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Implementing frailty into clinical practice:
Why has frailty not been operationalized? As a disease/syndrome?
As a health promotion/prevention strategy?
Pr Bruno Vellas M.D, Ph.D
Gérontopôle
UMR INSERM 1027
University of Toulouse
Implementing frailty into clinical practice: Strength and weakness
• 1. Rational for implementing frailty into clinical practice
• 2. Why has frailty not been operationalized? As a disease/syndrome?
• 3. Implementing frailty into clinical practice by the Toulouse Gérontopôle
Prevalence of dependency/disability: between 350-600M from 2010 to 2040
World Alzheimer Report 2013. ADI 2013
Older Adults
Robust
• 50% > 65 yrs
Frail and Pre-frail • 40% > 65 yrs • Reversible
• Unvoluntary weight loss, Fatigability, Muscular weakness, Slow gait speed, Low physical activity/inactivity
Dependent • 5-10% > 65 yrs • Nursing home
• Dependent for basic daily activities
NMAPS Results: Above: (Younger transition matrix - 60 ≤ age ≤ 78 years) Below: Older 78 +
.32
Speed low
1
Both low
3
3MSE low
2
Normal 0
.01
.10
.06 .06
.07
.86
.08
.25
Speed low
1
Both low
3
3MSE low
2
Normal 0
.20
.28
.18 .64
.50
.34
.05
.48
Speed low
1
Both low
3
3MSE low
2
Normal 0
.06
.18
.22 .08
.14
.72
.07
.44
Speed low
1
Both low
3
3MSE low
2
Normal 0
.11
.19
.19 .24
.27 .51
.10
2. Why has frailty not been operationalized? As a disease/syndrome?
• Was not the priority until now. Geriatric medicine was born 40 years ago with long-term care policy…
• In the past all was built to take care of dependency, not to prevent it: nursing home payment policy
• By definition frail older persons are not pro-active. Same for their caregiver, if any
• Change habits, it is much easier for a medical practitioner to wait for patients being admitted to an emergency unit and then to the geriatric ward
• No drug industry • Very few studies are based on clinical practice, few R.C.T but...
3. Implementing frailty into clinical practice by the Toulouse Gérontopôle
• 1. The Frailty clinic, Day Hospital
• 2. Frailty screening in the community with city hall
• 3. Frailty into family practitioner’s office
• 4. Frailty after an emergency call (911)
• 5. Frailty screening with retirement plan
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.
Gérontopôle Frailty Screening Tool
Recommendations from HAS (French health authority)
3. Implementing frailty into clinical practice by the Toulouse Gérontopôle
• 1. The Frailty clinic, Day Hospital
• 2. Frailty screening in the community with city hall
• 3. Frailty into family practitioner’s office
• 4. Frailty after an emergency call (911)
• 5. Frailty screening with retirement plan
93.6% of older adults referred to the Gérontopôle Frailty Clinic are frail or pre-frail
Description of 1108 older patients referred to the Gérontopôle Frailty Clinic (JNHA 2014)
Geriatric Assessment n=1108
Age (yrs), n=1108 82,9 ± 6,1
Sex (female), n=1108 686 (61,9%)
BMI (kg/m²), n=698 25,9 ± 5,1
Onco-geriatric, n=1103 230 (20,9%)
Vit D (ng/ml), n=1065 18,1 ± 11,3
MMSE/30, n=1071 24,6 ± 4,9
MIS/8, n=1038 6,6 ± 1,9
ADL/6, n=1102 5,5 ± 1,0
IADL/8, n=1094 5,6 ± 2,4
SPPB/12, n=1063
SPPB/12 (mean) 7,3 ± 2,9
(SPPB≥10) 272 (25,6%)
(7≤SPPB≤9) 388 (36,5%)
(SPPB ≤6) 403 (37,9%)
CDR/3, n=1039
CDR=0 353 (34,0%)
CDR=0,5 531 (51,1%)
CDR=1 111 (10,7%)
CDR≥ 2 44 (4,2%)
