FRAIL ELDERLY PATHWAY AND FRAILTY IN THE ELDERLY

Dr. M. Ganeshananthan

Problem

Increasing numbers of frail older people are attending the Emergency Department

Frail older people have the highest ‘conversion rate’

High risk of adverse events Long stays High readmission rates High rates of long term care

Solutions

Generic interventions Better access to health care systems Better communication

Specific pathways for frail older people Based on comprehensive geriatric

assessment Outlined national policy documents

Frail Elderly Pathway

Aim- Integrated pathway for frail elderly patients Incorporating acute hospital care, community

care social care and old age psychiatry Objectives

Enhance health of frail older people Reduce unnecessary emergency admissions Reduce the need for long term institutional

care

Frail Elderly Pathway

Maintaining independence

Choosing to admit (Enhanced rapid assessment in ED/MAU and in the community)

Discharging to assess(Supported early discharge for complex frail elderly patients)

Frail Elderly Pathway

The pathway is delivered by:

Two geriatriciansIDT/OPALICT in the communityPart time community psychiatristDay assessment centre at MilfordRapid Response clinic

Frail Elderly Pathway

How do we deliver this service in the acute setting?

Comprehensive Geriatric Assessment (CGA)

What is GCA?

CGA

‘Multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up

CGA

‘Multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up

CGA- Evidence

Improves outcomes of older people in various settings

Reduced mortality or deterioration Improved cognition Improved quality of life Reduced length of stay Reduced readmission rates Reduced rates of long term care use Reduced costs

CGA

The main domains of CGA

Medical Mental health Functional capacity Social circumstances Environment

Frailty

The condition of being weak and delicate: the increasing frailty of old age

(weakness in character or morals: all drama begins with human frailty)

Who is frail?

Frailty

Syndrome which results from a multisystem reduction in reserve capacity to the extent that a number of physiological systems are close to or past the threshold of symptomatic failure

Increased risk of disability or death from minor external stresses

Frailty

Frailty

Small insult results in a striking and disproportionate change in health state

Independent to dependent Mobile to immobile Postural stability to proneness to falling Lucid to delirious

Frailty

Distinct syndrome

Growing old is not in itself a prerequisite to becoming frail

A disability does not lead to frailty in a robust older person

Clinical presentations

Non-specific

Extreme fatigue Unexplained weight loss Frequent infections

Falls Due to gait and balance impairment Hot fall

Clinical presentations

Delirium

Due to reduced integrity of the brain function

Independently associated with adverse outcome

Fluctuating disability Day-to-day instability

Pathophysiology

Normal ageing Gradual decrease in physiological reserve

Frailty Accelerated Homoeostatic mechanisms start to fail

Pathophysiology

Cumulative decline in several physiological systems

Determined by genetic and environmental factors

Loss of physiological reserve of the brain, endocrine system, immune system and skeletal muscle

Nutritional status

Pathophysiology

Frail Brain

Associated with increased risk of developing delirium and reduced survival

Associated Increased cognitive impairment Faster rate of cognitive decline

Independent association with dementia

Frail immune system

Reduced stem cells Blunting of antibody response Reduced phagocytosis Impaired antibody response to vaccines

Frail Immune system

Inflammation has a major role in the pathophysiology of frailty

Abnormal low-grade inflammatory response Hyper-responsive to stimuli Persists for a long period

Inflammation leads to anorexia and catabolism

Sarcopaenia

Frail skeletal muscle Progressive loss of muscle mass,

strength and power Reduction in functional ability

Frailty Models

Phenotype model

Cumulative deficit model

Phenotype model

Phenotype model

Detection of frailty in routine care Difficult to translate to clinical practice Those with cognitive impairment not

included Increased adverse outcome

Cumulative deficit model-Frailty Index CSHA 92 baseline variables (health deficits) Presence or absence of each variable as

a proportion of the total Defined as cumulative effect of

individual deficits Clinically attractive- frailty is gradable Strongly related to the risk of death and

institutionalisation

Prevalence

Systematic review Frail 9.9% Pre-frail 42% F>M Steadily increased with age

65-69 4% >85 26%

Outcomes

Most frail worst outcomes Frail more frail Higher risk of:

Worsening disability Falls Admission to hospital Death Admission to long term care

Association between frailty, disability and comorbidity

Assessments to identify frailty CGA CGA when linked to interventions has

superior outcomes Gold standard to assess frailty

Edmonton Frailty scale CSHA scale

Interventions

Inpatient CGA More likely to return home Less likely to have cognitive or functional

decline Lower in-hospital mortality

Community CGA Continuing to live at home

Interventions

Exercise

Effect sizes are small/moderate Intensity uncertain

Nutritional interventions Scarce evidence

Interventions

Drugs

ACEI Testosterone Vitamin D

Conclusion

Frailty is a state of vulnerability to poor resolution of homeostasis

Cumulative decline in many physiological systems during a life time

Minor stressor events trigger a disproportionate changes in health status

Landmark studies have been used to develop valid models of frailty

Association of frailty and adverse health outcomes

Conclusion

Care is organised around single organ disease

Frailty is a practical unifying notion Strongly associated with adverse

outcome Moving away from age to using frailty Best evidence is for comprehensive

geriatric assessment