Frailty:
A useful concept in Long Term Care
Underwriting?
Kevin Somerville DM FRACP FRCP
Divisional Medical Consultant
Swiss Re Life & Health
Dallas, May 1998
An expert is someone who comes from
another place and brings slides
Michael O’Donnell
And speaks the language?
Swiss Re Life & Health
Dallas, May 1998
Elderly Underwriting: 1
• Ageing & non-ageing processes
– cohort effects
– selective survival
– differential challenge
– period effects
• Reduced adaptability
– functional decline
– reduced reserve
Swiss Re Life & Health
Dallas, May 1998
Elderly Underwriting: 2
• Increased heterogeneity
• What is ‘normal’ for pricing purposes?
• Biological vs Chronological age
• Theoretical threshold v dynamics
• Importance of fitness
(training)
Swiss Re Life & Health
Dallas, May 1998
Theoretical Threshold and Loss of
of Reserve
strength necessary to rise
from an armless chair
fast
75
100
50
slow
50
25
0
% strength
% muscle strength
100
0
20
50
80
Age (years)
adapted from Young (1986)
Swiss Re Life & Health
Dallas, May 1998
The importance of heterogeneity
and reduced function
% function
100
0
20 years
75 years
Age
Swiss Re Life & Health
Dallas, May 1998
The importance of heterogeneity
and reduced function
% function
100
theoretical
threshold
0
20 years
75 years
Age
Swiss Re Life & Health
Dallas, May 1998
Frailty: what is it?
Two Models
• Dependency/dysfunction/disease
– Woodhouse et al, 1998; Winograd et al 1991
•
Multisystem reduced resistance/
adaptability
– Verbrugge 1991; Campbell & Buchner 1997
Swiss Re Life & Health
Dallas, May 1998
Frailty
• Consequence of ageing + disease
• Reduced resistance to minor stressors often environmental
• Produces unstable disability or increased
increased risk of disability
• Possibility of modification/improvement
Adapted from Campbell & Buchner, 1997
Swiss Re Life & Health
Dallas, May 1998
Frailty: a dynamic model
Positive Features
Negative Features
•
•
•
•
•
•
•
•
•
•
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No impairments
Functional Reserve
Preserved Cognition
Positive outlook
Social Support
Dallas, May 1998
Impairments
Poor reserve
Forgetfulness
Negative outlook
Poor social
Disability & time trends
Function
100%
Stroke
Amputation
50%
Parkinson’s
Disease
Time
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Dallas, May 1998
Disability Time Trends
change
treatment
Function
chest
infection
poor
heating
(winter)
Independence
aspiration
chest
infection
Time
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Dallas, May 1998
Dependence
Components of frailty
musculoskeletal function
aerobic capacity
cognitive/neurological/motivation
nutrition
Modified from Campbell & Buchner, 1997
Swiss Re Life & Health
Dallas, May 1998
Musculoskeletal Function
• Components:
– strength
– power
– suppleness & dexterity
– reach
• Measurement
– grip strength
– chair stand
– dressing
Swiss Re Life & Health
Dallas, May 1998
Musculoskeletal Function
Lower limb function and disability (>70 years)
Rising from a Chair:
2.4 m Walk
Standing balance
5x timed
Timed
Tandem, semi tandem
side by side- 10 sec's.
Lay assessors: 10-15 minutes
Guralnik et al, 1994
Swiss Re Life & Health
Dallas, May 1998
Distribution of times to walk 8 feet
Age 71-79
40
Percent
males
30
females
20
10
0
0
5
4
3
Guralnik et al,1994
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2
10
15
Time (seconds)
20
1
unable
25
0
Performance test categories
Dallas, May 1998
Distribution of times to walk 8 feet according
to age group and sex: Females
40
Age 71-79
30
Age 80+
20
10
0
0
5
4
3
2
Guralnik et al, 1994
Swiss Re Life & Health
10
15
20
1
25
unable
0
Performance test categories
Dallas, May 1998
Distribution of times to complete five chair
stands
Age 71-79
40
males
females
30
20
10
0
0
10
4
Guralnik et al,1994
Swiss Re Life & Health
3
20
2
30
1
Performance test categories
Dallas, May 1998
40
unable
0
Distribution of times to complete five chair
stands: Females
Age 71-70
Age 80+
40
30
20
10
0
0
10
4
Guralnik et al,1994
Swiss Re Life & Health
3
20
2
30
1
Performance test categories
Dallas, May 1998
40
unable
0
Musculoskeletal Function
Lower limb function and disability (>70 years)
Rising from a Chair
2.4 m Walk
Standing balance
Graded from 0 (worst) to 4 (best): min 0/max 12
Guralnik et al, 1994 .
