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• home hazard assessment and modification with potential for collaboration with occupational therapy

(e.g. remove loose rugs and tripping hazards, add shower bars and stair railing, improve lighting)

• prescription of vitamin D 1000 1U daily if vitamin D stores are low

• optimization of calcium in diet with 1200 mg ofsupplemental calcium advised if osteoporosis is a risk

• tapering or gradual discontinuation of psychotropic medication

• postural hypotension, heart rate, and rhythm abnormalities management

• eyesight (cataract surgery) and footwear optimization

• compression socks if venousstasis edema

Will My Patient Fall ?

JAMA 2007;197:77-86

P urpoic Ip identify the prognostic Hint of mk

farlorslor future falls amoirqolder patients.

Study Selection: Meta anaiysisot prnspectnae cohort

studies of list factors lor falls.

Results It studieswere included. Clin calif

identiliable risk factors were identified across 6

domains:oitliostatic hypotenvon, visual impairment,

impairment of gait or balance,medication

use. limitations in DDLsor UDls.and cognitive

impairment.Ihe estimated pretest probebilitr ol

falling at least once in any g.ven yr lor individuals »

6b

yr was 2J% (95% Cl19-36% ).Patients who have fallen

m the past year are more likely to falI aga n (182.3•

2.8). Best predictors of future falls were dislorbances

n gait or balarce|lR 1.7-2.4).while visual

impairment impaired cognition,and medication were

not reliable predittors.

Conclusions Screening for nsk ot fallingdliragthe

cluneal examination begins with determining if the

patient hasfa lien in the past yr.For patentswho

have not previously fallen,screening consists of an

assessment of g ai t and balance. Patients who have

fallen or who have a gaitor balance problem are at

higher risk of future falls.

Frailty

Definition

• frailty:clinicallv-recognizable state of decreased reserve in older adults with increased vulnerability

to acute stressors resulting from functional decline across multiple physiologic systems

• functional decline: progressive limitation in the ability to carry out basic functional activities

• frailty is associated with higher risk of in-hospital death, adverse events, length of stay, hospital readmission, and newly dependent at discharge following critical illness

Dulhousie University Clinical Frailty Scale

Severe Frailty

Completely dependent on others

for personol cine,from whatever

cause Iphysical or cognitive I.

Even so.they seem stable and

not at high risk of dying (within

-6 mol

1 Very Fit

People who are robust, active,

enorgotlc.and inotnrotod.

They tend to exorclso regularly

and are among the fittest for

their ege.

4 Very Mild Fraility

Previously "vulnerable 'Eoily

transition from complete

Independence. While not dependent

on othersfor dally help,often

symptomslimit activities- A common

complaint is being "

slowed up"

onCkor bump bred during the day

i

Very Severe Frailly

Completely dependent for

personal cato and

approaching tho end of fafo.

Typically,they could not

recover even from a minor

Fit 5 Mild Frailty

A More evidentslowing and need

help with high ordoi lADLs

(finances, transportation, heavy

J

/A housework).Mild frailty

4 PfW^

ssivaly impairsshopping,

walking alone outside, moal prop. illness,

medications and bogins 1o restrict

light housework.

People who have no active

disoaso symptoms, but are lessfit

than category 1. Ofton, they

exercise or are very active

occasionally (e g. seasonally).

Moderate Frailty

Need help with all outsido activities

and housekeeping. Ofton have

problems with stairs,need help

bathing, and might need minimal

assistance with dressing (cuing.

Terminally III

Approaching tho end ol life

Poople w ill a life expectancy ol

<6 mo,who are not otherwise

living with severe frailty.(Many

terminally ill people can still

exorcise until very close to death).

(

Managing Well

Poople whoso medical problems

aie well controlled, ovoti if

occasionally symptomatic, but are

not regularly active beyond

routine walking

Scoring Frailty in People with Dementia

Degree of frailty generally correspondsto degree of dementia

Mild Dementia

Common symptoms include forgetting tho

details of a recent event,though still

remembering the event itself. Repeating the

samo question/story and social withdrawal

Severe Dementia

They cannot do personal caro without holp.

Very Severe Dementia

They are often bedfast Many are

virtually muto.

Moderate Dementia

Rocont memory is vary impair od. even

though they seemingly can remember

past life events well. Can do personal

care with prompting.

