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Toronto Notes 2019
Differential Diagnoses of Common Presentations
Geriatric Medicine GM3
1 Very Fit 4
Vulnerable 7
Severely Frail
Completely dependent on others for the activities of daily living, (physical or cognitive). Seem stable and not at high risk of dying (6 months).
Very Severely Frail
Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.
Terminally Ill
Approaching the end of life. This category applies to people with a life expectancy of
<6 months who are not otherwise evidently frail.
A Global Clinical Measure of Fitness and Frailty in Elderly People
CMAJ 2005;173:489-495
Canadian Study on Health & Aging, Revised 2008 The CSHA Clinical Frailty Scale – shown to predict death and need for institution
1. Very fit – robust, active, energetic, well motivated and fit; these people commonly exercise regularly and are in the most fit group for their age.
2. Well–withoutactivedisease,butlessfitthanpeoplein category 1.
3. Well,withtreatedcomorbiddisease–itssymptomsare well controlled compared with those in category 4.
4. Apparentlyvulnerable–althoughnotfranklydependent,
these people commonly complain of being “slowed up”
or have disease symptoms.
5. Mildly frail – with limited dependence on others for
instrumental activities of daily living.
6. Moderatelyfrail–helpisneededwithbothinstrumental
and non-instrumental activities of daily living.
7. Severelyfrail–completelydependentonothersforthe
activities of daily living, or terminally ill.
8. Very severely frail – completely dependent, approaching
theendoflife. Typically,theycouldnotrecovereven
from a minor illness.
9. Terminally ill – approaching the end of life. This category
applies to people with a life expectancy of <6 mo, who are not otherwise evidently frail.
Functional Assessment (ADLs and IADLs)
Robust, active, energetic, well
motivated and fit. These people
commonly exercise regularly and
are in the most fit group for their
age. during the day.
2 Well 5
Without active disease symptoms, but less fit than people in category 1. Excercise often or very active occasionally (e.g. seasonally).
3 Managing Well 6
Well treated comorbid disease and symptoms are well controlled. Not regularly active beyond routine walking.
Mild Dementia
Common symptoms include forgetting details of recent event, though still remembering the event itself. Repeating the same question/story and social withdrawal.
Figure 1. Frailty scale
8
9
Clinical Frailty Scale
Shown to predict death and need for institution
Not dependent, on others for daily help, but symptoms limit activies. Commonly complain of being “slowed up” and/or tired
Mildly Frail
More evident slowing and need help with high order IADLs (finances, transportation, heavy housekeeping and medication). Mild frailty progressively impairs shopping, walking alone outside, meal prep and housework.
Moderately Frail
Need help with all outside activities and housekeeping. Often have problems with stairs, bathing and may need minimal assistance with dressing (cuing, standby).
Dementia Frailty Scale
Degree of frailty corresponds to degree of dementia.
Moderate Dementia
Recent memory is very impaired, although can remember past life events well. Can do personal care with prompting.
Severe Dementia
Cannot do personal care without help.
Adapted from and reprinted with permission: Geriatric Medicine Research, Dalhousie University, Halifax, Canada. ©2007-2009 Version 1.2. All rights reserved.
Models of Frailty
Physical Frailty (PF) Phenotype (Fried et al.)
• Frail=3ormorecriteria;at-riskorpre-frail=1or2criteria
1. Shrinking: unintentional weight loss (baseline: >10 lbs or 5% total body weight lost in prior year) 2. Weakness: grip strength in lowest 20% (by gender, BMI)
3. Poor endurance: as indicated by self-report of exhaustion
4. Slowness: walking time/15 feet in slowest 20% (by gender, height)
5. Low activity: kcals/week in lowest 20% (males: <383 kcals/week, females: <270 kcals/week)
Cumulative Deficit Approach (Rockwood et al.)
• balancebetweenassets(e.g.health,attitudes,resources,caregiver)anddeficits(e.g.illness,disability, dependence, caregiver burden) that determines whether a person can maintain independence in the community
• FrailtyIndex=numberofdeficitspresent/numberofdeficitspossible
Etiology
• multifactorial - dysregulated immune, endocrine, stress, and energy response systems lead to development of clinical frailty
ADLs: ABCDE-TT Ambulating Bathing Continence Dressing
Eating Transferring Toileting
IADLs: SHAFT-TT
Shopping
Housework Accounting/Managing finances Food preparation Transportation
Telephone
Taking medications
Table 2. Etiologies of Frailty
Etiology
Physiologic Changes with Aging
Immune System
Endocrine System
Mechanism
Sarcopenia (age-related loss of skeletal muscle and strength), decreased mass and increased stiffness of organs, decreased reserve capacity of systems
Elevated levels of circulating interleukin-6, C-reactive protein, white blood cells, and monocytes associated with skeletal muscle decline
Elevated clotting markers (factor VIII, fibrinogen, D-dimer) upregulates clotting cascade Chronic inflammation
Decreased skeletal muscle mass via: Decreased growth hormone and IGF-1 Increased cortisol levels
Decreased DHEA-S
Can use formal assessment tools such as the Lawton-Brody Instrumental Activities of Daily Living Scale to assess functioning
Comprehensive Geriatric Assessment for Older Adults Admitted to Hospital
Cochrane DB Syst Rev 2017;CD006211
Inpatient comprehensive geriatric assessment increases likelihood that patients will be alive
in their own homes at 3-12 mo follow up (risk
ratio (RR) 1.06, 95% confidence interval (CI) 1.01-1.10), decreases the likelihood that patients will be admitted to a nursing home at 3-12 mo
(RR 0.80, 95% CI 0.72-0.89), and results in little
or no difference in dependence (RR 0.97, 95% CI 0.89-1.04). Evidence for cost-effectiveness is of low-certainty due to imprecision and inconsistency among studies.
Decreased 25 (OH) vitamin D Dysregulated Stress Dysregulation of autonomic nervous system
Age-related changes in renin-angiotensin system and mitochondria likely impact sarcopenia and inflammation
Evidence-based Approach to the Frail Older Patient
• ComprehensiveGeriatricAssessment
■ results in increased quality-of-life, functional ability, decreased hospitalization rate, increased survival and residence at home at 12 months (odds ratio 1.16; 95% CI 1.05-1.28; p=0.003)
• interdisciplinaryprimarycare
• pharmaceuticalcareandmedicationoptimization • diseasemanagement
• caregiversupport