Swiss Re Life & Health
Dallas, May 1998
Age and sex adjusted death rate: Boston, Iowa
and New Haven
14
Deaths per 100 person years
12.3
12
10
10
8
7.2
6.4
5.6
6
6.2
5.7
4.2
4
3.6
2.7
2.5
2
2
1.3
0
0
1
2
3
4
5
6
Performance test summary score
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Dallas, May 1998
7
8
9
10
11
12
Guralnik et al,1994
Age and sex-adjusted nursing home
admission rate: Iowa site
(average 2.6 years follow up)
Nursing home admissions
per 100 person years
25
20
22.5
19.6
17.5
15
12.8
11.6
10.2
10
6
7.2
4.6
5
4.8
2.7
0.8
0.7
11
12
0
0
1
2
3
4
5
6
7
Performance test summary score
Swiss Re Life & Health
Dallas, May 1998
8
9
10
Guralnik et al, 1994
10
8
Mean Score
Mean scores on
summary
performance scale
according for those who
report needing no help:
activities of daily living,
climbing stairs and
walking half a mile
6
4
2
0
7 1 -7 4
7 5 -7 9
8 0 -8 4
8 5 -8 9
Age
Men
Guralnik et al, 1994
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Dallas, May 1998
Women
90+
10
8
Mean Score
Mean scores on
summary
performance scale for
those who report they
cannot walk one half a
mile without help but
need no help with
activities of daily living
and climbing stairs
6
4
2
0
71-74
75-79 80-84
85-89
Age
Guralnik et al,1994
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Men
Dallas, May 1998
Women
90+
Performance Scores
and Self Reported Disability
40
30
Yes
No
No
Yes
Yes
No
percent
Disability
ADLs
Mobility
20
10
0
0
2
4
6
score
Swiss Re Life & Health
Dallas, May 1998
8
10
12
Musculoskeletal Function:
important?
Lower limb function and disability (>70 years):
Adjusted risk estimates for ADL disability
4 year follow up
Score
RR (95% CI)
4-6
7-9
10-12 1.0
4.2 (2.3 - 7.7)
1.6 (1.0 - 2.6)
Guralnik et al, 1995
Swiss Re Life & Health
Dallas, May 1998
Musculoskeletal Function:
important?
Lower limb function and disability
(>70 years):
Adjusted risk estimates for ADL disability- no
problems at baseline (n=400)
Score
RR (95% CI)
4-6
7-9
10-12
7.1 (2.4 - 20.9)
1.3 (0.6 - 2.9)
1.0
Guralnik et al, 1995
Swiss Re Life & Health
Dallas, May 1998
Gait speed as a clinical sign
1 year adverse outcome; n=431
Gait speed
ADV (%)
unadj RR
<0.6m/sec
0.6-1.0m/sec
>1.0m/sec
46
32
19
2.8 (2.2-3.8)
2.5 (2.1-3.1)
1.0
Mean (+SD) walking speed: 0.89m/sec (0.25)
Studenski et al, 1998
Swiss Re Life & Health
Dallas, May 1998
Grip Strength & Physical Activity
Age 75 years at baseline
Baseline
5 year FU
Men
393 (86)
369 (93) Newtons
Women
237 (53)
198 (56)
Men
AA
SS
417 (92)
371 (76)
387 (102)
339 (91)
Rantanen et al, 1997
Swiss Re Life & Health
Dallas, May 1998
‘It is possible for anyone, given a lot of guts and
a bit of luck, to overcome gigantic misfortunes
and terrible illness’
Roald Dahl
Swiss Re Life & Health
Dallas, May 1998
Swiss Re Life & Health
Dallas, May 1998
Components of frailty: measurement
musculoskeletal function
grip strength
chairstand
timed walk
aerobic capacity
6 minute walk
submaximal treadmill
cognitive/neurological
MMSE/DWR
GDS
standing balance
locus of control/world view
nutrition
body mass index
arm muscle area
Modified from Campbell & Buchner, 1997
Swiss Re Life & Health
Dallas, May 1998
Frailty: a way forward?
musculoskeletal function
grip strength/chairstand
recreation (walking)
aerobic capacity
lifespace/6 minute walk
submaximal treadmill
FEV1/FVC
cognitive/neurological
nutrition
Swiss Re Life & Health
4 item GDS
MMSE/DWR/Clock Drawing
standing balance test
Philadelphia Geriatric Morale
Scale
body mass index
albumin
Dallas, May 1998
Life space: an index of Frailty?
• BUT HOW RELIABLE IS SELF REPORT?
– 13.6% who couldn’t walk 8ft said they
could walk half a mile!
• Direct Measurement & Self Report are
complementary?
– Which would you choose?
Swiss Re Life & Health
Dallas, May 1998
IADL: Life space as an index of Frailty
• Driving
– self-imposed restrictions?
– recently stopped
– accident profile
• Public Transport travel
• Crossing a busy street
• Visiting Relatives
• Regular exercise?
Swiss Re Life & Health
Dallas, May 1998
Risk of ADL Failure
Examples
•
Aetiological factors
smoking, BMI, hypertension
•
Disease
stroke, CORD, foot problems, OA
•
Disability
reduced mobility, continence
•
Frailty
timed walk/chair stand, aerobic
capacity, balance
•
Social/personality
attributes
socialisation, recreation, IADL, AADL,
world view
•
Mental status
mood, cognitive
impairment
Swiss Re Life & Health
Dallas, May 1998
Caution
• Know what the pricing assumptions are
• Beware over measurement
– know how to interpret the data eg
balance testing, timed walk
– holism vs quantification
• Avoid needless repeated estimation of
the same measures
• Changes in social function/ curtailment of
activities suggest frailty/occult pathology
Swiss Re Life & Health
Dallas, May 1998