frailty: how to recognise it and why it matters - rcp london
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Frailty: how to recognise it and why it
matters
Andy Clegg
Senior Lecturer & Consultant Geriatrician
University of Leeds & Bradford Teaching Hospitals
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‘We see, but we do not always recognise’
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We move from seeing to recognising by understanding
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Increasing frailty
Fit Mild frailty Moderate frailty Severe frailty
Understanding frailty
Condition characterised by loss of biological
reserves, failure of homeostatic mechanisms, and
vulnerability to adverse outcomes
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Clegg, Young, Iliffe, Olde-Rikkert, Rockwood. Lancet 2013
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Clinical presentation of frailty
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Frailty models
Two main established ‘research standard’ international
models of frailty
1. Phenotype model (Fried JGMS 2001)
• Frailty identified on the basis of five characteristics
2. Cumulative deficit model (Rockwood CMAJ 2005)
• Frailty identified using a range of ‘deficits’ (symptoms, signs,
diseases, disabilities) – between 30 and 70
• Calculate frailty index (no. of deficits/total possible)
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Frailty assessment:
NICE + NHS
Primary care & outpatient settings
• An informal assessment of gait speed (time taken to answer the door, or walk from the waiting room)
• A formal assessment of gait speed (>5s to walk 4m)
• PRISMA 7 questionnaire (>3)
• Edmonton frail scale (>8)
• Clinical frailty scale (>5)
• eFI (routine data…...)
Inpatient settings
• Clinical frailty scale (>5)
• Reported Edmonton frail scale
• ISAR tool
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Development cohort 250,000
Internal validation cohort 250,000 External validation cohort 500,000
Identifying frailty using routine data:
the eFI
Clegg Age Ageing 2016 (open access)
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Outcome Mild frailty
(HR, 95% CI)
Moderate frailty
(HR, 95% CI)
Severe frailty
(HR, 95% CI)
1 yr care home admission 2.00 (1.68 to 2.39) 2.70 (2.41 to 3.04) 5.94 (4.61 to 7.64)
3 yr care home admission 1.52 (1.37 to 1.69) 2.70 (2.41 to 3.04) 3.42 (2.84 to 4.12)
5 yr care home admission 1.56 (1.43 to 1.70) 2.34 (2.10 to 2.61) 3.00 (2.42 to 3.70)
1 yr hospitalisation 1.85 (1.81 to 1.88) 2.96 (2.90 to 3.02) 4.62 (4.50 to 4.74)
3 yr hospitalisation 1.71 (1.69 to 1.73) 2.54 (2.51 to 2.58) 3.64 (3.57 to 3.70)
5 yr hospitalisation 1.63 (1.61 to 1.64) 2.43 (2.40 to 2.46) 3.59 (3.54 to 3.65)
1 yr mortality 1.91 (1.78 to 2.04) 3.39 (3.15 to 3.65) 5.23 (4.73 to 5.79)
3 yr mortality 1.74 (1.68 to 1.81) 3.02 (2.90 to 3.14) 4.56 (4.29 to 4.84)
5 yr mortality 1.66 (1.62 to 1.71) 2.73 (2.64 to 2.81) 3.88 (3.68 to 4.09)
Outcomes
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Implementation &
dissemination
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Why does it matter?????????
Three simple reasons!!!!!!!!!!!!!
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1. Predicts natural history
Specialty Outcome Adjusted OR/RR/HR
(95% CI)
Primary care Falls 1.23 (0.99 to 1.54)
Disability 1.79 (1.47 to 2.17)
Nursing home admission 2.60 (1.36 to 4.96)
Hospitalisation 1.27 (1.11 to 1.46)
Mortality 1.63 (1.27 to 2.08)
Cardiology 30 day mortality post ACS 2.17 (1.28 to 3.67)
Critical care Physical recovery 12m after ICU 0.32 (0.19 to 0.56)
General surgery Post-operative morbidity 2.06 (1.18 to 3.60)
General surgery 30 day post-operative mortality 4.00 (1.10 to 15.20)
Geriatric medicine Inpatient delirium 8.50 (4.80 to 14.80)
Oncology Chemotherapy intolerance 4.86 (2.19 to 10.78)
Renal medicine Mortality in ESRD patients on dialysis 2.24 (1.60 to 3.15)
Respiratory medicine 90 day readmission after COPD exac 1.43 (1.13 to 1.80)
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2. Informs evidence-based
prescribing
NICE Database of Treatment Effects
Treatment Outcome Trial duration Number needed
to treat (NNT)
Annualised NNT
(ANNT)
Antihypertensives MI 10 years 84 840
Statins
(secondary
prevention)
Mortality 3.8 years 67 255
Aspirin (angina) Mortality 4.2 years 46 192
Anticoagulants
(AF)
Stroke 1 year 40 40
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3. Predicts response to
therapeutic interventions
Intervention (community-based) Outcome
Comprehensive geriatric assessment
of older people
14% reduction in nursing home
admission
Comprehensive geriatric assessment
of ‘frail’ older people
10% reduction in hospital admissions
Community-based post discharge care 13% reduction in nursing home
admission
10% reduction in hospital admission
Group-based education (supported
self-management)
40% more likely to be living at home
Falls prevention 8% reduction in falls
Exercise interventions Improved function
Beswick Lancet 2008
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Summary
• See frailty, then recognise it!
• Use pragmatic approach or simple tool to enable
recognition
• Avoid conflating acute illness with frailty
• Consider using eFI in primary care setting
• Use epidemiological associations of frailty in many specialty
settings to support shared treatment decisions
• Use frailty to identify target population for a range of
interventions to improve outcomes
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Setting Outcome Reference
Primary care Falls Clegg Lancet 2013
Disability
Nursing home admission
Hospitalisation
Mortality
Cardiology 30 day mortality post ACS Ekerstad EJPC 2013
Critical care Physical recovery 12m after ICU admission Heyland ICM 2015
General surgery Post-operative morbidity Makary JACS 2010
General surgery 30 day post-operative mortality Hewitt Am J Surg 2015
Geriatric med Inpatient delirium Eeles Age Ageing 2012
Oncology Chemotherapy intolerance Handforth Ann Onc 2015
Renal med Mortality in ESRD patients on dialysis Johansen JASN 2007
Respiratory med 90 day readmission after COPD exacerbation Kon Thorax 2015
Thank You!!