implementing frailty into clinical practice•the governments have not anticipated aging •not a...
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Bruno Vellas M.D, Ph. D
Gérontopôle / UMR 1027 - Inserm Université de Toulouse
Implementing Frailty into Clinical Practice
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Life Expectancy Without Disabilities
• Many scientific publications on Frailty and on the impact of interventions on the prevention of further disabilities, in major journals
• But not yet in usual clinical practice, why ?
• Geriatric medicine was born 40 years ago, because many older adults with severe disabilities and dementia came to hospital emergency room
• Geriatric medicine was a new field
• The governments have not anticipated aging
• Not a simple drug, like statins…
• We cannot wait to implement Frailty into clinical practice
(Nutr Health Aging 2013, J Frailty Aging 2013, JAMDA 2013)
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Older Adults: 3 categories
Robust or Healthy Aging
• 60%
Frail and Pre Frail • 30%, Reversibility • fatigue, slow gait speed, weigth loss,
sédentarity, muscle weakness
Dependent • 10% • Basic ADL
Active Aging
Frail
Dependent for basic ADL
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Lancet, March 2013
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Frailty Consensus: A Call to Action Morley J.E et al., JAMDA, 2013
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Letter of Mission Ministry of Health
« Implementing Frailty into Clinical Practice»
1. How to screen frail older adults in clinical practice
2. How to assess frail older adults, look out after the causes of frailty and propose strong and long term usefull interventions
3. Develop translational, clinical, interventional and cost effective research on Frailty
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Recommandations HAS
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Implementing Frailty into Clinical Practice
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Frailty Screening
Older patients 65 yrs +, not dependent (ADL >= 5 /6)
YES NO UNKNOWN
Is your patient living alone ?
Unvoluntary weight loss in the past 3 months ?
Fatigability during the last 3 months ?
Mobility difficulties for the last 3 months ?
Memory complaints ?
Slow gait speed (+ 4s for 4 meters ? )
If yes to at least one of these questions:
In your own clinical opinion, do you feel that your patient is frail and at an increased risk for further disabities ? YES NO
If yes , kindly propose to the patient an assessment of the causes of frailty and prevention of disabilities in a day hospital.
Gerontopole Frailty Screening Tool
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Target
Sustained
Strong
Implementing Frailty into Clinical Practice:
TARGETED, STRONG, SUSTAINED INTERVENTION
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Assess the degree of frailty and the causes of frailty,
Objectives: • Assess the degree of frailty: fried Criteria
• Explore the causes of frailty: vision, hearing, mobility, cognitive, nutrition, sarcopenia…
• Elaborate a personalized Intervention plan
• Access to innovation and clinical research
Excellence of care, clinical and research
Strong Evaluation and Intervention:
in Hospital Outpatient Clinic
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Gerontopole Frailty Clinic: Targeted, Strong and Sustained Intervention
2011 : Hôpital Garonne
2013: Hôpital La Grave City center, close to the Gerontopole Clinical Research Center
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5/6/2013: + 828
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Gerontopole Frailty Assessment Clinic
• I - ANAMNESE
• II - CLINICAL EXAMINATION
Clinical examination
• III - TESTS
Cognitive: MMSE, CDR, F.C.S.R.T.
