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frailty

Spine Surgery Considerations in the Aging Population

Teaser: 

Erika Leck, MD, PGY 5,1, Sean D Christie, MD, FRCSC, 2,

1 Department of Surgery (Neurosurgery) Dalhousie University.
2 Vice-Chair and Director of Research Professor, Division of Neurosurgery , Department of Surgery (Neurosurgery), Healthy Populations Institute Flagship Project Co-Lead, Creating Sustainable Health Systems in a Climate Crisis, Dalhousie University.

CLINICAL TOOLS

Abstract: The global population is ageing, and with that there is a concomitant increase in spinal pain and mobility complaints, most related to degenerative changes. It is important to consider how the markers of aging and, specifically, frailty, can overlap with symptoms of spine disease. Although non-operative management should be the initial response, spine surgery in older adults is safe and should be considered as part of a holistic approach for patients with persistent neuropathic pain.
Key Words: Spine Surgery, Elderly, Older Adults, Frailty, Imaging, Spinal Degeneration.

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1. It is essential to remember that, while degeneration is inevitable, the appearance of symptoms is not and treatment decisions must be based on the clinical presentation, not the images.
2. Our ageing population will lead to an increase in the frequency of spine-related complaints.
3. It is important to consider how the markers of aging and frailty overlap with symptoms of spine disease.
4. The conservative approaches should always be pursued prior to consideration of surgical options.
5. When required, spine surgery in older patients is safe and efficacious, but should involve a healthcare team able to appropriately assess and support the patient and their loved ones.
1. Biological age does not necessarily equate to chronological age.
2. Radiological “abnormalities” become more common with age, but are frequently asymptomatic, order tests that direct care.
3. Combination, non-opioid, pharmacological strategies, with a ‘start low and go slow’ approach are preferred.
4. Tools such as the Clinical Frailty Scale can be helpful in predicting risk and clinical decision making.
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Frailty in Adult Spine Surgery—A Clinical Update

Teaser: 

1Eryck Moskven, MD,2Raphaële Charest-Morin, MD, FRCSC,

1PGY 1, Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC. 2Clinical Assistant Professor, Combined Neurosurgical and Orthopaedic Spine Program, Vancouver General Hospital, University of British Columbia, Vancouver, BC.

CLINICAL TOOLS

Abstract: Purpose: Frailty is a state of increased vulnerability. This paper reviews the definitions and applicability of frailty tools and discusses the impact of frailty in patients with spinal disease.
Recent Findings: Frailty is a significant risk factor for postoperative adverse-events (AEs), prolonged postoperative length of stay (LOS), adverse discharge disposition, and mortality following spine surgery. Cumulative deficit measures such as the mFI are appropriate risk stratification tools, while phenotypic measures are sensitive to capturing the relationship between spine disease and spine surgery on the frailty trajectory.
Summary: Frailty in patients with spinal disorders is predictive of postoperative adverse outcomes. The role of spine surgery to reverse frailty requires investigation.
Key Words: frailty, spine surgery, adverse outcomes, geriatric.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

Frailty is a state of decreased reserve and increased vulnerability associated with adverse health outcomes.
Clinical frailty measures derived from the cumulative deficit model of frailty such as the mFI are appropriate risk stratification tools for identifying patients at an increased risk of postoperative AEs following spine surgery.
Frailty tools with phenotypic constructs are the most sensitive measures in capturing the relationship between spinal pathology and surgical intervention on the frailty trajectory.
When assessing an elderly patient, the FRAIL acronym is a helpful guide to screen for frailty - F (fatigue), R (resistance/muscular weakness), A (ambulatory difficulty), I (illness and comorbidities), and L (unintentional loss of weight).
Access to a readily available clinical frailty assessment tool on a mobile device, such as the Clinical Frailty Scale (CFS), reduces the need for extensive chart review to calculate and determine frailty severity.
When assessing for surgical candidacy the clinician should evaluate the impact of spinal pathology on health-related quality of life, the magnitude of the proposed surgical intervention and the frailty status.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
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Palliative and Therapeutic Harmonization (PATH): A New Model for Decision-Making in Frail Older Adults

Palliative and Therapeutic Harmonization (PATH): A New Model for Decision-Making in Frail Older Adults

Members of the College of Family Physicians of Canada may claim one non-certified credit per hour for this non-certified educational program.

