What are we talking about?

14th October 2015

Dr Jane Shoote
Consultant Geriatrician
• Worldwide population is ageing
• Impacts healthcare planning and provision

• The most problematic expression of population ageing is

the clinical condition of FRAILTY

• Around 10% of over 65s have frailty

• Over 25 of over 85s have frailty (in some studies >50%)
 “a state of increased vulnerability to
stressors due to age-related declines in
physiologic reserves across neuromuscular,
metabolic, and immune systems”

American Geriatric Society 2004

 “a medical syndrome
with multiple causes and contributors
that is characterised by
diminished strength, endurance, and
reduced physiological function,
that increases an individual’s vulnerability for
developing increased dependency
and/or death”
J Am Med Dir Assoc 2013
• Related to the ageing process
• Independently associated with adverse outcomes
• Common
• Progressive
• Episodic deteriorations
• Preventable components
• Impact quality of life
• Expensive

Harrison J, Clegg A, Conroy S, Young J. Managing frailty

as along-term condition. Age Ageing 2015;44:732-5.
Impacting quality of life
• Accelerated decrease
in physiological reserve

• Failing homeostatic
mechanisms

Clegg A, Young J, Iliffe S, Rikkert M,

Rockwood K. Frailty in elderly people.
Lancet. 2013; 381: 752 - 762
Clegg A, et al. Frailty in elderly people. Lancet. 2013; 381: 752 – 762.
 Less
muscle
Sarcopaenia mass

Sensation
Lower
of
muscle
increased
mass
effort

Fewer
physical
activities
Frailty lies outside the comfort zone of Guideline Based Medicine
• State of increased vulnerability
• Not an inevitable part of ageing
• Is a chronic condition
• May be made better or worse

• Identification is important and should form part of

any health/social care interaction

Read codes for CTV3:

mild frailty = XabdY, moderate frailty = Xabdb, Severe frailty = Xabdd
1. Comprehensive geriatric assessment (CGA)
◦ Structured, multidisciplinary assessment

2. Simple assessment
◦ Gait speed
◦ Timed-up-and-go test (TUGT)
◦ PRISMA-7 Questionnaire

3. Routine data
◦ Electronic frailty index (eFI)
• Gait speed
• Timed-up-and-go test (TUGT)
• PRISMA-7 questionnaire

• Sensitive but not specific

• Good to exclude those not frail
• Need further clarification on those positive
• Requires a stop watch and 4 metre distance
• Median life expectancy 0.8 m/s
• > 5 seconds to walk 4 metres
• Good, valid, simple single tool to predict disability,
long term care, falls, mortality
• Studies suggest target further examination of gait
speeds slower than 0.6 m/s ??
• Especially informative if no self report of  function
For identifying frailty:
Gait speed <0.8m/s = Sensitivity 0.99, specificity 0.64
• TUGT > 10 seconds
• Positive predictive value = 0.17
• Negative predictive value = 0.99
• Very good for excluding frailty
• Similar to gait speed and PRISMA-7 would need
further clarification of results

For identifying frailty:

TUGT>10s = Sensitivity 0.93, specificity 0.62
 • ≥ 3 or above at risk
• Sensitivity 78.3%
• Specificity 74.7%S
• Used to identify those
who may benefit more
comprehensive
assessment

For identifying frailty:

PRISMA-7 = Sensitivity 0.83, specificity 0.83
 ‘The more things that are wrong with you, the more
likely you are to be frail’
• Canadian study of health and ageing
• Simple calculation of the presence of absence of a
variable
• Based on 92 baseline variables
• Cumulative effect of individual deficits
• 92 reduced to 36 without loss of predictability

