Frailty in Aging

Elizabeth Phung, DO Medical Director – Beacham Center for Geriatric Medicine, Johns Hopkins Bayview Medical Center Faculty, Division of Geriatric Medicine and Gerontology Johns Hopkins University School of Medicine

•  No financial disclosures

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Disclosures

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Defining Frailty

Defining Frailty

•  Picture someone you know who you might describe as frail

Defining Frailty

•  Picture someone you know who you might describe as frail

•  What makes frail the right word?

Defining Frailty

•  Picture someone you know who you might describe as frail

•  What makes frail the right word? •  Is there a difference between frail

and vulnerable?

8 https://www.theatlantic.com/health/archive/2014/12/the-challenge-of-treating-frailty/383327/

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The Case of Mrs. C

Defining Frailty

Two Frameworks: •  Physical Frailty (aka Frailty Phenotype) •  Accumulation of Deficits Frailty

Defining Frailty: Physical Frailty

Physiologic (Physical)

Frailty

Physical Activity

Muscle Strength

Weight Loss

Energy Level

Walking Speed

Robinson TN et al 2016

Biologic Aging

Chronic Disease - Depression - Cognitive Decline - Cancer - Cardiovascular - Diabetes/Obesity

Dependence Disability Chronic Disease Early Mortality

Genes Environment Diet Activity

Stress Response Systems

Energy Metabolism

Weakness

Fatigue

Slowness

Weight loss

Causes of Physical Frailty

Walston J, 2018

PhysiologyTriggers Symptoms Outcomes

FRAILTY

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Xue, Qian-Li & Bandeen-Roche, Karen & Varadhan, Ravi & Zhou, Jing & Fried, Linda. (2008). Initial Manifestations of Frailty Criteria and the Development of Frailty Phenotype in the Women's Health and Aging Study II.

Defining Frailty: Physical Frailty

•  Weight loss •  Weakness •  Exhaustion •  Slowed walking speed •  Low activity

Fried, LP et al 2001

* Frail if 3 of 5 are present

Defining Frailty: Deficit Accumulation

Deficit Accumulation

Frailty

Social Vulnerability

Nutrition

Cognition

Function Decline

Medical Conditions

Robinson TN et al 2016

Causes of Deficit Accumulation Frailty

https://www.flickr.com/photos/michpics17/7019477251

Defining Frailty

Deficit Accumulation

Frailty

Social Vulnerability

Nutrition

Cognition

Function Decline

Medical Conditions

Physiologic (Physical)

Frailty

Physical Activity

Muscle Strength

Weight Loss

Energy Level

Walking Speed

Robinson TN et al 2016

Modal Pathway- 2017 Outcomes

Falls

Disability

Dependency

Death

Syndrome

Weakness

Weight loss

Slowed performance

Exhaustion

Low activity

Molecular & Genetic

Mitochondria

Epigenetics

Senescence

Autophagy

Disease Varadhan ,et al, J Gerontology, 2014 Kalyani R, et al Lancet 2014 Leng, et al., Aging 2004 Walston, J et al Archives IM 2002

↑ IL-6, CRP, WBC ↑ Clotting

Glucose intolerance ↓IGF-1, DHEA-S

Physiology

↑ Cortisol

↑ Angiotensin

Consequences of Physical Frailty CHS WHAS

Incident Fall 1.29 (1.00 – 1.68) No Change Worsening Mobility

1.50 (1.23, 1.82) 10.44 (3.51, 31.00)

Worsening ADL Disability

1.98 (1.54 – 2.55) 15.79 (5.83, 42.78)

First Hospitalizations

1.29 (1.09,1.54) No Change

Death 2.24 (1.51,3.33) 6.03 (3.00, 12.08)

Fried LP et al 2001 Bandeen-Roche K et al 2006

Hazard Ratios Estimated Over 3 Years, covariate adjusted, p>0.01

How Do We Assess Frailty?

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Proliferation of Frailty Tools •Frailty is the wild west of geriatrics • ~75 assessment tools and rapidly growing • Due to a lack of biological understanding and lack of specificity (how is frailty distinct from aging or chronic diseases?) • There is no agreement on how to best measure it (Manas 2012)

Physical Frailty Phenotype (PFP)

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¬ Weight loss (more than 10lbs) ¬ Weakness (grip strength) ¬ Exhaustion (self-report) ¬ Walking Speed (15 feet) ¬ Physical Activity (Kcals/week) Scoring: • Not Frail: 0 • Intermediate: 1-2 • Frail: ≥3

(Fried at al 2001)

Frail Scale

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Rockwood Clinical Frailty Scale

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How Are Frailty Tools Being Used?

