Frailty syndrome

Revised and reviewed 15 August 2015

OVERVIEW

  • Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserves in vulnerability that predisposes to the accumulation of deficits and adverse outcomes from acute stressors
  • Frailty correlates with increasing age, but is not an inevitable consequence of ageing
  • Frailty affects ~10% of those aged >65y, and ~25+% of those aged >85y
  • Frailty is a dynamic condition, and is potentially reversible
  • Frailty is more than simply the combination of disability (functional impairment) and the presence of comorbidities
  • no single operational definition or simple assessment tool for frailty has been agreed upon

MODELS OF FRAILTY

Two major frailty models have been described: the frailty phenotype and the frailty index:

  • The frailty phenotype defines frailty as a distinct clinical syndrome meeting three or more of five phenotypic criteria: weakness, slowness, low level of physical activity, self-reported exhaustion, and unintentional weight loss
  • The frailty index defines frailty as cumulative deficits identified in a comprehensive geriatric assessment.

Proposed clinical definition of the frailty phenotype (McDermid et al, 2009) (aka Fried’s definition or Cardiovascular Health Study (CHS) definition)

Criteria:

  • Decreased grip strength
  • Self-reported exhaustion
  • Unintentional weight loss of more than 4.5 kg over the past year
  • Slow walking speed
  • Low physical activity

Definition

  • Positive for frail phenotype: ≥3 criteria present
  • Intermediate/pre-frail: one or two criteria present
  • Non-frail: no criteria present

Frailty Index

  • Frailty Index — a detailed 70-item inventory of clinical deficits, often used in research
  • Unclear if adds additional benefit to Comprehensive geriatric assessment (CGA)
  • Appears to be a more sensitive predictor of adverse health outcomes than the fragility phenotype
  • Does not attempt to distinguish frailty from disability or comorbidity; does not incorporate a pathogenic basis

Other Diagnostic Tools

  • There are numerous tools for the assessment of fragility, none of which are proven to have greater clinical utility compared to the others
  • Comprehensive geriatric assessment (CGA) is considered the gold standard, but cannot readily be performed in an acute care setting — This is a “multidisciplinary, diagnostic process to describe the medical, psychological and functional capabilities of a frail older person in order to keep a co-ordinated, integrated plan for long-term treatment and follow-up”
  • Edmonton Frail Scale — simpler assessment of function that is valid and reliable (see Table 1 from Wyrko, 2015)
  • Clinical Frailty Scale (CFS) — 7-point scale that correlates with frailty index (Rockwood et al, 2005)
  • Simple tests (high sensitivity, low specificity)
    • slow walking speed: >5 seconds to walk 4 metres
    • timed up-and-go test: >10 seconds to stand from a chair, walk 3 metres, turn round and sit down again
    • a score of 3 or above on the PRISMA 7 questionnaire (see www.bgs.org.uk/campaigns/fff/fff_full.pdf)

PATHOGENESIS

Etiology/ risk factors

  • ageing
  • genetics
  • lifestyle
  • diseases
  • environment

Potential mechanisms resulting in Frailty phenotype

  • chronic inflammation
  • effects on CVS, haematological, endocrine and musculoskeletal systems

Results in adverse health outcomes (death, disability, dependency and falls)

MANAGEMENT

Management strategies that may be of benefit:

  • Early physiotherapy (e.g. early mobilisation) and occupational therapy input to establish usual functional baseline, provide walking aids and prevent unnecessary deterioration by prolonged bed rest
  • Pharmacology
    • Dose reduction is often appropriate in the frail elderly
    • Pharmacy involvement for medicines reconciliation to reduce drug interactions and iatrogenic harm
  • Early assessment and treatment of complications of acute illness that are common in patients with frailty:
    • delirium
    • falls risk
    • pressure sore risk
  • Nutrition support
  • Early discussion of end of life goals and appropriate limitation of invasive therapies to avoid unnecessary iatrogenic harm

PROGNOSIS

Assessment of frailty and poor physiological reserve is becoming increasingly important as we become more cognisant of the poor longterm outcomes and costs associated with intensive care of the frail

  • Critically ill elderly frail patients, compared to similarly aged non-frail patients have worse outcomes (morbidity, mortality and institutionalisation)
  • Critically ill patients of all ages may share characteristics with frail elderly patients: “deficits associated with frailty, which typically take years to accumulate in the outpatient geriatric population, rapidly develop in a large proportion of critically ill patients independent of age and illness severity” (McDermid et al, 2009)

References and Links

LITFL

Journal articles

  • Bagshaw SM, Webb SA, Delaney A, George C, Pilcher D, Hart GK, Bellomo R. Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis. Crit Care. 2009;13(2):R45. doi: 10.1186/cc7768. PMC2689489.
  • British Geriatrics Society. Fit for frailty. Consensus best practice guidance for the care of older people living with frailty in community and outpatient settings. London: British Geriatrics Society 2014. Available online at www.bgs.org.uk/campaigns/fff/fff_full.pdf [Accessed 10 August 2015]
  • Chen X, Mao G, Leng SX. Frailty syndrome: an overview. Clin Interv Aging. 2014 Mar 19;9:433-41. PMC3964027.
  • Griffiths R, Mehta M. Frailty and anaesthesia: what we need to know. Contin Educ Anaesth Crit Care Pain (2014) doi: 10.1093/bjaceaccp/mkt069 [Free Full Text]
  • Lee L, Heckman G, Molnar FJ. Frailty: Identifying elderly patients at high risk of poor outcomes. Can Fam Physician. 2015 Mar;61(3):227-31. PMC4369632.
  • McDermid RC, Stelfox HT, Bagshaw SM. Frailty in the critically ill: a novel concept. Crit Care. 2011;15:(1)301.PubMed PMID: 21345259
  • Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, Mitnitski A. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173:489–495.[PMC free article] [PubMed]
  • Rusinova K, Guidet B. “Are you sure it’s about ‘age’?”. Intensive Care Med. 2014 Jan;40(1):114-6. doi: 10.1007/s00134-013-3147-x. Epub 2013 Nov 12. PubMed PMID: 24217659.
  • Søreide K, Desserud KF. Emergency surgery in the elderly: the balance between function, frailty, fatality and futility. Scand J Trauma Resusc Emerg Med. 2015 Feb 3;23:10. PMC4320594.
  • Wyrko, Z. Frailty at the front door. Clin Med August 1, 2015 vol. 15 no. 4 377-381 doi: 10.7861/clinmedicine.15-4-377 [Free Full Text]

FOAM and web resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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