Frailty- whats new? Dr. Martha Spencer, MD, FRCPC Division of - - PowerPoint PPT Presentation

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Frailty- whats new? Dr. Martha Spencer, MD, FRCPC Division of - - PowerPoint PPT Presentation

Oct 30, 2022 41 likes •488 views

Frailty- whats new? Dr. Martha Spencer, MD, FRCPC Division of Geriatric Medicine Associate Program Director, Internal Medicine Objectives Review the basics of frailty Using a cases-based approach, explore frailty and its application

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Frailty- what’s new?

  • Dr. Martha Spencer, MD, FRCPC

Division of Geriatric Medicine Associate Program Director, Internal Medicine

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Objectives

  • Review the basics of frailty
  • Using a cases-based approach, explore frailty and its

application in:

  • Peri-operative medicine
  • Nephrology
  • Oncology
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Frailty

  • Frailty= state of increased vulnerability

resulting from aging-associated decline in reserve and function

  • NOT synonymous with disability or

comorbidity

  • Multiple models exist to render it
  • bjectively measurable
  • Demographic vs. mathematical
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Frailty- definition

Clegg et al. Lancet (2013)

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Pathophysiology

Clegg et al. Lancet (2013)

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  • 1. Frailty Phenotype Model

0= non-frail/robust 1-2= pre-frail 2= frail

J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M157. J Am Geriatric Soc 2004; 52: 625-634.

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Survival by Frailty Phenotypes

Arch Intern Med 2006; 166: 418-423.

Mortality at 7 years: Non-frail- 12% Pre-frail- 23% Frail- 43% Hazard Ratio= 1.63

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Frailty Phenotype Model

  • Frailty also correlated with:
  • Worsening mobility
  • Falls
  • Fracture
  • Disability
  • Institutionalization

Arch Intern Med 2006; 166: 418-423.

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SLIDE 9
  • 2. Frailty Index

“Tipping Point”= 0.67 Hazard Ratio (mortality)= 1.57

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Can Med Assoc J 2005; 173: 489-495.

Each step up= increased risk

  • f death (21.2%) and

institutionalization (23.9%)

  • ver 70mon
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Peri-operative medicine

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Older adults and surgery

  • More than ½ the surgeries in the US are being performed on patients

>65 years old (Robinson, 2009)

  • Geriatric patients have unique physiological vulnerability that forces

us to go beyond standard pre-operative evaluations

  • Traditional pre-operative evaluations risk-stratify patients based on

compromise to a single organ system

  • Older adults often have decline of multiple physiological systems
  • Do not take into account other aspects of frailty (cognition, mobility,

nutrition, function)

Robinson, T. N., Eiseman, B., Wallace, J. I., Church, S. D., McFann, K. K., Pfister, S. M., ... & Moss, M. (2009). Redefining geriatric preoperative assessment using frailty, disability and co-morbidity. Annals of surgery, 250(3), 449-455.

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  • Mr. S
  • 79yo male, in LTC x 1 year after a stroke
  • Large abdominal hernia- causing post-prandial GERD and abdominal

pain

  • Post-stroke dysphagia- SLP concerned that GERD increasing risk of

aspiration

  • Weight loss= 10lbs in last 3 months
  • Surgeon: “I can fix that for you pretty easily.”
  • Referred to SPH geriatric peri-operative clinic
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  • Mr. S
  • PMHx:
  • CVA (L MCA)- R sided weakness
  • Hypertension
  • DM2 (non-insulin dependent, HbA1C= 7.8%, neuropathy)
  • Non-valvular atrial fibrillation (CHADS2= 3)
  • Bilateral knee OA
  • Medications:
  • Ramipril 2.5mg po daily
  • Metformin 1g po bid
  • Apixiban 5mg po bid
  • Pantaloc 40mg po daily
  • Domperidone 10mg po tid
  • Tylenol 1g po bid
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Investigations

  • WBC 6.4, Hb 96 (ferritin 21), Hct 0.30, plt 220
  • Na 140, K 4.9, CO2 22, Mg 0.77, PO4 0.84, Ca 2.21
  • Cr 66, BUN 8
  • Alb 22
  • TSH normal
  • Vitamin B12 150
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Geriatric- Sensitive Perioperative Cardiac Risk Index

Alrezk, R., Jackson, N., Al Rezk, M., Elashoff, R., Weintraub, N., Elashoff, D., & Fonarow, G. C. (2017). Derivation and Validation of a Geriatric-Sensitive Perioperative Cardiac Risk Index. Journal of the American Heart Association, 6(11), e006648.

