Define frailty.
A long term health condition characterised by a loss of physical, emotional and cognitive resilience.
What % of those over 65yrs are living with mild, moderate and severe frailty in England?
Severe - 3%
Moderate - 12%
Mild - 35%
What is the phenotype model of frailty?
Phenotype model of frailty is composed of at least 3 of the 5 following:
- Reduced muscle strength
- Unintentional weight loss
- Reduced gait speed
- Exhaustion
- Low energy expenditure
What is the Cumulative deficit model of frailty?
Consists of 36 deficits which are calculated to give a score predicting frailty. Usually easily done as these are coded in patient notes in GP –> eFI
What are the five frailty syndomes?
- Falls
- Immobility
- Delirium
- Incontinence
- Susceptibility to side effects of medication
This is like the “Geriatric giants” but more updated- GG = immobility, iatrogenesis, instability, incontinence, intellectual impairment.
What cognitive screening tests are available in GP? (2)
- 4AT
- GP-COG
In relation to daily activity, what should you always ask about in terms of mobility?
Are you driving?
Name 2 validated tools for diagnosing frailty (gait related).
Gait speed test - patient is asked to walk 4m - taking 5 seconds or longer may indicate frailty. Done twice.
Timed Up and Go test (TUG) - start seated and ask to walk 3m, turn back and sit again. Time starts when patient makes effort to stand up. Walking aids can be used.
What is PRISMA7?
PRISMA7 – 7Q, 3 or more “yes” answers indicate frailty. Validated tool for frailty.
- Are you more than 85 years?
- Male?
- In general do you have any health problems that require you to limit your activities?
- Do you need someone to help you on a regular basis?
- In general do you have any health problems that require you to stay at home?
- In case of need can you count on someone close to you?
- Do you regularly use a stick, walker or wheelchair to get about?
What 3 physical aspects of frailty can usually be easily addressed?
- Physio to increase muscle tone
- Protein intake
- Vitamin D levels
What is a tool used to reduce medication burden in a frail patient?
STOPP START
What aspects of a fall should be addressed according to NICE guidelines?
Falls risk: NICE guidance: multifactorial assessment (re falls):
- Identification of falls history
- Assessment of gait, balance and mobility, and muscle weakness
- Assessment of osteoporosis risk
- Assessment of person’s perceived functional ability and fear relating to falling
- Assessment of visual impairment
- Assessment of cognitive impairment and neurological examination
- Assessment of urinary incontinence
- Assessment of home hazards
- Cardiovascular examination and medication review
Questions you can ask:
- Have you had any falls? How many in the last year? Do you worry about falls/are you scared of falling? Do you stop yourself doing anything to prevent falls? Do you have anything in your house/any mobility aids to help you stop falling?
- Have you struggled to get about as easily as usual recently?
- Have you/your relative been more confused recently? Also AMTS/4AT – particularly focusing on orientation & attention.
- Do you have any problems going to the toilet? Any accidents? (specifying urine & faeces). Do you sometimes leak when you cough/laugh/stand/strain? Do you sometimes get the urge to go suddenly – and do you ever not make it to the toilet in time?
- Do you get dizzy on standing? How are your bowels – do you struggle to go? How often do you open your bowels?
How can you assess mood in a frail person? (3)
- Geriatric depression scale
- Sleep changes
- Appetite
- Medication
How can you screen for alcohol excess in a frail person?
CAGE
- cut down?
- annoyed?
- guilty?
- eye opener/morning?
Describe the response to an adverse event in a frail vs non-frail patient.
- Frail people have less functional reserve to begin with
- When they have an adverse event, they recover more slowly and may not go back to their baseline
Name 3 complications of frailty.
- Deteriorating mobility and falls
- Hospital admission
- Care home admission
- Death
Describe an electronic tool used to screen for frailty in GP and describe it.
This is only a screening tool - it is not diagnostic.
It uses a combination of 36 frailty deficits which include 20 diseases, an abnormal laboratory value, 8 signs/symptoms and 7 disabilities.
What further questions would you want to ask Frank?
- Fall history
- SH
- PMH
- Medication
- Examination
What is the definition of postural hypotension?
A 20mmHg drop in systolic BP or a 10mm drop in diastolic BP within 2-5min of standing up.
What conditions could this falls history be pointing to?
- Antalgic gait = painful gait, ? hip replcement or joint problems
- Little sensation in feet = diabetic neuropathy. Vibration and sharp touch lost first.
- Light headed on standing = postural hypotension, medication side effect
- Nocturia = BPH, diabetes
- Drowsiness = poor sleep, medication side effect
- Vision = diabetic retinopathy
Does he have postural hypotension? What is most worrying about this examination? What medication is he taking for Parkinson’s?
- Posural hypotension = yes; a drop in systolic greater than 20mmHg
- Blood sugar is worrying - low end of normal in a random blood sugar; this could be caused by the Gliclazide which has tendency to cause hypoglycaemia.
- Minimal sharp touch and vibration in a glove and stocking distribution suggests diabetic neuropathy
Madopar is for Parkinson’s (levodopa and benserazide)
Which of Frank’s medications could be causing drowsiness at night?
Amitriptyline is used for neuropathic pain at night but it can also cause drowsiness
What is the difference between a care plan and care planning?
Care planning
- Encourages doctors to work together to understand what is important to a patient
- Agree goals, support needs, develop action plan and monitor it
- It is a continuous process
Care plan vs planning
- Care plan: focus on disease of problem management
- Care planning: focus on person management
Graph: Single long term condition is on the left and each person has a care plan for their condition. As you move towards multiple LTCs you need individualised care
Which aspects of a frail patient’s life should you also try to address in a consultation?
- Mood
- Nutrition
- Cognition
- Skin integrity
- Continence - any leaks or problems going to the toilet?
- Social/activities
- Falls
- Medications
- Poor mobility
