The Frailty Syndrome - Today's Geriatric Medicine

The Frailty Syndrome ... Although it lacks a standardized clinical definition, older adults' frailty warrants special considerations in terms of treatment and ... Home|About|Events|Contact|AdvisoryBoard|Writer’sGuidelines|Reprints|Organizations|Advertising CurrentIssue ArticleArchive DigitalEditions Newsletter IndustryNews Webinars Jobs ProductShowcases Search Medication ClinicalReview Alzheimer’s/Dementia BabyBoomerIssues LongTermCareTrends Nutrition ResearchNews VintageVoices January/February2014 TheFrailtySyndrome ByZacharyJ.Palace,MD,CMD,andJenniferFlood-Sukhdeo,MS,RD,CDN Today’sGeriatricMedicine Vol.7No.1P.18 Althoughitlacksastandardizedclinicaldefinition,olderadults’frailtywarrantsspecialconsiderationsintermsoftreatmentandnutritionalneeds. Thenormalagingprocessischaracterizedbyaprogressionofphysiologiceventsthatoccurthroughoutthelifecycle.Changesassociatedwithagingoccurthroughoutthebodyandaremostprominentinthelateryears.Changesinthemusculoskeletalsystembegintooccurafterthethirddecadeandcontinueintotheeighthandninthdecades.Thefrailtysyndromecanbedescribedasaculminationoftheeffectsofthesechangesonthehumanbody. Asnormalagingprogresses,themusculoskeletalsystemshowsdeclinesinseveraldifferentareas.Theterm“sarcopenia”describesthebiochemicalchangesthatoccurwithinthemusclefibersastheyrelatetodecliningmusclemassandmusclefunction.Visibleatrophyofmusclefibersresultsindecreasedstrength.Thesechangesresultfromfatdepositionreplacingleanmusclemass,aprocessthatbeginsafterthethirddecadeoflifeandcanresultinuptoa40%decreaseinmusclemassbytheeighthdecadeoflife.Markedlossesinmusclestrengthanddecreasedendurancebecomemoreprominentovertimeandcorrelatewithanincreasedriskoffalls.1 Thestructuralintegrityoftheskeletonplaysamajorroleinmaintainingoptimalpostureandgait.Thebody’speakbonedensityoccursduringanindividual’slate20s.Anongoingprocessofboneformationandresorptionoccursthroughoutlifeinhealthybones.Aftertheageof40,however,therateofboneresorptionincreases,resultingindecreasedbonemassandbonedensity.Thisprocessisexacerbatedinwomenfollowingmenopauseandcanleadtoosteopeniaandosteoporosis.2 Independentofthedevelopmentofosteoporosis,normalage-relateddecreasesinbonedensityresultindecreasedstructuralbonestrength,whichcanincreasetheriskoffallsandfractures.Compressionfracturesoftheanteriorcervicalspineresultinkyphosis,astoopedposturethatoftenisreferredtoasadowager’shump.Thisforwardshiftofthecenterofgravityincreasestheriskofthelossofbalanceandfalls.2 RecognizingFrailty Thesenormalprocessesofagingaffectboththemuscularandskeletalsystemsand,asaresult,playasignificantroleinthedecreasedmobilitythatoftenisobservedinlaterlife.Nevertheless,thefrailtysyndromeisnotdefinedbymobilityalone;malnourishment,asevidencedbyinvoluntaryweightloss,alsoisanimportantcomponent.Althoughit’sdifficulttodefineprecisely,mostclinicianswillconcurthatfrailtycanbeeasilyrecognizedas“youknowitwhenyouseeit.”Thefollowingclinicalvignettesillustratethispoint: •Herbisan86-year-oldretiredattorneyresidingwithhiswifeintheirhome.Hehasamedicalhistorysignificantformildhypertensionanddegenerativejointdiseasewithseverekyphosisofthethoracicspine.Heunderwentarighthiphemiarthroplastyattheageof80andcontinuedtoremainmobileandphysicallyactivepostoperatively. Recently,asaresultoftheprogressionofkyphosis,hecannotholdhisheaduprightandwalkswithasevereforward-stoopedposture.Thisposturehassignificantlyshiftedhiscenterofgravityanteriorly,resultingintwotothreefallsperdaywhileambulating.Hehasdifficultyinrisingunassistedfromaseatedpositionandhasbecomemoresedentary. •Bettyisa78-year-oldretiredteacher.Shelivesinherapartmentinthecommunitywithahomehealthaidewhospendsseveralhoursperdayassistingherwithshoppingandhouseholdchores.Sheisindependentinheractivitiesofdailyliving.Hermedicalhistoryissignificantforinsulin-dependentdiabetesmellitus,hyperlipidemia,hypertension,andcataracts.Shealsosuffersfromchronicpainduetoseverebilateralkneeosteoarthritis,whichgreatlylimitshermobilityandkeepshersedentarymuchoftheday.Althoughshehasnorecentfallhistory,shedescribesherselfasfeelingweakandfatiguingeasily. •Ritaisa96-year-oldwidowwhoresidesinanursinghome.Shehasamedicalhistoryofdementiaandwasadmittedtolongtermcarethreeyearsago.Havingoutlivedallofherotherfamilymembers,Ritalivedinanapartmentinthecommunity,whereshewasfoundtohavepoorhygieneandwaswanderingfrequently,oftenbecominglost. Herstayinlongtermcarehasbeenunremarkable,andshereceivesassistancewithheractivitiesofdailyliving.Shehasaheartyappetite,attendsactivities,andcontinuestowanderthroughthehallwaysofthenursingfacility. Althoughthesethreeindividualspresentquitedifferently,mostclinicianslikelywouldagreethatbothHerbandBettywouldbeconsideredtomanifestfrailty.PhysicallimitationsduetoseverekyphosisandfrequentdailyfallswouldcausemostclinicianstolabelHerbasfrail.Betty’sclinicalpicturethatincludesmultiplecomorbiditiesandalimitedlevelofphysicalactivityalsowouldbeconsistentwithfrailty. However,mostclinicianswouldnotconsiderRitaasmanifestingthefrailtysyndrome.Althoughshe’s96yearsold,cognitivelyimpaired,andlivinginlongtermcare,herlevelofphysicalactivity,asmanifestbyherfrequentwandering,wouldbelessconsistentwithafrailtydiagnosis. Asthepopulationcontinuestoageandthepercentageofolderadultsovertheageof80continuestoexpand,itisnowmoreimportantthanevertoidentifythefrailtysyndromesooner.Todoso,itisnecessarytocodifyintoaworkingdefinitionthecommonfindingsassociatedwiththefrailtysyndrome.Severaldifferentstudieshaveattemptedtoidentifyfrailtybasedonrecognizableoperationalcriteriaorbyincorporatingmeasurablescalesofdisability.Inalandmarkstudyanalyzingmultiplecommonlyobservedcharacteristicsoffrailty,Friedetalidentifiedanddefinedfrailtyasasyndromethatisdistinctandindependentofmedicalcomorbiditiesanddisability.3 Thefrailtysyndromerequiresatleastthreeofthefollowingfivecharacteristics: •unintentionalweightloss,asevidencedbyalossofatleast10lbsorgreaterthan5%ofbodyweightintheprioryear; •muscleweakness,asmeasuredbyreducedgripstrengthinthelowest20%atbaseline,adjustedforgenderandBMI; •physicalslowness,basedonmeasuredtimetowalkadistanceof15ft; •poorendurance,asindicatedbyself-reportedexhaustion;and •lowphysicalactivity,asscoredusingastandardizedassessmentquestionnaire. Amongthestudypopulationofmorethan5,300participants,severalsignificantfindingsaboutfrailtywereobserved.Thosewhometthecriteriaforfrailtysyndromeweremorelikelytobeolderandinpoorerhealthandhadhigherratesofcomorbidchronicdiseaseanddisability.3Diagnosesofcardiovasculardisease,pulmonarydisease,diabetes,andarthritisaswellasimpairedcognitionanddepressionwerefoundtobemoreprevalentinthisgroup.3Studiesalsohaveidentifiedobesityasasignificantriskfactorforfrailtyinwomen.4 