CHANGES & CHALLENGES OF AGINGFRAILTY & IMPACT ON PATIENT OUTCOMES

Cathy A. Maxwell, PhD, RN, FAAN

Assistant Professor | Vanderbilt University School of Nursing

Photo: Getty Images

QUESTIONS

►Does the person get fatigued or exhausted easily?

►Can the person walk up one flight of stairs?

►Can the person ambulate or walk ¼ mile?

►Does the person have more than 5 medical problems?

►Has the person lost weight unintentionally in the past 6 months to 1

year?

►5-item FRAIL Questionnaire

►Frail >/= 3, 1 or 2 – Pre-frail

Objectives

►Describe the concept of frailty and

how frailty influences patient

outcomes.

►Describe an innovative approach

for upstream management of older

adults on aging trajectories.

Photo: Getty Images

Aging

►Aging reflects human entropy, or the body’s slow and gradual loss of the ability to generate energy to sustain itself. Changes, at cellular and subcellular levels begin years before outward manifestations appear.

►Older adults can be empowered to proactively manage their own personal trajectories of aging so that they experience increased quality of life, decreased health care utilization, and readiness for end of life.

Illustration: Public Domain

What to Expect

AGE END OF LIFE50

YRS OLD

Planning for the

8 Focus Areas

Planning for the 8 Focus Areas

AG

E

END OF LIFE50

YRS OLD

SAFETY

PHYSICAL ACTIVITY

RELATIONSHIP & COMMUNITY

FOOD & NUTRITION

SLEEP & REST

HEALTHCARE DECISION-MAKING

FINANCES/LEGAL

MIND/BODY HEALTH

Frailty Threshold

Trajectories of Aging

Source: T M Manini, and M Pahor Br J Sports Med 2009;43:28-31

Frailty

►A state of vulnerability to stressors

that increases the risk of adverse

events, disability, decline, and death.

►Two-thirds of frail adults are

hospitalized annually, accounting for a

large portion of preventable health

care spending.

►Public-at-large has a poor

understanding of the concept of frailty.

►Public perceptions are negative and

associated with giving up.

Photo: Getty Images

It’s OK to Use this “F-word”

Illustration: Getty Images

►What do we mean by “human

entropy?”

►Why is it important to talk about these

concepts at a lay person level?

►What can we do to help empower

adults to manage their personal

trajectories of aging?

MITOCHONDRIA IN HEALTH AND DISEASE

Illustration: Nathan Devery/Science Photo Library

Frailty Reflects Changes at Sub-cellular Levels

►Mitochondria

Evolved from bacteria

Contains DNA (37 genes) separate

from nuclear DNA (20,000 genes)

Tissue-specific mitochondrial content

Chondriome- subcellular network of

total mitochondria per cell

Illustration: Pasieka/Science Photo Library

Most

Abundant

— Muscle

— Brain

— Liver

Mitochondrial Biogenesis

►Mitochondria: Cellular respiration and energy production

►MB: Process by which mitochondria increase in size and number

►Activated by cellular stress (i.e., Exercise)

Illustration: Public Domain

Mitochondrion

►Cristae:

Surface area for

production of ATP

(energy carriers)

Illustrations: (clockwise): Keith R. Porter/Science Photo Library; Pearson Education, Inc.; Wikimedia Commons

Respiratory Chain

Supercomplexes

►Efficiency of mitochondria-

dependent cell growth depends

on cristae shape

Illustration: Public Domain

Facets of Mitochondrial and Cellular Function

-Fusion, fission, quality control

-OxPhos

-mtDNA

-Senescence & cell death

Physiological Functions

Central nervous system

Immune and inflammation

Metabolic & cardiovascular

Neuroendocrine

Clinical Outcomes

Cognitive decline

Diabetes

Functional decline

Cardiovascular disease

Psychiatric symptoms

Early and Midlife Later life

Multi-level Organization of Mitochondria and Clinical

Outcomes

Triggers inflammation

Long term effects of stress over time

Psychological Stress

and the Mitochondria

►Perceived threat:

Physical or psychological

►Engaged mitochondrial

energy production

Circulating cell-free

mitochondrialDNA

Infection

Trauma

Strenuous Exercise

Maximal oxygen consumption (VO2max) in sedentary (a)

and endurance-trained (b) males (diamonds) and females

(squares)

Sources: Johannes H. G. M. van Beek et al. Interface Focus 2016;6:20150079; ©2016 by The Royal Society

VO2:

Reflects the

body’s ability

to utilize

oxygen

Aerobic capacity versus

age in sedentary (squares)

and trained women (circles)

Sources: Johannes H. G. M. van Beek et al. Interface Focus 2016;6:20150079; ©2016 by The Royal Society

Why is this important?

►Person-centered approach

(vs. late response to disease)

►Need for holistic approaches

(multi-faceted)

►EARLY education and dialogue

Illustration adapted from: 12-25 Life

To Leave a Legacy

SPIRITUALM

EN

TA

L

PHYSICAL

SO

CIA

L

BALANCETo

Lear

n

To Live

To

Love

What can we do to empower older adults?