Functional & physical: IADL, SPPB, Fried
Visual functions: Monoyer Parinaud, Amsler Scale
Audition: HHIES
Depression & anxiety: GDS, Raskin, Covi, NPI
Nutrition (MNA), oral status
Falls
Social
• IV - OTHER INVESTIGATIONS
Biology
Vit D
ECG
I Dexa, Body composition
Retinography
Amyloïd TEP, MRI if needed
• V - SYNTHESIS
Preventive Personalized Plan
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Description of the population (n=160)
• Age: 82,7 6,1 yrs
• 62 % women
• 66 % receive some assistance at home
– 50 % «aide ménagère» (helper)
– 14 % APA
• 41% pre-frail; 53% frail, total: (94%)
• 84% slow gait speed < 1 m/s
• 54% high sedentarity
• 58% decrease of muscular strength
Subra, JNHA, 2012
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• 11,6% mild dementia
• 66 % CDR 0.5
• Basic Activity Daily Living maintained: ADL (/6) = 5.6 0.8)
• IADL 6.0 2.3 / 8
• 76% vision problems, 10 % Amsler (DMLA) abnormal
• 31 % hearing impairment
• 9 % protein caloric undernutrition, 34 % at risk for malnutrition ; 95 % vitamin D deficiency
Description of the population (n=160)
Subra, JNHA, 2012
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• Age: 82. 9 6 years • 62,5 % women • 42% alone at home, 59.3% high sedantarity • 31.1% pre-frail; 64.1% frail (95.2%) (Fried) • 58.5% SPPB <10/12)) • ADL (/6) = 5.6 0.8 (N=360) • IADL (/8)= 5.7 2.4 (N= 360) • 83.1% vision problem 17.6% Amsler • 7.8% undernutrition 36.8% at risk , weigth loss 37.9% • Gait speed 0.8 0.3 m/s • CDR 0.5: 53.4%, CDR 1: 12.7% • Vit D: 29.2% < 10 ng/l, 34% 10 -20 ng/l • Earing problem 41%
Description of the population (n=466)
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Gerontopole Frailty Clinic Associated Morbidity (n=481)
Comorbidity N %
No 16 3.44
Cardio vascular 364 78.28
MI 49 10.54
Cardiac Failure 55 11.83
Vascular 78 16.77
Others 321 69.03
Cancers 104 22.37
Cancer without metastasis 81 17.42
Cancers with metastasis 10 2.15
Myeloma 18 3.87
Lymphome 5 1.08
Psychiatric Diseases 74 15.91
Diabetes 64 13.76
Surgery 61 13.12
BPCO 59 12.69
Gastro-duodenale ulcer 56 12.04
Stroke 56 12.04
Fractures 41 8.82
Renal failure 28 6.02
Connectivite 24 5.16
Dementia 16 3.44
Liver failure 2 0.43
Others 308 66.24
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Gerontopole Frailty Clinic Associated Morbidity (n=481)
Patients without cancer
n= 392 (84.1%)
Patients with cancer
n= 74 (15.9%) P
Associated
Pathologies 4.2 (+/- 2.4) 5.2 (+/- 2.7) < 0.001
Charlson Score 1.4 (+/- 1.5) 3.9 (+/- 2.7) < 0.001
New medical problem
189 (48,2 %)
43 (58,1 %)
NS
Vision, earing deficit 330 (84%) 67 (90%) NS
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Pre-Frail (n=65) Frail (n=85) P
Age (yrs) 81,44 6,46 84,12 5,52 P=0.0125
Sex (% women) 55,38 68,67 P=0.097
Gait speed (m/s) 0,85 0,16 0,66 0,22 P=0.000
Sedentarity (% yes) 29,23 77,11 P=0.000
Poor muscular strength (% yes) 41,54 74,39 P=0.000
Exhausting (% yes) 3,08 19,51 P=0.003
Recent weight Loss (% yes) 16,92 49,40 P=0.000
Which Target: Frail vs Pre-Frail (n=160)
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Pre-Frail (n=65)
Frail (n=85)
P
MMSE (/30) 26,70 3,34 24,35 4,43 P=0.0006
Score CDR (%) 0 0.5 1 2
25,40 69,84 4,76 0,00
16,67 66,67 12,82 3,85
P=0.103
Score ADL(/6) 5,87 0,26 5,47 0,83 P=0.0002
Score IADL(/8) 6,78 1,71 5,38 2,48 P=0.0002
Score SPPB (/12) 8,58 2,10 6,06 2,78 P=0.0000
Which Target: Frail vs Pre-Frail (n=160)
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Fried criteria CDR 0.5
Cognitive Frailty
0 28.5 %
1 36.6 %
2 43.7 %
3 56.2 %
4 58.3 %
MAPT: Frailty status and CDR (n=1680)
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Cognitive Frailty: IANA/IAGG Consensus paper: J Nutr Health Aging 2013
• “Cognitive Frailty” as an heterogeneous clinical manifestation characterized by: –Presence of physical frailty and cognitive
impairment (CDR=0.5); with –Exclusion of concurrent AD dementia or
other dementias. - Cognitive frailty may represent a precursor of neurodegenerative processes. - A potential for reversibility may also characterize this entity. A psychological component of the condition must be taken into consideration.
