PRNTS X FRLTY SNDRM

Frailty syndrome

by Dr Chris Nickson, last update March 29, 2019

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Revised and reviewed 15 August 2015

OVERVIEW

• Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserves in vulnerability that predisposes to the accumulation of deficits and adverse outcomes from acute stressors
• Frailty correlates with increasing age, but is not an inevitable consequence of ageing
• Frailty affects ~10% of those aged >65y, and ~25+% of those aged >85y
• Frailty is a dynamic condition, and is potentially reversible
• Frailty is more than simply the combination of disability (functional impairment) and the presence of comorbidities
• no single operational definition or simple assessment tool for frailty has been agreed upon

MODELS OF FRAILTY

Two major frailty models have been described: the frailty phenotype and the frailty index:

• The frailty phenotype defines frailty as a distinct clinical syndrome meeting three or more of five phenotypic criteria: weakness, slowness, low level of physical activity, self-reported exhaustion, and unintentional weight loss
• The frailty index defines frailty as cumulative deficits identified in a comprehensive geriatric assessment.

Proposed clinical definition of the frailty phenotype (McDermid et al, 2009) (aka Fried’s definition or Cardiovascular Health Study (CHS) definition)

Criteria:

• Decreased grip strength
• Self-reported exhaustion
• Unintentional weight loss of more than 4.5 kg over the past year
• Slow walking speed
• Low physical activity

Definition

• Positive for frail phenotype: ≥3 criteria present
• Intermediate/pre-frail: one or two criteria present
• Non-frail: no criteria present

Frailty Index

• Frailty Index — a detailed 70-item inventory of clinical deficits, often used in research
• Unclear if adds additional benefit to Comprehensive geriatric assessment (CGA)
• Appears to be a more sensitive predictor of adverse health outcomes than the fragility phenotype
• Does not attempt to distinguish frailty from disability or comorbidity; does not incorporate a pathogenic basis

Other Diagnostic Tools

• There are numerous tools for the assessment of fragility, none of which are proven to have greater clinical utility compared to the others
• Comprehensive geriatric assessment (CGA) is considered the gold standard, but cannot readily be performed in an acute care setting — This is a “multidisciplinary, diagnostic process to describe the medical, psychological and functional capabilities of a frail older person in order to keep a co-ordinated, integrated plan for long-term treatment and follow-up”
• Edmonton Frail Scale — simpler assessment of function that is valid and reliable (see Table 1 from Wyrko, 2015)
• Clinical Frailty Scale (CFS) — 7-point scale that correlates with frailty index (Rockwood et al, 2005)
• Simple tests (high sensitivity, low specificity)
  • slow walking speed: >5 seconds to walk 4 metres
  • timed up-and-go test: >10 seconds to stand from a chair, walk 3 metres, turn round and sit down again
  • a score of 3 or above on the PRISMA 7 questionnaire (see www.bgs.org.uk/campaigns/fff/fff_full.pdf)

PATHOGENESIS

Etiology/ risk factors

• ageing
• genetics
• lifestyle
• diseases
• environment

Potential mechanisms resulting in Frailty phenotype

• chronic inflammation
• effects on CVS, haematological, endocrine and musculoskeletal systems

Results in adverse health outcomes (death, disability, dependency and falls)

MANAGEMENT

Management strategies that may be of benefit:

• Early physiotherapy (e.g. early mobilisation) and occupational therapy input to establish usual functional baseline, provide walking aids and prevent unnecessary deterioration by prolonged bed rest
• Pharmacology
  • Dose reduction is often appropriate in the frail elderly
  • Pharmacy involvement for medicines reconciliation to reduce drug interactions and iatrogenic harm
• Early assessment and treatment of complications of acute illness that are common in patients with frailty:
  • delirium
  • falls risk
  • pressure sore risk
• Nutrition support
• Early discussion of end of life goals and appropriate limitation of invasive therapies to avoid unnecessary iatrogenic harm

PROGNOSIS

Assessment of frailty and poor physiological reserve is becoming increasingly important as we become more cognisant of the poor longterm outcomes and costs associated with intensive care of the frail

• Critically ill elderly frail patients, compared to similarly aged non-frail patients have worse outcomes (morbidity, mortality and institutionalisation)
• Critically ill patients of all ages may share characteristics with frail elderly patients: “deficits associated with frailty, which typically take years to accumulate in the outpatient geriatric population, rapidly develop in a large proportion of critically ill patients independent of age and illness severity” (McDermid et al, 2009)