Mainpro+® Overview
Teaser: 

Paige Moorhouse, MD MPH FRCPC, and Laurie Mallery MD FRCPC, Division of Geriatric Medicine, Dalhousie University, Halifax Nova Scotia

www.pathclinic.ca

Abstract
As the population ages, advances in medical technology paradoxically result in the accumulation of multiple chronic health conditions—known as frailty. Despite increasing numbers of frail older adults, healthcare systems have not been designed to meet the challenges associated with caring for this patient population. This article describes the characteristics of health systems that exacerbate the complex issues associated with caring for those who are frail and reviews one possible model, known as PATH—Palliative and Therapeutic Harmonization, as a way to respond to these system challenges.
Keywords: frailty, care planning, dementia, knowledge translation, health program.

Fragilité : À la recherche d’un paradigme clinique et de recherche approprié

Fragilité : À la recherche d’un paradigme clinique et de recherche approprié

Teaser: 


Fragilité : À la recherche d’un paradigme clinique et de recherche approprié

Conférencier : Howard Bergman, M.D., professeur et titulaire de la chaire Dr Joseph Kaufmann et directeur du service de gériatrie, centre de santé universitaire McGill, Montréal (Québec); codirecteur du groupe de recherche Solidage, Montréal (Québec); directeur du réseau québécois de recherche sur le vieillissement et du Fonds de Recherche en Santé du Québec, Montréal (Québec); président du conseil consultatif, Institut du vieillissement, Instituts de recherche en santé du Canada, Ottawa (Ontario).

Le terme fragilité est fréquemment utilisé par les professionnels de la santé qui s’occupent des personnes âgées, a fait observer le Dr Howard Bergman. Néanmoins, le concept reste mal défini. Qu’est-ce que la fragilité, quels en sont les éléments, et comment l’évaluer en milieu clinique? Ce terme sert-il l’effort pour atténuer l’évolution défavorable de l’état de santé chez les personnes âgées?

Développer le concept de la fragilité et comprendre le processus de vieillissement
Selon le Dr Bergman, l’étude de la fragilité reste un défi puisqu’il n’existe pas de critères bien définis pour la caractériser. La différence entre la fragilité et l’incapacité, et la manière dont les chercheurs et les cliniciens définissent les effets du vieillissement par rapport au marqueur de fragilité, sont des aspects de la connaissance médicale qui continuent à évoluer. Par conséquent, les cliniciens utilisent le concept sans se concerter sur sa signification, et ce problème s’accentue par le fait que la fragilité est un terme non médical du langage courant.
La 2e séance de travail internationale sur la fragilité et le vieillissement, qui s’est tenue à Montréal en mars 2006, a cherché à répondre aux questions clés et aux controverses entourant le concept de fragilité. Cette séance de travail a débouché sur la définition des principales caractéristiques de la fragilité (Tableau 1). Les participants se sont entendus pour dire que la fragilité correspond à une plus grande vulnérabilité aux facteurs de stress, en raison des déficiences de plusieurs systèmes physiologiques interdépendants. Ces déficiences seraient à l’origine du déclin des réserves homéostatiques et de la résilience. Le groupe de travail a admis que la fragilité et l’incapacité sont deux concepts bien distincts, même s’ils se recoupent partiellement (Figure 1). Une des caractéristiques principales de la fragilité est qu’elle est associée à une augmentation du risque de morbidité et de mortalité, a déclaré le Dr Bergman.
On a décrit la fragilité grâce à plusieurs éléments combinés, notamment les anomalies physiologiques, les déficiences des fonctions physique, cognitive ou psychologique, et d’autres caractéristiques, comme l’âge avancé.

Selon le Dr Bergman, les stratégies de recherche qui utilisent l’approche fondée sur le parcours de vie peuvent contribuer de façon considérable à notre compréhension actuelle de la fragilité. Cette approche interactive et personnalisée considère que le processus de vieillissement est le résultat de facteurs survenant tout au long de la vie, comme les expositions environnementales, les prédispositions génétiques et les comportements en matière de santé. Des facteurs essentiels survenant tout au long de la vie pourraient déterminer si une personne vieillit sainement ou non. Une telle approche clinique et de recherche tente d’expliquer l’hétérogénéité du déclin fonctionnel chez les personnes âgées.

