Clinical Resources - Frailty

Frailty is a dynamic condition experienced by many older adults.  It is a vulnerability to adverse outcomes resulting from an interaction of physical, socio-economic and co-morbidity factors: major adverse events are more common among frail patients in comparison to non-frail patients. (1)

Why is it important?

  • Prevalence of frailty is higher in women and increases with age
  • Social vulnerability, aging, and chronic disease lends to development of frail elderly individuals
  • When an individual is frail the impact of an “illness” further impairs function and ability to cope
  • Frailty causes increased risk of other diseases
  • In-hospital mortality is higher among frail patients than among non-frail patients (1)
  • Frail individuals are more likely to become functionally dependent; have a lower quality of life; and are more often re-admitted to hospital than non-frail individuals
  • Frailty increases the risk for adverse health outcomes such as falls, hospitalization, increased length of stay, increased costs, with worsening of outcomes including mortality and need for long term placement (1) (3)

Common Causes

  • Physical: extreme age, weight loss, slow gait, fatigue, inactivity, poor grip strength
  • Socio-economic:  isolation, caregiver gaps, poverty, gender, immigration status
  • Co-morbidity factors:  impaired cognition/mood, poly-pharmacy, multiple chronic diseases

Key Considerations

  • CSHA Clinical Frailty Scale widely used to describe and classify the severity of frailty: based on  function for  Activities of Daily Living and Instrumental Activities of Daily Living (2) 
    http://geriatricresearch.medicine.dal.ca/pdf/Clinical%20Faily%20Scale.pdf
  • Align goals and preferences of the patient and family www.sagelink.ca/GPHE_intro_all_related_documents_2014_geriatric_periodic_health_exam
  • Components of the Comprehensive Geriatric Exam can be used to flag issues for further review with Geriatric Periodic Health Exam Focus should be on:
        • Early identification of onset and acute illness, optimizing sensory inputs, assessing cognition/mood, reviewing medications, and promoting regular exercise and nutrition supplementation.
        • Optimizing chronic disease management strategies and modify geriatric syndromes (e.g. falls, immobility, confusion, depression, incontinence)
        • Implementing  necessary environmental changes/adaptations and maximization of community and socio-economic supports
        • Encouraging activity and socialization in order to help prevent advancing frailty

References

1.  Bagshaw, S.M., et al (2014). Association between frailty and short and long-term outcomes among critically
     ill patients: a multicenter prospective cohort study.  CMAJ, 186 (2), doi: 10.1503/cmaj.130639.
     Retrieved Feb. 2014 from:
     http://www.cmaj.ca/content/186/2/E95

2.  B.C. Ministry of Health. (2012). Frailty in Older Adults- Early Identification and Management.  
     Retrieved February 2014 from:
     http://www.bcguidelines.ca/guideline_frailty.html

3.  Fried, L.P., et al (2001). Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontology:
     MEDICAL SCIENCES
, 56A(3), M146-M156.  Retrieved Feb. 2014 from:
     https://rds185.epi-ucsf.org/ticr/syllabus/courses/83/2012/02/15/Lecture/readings/fried%20frailty%202001.pdf

Clinical Care - Frailty Assessment Tools

This 5-Item Geriatric Depression Scale (GDS) screening / assessment tool is used for identifying depression in older adults. Applicable for a wide range of settings and can be used with older adults including those with mild to moderate cognitive impairment. 1 page.

Pre-frailty and frailty is an example of an elder care issue that, when identified and treated, may negatively impact quality metrics for the simple reasons that older adults don’t respond as well to treatment as younger cohorts.

This study shows that the level of frailty was distributed along the socioeconomic gradient in both higher and lower income countries such that those individuals with less education and income were more likely to be frail. 

Frailty is a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors. Upward of 20 frailty assessment tools have been developed, with most tools revolving around the core phenotypic domains of frailty—slow walking speed, weakness, inactivity, exhaustion, and shrinking—as measured by physical performance tests and questionnaires.

Clinical Care - Frailty Guidelines & Protocols

The European Society for Clinical Nutrition and Metabolism developed these guidelines with special considerations of older adults.  The authors point out that studies have shown an inverse relationship between nutritional status and complication rates, length of stay in hospital, etc.  Nutrition should be an integral part of an older adults overall care plan.  6 pages.  Last reviewed January 2017.

The 2010 clinical practice guideline for the diagnosis and management of osteoporosis in Canada focused on the care of adults living in the community. However, the fracture rate for adults living in long-term care (residents) is two to four times that of adults of similar age living in the community, and one third of older adults who experience hip fracture are residents in long-term care. 

This checklist identifies environmental adaptations for seniors that could help prevent accidents and enhance independent living at home. Guidelines on how to hire a reputable contractor are included.

A flowchart algorithm which recommends the approach and steps to take when performing the Geriatric Periodic Health exam. 1 page.

This document provides a complete health check up list for clinicians to use with adults, based on recommendations from the Canadian Task Force on Preventative Health Care (CTFPHC) It includes evidence and non evidence based components. 5 pages.

Clinical Care - Frailty Management Handouts

This reading list includes links to and summaries of a variety of open source resources related to a variety of eating disorders and nutritional considerations. Topics include:
  • anorexia of aging
  • anorexia nervosa and frailty
  • reduced appetite in older age
  • recommendations for optimal nutrition
  • malnutrition
  • dysphagia
  • special considerations for those with brain injury and degenerative diseases
  • obesity
  • diabetes

6 pages. Last reviewed January 2019.

This reading list includes links to and summaries of a variety of open source resources. Topics related to Indigenous Elders include:
  • dementia
  • palliative care
  • end-of-life
  • disparities and inequalities
  • successful aging
  • culturally sensitive care
  • nutrition
  • diabetes
  • cancer
  • frailty
  • LGBTQ
  • abuse and trauma

6 pages. Last reviewed November 2018.

This reading list includes links to and summaries of a variety of open source resources related to osteoporosis. Topics include:

  • the relationship between Alzheimer's Disease and osteoporosis
  • diabetes and lower bone mineral density
  • falls and fractures
  • exercise interventions
  • frailty and osteoporosis
  • osteoporosis in men
  • osteoporosis in women
  • glucocorticoid-induced osteoporosis
  • nutrition

5 pages. Last reviewed September 2018.

This month's reading list includes links to and summaries of a variety of open source resources on the importance of resilience and how to support resilience in older adults. Themes include:

  • resilience in the presence of disease
  • social and community supports and considerations
  • family and caregiver resilience
  • measuring resilience

6 pages. Last reviewed June 2018.

This reading list provides links to and summaries of a variety of open source resources related to delirium in older adults. Topics include risk factors related to hip fracture, the HELP program, delirium at the end-of-life, delirium in dementia, non-pharmacological interventions, nutrition and frailty. 3 pages.