Frailty and Functional Decline and ED Flashcards
What is frailty?
Frailty is a state of health where the person’s overall well-being and ability to function independently are reduced and vulnerability to deterioration are increased, usually resulting from multi-system impairment
- Loss of function, loss of ability to maintain homeostasis
- Decrease reserve and resistance to stressors
- Most often in people older than 65
Why the concept of frailty?
Not all aging is the same
Although risk of death increases with age, not everyone of the same age has the same risk of dying
Frailty is distinct but overlapping with both disability and comorbidity
Biological Aging Process
a. Sarcopenia
b. decline in functioning of endocrine system
c. low level of chronic inflammatory, age-related dysregulation of the immune system
Sarcopenia
age-related loss of skeletal muscle mass and function
Risk factors: age, women, level of physical exercise, protein-calorie malnutrition
Prevention: physical activity, strength training and adequate intake of energy and protein
Effect of Frailty
Managing well: stressor results in return to baseline function after bouncing back
Mildly frail: stressor results in slight decrease from baseline function after bouncing back
Severely frail: stressor results in negative outcome and dependence
Consequences of frailty
- disability
- death
- hospitalization
- risk of iatrogenic disability (avoidable dependence)
- greater risk of adverse health outcomes
Most important predictor of institutionalization
Why measure frailty?
a. informs clinical decision-making
b. monitor changes over time
c. early identification of OA at risk for geriatric syndromes and adverse outcomes
d. screen for OAs that might benefit from more in-depth comprehensive geriatric assessment
When to screen?
Screen: not specific, identifies what assessments are needed
Assessment: deep dive into care planning and intervention
a. for a specific population
b. at times of unanticipated health care needs such as ER
c. before elective procedures
Barriers to screening
a. Primary care
- often mistakes frailty as “normal signs of aging”
- most tools rely on self-reported deficits of function and health
b. Assisted living
- performance-based frailty criteria can be difficult to measure
c. Long-term homes
- highest rate of frailty
- focus is on preserving and enhancing quality of life
d. Acute care
- healthcare systems can accelerate decline because the system does not account for the impact of their frailty
- frailty screening only in ER prior to surgery
e. Critical care
- little evaluation on frailty of people admitted into ICU
Social aspects (SES) of frailty
- lower SES, education
- living situation
- social vulnerability
- low social support
- low social engagement and participation
Comprehensive Geriatric Assessment (CGA)
- Data gathering
- factors that affect older adult outcomes - Discussion among healthcare team and client
- Development of treatment plan
- Implementation of treatment plan
- Monitoring of treatment plan
- Evaluation of treatment plan
Frailty Assessment Tools (3)
- Frailty Phenotype (Fried, 2001)
- Frailty Index - deficit accumulation (Rockwood)
- Clinical Frailty Scale
Frailty Phenotype Model
Criteria:
a. weakness - grip strength, <20th percentile
b. slowness - walking time, slowest 20%
c. low level of physical activity, bottom 20th percentile - how they spend their time
d. exhaustion - self report on how they feel generally
e. weight loss - >10% of unintentional weight loss
Frailty: >= 3 criteria present
Pre-Frail: 2 criteria present
Frailty Index (Deficit Accumulation)
Frailty Index = (number of deficits)/(total number of potential deficits measured)
The more deficits you have, the more likely you are to be frail
Clinical Frailty Scale
- Very fit
- Well
- Managing well (well controlled medical problems)
- Vulnerable (symptoms limit activities)
- Mildly Frail (need help with IADLs)
- Moderately Frail (need help with ADLs - bathing)
- Severely Frail (completely dependent but stable)
- Very Severely Frail (cannot recover from minor illness)
- Terminally ill (end of life)
Dementia: Mild, moderate, severe
Limitations to Traditional Frailty Screening
- no consensus
- infrequent assessment
- self-report, subject to subjectivity and memory loss
- complex, requires clinician’s supervision
- no home-based remote assessment
Interventions for Frailty
Physical components:
a. exercise
b. caloric/protein support
c. vitamin D
d. reduction of poly-pharmacy
Multicomponent interventions and individually tailored geriatric care models
- symptom relief, caregiver support, hospice care
Functional Decline
New loss of independence in self-care capabilities and is typically associated with deterioration in mobility and performance in ADLs
Risk factors: age, cognitive status, depression, inactivity
- disuse muscle atrophy
- functional mobility decline
Functional decline in Acute Care
Hospitalization is dangerous for older adults because it results in functional decline and more dependency in ADLs
Care-related factors that contribute to functional decline
a. bedrest orders
b. physical restraints
c. mobility restricting devices (indwelling catheters)
d. insufficient nutrition and hydration
e. deconditioning (decreased participation in ADLs)
f. poly-pharmacy
g. late discharge planning
Behavioural and physical environmental factors that contribute to functional decline
a. social deprivation
b. physical environment (limit mobility)
c. environment disorientation (no clocks)
d. sensory deprivation
Identification of Seniors at Risk - Hospitalization Patients (ISAR-HP)
Screening instrument used to predict 90-day functional decline in older adults who were acutely admitted
Nursing Initiative on Functional Decline
- assess needs and risk to initiate interventions that prevent functional decline
i. e. person-centred walking intervention
Management of Frailty
a. senior-friendly hospital initiatives (mitigate impact)
b. better discharge planning and transitional care (prevent rehospitalization)
c. CGA (avoid hospitalization)
d. assessment, advocacy, person-centred care (nursing interventions)
Nursing Process
a. assessment
b. diagnosis
c. planning
d. implementation
e. evaluation
Canadian Triage and Acuity Scale (CTAS)
Level 1: Resuscitation
- threat to life or limb
Level 2: Emergent
- potential threat
Level 3: Urgent
Level 4: Less Urgent
Level 5: Non-urgent
- part of chronic problem
ED Utilization in Older Adults
- most common reason: symptoms, signs and ill-defined conditions
- use CGA to assess older adults in ED
