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Frailty, insomnia, and their risks in neurological conditions

Dr Roger Henderson, a senior GP based in Shropshire, offers some practical thoughts on managing frailty, with a focus on people with progressive neurological conditions, such as Parkinson’s.

Frailty

Dr Roger Henderson is a senior GP based in Shropshire and lecturer on a wide range of health-related topics. He sits on a number of health advisory boards both in the UK and globally.

He has been the medical columnist for The Sunday Times and the Spectator, contributes regularly to other national newspapers and magazines and appears on the television, radio and internet.


His books include ‘Stress Beaters; 100 Proven Ways to Manage Stress’, ‘100 ways to live to 100’, and ‘Over 50 Men’s Health Check.’

Frailty is a spectrum condition, ranging from mild to severe, and is best described as a distinct health state related to lowered function across multiple body systems that develop as part of ageing. It means that even minor events can trigger significantly disproportionate adverse changes in an individual’s health, following which they are unable to recover to their previous health level.

Around 5-10% of all attendances at emergency departments and 30% of patients in Acute Medical Units are older people with frailty. Although the risks of both frailty and the hospitalisation of people with frailty are well known, at the moment there is almost a different frailty tool used in every hospital and there is also limited evidence for the discriminant ability of frailty scales in the urgent care context. People with neurological disorders are especially likely to have a degree of frailty, increasing with age and progression of their condition.

When assessing someone with a neurological condition for frailty, after taking a detailed history and a comprehensive geriatric assessment, the routine general examination should always include;

1. A Mini Mental State Examination (MMSE). This evaluates cognitive function, with a score of less than 26 being abnormal. A clock drawing test should always be included here as this assesses executive control and visual spatial skills, which are incompletely tested by a MMSE.

2. Visual testing, hearing assessment and nutrition assessment (a weight loss of more than 10 lb in 6 months, or a BMI below 20 needs further evaluation.

3. Psychiatric assessment. A good question to ask is ‘Do you often feel sad or depressed? If the answer is yes, proceed to the Geriatric Depression scale which is a 15-item scale with scores of 6 or more suggesting a depressive illness.

4. Range of joint motion, such as at the knees, shoulders and hips.

5. Muscle strength both proximally (hip flexors) and distally (grip).

6. Fall risk should be predicted by asking the patient to stand with their feet side by side, then in a semi-tandem position, then a tandem position. Difficulty in doing this indicates a risk of falls. This should be supplemented by the TUG (Timed Up-and-Go) test where the patient gets up from an armchair, walks 3m in a straight line, turns around, walks back to the chair and sits down. This should take 10 seconds or less. If it takes longer than 20 seconds then future disability and falls are strongly suggested. Truncal ataxia and proprioception assessment should also be checked

In addition, NICE have recommended a range of simple tests for frailty in primary care including gait speed, self-reported health status (www.nice.org.uk/ng56) and the PRISMA 7 questionnaire (www.cgakit.com/fr-1-prisma-7). Primary care professionals should also consider using an electronic frailty index (eFI) which is linked to most electronic medical record systems and which uses data on 36 conditions associated with frailty such as polypharmacy, mobility, weight loss and osteoporosis. It allows GPs to identify mild, moderate and severe frailty and has been shown to predict nursing home admission, risk of falls, hospitalisation and mortality.

Patients with neurological disorders and frailty may also have comorbid sleep disorders of any kind, not only because problems such as sleep apnoea and insomnia are common in neurological patients but also because sleep disorders may increase the risk of developing a neurological disorder. There is certainly an argument to be made that treating an underlying sleep disorder has the potential to improve quality of life and objective neurological function or outcome. Sleep deprivation causes impaired cognitive performance due to increasing sleep propensity and instability of waking neurobehavioral functions. Cognitive functions particularly affected include:

  • Slowed psychomotor response time.
  • A decline in both short-term recall and working memory
    performance.
  • The reduced learning (acquisition) of cognitive tasks.
  • Cognitive slowing in subject-paced tasks, where time pressure increases cognitive errors.
  • Poor attention-intensive performance, with increased lapses and wrong responses.
  • Performance deterioration of a task as duration increases even if the task started well.

Many cases of insomnia are treated with hypnotics, and it is estimated that there are between 265,000 and 295,000 patients taking benzodiazepines and Z-drugs over the long-term in the UK.

Safety issues associated with the use of traditional hypnotics have been well-documented and include the risk of dependence, withdrawal symptoms, rebound insomnia, residual daytime disturbances, traffic accidents, falls and injuries. These risks are of particular concern in the elderly population and those with neurological disorders as the risk-benefit profile of these drugs has been judged unfavourable even for short term use
in older insomnia patient. The BNF recommends avoiding benzodiazepines and Z-drugs in the elderly because they are at risk of becoming ataxic and confused, leading to falls and injury. This is particularly pertinent if a patient has additional risk factors for cognitive or psychomotor adverse events, such as those with longstanding neurological conditions.

The latest Clinical Knowledge Summary from NICE concerning managing long term insomnia now suggests modified release melatonin as a therapeutic option here and this could help address some concerns regarding frailty in the older population with a neurological condition.

Neurological conditions must always be assessed holistically rather than on a purely symptomatic basis, and the impact of both frailty and insomnia on someone with a neurological disorder should never be underestimated and always considered in any comprehensive evaluation of such a patient.