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NUR360 LS2 > Frailty and functional decline > Flashcards

Frailty and functional decline Flashcards

1
Q

What is frailty

A

Risk of death increases with age, but not everyone of the same age has the same risk of dying. This observation led to the concept of frailty.

  • Clinical frailty can occur at any age; frailty most often occurs in people older than 65 years
  • Frailty is distinct but overlapping with both disability and comorbidity/multi- morbidity

NO DEFINITION

  • Manifested as a loss of function and increased risk of inability to maintain homeostasis (e.g. function as a person)
  • People at a particular age who, in consequence of multisystem impairments, are at higher risk of dying are said to be frail while those at lower risk are said to be fit
  • A physiologic syndrome characterized by decreased reserve and resistance to stressors, resulting from cumulative decline across multiple physiologic systems, and causing vulnerability to adverse outcomes
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2
Q

The role of the aging process in frailty

A

• Sarcopenia - the age-related loss of skeletal muscle mass and function
• Decline in the functioning of endocrine system • Low level of chronic inflammation secondary
to age-related dysregulation of the immune system

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3
Q

Sarcopenia

A

Age-related changes to skeletal muscle; the progressive loss of skeletal muscle mass, strength and function that further contributes to mobility impairments and disability.
- Sarcopenia is therefore a marker of frailty

  • Muscle mass can continue to build until a person is in their 50’s. However, between 30% and 50% of the skeletal muscle mass of a 30 year old may be lost by the time the person reaches their 90’s; disuse of muscles accelerates the loss of strength
  • Risk factors: age, gender, levels of physical exercise, protein-calorie malnutrition
  • Physical activity, particularly strength training and adequate intake of energy and protein can prevent or reverse sarcopenia
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4
Q

How frailty responds to stressors

A

Managing well

  • External stressor (e.g. minor illness or injury)
  • Resilience and ability to bounce back to baseline

Mild frailty

  • Increased vulnerability to those who are frail
  • Hard to go back to their previous state

Severe frailty
- Takes much longer to recover and after they could be at level that they are no longe4r independent

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5
Q

Consequences of frailty

A

Frailty is crucial because it can lead to adverse health outcomes:
• Disability
• Death
• Hospitalization
• Risk of iatrogenic disability which is defined as the avoidable dependence which often occurs during the course of care

Increasing frailty was associated with:
• A 4 times increased 5-year risk for death among mildly frail people and 7 times increase among severely frail people.
• Frailty was the most important predictor of institutionalization

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6
Q

Scope and risk factors of frailty

A

• Very common; hallmark of geriatric syndromes
- Frailty is a geriatric syndrome, but it can also cause other geriatric syndromes
• Community-dwelling older adults varies from 4.0% to 59.1%

  • Increases with age
  • Greater in women than in men
  • Lower education and income,
  • poorer health and high rates of co-morbid conditions
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7
Q

Older Canadians living with frailty

A
  • 25% over 65
  • 50% over 85
  • That more than 1 million Canadians
  • In 10 years, expected to be 2 million
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8
Q

Why measure frailty

A
  • It informs clinical decision-making
  • Failure to detect frailty potentially exposes patients to interventions from which they might not benefit or indeed be harmed
  • Conversely, exclusion of non-frail elderly people merely on the basis of age is unacceptable
  • FRAILTY IS ASSESSED, NOT ASSUMED
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9
Q

Why use a standardized tool to measure frailty

A
  • To allow early identification of older adults at risk of geriatric syndromes and adverse outcomes to start interventions
  • Common language
  • Global assessment of functioning
  • Ability to monitor changes over time
  • The use of a short frailty screen allows selection of older adults that can undergo further assessment, comprehensive geriatric assessment
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10
Q

Canada’s population and acute care spending

A

Adults aged 65+

  • 16.8% of population
  • 60% of hospital spending
  • Tend to use more money on older people because out healthcare system is not designed to look at people who have multi-system diseases
  • Also at greater risks once hospitalized for other infections
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11
Q

Screening for frailty

A

• Screening – identifying those at risk; does not provide specific information. Indicates whether an assessment should be done

Occurs in three contexts:

(1) for specific populations – oncology, cardiology
(2) at times of unanticipated health care needs such as in emergency departments or pre-hospital care
(3) before elective procedures

