Treatment of vulnerable patients requires ‘precision gerontology’

An estimated 15% of Americans over age 65 who do not live in institutions are considered frail — a complex geriatric syndrome that increases the likelihood of disability, hospitalization, the need for nursing care, and death.

But while the word vulnerability can conjure up images of withered and weakened men and women, the clinical picture is much less clear.

dr. George Kuchel

“We have made great progress in some areas, but there is still a lot of work to be done in other areas,” said George A. Kuchel, MD, CM, chair of geriatrics and gerontology and director of the UConn Center on Aging. in Farmington, Connecticut.

“You have to be very careful about generalizations,” Kuchel said during a presentation on vulnerability in primary care at the 2022 meeting of the American College of Physicians Internal Medicine. “This is very important if you’re thinking about managing it.”

One of the most important messages to take home, Kuchel said, “and one of the first things I learned as a geriatrician is that if you’ve seen one elderly person, you’ve only seen one elderly person.”

What this means is that although all people age, there is huge variation in how they age. “Some become quite frail and disabled and need to be hospitalized, while some grow old gracefully and live well,” he said. “Most fall somewhere in between.”

The second important consideration is that frailty is multifactorial – a critical consideration when it comes to dealing with elderly patients.

“Unlike other conditions, there’s no single medication, there’s not one thing you can do — it’s really multifactorial,” he said. “What it means is to tailor the components to unique needs, and that’s something we call ‘precision gerontology,’ as opposed to precision medicine.”

Vulnerability definitions vary, but may include:

  • Increased vulnerability

  • Increased risk of declining function, disability and death

  • Decline in functioning across multiple physiological systems, accompanied by increased vulnerability to stressors

Key features clinicians should emphasize include multifactorial etiology, with each risk factor contributing only modestly:

  • Multidimensional nature, involving physical and psychosocial factors

  • Vulnerability is an extreme consequence of the normal aging process

  • The process is dynamic and individuals can fluctuate between states of vulnerability

Diagnosing Vulnerability

Diagnosing frailty in the average clinical setting can be challenging. Unlike other conditions, there is no single testing or assessment tool for the condition. For example, most institutions or patients don’t even have the device to measure handgrip strength, Kuchel said. Other obstacles are lack of time and reimbursement.

What it means is to tailor the components to unique needs – and that’s something we call “precision gerontology,” as opposed to precision medicine.
dr. George A. Kuchel

However, doctors can quickly and easily assess patients for several warning signs. These include the presence of multimorbidity (>5 diseases), slow walking speed (<1 m/sec), inability to climb stairs and/or walk a block or get up five times from a chair with folded arms.

“These are simple questions that can be asked in advance by a medical assistant or even over the phone,” he said.

Vulnerability and sarcopenia are closely related, but they are not equivalent. As a result, dual-energy x-ray absorptiometry (DXA), which can measure both bone mineral density and muscle mass, is not a good assessment of frailty, as muscle mass per se is not necessarily linked to weakness. Instead, Kuchel said, measuring muscle function and quality is much more effective at identifying vulnerable patients.

“The walking speed is possibly the biggest measure, and if there’s one thing you need to do with your patient, it’s monitor the walking speed,” Kuchel said. Researchers at his facility are working on a radiotechnology-based device that can measure gait as a patient walks down the hallway.

“Measuring gait should be the sixth vital sign, and you need to have that information in front of you if you’re working with older patients,” he said. “We’re working on integrating it into our system.”

Manage Vulnerability

Although no single intervention for frailty exists, physical activity has been shown to delay its onset. Still, Kuchel said, clinicians can try a range of approaches, both biological and social, to address the condition.

For example, assessing and treating depression can help reduce frailty fatigue, as can stopping medications — including benzodiazepines and corticosteroids — that can make the condition worse. Another step is to check for low vitamin D levels and hypothyroidism, he said.

Some patients have unexplained anemia that can be corrected, as well as correcting basal and orthostatic hypotension, which can develop from overtreatment, Kuchel added.

People with HIV can experience accelerated aging, as can adults who were treated with chemotherapy and radiation as children. “We’re also starting to see some of this with long-term COVID, so there seems to be some overlap,” he said.

Finally, socio-economic considerations include the potential for neglect and/or abuse by the elderly, and the effects of poverty on nutrition and the ability to afford necessary medications.

The bottom line, Kuchel said, is that controlling vulnerability is possible, but doing it effectively may require stopping and starting.

“Correct what is correctable, such as diet, vitamin D, depression and stopping offending drugs,” he said. “Match multicomponent interventions with deficits and interventions targeting health care systems will include better care coordination. A comprehensive geriatric assessment is important in the care of this geriatric syndrome.

Kuchel has not disclosed any relevant financial relationships.

American College of Physicians Internal Medicine Meeting 2022: Vulnerable patients in primary care: I know it when I see it, but then what? Presented on April 28, 2022

Roxanne Nelson is a registered nurse and award-winning medical writer who has written for many major news outlets and is a regular contributor to Medscape.

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