Identifying Frailty (and Sarcopenia) in the SCGH Falls and Fragile Bone Clinics.

Mr Tony Petta1

Clinical Professor Charles Inderjeeth1,2,3,4

Ms Shona Beesley1

Ms Tara Reen1

Mrs Odile Roberts1

1. Sir Charles Gairdner Hospital, Nedlands, Australia2. Osborne Park Hospital Program, Osborne park, Australia3. University of Western Australia, Nedlands, Australia4. Linear Research PTY LTD, Nedlands Australia

https://www.reismandentalgroup.com/poor-oral-health-linked-with-frailty-in-elderly-men/

Frail – a term commonly used…

“Thanks for assessing this frail elderly lady with……”

“This frail elderly gentleman was assessed…”

…. but what does it actually mean?

http://www.drbriffa.com/2012/09/07/exercise-found-to-bring-benefits-for-frail-older-individuals/https://www.prescriber.co.uk/article/optimising-medication-in-frail-older-people/

Frail or not?

“No, No...I am still quite capable of planting a tree!” The Queen, July 09 2019.

• Frailty: a medical syndrome of physiological decline in late life, characterized by marked vulnerability to adverse health outcomes– ↓strength, endurance and physiological reserve– a forerunner to other geriatric syndromes, such as falls & fractures

• Sarcopenia: A progressive and generalised skeletal muscle disorder that is associated with increased likelihood of adverse outcomes– low muscle strength (rather than just muscle mass)– risk of falls, fractures, functional decline, dependence and ↑mortality

Frailty & Sarcopenia

Why are Frailty and Sarcopenia Important?

• Early identification of those at risk could help to delay or prevent the adverse outcomes of frailty and sarcopenia. – high individual, social and economic burden if left untreated

• Evidence suggest that frailty and sarcopenia may be modifiable. Identifying those older people at risk may help to target specific health care interventions and services.

Interventions for Frailty and SarcopeniaFrailty occurs along a spectrum

– Target interventions according to patient preference (Goal-setting)

• CGA (i.e. MDT approach)

• Exercise (include progressive resistance training)

• Nutritional support (Dietary / Oral care etc)

• Lifestyle Modification - smoking, alcohol, obesity

• Optimise pharmacotherapy (medications & polypharmacy)

• Advanced Care Planning / End of Life Care

Measuring Frailty – different (complementary) approaches!

• Frailty Phenotype (Fried et al. 2001)

– Biological Syndrome – 5 pre defined physical criteria

• Frailty Index (Mitnitski, 2001; Rockwood and Mitnitski 2007)

– Non specific accumulation of health deficits across multiple domains

• Frailty Indicators (e.g. Edmonton Frail Scale – Rolfson et al. 2006)

– Multidimensional approach to frailty, assessing physical, psychologic, and social aspects of human functioning

– Multiple domains that are pre-defined

What are we doing?

• Identify Frailty & Sarcopenia in DTU patients attending Falls and Fragile Bone Clinic

– Questionnaire & Routine Physical Assessments

• Is there a tool or measure that is more effective?

• Do our current interventions (standard care) have an affect on Frailty & Sarcopenia in our population?

Frailty Scales – So many to choose!• Edmonton Frail Scale (Score 0 – 17)

– + Self reported version

https://www.youtube.com/watch?v=j77QUMPTnE0

Frailty Scales – So many to choose!• Fried’s Criteria (Score 0 – 5)

– Not Frail (0)– Pre Frail (1 -2)– Frail (3+)

https://www.belmarrahealth.com/wp-content/uploads/2017/03/fatigue-in-the-elderly-500x338.jpg

Frailty Scales continued….

• The FRAIL Scale– Fatigue

– Resistance

– Ambulation

– Illness

– Loss of Weight

• FiND (Frail not Disabled)

– Disability• Walking Distance

• Stairs

– Frailty• Effort

• Weight Loss (>4.5 kg)

• Physical Activity

• SOF Criteria for Frailty – Weight Loss

– Energy

– Chair Stands

Sarcopenia – How is it measured• Clinical History• Questionnaire – e.g. SARC F• Muscle Strength (Assess)

– Grip Strength (M < 27kg F < 16kg)– X5 Repeated STS (>15 s)

• Skeletal Muscle Mass (Confirm)– DEXA / CT / MRI– Appendicular Lean Mass Index (Kg/m2)

• Physical Performance (Severity)– Gait Velocity (≤ 0.8 m/s or < 48 m/min)– TUG (≥ 20 s) FAT LEAN BONE

