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 • ACG Junior Faculty Career Development Award Transplant Hepatology • American Federation for Aging Research Beeson Scholar Award University of California, San Francisco Alliance for Academic Internal Medicine (T Franklin Williams Scholar Award) • UCSF Older Americans Independence Center • Beeson Scholar in Aging Research UCSF Liver Center • UCSF Resource Allocation Program • Case: Barrier to Transplant? 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? 1
9/29/2016 PROMIS Frailty tool: The Eyeball Test Clinical Frailty Fried Frailty Index TUG SPPB Scale physical ADL activity 6MWT grip gait speed Pitfalls of the eyeball test: strength Vulnerable Elders • Subjective exhaustion Survey IADLs • Detects frailty too late • Can be deceiving: Selection • Obesity criteria • Women - Commonly used in research and/or clinical practice • Well-groomed - Have been used in end-stage organ disease • Variable application in - Ones that I have heard you are clinical practice using in your practice Tools to use in the transplant setting (Maximum) GRIP STRENGTH (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 Dial stop.” turned away from Forearm in - Average of 3 trials patient midprone - Grip duration of 3 seconds with 15 seconds rest in position between Seated (neutral) Elbow flexed 90 degrees Clinical Assessment Recommendations, 3 rd edition. American Society of Hand Therapists 2
9/29/2016 Fried Frailty Instrument Minnesota Leisure Time Activity Questionnaire Questionnaire administered to the patient by a trained interviewer: Characteristic Measure Weight loss: “In the last year, have you Shrinking unintentionally lost 10 pounds?” Self-report “In the last 7 days, how many days have you felt: Exhaustion • That everything I did was an effort? • That I could not get going? ( ≥ 3 days)” Low activity Minnesota Leisure Time Activity questionnaire Performance Slowness Walk time (adjusted for height) -based Weakness Grip strength (adjusted for gender, BMI) Fried, J Gerontol 2001. Taylor HL. J Chron Dis 1978. Fried Frailty Instrument Gait speed Characteristic Measure Weight loss: “In the last year, have you Shrinking unintentionally lost 10 pounds?” Self-report “In the last 7 days, how many days have you felt: “Walk at a Exhaustion • That everything I did was an effort? • That I could not get going? ( ≥ 3 days)” comfortable pace” Low activity Minnesota Leisure Time Activity questionnaire Performance Slowness 15 foot gait speed (adjusted for height) -based Weakness Grip strength (adjusted for gender, BMI) Fried, J Gerontol 2001. 3
9/29/2016 Fried Frailty Instrument Fried Frailty Instrument - Scoring Characteristic Measure Characteristic One point if… Weight loss: “In the last year, have you Shrinking Shrinking Yes unintentionally lost 10 pounds?” Self-report Self-report “In the last 7 days, how many days have you felt: Exhaustion Exhaustion 3 or more days • That everything I did was an effort? • That I could not get going? ( ≥ 3 days)” Men: <383 kcal/week Low activity Low activity Minnesota Leisure Time Activity questionnaire Women: <270 kcal/week Performance Performance Slowness Slowness 15 foot gait speed (adjusted for height) Cut-offs based on gender and height -based -based Weakness Weakness Cut-offs based on gender and BMI Grip strength (adjusted for gender, BMI) Fried, J Gerontol 2001. Fried, J Gerontol 2001. % frail by Fried Frailty criteria Six-minute walk test Wait list candidates - 100 foot hallway Marked every 3 m (~10 feet) - Flat = - Record distance traveled in 6 minutes Lai 2014. McAdams-Demarco 2015. Singer 2015. Fried 2001. Guidelines for the 6MWT, American Thoracic Society 2002. 4
9/29/2016 Six-minute walk test: Real-life results Timed Up and Go Test (TUG) 100m 300m 600m “When I say ‘Go’, I want you to: ~1/8 mile ~1/4 mile ~1/3 mile Stand up from the chair 1) Walk to the line on the floor 2) 571m ≈ 1/3 mile at your normal pace Healthy adults 3) Turn 369m ≈ 1/4 mile Cirrhotic pts 4) Walk back to the chair at your normal pace 5) Sit down again” 319m ≈ 1/5 mile Dialysis pts Lung tx 348m ≈ 1/4 mile candidates Podsiadlo D, J Am Geriatrics Soc 1991. Casanova 2011. Carey 2010. Dudley 2012. Disability: Activities of Daily Living (ADLs) Short Physical Performance Battery Instrumental ADLs (IADs) Balance Gait speed Necessary for Enable an individual to live fundamental functioning. independently in a community. “Do you have difficulty with…” Chair stands 10 sec each • Dressing • Using a telephone • Shopping • Eating • Preparing meals • Ambulating • Housekeeping • Transferring • Doing laundry • Toileting • Arranging transport • Hygiene • Taking meds • Managing finances Guralnik, NEJM 1995. Katz S, JAMA 1963. Lawton MP, Gerotologist 1969. 5
9/29/2016 A Frailty Index for Instruments to Assess Frailty patients with end-stage liver disease Objective Tools + + • Hand grip strength • Fried Frailty Index • 6 minute walk test • Timed up and go Compared to MELDNa alone, the • Short Physical Frailty Index correctly reclassifies Performance Battery 1 out of 5 patients • ADL / IADL scales by their survival status Data in submission. Please do not distribute. Waitlist survival in liver transplant What is your grip strength? candidates (n=536) MELDNa 14 (better liver function) MELDNa 23 (worse liver function) MELDNa 14, Robust MELDNa 23, Robust MELDNa 14, Frail MELDNa 23, Frail Lai JC. In submission. 6
9/29/2016 Average maximum grip strength Key Point We have the tools to operationalize: ~30 kg ~50 kg Adults 1 End-stage 22 kg 35 kg liver dz 2 End-stage 21 kg 37 kg lung dz 3 We need to implement these in clinical practice! End-stage 17 kg 28 kg kidney dz 4 1 Mathiowetz V 1984. 2 Lai JC 2014. 3 Singer J 2016. 4 Chang Y-T 2011. Fried, SPPB, ADL, IADL scales are available in the Appendix of: Lai JC, AJT 2014. Characteristics of tools to consider Type Ease of use Length of time to administer # of questions/compon ents Domains tested 7
9/29/2016 Waitlist survival in liver transplant Clinical Frailty Scale candidates by MELDNa and Frailty 100% MELDNa 14, Robust 80% MELDNa 23, Robust Survival Probability MELDNa 14, Frail 60% 40% MELDNa 23, Frail 20% 0% 20 0 10 30 Time since assessment (months) Lai JC. In submission. 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 Lai JC. In submission. 8
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