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12
Q

How screening for frailty works

A

Categories (for older adults)

  • Fit
  • Pre-frail
  • Mild/moderate frailty
  • Severe/very severe frailty

1) Frailty case finding
2) Classification
3) Comprehensive assessment
4) Integrated care; individualized patient-centred care
- Medication
- Medical issues
- Physical capabilities
- Functional capabilities
- Psychological capabilities
- Social factors
- Environmental factors

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13
Q

Barriers to frailty screening: primary care

A
  • Ideally situated to screen
  • But often mistake frailty as “normal signs of aging”
  • Risk factors like dementia are under recognized
  • Most tools rely on self-reported deficits of function and health
  • No consensus on tools.
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14
Q

Frailty screening: assisted living

A
  • Protective environment that can offer increased supervision and assistance with activities of daily living
  • High levels of cognitive and physical impairment found in this population
  • Performance-based frailty criteria such as gait speed and grip strength can be difficult to measure
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15
Q

Frailty screening: long-term homes

A
  • Residents are a frail or potentially frail group of vulnerable older adults and focus on preserving and enhancing quality of life in very late life

Screening can:

1) identify frailty or to serve as catalyst to measure its severity, or
2) support advance care planning. There are specific tools for the nursing home population

  • Use of EMR data to detect frailty using predictive models
  • Highest rates of frailty found in nursing homes; 24Hr supervision, focus on quality of live as opposed to interventions
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16
Q

Frailty screening: acute care

A
  • Small proportion of OAs are high users of acute care services
  • Those users tend to have multiple chronic conditions, at least one functional impairment, and inadequate social supports at home
    • Almost half experience a decline in their functional abilities in the weeks before their admission
    • Frailty screening in ER, prior to surgery
  • Screening should not be used in isolation but rather should be embedded in proactive systems of care that support immediate action
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17
Q

Frailty screening: critical care

A
  • Frailty among people admitted to intensive care units has had little evaluation
    • Frail people were more likely to suffer adverse events and have longer stays in ICU and hospital. Their probability of in-hospital death was almost double that of non-frail people.
    • Much is unknown about frailty in the ICU
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18
Q

Assessment of frailty

A
  • Assessment – in-depth assessment to create a care plan
  • There is many frailty assessments (67 different tools found)

• Comprehensive Geriatric Assessment is the gold- standard in assessment (CGA)
• Unlikely to be adopted in low resource settings
• Frailty scales are often used as one part of a CGA to help clinicians hone in on areas that need more evaluation
- If you screen someone and they are frail; it is likely that you will follow up with a CGA

19
Q

Domains of the frailty instruments

A
  • Physical
  • Cognitive
  • Medical
  • Nutritive
  • Psychological
  • Sensory
  • Social
  • Demographic
  • Economic
  • Environmental
20
Q

Social aspects of frailty

A

In Canadian studies:
• Lower social position (education and income) was strongly associated with frailty
• Living situation - alone
• social vulnerability correlated moderately with frailty, with both contributing independently to risk of death
• Low socioeconomic status
• Having few relatives and neighbours or little contact with
them
• Low participation in community or religious activities (social engagement)
• Low social support

An understanding of social circumstances is necessary to reduce social risk factors for poor health outcomes from frailty
• Overall social vulnerability is linked to cognitive decline and mortality - even among the fittest older people
• Health care providers need a comprehensive, organized understanding of social circumstances, available resources, and supports.
• These are key to planning care for people identified as frail, particularly in care transitions such as hospital discharge and in making decisions about care needs and residence

21
Q

Items in the frailty instruments

A
  • Most frailty instruments contain 6-15 items

6-10), (11-15

22
Q

Comprehensive Geriatric Assessment (CGA): six steps

A
  1. Data-gathering
  2. Discussion among the team,
    increasingly including the patient and/or caregiver as a member of the team
  3. Development, with the patient and/or caregiver, of a treatment plan
  4. Implementation of the treatment plan
  5. Monitoring response to the treatment plan
  6. Revising the treatment plan
23
Q

Comprehensive Geriatric Assessment (CGA): domains

A
  • Functional status
  • Socio-environmental
  • Psychological
  • Physical
  • Functional status