Frailty Assessment n=1108
Fried/5, n=1082 2,64 ± 1,4
Fried/5, n=1082
Robust (0 criteria) 69 (6,4%)
Pre-frail (1-2 criteria) 423 (39,1%)
Frail (3-5 criteria) 590 (54,5%)
Unvolontary weight loss (yes), n=1098 358 (32,6%)
Weakness, n=1083 353 (32,6%)
Gait speed, n=1065
Mean (m/s) 0,78 ± 0,27
< 1m/s 814 (76,4%)
<0,8m/s 547 (51,4%)
Grip strength (kg), n= 1083 20,3 ± 8,2
Sedentarity (yes), n=1096 665 (60,7%)
Alone at home (yes), n=1083 460 (42,5%)
Help at home (yes), n=1105 767 (69,4%)
Help at home (yes), n=1105 575 (52,0%)
APA (yes), n=1105 190 (17,2%)
Descriptive data of 1108 older adults referred to the Gérontopôle Frailty Clinic (JNHA 2014)
Geriatric Assessment n=1108
Vision
Vision far (abnormal), n=1019 840 (82,4%)
Vision near (abnormal), n=1039 232 (22,3%)
Amsler (abnormal), n=1060 177 (16,7%)
Audition
HHIE-S/40, n=1055 9,5 ± 9,8
Disability (HHIE-S >21), n=1055 330 (31,3%)
Nutrition
MNA/30, n=1048 23,2 ± 4,1
(MNA>23,5), n=1048 550 (52,5%)
At risk of malnutrition (17≤MNA≤ 23,5), n=1048
414 (39,5%)
Undernutrition (MNA< 17), n=1048 84 (8,0%)
Urinary incontinence
Incontinence scale/6, n=280 1,7 ± 1,4
Daily problem (score≥ 1), n=280 215 (76,8%)
Depression GDS/15, n=424 4,8 ± 3,1
History of falls n=285 108 (37,9%)
Interventions: Personalized Care and
Prevention Plan
n=1108
New medical conditions (yes), n=1104
603 (54,6%)
Special advice (dentistry, ORL, ophtalmo, urology) (yes), n=1101
532 (48,3%)
Change in drug prescription (yes), n=1102
362 (32,8%)
Nutrition intervention (yes), n=1105
683 (61,8%)
Physical activity intervention (yes), n=1101
624 (56,7%)
Social intervention (yes), n=1106
284 (25,7%)
Descriptive data of 1108 older adults referred to the Gérontopôle Frailty Clinic (JNHA 2014)
Frailty clinics
• Most of the physicians, healthcare professionals, policy makers were not aware about frailty
• We had to educate them, explain the concepts in a very simple way
• After 2 years, we succeeded (+ 3500 subjects) with some enormous efforts, and my personal involvement on a daily basis, explanation to the care payer (cost 500 Euros)
• How is it translatable ?
3. Implementing frailty into clinical practice by the Toulouse Gérontopôle
• 1. The Frailty clinic, Day Hospital
• 2. Frailty screening in the community with city hall
• 3. Frailty into family practitioner’s office
• 4. Frailty after an emergency call (911)
• 5. Frailty screening with retirement plan
Cesari M et al. PLOS ONE 2014;9(7):e101745
Domain Questions Answers Score
Disability A. Have you any difficulties in walking 400 meters?
a. No or some difficulties
b. A lot of difficulties or unable
0
1
B. Have you any difficulties in climbing up a flight of stairs?
a. No or some difficulties
b. A lot of difficulties or unable
0
1
Frailty C. During the last year, have you involuntarily lost more than 4.5 kg?
a. No
b. Yes
0
1
D. How often in the last week did you feel than everything you did was an effort or that you could not get going?
a. Rarely or sometimes (≤2 times/week)
b. Often or almost always (≥3 or more times per week)
0
1
E. Which is your level of physical activity?
a. Regular physical activity (at least 2-4 hours per week)
b. None or mainly sedentary
0
1
If A+B ≥1, the individual is considered "disabled". If A+B=0 and C+D+E ≥1, the individual is considered “frail”. If A+B+C+D+E=0, the individual is considered “robust”.