►Knowledge

►Understanding the broader

picture

►Addressing multiple domains

►Communication skills that

promote agency and self-efficacy

►Domains:

Safety

Physical Activity

Food & Nutrition

Relationships & Community

Sleep & Rest

Health Care Decisions

Finances & Aging

Mind/Body Health

EMPOWERING

OLDER ADULTS

TO MANAGE THEIR

OWN PERSONAL

TRAJECTORIES

OF AGING

FRAILTY AND ENERGY

Photo: Getty Images

One Year Outcomes:ALL Patients

One Year Outcomes: Non-frail Patients

6.5 out of 10

Returned to where they

were before injury

3 out of

10

Worse

than

before

injury

0.5

out

of 10

Died

3 out of 10

Returned to

where they

were before

injury

5 out of 10

Worse than

before

injury

2 out of 10

Died

INJURED OLDER ADULTS ONE YEAR AFTER INJURY

4 out of 10

Returned to where they were

before injury

5 out of 10

Worse than before injury

1 out of 10

Died

One Year Outcomes: Pre-frail Patients

INJURED OLDER ADULTS ONE YEAR AFTER INJURY

One Year Outcomes: Frail Patients

INJURED OLDER ADULTS ONE YEAR AFTER INJURY

2 out of 10

Returned to where

they were before injury

4 out of 10

Worse than before injury

4 out of 10

Died

Components

►Frailty and Falls

►Frailty and Injury Outcomes

►Frailty and Energy Production

►Stages of Aging (Trajectories)

& Anticipatory Care

►Making a Plan

(Proactive Planning)

Energy Engines (Mitochondria)

STAGES OF AGING: UNDERSTANDING FRAILTY AND PATTERNS OF CHANGE

Oxygen

NutritionENERGY Removal

of spent

mitochondri

a

New

mitochondria

Demand for new

mitochondria

(Movement)

The body makes and removes these engines on a daily basis, but over time, as we age, the size and number decrease.

Cell Illustrations: Science Photo Library; Engine, Woman: Getty Images

Physical Activity: Muscles and Brain

►Energy engines are especially found in muscle and brain.

EXERCISE!

Illustrations: Science Photo Library

Psoas Muscles

Leg Muscles

HeartBalance

and Posture

Cerebellum

Possible Aging Paths

TYPICAL: Slow

decline over time

and possibility of

delay with physical

activity

Ph

ysic

al

cap

acit

y

Age

B

C

BEST: High

ability until just

before end-of-life

UNEXPECTED EVENT:

Different levels of ability

depending on recovery

effort

A Closer Look Towards the End

►Loss of abilities

►Dealing with emotions

Photo: Getty Images

A Closer Look and What to Expect

COPING - STRUGGLING - FEELING OVERWHELMED SYMPTOMS

“but I can’t do anything like the

cooking I used to do and the

baking, no I can’t. So, so much

of my life’s changed.”

“She’s waiting for the next stage all

the time when things are going to

get better. I think she’s harping back

to the past when she was much

more able to manage.” (caregiver)

► No Appetite

► Severe Fatigue

► Pain

► Depression

► Trouble Breathing

► Confusion

► Leaking Urine or Stool

“Well, if it wasn’t for reading I

don’t know what I would do –

and television but I’m not all that

interested. I mean, I like things

like tennis on the television.”

“No I don’t see many friends

nowadays. I used to go regular to

church, I used to travel all over, but I

don’t see anybody now.”

Anticipatory CareMany people experience many emotions and symptoms as they near end

of life. If you experience any of the emotions noted below, talk to trusted

friends, family and professionals.

8 FOCUS AREAS

Photo: Mint Images/Science Photo Library

(8) Focus Areas

► Safety

► Physical Activity

► Relationships

& Community

► Food & Nutrition

► Sleep & Rest

► Healthcare

Decision-making

► Finances/Legal

► Mind/Body Health

Making a Plan and Anticipatory Care

Knowing that frailty happens when we lose the ability

to make energy AND knowing that it can eventually

happen to anyone, what are some areas that we

need to think about as we age?

Thinking about these areas NOW, instead of later,

helps us to make better decisions.

This section discusses eight areas that older adults

need to think about. Each area briefly describes two

phases to think about:

1. Early planning

2. Late planning, when we begin to lose

physical abilities.

►Security and protection

Safety

►Home safety

►Driving safety

►Fall prevention

Photo: Getty Images

►New hobbies and activities

Physical Activity & Movement

►Time spent sitting, standing and moving

►Reduced risk of chronic diseases (diabetes, heart disease, high blood pressure)

►1 hour exercise = 2 hours in life expectancy

►150 minutes/week of moderate activity

►75 minutes/week of vigorous activity

Photo: Getty Images

HABITUAL!

►Maintaining a sense of self

Relationships

and Community

►Social connections and mortality

►Investment in relationships

►Autonomy and connection

Photo: Getty Images

►Loss of appetite and interest

in eating

Food and Nutrition

►Drinking water

►Add color to your plate

►Focus on fiber

►Mediterranean diet

►Protein

Photo: Getty Images

►Frailty: Why am I sleeping so

much?

Sleep and Rest

►How much is enough?

►Waking calm

►Benefits of sleep (thinking, immune

system, memory, weight control)

►Ways to enhance sleep

Photo: Getty Images

►Addressing FEAR

►My healthcare needs

(pain, constipation, comfort)

Healthcare Decisions

►Early vs. late planning

►Goals of care

►Caring relationships

►Advance care planning

Photo: Getty Images

►Is everything settled? At peace?

Finances and Aging

►Legal: Estate planning,

documents, wills, power of attorney

►Health care: Insurance, assets

►Income & Expenses: Debt

Photo: Getty Images

►Mind/Body: How does my mind affect

my body, prayer, meditation?

►Sharing Memories, Stories, Values

Holistic Health: The Mind and Body

►Daily Balance: How do I spend time?

►Compassion for Self: Do I care for myself? Physical needs?

Photo: Getty Images; Illustration: Public Domain

Summary

►Concept of frailty and how frailty

influences patient outcomes

►Innovative approach for upstream

management of older adults on

aging trajectories

Photo: Getty Images

Illustration: Public Domain

Photo: Getty Images

QUESTIONS?For more information:

Email: cathy.maxwell@Vanderbilt.edu

Faculty webpage:

nursing.vanderbilt.edu/people/bio/cathy-maxwell