![Page 1: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/1.jpg)
Identifying frailty in older people
Louise Briggs AHP Therapy Consultant
St Georges Healthcare NHS Trust October 2014
![Page 2: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/2.jpg)
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
![Page 3: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/3.jpg)
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
![Page 4: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/4.jpg)
![Page 5: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/5.jpg)
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
![Page 6: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/6.jpg)
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
![Page 7: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/7.jpg)
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)
![Page 8: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/8.jpg)
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
![Page 9: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/9.jpg)
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?
![Page 10: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/10.jpg)
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
![Page 11: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/11.jpg)
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
![Page 12: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/12.jpg)
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
![Page 13: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/13.jpg)
WHO ICF model
![Page 14: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/14.jpg)
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
![Page 15: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/15.jpg)
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
![Page 16: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/16.jpg)
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
![Page 17: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/17.jpg)
Thank you for listening!
![Page 18: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/18.jpg)
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
![Page 19: Identifying frailty in older people · Frailty syndromes • The presence of one or more of these 5 syndromes should raise suspicion of frailty –Falls (e.g “collapse”, “legs](https://reader036.vdocument.in/reader036/viewer/2022070915/5fb57dc857a49c23db10667b/html5/thumbnails/19.jpg)
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