Bharati Kochar, MD, on Frailty in IBD

In this podcast, Dr Kochar discusses her research into the prevalence of frailty among patients with inflammatory bowel disease.

For more about this study, click here.
 

Bharati Kochar, MD, is a gastroenterologist at Massachusetts General Hospital and an instructor at Harvard Medical School.

For more insights from experts like Dr Kochar, click here.

TRANSCRIPT

Rebecca Mashaw: Welcome to this podcast from the Gastroenterology Learning Network. I'm your moderator, Rebecca Mashaw. I'm very pleased to have Dr. Bharat Kochar from Massachusetts General Hospital and Harvard Medical School here to talk with us about her research into frailty among patients with inflammatory bowel disease.

Thank you for taking the time to talk with us.

Dr Bharati Kochar, MD:  Absolutely. Thank you so much for having me. I'm excited to talk about this.

Rebecca:  Let's start out by explaining how you define frailty. What does that term mean in a medical context?

Dr Kochar:  That's a great question, Rebecca. It's actually a loaded question in the geriatrics world. There's actually no universally accepted definition of frailty. There's different ways of measuring frailty, which would obviously impact the definition, as well. Overall, in general, what people can agree upon is that frailty is an expression that's used to measure biologic reserve. It represents a decreased capacity of the body to respond to stressors such as an infection or a trauma. That's big picture what most people will agree is the definition of frailty.

Rebecca:  How can you assess or measure this in a patient?

Dr Kochar:  There are a number of ways of measuring frailty. Many of the studies of frailty, and to date all of the studies of frailty in the IBD world, have been done with what's called a cumulative deficit model of frailty. That's based on Kenneth Rockwood's work where he identified 92 variables that indicate higher risks for frailty and created an index of sorts based on relative merits of these variables. These variables span things. It's been adapted to administrative claims databases, which is a good way of studying IBD and rare conditions where you look at diagnosis codes. 

The study that we just did in the Swedish cohort is one of those administrative claims database type studies where we have access to diagnosis codes and we look for a combination of diagnosis codes that indicate comorbidities that confer frailty, as well as sensory-related diagnosis codes. Things like hearing loss or peripheral neuropathy, other codes that indicate function. There's actually codes for whether you're wheelchair-dependent or whether you need a walker, codes that indicate mentations, codes that indicate cognitive impairment or dementia, depression, and so on.

In IBD to date, all of the studies have used this cumulative deficit model of frailty. There's different ways of implementing those in different measures and scales. Those are mostly semantic but the idea is that it indicates people who are at higher risk for frailty or lower risk for frailty or no risk for frailty, for the most part. The concept of studying frailty prospectively was pioneered by Linda Fried, who developed a phenotypic model of frailty, looking at five factors that impact people and make them frail. She talked about unintentional weight loss and fatigue, exhaustion, decreased muscle strength, slow walking speed. Factors like this that make a person frail.

When we think about frailty in common parlance, that's who we're thinking about, the person that needs the walker and the wheelchair and is getting exhausted all the time. If you look at the phenotypic model of frailty, there's actually a lot of overlap in symptoms that patients with IBD experience. That's what makes this very interesting and pertinent to study in IBD patients of all ages. Frailty has been studied and propagated as a construct that is most pertinent to older adults.

Rebecca:  That sort of answers my next question, was whether frailty is exclusively an issue of aging or if younger patients might also be classified as frail, particularly because of comorbidities and other conditions. Apparently, that is the case. This crosses the boundaries of aging. It's more an issue of aging. It's a bigger issue among older patients.

Dr. Kochar:  I think that's very fair to say. It's definitely a bigger issue amongst older patients. Traditionally, it's been studied in older adults but some of that is how do you define aging. For a childhood lymphoma survivor, 40 might be older. In the childhood lymphoma community, they start studying frailty at age 40. In HIV, they start studying frailty at age 50. When I said, "Let's start studying frailty in IBD patients at age 60," many geriatricians said, "Well, 60 is not old. That's quite young." Again, because IBD patients have traditionally not been 60 and 70 years old, I thought it was reasonable to start at that age. A lot of it depends on how you define old, but I do think, as you were saying, that it's very reasonable to consider frailty to be a pertinent concept to younger patients with IBD, as well.

