A Geriatricians approach to frailty in Parkinson's

Webinar objectives

Delegates will gain a greater understanding on what Frailty is, how this affects someone living with Parkinson’s and be given the tools to support the individual.

Webinar summary

Frailty is defined as a state of vulnerability to poor resolution of homeostasis after a stressor event, and is strongly associated with adverse outcomes.

Dr Tom Mace, consultant physician at Hull University Teaching Hospitals NHS Trust, explained that a “stressor event” might include a period of ill health, or a stressful occurrence such as a bereavement or even moving home. Afterwards, someone with frailty will be less likely to return to baseline, and more likely to live with some dependency or disability. “They are at a higher risk of ending up in 24-hour care or even dying,” said Tom.

The Rockwood Clinical Frailty Score (CFS) for over 65s classifies mild frailty, or CFS 5, as needing help with heavy housework, finances, medicines, shopping, and walking outside. At CFS 7, or severe frailty, the person will be completely dependent on others for personal care; at CFS 8, or very severe frailty, they will be approaching end of life.

Frailty in Parkinson’s

Evidence on the association between Parkinson’s disease (PD) and frailty is limited, but “expanding rapidly”, said Tom.

Outlining the current literature, he said that studies had shown it to be prevalent in people with advanced PD, and that it was associated with cognitive impairment, hallucinations, and dementia. Another found that 84% of PD patients over the age of 75 admitted to a UK hospital were frail, and that those with severe to very severe frailty had an eight-fold increased risk of dying during admission.

Tom also pointed to evidence that suggests the prevalence of frailty increases in line with disease duration and severity, and that it is more closely associated with non-tremor dominant type PD.

“We are now developing a picture that the older the patient, the longer the duration, and higher the severity, the higher the chances of frailty, which is all intuitive,” said Tom, highlighting that no study has yet identified any causal links.

Multi-system approach

The main frailty syndromes, namely falls, immobility, incontinence, cognitive dysfunction, and susceptibility to treatment side effects, can all apply to people with PD.

“It means we are all managing people with frailty at all times, and this multi-system disorder requires and multi-system approach,” said Tom, adding that it was not always linked to older age, that some people would have frailty at PD diagnosis, and that some would develop it as the PD progressed.

The Frailty Fulcrum concept works on the theory that holistic care that goes beyond the patient’s physical health- and PD-related needs can help them to build resilience to frailty, and gibe them the best chance of returning to baseline post0sterssor event. “It means supporting them psychologically, looking at their other chronic illnesses, ensuring they are reviewed, they their needs are met, and supporting their carer,” Tom said, explaining that “it doesn’t take much to tip the scales”.

“When a patient becomes unwell, there is often a delirium that may be followed by constipation; they end up in hospital, diagnosed with undertreated Parkinson’s… but we know that this is the Parkinson’s being decompensated by something else.”

Instead, PD services can help people to build resilience by providing proactive care that would help them to recover quickly from an acute illness. As well as managing anxiety and delirium, this model includes educating and supporting carers to manage issues at home, and providing quick access to specialist care when needed.

Quoting a 2020 paper from Tenison et al, Tom said there was a need to adapt our approach: from one focused on single diseases to a proactive, coordinated and person-centred care model.

Management approaches

The comprehensive geriatric assessment can be adapted to the PD population, said Tom. It starts with regular holistic assessment of physical, socioeconomic/environmental and functional factors, as well as mental health and medications. This informs the creation of a problem list, and a personalised care plan. Interventions can then be delivered by a multi-disciplinary team (MDT) and the results reviewed.

To build an effective MDT, PD teams will often need to work with people outside of the traditional “inner circle”, such as GPs, bladder and bowel services, dietitians, mental health services, and palliative care teams. “These people are out there. They often feel just as alone managing these complex patients as we do, and they value support,” said Tom, explaining that, in his experience, delivering PD training to colleagues in other clinical areas had proved very useful.

The MDT approach places the patient at the centre of a larger network of healthcare and allied healthcare professionals. This increases oversight, enabling clinicians to prescribe “high reward, high risk” treatments, confident that their upskilled colleagues will be able to identify and report adverse events, said Tom.

This is important as fear of side effects often means PD goes undertreated in the presence of frailty. It can result in a arrange of issues including social isolation, increased dependency, an increased risk and fear of falls, depression, and increased carer burden. Tom said: “In my opinion, this can lead to a poorer decreased quality of life and complications that drive frailty.”

Future of frailty care

Summing up, Tom said that treating people with PD and frailty required a holistic approach that involves a whole team of professionals. Using the CFS can uncover multiple symptoms and difficulties, many of which will be driving frailty in that patient, he added.

References

Tenison, E., & Henderson, E. J. (2020). Multimorbidity and frailty: tackling complexity in Parkinson’s disease. Journal of Parkinson's Disease, 10(s1), S85-S91.

Peball, M., Mahlknecht, P., Werkmann, M., Marini, K., Murr, F., Herzmann, H., ... & Seppi, K. (2019). Prevalence and associated factors of sarcopenia and frailty in Parkinson’s disease: a cross-sectional study. Gerontology, 65(3), 216-228.

Torsney, K. M., & Romero-Ortuno, R. (2018). The clinical frailty scale predicts inpatient mortality in older hospitalised patients with idiopathic Parkinson's disease. Journal of the Royal College of Physicians of Edinburgh, 48(2), 103-107.

Moody, D. The Frailty Fulcrum. Available at: https://www.england.nhs.uk/blog/dawn-moody/ Last accessed: 17^th July 2023.

Bernabei, R., Venturiero, V., Tarsitani, P., & Gambassi, G. (2000). The comprehensive geriatric assessment: when, where, how. Critical reviews in oncology/hematology, 33(1), 45-56.