Frailty

Something real or just a fad?

Mr AS 81• Admitted DGH April ‘Dry’ AKI. ‘Diarrhoea’• Discharged, no care, after 2/7 GP called as ‘confused’-

bloods taken – no real action• July readmitted with CP – diagnosis is IHD and CCF,

discharged with care from Soc serv, • 1 week later – acute immobility - readmitted – found

hypotensive – meds all changed • Referral to CCT for ‘incontinence’ on discharge, patient

weighed – no change – but increasing confusion• GP x 2 visits – different GPs eventually calls Comm Ger

Mr AS Continued….

• Comm Ger visits and finds;– Pats family very confused about drugs so reverted

to previous drugs from GP/2nd hospital admission– Has had diarrhoea on and off for 6 months with

incontinence (not recognised)– BP Very low, pt dry and delerious– Progressive cognitive decline over 6 – 12 months.

• Patient readmitted – 4th Admission in 6 months – very, very unwell.

Mrs Andrews story

What is Frailty?

A state of impaired homeostasis leading to increased vulnerability to minor stressor events.

In other words; Older people living with frailty are at risk of adverse outcomes such as dramatic changes in their physical and mental wellbeing after an apparently minor event which challenges their health, such as an infection or new medication.

Adverse outcomes include reduced mobility, loss of independence or death.

Trajectory of Frailty

From Clegg et al – Lancet 2013

Is this just Old Age?

Bronze Age

Iron Age

Stone Age

Rowe 2005

What is the evidence of a separate group.?

CHS 2001USA

5317 subjects

Hospitalisation Disability Death

Intermediate Frailty

Severe Frailty

Intermediate

Frailty

SevereFrailty

Intermediate

Frailty

SevereFrailty

7 year Follow up

1.11(1.03- 1.19)

1.27(1.11- 1.46)

1.55(1.38- 1.75)

1.79(1.47- 2.17)

1.32(1.13- 1.55)

1.63( 1.27- 2.08)

Phenotype of frailty;• Unintended Weight Loss• Slow Gait Speed• Low Energy Expenditure• Self Reported Exhaustion• Poor Grip Strength ( sarcopenia)

Fried et al 2001

Rockwood CFS 2004

Canadian Study 2004

CSHA 2004 Song, Rockwood et al.

Cumulative Deficit model of frailty.

How does it fit with multimorbidity?

From CHS Fried et al 2001

Frailty

DisabilityMultimorbidity

5.7

26.6

46.2

21.5

How do we recognise Frailty?• Models of frailty

– Phenotype( Fried)• Unintended weight loss• Loss of muscle strength(sarcopenia)• Self reported exhaustion• Slow Gait speed• Low Energy Expenditure

– Cumulative deficit (Rockwood)• A number of things(signs, symptoms and diseases)

accumulating

BGS.org.uk Download ‘Fit for Frailty’

Recognising Frailty using tests..

– Gait Speed < 0.8 m/s or >5s to walk 4m.– Timed up-and-go test >10secs– Questionnaire

Prisma 7 QuestionnairePrisma 7 Questions

1] Are you more than 85 years?

2] Male?

3] In general do you have any health problems that require you to limit your activities?

4] Do you need someone to help you on a regular basis?

5] In general do you have any health problems that require you to stay at home?

6] In case of need can you count on someone close to you?

7] Do you regularly use a stick, walker or wheelchair to get about?

All have limitations;

• Acceptability• Response rate• High Sensitivity but low specificity( eg Gait Speed PPV = 33% for over 75’s)

Positive Response to 3 or more;

Sensitivity of 0.83 Spec 0.80PPV= 40%

Recognising Frailty Using Clinical Info

Frailty syndromes – Falls(collapse, flof)– Reduced mobility(stuck on toilet, wobbly, cant walk)– Delirium(acute confusion or change in function)– Incontinence - urgency– Sensitivity to drug effects– UTI !!!– ACOPIA(!)– ‘Social admission’.

Treating Frailty;

• Changing Severity ( in due course)– with nutrition?– exercise programmes to address the sarcopenia-details unclear but

definite evidence for intensive resistance exercise( which is hardly available)

– Multi faceted approach to target the characteristics– Eg Cameron et al 2013.

• Managing the Effects of Frailty; ‘Frailty marks the point at which disease based guidelines are

no longer the priority’ .

Comprehensive Geriatric Assessment( a process of care)

Managing Frailty

Comprehensive Geriatric Assessment Ellis et al 2011.Metanalysis of controlled trials of CGA in acute hospitals

– Less likely to die– More Likely to end up living at home in 6/12NNT = 13

Beswick 2008 and 2012- Complex interventions can reduce hospital admissions in those with frailty and reduce admission to NH ( NNT = 33)

Assessment

Creation of stratified

problem list

Identification of Goals

Bespoke Care Plan

Interventions

Regular Planned Review

Mental/ Psychological

Physical

Functional

Social

Environmental

What is CGA?

Multiprofessional, holistic review, PERSONALISED problem/goal list and care plan, with intervention and review.