Rebecca:  In your recent study, you and your colleagues compared the prevalence of frailty among patients with IBD to population comparators based on age, sex, place of residence, and calendar year. What did you find out? What did this tell you?

Dr. Kochar:  This is a study that I was particularly excited about because of the uniqueness of the data set that we were working in. This would be International Registrar's. As many people know, are quite unique and have longitudinal access. We were interested in looking at older adults with incident IBD, so those who were newly diagnosed. Again, we just used 60, which I think is reasonable, and said those two were frail at the time of diagnosis defined by diagnosis codes. How did they do over time? The first thing we said was, "How did they do over time?" We had other studies in US claims databases that have looked at this question, as well. We found, unsurprisingly, that older adults who were frail are more likely to be hospitalized or die compared with older adults with incident IBD who were not frail.

What was very interesting with this cohort is that we were able to do these population matched comparators. For the first time, we've demonstrated that older adults with incident IBD were much more likely to be frail than those without IBD. It was 61 percent of older adults with IBD were at risk for frailty versus 27 percent of age and sex and location matched older adults without IBD. Frailty seems to be about three times more prevalent in older adults with IBD, which reinforces our hypothesis that it's worth studying. As a part of this analysis we also looked at causes of death in older adults with IBD. What was very interesting is that frail older adults with IBD were more likely to die from digestive diseases and the codes were mostly from IBD, respiratory diseases, and cardiovascular diseases and not actually oncologic conditions, which is what has been shown as the leading cause of death in older adults with IBD in other studies, both in Sweden and in Canada. It does seem that frailty is even modulating the cause of death. Obviously, this is a retrospective study. It's a diagnosis-claims-based study. There's inherently a number of limitations in how to apply this, but it certainly indicates that this is an interesting topic to consider in older adults with IBD.

Rebecca:  You mentioned not just the presence of frailty but the risk of frailty. Can you tell us what you mean by that? When you look at a patient and you say this is a patient who is at risk of becoming frail. What are those indicators?

Dr. Kochar:  Thank you for pointing that out. It's almost a semantic on which model of frailty you're using. When you use the cumulative deficit model of frailty that looks at different weights for these diagnosis codes. Because we're not actually seeing a patient ourselves, it's very hard to say that they are frail. The correct term to use is that they are at higher risk for frailty because these scales have been validated in prospective cohorts where they then measure frailty prospectively with things like grip strength, [inaudible 10:47] , chair stands, and unintentional weight loss, and look at them prospectively and say this measure and this index held up against a prospective measure of frailty. That's the reason I say at risk of frailty because I think, truly, with diagnosis codes it's very hard to say that a person is definitively frail. 

In clinic, pre-frailty is, I think, much more important than...Frailty is important, too, but pre-frailty might be where we can intervene and mitigate the progression to frailty. There's a lot of research on this in the geriatric world on the whole. It would be interesting to see how that applies to IBD. Pre-frailty are people who might have, maybe, one or two features of these five features of phenotypic frailty where the definition is three or more features make you frail. If you have one or two, maybe you're at risk for frailty and at risk for progression to frailty. Perhaps we can intervene and prevent someone from becoming frail. I think that's truly very interesting clinically. We unfortunately don't have any literature right now that can help us bring that to IBD clinic.

Rebecca:  That then leads to my next question, which is how can understanding frailty inform gastroenterologists' practice. I guess it's a matter of understanding both frailty and those pre-frailty conditions. How can a gastroenterologist apply this in their own practice?

