Frailty Screening and Management

Presented by: PT Susan Kalu (Cardiopulmonary Physiotherapist)

Nepal Mediciti Hospital
 Contents

Prevalence and
01 Introduction 02 Pathophysiology 03 Risk Factor

Guideline Screening and Physical Activity

04 Recommendations 05 Assessment 06
WHO Definition of Old Age

• Old age >65years

• Very old age >80years
Biological changes in ageing

Mechanism of biological changes:

• Structural changes in chromosome (in the DNA)
Effect:
Homeostenosis-
• Homeostatic reserve of each organ gets constricted
• However, does not affect individual during normal activity
Physiological Effect in Important Organs
CVS-
• Systolic Hypertension
• Postural hypotension
• Unfolding of aorta and aortosclerosis
Respiratory System-
• Loss of lung Compliance
CNS-
• Loss of cortical cells
• Loss of posterior column fibers
Kidney and G-U tract
• Decreased GFR
• Prostatic enlargement
Endocrine-
• Impaired GTT
• Decreased thyroxine, decreased testosterone level
Skeletal system-
• Cervical spondylosis
• Osteoporosis
• Osteoarthritis
GI system-
• Decrease colonic motility
Skin – wrinkling
Eyes – cataract
Ear – high tone deafness
Increased physical stress
 Frailty
• “A clinical state in which there is an increase in an individual’s vulnerability for
developing an increased dependency and/or mortality when exposed to a
stressor”
International Association of Gerontology and Geriatrics Frailty Consensus

• Frailty is a state of reduced physiologic reserve beyond that which would be

expected with normal aging and is thought to result from the cumulative effect
of multiple physiologic changes over time.
Morley JE et al. 2013
• There are multiple etiologic factors leading to frailty, including physiological
changes and diseases associated with aging, inflammation, sarcopenia,
polypharmacy, endocrine disorders, protein energy malnutrition, social
isolation, and poverty
• Frailty can begin before 65 years of age, but the onset escalates in those
aged 70 years and over
Morley JE et al. 2013
• Frailty increases the risk of adverse outcomes in community, inpatient, and
perioperative patient populations including loss of function, falls, delirium,
disability, hospitalization, and death

Fig: Vulnerability of older

people following acute
stress. Clegg A et al, 2013
Prevalence
• The current estimate of physical frailty prevalence is around 15% for
adults aged 65 years and over, based on a recent meta-analysis of
community-dwelling older Europeans.
• In adults aged over 85 years, prevalence increases to over 25%.
O’Caoimh R et al 2018

• The prevalence of frailty in community-dwelling older adults in the

Asia-Pacific region is approximately 3.5%-27%
Lee Y, et al. 2014

• In rural eastern Nepal, 65% of the population older than 60 is frail

UN Yadav et al. 2019
Pathophysiology

Fig: Pathophysiology of Frailty

 Physical Frailty
• Physical frailty can be considered as pre-disability, with disability
defined as needing assistance with basic Activities of Daily Living (ADL)
• Frailty was first described by Fried and colleagues in terms of its physical
characteristics, or ‘phenotype’, and is objectively identified as three or
more of five components:
 Physical Frailty Assessment

• The ICFSR recommended standard for clinical frailty assessment is the highly
validated physical frailty phenotype, developed by Fried and colleagues in 2001
1. Weight loss: self-reported weight loss of >4.5 kg or recorded weight loss of 5%
per year
2. Exhaustion: self-reported exhaustion on US Center for Epidemiologic Studies
depression scale (3–4 days per week or most of the time)
3. Low energy expenditure: energy expenditure <383 kcal/wk (men) or <270
kcal/wk (women)
4. Slow gait speed: stratified by sex and height
5. Weak grip strength: grip strength, stratified by sex and body mass index
• Frailty is a dynamic entity where an individual can transition between states.
For example, hospitalization can transition an older adult from robust to frail
Lee JS et al, 2014
Guidelines for screening and management of frailty