The Silver Book 2012

Fit for Frailty Parts 1 and 2BGS 2014 and 2015

Both available from the BGS website= bgs.org.uk

Philp et al ‘Reducing Hospital Bed Use’ Int J Integrated Care2013

• 2007 – date- 48 studies;– 8 metanalyses, 9 systematic reviews, 5 literature

reviews, 8RCT and 15 others.– Prevention Hospital Admission;

• Care Coordination• Preventive health Checks• Care Home Liaison

– Reducing LOS and Preventing Readmission• Linking Hospital and community care inc discharge

planning, Information sharing and RRR in home.

– No Value; Falls prevention, Meds review, Ex Prog, Nutrition and Nurse led Intermediate care

Medication Review

Works

• When uses Evidence Based guidance• When part of an Holistic Med Review (so possibly

not effectively done by pharmacists alone)• To avoid Potentially Inappropriate Drug Use in OP-

PIDU-• To avoid Adverse Drug Reactions(3-5% adm)

• Number of drugs is a strong RF for ADR( ? Good outcome indicator)

• Only 6% of ADR are due to PIDU

• Possibly improves patient outcomes?

Screening Tool of Older Persons’ Prescriptions (STOPP) version 2

http://ageing.oxfordjournals.org/content/early/2014/11/18/ageing.afu145

Section A: Indication of medication

• 1. Any drug prescribed without an evidence-based clinical indication.

• 2. Any drug prescribed beyond the recommended duration, where treatment duration is well defined.

• 3. Any duplicate drug class prescription e.g. two concurrent NSAIDs, SSRIs, loop diuretics, ACE inhibitors, anticoagulants (optimisation of monotherapy within a single drug class should be observed prior to considering a new agent).

Sections B- J – relate to body systems

Section K: Drugs that predictably increase the risk of falls in older people

• 1. Benzodiazepines (sedative, may cause reduced sensorium, impair balance).

• 2. Neuroleptic drugs (may cause gait dyspraxia, Parkinsonism).

• 3. Vasodilator drugs (e.g. alpha-1 receptor blockers, calcium channel blockers, long-acting nitrates, ACE inhibitors, angiotensin I receptor blockers, ) with persistent postural hypotension i.e. recurrent drop in systolic blood pressure ≥ 20mmHg (risk of syncope, falls).

• 4. Hypnotic Z-drugs e.g. zopiclone, zolpidem, zaleplon (may cause protracted daytime sedation, ataxia).

Section L: Analgesic Drugs

Section N: Antimuscarinic/Anticholinergic Drug Burden

Anticholinergic Burden

• Section A: Cardiovascular System

Statin therapy with a documented history of coronary, cerebral or peripheral vascular disease, unless the patient’s status is end-of-life or age is > 85 years

• Section B: Respiratory System

• Section C: Central Nervous System& Eyes

• Section D: Gastrointestinal System

• Section E: Musculoskeletal System

• Section F: Endocrine System

• Section G: Urogenital System

• Section H: Analgesics

• Section I: Vaccines

Also Beers Criteria – AGS- https://www.dcri.org/trial-participation/the-beers-list

Screening Tool to Alert to Right Treatment (START)

http://ageing.oxfordjournals.org/content/early/2014/11/18/ageing.afu145

Crime Criteria( CRIteria to assess approp Medication use Among Elderly complex pts)

Drugs and Aging 2014 Italy.

Diabetes• Recommendation 1: In patients with limited life expectancy(\5 years) or functional limitation, intensive glycemic control (HbA1c<7 %) is not

recommended.• Recommendation 2: In patients with a history of falls or cognitive impairment or dementia, intensive glycemic control (HbA1c of <7 %) or use of

insulin is not recommended.• Recommendation 3: In patients with a recent fall or high risk of falls or orthostatic hypotension, intensive blood pressure lowering (\130/80 mmHg) is

not recommended.• Recommendation 4: Use of statins in older adults with limited life expectancy (\2 years) or advanced dementia is not recommended.• Recommendation 5: Metformin should be avoided in malnourished (body mass index\18.5 kg/m2) older adults.Hypertension• Recommendation 1: In patients with dementia or cognitive impairment or functional limitation, a tight blood pressure control (\140/90 mmHg) is not

recommended.• Recommendation 2: In patients with dementia or cognitive impairment or functional limitation, use of more than three antihypertensive drugs should

be avoided.• Recommendation 3: In patients with limited life expectancy (\2 years), a tight blood pressure control (\140/90 mmHg) is not recommended.• Recommendation 4: In case of falls associated with orthostatic hypotension (or symptomatic orthostatic hypotension),the number of antihypertensive

drugs should be reduced and concomitant use of multiple antihypertensive agents should be avoided.Congestive Heart Failure• Recommendation 1: In the presence of orthostatic hypotension or falls, increasing the dosage of antihypertensive drugs is not recommended; the

reduction of drug dosages should be considered.• Recommendation 2: The chronic use of diuretics in asymptomatic or minimally symptomatic older adults with a history of falls and increased fracture

risk is not recommended.• Recommendation 3: Pursuit of low blood pressure targets (systolic blood pressure\130 mmHg) in older adults with dementia or cognitive impairment

is not recommended.•  

Crime Criteria( CRIteria to assess approp Medication use Among Elderly complex pts) contd…

Atrial Fibrillation

• Recommendation 1: In patients with non-valvular atrial fibrillation and limited life expectancy (\6 months), avoid the use of oral anticoagulants Recommendation 2: In non-valvular atrial fibrillation,the use of warfarin in the presence of malnutrition or irregular food intake is not recommended.

