Evidence-Based Geriatric Medicine

A Practical Clinical Guide

Jayna Holroyd-Leduc, Madhuri Reddy, Jayna Holroyd-Leduc, Madhuri Reddy

• Publisher: BMJ Books
• Year: 2012
• Print ISBN: 9781444337181
• eBook ISBN: 9781118281819
• Edition: 1
• Topic: Medicina
• Subtopic: Geriatria

The latest addition to the Evidence-Based Book series, Evidence-Based Geriatric Medicine provides non-geriatrician clinicians an overview of key topics central to the care of the older patient. This guide focuses on the management of common problems in the elderly taking into account their life situations as well as treatment of specific conditions. Leading geriatricians with expertise in evidence-based medicine utilize the best available evidence and present this information in a concise, easy-to-use, question-based format. Evidence-Based Geriatric Medicine is a unique guide to the optimum management of older patients.

CHAPTER 1
Function and frailty: the cornerstones of geriatric assessment

Paige K. Moorhouse^1,2 & Kenneth Rockwood^1,2

¹Department of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada

²Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada

Introduction

Older people are more likely to be ill than younger people, and most of the older people who are ill have more than one illness. Yet this is generally not what we teach medical students. Instead, reflecting the scientific tradition of reductionism from which real progress has been possible, medicine is generally taught on a “one thing wrong at once” basis, often with younger patients as prototype [1]. Consequently, many physicians have an ambivalent understanding about medicine and aging.

We discuss two main topics in this chapter. The first is frailty. Frail older adults often behave as complex systems that are close to failure. One aspect of acting in a complex system is that when the system fails, it will fail in its highest order functions first. For humans, these high order functions are divided attention, upright bipedal ambulation, opposable thumbs, and social interaction. Their failures are delirium, mobility impairment and falls, impaired function, and social withdrawal/abandonment. Another essential aspect of acting in a complex system is that any single act is likely to have multiple consequences. For example, the medication given in an evidence-based way to treat inflammatory arthritis to allow mobilization, so as to comply with evidence-based exercises and to improve cardiac conditioning, might decrease heart function in a frail patient through fluid retention that precipitates heart failure. That is why the specialty of geriatrics has evolved dicta such as “start low, go slow”. This is not simply codified common sense, but a rational response to the patients’ complexity.

The second main topic that we discuss in this chapter is function. Functional impairment in an older adult is often characterized as a “sensitive but nonspecific” sign of illness. While true, it is an inadequate account of why it should have the iconic status of a “geriatric giant” [2], because medicine is replete with other sensitive but nonspecific signs, from chest pain to chapped lips. Intact functioning requires a lot to be right; compromised function can reflect a single cause (e.g., a catastrophic stroke), but commonly, in older adults, it reflects problems in more than one area. It is this “more than one thing wrong” aspect of functional impairment that makes it so useful as an overall sign of a patient's state of health.

Table 1.1 Contrasting the frailty phenotype and the frailty index

	Frailty Phenotype	Frailty Index
General	Five items: (1) weakness, (2) exhaustion, (3) reduced activity, (4) motor slowing, and (5) weight loss	Any set of items that are age associated, associated with adverse outcomes, do not saturate at some young age, and have <5% missing data.
Data collection	Usually must be prospective	Can be operationalized in many existing data sets
Number of items	5	Can be as few as 30, as many as 100; most often about 40–50
Is supported by a theory of frailty	Yes	Yes
Uses performance measures	Yes	Usually not
Uses disability items	No	Usually
Uses comorbidity items	No	Yes
Cross-validated	Extensively (>100 groups)	Somewhat (about a dozen groups)
Samples other than physical domains	Possibly (feeling of exhaustion)	Yes
Most common criticism	Covers too few domains	Includes too many items, especially disability and comorbidity
Animal model	Yes	Yes

Search strategy

Frailty

We searched PubMed for systematic reviews, meta-analyses, and practice guidelines published in the last 5 years in English for those aged 65 and older using the following search terms: “frailty,” “frailty index,” and “frailty phenotype.” This yielded 144 articles, 25 of which were narrative reviews and 21 of which were systematic reviews.

Functional assessment

We searched PubMed for systematic reviews, meta-analyses, and practice guidelines published in English with subjects 65 and older in the last 24 months using the following search terms: “activities of daily living” (ADL), “ADL,” “evaluation,” “measurement,” “assessment,” and “functional.” This yielded 50 articles, 13 of which were pertinent to the topic. Expanding the search to articles published in the last 5 years yielded 138 new articles, 15 of which were pertinent to the topic. We then searched related citations of the 28 articles selected. This yielded four additional items. A total of 32 articles were reviewed in detail.

For this chapter, we graded relevant clinical studies using the US Preventative Task Force levels of evidence.

What is frailty?

Frailty is the variable susceptibility to adverse health outcomes, including death, of people of the same chronological age. Controversy in the definition of frailty arises in how frailty is best operationalized. Pending the results of an ongoing large meta-analysis [3], two frailty operationalization camps have arisen (Table 1.1). One group emphasizes a frailty phenotype [4]. Another emphasizes a frailty index, and states that susceptibility to adverse outcomes arises as a consequence of the accumulation and interaction of deficits, for which various phenotypes might exist [5,6].

The frailty phenotype

The frailty phenotype specifies five characteristics: (1) slowness, (2) weight loss, (3) impaired strength, (4) exhaustion, and (5) low physical activity/energy expenditure. A person is said to be frail if they have any three of these five characteristics. People who have only one or two of the characteristics, while still at an increased risk compared to people with none of the phenotypic characteristics, are said to be “prefrail.” People with none of the characteristics are said to be “robust.” A strength of this approach is that at least four of the items are measurable by performance and in that way, objective. It also offers some prospect of finding mechanisms that might be associated with development and progression of frailty. The phenotype definition has been extensively validated and is reliably associated with an increased risk of death and with other adverse health outcomes.

The phenotypic view is well accepted, in that over a hundred separate groups have conducted stud...

Table of contents

• Cover
• Table of Contents
• Series
• Title
• Copyright
• List of Contributors
• Foreword
• CHAPTER 1: Function and frailty: the cornerstones of geriatric assessment
• CHAPTER 2: Computer-based clinical decision support systems in the care of older patients
• CHAPTER 3: Simplifying the pillbox: drugs and aging
• CHAPTER 4: Breathing easier: respiratory disease in the older adult
• CHAPTER 5: Breathing easier: an approach to heart failure in a patient with an aging heart
• CHAPTER 6: Clarifying confusion: preventing and managing delirium
• CHAPTER 7: Preserving memories: managing dementia
• CHAPTER 8: Enjoying the golden years: diagnosing and treating depression
• CHAPTER 9: A balancing act: preventing and treating falls
• CHAPTER 10: Keeping dry: managing urinary incontinence
• CHAPTER 11: Keeping things moving: preventing and managing constipation
• CHAPTER 12: Preventing and treating pressure ulcers
• CHAPTER 13: Elder abuse
• CHAPTER 14: A good death: appropriate end-of-life care
• Index
• End User License Agreement