Rockwood K, Song X, Macknight C et al. A global clinical

measure of fitness and frailty in elderly people. CMAJ
2005;173:489-95.
• Validated using 500,000 patients
• >2000 Read codes
• Calculated as cumulative deficit model
E.g. 18 deficits 18/36 = 0.5
• Scoring:
0 - 0.12 = Fit
0.13 – 0.24 = Mild Frailty
0.25 – 0.36 = Moderate Frailty
>0.36 = Severe Frailty
• Runs through SystmOne
• Relates to the risk of adverse outcomes
 Activity limitation  Ischaemic heart disease
 Anaemia & haematinic deficiency  Memory & cognitive problems
 Arthritis  Mobility and transfer problems
 Atrial fibrillation  Osteoporosis
 Cerebrovascular disease  Parkinsonism & tremor
 Chronic kidney disease  Peptic ulcer
 Diabetes  Peripheral vascular disease
 Dizziness  Polypharmacy
 Dyspnoea  Requirement for care
 Falls  Respiratory disease
 Foot problems  Skin ulcer
 Fragility fracture  Sleep disturbance
 Hearing impairment  Social vulnerability
 Heart failure  Thyroid disease
 Heart valve disease  Urinary incontinence
 Housebound  Urinary system disease
 Hypertension  Visual impairment
 Hypotension/syncope  Weight loss & anorexia

> 2000 Read codes

CTV3
X76Ao | Frailty
XabdY | Mild frailty
Xabdb | Moderate frailty
Xabdd | Severe Frailty

Read V2
2jd.. | Frailty
2Jd0. | Mild frailty
2Jd1. | Moderate frailty
2Jd2. | Severe frailty
Young J. 2014 Frailty is the
future talk.
• Predictive validity similar to Frailty Index
• Good correlation with other scales
• Unclear inter-rater reliability
• Best used with CGA and geriatrician
• Timely assessment
• Ongoing studies
Shi et al. Analysis of frailty and survival.
BMC Geriatr. 2011;11:17.
• Non-specific presentations
• Multiple co-morbidities
• Communication barriers
• Disability and complexity
• Recognition and interpretation