Nevertheless,7%ofthepopulationaged65andolderand20%ofthepopulationaged80andovermeetthecriteriaforfrailtyintheabsenceofanyacuteorchronicmedicalconditions.5 NutritionalConsiderationsforFrailty Nutritionisanimportantcomponenttoconsiderintheevaluationoffrailty.Physiciansshouldassessandevaluatenutritionalstatusindiscussionswithfamilymembersandothercaregivers.Weightshouldbemeasuredateachvisittoidentifyunintendedorunexplainedweightchanges. Manyfactorscontributetopoornutritionalstatusintheelderly.Weightlossoftenoccurssecondarytoanunderlyingconditionthatmaybeeitherphysicalorpsychologicalandcanaffectapatient’sabilitytoconsumeadequatecaloriesorproteinonadailybasistomaintainoptimalfunctionalstatus.Forexample,poordentitioncanaffecttheabilitytochewandswallowfoodsofafirmconsistency.Patientswithdiabetesmayhavedelayedgastricemptying,whichcanresultinearlysatiety.Depressioncanpresentwithpoorappetiteandamalnourishedstate.Prescribedmedicationscancausedysgeusia,analterationintheperceivedtasteoffoods,resultinginanorexiaandweightloss. Physiciansneedtoperiodicallymonitordiagnosticlabtests,includingbloodchemistries.Thesetestscanbeusedtodetermineelectrolyteimbalances,macro-ormicronutrientdeficiencies,andanemia.Inparticular,vitaminDlevelsshouldbecheckedandsupplementediftheyarelowbecauseofvitaminD’sroleincalciumabsorptionanditsimportantaspectinthepreventionandtreatmentofosteoporosisandoverallbonehealth. Primarycarephysicians,inconjunctionwithotherhealthcareproviders,shouldbeawareofphysicallimitationsthatmayimpedefoodpurchasingandpreparation.Inthesesituations,areferraltocommunity-basedprogramsthatmayprovidemealsatseniorcentersordelivermealstohomeboundeldersshouldbeconsidered. Fraileldersareatgreaterriskofskinbreakdowncausedbyproteinmalnutritionorunintendedweightloss.Meetingspecificnutritionrequirementsmayplayanintegralpartinpreventingfurtherdeteriorationinstatusandmayinfactshowpositiveoutcomes.6 Anotherfactorcontributingtofrailtymaybetheabilitytoadequatelyandsafelychewandswallow,7knownasdysphagia.Nutritioninterventionstoeasechewingandswallowingdifficultiesincludemechanicallyalteringtheconsistencyoffoodand/orliquids.Othernutritionalrecommendationsthatareappropriateforfraileldersmayincludesmallermorefrequentmeals,supplementationuse,andreferralstospeechpathologists,occupationaltherapists,anddietitians. Supplementationcanplayamajorroleinpositivelyimpactingthenutritionalstatusofafrailindividual,particularlywhendietalonefailstomeetdailydietaryneeds.Specificindicationsfortheuseofsupplementsmayincludedifficultychewingorswallowing,unintendedweightloss,protein/caloriemalnutrition,orincreasedcalorieneedssecondarytoahypermetabolicstate.Contraindicationsforsupplementationmayincludeunintendedweightgain,renalconditions,andnutrient-druginteractions. TreatingFrailty