Dr. Kochar:  Absolutely. That is what we are looking to do here at Mass General, along with many of our collaborators across the country. Really, come up with a frailty assessment that we can do in clinic because no one really wants to spend 30 minutes assessing frailty in clinic. What are the most pertinent features that we can boil down a fast frailty assessment to? What does that mean for patients moving forward? If we do this frailty assessment, and someone scores to be frail, how do we counsel that patient, then what their risks are, both with their disease, but also the medications that we're using. How do the medications modulate frailty? There's a lot of questions here that need to be asked and answered, but eventually I think it would be great to come up with the ECOG score, a performance score of some sort that they use widely in oncology, which again does not actually include frailty but they're moving, in oncology, towards trying to include frailty in their performance score. Their performance score very much determines who gets what form of chemotherapy or radiation or surgery or what their cancer plan is. I think the Holy Grail for looking at frailty in IBD is to come up with that analogy in the IBD world.

Rebecca:  Something that's interesting about this is that you... Is this a chicken or an egg situation? Does IBD predispose people to become frail or are people who are already in that pre-frailty stage more likely to develop? Do we even know? Do you have a guess?

Dr. Kochar:  That's a fantastic question. Do you want to come join my research team, Rebecca?

Rebecca:  I'd love to. Thank you.

Dr. Kochar:  I think that's a great question. It's obviously very hard to tease out. I do think that there is some kind of cyclical nature to this, as well, that would be interesting to try to tease apart. We may never know.

Rebecca:  That's going to be a tough one, I'm sure, to figure out if it's possible to do it.

Do you have any other advice for practicing clinicians about what they should watch for in their patients, especially older patients with incident IBD, because you did specifically mention that as the key criterion here? Patients 60 or older who are just now being diagnosed. What should clinicians be watching for with these patients to help stave off this risk of frailty?

Dr. Kochar:  That's another great question. I wish I had very evidence-based recommendations there, but what I can say is that I do think, and I think there's increasing recognition of this in the IBD community, is that we have to consider the overall functional status of the patient in front of us and not as much the chronologic age. Not, "You're 70. I think that's old so now I consider you older," because there's very many highly functional people at 70 who are very robust.

The other thing I would say is what you were talking about, which is trying to figure out if the disease is making them frail or if they were frail at baseline that now increases their risk for all sorts of adverse events. We need to be aware of that as we're picking our therapeutic options. 

If it is truly the disease making them frail, aggressively treating that disease may actually reverse the frailty. I've seen this in a number of my patients. This is very anecdotal and I don't want to put this out there as a guideline for what to do, but I can think of many patients who, at older ages, in their 80s or so, feel that they've gotten their life back because I started them on a biologic. They went from not being able to leave their house to golfing and having dinner with their girlfriends and being able to travel again, and doing all sorts of things that made their life meaningful because we said, "There is an increased risk for infections because you're in your 80s and pretty frail. Let's go ahead and take that increased risk for infections and see if we can get you to feel better." It really does work. Obviously, it doesn't work 100 percent. It's very important to treat the patient in front of you. I think a lot of the talk on frailty and IBD right now is not really ready for clinical application yet.

Rebecca:  This is another of those situations in which shared decision-making with the patient does set the course because they can tell you it's more important to me to be able to do my daily activities than it is to be sure that I'm never going to get an infection. I would take the risk in order, as you say, to have my life back.

Dr. Kochar:  Absolutely. I think recognizing, also, that older, frailer individuals have slightly higher baseline risks for everything. If I start a patient on an anti-TNF agent and they ended up with an urinary tract infection, the baseline risk for an urinary tract infection was high. Obviously, the drug contributed but it's not catastrophic. Again, as long as we're having these in-depth conversations with our patients and clinics. This requires a lot of time.

Rebecca:  Which is always one of the difficulties in your day-to-day practice, I know.

Thank you so much for your time to discuss this with us. We will look forward to your future research and results and hopefully get some of that evidence-based advice available to our clinicians.

Dr. Kochar:  Thank you very much for featuring our work, Rebecca.

Rebecca:  Sure.