Frailty: how to recognise it and why it

matters

Andy Clegg

Senior Lecturer & Consultant Geriatrician

University of Leeds & Bradford Teaching Hospitals

‘We see, but we do not always recognise’

We move from seeing to recognising by understanding

Increasing frailty

Fit Mild frailty Moderate frailty Severe frailty

Understanding frailty

Condition characterised by loss of biological

reserves, failure of homeostatic mechanisms, and

vulnerability to adverse outcomes

Clegg, Young, Iliffe, Olde-Rikkert, Rockwood. Lancet 2013

Clinical presentation of frailty

Frailty models

Two main established ‘research standard’ international

models of frailty

1. Phenotype model (Fried JGMS 2001)

• Frailty identified on the basis of five characteristics

2. Cumulative deficit model (Rockwood CMAJ 2005)

• Frailty identified using a range of ‘deficits’ (symptoms, signs,

diseases, disabilities) – between 30 and 70

• Calculate frailty index (no. of deficits/total possible)

Frailty assessment:

NICE + NHS

Primary care & outpatient settings

• An informal assessment of gait speed (time taken to answer the door, or walk from the waiting room)

• A formal assessment of gait speed (>5s to walk 4m)

• PRISMA 7 questionnaire (>3)

• Edmonton frail scale (>8)

• Clinical frailty scale (>5)

• eFI (routine data…...)

Inpatient settings

• Clinical frailty scale (>5)

• Reported Edmonton frail scale

• ISAR tool

Development cohort 250,000

Internal validation cohort 250,000 External validation cohort 500,000

Identifying frailty using routine data:

the eFI

Clegg Age Ageing 2016 (open access)

Outcome Mild frailty

(HR, 95% CI)

Moderate frailty

(HR, 95% CI)

Severe frailty

(HR, 95% CI)

1 yr care home admission 2.00 (1.68 to 2.39) 2.70 (2.41 to 3.04) 5.94 (4.61 to 7.64)

3 yr care home admission 1.52 (1.37 to 1.69) 2.70 (2.41 to 3.04) 3.42 (2.84 to 4.12)

5 yr care home admission 1.56 (1.43 to 1.70) 2.34 (2.10 to 2.61) 3.00 (2.42 to 3.70)

1 yr hospitalisation 1.85 (1.81 to 1.88) 2.96 (2.90 to 3.02) 4.62 (4.50 to 4.74)

3 yr hospitalisation 1.71 (1.69 to 1.73) 2.54 (2.51 to 2.58) 3.64 (3.57 to 3.70)

5 yr hospitalisation 1.63 (1.61 to 1.64) 2.43 (2.40 to 2.46) 3.59 (3.54 to 3.65)

1 yr mortality 1.91 (1.78 to 2.04) 3.39 (3.15 to 3.65) 5.23 (4.73 to 5.79)

3 yr mortality 1.74 (1.68 to 1.81) 3.02 (2.90 to 3.14) 4.56 (4.29 to 4.84)

5 yr mortality 1.66 (1.62 to 1.71) 2.73 (2.64 to 2.81) 3.88 (3.68 to 4.09)

Outcomes

Implementation &

dissemination

Why does it matter?????????

Three simple reasons!!!!!!!!!!!!!

1. Predicts natural history

Specialty Outcome Adjusted OR/RR/HR

(95% CI)

Primary care Falls 1.23 (0.99 to 1.54)

Disability 1.79 (1.47 to 2.17)

Nursing home admission 2.60 (1.36 to 4.96)

Hospitalisation 1.27 (1.11 to 1.46)

Mortality 1.63 (1.27 to 2.08)

Cardiology 30 day mortality post ACS 2.17 (1.28 to 3.67)

Critical care Physical recovery 12m after ICU 0.32 (0.19 to 0.56)

General surgery Post-operative morbidity 2.06 (1.18 to 3.60)

General surgery 30 day post-operative mortality 4.00 (1.10 to 15.20)

Geriatric medicine Inpatient delirium 8.50 (4.80 to 14.80)

Oncology Chemotherapy intolerance 4.86 (2.19 to 10.78)

Renal medicine Mortality in ESRD patients on dialysis 2.24 (1.60 to 3.15)

Respiratory medicine 90 day readmission after COPD exac 1.43 (1.13 to 1.80)

2. Informs evidence-based

prescribing

NICE Database of Treatment Effects

Treatment Outcome Trial duration Number needed

to treat (NNT)

Annualised NNT

(ANNT)

Antihypertensives MI 10 years 84 840

Statins

(secondary

prevention)

Mortality 3.8 years 67 255

Aspirin (angina) Mortality 4.2 years 46 192

Anticoagulants

(AF)

Stroke 1 year 40 40

3. Predicts response to

therapeutic interventions

Intervention (community-based) Outcome

Comprehensive geriatric assessment

of older people

14% reduction in nursing home

admission

Comprehensive geriatric assessment

of ‘frail’ older people

10% reduction in hospital admissions

Community-based post discharge care 13% reduction in nursing home

admission

10% reduction in hospital admission

Group-based education (supported

self-management)

40% more likely to be living at home

Falls prevention 8% reduction in falls

Exercise interventions Improved function

Beswick Lancet 2008

Summary

• See frailty, then recognise it!

• Use pragmatic approach or simple tool to enable

recognition

• Avoid conflating acute illness with frailty

• Consider using eFI in primary care setting

• Use epidemiological associations of frailty in many specialty

settings to support shared treatment decisions

• Use frailty to identify target population for a range of

interventions to improve outcomes

Setting Outcome Reference

Primary care Falls Clegg Lancet 2013

Disability

Nursing home admission

Hospitalisation

Mortality

Cardiology 30 day mortality post ACS Ekerstad EJPC 2013

Critical care Physical recovery 12m after ICU admission Heyland ICM 2015

General surgery Post-operative morbidity Makary JACS 2010

General surgery 30 day post-operative mortality Hewitt Am J Surg 2015

Geriatric med Inpatient delirium Eeles Age Ageing 2012

Oncology Chemotherapy intolerance Handforth Ann Onc 2015

Renal med Mortality in ESRD patients on dialysis Johansen JASN 2007

Respiratory med 90 day readmission after COPD exacerbation Kon Thorax 2015

Thank You!!