Oncethefrailtysyndromeisrecognized,thenextstepistreatment.Thekeyintreatingfrailtyliesintargetingtheconditionsassociatedwithit.Developingappropriateinterventionsisanimportantmultifacetedprocess. Aspreviouslymentioned,frailtyisnotdefinedbymedicaldiagnoses.Nevertheless,commonchroniccomorbiditieshavebeennotedwithhigherprevalenceinthispopulation.Evidence-basedmedicationmanagementofcongestiveheartfailureresultsinbetteroutcomes,fewerexacerbations,andanoverallimprovementinphysicalfunctionandqualityoflife.Optimizedmanagementofchronicpulmonarydiseaseaswellasimprovedglycemiccontrolofdiabetesresultsinimprovedhealthstatus,fewerhospitalizations,andreductionsinthephysicaldeclinesassociatedwiththefrailtysyndrome. Consistentwiththefundamentalsofgeriatricmedicine,athoroughmedicationreviewshouldbeperformedduringperiodicofficevisitstoinventoryallmedications,includingprescriptionandover-the-countermedications.Unrecognizeddrugsideeffectsaswellasdrug-druginteractionscancauseunexpectedadverseeffectsthatcanpredisposepatientstoweakness,slowness(bothphysicalandmental),andfalls.Frequentmedicationreviewcanidentifyopportunitiesformedicationreductionandavoidpolypharmacy. Acomprehensiveexerciseprogramandincreasedphysicalactivityhavebeenshowntobenefitthefrailtysyndrome.Muscleweaknessandmuscledisuseatrophyresultingfromasedentarydispositionandchronicillnessrespondwelltophysicaltherapy.Studieshavedemonstratedpositiveoutcomesinincreasedmusclestrengthandmusclemassasaresultofparticipatinginaphysicalfitnessprogramfocusedonresistancetraining.8Studiesalsohavesupportedthebeneficialeffectsoftaichionreducingfrailtyaswellasreducingtheoccurrenceoffallsintheelderly.9 InConclusion Withthesignificantgrowthoftheover-80populationandtheincreaseinaveragelifeexpectancy,clinicianswillnodoubtencounteranincreaseintheprevalenceofthefrailtysyndrome.Manyofthepredisposingfactorsoffrailtyoccurasaresultoftheagingprocess.Mostcliniciansgenerallyidentifyfrailelderssuperficiallybythe“youknowitwhenyouseeit”test. However,earlyrecognitionandassessmentoftheidentifiedstandardizedcriteriaforthediagnosisofthefrailtysyndromeisanimportantfirststepthatwillguidetheappropriatetreatmentinterventionsandimproveoutcomes.Helpingolderadultsattainandmaintaintheirhighestleveloffunctionisthegoalofoptimalgeriatriccare. —ZacharyJ.Palace,MD,CMD,isaboard-certifiedgeriatricianandthemedicaldirector,andJenniferFlood-Sukhdeo,MS,RD,CDN,isaclinicaldietitianandthedirectorofnutritionatTheHebrewHomeatRiverdaleinNewYork.   References 1.DharmarajanTS,NormanRA(eds).ClinicalGeriatrics.NewYork,NY:CRCPress;2002. 2.HamRJ,SloanePD,WarshawGA,BernardMA,FlahertyE.PrimaryCareGeriatrics:ACase-BasedApproach.5thed.Philadelphia,PA:Mosby;2006. 3.FriedLP,TangenCM,WalstonJ,etal.Frailtyinolderadults:evidenceforaphenotype.JGerontolABiolSciMedSci.2001;56(3):M146-156. 4.BlaumCS,XueQL,MichelonE,SembaRD,FriedLP.Theassociationbetweenobesityandthefrailtysyndromeinolderwomen:theWomen’sHealthandAgingStudies.JAmGeriatrSoc.2005;53(6):927-934. 5.AhmedN,MandelR,FainM.Frailty:anemerginggeriatricsyndrome.AmJMed.2007;120(9):748-753. 6.DornerB,PosthauerME,ThomasD;NationalPressureUlcerAdvisoryPanel.Theroleofnutritioninpressureulcerpreventionandtreatment:NationalPressureUlcerAdvisoryPanelwhitepaper.AdvSkinWoundCare.2009;22(5):212-221. 7.NationalDysphagiaDietTaskForce.NationalDysphagiaDiet:StandardizationforOptimalCare.Chicago,IL:AmericanDieteticAssociation;2002:43 8.FiataroneMA,O’NeillEF,RyanND,etal.Exercisetrainingandnutritionalsupplementationforphysicalfrailtyinveryelderlypeople.NEnglJMed.1994;330(25):1769-1775. 9.WolfSL,BarnhartHX,KutnerNG,etal.Reducingfrailtyandfallsinolderpersons:aninvestigationoftaichiandcomputerizedbalancetraining.JAmGeriatrSoc.2003;51(12):1794-1803. 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