Controverses actuelles liées à la définition et à l’utilisation du concept de fragilité
La fragilité n’est pas encore un instrument clinique. Ce concept demeure associé à des controverses et des zones d’ombre : il reste notamment à faire la distinction entre les maladies chroniques et la fragilité. Selon le Dr Bergman, il s’agit d’une relation complexe : même si les maladies chroniques et la fragilité sont parfois associées, la majorité des personnes fragiles souffrent de maladies chroniques, alors que les personnes atteintes de maladies chroniques ne sont pas toutes fragiles; c’est là la différence essentielle. La prévalence de la fragilité augmente distinctement avec le nombre et la gravité des maladies chroniques. On tente cependant toujours de déterminer si la fragilité est un trouble secondaire ou un état sous-jacent. De plus, ce n’est pas la même chose pour une personne d’être fragile ou de présenter un grand nombre de comorbidités. En matière de soins de santé, il est important de considérer les enjeux liés au contexte. Par exemple, des études suggèrent que les patients ayant un accès restreint aux soins de santé seront plus fragiles.

Il existe un spectre de modèles de fragilité. À l’une extrémité du spectre, la fragilité est représentée comme un syndrome médical, tandis qu’à l’autre extrémité il s’agit d’un groupe de facteurs de risque (Tableau 2).

Si l’on considère la fragilité comme un syndrome, avec des caractéristiques de base bien définies, on pourrait tirer d’importantes leçons du syndrome métabolique, a suggéré le Dr Bergman. Comme pour la fragilité, la définition clinique du syndrome métabolique est un sujet de discussion et de controverse. Puisqu’il s’agit de syndromes, on s’attend à ce que la présence d’éléments multiples soit plus fortement corrélée à une évolution défavorable, que la somme de chaque élément.

Le Dr Bergman a reconnu que l’utili-sation accrue du concept de fragilité entraînait des inconvénients. Par exemple, les médecins pourraient surestimer l’ensemble des symptômes, négligeant un symptôme particulier qui pourrait s’avérer précieux. De plus, étant donné que les seuils associés à certaines des mesures de fragilité proposées, comme la vitesse de marche ou la force de préhension, n’ont pas encore été établis, il est difficile de déterminer comment classer les individus. Le fait d’introduire un diagnostic de « fragilité » en pratique clinique peut également s’avérer dangereux, car une appellation impropre peut avoir des conséquences négatives sur la santé mentale d’un patient ou sur la prise de décision en matière de santé.

Selon le Dr Bergman, cependant, le concept de fragilité pourrait s’avérer de grande valeur pour les médecins, puisqu’il est associé à une utilité fonctionnelle en pratique clinique. Le terme identifie un sous-groupe de personnes âgées vulnérables dont le devenir est très susceptible d’être défavorable. En matière de santé, les besoins des personnes âgées indépendantes sur le plan fonctionnel et montrant une fonction cognitive apparemment normale peuvent être négligés si les médecins ne prennent pas en compte les marqueurs reconnaissables de la fragilité.
Selon le Dr Bergman, les marqueurs de la fragilité permettent aux planificateurs de soins de santé d’effectuer des prédictions utiles. À une plus grande échelle, une utilisation clinique de ce concept pourrait améliorer notre compréhension du processus de vieillissement et permettre aux médecins de mieux caractériser l’hétérogénéité de la santé des personnes âgées. En raison du vieillissement de la population, le fait de pouvoir mieux cibler les risques des personnes âgées atteintes d’une maladie chronique, mais non handicapées, et d’y remédier, pourrait entraîner des interventions plus ciblées en matière de santé et, par conséquent, améliorer l’évolution de la santé. Par exemple, le Dr Bergman a cité une étude montrant que des soins aux patients qui retardaient l’apparition d’une invalidité ou d’une dépendance, ne serait-ce que d’un ou deux ans, réduisaient considérablement les besoins en matière de soins de lonque durée et de ressources des établissements.