Older patient

Outcomes

Bioethical considerations

24
Q

Clinical scales

A

• 3 of the most commonly used frailty clinical scales in Canada:

  1. Frailty Phenotype – Fried, 2001
  2. Frailty Index (Deficit accumulation) – Rockwood
  3. Clinical Frailty Scale
25
Q

Frailty phenotype model

A

5 elements

1) Weakness - grip strength (<20th percentile)
2) Slowness - walking time (15 feet), slowest 20% by sex and height
3) Low level of physical activity - bottom 20th percentile of calculated kcal
4) Exhaustion - self reported
5) Weight loss - >10% of unintentional weight loss during the prior year

  • Need 2 to be pre-frail
  • 3 or more is frailty
26
Q

Frailty: accumulation of deficits

A

Frailty index = number of deficits in an individual / total number of potential deficits measured

• A deficit = a thing that is “wrong” with you (sign, symptom, impairment; diseases, conditions, and co- morbidities)
• The more deficits you have, the more likely you are to be frail
- Index: scale used on a population/institutional level, more research based instead of clinical
- Specific quantification of frailty

27
Q

Clinical frailty scale (CFS)

A
  • Most commonly used scale
  • Nine categories of frailty

1) Very fit
2) Well - no active disease symptoms, active occasionally
3) Managing well - medical problems are well controlled, not regularly active
4) Vulnerable - not dependant, symptoms limit activities
5) Mildly frail - more evident slowing, need help in higher order IADLs
6) Moderately frail - all outside activities help, help keeping house, help with bathing
7) Severely frail - completely dependent for personal care
8) Very severely frail - don’t have resilience to bounce back from illness
9) Terminally ill - a life expectancy <6months, not otherwise evidently frail

28
Q

Limitations of traditional frailty screening

A

• No consensus, different settings will use different tools
• Infrequent assessment – usually after a big change, or upon entry into
the HC system
• Subject to subjectivity, memory loss – those with cognitive decline may not accurate report
• Complex, requires clinician’s supervision – measurement of performances; based on clinical judgement
• No home-based remote assessment

29
Q

Frailty home sensor system and prediction

A
  • Want to address the problem that there is no home based assessment of frailty
- Examine in home;
Gait speed
Muscle strength
Weight loss
Physical activity
Exhaustion 
- Frailty statuses: frail, pre-frail, non-frail
30
Q

Interventions for frailty

A 
• Don’t bail on the frail
• Four treatments appear to have potential to manage physical components of frailty:
1) Exercise
2) Caloric and protein support
3) Vitamin D
4) Reduction of polypharmacy

• Multicomponent interventions, and individually-tailored geriatric care models

31
Q

Potential interventions along the spectrum of frailty in older adults

A

Robust

  • Symptom relief
  • Patient-centred goal setting
  • Family/caregiver support
  • Exercise
  • Interventions

Increasingly frail

  • Exercise
  • Interventions
  • CGA and treatment
  • Geriatric evaluation and management (GEM)
  • Acute care for elders unit (ACE)
  • Program for all-inclusive care fo the elderly (PACE)

End stage frailty

  • Hospice care
  • Comfort
  • Dignity
32
Q

What is functional decline

A
  • A new loss of independence in self-care capabilities
  • Associated with deterioration in mobility and in the performance of activities of daily living (ADLs) such as dressing, toileting, and bathing
33
Q

Age-related changes associated with functional decline

A
  • Decline in muscle strength and aerobic capacity
  • Vasomotor instability
  • Reduced bone density
  • Diminished pulmonary ventilation
  • Altered sensory “continence”, appetite and thirst
  • A tendency toward urinary incontinence
34
Q

Risk factors for functional decline

A
  • Age
  • Cognitive status
  • Depression
  • Lifestyle factors such as inactivity
35
Q

Concepts related to functional decline

A
  • Disuse muscle atrophy – reduction in muscle mass and strength caused by muscle inactivity or disuse
  • Functional mobility decline: the capacity to execute safe, efficient walking (with or without a gait aid) within the environmental constraints encountered in everyday life
  • Functional decline; ability to do ADL in general
  • Functional ability; ability to get up from chair and walk the distance - adds to functional decline
36
Q

