FRAILTY

Presented by : Dr Zeba Firdous , JR-III, GERIATRICS

Under Guidance of Dr Mangala Borkar Sonavani, Professor &
Head ,
Dr Shailaja V Rao , Associate Professor
Dr Ganesh Sonvane , Lecturer , Dr Nilesh Wagh SR ,
Department of Geriatrics , GMCH Aurangabad .
 “
Frailty is a common clinical syndrome in older
adults that carries an increased risk for poor health
outcomes including falls, incident disability,
hospitalization, and mortality .Elucidating its etiology and
natural history is therefore critical for identifying high risk
subsets and new arenas for frailty prevention and
treatment.

2
Schematic
representation of the
domains of the aging
phenotype, and their
relationship with frailty
and with the geriatric
syndrome.
3
Definition
◦ Clinically recognizable state of increased vulnerability
resulting from aging-associated decline in reserve and
function across multiple physiologic systems such that
the ability to cope with everyday or acute stressors is
comprised.

4
◦ Operationally defined by Fried et al. as meeting
three out of five criteria : low grip strength, low
energy, slowed waking speed, low physical activity,
and/or unintentional weight loss .
◦ A pre-frail stage, in which one or two criteria are
present, indentifies a subset at high risk of
progressing to frailty .

5
Defining Frailty ?
◦ Delphi process( 2011 and 2012 ) : “Clinical syndrome that involves
multiple physiologic systems, characterized by decreased reserve and
impaired ability to respond to stress” (did not mention ,
clinical/laboratory biomarkers useful for diagnosis)
◦ A consensus conference was convened in Orlando, Florida, on December 7,
2012 , “medical syndrome with multiple causes and contributors characterized by
diminished strength, endurance, and reduced physiologic function that increases
an individual’s vulnerability for developing increased dependency and/or death”

6
Operational definitions
◦ Frailty as a syndrome or phenotype
◦ Frailty as a deficit accumulation
◦ Frailty as age related biological decline

7
Frailty as a syndrome or phenotype
◦ Fried definition is base on this concept

8
Pathologic vicious
cycle supposed
to lead to a
progressive
decline in health
and function

9
An updated version of the frailty
model

10
Frailty as Deficit Accumulation
◦ In this approach, frailty is considered an
accumulation of illnesses, signs,
symptoms, and laboratory abnormalities,
based on the observation that “the more
things individuals have wrong with them,
the higher the likelihood that they will be
frail”.

11
Frailty tools published in literature
Physical Frailty Phenotype (PFP ) Brief Frailty Instrument

Deficit Accumulation Index ( DAI) Vulnerable Elders Survey -13

Gill Frailty measure FRAIL Scale

Frailty /Vigor assessment Winograd Screening Instrument

Clinical frailty scale

12
Epidemiology of Frailty …
◦ In community-dwelling adults - 10.7%
◦ Prevalence of frailty increases with age, reaching 15.7%
in individuals aged 80 to 84 and 26.1% in those aged
85 or more.
◦ Prevalence is higher in women than men
◦ In older hospitalized patients, the frailty prevalence
varied from 27% to 80%.
◦ Institutionalized older adults - varies from 29.2% to
68.8%. 13
◦ Frailty can be conceptualized,
similar to layers of an onion.
The clinical presentation,
including cognitive and
physical impairments, is in the
first, most superficial layer. The
second layer includes a number
of hypothetical
pathophysiologic mechanisms
and can also be considered as
the “area of biomarkers.” The
third, most inner layer includes
the biological mechanisms that
are hypothesized to be primary
causes of frailty.

