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This case is part of a case-study series on common diseases in aging HIV-infected patients. New cases will be posted monthly on our website. Users should first download the learner portion or read on below, review the suggested reading, and answer the case questions. When you’re ready to check answers, download the answer key to do so. Please contact Ken South at firstname.lastname@example.org if you’d like more information on the series.
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Mrs. Feeble is a 70-year-old woman with end-stage-renal disease (ESRD) from hypertension on dialysis, chronic obstructive pulmonary disease (COPD) on 2L oxygen with recurrent pulmonary Mycobacterium Avium Intracellulare (MAI) infection failing past therapies, coronary artery disease s/p stent placement 1 year prior with congestive heart failure (ejection fraction of 40%), right hip osteoarthritis and HIV well-controlled on ART. Patient is in your clinic with her daughter who is her health care proxy for a pre-operative assessment of an elective ventral hernia repair. The daughter tells you the surgeon mentioned that Mrs. Feeble looks frail and wants her optimized before the surgery.
1. What is frailty? How do you determine if someone is frail?
2. How is frailty different in HIV-infected patients compared to the general population?
3. What is the effect of frailty on health outcomes?
Mrs. Feeble lost 20 lbs in the past 3 months due to recurrent MAI infections in her lungs. She spends most of her time at home due to weakness and fatigue, except on dialysis days when she gets transported to the dialysis center. She is unstable on her feet and usually holds on to other people when she walks outside her apartment. She feels depressed due to her decline in health and her dependence on dialysis, although she denies suicidal or homicidal ideation. She does not have pain related to the hernia or her other medical conditions.
On exam, her pulse was 78, BP 120/65, oxygen saturation 90% on 2L. Her six-minute walk distance was 300 m. Her albumin was 3.0 g/dL.
1. Is Mrs. Feeble frail? What frailty measure would you use to answer this question.
2. What would you do to optimize Mrs. Feeble for the upcoming elective surgery? How would you address her mood, nutrition, and physical function?
3. How would you counsel Mrs. Feeble’s daughter regarding the prognosis?