Quant Imaging Med Surg 2018;8(1):86-99EWGSOP2 Age and Ageing 2019; 48: 16–31 doi: 10.1093/ageing/afy169

Sarcopenia Algorithm

• FACS pathway

Beaudart et al. BMC Geriatrics 2016 16:170 DOI 10.1186/s 12877-016-0349-4EWGSOP2 Age and Ageing 2019; 48: 16–31 doi: 10.1093/ageing/afy169

SCGH Day Therapy Unit• 65 years + (ATSI < 45) • Clinics

– Falls– Memory– Fragile Bone– Continence– General– Allied Health Services (OT and PT)

• Frailty not formally assessed using standardised scales– document various aspects of frailty in routine assessment

SCGH DTU Demographics (Sept 2018 – Sept 2019)• Falls Clinic (n = 151)

– 63% Female– Age: 81.3 yrs

• Fragile Bone (n = 127)– 84% Female– Age: 70.8 yrs

• Falls Home Visit (n = 224)– 55% Female– Age: 83.9 yrs 0

20

40

60

80

100

120

140

<65 65 - 74 75 - 84 85 - 95 95+

Falls Clinic

Fragile Bone

Falls HV

Early Data• n = 46• 32 Females• Age: 78.7 yrs• Falls Hx: 50% Multiple (2+) falls• Mobility

– Gait Velocity 53.9 m / min (42% ≤ 48 m / min)– TUG 17.8 s (28% ≥ 20 s)– Sit to Stand (x5) 17.3 s (56% > 15 s)

• 45% (n = 25) were unable to perform

0

5

10

15

20

65 - 75 76-85 86-95

Age Distribution

Early Data – Frailty

0 5 10 15 20 25

Not Frail

Vulnerable

Mild Frailty

ModerateFrailty

SevereFrailty

MeasureVulnerable

or Frail (n=22)

Not Frail (n = 24)

AGE 79.1 78.3

TUG (s) 24.1 12.1

GV (m/min) 42.6 63.8

STS (s) 21.8 14.4

STS Unable 12 9

Total Number of Falls 52 55

2+ Fallers (%) 55 45

Edmonton Frail Scale

Final Thoughts?• Frailty and Sarcopenia are common

– Accurate Identification to prompt intervention– Current tools though useful, are not perfect

• Though important, factors other than Frailty and Sarcopenia may influence outcomes in older people e.g. Resilience

• Current QI – Larger sample + Need follow up data– Investigate interventions delivered

• Future Research (Biomarkers; Interventions)

References• Fried LP, Tangen CM, Walston J, et al; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J

Gerontol A Biol Sci Med Sci. 2001;56(3):M146–M156. • Mitnitski, AB., Mogilner, AJ, & Rockwood, K. Accumulation of deficits as a proxy measure of aging. The Scientific World Journal. 2001; 1, 323–336.

doi:10.1100/tsw. 2001.58• Rocwood, K. & Mitnitski, A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007. 62(7):722-7• Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006 35(5):526-9. doi:

10.1093/ageing/afl041. Epub 2006 Jun 6. PMID: 16757522; PMCID: PMC5955195.• European Working Group on Sarcopenia in Older People (2), Sarcopenia: revised European consensus on definition and diagnosis. Age and Ageing 2019;

48: 16–31doi: 10.1093/ageing/afy169 Published electronically 24 September 2018• Beaudart et al. Sarcopenia in daily practice: Assessment and Management. BMC Geriatrics 2016 16:170 DOI 10.1186/s 12877-016-0349-4• Walston, J.D. Frailty. UptoDate.DOA 2019.

https://www.uptodate.com%2fcontents%2ffrailty%2fprint%3fsearch%3dFrailty%26source%3dsearch_result%26selectedTitle%3d1%257E137%26usage_type%3ddefault

• Messina et al. Diagnostic imaging of osteoporosis and sarcopenia: a narrative review. Quantitative Imaging in Medicine and Surgery, 2018; 8 (1) 96 – 90.• Gobbens et al. Exploring the efficiency of the Tilburg Frailty Indicator: a review. Clinical Interventions in Aging 2017:12 1739–1752• Ensrud KE, Ewing SK, Taylor BC, et al. Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women. Arch Intern

Med. 2008 Feb 25;168 (4):382-9 • Morley Et al. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012 July ; 16(7): 601–608.• Cesari M, et al. A Self-Reported Screening Tool for Detecting Community-Dwelling Older Persons with Frailty Syndrome in the Absence of Mobility

Disability: The FiND Questionnaire. 2014 PLoS ONE 9(7): e101745. doi:10.1371/journal.pone.0101745