frailty

With an increasing number of geriatric patients seeking IR services, identification of patients at higher risk for complications will allow for improved pre-procedural counseling and patient selection, as well as targeted application of resources to improve the perioperative risk profile for select patients.

In the audio version of "Patient frailty and IR: The case for frailty as a geriatric diagnostic tool" (Fall 2021 IR Quarterly, pp. 20-22), authors Rana Rabei, MD, MHA, and Maureen P. Kohi, MD, FSIR, describe the pathophysiology of patient frailty, how frailty can be measured, and the potential role of frailty in guiding treatment decisions within interventional radiology.

Read the article.


Contact us with your ideas and questions, or read more about about interventional radiology in IR Quarterly magazine or SIR's Patient Center.

(c) Society of Interventional Radiology.

Presenter:

Javed Butler MD, MPH, MBA
Professor and Chairman
Department of Medicine
University of Mississippi
Jackson, Mississippi

Heart Failure is a serious health concern amongst older adults, afflicting over 6 million Americans, the majority of whom are 65 years of age or older. It is the leading cause of hospitalization, morbidity, and mortality in this population. It is more challenging to diagnose and manage HF in older patients due to multiple factors including multimorbidity, polypharmacy, cognitive impairment, and frailty. Furthermore, clinicians struggle to remain up-to-date on key clinical trial data and recent guidelines on developing individualized treatment plans for patients. To improve outcomes for patients with HF, clinicians must be adept at recognizing its common signs or symptoms, conducting a thorough diagnostic evaluation, and developing a treatment plan that addresses the multiple challenges and complexities that this patient population faces. Here, we cover these key principles in a short, case-based teaching module.

Follow along with the slideset located here:
https://bit.ly/3EGHtBx

Welcome to Movie Challenge 3! The boys are coming in hot and depressing with Frailty, a 2002 thriller starring Bill Paxton and Matthew McConaughey about a family that takes religion a little too far. Will the boys find the good in this film, or see it's sins and cast it to the bowels of hell? 

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Theme: 
Medical Oncology.

Participants: 

Professor Nicholas Wilcken, Sarah Rashid, Bratati Karmakar, Harry Hong, Dr Pramod Chandru, Shreyas Iyer, Caroline Tyers, and Kit Rowe.

Discussion 1:
Thomas, B., Lo, W., Nangati, Z., & Barclay, G. (2021). Dexmedetomidine for hyperactive delirium at the end of life: An open-label single-arm pilot study with dose escalation in adult patients admitted to an inpatient palliative care unit. Palliative Medicine, 35(4), 729-737. https://doi.org/10.1177/0269216321994440. 

Presenter -  Sarah Rashid, physician trainee at Westmead Hospital. 

Summary:

• Terminal agitation and delirium are difficult to define and even harder to design studies around which to improve its management.
• The current treatment algorithm advises the use of neuroleptics, benzodiazepines, opiates, and barbiturates; often at the cost of wakefulness and interaction with loved ones.
• Dexmedetomidine can provide rousable sedation, a decreased severity of delirium, analgesia, a decrease in secretions, and potential anti-emetic effects. 
• The aim of this study was to describe a potential reduction in delirium and the presence of rousable sedation with dexmedetomidine in palliative care patients suffering terminal delirium, with a secondary aim to determine whether reduced opiate requirements were observed.
• There was a reduction in delirium (as measured by MDAS scores).
• Almost 50% of patients crossed over to routine care, with 27% of these due to family request for deeper sedation. 
• 15 of the 22 patients required an increase in opiate dosing, however, there were no negative survival benefits and there was a notable reduction in the use of other PRN medications (such as, for secretions). 
• Ultimately, this pilot demonstrated promise for the use of dexmedetomidine in these patients (and prompts the need for further research in this area). 

Take-Home Points:

• There is minimal evidence even behind our standard of care for these patients (midazolam, neuroleptics, and barbiturates). 
• This paper encourages us to think laterally about what medications can be used for these patients. 
• Terminal delirium is distressing for patients and their families, and at present, our treatments provide comfort but at the expense of wakefulness and interaction.
• More research needs to be done into agents such as dexmedetomidine which could allow for a better-sedated experience.
• More research also needs to be done into the experience of the dying process for patients and their families. 
• Families have large effects on the management of dying patients, and thus there is limited value in doing a study without measuring outcomes for both the patients and their families. 

Discussion 2:
Wang, D., Salem, J., Cohen, J., Chandra, S., Menzer, C., & Ye, F. et al. (2018). Fatal Toxic Effects Associated With Immune Checkpoint Inhibitors. JAMA Oncology, 4(12), 1721. https://doi.org/10.1001/jamaoncol.2018.3923.

Presenter - Harry Hong - ED senior resident medical officer, at Westmead Hospital.

