Modulate the prevention stategy according to the level of frailty - - PowerPoint PPT Presentation

Modulate the prevention stategy according to the level of frailty

Prof Leocadio Rodríguez Mañas Hospital Universitario de Getafe

CONFLICT OF INTEREST DISCLOSURE

I have no potential conflict of interest to report

Is it possible to assess “the level of frailty”? Is there different clinical phenotypes of frailty? Is there any evidence-based strategy to prevent frailty? Is it the prevention strategy the same in different settings?

Robust Frail Functional Limitation Disability Dependency Definition Interventions to improve quality and outcomes - and prevent or delay further functional decline

What How Where

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What How Where

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What How Where

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What How Where

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What How Where

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Potential reversibility of functional decline

Frailty as a dynamic functional state CARE FOCUSED ON

Preventing frailty Preventing Disability Treating Frailty Preventing Disabilty Treating Functional Decline Preventing Dependency Treating Disability Managing Dependency

Frailty conceptual models

B) Frailty phenotype A) Deficit accumulation

Rockwood K. J Am Geriat Soc. 2006;54:975-979 Fried et al. J Gerontol Med Sci. 2001;56A:M146-M156

Rodriguez-Mañas L & Walston JD Rev Esp Geriatr Gerontol 2017

The functional continuum ROBUSTNESS LOW FUNCTIONAL RESERVE DISABILITY-DEPENDENCY SEVERE DEPENDENCY DEATH Isolated Physiological Vulnerability MULTYSYSTEMIC IMPAIRMENT Multiple Non-reversible conditions

CURRENT TOOLS: DICHOTOMIC (FRAIL vs NON-FRAIL)

Frailty Trait Score (FTS) vs Frailty Phenotype

Frailty Trait Score (0-100) Frailty Phenotype (Robust/Pre-frail/Frail) Domain (Score) Item Criteria Domain/ (Score) Item Criteria

Energetic balance/ Nutrition (0-32) BMI Weigth loss

• Abd. Obesity

Serum Alb. (mg/dl) BMI >4.5 Kg/12m Waist circum Lowest Quin. Energetic balance/ Nutrition (1) Weigth loss >4.5 Kg/12m Weakness (0-16) Grip strength Knee extension Lowest Quin. Lowest Quin. Weakness (1) Grip strength Lowest Quin. Endurance (0-10) Chair test (times

• stand. up/30 sc)

Lowest Quin. Endurance (1) Exhaustion CES-D (2 qst) Slowness (0-8) Gait speed Lowest Quin. Slowness (1) Gait speed Lowest Quin. Low activity (0-8) PASE Lowest Quin. Low activity (1) Kcals/week Lowest Quin. Nervous System (0-16) Fluency (animals in 60 s) Balance Lowest Quin. SPPB criteria Vascular system (0-10) Brachial/Ankle Index Fowkes criteria

CHARACTERIZATION OF FRAILTY STATUS BY FRAILTY TRAIT SCORE (FTS)

Variable [0-20] (20-30] (30-40] (40-50] (50-60] (60-70] (70-100] N 150 262 401 418 287 201 106 Age 70 (68, 73) 72 (69, 75) 73 (70, 77) 75 (71, 78) 77 (74, 81) 79 (75, 83) 81 (77, 85) Men (%) 64.00 55.34 48.38 41.63 33.80 35.32 21.70 FI (Rockwood) 0.28 (0.25, 0.31) 0.29 (0.26, 0.33) 0.31 (0.27, 0.35) 0.34 (0.30, 0.40) 0.40 (0.34, 0.47) 0.46 (0.39, 0.55) 0.54 (0.45, 0.60) Frailty status (% across categories) Robust 16.32 25.28 30.18 21.47 6.01 0.74 0.00 Prefrail 2.00 6.67 18.93 27.87 25.33 15.33 3.87 Frail 0.00 0.00 2.41 7.83 18.67 36.75 34.34

Carnicero JA, Caballero MA, Rodríguez-Mañas L, 2017

Variable [0-20] (20-30] (30-40] (40-50] (50-60] (60-70] (70-100] pv test for trend N 150 262 401 418 287 201 106 Age 70 72 73 75 77 79 81 Men (%) 64.00 55.34 48.38 41.63 33.80 35.32 2170 Frailty status (% across categories) Robust 16.32 25.28 30.18 21.47 6.01 0.74 0.00 Prefrail 2.00 6.67 18.93 27.87 25.33 15.33 3.87 Frail 0.00 0.00 2.41 7.83 18.67 36.75 34.34 Outcomes Death (%) 4.67 6.11 7.98 12.92 24.04 40.80 53.77 <0.001 3.1E-42 Hospi (%) 8.67 15.65 18.95 24.88 28.92 33.33 28.30 <0.001 3.8E-11

• inc. Disability

(%) 1.16 12.56 20.86 32.83 44.56 54.55 57.45 <0.001 6.9E-29 falls (%) 15.50 17.86 20.17 22.32 28.21 29.09 27.66 <0.001 2.6E-4 fear to falling (%) 27.91 37.39 40.52 53.61 51.05 50.91 61.36 <0.001 9.6E-9

CHARACTERIZATION OF INCIDENT ADVERSE OUTCOMES BY FTS SCORE

Carnicero JA, Caballero MA, Rodríguez-Mañas L, 2017

70% Robust people 70% Prefrail people 70% Frail people

• Mi. Mo. Sev.
• Mi. Mo./Sev.