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Cognitive Frailty: IANA IAGG J Nutr Health Aging 2013
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Institut of Aging Sciences / Gérontopole
8
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• Randomised, placebo control study • 1680 subjects; 70 yrs and older, living in the community • Inclusion criteria: Pre-frail subjects
– Slow walking speed (4 meters test) – Subjective memory complaint expressed to P.C.P – A limitation in one instrumental activity of daily living
(IADL) • Exclusion criteria: dementia, dependency for basic ADL • Randomisation in 4 groups (N=420 each), 3 years of
follow-up: Omega 3 alone, Placebo, Omega 3 + Multidomain, Placebo + Multidomain
• End Point: Cognitive decline FCRST, MRI (500), Florbetapir PET (250)
M.A.P.T: Multidomain Alzheimer Preventive Trial
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SUVr 50-60 min
SUVr 50-60 min
Amyloid Image Florbetapir F 18
Cognitively Healthy Control
Aβ+ AD patient
Aβ+ MCI Aβ- MCI
SUVr 1.03, VR 0 SUVr 1.61, VR 4
SUVr 1.68, VR 3 SUVr 0.98, VR 0
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Amyloid negatif Amyloid positif
Variable N Moyenne N Moyenne p
Age, (sd) 126 75.6 (4.2) 72 76.63 (4.5) 0.1163
TEP Amyloid , Florbetapir
36,4 % des sujets de MAPT sont amyloide positif
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Future Preventive Trials
• DO-Health: Vit D 3:2000 UI, Omega 3, Multi-domain, European Commission
• HATICE : Multidomain Prevention Trials, new Technologies , e-Health, for monitoring, European Commission
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• New technology
HATICE: European Dementia Prevention Initiative
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Age-associated loss of skeletal muscle mass Rosenberg, Summary Comments
Am J Clin Nutr 1989;50:1231-3
Sarcopenia Clinical Research and Practice : Drug Discovery
Functional Decline
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Biomarkers: FRAILOMIC
Cohortes prospectives avec suivi ≥ 3 ans
+ Biobanques
BioMarqueurs (BM) Génomiques Protéomiques Métabolomiques Classiques
BM potentiels - Facteurs de risque - Diagnostic - Facteurs pronostic
PHASE 1 PHASE 2
Suivi durant 2.5 ans + prélèvements
BioMarqueurs (BM) Génomiques Protéomiques Métabolomiques Classiques
Validation - Facteurs de risque - Diagnostic - Facteurs pronostic
Sous études dans des populations et conditions spécifiques : diabète, pathologies cardiovasculaires, facteurs de risque vasculaire, nutrition, activité physique
Modèles les plus pertinents en terme de prédiction, diagnostic et pronostic
PHASE 3
PHASE 4
Outils Dissemination Exploitation
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Futur of Geriatric Medicine
• Target the Frail, strong evaluation, sustained intervention
• Propose Multi-Domain Intervention
– Physical Exercise Program
– Nutrition Intervention
• New Drug Discovery
– For Prodromal Alzheimer; eg: anti-amyloid drugs
– For Cognitive Frailty, nutritional products
– For Sarcopenia: eg anti-myostatin