Summary:

• This study looks at immune checkpoint inhibitors targeting cytotoxic T lymphocyte antigen-4 (CTLA-4) and programmed death-1/ligand-1 (PD-1/PD-L1). 
• There is increasing use of these agents individually and in combination for various cancers.
• This paper looks at multiple databases and analyzed data to characterize the rare but fatal side effects of these drugs. 
• 613 fatal adverse effects were described: 193 associated with ipilimumab (anti-CTLA-4), 333 with anti-PD-1/PD-L1, and 87 in combination therapy (most commonly for the treatment of melanoma and lung cancer).  
• The type of fatal adverse events differed between the treatment groups; with ipilimumab monotherapy associated mostly with colitis (70% of adverse events) compared with anti-PD-1/PD-L1 monotherapy where adverse events were more varied (colitis, pneumonitis, hepatitis) and combination regimens where there were additionally increased rates of myocarditis and myositis. 
• The highest fatality rates were seen in myocarditis. 
• The multicentre analysis also revealed the median time to onset of disease following commencement on therapy was 40 days with monotherapy and 14.5 days for those on combination treatment. 
• Interestingly, the median time to steroid use for these patients was 5 days (suggested to be due to difficulty recognizing the diagnosis in these patients). 

Take-Home Points:

• These drugs for some cancers have completely revolutionized treatment (they are not going away!). 
• It is important to remember that the rate of fatal adverse events with these agents is still very low (particularly when compared with other oncology treatments). 
• This data gives us information for what to be vigilant for when caring for these patients (particularly those presenting with non-specific symptoms and recent commencement on these agents). 
• Take colitis seriously; it can be fatal. 
• We are all learning; this is a new class of drugs with completely different toxicity to what we are used to – if in doubt ask the medical oncologist! 

Discussion 3:
Biganzoli, L., Mislang, A., Di Donato, S., Becheri, D., Biagioni, C., & Vitale, S. et al. (2017). Screening for Frailty in Older Patients With Early-Stage Solid Tumors: A Prospective Longitudinal Evaluation of Three Different Geriatric Tools. The Journals Of Gerontology: Series A, 72(7), 922-928. https://doi.org/10.1093/gerona/glw234.

Presenter - Bratati Karmakar, physician trainee at Napean Hospital.  

Summary:

• Frailty is a concept or syndrome which lacks a unified definition.
• It is broadly defined as a vulnerability to stressors such as illness or treatment, which may aid in patient prognostication. 
• Currently, there is no single standardized frailty assessment tool to guide our clinical practice. 
• The presence of frailty has been associated with increased mortality, increased frequency of hospitalizations, intolerance to treatments, and a reduction in quality of life.
• Data suggests that we as clinicians at the bedside are not accurate assessors of patient frailty.
• This study compares well-established (however cumbersome) frailty scores; the Balducci frailty criteria and the Fried frailty criteria, with the Vulnerable Elders Survey (VES-13) which may be easier to use and apply in the emergency setting (requiring only self-reported data from the patient). 
• The outcomes measured were functional decline (or loss of an ADL) and mortality.
• 17% of patients were classified as frail using the Fried frailty criteria, and 25% when looking at the Balducci criteria and the VES-13.
• The Fried frailty criteria and the VES-13 both showed that the probability of a functional event was higher in the frail group (with time to functional decline being 13 months in the frail and 36 months in the non-frail group using the VES-13). 
• Regarding mortality, all 3 tools demonstrated prognostic value for overall survival.
• Thus, according to this study, the VES-13 can be used to predict mortality and functional decline.
• However, there was poor concordance between the three tools, suggesting that no single ...

Growing up in Texas with a religious upbringing that usually involved reading the Book of Revelations and the Old Testament in the bible, writer Brent Hanley was inspired to write a movie based on some of those same kind of themes. 

A huge fan of Alfred Hitchcock and Stephen King as well, Hanley crafted a story about a single father with two sons, who is visited by an angel one day and he’s informed that he’s been tasked by God to become a demon slayer. 

While one of the boys is more than happy to join this idyllic crusade, the other is horrified at his father’s actions to snuff out people he’s supposedly been told are evil doers. 

With a running narrative by Matthew McConaughey with Bill Paxton as a first time director, the film went onto be called an “underrated gem” while earning high marks from reviewers. 

In the latest episode of Rewind of the Living Dead, we’re going to make our list and sharpen up our axe named Otis as we talk about the 2001 film “Frailty”…

Music courtesy of Andrew Scott Bell and Karl Casey @ White Bat Audio

For more Rewind of the Living Dead, follow on social media:

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It is often said that it is never too late to adopt a healthy lifestyle - never too late to incorporate more exercise into our daily routine or focus on a healthier diet, to reap the rewards as we age. In reality, a message that it is never too early to focus on our wellbeing and longevity, is equally important. Perhaps more so. Cathy Richards is an exercise physiologist and founder of Inspiring Vitality, an online coaching program focussing on the needs of people over 40.  In this LLAMA podcast interview with Peter Bowes, Cathy discusses her mission to encourage more people to take steps - even tiny steps - in their daily lives, to incorporate strength building activity into their routines.  She also highlights the significance of deteriorating hearing for overall health and the likelihood that impaired hearing can lead to social isolation and loneliness.