• Recommendation 3: In non-valvular atrial fibrillation,the use of anticoagulants is not recommended in elderlypatients with dementia if any of the following characteristics are present: unable to manage medications and living alone or high risk for falls.

• Recommendation 4: In patients with non-valvular atrialfibrillation and high risk for falls or poor physical performance,the use of anticoagulants is not recommended if the risk for stroke is low. (i.e.CHADS2 score \2 or CHA2DS2-VASc \2)

• Recommendation 5: In patients with known difficulties in managing therapy (i.e. cognitive impairment) and lack of assistance (i.e. caregiver), the use of drugs with a narrow therapeutic index, including digoxin and warfarin, is not recommended.

Coronary Artery Disease• Recommendation 1: The use of statins for secondary prevention in older adults with limited life expectancy (<2 years) or advanced dementia is not

recommended.• Recommendation 2: In case of orthostatic hypotension, the dosage of antihypertensive drugs should be reduced and the concomitant use of multiple

antihypertensive agents should be avoided.

Effect on Patient Outcomes?Hospitalised Patients with Frailty. Drug use during admission CRIME study 2014 Age Ageing. • PIDU using STOPP criteria associated with ADR – OR = 2.36(1.1- 5.06)• PIDU using STOPP (2 or more drugs) associated with Functional Decline

OR= 3.5(1.77- 6.91)

BP management

Ogliari G et al Age and Ageing 2015; 44: 932–93775 yrs + cohort study

Assessment

Creation of stratified

problem list

Identification of Goals

Bespoke Care Plan

Interventions

Regular Planned Review

Mental/ Psychological

Physical

Functional

Social

Environmental

What is CGA?

Multiprofessional, holistic review, PERSONALISED problem/goal list and care plan, with intervention and review.

‘I ‘Statements for Older people – from ‘I’m still me’

Independence• I am recognised for what I can do rather than making assumptions about what I cannot• I am supported to be independent• I can do activities that are important to me• Where appropriate, my family are recognised as being key to my independence and

quality of life• Community interactions• I can maintain social contact as much as I wantDecision making• I can make my own decisions, with advice and support from family, friends or

professionals if I want itCare and support• I can build relationships with people who support me• I can plan my care with people who work together to understand me and my carer(s),

allow me control, and bring together services to achieve the outcomes important to me• Taken together, my care and support help me live the life I want to the best of my ability

Age UK, UCL Partners, National Voices and NHS E December 2014.

Also made the point that OP do not like being called frail!....

In more detail – where does care take place?

Patterns of Care

• Challenges for community services and primary care• Supporting Self care, informal care and communities • Supporting Choices and priorities • Cognition, capacity and best interests(for the whole not the disease)• Recognising End of Life – ‘The Surprise Question’ and planning for it• Supporting Carers

• Challenges for specialists Availability at all times and places– Planning and escalation– Avoiding silos and parallel service streams– Communication direct and technological– Education of teams and patients – Recognition that the whole may be more important than the components. e.g Hb level, blood sugar, drug formulary

The scourge of the specialist

From Barnett at al – 2012 Lancet 380 37-43

Where are the vulnerable points?

• Getting to the pathway – falling, memory etc• New diagnosis of frailty/ dementia• Admission to hospital• Leaving hospital• Changing medications • Declining to engage

Leaving hospital

Medicines-related results from the 2011 Care Quality Commission Survey of Adult Inpatients, carried out by the Picker Institute, are presented below. There is considerable room for improvement, particularly with regard to counselling about side effects.

Why do it in hospital at all?

But….

• Investment in Community Services has not followed the increase in NHS Budget– Numbers of DN’s fell by 38% between 2001 and

2011( RCN 2013)• ‘Primary care in crisis’• ‘The staff we will have are the staff we

already have’ Imison C, Kings Fund 2014– So we need to work differently and where the patients are –

aligning the workforce to the work- should pharmacists follow patients up at home?

Back to Mr Stewart

• What could have happened…– Frailty Recognised and proactive care plans in situ for

management of diarrhoea and drug review– First admission recognised previous work and full

communication with GP/Comm Team and community pharmacist

– After second admission (if needed) no changes in drugs made in hospital – but followed up at home for treatment and drug review between pharmacist and GP

– Probably no third or fourth admission

A thought

‘We’ve been wrong about our job in medicine…..it is to enable wellbeing. And wellbeing is about the reasons one wishes to be alive.’