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Frailty

Medicine > Medicine of older adult

Differential Diagnosis Schema 🧠

Frailty

  • Physical Frailty: Characterized by unintentional weight loss, exhaustion, weakness, slow walking speed, and low physical activity.
  • Cognitive Frailty: Co-existence of physical frailty and cognitive impairment without dementia; associated with a higher risk of adverse outcomes.
  • Social Frailty: Lack of social support, isolation, or limited social networks, contributing to the overall vulnerability of older adults.
  • Frailty Syndrome: A multi-dimensional syndrome including physical, cognitive, and social components, leading to increased vulnerability.
  • Comorbid Frailty: Frailty complicated by chronic diseases such as heart failure, COPD, or diabetes, which exacerbate the frailty state.
  • Frailty in Acute Illness: Acute illness (e.g., infection, surgery) leading to decompensation in a frail individual, often resulting in prolonged recovery or increased mortality.

Key Points in History 🥼

Functional Assessment

  • Activities of Daily Living (ADLs): Assess the patient’s ability to perform basic self-care tasks such as bathing, dressing, and feeding.
  • Instrumental Activities of Daily Living (IADLs): Evaluate more complex activities such as managing finances, transportation, and medication management.
  • Mobility: Assess the patient’s ability to walk, transfer, and climb stairs, noting any aids used and the distance they can walk without assistance.
  • Falls History: Document any history of falls, including the frequency, circumstances, and any injuries sustained.
  • Nutritional Status: Inquire about recent weight loss, changes in appetite, and dietary intake.
  • Cognitive Function: Screen for cognitive impairment using tools like the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA).
  • Fatigue and Energy Levels: Ask about general fatigue, energy levels, and any limitations in endurance.
  • Social Support: Assess the availability of social support, including family, friends, and community services.
  • Mood and Psychological State: Screen for depression or anxiety, which may exacerbate or mimic frailty symptoms.

Background

  • Past Medical History: Document chronic conditions such as cardiovascular disease, diabetes, osteoporosis, and any history of stroke or malignancy.
  • Drug History: Review all current medications, including over-the-counter drugs and supplements, to identify polypharmacy and potentially inappropriate medications.
  • Family History: Consider genetic predispositions to conditions that may influence frailty, such as dementia or cardiovascular disease.
  • Social History: Assess living conditions, financial stability, and access to care, which can impact the management of frailty.
  • Environmental Factors: Evaluate the home environment for hazards that may contribute to falls or difficulty in performing daily activities.
  • Lifestyle Factors: Consider the patient’s level of physical activity, smoking status, alcohol consumption, and dietary habits.
  • Recent Hospitalizations: Document any recent admissions, surgeries, or acute illnesses, as these may have exacerbated frailty.
  • Advanced Directives: Discuss the patient’s preferences regarding advanced care planning and end-of-life care.

Possible Investigations 🌡️

Basic Blood Tests

  • Full Blood Count (FBC): To assess for anemia, which can contribute to fatigue and frailty.
  • Urea and Electrolytes (U&E): To check renal function and electrolyte balance, important in assessing dehydration and kidney function.
  • Liver Function Tests (LFTs): To rule out hepatic causes of fatigue or confusion.
  • Thyroid Function Tests: Hypothyroidism can present with symptoms of frailty, such as fatigue and weakness.
  • Vitamin D and Calcium Levels: To assess bone health and risk of osteoporosis or fractures.
  • Vitamin B12 and Folate Levels: Deficiencies can lead to cognitive impairment and contribute to frailty.
  • Inflammatory Markers (CRP/ESR): Elevated levels may indicate underlying infection or inflammatory conditions.
  • Glucose and HbA1c: To assess for diabetes or poor glycemic control, which can exacerbate frailty.
  • Lipid Profile: To assess cardiovascular risk factors.
  • Bone Profile: Including calcium, phosphate, and alkaline phosphatase, to assess for metabolic bone disease.
  • Renal Function: Consider eGFR to assess renal health, particularly in patients on multiple medications.
  • Coagulation Profile: Important in patients with a history of thromboembolic events or those on anticoagulation therapy.

Special Investigations

  • DEXA Scan: To assess bone mineral density in patients at risk of osteoporosis.
  • ECG and Echocardiography: To assess for cardiac causes of frailty, such as heart failure or valvular disease.
  • Cognitive Testing: Formal neuropsychological testing may be warranted if significant cognitive impairment is suspected.
  • Gait Analysis: Can help identify balance issues or gait abnormalities that increase fall risk.
  • Chest X-Ray: To assess for chronic lung conditions such as COPD or evidence of heart failure.
  • Echocardiogram: To evaluate cardiac function, especially in patients with symptoms of heart failure.
  • Nutritional Assessment: Detailed assessment including dietary intake and serum albumin to identify malnutrition.
  • Pulmonary Function Tests (PFTs): In patients with a history of smoking or respiratory symptoms, to assess for chronic lung disease.
  • Holter Monitoring: To assess for arrhythmias that could contribute to falls or syncope.
  • Tilt Table Test: In patients with unexplained falls or syncope, to assess for orthostatic hypotension or vasovagal syncope.
  • Comprehensive Geriatric Assessment (CGA): A multidimensional assessment often performed by a geriatrician to evaluate frailty, including physical, cognitive, psychological, and social aspects.

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Medicine of older adult