frailty in the older adult cynthia j. brown, md, msph associate professor director, geriatric...

Frailty in the Older Adult

Cynthia J. Brown, MD, MSPHAssociate ProfessorDirector, Geriatric Medicine SectionBirmingham/Atlanta VA GRECCUniversity of Alabama at Birmingham

Learning Objectives

• Identify key features of frailty as currently defined

• Define sarcopenia

• Understand changes in body composition associated with aging

• Describe how a multidisciplinary team might approach frailty in the older adult

Case Presentation

Case 1: An 82-year old man with a history of heart failure, knee osteoarthritis, and hypertension presented for elective knee replacement.

Case 2: An 82-year-old man with a history of heart failure, knee osteoarthritis, and hypertension presented for elective knee replacement.

Case 3: An 82-year-old man with a history of heart failure, knee osteoarthritis, and hypertension presented to the ED after being found by a neighbor on the floor.

• These three patients demonstrate different levels of susceptibility and clinical stability, which strongly affected clinical outcomes.

• There appears to be a spectrum of resilience, from highly independent and robust to the most frail and vulnerable.

Defining Frailty

Break into your small groups and answer the following questions:

• How would you define the term “frail”?• What makes a person frail?• Are there key components to frailty?

Frailty Definitions

• A variety of definitions have been used defining frailty as synonymous with:– Disability– Comorbidity– Advanced Old Age

• However, while there is some overlap, frailty appears to encompass more than disability or comorbidity.

Overlap of Frailty with ADL Disability and Comorbidity

Disability: > 1 ADL

FrailtyComorbidity

N=67

26.6%

N=98

N=2131

21.5%

46.2%

5.7%

Fried LP, J Gerontol Med Sci, 2001

Frailty Definition

• Clinicians have begun to define frailty as:

“a syndrome of decreased reserve and resistance to stressors, that result in cumulative declines across multiple physiologic systems, causing vulnerability to adverse outcomes.”

• It has been postulated that there are key components of frailty, and multiple components must be present to constitute frailty.

Fried LP, J Gerontol Med Sci, 2001

Fried’s Model of Frailty

Fried’s Model of Frailty

Definitions of Components of Frailty– Shrinking

• > 10 pounds lost unintentionally in past year

– Self-reported exhaustion• Self-report of exhaustion on CES-D questions

– Weakness (grip strength)• Grip strength lowest 20% adjusted for gender &

BMI

– Slow walking speed• Slowest 20% to walk 15 feet

– Low physical activity• Lowest quintile of weighted kilocalorie expended

per week

Sarcopenia in the Older Adult

Sarcopenia

• Sarcopenia: age-related loss of muscle mass and strength.

• Changes in the muscle fiber itself, and an increase in infiltration of fat into the muscle (myosteatosis) also common with aging.

• Changes all lead to a decline in muscle function.

Top: Young Male, age 25 Bottom: Older Male, age 63 Height and weight matched

Top: Young Female, age 27 Bottom: Older Female, age 65 Height and weight matched

Sarcopenia and MyosteatosisPetrella et al. Eur J Appl Physiol 2007

Physical activity Disability

Strength Power MuscularEndurance

Difficultywith weightbearing tasks

Risk of fallsand fracture Fatigability

Muscle Aging

25 y 37 y 61 y 72 y

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Women

25 y 37 y 61 y 72 y

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25 y 37 y 61 y 72 y

% o

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25 y 37 y 61 y 72 y

5.5

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C. Men D. Women

25 y 37 y 61 y 72 y

Bila

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10000

12000

14000

16000

18000

20000

22000

24000Men

Women

F.E.

*‡

*‡

*‡*‡

Age-related Loss of Muscle Mass

Values are mean ± SE. Main age group effects, P<0.001.

*Different from 25 y, P<0.05. ‡Different from 37 y, P<0.05. DXA-determined limb muscle mass. MM Bamman, et al.

N=211

Functional Consequences

• Walking fundamental mobility task.• Variables that influence walking speed

include:– Musculoskeletal status

– Sensory function

– Motor control

– Cognitive status

• Walk speed a general summary indicator; could be useful single-item screening tool

Evaluation of Function

Gait Speed

Predicted Median Life Expectancy by Age and Gait Speed

Studenski S, et al. JAMA. 2011;305(1):50-58.

Timed Chair Stands

• Used to evaluate lower body strength and endurance

• Instruct to stand from chair without using arms 5 times while being timed.

• Normative values available, can identify which older persons may have problems with strength.

Get Up and Go Test

• The get up and go test asks a person to:– stand from a chair without using their arms – walk 10 feet – turn around and walk back – and sit in the chair

• Can be timed with a time of ≥ 20 seconds indicating risk for adverse outcomes.

• Can also observe for unsteady gait.

Now it is your turn to try these easy clinical assessments

Health Literacy in Older Adults

Contributing Factors in Older Adults

• Fewer years of schooling, poorer—fixed incomes

• > 50% do not take meds as directed• 68% cannot interpret blood sugar value• 76% cannot follow Upper GI instructions• 100% could not understand Medicaid rights

in one study

Related Cultural/Language Barriers

• Non-English speaking • Immigrant status• Ethnic interpretation of illness• Spiritual and religious beliefs• Default answers• Lack of insurance/transportation

Testing in a Busy Practice

• Always assume and ask in sensitive way– ”How do you get your information?”– “What things do you like to read?” – “How satisfied are you with how you read?”

• Eyes wandering over page, very slow to finish, sounding out words, look confused

• Remember the “pill bottle” prop– Ask questions about the dosage and frequency

Nutrition Problems in the Older Adult

Changes in Body Composition

• There is a net decrease in:– Bone mass– Lean muscle mass– Water content

• There is a net increase in:- Total body fat- Especially intra-abdominal (fat located

inside the belly area/abdominal cavity)

Physiological Changes Accounting for Nutrition Risk in Elderly

Changes in taste, and smell

Changes in the gastrointestinal system

Impaired thirst sensation

Atrophic gastritis (chronic inflammation of stomach with reduced stomach secretions.

Pathologic Changes Common in Aging

• Chronic diseases and restrictive diets

• Dental problems

• Depression

• Alcohol abuse

• Medication side effects