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1. FRAILTY
IN
AGEING POPULATION

2. At the end of the session, you will be
able to:
• Understand the physical and
psychological changes in ageing
population;
• Discuss frailty as an example of such
changes in ageing population;
• Assess and plan to respond to frailty
and other changes in ageing
population.

3. • Multiple definitions available.
• The condition of being weak and delicate…
• Frailty is most often defined as a syndrome
of physiological decline in late life,
characterized by marked vulnerability to
adverse health outcomes.
• Frailty can be defined as a clinical state where
there is a increase in individual’s vulnerability
to develop negative health-related events
(including disability, hospitalizations, and
death).
• Age-associated declines in physiologic
reserve and functions…
Frailty -Definition

4. • Physical frailty
and
psychological
frailty
• Aging-related state
of vulnerability
• High risk - for: mortality;
falls; disability;
hospitalization
• Potential for treatment and
prevention of frailty as well
as its poor outcomes
• Syndrome of shrinking,
slowing and weakness,
with low activity and low
Frailty:Geriatricians’Perspective

5. • Frailty is a common geriatric syndrome.
Estimated frailty prevalence is 7–16%.
• The occurrence of frailty increases incrementally
with advancing age, and is more common in
older women than men, and among those of
lower socio-economic status.
• Chronic diseases, such as cardiovascular
disease, diabetes, chronic kidney disease,
depression, and cognitive impairment.
• Physiologic impairments: Activation of
inflammation and coagulation systems,
anemia,
atherosclerosis, autonomic dysfunction,
hormonal abnormalities, hypovitaminosis etc.
Why??…Understanding ofFrailty

6. • The cardiac output decreases, blood pressure
increases and arteriosclerosis develops.
• The lungs show impaired gas exchange, a
decrease in vital capacity and slower expiratory
flow rates.
• Atrophic gastritis and altered hepatic drug
metabolism are common in the elderly.
• Progressive elevation of blood glucose.
• Osteoporosis is frequently seen due to a linear
decline in bone mass after the fourth decade.
• Metabolism is altered – e.g. Reduced glucose
tolerance, Reduced resting metabolic rate (RMR),
and reduced kidney function.
Physiological changes inageing

7. • Impaired digestion due to: deterioration of
digestive enzyme production, decrease in
the production of stomach acid, slower
bowel movements caused by inadequate
liquid and dietary fibre intakes.
• Oral health problems: dry mouth or xerostomia
due to inadequate production of saliva can
affect more than 70% of the elderly population.
• Loss of sensory perception: reduced taste
perception (dysgeusia) and impaired ability to
smell (hyposmia)
• Deterioration or loss of sight may also
negatively affect food intake
Physiological changesCont….

8. • Cognitive impairment increases with age
• 5-10% of elderly have dementia
• Alzheimer’s disease is most prevalent
type of dementia
• Some cognitive functions decline with age,
while others are stable or improve
Intellectual Changes withAgeing

9. • Theories of aging can be divided into
two categories:
• those that answer the question “Why do we age?”
and
• those that address the question “How do we age?”
• Theories or Hypotheses? About “How do we
age?”
• BIOLOGIC THEORY OF AGEING
• ‘PROGRAMMED’ THEORY OF DEVELOPMENT
• EVOLUTIONARY THEORY OF AGING
• CROSS-LINKING/GLYCATION HYPOTHESIS
OF AGING GENOME MAINTENANCE
HYPOTHESIS OF AGING
• NEUROENDOCRINE HYPOTHESIS OF AGING
• OXIDATIVE DAMAGE/ FREE RADICAL
Theories ofAging

10. Curve 1: Modern non-programmed aging theories – The evolutionary value of
furtherlifeand reproduction is effectivelyzero beyond some species-specific age.
Curve 2: Modern programmed aging theories – There is an evolutionary cost
associatedwith survivingbeyond a species-specificage.
Curve3:Medawar’s concept – The evolutionaryvalueof survivaland
reproduction declines with age followinga species-specificage.