Recorded: January 11, 2021 | Read a transcript and show notes at the LLAMA podcast website.

This episode is brought to you by AgeUp, a new financial product that provides guaranteed supplemental income for people who worry about the financial impact of longevity. To find out more, visit Age-Up.com

Topics covered in this interview include:

• Adapting to a new way remote way of working out during and likely after Covid
• Learning about the behavioral trail of very old populations and joining the longevity dots
• The onset of frailty and the snowball effect of muscle decline
• Implementing resistance training into exercise regimes to maintain muscle strength
• Doing the bare minimum exercise to still realize significant result. 
• Small, step and changes that add up and make a difference over time
• Persuading younger generations that it is never too early to think about being fit at 85. 
• Hearing loss and the impact on our quality life as we age  
• The stigma associated with hearing loss and dangers 
• The correlations been hearing loss and dementia.

Listen on: Apple Podcasts   Spotify

Time-line

Mitopure (a highly pure form of Urolithin A) boosts the health of our mitochondria – the battery packs of our cells – and improves muscle strength. Time-line is offering LLAMA listeners a 10% discount on its range of products – Mitopure powders, softgels & skin creams.  Use the code LLAMA at checkout
-

FlexBeam red light therapy

Recharge Health is offering LLAMA listeners a discount on the purchase of FlexBeam, the wearable red light therapy device which targets key parts of the body to improve sleep, treat injuries and sooth aches and pains associated with aging. Discounts vary - see details of the current offer here

The Live Long and Master Aging (LLAMA) podcast, a HealthSpan Media LLC production, shares ideas but does not offer medical advice. If you have health concerns of any kind, or you are considering adopting a new diet or exercise regime, you should consult your doctor.

It is often said that it is never too late to adopt a healthy lifestyle - never too late to incorporate more exercise into our daily routine or focus on a healthier diet, to reap the rewards as we age. In reality, a message that it is never too early to focus on our wellbeing and longevity, is equally important. Perhaps more so. Cathy Richards is an exercise physiologist and founder of Inspiring Vitality, an online coaching program focussing on the needs of people over 40.  In this LLAMA podcast interview with Peter Bowes, Cathy discusses her mission to encourage more people to take steps - even tiny steps - in their daily lives, to incorporate strength building activity into their routines.  She also highlights the significance of deteriorating hearing for overall health and the likelihood that impaired hearing can lead to social isolation and loneliness.

Recorded: January 11, 2021 | Read a transcript and show notes at the LLAMA podcast website.

This episode is brought to you by AgeUp, a new financial product that provides guaranteed supplemental income for people who worry about the financial impact of longevity. To find out more, visit Age-Up.com

Topics covered in this interview include:

• Adapting to a new way remote way of working out during and likely after Covid
• Learning about the behavioral trail of very old populations and joining the longevity dots
• The onset of frailty and the snowball effect of muscle decline
• Implementing resistance training into exercise regimes to maintain muscle strength
• Doing the bare minimum exercise to still realize significant result. 
• Small, step and changes that add up and make a difference over time
• Persuading younger generations that it is never too early to think about being fit at 85. 
• Hearing loss and the impact on our quality life as we age  
• The stigma associated with hearing loss and dangers 
• The correlations been hearing loss and dementia.

Listen on: Apple Podcasts   Spotify

Time-line

Mitopure (a highly pure form of Urolithin A) boosts the health of our mitochondria – the battery packs of our cells – and improves muscle strength. Time-line is offering LLAMA listeners a 10% discount on its range of products – Mitopure powders, softgels & skin creams.  Use the code LLAMA at checkout
-

FlexBeam red light therapy

Recharge Health is offering LLAMA listeners a discount on the purchase of FlexBeam, the wearable red light therapy device which targets key parts of the body to improve sleep, treat injuries and sooth aches and pains associated with aging. Discounts vary - see details of the current offer here

The Live Long and Master Aging (LLAMA) podcast, a HealthSpan Media LLC production, shares ideas but does not offer medical advice. If you have health concerns of any kind, or you are considering adopting a new diet or exercise regime, you should consult your doctor.

Anne Kenny, MD, author of "Making Tough Decisions about End-of-Life Care in Dementia", is a Professor of Medicine with specialty training and board certification in Geriatric Medicine, and Palliative and Hospice care. She has been a practicing physician for over 30 years and has been recognized by her peers as a “Top Doc” in Geriatric Medicine. She has been honored with a Brookdale National Fellow and the prestigious Paul Beeson Physician Faculty Scholar awards.

