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9/29/2016 Conflicts of Interest I have no financial conflicts of interest to disclose that are relevant to this presentation. Frailty in Transplantation Grant support: K23 AG048337 R03 AG 045072 Jennifer C. Lai, MD, MBA

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Frailty in Transplantation

Jennifer C. Lai, MD, MBA Transplant Hepatology University of California, San Francisco

Beeson Scholar in Aging Research

Conflicts of Interest

  • I have no financial conflicts of interest to disclose that are

relevant to this presentation.

  • Grant support:
  • K23 AG048337
  • R03 AG 045072
  • ACG Junior Faculty Career Development Award
  • American Federation for Aging Research Beeson Scholar Award
  • Alliance for Academic Internal Medicine (T Franklin Williams Scholar Award)
  • UCSF Older Americans Independence Center
  • UCSF Liver Center
  • UCSF Resource Allocation Program

Case: Barrier to Transplant?

  • 64 yo woman with progressive end-organ disease coming

to your center for evaluation for solid organ transplant

  • PMH: controlled hypertension, Type 2 diabetes on oral

agents (hemoglobin A1c 6.9%)

  • PSH: Tonsillectomy
  • SHx: Retired teacher, married, 2 adult children who live

nearby and want to be living donors; non-smoker, non- drinker Based on the above do you anticipate any barriers to transplant listing?

Case: Barrier to Transplant?

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Frailty tool: The Eyeball Test

Pitfalls of the eyeball test:

  • Subjective
  • Detects frailty too late
  • Can be deceiving:
  • Obesity
  • Women
  • Well-groomed
  • Variable application in

clinical practice

Tools to use in the transplant setting

Fried Frailty Index grip strength SPPB gait speed 6MWT physical activity exhaustion TUG Clinical Frailty Scale ADL IADLs Selection criteria

  • Commonly used in research

and/or clinical practice

  • Have been used in end-stage
  • rgan disease
  • Ones that I have heard you are

using in your practice

PROMIS

Vulnerable Elders Survey

(Maximum) GRIP STRENGTH

Clinical Assessment Recommendations, 3rd edition. American Society of Hand Therapists

Seated Elbow flexed 90 degrees Forearm in midprone position (neutral) Dial turned away from patient

(Maximum) GRIP STRENGTH

“This test will tell me your maximum grip strength. When I say go, grip as hard as you can until I say stop.”

  • Average of 3 trials
  • Grip duration of 3 seconds with 15 seconds rest in

between

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Fried Frailty Instrument

Fried, J Gerontol 2001.

Characteristic Measure Self-report Shrinking

Weight loss: “In the last year, have you unintentionally lost 10 pounds?”

Exhaustion

“In the last 7 days, how many days have you felt:

  • That everything I did was an effort?
  • That I could not get going? (≥3 days)”

Low activity

Minnesota Leisure Time Activity questionnaire

Performance

  • based

Slowness

Walk time (adjusted for height)

Weakness

Grip strength (adjusted for gender, BMI)

Minnesota Leisure Time Activity Questionnaire

Taylor HL. J Chron Dis 1978.

Questionnaire administered to the patient by a trained interviewer:

Fried Frailty Instrument

Fried, J Gerontol 2001.

Characteristic Measure Self-report Shrinking

Weight loss: “In the last year, have you unintentionally lost 10 pounds?”

Exhaustion

“In the last 7 days, how many days have you felt:

  • That everything I did was an effort?
  • That I could not get going? (≥3 days)”

Low activity

Minnesota Leisure Time Activity questionnaire

Performance

  • based

Slowness

15 foot gait speed (adjusted for height)

Weakness

Grip strength (adjusted for gender, BMI)

Gait speed

“Walk at a comfortable pace”

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Fried Frailty Instrument

Fried, J Gerontol 2001.

Characteristic Measure Self-report Shrinking

Weight loss: “In the last year, have you unintentionally lost 10 pounds?”

Exhaustion

“In the last 7 days, how many days have you felt:

  • That everything I did was an effort?
  • That I could not get going? (≥3 days)”

Low activity

Minnesota Leisure Time Activity questionnaire

Performance

  • based

Slowness

15 foot gait speed (adjusted for height)

Weakness

Grip strength (adjusted for gender, BMI)

Fried Frailty Instrument - Scoring

Fried, J Gerontol 2001.