• 30 – 60% new dependency in ADLs following

admission
• Adverse outcomes
• Worsening disability
• Falls
• Admission to hospital
• Increasing length of stay
• Risk of admission to long term care
• Death
Mrs A a 78 year old lady with COPD and Type II
diabetes, previous MI, depression and
osteoarthritis…………….
• 11 drugs
• 10 possible further drugs recommended
• 9 lifestyle modifications advised
• 8–10 routine primary care appointments
• 8–30 psychosocial interventions
• Smoking cessation appointments
• Pulmonary rehabilitation
Hughes et al. Guidelines for people
not diseases. Age Ageing 2013;42:62-9.
 Medication and Falls Risk
Group Common Drug Names Contributing Factors Possible Actions for
Prescribers
Sedatives and Temazepam, diazepam, lorazepam, Orthostatic hypotension,  Stop if possible
hypnotics nitrazepam sedation which can last into the  Long term use will need
Zopiclone, Zolpidem, next day, lightheadedness, slow slow, supervised withdrawal
chlordiazepoxide, chloral betaine reactions, impaired balance,  No new initiation
(Welldorm), clomethiazole confusion Medication and Falls Risk
Antipsychotics Chlorpromazine, haloperidol, orthostatic hypotension,  Review indication and stop if
lithium, promazine, confusion, drowsiness, slow possible (may need specialist
trifluoperazine, quetiapine, reflexes, loss balance. Long opinion/support) All patients who present with a fall must have a medication review
olanzapine, risperidone term use - Parkinsonian  Reduce dose/frequency if with modification/withdrawal (NICE CG 161)
symptoms. unable to stop
Antidepressants Tricyclics - amitriptyline, Double risk of falls  Review indication (do not use
dosulepin (Dothiepin), Drowsiness, blurred vision, amitriptyline as night
imipramine, lofepramine dizziness, orthostatic sedation) Whilst any medication changes will be finally decided by the doctor (GP or consultant) anyone
Other sedating – trazadone, hypotension, constipation,  Stop if possible, may need working in falls can help to make this review as useful as possible:
mirtazepine urinary retention slow supervised withdrawal
Take a comprehensive list of all medications currently taken (NB this should be what they
SnRI – venlafaxine and MAOI Orthostatic hypotension (OH)  Populations studies show actually take, not what has been prescribed!). Anyone on FOUR or more medications are at
increased falls risk with SSRI increased risk of falls.
but mechanism unclear, Check the patient’s understanding of their medication and how they take them. Consider
SSRI – citalopram, fluoxetine probably safest class to use concordance and compliance aids.
Check lying and standing BP (5 mins lying down, check BP, stand, check BP then every
Drugs with Procyclidine, trihexyphenidyl Dizziness, blurred vision,  Review indication
minute for 3 minutes). A drop of 20 systolic or 10 diastolic is abnormal. Record any symptoms
anticholinergic (Benzhexol), prochlorperazine, retention of urine,  Reduce dose or stop
experienced and send this in to the doctor who is doing the medication review.
oxybutynin, tolterodine confusion, drowsiness,
side effects Look for high or moderate risk drugs – see chart and highlight these for the doctor.
hallucinations.
Drugs for Co-beneldopa, co-careldopa, Sudden daytime  Check L&S BP, drugs and
Parkinson’s rotigotine, amantadine, sleepiness, dizziness, PD itself can cause OH Medication review:
entacapone, selegiline, insomnia, confusion, low  Poorly controlled PD can
disease
rivastigmine. blood pressure, orthostatic cause falls  Is it still the right drug? (eg methyl dopa should no longer be used for hypertension)
hypotension, blurred vision.  It may not be possible to
change the medication  Is it still necessary? (eg analgesia given for acute flare OA, now resolved)
 Do not change treatment
without specialist advice  Is it a moderate or high risk drug (see chart)? If so what is the risk/balance ratio?
Vestibular Phenothiazines – prochlorperazine Movement disorder with long  Do not use long term – no
Sedatives term use evidence of benefit  Is there a safer alternative?
Antihistamines- cinnarazine, Sedating, orthostatic
betahistine hypotension  Could the dose be reduced? (eg 5mg bendroflumethiazide no significant increase in
antihypertensive effects, but significant increase in side effects compared with 2.5mg)
Cardiovascular ACE inhibitors/Angiotensin-II Low blood pressure,  Check L&S BP
drugs antagonists orthostatic hypotension,  Review indication, use  Should they be on calcium and vitamin D? – Ca and Vit D (800iu daily) reduce falls by up to
Ramipril, lisinopril, captopril, dizziness, tiredness, alternative if possible, 20% by improving muscle function and reducing body sway. Consider vitamin D level in patients
irbesartan, candesartan sleepiness, confusion, especially for alpha blocker with falls over age 65 (see pathway for management of deficiency). Consider supplements in all
Vasodilators - Hydralazine hyponatraemia,  Reduce dose if possible people who fall and are housebound or in residential or nursing homes. Don’t forget osteoporosis
Diuretics - bendroflumethiazide, hypokalaemia risk assessment / treatment.
bumetanide, indapamide, Symptomatic OH + LVF – if
furosemide, amiloride, systolic LVF then try to maintain
spironolactone, metolazone. Stopping or reducing medication isn’t always easy and requires commitment and
ACEi and β Blocker as survival
Beta-blockers - Atenolol, Bradycardia, hypotension, understanding by the prescriber and patient. Advice on complex cases is always available from the
benefit clear. Stop nitrates, CCB,
bisoprolol, carvedilol, orthostatic hypotension, consultant geriatricians at Ipswich Hospital, in the community sessions or via the Rapid Assessment
other vasodilators and if no fluid
propranolol, sotalol syncope Falls Clinic.
overload reduce or stop diuretics.
Alpha-blockers - doxazosin,  Seek specialist advice if
alfuzosin, terazosin, tamsulosin needed The attached table is provided as a guide to medication review in falls only. Each patient must
Analgesics Codeine, tramadol. Drowsiness, confusion,  Start low, go slow, review be assessed as an individual and the risk/benefit for each drug considered and discussed and a
hallucinations, orthostatic dose and indication regularly decision made by the prescriber in consultation with the patient.
Opiates – morphine, oxycodone.
hypotension, slow reactions
Anti-epileptics Carbamazepine*, phenytoin*, Unsteadiness & ataxia if levels  Consider indication (many
phenobarbitone*, primidone* high used for pain or mood) Higher risk drugs Moderate risk drugs
Phenytoin – permanent  May need specialist review
sodium valproate*, gabapentin cerebellar damage and  *Consider Vitamin D
unsteadiness in long term use Never stop or withhold medication without agreement from the medical team
supplements for at risk Adapted from © The Ipswich Hospital NHS Trust, April 2014.Dr Julie Brache. All rights reserved. Not to be reproduced in whole, or in part, without the permission of the copyright
patients on long term owner.
lamotrigine, topiramate, Newer agents – insufficient data treatment with these drugs
levatiracetam, pregabalin regarding falls risk