Dr. Kenny has worked clinically as a geriatrician in nursing homes, assisted living, rehabilitation and clinical outpatient settings. Dr. Kenny has found joy in her work with individuals and their families managing issues related to the diagnosis of dementia. Her experience in partnering in the care of these families touched close to home when her own mother was diagnosed with dementia.

Dr. Kenny joined with her mother and her brothers and sister to provide the best care for her mother during the early and middle years following her mother’s diagnosis. Her expertise, coupled with her mother’s playful spirit and her sibling’s openness, support, intelligence and compassion, allowed for the highest functioning and independence of her mother for several years.

Dr. Kenny’s expertise and experience in inpatient and outpatient Palliative and Hospice care were called on when her mother reached the final stages of living with dementia. The Kenny family worked together for their mother’s graceful exit from this planet.

In addition to her clinical practice, Dr. Kenny lectures to both healthcare professionals and the public on aging related issues including navigating dementia, exercise, nutrition, hormone therapy, death and dying, and frailty. She is an educator of medicine and research skills. She has over 100 scientific publications and presentations focused on improving the care and functioning of older adults.

Dr. Kenny is the author of "Making Tough Decisions about End-of-Life Care in Dementia", published by Johns Hopkins University Press in September 2018. The book outlines care and communication issues at endof-life in dementia. In addition, she hosts a blog focusing on issues common to Alzheimer’s and related dementias and caregiving.

Anne's LinkedIn: https://www.linkedin.com/in/anne-kenny-b1809b19a/
Personal Website: https://annekennymd.com/

Key Verse:    2 Corinthians 4:16-18 That is why we never give up. Though our bodies are dying, our spirits are being renewed every day.

Main Point: Being mindful of and investing in eternity is the way to enjoy life and to glorify God.

2 Corinthians 5:1-8   

We will be looking at this portion of scripture to gain an eternal perspective for our lives. We will draw out 3 aspects about the need to live with eternity on our minds and hearts in order to better deal with circumstances around us.

Entertaining Eternity Means:

1. Accepting our Frailty 2 Cor 5:1-4 

We tend to fear what we don’t understand, and fear causes stress and anxiety. 

Ecclesiastes 3:11 He has made everything beautiful in its time. Also He has put eternity in their hearts, except that no one can find out the work that God does from beginning to end.

James 4:14 whereas you do not know what will happen tomorrow. For what is your life? It is even a vapor that appears for a little time and then vanishes away.

Psalm 90:12 So teach us to number our days,That we may gain a heart of wisdom.

1 Corinthians 15:26  The last enemy that will be destroyed is death.

Romans 6:23, 3:23, John 11:25 

2. Understanding God’s Favor (2 Corinthians 5:5-6)

• God has purposed this for us
• John 14:1-3
• Romans 8:28-30
• Has given us the Spirit as a guarantee 2 Corinthians 5:5

Ephesians 1:13-14  13 In Him you also trusted, after you heard the word of truth, the gospel of your salvation; in whom also, having believed, you were sealed with the Holy Spirit of promise, who is the guarantee of our inheritance until the redemption of the purchased possession, to the praise of His glory.

3. Believing our Future (2 Corinthians 5:7-8)

Faith Heb 11:6 And it is impossible to please God without faith. Anyone who wants to come to him must believe that God exists and that he rewards those who sincerely seek him.

• Absent from the body and to be present with the Lord. 2 Corinthians 5:8  

Romans 8:16-18 The Spirit Himself bears witness with our spirit that we are children of God, and if children, then heirs—heirs of God and joint heirs with Christ, if indeed we suffer with Him, that we may also be glorified together. For I consider that the sufferings of this present time are not worthy to be compared with the glory which shall be revealed in us.

• Do you believe that God loves you? That He is for you and not against you? 

2 Corinthians 4:16-18 16 Therefore we do not lose heart. Even though our outward man is perishing, yet the inward man is being renewed day by day. For our light affliction, which is but for a moment, is working for us a far more exceeding and eternal weight of glory, while we do not look at the things which are seen, but at the things which are not seen. For the things which are seen are temporary, but the things which are not seen are eternal.   

Paul's maiden voyage to Rome is filled with storms and shipwreck. In Luke's detailed account we see man's frailty and God's sovereignty on full display. Paul is not in control of his circumstances, but with the help of his co-prisoners, Luke and Aristarchus, he trusts the God who sent the storm and rules over it. So should we, as we encounter life's storms, trust our Father to use them for our good and His glory.

Kaare Christensen discusses an Article that compares physical and mental functioning in people born in 1905 and 1915.

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