Characteristic One point if… Self-report Shrinking

Yes

Exhaustion

3 or more days

Low activity

Men: <383 kcal/week Women: <270 kcal/week

Performance

  • based

Slowness

Cut-offs based on gender and height

Weakness

Cut-offs based on gender and BMI

% frail by Fried Frailty criteria

Lai 2014. McAdams-Demarco 2015. Singer 2015. Fried 2001.

Wait list candidates

=

Six-minute walk test

Guidelines for the 6MWT, American Thoracic Society 2002.

  • 100 foot hallway

Marked every 3 m (~10 feet)

  • Flat
  • Record distance

traveled in 6 minutes

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Six-minute walk test: Real-life results

Casanova 2011. Carey 2010. Dudley 2012.

Healthy adults 600m 300m 100m Cirrhotic pts 571m ≈ 1/3 mile ~1/3 mile ~1/4 mile ~1/8 mile 369m ≈ 1/4 mile Dialysis pts 319m ≈ 1/5 mile Lung tx candidates 348m ≈ 1/4 mile

Timed Up and Go Test (TUG)

3) Turn 4) Walk back to the chair at your normal pace 5) Sit down again”

“When I say ‘Go’, I want you to:

1)

Stand up from the chair

2)

Walk to the line on the floor at your normal pace

Podsiadlo D, J Am Geriatrics Soc 1991.

Short Physical Performance Battery

Balance

10 sec each

Guralnik, NEJM 1995.

Gait speed Chair stands

Disability: Activities of Daily Living (ADLs) Instrumental ADLs (IADs)

Enable an individual to live independently in a community. Necessary for fundamental functioning.

  • Dressing
  • Eating
  • Ambulating
  • Transferring
  • Toileting
  • Hygiene

“Do you have difficulty with…”

  • Using a telephone
  • Shopping
  • Preparing meals
  • Housekeeping
  • Doing laundry
  • Arranging transport
  • Taking meds
  • Managing finances

Katz S, JAMA 1963. Lawton MP, Gerotologist 1969.

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Instruments to Assess Frailty

Objective Tools

  • Hand grip strength
  • Fried Frailty Index
  • 6 minute walk test
  • Timed up and go
  • Short Physical

Performance Battery

  • ADL / IADL scales

A Frailty Index for patients with end-stage liver disease

+ +

Data in submission. Please do not distribute.

Compared to MELDNa alone, the Frailty Index correctly reclassifies 1 out of 5 patients by their survival status Waitlist survival in liver transplant candidates (n=536)

Lai JC. In submission.

MELDNa 14 (better liver function) MELDNa 23 (worse liver function)

MELDNa 23, Frail MELDNa 23, Robust MELDNa 14, Robust MELDNa 14, Frail

What is your grip strength?

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Average maximum grip strength

1Mathiowetz V 1984. 2Lai JC 2014. 3Singer J 2016. 4Chang Y-T 2011.

Adults1

End-stage liver dz2

~50 kg ~30 kg 35 kg 22 kg 28 kg 17 kg

End-stage kidney dz4

37 kg 21 kg

End-stage lung dz3

Key Point

We have the tools to operationalize:

Fried, SPPB, ADL, IADL scales are available in the Appendix of: Lai JC, AJT 2014.

We need to implement these in clinical practice!

Characteristics of tools to consider

Ease of use Type

Length of time to administer # of questions/compon ents Domains tested

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Clinical Frailty Scale

Rockwood K, CMAJ 2005.

Waitlist survival in liver transplant candidates by MELDNa and Frailty

MELDNa 14, Robust MELDNa 23, Robust MELDNa 14, Frail MELDNa 23, Frail

0% 20% 40% 80% 100% 60%

Survival Probability

10

Time since assessment (months)

20 30

Lai JC. In submission.

Waitlist survival in liver transplant candidates by MELDNa and Frailty

Lai JC. In submission. MELDNa 14, Frail MELDNa 23, Frail MELDNa 23, Robust MELDNa 14, Robust