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Buta BJ, Walston JD, Godino JG, et al. Frailty assessment instruments: Systematic characterization of the uses and contexts of highly-cited instruments. Ageing Res Rev. 2016;26:53–61. doi:10.1016/j.arr.2015.12.003

Common problems in frailty to reduce the severity and improve outcomes

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Falls Cognitive impairment Continence Mobility Weight loss and poor nutrition Polypharmacy Physical inactivity

Low mood Alcohol excess Smoking Vision Problems Social isolation and loneliness

Treating Frailty

•  Exercise •  Increase protein in diet •  Vitamin D supplementation (only if low) •  Focus medications (weigh risk/benefit) •  Plan carefully for surgery = Outcomes show improvement in functional outcome and patient survival, reduction in hospital days and readmission rates. No increase in mortality Morley 2013

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The Case of Mrs. C

Would these patients benefit from the same perioperative care plan?

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LOS 5.3 days 1 in 3 patients will suffer complication 1 out of 5 patients will be readmitted

LOS 2.5 days 1 in 20 patients will suffer a complication 1 in 20 patients will be readmitted

Premier data JHBMC 2017

History of the Geriatric Pilot at JHBMC

30 Verification process through ACS goes live in 2019

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Tinetti, Molnar and Huang, JAGS 2017; Slide by Andrea Schwartz MD MPH

The Geriatric 5Ms

•  11 item screening validated tool •  Takes 3 minutes to complete •  Does not require geriatric expertise •  Incorporates a cognitive screen and psychosocial

determinants •  Implemented in general, vascular, urology, and

gynecology services in February 2018 for ≥ 65 yrs. •  Successful screened 492 patients (42%) •  Identified 175 patients (36%) with a high frailty score (≥

6)

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Edmonton Frail Scale

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Benefits of the Edmonton Cognition Screen

•  During the past 4 months, 21 patients have been identified as having cognitive impairment (Clock Draw = 2) with NO previous history

•  17/21 patients (80%) were on more than 5 prescription medications

•  6/21 patients (29%) often forgot to take prescribed medications

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Using the Edmonton to Improve Care Coordination

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Category Edmonton Screen Intervention

Cognitive Impairment Clock Draw, Remembering Medication Regional Anesthesia/ Avoid Narcotics Delirium Prevention/Screening Aspiration Precautions Fall Precautions Geriatric Resource Nurse Co-Management with Geriatric Medicine

Functional Impairment Get up and Go, Functional dependence Referral to PT/OT Fall Precautions Co-Management with Geriatric Medicine

Lack of Social Support Social Support Social work consult/SNF placement Alert case manager

Depression

Depression Social work consult Case manager Communication with Caregiver Geriatric Resource Nurse Co-Management with Geriatric Medicine

Malnutrition Weight loss Nutrition Consult, Nutritional Supplements

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The Case of Mrs. C

Weekly Preoperative Multidisciplinary Call

•  Representation from Anesthesia, Geriatric Medicine, Surgery, Nursing, Case Management, Rehabilitation Medicine, Chaplaincy

•  Review average of 3 high risk patients per week

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Outcomes from Multidisciplinary Call – First 3 months (EFS ≥ 6, Age ≥ 85)

•  34 patients identified (30% of our IP surgery population) – mean age 77 –  mean Edmonton 7.4

•  Most highly scoring EFS variables: polypharmacy, multiple admissions, functional impairment

•  No ACP in 12/34 (35%) of patients

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•  8/34 (24%) cases were cancelled •  Geriatric co-management: 10/26 (38%)

–  60% seen on POD #1 –  40% seen range POD #2 - 16

•  PT/OT consultation: 18/26 (70%) –  76% seen POD #1 –  24% seen range POD #2 – 8

•  8/26 (31%) discharged to SNF

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Outcomes from Multidisciplinary Call – First 3 months (EFS ≥ 6, Age ≥ 85)

Outcomes from the Geriatric Surgery Pilot March 2018 – July 2018, JHBMC General Surgery patients ≥ 75 (pilot cohort) compared to March 2017 –

July 2017 (pre-pilot cohort)

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Outcome Pre-Pilot (n = 98)

Obs. Exp. O/E Pilot (n = 96)

Obs. Exp. O/E

LOS (median) 4.69 4.89 0.96 3.82 4.55 0.84 Complications 28.6% 30.2% 0.95 15.6% 27.5% 0.57 Readmissions 21% 12.6% 1.67 8.79% 12.97% 0.68 Mortality 0% 6.5% 0 5.2% 5.8% 0.9 Cost $23,094 $16,252 1.42 $17,133 $14,393 1.19

Next steps:

•  Identify high risk patient who will benefit from improved care coordination/resource allocation

•  Develop and sustain a value driven protocol for high risk patients that would benefit the health system

•  Recognition for our care of the older surgical patient by organizations nationwide

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•  Susan Gearhart, M.D, Jeremy Walston, M.D. & Dianne Bettick, MSN, RN for slide contribution and mentorship

•  Heather Agee, M.D., John Anderson, M.D., & Beacham Center Staff for their continued mentorship in my career development

•  My parents, husband and son for their never-ending support

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Many thanks to:

Questions?

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