11. Frailty as aSyndrome

12. Frailty as aSyndrome

13. Cycle ofFrailty

14. Preventing frailty or itsprogression,
adverseoutcomes
• Prevention of frailty:
• Preventing onset
• Improving frailty
• Preventing outcomes, minimizing associated risks – at
times of stressors
• Minimizing interactions: of frailty with other comorbidity
• Medications tolerance
• Treating the frail patient at times of stressors to
decrease risk
• Hospitalization
• Surgery
• Acute illness, bed rest

15. PH Goals forAgeing Population
• Compression of morbidity
• Active life expectancy
• Support healthy conditions
for people of all ages
• Ensure effective PH and
preventive approaches (all
levels) for older people
• Provide community and
home- based supports
• Effective care systems and
competent work force to
support healthy aging

16. Challenges in relation to:
• Improve quality of acute hospital care -
costly
• Be aware of “cascade” of acute hospital care
• Early detection and screening – resources,
skills, willingness, social norms etc.
• Comprehensive geriatric assessment – site,
skills
• Home-based vs palliative care alternatives
• Rehab and improve survival
Challenges and Solutions in Careof
FrailElderly

17. Assessment of elderly people
in hospital
• The holistic assessment of older people.
• The MDT members include doctors, nurses,
physiotherapist (PT), occupational therapist (OT),
dietician, clinical pharmacist, social worker (SW),
specialist nurses (e.g. tissue viability nurse and
Parkinson’s disease nurse specialist), hospital
discharge liaison team and care givers.
• Input from a clinical psychologist or old age
psychiatrist may be needed depending on
individual patients’ needs.
• All members engage with patients and care givers
to complete their assessments and intervention,
followed by multidisciplinary meeting (MDM) to
formulate ongoing care plan and follow-up.

18. Assessment and Management of
elderly people
• Multiple co-morbidities, physical limitations, increased
functional dependence and complex psychosocial
issues are common health problem of elderly people.
• The elderly people are more vulnerable and could
easily decompensate with minor stressors, resulting
in increased frailty.
• To improve outcomes for frail older people with multiple
co- morbidities, admission should be to an Emergency
Frailty Unit (EFU) having Acute Medical Unit (AMU) for
elderly.
• The physical illness or adverse effects of drugs are
more pronounced in atypical presentation among
elderly people and cognitive decline, delirium or
inability to manage routine activities of daily living
(ADLs) are common.

19. Medical Problems in Old Age (1)
Common medical
conditions seen in
older people
• Alzheimer’s disease
• Normal pressure hydrocephalus
• Temporal arteritis (giant cell arteritis)
• Diastolic heart failure
• Inclusion body myositis
• Atrophic urethritis and vaginitis
• Shingles (herpes zoster)
• Benign prostatic hyperplasia
• Aortic aneurysm
• Polymyalgia rheumatic arthritis.

20. Common medical
conditions in older
age group
• Degenerative osteoarthritis
• Overactive bladder with urinary
incontinence
• Diabetic hyperosmolar non-ketotic coma
• Falls and fragility hip fracture
• Osteoporosis
• Parkinsonism
• Accidental hypothermia
• Pressure ulcers
• Prostate cancer
• Stroke
• Glaucoma and cataract
Medical Problems in Old Age (2)

21. Two Key Drivers of Age-
Friendly Health Systems
Age-Friendly
Health
System:
4Ms
Assess:
Know about the 4Ms for
each elderly people in
your care
Act On:
Incorporate 4Ms in
the Plan of Action

22. Putting the 4Ms into Practice
Integrating the 4Ms into Care Using the PDSACycle
• Provide
care
• Study your
performance (M&E,
CBA, CEA etc)
• Understand
your current
state
• Describe care
consistent with
4Ms
• Design or adapt
your health
workforce
• Improve and sustain
care
Ac
t
Pla
n
D
o
Stud
y

23. • Ask the older adult What Matters most,
document it, and share What Matters across the
care team
• Align the care plan with ‘What Matters’ most
• Review for high-risk medication use and
document it
• Avoid high-risk medications, and document
and communicate changes
• Ensure sufficient oral hydration
• Orient to time, place, and situation
• Ensure older adults have their personal
adaptive equipment
• Support non-pharmacological sleep
4Ms in an Age-Friendly Health
System Hospital & Practice

24. • Screen for delirium at least every 12 hours
and document results
• Screen for dementia/cognitive impairment
and document the results
• Screen for depression and document the results
• Consider further evaluation and manage
manifestations of dementia, educate older adults
and caregivers, and/or refer out
• Identify and manage factors contributing to
depression and/or refer out
• Screen for mobility limitations and document
the results
• Ensure early, frequent, and safe mobility.
4Ms in an Age-Friendly Health
System Hospital & Practice

25. Challenges & Opportunities
for 4Ms
Lack of a framework for the technological
ecosystem
Wide variety of country socio-economic-
cultural contexts
Need to engage all!
Need political commitment and
champions
Put it within the existing health system –
no parallel