Figure 2. Rockwood Clinical Frailty Scale

Adapted from and reprinted with permission:Geriatric Medicine Research,Dalhousie University.Halifax,Canada. :2005-2020 Version 2.0.Allrights

reserved.

MODELS OF FRAILTY

Physical Frailty (PF) Phenotype (Fried et al.)

•Frail: >3 criteria; at-risk or pre-frail = 1 or 2 criteria

1. shrinking: unintentional weight loss (baseline:>10 lbs or 5% total body weight lost in prior

yr)

2. weakness: grip strength in lowest 20% (by gender, BMl)

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: keals/wk in lowest 20% (males: <383 keals/wk,females: <270 keals/wk)

Cumulative Deficit Approach (Rockwood et al.)

•balance between assets (e.g. health, attitudes, resources, caregiver) and deficits (e.g. illness, disability,

dependence, caregiver burden) that determines whether a person can maintain independence in the

community

•frailty index: number of deficits present/number of deficits possible

Etiology

•multifactorial:dvsregulated immune, endocrine,stress, and energy response systemslead to

development of clinical frailty

ri

L J

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G

home hazard assessment and modification with potential for collaboration with occupational therapy

(e.g. remove loose rugs and tripping hazards, add shower bars and stair railing, improve lighting)

• prescription of vitamin D 1000 1U daily if vitamin D stores are low

• optimization of calcium in diet with 1200 mg ofsupplemental calcium advised if osteoporosis is a risk

• tapering or gradual discontinuation of psychotropic medication

• postural hypotension, heart rate, and rhythm abnormalities management

• eyesight (cataract surgery) and footwear optimization

• compression socks if venousstasis edema

Will My Patient Fall ?

JAMA 2007;197:77-86

P urpoic Ip identify the prognostic Hint of mk

farlorslor future falls amoirqolder patients.

Study Selection: Meta anaiysisot prnspectnae cohort

studies of list factors lor falls.

Results It studieswere included. Clin calif

identiliable risk factors were identified across 6

domains:oitliostatic hypotenvon, visual impairment,

impairment of gait or balance,medication

use. limitations in DDLsor UDls.and cognitive

impairment.Ihe estimated pretest probebilitr ol

falling at least once in any g.ven yr lor individuals »

6b

yr was 2J% (95% Cl19-36% ).Patients who have fallen

m the past year are more likely to falI aga n (182.3•

2.8). Best predictors of future falls were dislorbances

n gait or balarce|lR 1.7-2.4).while visual

impairment impaired cognition,and medication were

not reliable predittors.

Conclusions Screening for nsk ot fallingdliragthe

cluneal examination begins with determining if the

patient hasfa lien in the past yr.For patentswho

have not previously fallen,screening consists of an

assessment of g ai t and balance. Patients who have

fallen or who have a gaitor balance problem are at

higher risk of future falls.

Frailty

Definition

• frailty:clinicallv-recognizable state of decreased reserve in older adults with increased vulnerability

to acute stressors resulting from functional decline across multiple physiologic systems

• functional decline: progressive limitation in the ability to carry out basic functional activities

• frailty is associated with higher risk of in-hospital death, adverse events, length of stay, hospital readmission, and newly dependent at discharge following critical illness

Dulhousie University Clinical Frailty Scale

Severe Frailty

Completely dependent on others

for personol cine,from whatever

cause Iphysical or cognitive I.

Even so.they seem stable and

not at high risk of dying (within

-6 mol

1 Very Fit

People who are robust, active,

enorgotlc.and inotnrotod.

They tend to exorclso regularly

and are among the fittest for

their ege.

4 Very Mild Fraility

Previously "vulnerable 'Eoily

transition from complete

Independence. While not dependent

on othersfor dally help,often

symptomslimit activities- A common

complaint is being "

slowed up"

onCkor bump bred during the day

i

Very Severe Frailly

Completely dependent for

personal cato and

approaching tho end of fafo.

Typically,they could not

recover even from a minor

Fit 5 Mild Frailty

A More evidentslowing and need

help with high ordoi lADLs

(finances, transportation, heavy

J

/A housework).Mild frailty

4 PfW^

ssivaly impairsshopping,

walking alone outside, moal prop. illness,

medications and bogins 1o restrict

light housework.

