Frailty- what’s 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 in: • Peri-operative medicine • Nephrology • Oncology
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 objectively measurable • Demographic vs. mathematical
Frailty- definition Clegg et al. Lancet (2013)
Pathophysiology Clegg et al. Lancet (2013)
1. Frailty Phenotype Model 0= non-frail/robust 1-2= pre-frail J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M157. 2= frail J Am Geriatric Soc 2004; 52: 625-634.
Survival by Frailty Phenotypes Mortality at 7 years: Non-frail - 12% Pre-frail - 23% Frail - 43% Hazard Ratio= 1.63 Arch Intern Med 2006; 166: 418-423.
Frailty Phenotype Model • Frailty also correlated with: • Worsening mobility • Falls • Fracture • Disability • Institutionalization Arch Intern Med 2006; 166: 418-423.
2. Frailty Index “Tipping Point”= 0.67 Hazard Ratio (mortality)= 1.57
Each step up= increased risk of death (21.2%) and institutionalization (23.9%) over 70mon Can Med Assoc J 2005; 173: 489-495.
Peri-operative medicine
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.
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
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
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
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.
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.
Mr. S • Revised Cardiac Risk Index (RCRI)= 6.0% • Geriatric-Sensitive Perioperative Cardiac Risk Index= 1.6%
Frailty for All Surgeries Points Timed up and go 1 Katz score 1 Frailty and Mini Cog 1 surgery 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 of Surgery , 206 (4), 544-550.
Frailty and Surgery Non-Frail Frail Post-operative 21% 58% complications 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 of Surgery , 206 (4), 544-550.
Frailty for All Surgeries Points Timed up and go 1 Katz score 1 Frailty and Mini Cog 1 surgery 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 of Surgery , 206 (4), 544-550.
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
Frailty and Nephrology
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
Can Med Assoc J 2005; 173: 489-495.
Frailty Phenotype Model 0= non-frail/robust 1-2= pre-frail J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M157. 2= frail J Am Geriatric Soc 2004; 52: 625-634.
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.
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.
Frailty independently predicted >3 -fold risk of falling Frailty, CKD, Falls 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.
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.
Hospitalization Death 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.
Mortality at 3 and 6 months: Score 3 mon 6 mon 3 12% 20% ≥8 39% 55% 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.
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
Frailty and Oncology
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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