14
Frailty as age related biological
decline
◦ (1) signalling networks that maintain
homeostasis;
◦ (2) body composition;
◦ (3) balance between energy
◦ availability and energy demand;
◦ and (4)
neurodegeneration/neuroplasticity

15
Signalling networks that maintain
homeostasis
◦ Inflammaging - elevated levels of serum
proinflammatory cytokines such as interleukin 6 (IL-
6) and tumor necrosis factor α (TNF-α).
◦ Anabolic hormone deficiency

16
Body composition
◦ Decline in muscle mass
◦ Increase in visceral fat
◦ Decrease in muscle strength
◦ Fatty infilteration of muscle
◦ Failure of mechanisms of the maintenance and repair of
damaged muscle fibers
◦ Demineralization of bones and osteoporosis

17
Balance between energy
availability and energy demand
◦ Lack of energy or even an excess of
energy that is not utilized
◦ Age related decline in -
◦ Resting metabolic rate
◦ Aerobic capacity

18
Neurodegeneration

◦ An important biomarker of frailty

◦ Age-related degeneration of the central and
peripheral nervous system
◦ Results in declining performance in specific
cognitive abilities, like memory, processing speed,
executive function, reasoning, and multitasking

19
◦ Degeneration in structure and function from the spinal cord motor neuron
to the neuromuscular junction.
◦ The number of motor neurons declines with aging –loss of muscle
strength and quality
◦ Age-related motor unit remodeling - motor units decrease in number and
become progressively larger, but less functional with aging with reductions
in fine motor control.
◦ Segmental demyelination-remyelination process declines with aging,
resulting in slower conduction of the impulses, with consequent
decreased sensation as well as slower reflexes.

20
Frailty in context of special
medical situations

21
Frailty to evaluate surgical risk

◦ – increased incidence of postoperative

complications , higher mortality
◦ Alternative tools for assessment are
emerging : eg multidimensional frailty
score . More useful in predicting items

22
Composition of multidimensional
frailty score …

23
Frailty and cancer
◦ To estimate risk of side effects of
potentially harmful treatments and make
most appropriate choices among available
treatments
◦ CGA is done which identifies reversible
conditions
◦ VES-13 score 3 or more- do CGA

24
Chronic Kidney Disease
◦ Early renal impairment , more need for
dialysis , adverse outcome even if dialysis
is done , poor candidate for renal
transplant

25
CVD
◦ Three times more prevalent in heart disease patients
◦ Subclinical CVD
◦ Heart failure
◦ Stronger predictor of mortality , length of hospital
stay , readmission
◦ In one study of patients who underwent PCI , 3 year
mortality was 28% for frail patients and 6 % for non
frail patients
26
Diabetes
◦ In the CHS, 25% of frail subjects had diabetes, and
18% of prefrail subjects had diabetes, but only
12% of nonfrail subjects had diabetes.
◦ The increased expression of inflammatory markers
in frail older adults may negatively influence late-
life glucose tolerance
◦ Adverse impact on the microvascular effects of
diabetes itself.
27
HIV
◦ frail HIV-infected persons have greater
comorbidity including chronic kidney disease,
cognitive impairment, and depression.
Furthermore, frail HIV-infected persons have
higher rates of nonelective hospitalization and
longer inpatient admissions.

28
Transplantation
◦ One prospective study of 487 patients
with end-stage liver disease referred for
liver transplant demonstrated that frailty,
defined using the Fried criteria, is a better
indicator of quality of life than severity of
liver disease measured as MELD

29
Take Home Message
◦ Frailty is a topic of research and debate
◦ Researchers and clinicians have no disagreement on
severe impact of frailty on older adults, their care
givers, and on society as a whole.
◦ Specific treatments - yet to be developed and tested,
◦ The existing clinical measures of frailty are useful to
identify high risk individuals
◦ This can improve treatment , decision making and
management. 30
References
 Luigi Ferrucci, Elisa Fabbri, Jeremy D. Walston. Frailty. Hazzard’s Textbook of
Geriatric Medicine and Gerontology Seventh Edition.
 Sun-wook Kim, Ho-Seong Han, Multidimensional Frailty Score for the Prediction of
postoperative Mortality Risk. JAMA Surg.doi:10.1001/jamasurg.2014.241 Published
onlineMay 7, 2014.
 Afilalo J, Alexander KP, Mack MJ, et al. Frailty assessment in the cardiovascular care
of older adults. J Am Coll Cardiol. 2014;63(8):747–762.
 Ferrucci L, Studenski S. Clinical problems of aging. In: Longo DL, Fauci AS, Kasper
DL, et al., eds. Harrison’s Principles of Internal Medicine. 18th ed. New York, NY:
McGraw-Hill; 2012.

31
Thank You