CLINICAL Frailty Syndrome: Physical Therapy REVIEW Indexing Metadata/Description › Title/condition: Frailty Syndrome: Physical Therapy › Synonyms: Frailty, physical therapy; senility, physical therapy; functional decline in the elderly; frailty syndrome › Anatomical location/body part affected: Multiple systems/generalized functional disability › Area(s) of specialty: Geriatric rehabilitation, home health › Description • Frailty is a clinical syndrome resulting from multisystem impairments. Frailty increases in prevalence in old age (> 65 years of age) but is not considered part of normal aging(32) • Frailty results in a functional decline in older adults that necessitates the assistance of others to perform activities of daily living (ADLs), including either or both instrumental and noninstrumental ADLs • There are a number of definitions of frailty in use, and there is not one gold standard definition(32) • One definition, developed in 2001 by Fried, refers to a frailty phenotype in which 3 or more of the following 5 criteria are present:(33) –Unintentional weight loss (10 lb/4.5 kg in past year) –Self-reported exhaustion –Weakness (as measured with grip strength) –Slow walking speed –Low physical activity • Presence of 1 or 2 of these criteria is considered “pre-frail,” “intermediate frail,” or vulnerable to frailty • Comprehensive evaluation of the extent of frailty in the primary care setting involves Authors geriatric assessment in multiple physical and psychological domains with a screening Rudy Dressendorfer, BScPT, PhD Cinahl Information Systems, Glendale, CA instrument such as the Clinical Frailty Scale, the Tilburg Frailty Indicator, or the Survey (1) Ellenore Palmer, BScPT, MSc of Health Aging and Retirement in Europe (SHARE) Frailty Index Cinahl Information Systems, Glendale, CA –The SHARE Frailty Index differs from the criteria originally proposed by Fried in (34) Reviewers that: Brian Dy, DPT - weight loss is replaced with appetite loss Cinahl Information Systems, Glendale, CA - slowness is measured by a self-reported mobility limitation Abigail Grover Snook, PT, MS, MEd • The term frailty is used clinically to refer to older patients with low functional reserve Cinahl Information Systems, Glendale, CA (32) Rehabilitation Operations Council who are vulnerable to external stressors and at high risk for adverse outcomes, Glendale Adventist Medical Center, including disability, hospitalization, institutionalization, and death. Frailty is not Glendale, CA synonymous with either comorbidity or disability. Comorbidity is an etiologic risk factor (33,35) Editor for frailty, and disability is an outcome of frailty Sharon Richman, MSPT • This Clinical Review focuses on the components of frailty that physical therapists can Cinahl Information Systems, Glendale, CA address: unintentional weight and muscle loss, persistent fatigue, increased fall risk, and functional decline in strength, gait speed, and ADLS(2,3) December 30, 2016 Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2017, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206 • Individuals may present with deficits in cognition and sensorimotor input and integration. Multiple medication intake, dehydration, and malnutrition can also lead to frailty • See also Clinical Review…Falls in Older Adults; Item Number: T708541 › ICD-9 code • 797 senility without mention of psychosis › ICD-10 code • R54 senility (ICD codes are provided for reader’s reference, not for billing purposes) › G-Codes • Mobility G-code set –G8978, Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals –G8979, Mobility: walking & moving around functional limitation; projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting –G8980, Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting • Changing & Maintaining Body Position G-code set –G8981, Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals –G8982, Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting –G8983, Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting • Other PT/OT Primary G-code set –G8990, Other physical or occupational primary functional limitation, current status, at therapy episode outset and at reporting intervals –G8991, Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting –G8992, Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end reporting • Other PT/OT Subsequent G-code set –G8993, Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at reporting intervals –G8994, Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting –G8995, Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to end reporting › . G-code Modifier Impairment Limitation Restriction CH 0 percent impaired, limited or restricted CI At least 1 percent but less than 20 percent impaired, limited or restricted CJ At least 20 percent but less than 40 percent impaired, limited or restricted CK At least 40 percent but less than 60 percent impaired, limited or restricted CL At least 60 percent but less than 80 percent impaired, limited or restricted CM At least 80 percent but less than 100 percent impaired, limited or restricted CN 100 percent impaired, limited or restricted Source: https://www.cms.gov/ . › Reimbursement: Reimbursement for therapy will depend on insurance contract coverage; no specific special agencies are applicable for this condition. No specific issues or information regarding reimbursement have been identified › Presentation/signs and symptoms (1,2,3) • Older adult –Chronological age is generally a poor indicator of physical or cognitive function, and each patient should be addressed individually • Impaired functionality in ADLs • Muscle weakness (e.g., reduced grip and lower extremity strength) • Slow gait speed • Unintentional body weight loss • Muscle loss • Persistent fatigue • Impaired posture and balance that increase falls risk • Impaired eyesight • Poor respiratory function and cardiovascular function • Social isolation Causes, Pathogenesis, & Risk Factors › Causes (1,2,3) • Age-related physical and cognitive impairments • Multiple systems are thought to be involved in the development of frailty, including the immune, cardiovascular, neuroendocrine, metabolic, and nervous systems.(32) The more of these systems that become dysregulated, the more likely a person will become frail(32) –Dysregulation is thought to be multifactorial in origin, with genetic, biological, physical, psychological, social, and environmental components contributing(32) • Contributors –Chronic undernutrition (e.g., insufficient caloric intake) with weight loss(5) –Hypokinetic lifestyle (i.e., minimal physical activity) leading to reduced functional capacity –Sarcopenia (i.e., deficiency of muscle mass) with generalized weakness –Behavioral precursors include a decrease in life space, defined as the size of the area a person purposely moves through in his or her daily life, as well as the frequency of travel within a specific time frame(45) › Pathogenesis • In general, frailty status is a continuum of the self-reported need for assistance to perform instrumental and noninstrumental ADLs.(1,2) Consequently, individuals with disabling comorbidities may not be overtly frail, but rather “prefrail” or “vulnerable” to frailty(6) • Frailty status was diagnosed independently of cognitive impairment in Italian community-dwelling patients (N = 109) with Alzheimer’s disease using the Study of Osteoporotic Fractures criteria, which include dependence in basic ADLs, especially self-dressing(7) • It has been proposed that decreased total energy expenditure, due mainly to insufficient physical activity, initiates a “frailty cycle” that perpetuates the risk of further decline and greater disability with advancing age(8) –Components of the frailty cycle include neuroendocrine dysregulation, anorexia, chronic undernutrition, negative energy and nitrogen balance, weight loss, sarcopenia, reduced daily activity, decreased physical fitness (e.g., aerobic power, strength), slow walking speed, hypometabolic state, and disability in ADLs(8) • Multiple comorbidities likely contribute to a high disease burden that promotes functional decline due, for example, to lower