Conclusions et recommandations

Le Dr Bergman a conclu sa présentation en déclarant que bien que la recherche et le débat sur la fragilité ont permis de mieux comprendre les personnes âgées, le concept reste à l’heure actuelle d’une utilité plus théorique que pratique. En définitive, davantage d’initiatives de recherche sur la fragilité permettront d’en déterminer la pertinence et d’évaluer si les professionnels médicaux réussissent à améliorer la promotion de la santé, la prévention, le traitement, la rééducation et les prestations de soins pour les personnes âgées.

Frailty: Searching for a Relevant Clinical and Research Paradigm

Frailty: Searching for a Relevant Clinical and Research Paradigm

Teaser: 

Click here to view the entire report from the 28th Annual Scientific Meeting of the Canadian Geriatrics Society

Frailty: Searching for a Relevant Clinical and Research Paradigm

Speaker: Howard Bergman, MD, The Dr. Joseph Kaufmann Professor and Director Division of Geriatric Medicine, McGill University, Montreal, QC; Co-Director: Solidage Research Group, Montreal, QC; Director, Quebec Research Network in Ageing/Fonds de Recherche en Santé du Québec, Montreal, QC; Chair, Advisory Board, Institute of Aging, Canadian Institutes of Health Research, Ottawa, ON.

The term frailty, observed Dr. Howard Bergman, is widely used by health professionals who treat aging adults. Nonetheless, the concept remains ill-defined. What is it, what are its components, and how is it measured in the clinical setting? Does the term add something to the effort to mitigate adverse health outcomes among older adults?

Conceptualizing Frailty and Understanding the Aging Process
The challenge of studying frailty, Dr. Bergman maintained, is the lack of clear criteria to designate it. How frailty differs from disability, and how researchers and clinicians define effects of aging versus markers of frailty are areas of evolving medical knowledge. The result is that clinicians are utilizing the concept without agreement on its meaning, a problem exacerbated by the fact that frailty is a nonmedical term circulating in popular language.
The 2nd International Working Meeting on Frailty and Aging held in Montreal in March of 2006 sought to address key issues and controversies related to the concept of frailty. The core features agreed upon are presented in Table 1. Participants concurred that frailty is “an increased vulnerability to stressors due to impairments in multiple, inter-related physiologic systems.” These impairments are believed to lead to declining homeostatic reserve and resiliency. The working group acknowledged that while frailty and disability have overlap, they remain distinct concepts (Figure 1). A key feature of frailty is that it is associated with increased risk of morbidity and mortality, stated Dr. Bergman.

Frailty has been described with various combinations of components including physiological abnormalities, impairments in physical, cognitive, and/or psychological function, and other features such as advanced age.
According to Dr. Bergman, research strategies that use the life-course approach can significantly contribute to the current understanding of frailty. This individualized, integrative approach conceives that how one ages is a product of factors across the whole life span—including environmental exposures, genetic predispositions, and health behaviours. Critical factors across the life course may determine whether one ages healthfully or not. This research and clinical approach attempts to elucidate the heterogeneity of functional decline in older people.

Ongoing Controversies in Defining and Using the Frailty Concept
Frailty is not yet a clinical instrument. Controversies and grey areas that persist include disentangling chronic disease states from frailty. Dr. Bergman described the two as bearing a complex relationship: there is some overlap, but the key distinction is that while most frail persons have chronic disease, most people with chronic disease are not frail. There is a distinct increase in the prevalence of frailty when the number and severity of chronic diseases increase. Whether frailty is a secondary condition rather than an underlying state is still being explored. Further, being frail and having a high index of comorbidities are not equivalent. It is important to consider contextual issues in health care—for example, studies suggest that patients with poor access to health care will show higher degrees of frailty.
Dr. Bergman highlighted that there is a spectrum of frailty models. At one extreme of the spectrum frailty is represented as a medical syndrome and at the other it is a group of risk factors (Table 2).

In viewing frailty as a syndrome with defining core features, Dr. Bergman suggested that there may be important lessons to be learned from the metabolic syndrome. As with frailty, there is debate and controversy about the clinical definition of the metabolic syndrome. As syndromes, the presence of multiple components are expected have a stronger association with adverse outcomes than the sum of the individual components.