Frail Non-Disabled (FIND) questionnaire
Frailty screening in the community:
• City of Cugnaux: 16 314 inhabitants
• 75 yrs +: 1 403 subjects, response 44% (611)
• 70 - 74 yrs: 600 subjects, response 19% (111)
• Frail and pre-frail: 298, 124 (42%) got complete frailty assessment and intervention program
• Almost 30% of the frail and pre-frail subjects
• Cost: 50 000 Euros
• Extended to the Toulouse urban area, 1 million people
3. Implementing frailty into clinical practice by the Toulouse Gérontopôle
• 1. The Frailty clinic, Day Hospital
• 2. Frailty screening in the community with city hall
• 3. Frailty into family practitioner’s office
• 4. Frailty after an emergency call (911)
• 5. Frailty screening with retirement plan
Frailty assessment in family practitioner’s office
22
Study process
Patient with cognitive complaint
Medical history, comorbidities, treatments, weight, vision, audition, lifestyle, home support, …
Consultation with a nurse
Frailty sensation
Older patient in General Practitioner’s consultation
or
16 GP’s offices around Toulouse
Evaluation • MMSE • WMS-R • Mini-GDS • Fried criteria • MNA • SPPB • ADL • IADL
Summary, propositions of recommendations and orientation proposed by the GP
Implementing frailty into family practitioner’s office (N=375)
23
• Female: 62.3%
• Age: 81.0 ± 6.4 yrs (65-74: 15.7%, 75-84: 51.1%, 85 +: 33.2%)
• Comorbidities: 2.8 ± 1.6
• Treatments: 3.7 ± 1.9
• ADL/6: 5.8 ± 0.2, IADL/8: 6.9 ± 1.5
• Fall in the last 3 months: 24%
• Frailty: Robust: 23.9%, Pre-frail: 45.1%, Frail: 31%
• MMSE/30: 25.1 ± 4.2
• SPPB/12: 9. ± 2, SPPB<10: 48.1%
Family practitioner’s office
• Not so easy
• 50% OK, space, not interested
• The process is currently undergone in 20 family physician’s offices, once a month
• Most of these patients will not have accepted to go to the hospital
• Able to identify what is really the main problem for the frail older adults
3. Implementing frailty into clinical practice by the Toulouse Gérontopôle
• 1. The Frailty clinic, Day Hospital
• 2. Frailty screening in the community with city hall
• 3. Frailty into family practitioner’s office
• 4. Frailty after an emergency call (911)
• 5. Frailty screening with retirement plan
Descriptive data Typology Cugnaux SAMU
Nb 136 75
Women 95 (69,9%) 56 (73,7%)
Age 79,9 ± 5,4 85,8 ± 6,7
65-74 yrs 22 (16,2%) 5 (6,9%)
75-84 yrs 85 (62,5%) 24 (33,3%)
≥ 85 yrs 29 (21,3%) 43 (59,7%)
Comorbidity 3,0 ± 1,4 3,0 ± 1,4
Number of medications 4,2 ± 2,5 6,2 ± 3,0
ADL (0-6) 5,8 ± 0,5 4,6 ± 1,2
IADL (0-8) 6,9 ± 1,7 3,6 ± 2,2
Falls in the last 3 months 24 (17,6%) 62 (82,3%)
Fried 1,9 ± 1,2 3,4 ± 0,9
Robust 19 (14 %) 0 (0 %)
Pre-frail 74 (54,4 %) 10 (13,3 %)
Frail 37 (27,2 %) 31 (41,3 %)
Dependent 6 (4,4 %) 34 (45,3 %)
MMSE (0-30) 25,3 ± 4,5 19,3 ± 8,5
SPPB (0-12) 8,7 ± 2,9 3,3 ± 2,5
SPPB < 10 69 (50,7%) 63 (84,0%)
3. Implementing frailty into clinical practice by the Toulouse Gérontopôle
• 1. The Frailty clinic, Day Hospital
• 2. Frailty screening in the community with city hall
• 3. Frailty into family practitioner office
• 4. Frailty after an emergency call (911)
• 5. Frailty screening with the retirement insurance scheme
Frailty screening with the retirement insurance scheme
• CARSAT (National health and retirement scheme)
• A.P.A.(Social allowance for personalized autonomy)
• Set up frailty assessment and provide appropriate interventions by a trained nurse practitioner
• Target the population that needs help
• Just starting now, it took 2 years to get all the authorizations from these large public institutions
Targeted
Strong
Implementing frailty into clinical practice: TARGETED, STRONG, SUSTAINED INTERVENTION
Sustained
Strong and sustained intervention
• Ability to find a cause:
- 50% reported at the frailty clinic, less in home visits
• Direct connection with paying institutions
• Precision medicine for frailty and pre-frail?
• How to bring the frail to intervention? Not easy as few use new technologies
• Future for the pre-frail? P4 Medicine • Pro-active • Precision • Participatory (wellness) • Personalized (e-platform)
• IHU Project
P4 Medicine / Modern medicine
P4 Medicine Pro-active, predictive Individual, precision medicine Wellness & diseases Personalized data clouds Personalized data clouds for clinical trials
Modern medicine Reactive Population Only diseases Average patient population Average patient population for clinical trials
Our health determinants
•Healthcare: 10%
•Genetic: 30%
•Behavior environnment: 60%
•Precision medicine for pre-frail and for intrinsic capacities