As Maurice Chevalier once said: “old age isn’t so bad when you consider the alternative.” Frailty assessment and intervention is now of huge importance to the wider healthcare system in the UK: around one in ten people aged over sixty-five years old is living with frailty, rising to a third of those aged eighty-five or over.
What is Frailty and what is its relevance?
Frailty is not a synonym for the natural ageing process. It is a distinct, long-term condition ‘in which multiple body systems gradually lose their in-built reserves’1. Slow walking speed, lack of energy and loss of strength are key symptoms, usually resulting from an accumulation of health deficits.
This means that patients are far more vulnerable to stressor events that tip their delicate homeostatic mechanisms out of kilter. It is relevant to all doctors, nurses and allied health professionals who manage adult patients, regardless of specialty. Frailty cannot be looked at in isolation; a holistic view is required by a multi-disciplinary team. As teamwork is the bedrock of Respiratory Medicine and frailty is so common in the specialty there is a big opportunity to improve care for this vulnerable group.
Not all patients with frailty can be cared for on a specialist Frailty Unit or Geriatric Medicine Ward, and their admissions will often relate to one of their other long-term health problems such as COPD, or to an acute infection, such as pneumonia. For example, patients with frailty are more likely to have:
- Poor nutritional status
- Reduced mobility
- Polypharmacy
- Depression
- Impaired cognition
- Functional dependence
These factors impact on every aspect of patient care resulting in poorer outcomes– such as prescribing, patients’ ability to undergo certain investigations or procedures, wound healing, rehabilitation and discharge planning to name but a few.
There are a number of red flags that should make you think: ‘Is this patient frail?’ These are also known as ‘Frailty Syndromes’:
- Delirium/ dementia
- Immobility
- Falls
- Incontinence
- Susceptibility to side effects of medication
Once you identify frailty1, that should lead to early input from other members of the MDT, and then liaison with community services.
By March 2020 the NHS Long Term Plan requires all acute trusts to identify frail patients within 30 minutes of arrival in the Emergency Department. This is so that patients can be identified to frailty teams and assessed using ‘Comprehensive Geriatric Assessment’ (CGA) as rapidly as possible. Identifying frail patients and quantifying the level of frailty using an evidence-based tool2 will help us to manage patients appropriately in whichever specialty they end up.
The most popular tool is the Rockwood Clinical Frailty Scale3, which is a simple 30 second pictorial tool used to assess levels of frailty [see figure]. However, the patient should be assessed based on how they are when well, at home, not how they appear on admission with an acute illness, and so those using it need to take care. Most hospitals suggest finding out how the patient was two weeks before admission.
Another popular tool is the Edmonton Frailty Scale4 which gives a bit more detail but takes a little longer– this covers 11 areas such as functional independence, medications, mood, cognition, and gives a numerical score 0-17. It is straightforward to use, validated in the outpatient setting, and can be carried out by any clinician. The score then categorises the patient as ‘Not Frail’, ‘Vulnerable to Frailty’, ‘Mildly Frail’, ‘Moderately Frail’ or ‘Severely Frail’.
These tools can help in clinical practice in a number of ways as we shall discuss further.
What advice do you have to acute respiratory teams in managing frail older patients?
After explicitly recognising and recording the level of frailty in an older patient (over 75), then kick off the process of CGA. This is not something that should be confined to the specialty of Geriatric Medicine.
CGA has Grade A evidence of benefit in the hospital setting5: proven to allow more frail patients to be alive and living at home at one year. It’s a simple treatment and has no side effects. A patient who is vulnerable to frailty on admission, who spends one week in hospital with the associated loss of muscle mass and independence, may leave hospital mildly or moderately frail6.
But how can it be done swiftly and effectively on a busy ward? Ten days in bed causes the equivalent of ten years loss of muscle strength so try to ensure your patient is up as soon as possible. You can find out more through the #endpjparalysis campaign.
CGA involves the whole team looking at not just the medical aspects and disability, but a set of domains as shown in Table 1.
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Table 1. Key Domains of Comprehensive Geriatric Medicine |
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Physical conditions |
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Medication Review |
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Nutritional status |
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Cognition/ mood |
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Functioning |
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Social circumstances |
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Environment |
Ward therapists are key to several of these and many trusts use a combined medical/ therapy assessment proforma for all older adults to screen for frailty. You can find the RUH Bath Emergency Medical Assessment Proforma for Older Adults here.