 International Conference of Frailty and Sarcopenia Research (ICFSR)

which is an international alliance of subject-matter experts in the
fields of both frailty and sarcopenia
 The Asia-Pacific Clinical Practice Guidelines for the Management of
Frailty
International Conference of Frailty and Sarcopenia
Research (ICFSR) 2019
Recommendation Certainty Evidence

1. Frailty Screening Strong Low

2. Frailty assessment Strong Low

3. Development of Comprehensive management plan Strong Very low

4. Physical Activity/Exercise Strong Moderate

5. Nutrition and oral health Conditional Very low

6. Pharmacological intervention Consensus Very low

based
7. Additional therapies and treatments Consensus Very low
based
The Asia-Pacific Clinical Practice Guidelines for the
Management of Frailty, 2017
Recommendation Certainty

1. Frailty Screening Strong

2. Frailty assessment Strong

3. Development of Comprehensive management plan Strong

4. Physical Activity/Exercise Strong

5. Nutrition and oral health Conditional

6. Pharmacological intervention Conditional

7. Additional therapies and treatments No

 Frailty Screening

• All adults aged 65 years and over should be screened for frailty using a
simple, validated frailty instrument suitable to the specific setting or
context
 Physical Frailty Assessment

• The ICFSR recommended standard for clinical frailty assessment is the highly
validated physical frailty phenotype, developed by Fried and colleagues in 2001
1. Weight loss: self-reported weight loss of >4.5 kg or recorded weight loss of 5%
per year
2. Exhaustion: self-reported exhaustion on US Center for Epidemiologic Studies
depression scale (3–4 days per week or most of the time)
3. Low energy expenditure: energy expenditure <383 kcal/wk (men) or <270
kcal/wk (women)
4. Slow gait speed: stratified by sex and height
5. Weak grip strength: grip strength, stratified by sex and body mass index
Development of a Comprehensive Management Plan

• A comprehensive care plan for frailty should systematically

address:
 Polypharmacy
 the management of sarcopenia
 treatable causes of weight loss
 the causes of exhaustion (depression, anaemia, hypotension,
hypothyroidism, and vitamin B12 deficiency)
 Physical Activity
• Older people with frailty should be offered a multi-component physical
activity program
• Combining resistance-based training with aerobic and balance training
were effective at managing frailty in older adults
Lorenzo T et al. 2015

• Recent systematic reviews which only include trials of frailty treatment

have reported that multicomponent training improved the outcomes of
muscle strength, balance, disability and falls in older adults with frailty
Gine-Garriga M et al. 2014
• There was insufficient evidence to identify the optimal frequency, intensity, time
and type (FITT) of physical activity required to treat frailty. Similarly, there was
insufficient literature to determine the exact combination of training modes most
effective for frailty management.
ICFSR Guidelines, 2019

• For physical activity programs to be effective for those with frailty, a minimal level
of intensity and an adequate program timespan are needed
Veninsek G et al. 2018

• Group physical activity sessions were more likely to be successful in improving

frailty than individual sessions according to a recent systematic review
Apostolo J et al. 2018
• First-line therapy for the management of frailty should include a multi-
component physical activity program with a resistance-based training
component
Supportive Evidence
 Take Home Message

• A clinical state in which there is an increase in an individual’s

vulnerability for developing an increased dependency and/or mortality
when exposed to a stressor
• Frailty increases the risk of adverse outcomes including loss of
function, falls, delirium, disability, hospitalization, and death.
Therefore, diagnosis, prevention, and treatment of frailty is critical for
health promotion
 Take Home Message
• All adults aged 65 years and over should be screened for frailty using a
simple, validated frailty instrument suitable to the specific setting or
context
• Clinical frailty assessment is the highly validated physical frailty
phenotype, developed by Fried and colleagues in 2001
• First-line therapy for the management of frailty should include a multi-
component physical activity program with a resistance-based training
component