness of frailty profile for targeting older heart failure patients in
disease management programs: a cost-effectiveness, pilot study. J Cardiovasc Med (Hagerstown).
2010 Oct; 11(10):739-47.
• Hastings SN, Purser JL, Johnson KS, Sloane RJ, Whitson HE. Frailty predicts some but not all adverse
outcomes in older adults discharged from the emergency department. J Am Geriatr Soc.
2008;56:1651–1657
• Evans SJ, Sayers M, Rockwood K. The risk of adverse outcomes in hospitalized older patients in
relation to a frailty index based on a comprehensive geriatric assessment. Age Ageing. 2014
Jan;43(1):127-32