Never stop or withhold medication without agreement from the medical team
Adapted from © The Ipswich Hospital NHS Trust, April 2014.Dr Julie Brache. All rights reserved. Not to be reproduced in whole, or in part, without the permission of the copyright owner.
BGS Spring 2015 Prof J Young, Dr E Burns
Categorise numerically

 Mildly frail – Supported Self Management

 eg Age UK a practical guide to healthy ageing

 Moderately frail – Care and Support Planning

 eg CGA and care plan

 Severely frail – anticipatory care planning

 eg Case management, ACP and end of life care
Preventable components for ‘Frailty’
• Affect (Mood problems)
Stuck et al. Soc Sci Med.
• Alcohol excess 1999 (Systematic review
• Cognitive impairment of 78 studies)
• Falls
• Functional impairment
• Hearing problems Additional topics:
• Nutritional compromise • Look after your feet
• Physical inactivity • Make your home safe
• Vaccinations
• Polypharmacy
• Keep warm
• Smoking
• Get ready for winter
• Social isolation and loneliness • Continence
• Vision problems ………others……??
 Produced to help people
improve their health and
general fitness,
particularly those aged 70
or over with ‘mild frailty’.

To reorder this guide

please order for free
online via
www.orderline.dh.gov.uk
or call 0300123 1002
quoting reference HA2.
Publication date 01/10/15.
http://infolink.suffolk.gov.uk/kb5/suffolk/infolink/home.page
 “Right care,
at the right time,
in the right place”

NHS England. Commissioning for carers principle 3

• Improved access – The ‘Hot Phone’
◦  07930181236

• Regular risk profiling / case finding

• Named accountable GP / Care co-ordinator

• Holistic care plan

• Internal reviews / MDTs of unplanned admissions

• Clinicians and patient with LTC
• Collaborative approach to identify
◦ What is important to that individual
◦ Goals
◦ Support needs
◦ Action plans
• Progress is monitored
• Continuous process not a one-off event
 FAB at a glance The future:
Centre of excellence and resource
Education and outreach
ED ETT GP EAU phone Hot phone Staff development (GP, ENP etc)
Extended management via virtual ward
Routes in

Incorporation of falls and other clinics

Email/Phone Full 7 day working
Inreach to IHT wards
Seen within 48
hours

Frailty Assessment Base

Comprehensive Geriatric Assessment
Dr, Nurse, Therapy, Dietician, Pharmacist
Shared Care
Plan
Frailty Score
Problem list
Action plan
Routes out

Admitted Home ICB

Front loaded assessment CHT
CAT Interface geriatrician case management
and management plans
FAB team ward follow-up Voluntary sector
DIST
ACS
Geriatrician follow-up
• Hot Phone – advice/same day assessment
07930 181236

• Email – 2 working day review

[email protected]

• SHARE SystmOne record

• Advanced frailty means EOL is close and should
trigger a proactive care approach.
• People in their last year of life are admitted an
average of 3.5 times

4 T’s - Reflective practitioner questions

• Think Frailty
• Timid – am I being timid?
• Timeliness – is this the right time?
• Time – do I need to make time?

Uncertainty causes anxiety

• Is important to prepare for and aim to postpone

• Important to recognise as a state of vulnerability to

poor recovery from simple stressor events

• Failure to detect frailty potentially exposes patients

to interventions from which they might not benefit
and may be harmed

• Recognising advancing frailty should trigger a

proactive care approach to EOL care planning
[email protected]
Secretary: 01473 704137
Hot phone: 07930 181236
1. NHS England. Toolkit for general practice in supporting older
people with frailty. 2014.
2. http://www.bgs.org.uk/index.php/fit-for-frailty
3. http://www.york.ac.uk/inst/crd/effectivenessmatters.htm
4. Report by the comptroller and auditor general. End of life care. HC
1043 Session 2007-2008 | 26 November 2008.
5. Morley et al. Frailty consensus: a call to action. J Am Med Dir
Assoc 2013;14:392-7.