Identifying frailty in older people

Louise Briggs AHP Therapy Consultant

St Georges Healthcare NHS Trust October 2014

Learning objectives

By the end of the session:

• To be able to recognise frailty in older adults in your clinical setting

• To enhance your skills in assessment of the frail older adult

What is frailty? “A physiological syndrome characterised by decreased reserve and diminished resistance to stressors, resulting from cumulative decline across multiple physiological systems and causing vulnerability to adverse outcomes”

Ferrucci et al: American Geriatrics Society/National Institute on Aging conference on frailty in older adults 2004

When and how should frailty be recognised?

• At any contact between the physiotherapist and an older adult

• Type of assessment will differ depending on the circumstances

– Pre-operative assessment clinics

– Admission avoidance e.g. Emergency Departments/Acute Medical Units

– Community settings

Simple assessments

• Gait speed • Taking more than 5 seconds to cover 4 metres

• Timed Up and Go: a cut off score of 10 seconds

Good sensitivity but only moderate specificity

Essential to exclude false positives through clinical reasoning

Frailty syndromes

• The presence of one or more of these 5 syndromes should raise suspicion of frailty

– Falls (e.g “collapse”, “legs gave way”)

– Immobility (e.g “off legs, “acopia”, “stuck on toilet”)

– Delirium (e.g acute confusion, fluctuating)

– Incontinence (e.g new incontinence or worsening of urinary or faecal incontinence)

– Susceptibility to side-effects of medication (e.g confusion with analgesia, hypotension with anti-depressants)

Subjective assessment

• History taking

– Time-line

• The present: at crisis

• Base-line: within the last 2-4 weeks

• Over the last 6 months

– Gradual loss of independence in several domains?

– Repeated admissions to the ED?

– Failure to maintain health at home? eg: weight loss, increasing social isolation, declining mobility and ADLs

Subjective assessment

Cognition

– Nature, timeline and extent plus functional implications

• Worse than usual?

• May need input from carers for collateral

Mobility

– History of falls may indicate frailty or acute illness

– Life-space

Function

– Nature, timeline and extent

Social

– Include social activities and engagement/participation

Co-morbidities

– Stage and severity, disease burden and symptom control

Medications

– Clarifies disease and symptom burden

– Poly-pharmacy

– Compliance

– Recently started on new medication/change of dose?

Conceptual model showing life-space levels as a series of concentric areas radiating from the

room where a person sleeps.

Peel C et al. PHYS THER 2005;85:1008-1019

Physical Therapy

Identifying the Frailty Phenotype Frailty indicator Possible measure

Strength Grip strength, five sit to stand test, chair stand test (30 seconds)

Fatigue Tools available but not many validated in older people FACIT Fatigue Scale “ In the past week, how often have you felt that you could not get going?”

Slowness 6 metre walk test, Timed up and go

Physical activity CHAMPS (Community Healthy Activities Model Program for Seniors) Phone-FITT APAFOP (Assessment of Physical Activity in Frail Older People) Life Space Questionnaire

Weight loss MUST, observation –loose clothes Unintentional weight loss>4.5kg in past year

Principles of Assessment

1. Comprehensive interdisciplinary assessment of physical, emotional, psychological, social and support factors

2. Assessment of psychological and social factors that are potential barriers to implementation, uptake and adherence with interventions

3. Regular reassessment eg: following illness or injury to detect changes in needs and timely modification of care provision

WHO ICF model

Level of ICF Pattern Common causes Other causes

Health condition Unstable health conditions Under-nutrition Over-nutrition?

Injury, sepsis, exacerbation long term condition Inability to prepare meals

Frequent transitions between acute/community Sub-optimal management Unable to purchase food

Impairment Cognition Sensory Motor

Depression, grief Cataract OA

Low self-efficacy Lack of appropriate aids/glasses

Activity limitation Reduced mobility Decreased self-care

Impaired power/balance

Decreased endurance Fear of falling

Participation restriction

Lack of participation in life roles

Social barriers Limited family contact

Low self-efficacy

Environmental/ contextual factors

Difficulties with accessing services

Services not available or fragmented

Carer stress Isolation

How should frailty be managed?

• All frail older adults should have a medical review by their GP based on the principles of comprehensive geriatric assessment

– A personalised care and support plan

– Optimise health and function • Physical activity and exercise programme

• Education

– Escalation plan advising when the patient/carer may need to seek advice

– An urgent care plan

– Where appropriate, an end of life care plan » Fit for Frailty Consensus Guidance BGS 2014

Conclusions

• Physiotherapists are ideally placed to case find and identify frailty in older adults

• We have a key role in: – prevention of frailty

– optimising and maintaining physical activity and independence in frail older people

– end of life care

• Personalised integrated care plans shared across the acute and community interface are essential for optimising health and well being in frail older adults

Thank you for listening!

References

• Abellan et al 2009. Gait speed at usual pace as a predictor of adverse outcomes in community dwelling older people an International Academy on Nutrition and Aging (IANA) Task Force. Journal of Nutrition, Health and Aging 13 (10): 881-9

• BGS 2014. Fit for Frailty Consensus best practice guidance for the care of older people living with frailty in community and outpatient settings.

• Gill et al 2008. The Phone-FITT: a brief physical activity interview for older adults. Journal of Aging and Physical Activity 16 (3): 292-315

• Hauer et al 2010. Assessment of physical activity in older people with and without cognitive impairment. Journal of Aging and Physical Activity 19 (4): 347-372

• Hubbard et al 2010. Frailty, body mass index, and abdominal obesity in older people. Journal of Gerontology and Biological Sciences and Medical Sciences 65 (4): 377-81

References

• Peel C et al 2009. Assessing mobility in older adults: the UAB Study of Aging Life-Space Assessment. Physical Therapy 85 (10): 1008-119

• Stewart et al 2001. CHAMPS physical activity questionnaire for older adults: outcomes for interventions. Medical Science and Sports Exercise 33 (7): 1126-41

• Tang et al 2014. Motor dual task Timed Up and Go test better identifies prefrailty individuals than single task Timed Up and Go. Geriatrics and Gerontology International Feb 27. dol:10.1111/ggl.12258

• Webster et at 2003. The functional assessment of chronic illness therapy (FACIT) measurement system: properties, applications and interpretation. Health and Quality of Life Outcomes 1 (79): 1-7

• Xue et al 2007. Life-space constriction, development of frailty, and the competing risk of mortality: the Women’s Health and Aging Study. American Journal of Epidemiology 167 (2): 240-8