Muscle atrophy

A
  • Degradation of muscle

- “if you don’t use it, you lose it”

37
Q

Functional decline in acute care: how dangerous is it

A
  • High up on lives lost per year vs. encounters per death
  • Close to that of driving
Other adverse and cascading consequences:
• Delirium+ deconditioning
• Increased LOS
• Progressive functional decline
• Re-admission
• ALC
• Institutionalization
38
Q

Functional decline related to hospitalization

A

“It is common but not inevitable.”
• Functional decline may occur a few days before hospitalization as a consequence of the acute medical illness
• Functional losses can occur as early as the second day of hospitalization
• 30-60% experience functional decline resulting in more dependency in ADLs and other adverse events

• After hospital admission, approximately 20% experience significant functional improvement during their hospital stay
• Deconditioning contributed to delayed discharge in more than 47% of older adult patients
• At least 30% of patients ≥ 70 years old are discharged with an ADL disability they did not have before becoming acutely ill
- Hospitalization-associated
disability: During hospitalization, the acute medical issues are treated. However, the patient is discharged with a major new disability that was not present before the onset of acute illness
• One year after discharge, fewer than half will recover to the pre-illness level of function.

39
Q

Complications of hospitalization

A 
Delirium: 25-60%
Functional decline: 34-50%
Adverse drug event: 54%
Surgical complications: 52%
Diagnostic and therapeutic mishap: 31%
Nosocomial infections: 17%
Physical injury/fall: 15%
Pressure sores: 10%
Pulmonary embolism: 3%
40
Q

Care related factors that contribute to functional decline in hospitals

A

• Bedrest orders; consequences of Bedrest Table
• Physical restraints
• Mobility restricting devices; indwelling catheters, IVs, chest
tubes
• Insufficient nutrition and hydration; NPO (no food by mouth) orders; diet not preferred by the patient; new texture of food; inadequate access to water and fluids
• Deconditioning; Decreased participation in own ADLS
• Polypharmacy; new medications that can influence activity or mobility (e.g. sleep medications, pain medications, anti-depressives)
• Late discharge planning

41
Q

Behavioural and physical environmental factors that contribute to functional decline in hospital

A
  • Social deprivation – socially isolated
  • Physical environment does not encourage mobility – cluttered, high beds, rails, meals served in bed; furniture on wheels, no handrails in rooms
  • Environment contributes to disorientation – can’t see the clock, no calendar in the room, lighting does not match time of day; shiny floors that cause glare = falls; noisy environment which disrupts sleep
  • Sensory deprivation – lost or broken hearing aid or glasses
42
Q

Identification of seniors at risk; hospitalized patients (ISAR-HP)

A

The ISAR-HP is a recently developed screening instrument to predict 90- day functional decline in older patients who were acutely admitted to the department of internal medicine
• Nurses should assess needs and risks to initiate interventions that can prevent functional decline
• 4 different questions that assess needs and risks

1) Before hospital admission, did you need assistance for IADL on regular basis?
2) Do you use a walking device?
3) Do you need assistance for travelling
4) Did you pursue education after age 14?

  • Each score gets 1 or 0
  • Total score 0 or 1 = not at risk
  • Total score >2 = patient is at risk for functional decline
43
Q

Mobilization and exercise for functional decline

A
  • Overall found a significant decline in all three functional mobility measures over a 2- months of usual care
  • Participation in a person-centred walking intervention reduced functional mobility
    decline and led to improvement - Participants were able to regain what they lost in the control period
  • Participants had improved scores after the MWI compared to baseline

knowing information and applying it to you patient can reduce functional decline

44
Q

Can we manage frailty and functional decline better?

A

• Can we mitigate the impact of hospitalization?
- Yes: Senior Friendly Hospitals (SFH)

• Can we prevent rehospitalization?
- Yes: better discharge planning and transitional care

• Can hospitalization be avoided in the first place?
- Yes: interdisciplinary, Comprehensive Geriatric Assessment (CGA), including in
primary care

• Does Nursing have a role to play in the prevention of hospital aquired disability?
- Yes. Assessment, advocacy, daily care to preventing deconditioning; person- centered care

NUR360 LS2 (11 decks)

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