The “Normal” Aging & Frailty Syndrome

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WHO Definition of Old Age

Old age - >65 yrsVery old age - >80 yrs

Interesting general facts:Average life expectancy -

At 65 yrs – 17 yrs (82)At 75 yrs – 11 yrs (86)At 85 yrs – 6 yrs (91)

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Biologic changes in ageing

Mechanism of biologic changes:Structural changes in chromosome ( in the DNA)

Effect:Homeostenosis -

Homeostatic reserve of each organ gets constrictedHowever, does not affect individual during normal

activity

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Physiological Effect in Important Organs

CVS – Systolic HTPostural hypotensionUnfolding of aorta & aortosclerosis

Resp. System-Loss of lung compliance FEV1

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Physiological Effect in Important Organs cont…

CNS-Loss of cortical cellsLoss of posterior column fibres Impaired balance

Kidney & G-U tract - GFR - Prostatic enlargementEndocrine – Impaired GTT - thyroxine, testosterone level

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Physiological Effect in Important Organs cont…

Skeletal system – cervical spondylosis osteoporosis osteoarthritis

GI system: colonic motility constipationSkin - wrinklingEyes – cataractEar – High tone deafness

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Physiological Effect in Important Organs: Increased Physical Stress

Handling physical stress becomes more difficult as you get older People are less able to adjust to such stresses as heat, cold, physical exertion, and illness

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Summary

Not every person will experience all of these changesAging is a physical and psychological journey

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Frailty syndrome

Frailty Syndrome

• A physiologic syndrome, NOT a single disease • Results from cumulative decline of multiple

organ systems (i.e. homeostenosis)• A syndrome of decreased body reserve• Inability to withstand minor stress (in contrast to

a fit person of same age) i.e. has poor performance status

• This, leads to vulnerability to adverse outcomes, organ failure and death

Domains affected

• Body composition• Homeostatic dysregulation• Energy failure• Neurodegeneration

Components

• Sarcopenia• Osteoporosis• Muscle weakness (atrophy)

Consequences• Ineffective/incomplete homeostatic

response to stress• Multiple co-morbidity• Polypharmacy• Physical disability• ‘So-called’ geriatric syndrome

Common geriatric syndromes

Mechanism – Multifactorial pathology•Delirium

•Falls

•Urinary incontinence

•Chronic pain

•Anorexia

•Depression

•Dementia

•Unstable balance

•Slow gait

•Fatigue

•Weight loss

Frailty phenotype (Dwindles syndrome)

Presents as (poor performance status):

•Weight loss

•Weariness

• Exercise tolerance

• Physical activity

•Slow walking speed (6 minute walk test)

•Depression

•Cognitive impairment:

The accumulation of common brain pathologies contributes to progressive physical frailty in old age

The presence of macroinfarcts, Alzheimer disease, Lewy body pathology, and nigral neuronal loss are associated with a more rapid progression of frailty

Common Symptoms in Geriatric Illness

Whatever the underlying illness (be it MI, stroke or septicemia) –

Patient has limited common symptoms (especially in very old i.e. age >80) :

Acute confusion Incontinence Instability of posture (fall)

Common Geriatric Problems in Very Olds

Five ‘I’s :1. Intellectual impairment2. Immobility3. Instability (Falls)4. Incontinence5. Iatrogenic drug reactions

Intellectual Impairment

In form of 3 D’s:• Dementia• Depression• Delirium

Dementia• >65 years – 5%• >80 years – 20%• Common presentation – Forgetfulness• Screening tests for cognitive function –

(i) 3 item recall after 3 minutes

(ii) Clock draw test• If abnormal – Minimental scale examination

(MMSE)

Instability and Falls• >65 yrs – one-third have a fall each year• Frequency of fall – increases with

advancing age• 5% falls – associated with hip fracture• Swaying – common manifestation• Screening – Gait and balance assessment• Complications – Fracture, subdural

hematoma

Falls - Causes• Visual disturbance• Vestibular dysfunction• Hearing difficulty• Proprioceptive dysfunction and peripheral

neuropathy• Postural hypotension• Urinary urgency• TIA/Vertebrobasilar insufficiency/Parkinsonism• Medications/ Alcohol – Important, since reversible

cause

Falls : Due to Medications

• Polypharmacy: 4 or more drugs• Sedatives – benzodiazepines,

phenothiazine• Orthostatic drugs (causing postural

hypotension):Alpha blockers, nitrates, CCB, diuretics

• Haloperidol – leading to Parkinsonism

Falls: Management• ↓ Number of drugs to preferably three• Stop tranquilisers/sedatives• Treat postural hypotension :

- Elevate bed head

- Practise hand clenching

- Discontinue offending drugs• Correct vision

Orthostatic Hypotension (OH)

• Normal resting BP = 120/80 mmHg• OH: a drop in systolic BP by 20 mmHg after

standing 2-3 min from supine• Causes: adverse effects of drugs,

arrhythmias, immobility, adrenal insufficiency, autonomic dysfunction due to DM, Parkinson's CNS impairments

• Patients with OH are at risk for sustaining injuries, including falls, fractures etc.

Comprehensive Geriatric Assessment (CGA)

Physical evaluation-•ADL (Activities of Daily Living): walking, dressing, bathing, feeding etc.•IADL (Instrumental activities of Daily Living): shopping, cooking, using telephone, driving car, managing money etc.

Mental evaluation-•Orientation•Quick memory recall test (3 name recall test)

•MMSE

Comprehensive Geriatric Assessment (CGA) - Tests

• MMSE or Mini Cog for cognition• Geriatric Depression • ADL scale (Katz Index)• Physical Performance Test (PPT)• Vulnerable Elders-13 survey (VE-13)• Barthel Index (BI)• Pain Scale• Nutritional assessment• Functional assessment• Gait assessment (various tools used)

Treatment of frailty

• Prevent dwindle• Early detection of acute illness and

polypharmacy• Mobilise (to minimise muscle wasting)• Improve nutrition

Traditional Definition of Frailty: Fried Model

• Frail: a person meets > 3 of the criteria• Prefrail: a person meets 1 or 2 of the criteria

Fried 2001

Physical and performance measures to identify mild to moderate frailty

• Brown et al (2000) studied the correlation of physical measures (UE and LE strength, ROM, balance, coordination, sensation, and gait) with a 36-point Modified Physical Performance Test (Modified PPT)

• Physical measures correlated with PPT• Frailty according to the PPT score

―NOT frail = 32-36―Mildly frail = 25-31―Moderately frail = 17-24

Comprehensive Geriatric Assessment (CGA)

• Multidimensional, multidisciplinary diagnostic instrument

• Usually coordinated by a case manager • Used to collect data on the medical,

psychological, functional capabilities and limitations of complex elderly patients.

• To develop a coordinated and integrated plan for treatment and follow-up, including primary care and rehabilitation, and make the best use of health care resources.

Comprehensive Geriatric Assessment (CGA)

• CGA focuses on ―Elderly individuals with complex problems―Functional status and QoL―Frequently takes advantage of an

interdisciplinary team of providers• The "Five I's of Geriatrics“ are easily

missed in a standard medical evaluation―intellectual impairment, immobility, instability,

incontinence and iatrogenic disorders