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Geriatric- Sensitive Perioperative Cardiac Risk Index

Alrezk, R., Jackson, N., Al Rezk, M., Elashoff, R., Weintraub, N., Elashoff, D., & Fonarow, G. C. (2017). Derivation and Validation of a Geriatric-Sensitive Perioperative Cardiac Risk Index. Journal of the American Heart Association, 6(11), e006648.

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  • Mr. S
  • Revised Cardiac Risk Index (RCRI)= 6.0%
  • Geriatric-Sensitive Perioperative Cardiac Risk Index= 1.6%
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Frailty and surgery

Frailty for All Surgeries Points Timed up and go 1 Katz score 1 Mini Cog 1 Charleson index ≥3 1 Hct<35% 1 Albumin <34 1 ≥1 fall in 6 mo 1 Total (≥4=Frail)

Robinson, T. N., Wu, D. S., Pointer, L., Dunn, C. L., Cleveland Jr, J. C., & Moss, M. (2013). Simple frailty score predicts postoperative complications across surgical specialties. The American Journal

  • f Surgery, 206(4), 544-550.
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Frailty and Surgery

Non-Frail Frail Post-operative complications 21% 58% Length of stay 6 ± 3.6 days 14 ± 11.days 30-day readmission 6% 29%

Robinson, T. N., Wu, D. S., Pointer, L., Dunn, C. L., Cleveland Jr, J. C., & Moss, M. (2013). Simple frailty score predicts postoperative complications across surgical specialties. The American Journal

  • f Surgery, 206(4), 544-550.
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Frailty and surgery

Frailty for All Surgeries Points Timed up and go 1 Katz score 1 Mini Cog 1 Charleson index ≥3 1 Hct<35% 1 Albumin <34 1 ≥1 fall in 6 mo 1 Total (≥4=Frail)

Robinson, T. N., Wu, D. S., Pointer, L., Dunn, C. L., Cleveland Jr, J. C., & Moss, M. (2013). Simple frailty score predicts postoperative complications across surgical specialties. The American Journal

  • f Surgery, 206(4), 544-550.
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What now?

  • Ability to consent
  • Goals and values
  • Is Mr. S willing to accept risks to current functional status for possible

symptomatic improvement/longevity?

  • Prehabilitation
  • Medical optimization
  • Mobility
  • Nutrition
  • Advanced Care Planning
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Frailty and Nephrology

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  • Ms. T
  • 86yo female living in long-term care for 2 years
  • Alzheimer’s Dementia- MMSE 15/30, requires assistance with bathing

and IADLs

  • Stage 4 CKD (IgA nephropathy)
  • Other PMHx- heart failure (EF 40%) with hospitalization Feb 2019,

hypothyroidism, bilateral knee OA

  • Geriatric review of systems
  • Recurrent falls
  • Good appetite
  • Good sleep
  • Mood stable, no behavioral symptoms
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SLIDE 25

Can Med Assoc J 2005; 173: 489-495.

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Frailty Phenotype Model

0= non-frail/robust 1-2= pre-frail 2= frail

J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M157. J Am Geriatric Soc 2004; 52: 625-634.

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SLIDE 27

Nixon, A. C., Bampouras, T. M., Pendleton, N., Woywodt, A., Mitra, S., & Dhaygude, A. (2017). Frailty and chronic kidney disease: current evidence and continuing

  • uncertainties. Clinical kidney journal, 11(2), 236-245.
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Frailty and Chronic Kidney Disease

  • Systematic review (2016):
  • Wide range of frailty prevalence in CKD population
  • 7% in community-dwelling CKD Stage 1-4
  • 73% in hemodialysis patients
  • Prevalence of frailty increases as GRF reduces
  • Frailty is associated with adverse health outcomes
  • Falls
  • Hospitalization
  • Mortality

McAdams-DeMarco, M. A., Suresh, S., Law, A., Salter, M. L., Gimenez, L. F., Jaar, B. G., ... & Segev, D. L. (2013). Frailty and falls among adult patients undergoing chronic hemodialysis: a prospective cohort study. BMC nephrology, 14(1), 224.

