Frailty syndrome

Frailty syndrome [1-4] was discussed at the last lunchtime meeting. It was something I've certainly used when commenting on patients but hadn't been aware of the (largely) research definitions of the physical phenotype. As you'd expect it is linked with increased risks of morbidity and mortality.

A commonly cited definition is by Fried:

"a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity" [4]

A good clinical pointer is the 'get up and go' test which is often used in geriatric ward rounds to assess a person's mobility and the presence of difficulties that may not be apparent in the history and examination.


1. Santos-Eggimann B, Cuénoud P, Spagnoli J, Junod J. Prevalence of frailty in middle-aged and older community-dwelling Europeans living in 10 countries. J. Gerontol. A Biol. Sci. Med. Sci. 2009;64(6):675-681. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19276189 [Accessed March 30, 2011].

2. Abellan van Kan G, Rolland Y, Houles M, et al. The assessment of frailty in older adults. Clin. Geriatr. Med. 2010;26(2):275-286. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20497846 [Accessed March 30, 2011].

3. Xue Q. The frailty syndrome: definition and natural history. Clin. Geriatr. Med. 2011;27(1):1-15. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21093718 [Accessed March 30, 2011].

4. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J. Gerontol. A Biol. Sci. Med. Sci. 2001;56(3):M146-156. Available at: http://www.ncbi.nlm.nih.gov/pubmed/11253156 [Accessed March 30, 2011].

Clinical queries

A (public) collection of clinical queries for my own CME. Please feel free to comment!

In patients with ischaemic stroke and essential thrombocythaemia some papers suggested referring to haematology.[1] Which patients with stroke and apparent essential thrombocythaemia should be referred?*

Almost all patients on the medical admissions unit round had a C-reactive protein result in the notes. Admittedly I am seeing the 'complex discharge patients' so the diagnoses may not be so straight forward in them but still seemed a high figure to me and unnecessary CRPs are well known in the literature.[2] Which patients require CRP on acute admission? Is there a local policy?

1. Richard S, Perrin J, Baillot P, Lacour J, Ducrocq X. Ischaemic stroke and essential thrombocythemia: a series of 14 cases. Eur. J. Neurol. 2010. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20722707 [Accessed March 21, 2011].

2. Kelly AP, Murphy AM, Hughes R. A retrospective analysis of the use of C-reactive protein assays in the management of acute medical admissions. N. Z. Med. J. 2009;122(1293):3559. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19448789 [Accessed March 21, 2011].

* I've edited this entry following a discussion on #nhssm [March 23rd 2011]. It was based on a patient I had seen recently (as most clinical queries would be). The emphasis is now on my particular learning point and not any details of the case.

Confrontational small group teaching

Was introduced to an interesting small group technique by one of the physicians at Truro in the Friday lunchtime meeting.

She circulated an article on Parkinson's disease in the acute hospital (1) prior to the meeting and then formed three small groups of about 5 or 6. Within the groups we had to quiz each other to see if we had read and understood the article.

It certainly worked for me - though it would have helped even more if I had read the article ahead of the meeting. I updated myself on a number of things and have been searching on PubMed for some other reviews:

• the importance of early consideration of alternative routes for medication during an acute admission for another illness especially on surgery
• the use of rotigotine patches (2) as a logistically easier alternative to subcutaneous apomorphine
• the Parkinsonism-hyperpyrexia syndrome (3) which none of us were aware of but several could recognise past patients that may have had it
• Deep Brain Stimulation (4)
• Duodopa (5)

All in all I think I learnt a lot more from this session on Parkinson's disease than any other I've sat through before. Confrontation stimulates learning and especially if it is done in such a friendly way. Some may find it quite challenging though.

1) Jones SL, Hindle JV. Parkinson's disease in the acute hospital. Clinical Medicine 11(1);84-8: 2011. Available at: http://www.rcplondon.ac.uk/sites/default/files/clinical-medicine-11-1-pp84-88.pdf [Accessed March 19, 2011].

2) Wüllner U, Kassubek J, Odin P, et al. Transdermal rotigotine for the perioperative management of Parkinson's disease. J Neural Transm. 2010;117(7):855-859. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20535621 [Accessed March 19, 2011].

3) Newman EJ, Grosset DG, Kennedy PGE. The parkinsonism-hyperpyrexia syndrome. Neurocrit Care. 2009;10(1):136-140. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18712508 [Accessed March 19, 2011].

4) Okun MS, Foote KD. Parkinson’s disease DBS: what, when, who and why? The time has come to tailor DBS targets. Expert Rev Neurother. 2010;10(12):1847-1857. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21384698 [Accessed March 19, 2011].

5) Karlsborg M, Korbo L, Regeur L, Glad A. Duodopa pump treatment in patients with advanced Parkinson's disease. Dan Med Bull. 2010;57(6):A4155. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20515603 [Accessed March 19, 2011].

Culture and cardiac care quality

"High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI."

concluded researchers in the US who looked at hospitals ranked in the top or bottom 5% in mortality rates for acute MI. (1)

What differentiated the best performing hospitals from the weakest was not their use of guidelines or dedicated teams but organisational values, communication, coordination and problem solving capabilities.

From a performance improvement perspective quantitative outcomes of mortality rates and compliance with scientific evidence are only the starting point for designing an educational intervention. The real challenge is correctly analysing and addressing the more woolly qualitative issues that can be the more resistant barriers to performance improvement.

The medical education world is evidence-based obsessed and rightly so. However, it also needs to recognise that the higher educational outcomes of analysis, synthesis and creativity need to be addressed as well as the broadcasting of knowledge.

An old (medic) joke about medical schools' teaching ward rounds is that they often resemble shifting dullness.(2) If the round only involves talk of knowledge and existing evidence and does not explore the organisational and cultural perspectives of patient care then it certainly will be dull (and less effective).

So, this report in the Annals of Internal Medicine makes for interesting reading and opens the field for similar league table research in other therapeutic areas.

1. Curry LA, Spatz E, Cherlin E, et al. What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates? Annals of Internal Medicine. 2011;154(6):384 -390. Available at: http://www.annals.org/content/154/6/384.abstract [Accessed March 17, 2011].

2. "Shifting dullness" being a clinical sign of ascites not the implied meaning of "mobile stupidity".