Carnicero JA, Caballero MA, Rodríguez-Mañas L 2017

Table 3: Combining both frailty and sarcopenia N=1611 Frailty Robust Pre-Frail Frail EWGSOP Sarcopenic 352 (21.8%) 182 (17.3) 141 (29.3) 29(40.3) Non-sarcopenic 1250 (78.2%) 867 (82.7) 340 (27.2) 43 (59.7) FNIH Sarcopenic 705 (43.7%) 348 (33.3) 303 (62.9) 54 (76.1) Non-sarcopenic 894 (56.3%) 698 (66.7) 179 (37.1) 17 (23.9) Quintiles Sarcopenic 134 (8.3%) 31 (3.0) 84 (17.5) 29 (40.8) Non-sarcopenic 1453 (91.7%) 1014 (97.0) 397 (82.5) 42 (59.2)

Table 4. Sensitivity and specificity N=1611 Frailty Sensitivity Specificity PPV NPV EWGSOP 0.60 (0.47, 0.71) 0.21 (0.19, 0.23) 0.03 (0.02, 0.05) 0.92 (0.88, 0.94) FNIH 0.24 (0.14, 0.35) 0.43 (0.40, 0.45) 0.02 (0.01, 0.03) 0.92 (0.90, 0.94) Quintiles 0.60 (0.47, 0.71) 0.08 (0.06, 0.09) 0.03 (0.02, 0.04) 0.80 (0.73, 0.86)

Davies B, F García-Garcia FJ, Ara I, Walter S, Rodriguez-Mañas L JAMDA, 2017 Frailty and sarcopenia are related but different entities Sarcopenia is not useful to screen frailty (low PPV) but to rule it out (very high NPV) 8 % 3.4 % 7.6 % 1.9 % 22 % 2.9 %

Raising misclassification with changing risks

Alonso Bouzón C, Carnicero JA, Turín JG, García-García FJ, Esteban A, Rodríguez-Mañas L. JAMDA, 2017

Time to event

Alonso Bouzón C, Carnicero JA, Turín JG, García-García FJ, Esteban A, Rodríguez-Mañas L. JAMDA, 2017

Frailty classification by tool and setting

Setting Fried (%) FRAIL (%) Tilbg (%) Grng (%) Rockw (%) ISAR (%) Bald (%) G8 (%) VES 13 (%) Total (%) Emergency Room 50,51 40,71 68,14 74,34 47,46 78,76

• 60,00

Cardiology 61,39 41,36 65,55 62,32 42,47

• 54,61

Elective Surgery 24,67 15,48 30,32 30,72 5,16

• 21,27

Urgent Surgery 53,33 41,54 37,50 50,77 18,46

• 40,32

Oncology 47,92 30,00 36,00 40,00 6,00

• 14,28

81,63 34,69 36,31 Agregate 47,43 33,67 51,27 53,23 28,34

• 42,78

70% Robust people 90% Prefrail people

OCTOBER, 2015

The Energetic Pathway to Mobility Loss: An Emerging New Framework for Longitudinal Studies on Aging Jennifer A. Schrack, J Am Geriatr Soc . 2010 October ; 58(Suppl 2): S329–S336.

Disability

Functional Capacity

Death Usual Successful Accelerated

D E A T H

Observational studies: Nutrition: Macronutrients and adherence to Mediterranean Diet and Mediterranean Drinking pattern Physical activity: Avoiding sedentariness, Mod-Vigor physical exercise Ideal CV risk: Diet rich in fruit and vegetables, moderate exercise, non obesity, non diabetes Del Pozo-Cruz y cols., PLoS One 2017 Sandoval-Insausti et al., J Gerontol 2016 McClintock et al., PNAS 2016 Garcia-Esquinas et al., JAMDA, 2015 Ortolá R et al., J Gerontol 2016 Graciani et al., Circ Cardiovasc Qual Outcomes., 2016

Interventional studies: Nutrition: ?????????? Physical activity: LIFE study (pre-frail and frail) Ideal CV risk: MID-FRAIL study (pre-frail an frail)

Outcomes: SPPB Non-robust

Sample size (Size effect) Time of follow-up Clinical phenotypes Settings

IS IT POSSIBLE TO DESIGN SUCH A FLOWCHART FOR FRAILTY

AT RISK NO YES SCREENING PROGNOSIS TREATMENT DIAGNOSIS NO YES NO YES

Yes Is it necessary to modulate the prevention strategy according to the level of frailty? How should it be modulated Clinical Phenotypes By severity By comorbidity By setting With which approaches Improving diet Physical exercise Managing cardiovascular risk Others INTUITIVE NOT EVIDENCE-BASED GREAT OPPORTUNITIES FOR RESEARCH

OBSERVATIONAL STUDIES

RCTS

THANK YOU

e.mail: leocadio.rodriguez@salud.madrid.org