Frailty and functional decline

Question 1

What is frailty

Answer 1

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

Question 2

The role of the aging process in frailty

Answer 2

• 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

Question 3

Sarcopenia

Answer 3

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

Question 4

How frailty responds to stressors

Answer 4

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

Question 5

Consequences of frailty

Answer 5

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

Question 6

Scope and risk factors of frailty

Answer 6

• 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

Question 7

Older Canadians living with frailty

Answer 7

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

Question 8

Why measure frailty

Answer 8

• 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

Question 9

Why use a standardized tool to measure frailty

Answer 9

• 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

Question 10

Canada’s population and acute care spending

Answer 10

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

Question 11

Screening for frailty

Answer 11

• 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

Question 12

How screening for frailty works

Answer 12

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

Question 13

Barriers to frailty screening: primary care

Answer 13

• 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.

Question 14

Frailty screening: assisted living

Answer 14

• 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

Question 15

Frailty screening: long-term homes

Answer 15

• 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

Question 16

Frailty screening: acute care

Answer 16

• 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

Question 17

Frailty screening: critical care

Answer 17

• 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

Question 18

Assessment of frailty

Answer 18

• 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

Question 19

Domains of the frailty instruments

Answer 19

• Physical
• Cognitive
• Medical
• Nutritive
• Psychological
• Sensory
• Social
• Demographic
• Economic
• Environmental

Question 20

Social aspects of frailty

Answer 20

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

Question 21

Items in the frailty instruments

Answer 21

• Most frailty instruments contain 6-15 items

6-10), (11-15

Question 22

Comprehensive Geriatric Assessment (CGA): six steps

Answer 22

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

Question 23

Comprehensive Geriatric Assessment (CGA): domains

Answer 23

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

Older patient

Outcomes

Bioethical considerations

Question 24

Clinical scales

Answer 24

• 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

Question 25

Frailty phenotype model

Answer 25

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

Question 26

Frailty: accumulation of deficits

Answer 26

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

Question 27

Clinical frailty scale (CFS)

Answer 27

- 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

Question 28

Limitations of traditional frailty screening

Answer 28

• 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

Question 29

Frailty home sensor system and prediction

Answer 29

- 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 ```

Question 30

Interventions for frailty

Answer 30

``` • 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

Question 31

Potential interventions along the spectrum of frailty in older adults

Answer 31

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

Question 32

What is functional decline

Answer 32

- 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

Question 33

Age-related changes associated with functional decline

Answer 33

* 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

Question 34

Risk factors for functional decline

Answer 34

* Age * Cognitive status * Depression * Lifestyle factors such as inactivity

Question 35

Concepts related to functional decline

Answer 35

* 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

Question 36

Muscle atrophy

Answer 36

- Degradation of muscle | - "if you don't use it, you lose it"

Question 37

Functional decline in acute care: how dangerous is it

Answer 37

- 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 ```

Question 38

Functional decline related to hospitalization

Answer 38

“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.

Question 39

Complications of hospitalization

Answer 39

``` 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% ```

Question 40

Care related factors that contribute to functional decline in hospitals

Answer 40

• 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

Question 41

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

Answer 41

* 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

Question 42

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

Answer 42

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

Question 43

Mobilization and exercise for functional decline

Answer 43

- 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**

Question 44

Can we manage frailty and functional decline better?

Answer 44

• 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