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Frailty, CKD, Falls

Frailty independently predicted >3-fold risk of falling

McAdams-DeMarco, M. A., Suresh, S., Law, A., Salter, M. L., Gimenez, L. F., Jaar, B. G., ... & Segev, D. L. (2013). Frailty and falls among adult patients undergoing chronic hemodialysis: a prospective cohort study. BMC nephrology, 14(1), 224.

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Frailty and dialysis initiation

Bao et al, 2012

  • US Renal Data System- 1576 patients, 2005-2009
  • 73% frailty (phenotypic criteria)
  • Frailty associated with:
  • Higher GFR at dialysis initiation
  • Higher risk of first-time hospitalization
  • Higher risk of mortality (increased by 80%!)
  • Early GFR at dialysis initiation associated with mortality (no

association when frailty included in model) and time to first hospitalization

Bao, Y., Dalrymple, L., Chertow, G. M., Kaysen, G. A., & Johansen, K. L. (2012). Frailty, dialysis initiation, and mortality in end-stage renal disease. Archives of internal medicine, 172(14), 1071-1077.

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SLIDE 31

Bao, Y., Dalrymple, L., Chertow, G. M., Kaysen, G. A., & Johansen, K. L. (2012). Frailty, dialysis initiation, and mortality in end-stage renal disease. Archives of internal medicine, 172(14), 1071-1077.

Hospitalization Death

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Thamer, M., Kaufman, J. S., Zhang, Y., Zhang, Q., Cotter, D. J., & Bang, H. (2015). Predicting early death among elderly dialysis patients: development and validation of a risk score to assist shared decision making for dialysis initiation. American Journal of Kidney Diseases, 66(6), 1024-1032.

Score 3 mon 6 mon 3 12% 20% ≥8 39% 55% Mortality at 3 and 6 months:

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Shared Decision Making

  • Early conversations about dialysis initiation
  • Primary practitioner
  • Nephrology
  • Geriatric Medicine
  • Use of frailty and evidence-based risks scores can be helpful to guide

conversations with patients and families

  • Presenting supportive care (no dialysis) as an equally valued

treatment option

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Frailty and Oncology

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  • Ms. M
  • 86yo female living in LTC for 7 years
  • Recurrent falls, moderate vascular dementia with behavioral

symptoms

  • Developed back pain- found to have lytic lesions in L spine,

hypercalcemic, M-spike in gamma region

  • Bone marrow biopsy- 60% clonal plasma cells= multiple myeloma
  • Daughter (SDM) asks: “Doctor, what should we do now? I think my

mom would want treatment if it would give her a few more years.”

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American Society of Clinical Oncology

Mohile, S. G., Dale, W., Somerfield, M. R., Schonberg, M. A., Boyd, C. M., Burhenn, P. S., ... & Janelsins, M. C. (2018). Practical assessment and management of vulnerabilities in

  • lder patients receiving chemotherapy: American Society of

Clinical Oncology Guideline for Geriatric Oncology. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 36(22), 2326.

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Chemotherapy toxicity

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Chemotherapy toxicity

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Frailty and multiple myeloma

  • Mian et al., 2018
  • Frailty index based on Rockwood Accumulation of Deficits model
  • General health domains:
  • Activities of Daily Living
  • Chronic Health Conditions- CAD, HTN, DM2, emphysema, stroke
  • Functioning- incontinence, hearing, vision, getting out of chair
  • General Health- self-rated (ex. energy, pain)
  • Mental health
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Frailty Index

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  • 52% of multiple myeloma

patients considered frail

  • Advancing chronological

age only weakly correlated with an increase in deficits

  • Odds of survival:
  • Non-frail= 43.7 mon
  • Frail= 26.8 mon
  • 10% increase in frailty

score= 16% increased risk

  • f death
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Shared decision making

  • Frailty index calculated- Ms. M is frail (life expectancy approx. 2 years)
  • Discussed with hematology
  • Potential toxicity of chemotherapy
  • Practical challenges of getting patient to hospital for IV treatments
  • Possible psychosis/worsening BPSD with Dexamethasone
  • Decision made for trial of lenalidomide + Dexamethasone with

immediate discontinuation if side effects

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Final Thoughts

  • Frailty in no longer ”owned” by geriatricians
  • Frailty is being embraced by many medical and surgical

specialties and is a hot area of research

  • Frailty is an important prognostic factor when making

treatment decisions with older adults and their caregivers

  • Consideration of frailty and use of evidence-based

assessment tools can lead to more informed shared care decision making

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Thanks!

Questions?