Dr. Bergman acknowledged the disadvantages associated with increasing utilization of the frailty concept. For example, physicians may overvalue the symptom cluster, thereby overlooking the possible value of a single symptom. In addition, some of the measures proposed for frailty such as gait velocity or grip strength do not have established cut-offs, thereby making it difficult to determine how to classify individuals. Further, introducing “frailty” as a diagnosis in clinical practice carries the potential danger of inappropriate labeling, which can have various negative effects on a patient’s health state and health-related decision-making.

However, Dr. Bergman stated, the concept of frailty also holds great potential value for physicians, as it has functional utility in clinical practice. The term identifies a subset of vulnerable older adults at high risk of adverse outcomes. The health needs of older persons who are functionally independent, with apparently normal cognitive function, may be overlooked if clinicians disregard identifiable frailty markers.

Frailty markers provide health care planners with the ability to make valuable predictions, according to Dr. Bergman. A wider clinical application of the concept could improve understanding of the aging process and enhance clinicians’ ability to characterise the heterogeneity in the health of older persons. With an aging population, the capacity to better target and remediate risk in nondisabled older adults with chronic disease could lead to better tailoring of health interventions, and correspondingly, improved health outcomes. For example, Dr. Bergman cited a study that found that patient care measures that delayed the onset of disability and/or dependence by only 1 or 2 years reduced needs for long-term care and institutional resources significantly.

Conclusions and Recommendations

Dr. Bergman concluded that while research and debate on frailty has improved understanding of aging adults, the concept retains at present more potential than practical and acknowledged utility. Ultimately the test of frailty’s relevance will lie in further research initiatives on frailty and whether medical professionals succeed in improving health promotion, prevention, treatment, rehabilitation, and care interventions for aging adults.

Heart Failure: Old Disease, Older Adults, Fresh Perspective

Heart Failure: Old Disease, Older Adults, Fresh Perspective

Teaser: 


George A. Heckman, MD, MSc, FRCPC, McMaster University, Hamilton General Hospital, Hamilton, ON.
Catherine Demers, MD, MSc, FRCPC, McMaster University, Hamilton, ON.
David B. Hogan, MD, FCRPC, University of Calgary, Calgary, AB.
Robert S. McKelvie, MD, PhD, FRCPC, McMaster University, Hamilton, ON.

The burden of heart failure is rapidly rising. Heart failure is associated with substantial mortality, morbidity, and economic cost, which disproportionately affect older adults. Heart failure among older individuals is frequently complicated by geriatric syndromes, including frailty, functional decline, cognitive impairment, and atypical clinical presentations. Understanding the nature of these geriatric syndromes and their impact on the assessment and management of heart failure is a critical component to diagnosing and delivering appropriate care to these patients. In this article we review the geriatric aspects of heart failure.
Key words: geriatric syndrome, heart failure, older adults, diagnosis, frailty.

The Sad Truth About Falls: Depression, Isolation and Increased Frailty all Common Consequences

The Sad Truth About Falls: Depression, Isolation and Increased Frailty all Common Consequences

Teaser: 

Brian E. Maki, PhD, PEng
Professor, Department of Surgery
and the Institute of Medical Science,
University of Toronto; and Senior Scientist,
Sunnybrook and Women's College Health Sciences Centre

Hip fractures and other physical consequences of falls in older adults have received a great deal of attention, both in the scientific literature and the popular press. It is only recently, however, that the psychosocial consequences of falling, such as fear of falling, have begun to receive due recognition. The injuries due to falls may well prove to be the "tip of the iceberg", with the psychosocial sequelae incurring even greater societal costs.

Murphy and Isaacs1 first described the "post-fall syndrome" as an extreme fear of falling, characterized by a tendency to stagger, to clutch at objects, and to show hesitancy or alarm when asked to walk without assistance. Some researchers believe that such an anxiety syndrome can be viewed as a classic phobia, and in fact have coined the phrase "ptophobia" to refer to a phobic reaction to standing or walking.2 While such a severe reaction may be relatively uncommon, a more moderate fear of falling is very widespread among older adults, with reported prevalence ranging from 20-60%.3,4 The prevalence increases with age and is reportedly more common among women.4 One should note, however, that a gender-related bias in the willingness to report fear could confound the latter finding.