Frailty in Family Practice: Diagnosis and Management

Abstract

The frequency of frailty is increasing with the aging world population. Frailty is a long-term process and physiopathological theory describes six different dysfunction systems to be considered (i.e. hemoglobin, IL-6, IGF-1, DHEA-S, HgbA1c, triceps skinfold, fine motor movement, micronutrients). The definition of frailty is an important task. Two different models have been described: the phenotype of frailty and cumulative deficit model. Symptoms and findings of frailty are commonly non-specific. Additionally extreme fatique, unexplained weight loss and infections are observed. Frailty is a leading cause of mortality and the prevalence is 4-59% depending on the definition. It is frequent in women and the prevalence increases with age (65–69: %4;>84:%26). Although the number of studies has increased in family medicine, further studies are needed. This field needs to be prioritized in family practice.

Keywords

• Frailty, family practice, aging

Aile Hekimliğinde Düşkünlük: Tanısı ve Yönetimi

Öz

Dünya nüfusunun yaşlanmasıyla birlikte düşkünlük artmaktadır. Düşkünlük uzun erimli bir süreçtir ve fizyopatolojisine ilişkin kuram altı farklı sistemin disfonksiyonu suçlanmaktadır (Hemoglobin, IL-6, IGF-1, DHEA-S, HgbA1c, triseps kası deri kıvrım kalınlığı, ince motor hareketler, mikronutrientler (25-OH D3, B12 Vitamin, Total karotenoid). Düşkünlük aile hekimliği alanı için de önemli bir sorundur. Düşkünlüğün tanımlanması önem arz etmektedir. Iki farklı model bu sorunu tanımlamaya çalışmaktadır: Düşkünlüğün Fenotipi ve Kümülatif Defisit Modeli. Klinik olarak düşkünlüğe ilişkin semptom ve belirtiler sıklıkla non-spesifiktir. Buna ilaveten aşırı halsizlik, açıklanamayan kilo kaybı ve enfeksiyonlar gözlenebilir. Düşkünlük toplumda yaşayan bireylerin ölüm nedenleri arasında en önde yer almaktadır ve prevalansı tanımlama yöntemine göre %4-59 arasında bulunmaktadır. Kadınlarda daha sıktır ve  yaşla birlikte artmaktadır (65–69: %4; >84:%26). Düşkünlük konusunda son yıllarda aile hekimliği alanında çalışmalarda artış kaydedilse de bu konuya ilişkin yeni çalışmalara gereksinim bulunmaktadır. Bu alanının aile hekimliği tarafından ele alınması son derece önem arz etmektedir. 

Anahtar Kelimeler

• Düşkünlük, Aile Hekimliği, Yaşlanma

References

1. TDK websitesi. Erişim: www.tdk.gov.tr( Erişim tarihi: 01.04.2014).
2. Clegg A, Young J, Iliffe S, Olde Rikkert M, Rockwood K. Frailty in elderly people. Lancet 2013;381:752–62.
3. Sternberg SA, Wershof Schwartz A, Karunananthan S, Bergman H, Clarfield MA. The identification of frailty: a systematic literature review. J Am Geriatr Soc 2011;59:2129–38.
4. Fried LP, Xue QL, Cappola AR et al. Nonlinear Multisystem Physiological Dysregulation Associated With Frailty in Older Women: Implications for Etiology and Treatment. J Gerontol A Biol Sci Med Sci 2009;64A: 1049–57.
5. Fried LP, Tangen CM, Walston J et al. Frailty in older adults: evidence for a phenotype. J Gerontol Med Sci 2001; 56:146–56.
6. Chen X, Mao G, Leng SX. Frailty syndrome: an overview. Clinical Interventions in Aging 2014;9:433–41.
7. Bodenheimer et al Improving primary care for patients with chronic illness. JAMA 2002;288: 1775-9.
8. De Lepeleire J, Iliffe S, Mann E, Degryse JM. Frailty: an emerging concept for general practice. Br J Gen Pract 2009; 59(562):e-177-182 (DOI: 10.3399/bjgp09X420653).