From a medical perspective, we would advocate taking the following steps:
- Complete a problem list
- Record the Abbreviated Mental Test Score (at least AMT4)
- Check for delirium (the ‘4AT’ tool is simple)
- Ask your team to uncover the person’s usual physical and cognitive level
- Prescribe build ups +/- laxatives
- Review medication and stop what you can
It’s amazing that some patients can be in for many days before someone checks out these basic facts. Delirium doubles mortality. Many wards check at least one lying and standing blood pressure as it is such a huge risk factor for inpatient falls. A good medication review is appropriate, eliminating drugs that are unnecessary – does a frail 90 year really need triple blood thinners and a statin?
If your patient has severe or very severe frailty, your approach to starting ‘aggressive interventions’ such as NIV may be adjusted following a conversation with them or family. Add your findings to the discharge summary and consider if further intermediate care or end of life care is appropriate in those with the highest frailty levels.
How does frailty impact on intermediate respiratory care? For example, pulmonary rehabilitation, early supported discharge?
Many patients with COPD are frail. In a 2016 study of 816 patients aged 70 or over referred for pulmonary rehabilitation (PR), Maddocks et al found that 1 in 4 people referred for PR were frail according to the Fried criteria, twice the number expected by age alone6.
Although non-compliance was twice as high as non-frail patients due to exacerbations and hospital admission, those with frailty who did complete PR did better in terms of health status and exercise performance than the overall cohort. There could well be selection bias regarding those referred in the first place, of course. The frail group (who had to walk at least 5m at baseline) could manage, on average, just 100m on the six minute walk but did improve significantly.
There is also evidence that integrated community care for frail patients with lung disease does reduce Emergency Department visits and mortality7. Many patients are discharged from hospital with high levels of anxiety and with uncertain provision of care. They may also be less mobile than on admission. The early identification of those who may need increased support on discharge should be a priority. Hospitals are artificial environments in which to assess how safely patients will manage at home.
A simple CGA assessment by a skilled therapist will flag those who may benefit from a ‘discharge to assess’ pathway. As long as patients need no more than the maximum available support (usually up to four times a day, occasionally night sitters too), they can be discharged to be worked up at home. It is important that early discharge services for COPD work collaboratively with other such community services.
Can frailty assessment help us identify and manage patients at the end of life?
Studies have shown that 120-day mortality is approximately 20% for patients with frailty of whatever level. If only those with severe frailty are selected, this increases to around 60%8. So a diagnosis of severe frailty should prompt consideration of resuscitation status, decisions about ceilings of treatment, and advance care planning. It should also prompt honest discussions with the patient and their relatives, and a thorough medication review. It can lead to earlier recognition of those at the end of their life, allowing more patients to die in their preferred place of care, with the relevant community support in place.
At the other end of the spectrum, those with ‘Vulnerability’ or ‘Mild Frailty’ need targeted support to prevent progression towards more severe frailty. This should also involve an MDT approach, and cover areas such as nutrition, medication aids, continence issues, occupational therapy and physiotherapy input. So thinking about frailty in our patients with respiratory conditions, in or out of hospital, should lead to important considerations at all stages of frailty.
Final thought: As a first step why not set up a local meeting with your (hopefully) friendly Geriatrician to discuss your patients’ care needs?
References
- British Geriatrics Society. Fit for Frailty. 2014 [online] Available at https://www.bgs.org.uk/sites/default/files/content/resources/files/2018-05-14/fff2_short.pdf Accessed 31/01/2019.
- National Institute for Health and Clinical Excellence. Multimorbidity: clinical assessment and management. 2016 [online] Available at https://www.nice.org.uk/guidance/NG56/chapter/Recommendations#how-to-assess-frailty Accessed 31/1/2019.
- Rockwood K, Song X, MacKnight C et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173: 489–95.
- Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age & Ageing 2006 6:526-529.
- Ellis G et al. Comprehensive Geriatric Assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews. 2017; 9: CD006211.
- Maddocks M. Physical frailty and pulmonary rehabilitation in COPD: A prospective cohort study. Thorax 2016; 71(11):988-995.
- Hernandez et al. Effectiveness of community-based integrated care in frail COPD patients: a randomised controlled trial. Primary Care Respir Medicine 2015;2 5:15022.
- Evans SJ, Sayers M, Mitnitski A, Rockwood K. The risk of adverse outcomes in hospitalized older patients in relation to a frailty index based on a comprehensive geriatric assessment. Age & Ageing 2014; 43:1: 127-132.