People who have no active

disoaso symptoms, but are lessfit

than category 1. Ofton, they

exercise or are very active

occasionally (e g. seasonally).

Moderate Frailty

Need help with all outsido activities

and housekeeping. Ofton have

problems with stairs,need help

bathing, and might need minimal

assistance with dressing (cuing.

Terminally III

Approaching tho end ol life

Poople w ill a life expectancy ol

<6 mo,who are not otherwise

living with severe frailty.(Many

terminally ill people can still

exorcise until very close to death).

(

Managing Well

Poople whoso medical problems

aie well controlled, ovoti if

occasionally symptomatic, but are

not regularly active beyond

routine walking

Scoring Frailty in People with Dementia

Degree of frailty generally correspondsto degree of dementia

Mild Dementia

Common symptoms include forgetting tho

details of a recent event,though still

remembering the event itself. Repeating the

samo question/story and social withdrawal

Severe Dementia

They cannot do personal caro without holp.

Very Severe Dementia

They are often bedfast Many are

virtually muto.

Moderate Dementia

Rocont memory is vary impair od. even

though they seemingly can remember

past life events well. Can do personal

care with prompting.

Figure 2. Rockwood Clinical Frailty Scale

Adapted from and reprinted with permission:Geriatric Medicine Research,Dalhousie University.Halifax,Canada. :2005-2020 Version 2.0.Allrights

reserved.

MODELS OF FRAILTY

Physical Frailty (PF) Phenotype (Fried et al.)

•Frail: >3 criteria; at-risk or pre-frail = 1 or 2 criteria

1. shrinking: unintentional weight loss (baseline:>10 lbs or 5% total body weight lost in prior

yr)

2. weakness: grip strength in lowest 20% (by gender, BMl)

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: keals/wk in lowest 20% (males: <383 keals/wk,females: <270 keals/wk)

Cumulative Deficit Approach (Rockwood et al.)

•balance between assets (e.g. health, attitudes, resources, caregiver) and deficits (e.g. illness, disability,

dependence, caregiver burden) that determines whether a person can maintain independence in the

community

•frailty index: number of deficits present/number of deficits possible

Etiology

•multifactorial:dvsregulated immune, endocrine,stress, and energy response systemslead to

development of clinical frailty

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GM9Geriatric Medicine Toronto Notes 2023

Table 4. Etiologies of Frailty

Etiology Mechanism

Physiologic Changes with Aging Saicopenia (age-related loss of skeletal muscle and strength),

decreased mass and increased stiffness of organs, decreased reserve

capacity of systems

Elevated levelsof circulating interleukin-6,C-readive protein,white

blood cells.and monocytes associated with skeletal muscle decline

Elevaled dotting markers (factor VIII, fibrinogen, D-dimer) upregulates

dolling cascade

Chronic inflammation

Sarcopenia via:

Decreased growth hormone and IGF-1

Increased cortisol levels

Decreased 0HEAS

Decreased 25 (OH) vitamin D

Immune System

Endocrine System

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

. CGA

• includes: past medical history, medications, allergies,social history,function, and geriatric

review ofsystems(cognition,mood,sleep, pain, nutrition,falls, continence, vision/hearing,skin,

and safety)

• physical exam

investigations:CBC, electrolytes, TSH, vitamin Bi

’

, vitamin D, LFTs,extended electrolytes

• management

CGA to tailor management of geriatric syndromes(e.g. falls,cognitive impairment, incontinence)

• physical activity programs, nutritional optimization, multicomponent interventions

interdisciplinary primary care

referral to AcuteCare for Elders (ACE) unit for inpatients who are living with frailty

• medication optimization

• caregiver support

Immobility

Definition

• limitation in independent and voluntary physical movement of the body or one or more lower

extremities

• associated with disability, increased frailty and risk of falls, decreased quality of life