9. Lacas A, Rockwood K. Frailty in primary care: a review of its conceptualization and implications for practice. BMC Medicine 2012,;10:4 (doi:10.1186/1741-7015-10-4).
10. Fried LP, Borhani NO, Enright P, et al. The Cardiovascular Health Study: design and rationale. Ann Epidemiol 1991; 1: 263–76.
11. Fried LP, Ferrucci l, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol.A Biol.Sci.Med Sci 2004;59:255-63.
12. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of defi cits as a proxy measure of aging. Scientific World Journal 2001;1:323–36.
13. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci 2007;62:722–7.
14. Scheffer M. Complex systems: Foreseeing tipping points. Nature 2010; 467: 411–2.
15. Searle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC Geriatr 2008;8:24 (doi:10.1186/1471-2318-8-24) .
16. Mitnitski A, Song X, Skoog I, et al. Relative fitness and frailty of elderly men and women in developed countries and their relationship with mortality. J Am Geriatr Soc 2005;53:2184–9.
17. Kulminski AM, Ukraintseva SV, Kulminskaya IV, Arbeev KG, Land K, Yashin AI. Cumulative deficits better characterize susceptibility to death in elderly people than phenotypic frailty: lessons from the Cardiovascular Health Study. J Am Geriatr Soc 2008;56:898–903.
18. Gloth FM, Scheve AA, Shah S, Ashton R, McKinney R. The Frail Elderly Functional Assessment questionnaire: its responsiveness and validity in alternative settings. Arch Phys Med Rehabil 1999;80:1572–6.
19. de Vries NM, Staal JB, van Ravensberg CD, Hobbelen JSM, Olde Rikkert MGM, Nijhuis-van der Sanden MWG. Outcome instruments to measure frailty: A systematic review. Ageing Research Reviews 2011;10: 104–14.
20. Saliba D, Elliott M, Rubenstein LZ et al. The Vulnerable Elders Survey: A tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001;49:1691–9.
21. Mitnitski AB, Graham JE, Mogilner AJ et al. Frailty, fitness and late-life mortality in relation to chronological and biological age. BMC Geriatr 2002;2:1 (doi:10.1186/1471-2318-2-1).
22. Gill TM, Gahbauer EA, Han L, Allore HG. Trajectories of disability in the last year of life. N Engl J Med 2010;362:1173–80.
23. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc 2012;60:1487–92.
24. Santos-Eggimann B, Cuenoud P, Spagnoli J, Junod J. Prevalence of frailty in middle-aged and older community- dwelling Europeans living in 10 countries. J Gerontol A Biol Sci Med Sci 2009;64:675–81.
25. Beswick AD, Rees K, Dieppe P, et al. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet 2008;371:725–35.
26. Stuck AE, Egger M, Hammer A, Minder CE, Beck JC. Home visits to prevent nursing home admission and functional decline in elderly people: systematic review and meta-regression analysis. JAMA 2002;287:1022–8.
27. Onder G, Penninx BW, Balkrishnan R, et al. Relation between use of angiotensin-converting enzyme inhibitors and muscle strength and physical function in older women: an observational study. Lancet 2002;359:926–30.
28. Wicherts IS, van Schoor NM, Boeke AJ, et al. Vitamin D status predicts physical performance and its decline in older persons. J Clin Endocrinol Metab 2007;92:2058–65.
29. Hoogendijk EO, van der Horst HE, Deeg DJ, Frijters DH, Prins BA, Jansen AP, Nijpels G, van Hout HP. The identification of frail older adults in primary care: comparing the accuracy of five simple instruments. Age Ageing. 2013;42:262-5.
30. Macklai NS, Spagnoli J, Junod J, Santos-Eggimann B. Prospective association of the SHARE-operationalized frailty phenotype with adverse health outcomes: evidence from 60+ community-dwelling Europeans living in 11 countries. BMC Geriatr 2013;13:3 (doi:10.1186/1471-2318-13-3).
31. Romero-Ortuno R. The Frailty Instrument for primary care of the Survey of Health, Ageing and Retirement in Europe predicts mortality similarly to a frailty index based on comprehensive geriatric assessment. Geriatr Gerontol Int 2013;13:497-504.
32. Metzelthin SF, van Rossum E, de Witte LP, Ambergen AW, Hobma SO, Sipers W, Kempen GI. Effectiveness of interdisciplinary primary care approach to reduce disability in community dwelling frail older people: cluster randomized controlled trial. BMJ 2013;10:347.
33. Theou O, Brothers TD, Mitnitski A, Rockwood K. Operationalization of frailty using eight commonly used scales and comparison of their ability to predict all-cause mortality. J Am Geriatr Soc. 2013;61:1537-51.