Etiology and Risk Factors

• multifactorial;functional assessment in addition to comprehensive history-taking and

interdisciplinary approach to care is crucial

• psychological

• fear of falling, motivation, depression

• physical changes

MSK disorders: history of hip or leg fractures,osteoporosis,arthritis

• neurologic disorders:stroke, Parkinson'

s disease,severe dementia, neuropathies

• cardiovascular: CHE, angina secondary to CAD, claudication secondary to PVD

• sensory:poor vision,decreased peripheral sensation/proprioception

• interpersonal/social factors

• environmental changes

• iatrogenic ( healthcare facilities)

deconditioning secondary to prolonged bed rest

inadequate mobility aids

• poorly controlled chronic and acute pain

Complications

• cardiovascular: orthostatic hypotension, venous thrombosis, embolism

• respiratory:decreased ventilation, atelectasis, pneumonia

• gastrointestinal:anorexia, constipation, incontinence,dehydration, malnutrition

• genitourinary:infection, urinary retention,bladder calculi, incontinence

• MSK: atrophy, contractures, bone loss

• skin: pressure injuries

• psychological:sensory deprivation,delirium, depression

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Incontinence

Fecal Incontinence

Definition

• involuntary or inappropriate passing of feces that impacts social functioning or hygiene

• severity can range from unintentional flatus to the complete evacuation of bowel contents

• there are three subtypes:

1. passive incontinence:involuntary discharge of stool or gas without awareness

2. urge incontinence: discharge of fecal matter in spite of active attempts to retain bowel

contents

3. fecal seepage:leakage ofstool following otherwise normal evacuation

Epidemiology

• the incidence of fecal incontinence differs by setting:community (17-36%), hospital (16%), and nursing

home (33-65%)

• risk factors: constipation, age >80 yr,female sex, UJ, impaired mobility, dementia, neurologic disease

Etiology

• physiological changes with age >80 yr (e.g. decreased external sphincter strength, decreased resting

tone of internal sphincter, weakened anal squeeze, increased rectal compliance, and impaired anal

sensation)

• trauma (e.g. vaginal delivery, pudendal nerve damage, cauda equina)

• iatrogenic

• surgical (e.g. anorectal surgery,lateral internal sphincterotomy, hemorrhoidectomy, colorectal

resection)

• radiation (e.g. pelvic radiation)

• neurogenic (e.g. neuropathy,stroke, MS, diabetic neuropathy)

• anorectal/colorectal diseases (e.g.rectal prolapse, hemorrhoids,1BD, rectocele, cancer)

• medication (e.g. laxative, anticholinergics, antidep

• cognitive (e.g. dementia, willful soiling with psychosis)

• constipation/fecal impaction

ressants, caffeine, muscle relaxants)

Investigations (if cause not apparent from history and physical)

• differentiate true incontinence from frequency and urgency

• stool studies

• endorectal ultrasound

• colonoscopy,sigmoidoscopy, anoscopy

• anorectal manometry/functional testing

Management

• physiological changes with age: medication management (antimotility agents (e.g. loperamide), diet/

bulking agents forloose stool), increase fluid intake, biofeedback, retraining of pelvic floor muscles,

surgery

• trauma:direct surgical repair or augmentation of the sphincters

• iatrogenic:surgical repair, artificial sphincters

• neurogenic: medication management, abdominal massage, digital stimulation for dysfunction,

biofeedback and behavioural training, prevent autonomic dysreflexia in spinal injury

• anorectal/colorectal diseases: treat underlying cause (optimize IBD medications),surgical (e.g. mass

removal, prolapse repair,hemorrhoid removal, colostomy)

• medication-related causes:stop laxatives, lower dose, or discontinue any other offending agents

. cognitive: regular defecation program in patients with dementia, psychiatric consult (optimize

medications and cognitive function)

• constipation/fecal impaction: disimpaction, prevent impaction, enema, or rectal irrigation

• safety assessment:assess bathroom distance, fall prevention strategies, need for a bedside commode,

liaise with occupational therapy if necessary

Urinary Incontinence

• see Urology, U6

Definition

• complaint of any involuntary loss of urine

• there are 4 subtypes:

1. stress incontinence: leakage associated with physical strain

2. urge incontinence:leakage associated with strong urge to urinate

3. overflow incontinence:leakage associated with poor bladder emptying

4. functional incontinence:leakage due to illness or disability not related to the urinary tract

r i

Transient Causes of Incontinence cJ

DIAPERS

De lirium

Infection

Atrophic urethritis/vaginitis

Pharmaceuticals

Excessive urine output

Restricted mobility

Stool impaction

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