Special Considerations for Frail Older Patients

December 6, 2018

By Jessica K Qiu

Peer Reviewed

In 1998, there were 34 million adults aged 65 years or older in the US.1 By 2030, that number is expected to double.1 This dramatic increase in the number of geriatric patients poses a number of challenges to the health care system and the providers who operate within it. In order to address these challenges, physicians in all fields must become familiar with some of the special considerations that accompany geriatric patients and their care.

Geriatric medicine encompasses a broad spectrum of geriatric syndromes, the most common of which include changes in sensory perception, cognition, and mobility.1 The syndrome of frailty is also highly prevalent, affecting an estimated 25% to 50% of individuals aged 85 years or older.2,3 Frailty is an important syndrome to identify, as frail patients are more likely than their non-frail counterparts to experience falls, hospitalizations, and other adverse outcomes.2

Definition of Frailty
Frailty is not identified as any individual symptom but rather as a syndrome seen in older adults. The syndrome of frailty has been described as a state of increased vulnerability to stressors, either acute or chronic, due to aging-associated physiologic decline and reduction in physiologic reserve.4,5 The resulting inability to sufficiently compensate in the setting of one or more stressors can have severe consequences, including disability, hospitalization, institutionalization, or death.4

Two main models exist for defining frailty: the phenotype model and the cumulative decline model.

The phenotype model grew out of a secondary analysis of data from the Cardiovascular Health Study, a prospective cohort study of over 5000 adults aged 65 years or older.6 Fried and colleagues defined a phenotype of frailty that satisfies at least three of the following five criteria: low grip strength, low energy, slowed walking speed, low physical activity, and/or unintentional weight loss.2 Notably, markers of cognition are not included in the phenotype. Individuals meeting criteria for frailty were observed to have poorer outcomes, namely increased falls, reduced mobility and function, and increased rates of hospitalization and death.2 Even after adjustment for clinical or subclinical disease, disability status, depressive symptoms, and socioeconomic status, frailty as defined by the phenotype model remained an independent predictor of risk of these poor outcomes.2

Frailty can also be defined with the cumulative deficit model via calculation of a patient’s Frailty Index. Based on 92 individual parameters including a variety of signs, symptoms, laboratory data, disease states, and disabilities, the Frailty Index is calculated as the percentage of parameters or deficits present in an individual.7 A higher percentage is reflective of more cumulative deficits and thus a frailer individual. Studies have identified a Frailty Index of 0.67 as a “tipping point” for patients at which further deficit accumulation is likely to result in death.8,9

The phenotype model and cumulative deficit model have both been shown to be valid predictors of frailty-associated decline with overlap in identification of frail patients and statistical convergence.10,11 The Frailty Index has demonstrated greater precision in discriminating between moderate and severe frailty, perhaps because it is a continuous rather than categorical model.12 Models derived from the original Frailty Index have reduced the number of parameters to roughly 30 without loss of predictive validity.3 Still, the Fried model is a valid tool and is used commonly in practice.

It is important to note that frailty is distinct from disease or disability, as noted by Fried and colleagues, although overlap with these other entities is commonly observed.2 Additionally, frailty is a dynamic process. Although progression to greater frailty occurs more frequently than improvement to a lesser degree of frailty, there are several interventions that have been shown to improve outcomes for frail patients.2

While exercise to promote fitness is recommended for all patients regardless of age, it is especially important in frail older adults. Exercise is one of the most effective interventions for keeping frailty at bay and maintaining the quality of life and functionality of geriatric patients. Studies have demonstrated that regular exercise in older adults improves gait and muscle strength, resulting in increased mobility and fewer falls.13,14 In a 2009 Cochrane review of 49 randomized controlled trials of exercise interventions for residents of long-term care facilities (a population that is predisposed to frailty), strength and balance exercises were particularly helpful for increasing muscle strength and improving functionality.15 The benefits of exercise interventions for older patients have been demonstrated in several home-based and group-based settings.16-18

The optimal duration and frequency of exercise for frail older adults is currently unknown on a population level.4 Exercise should be pursued at an intensity that is safe and appropriate for the patient. This determination can be made with the assistance of a trained physiotherapist.

Comprehensive Geriatric Assessment
Another important intervention in the care of frail of vulnerable older patients is the comprehensive geriatric assessment, a multidisciplinary process involving a range of health domains for the ongoing evaluation and management of frail or vulnerable older adults. These domains include physical medical conditions, mental health conditions, level of functioning, social circumstances, and environmental considerations.19 Coordination of care among all providers is key for successful comprehensive geriatric assessment. The core team of providers usually includes a primary care physician, nurse, occupational therapist, physiotherapist, and social worker.19 The primary care physician is not necessarily a geriatrician. The physiotherapist can assist with exercise to improve gait and muscle strength to increase mobility and reduce falls.

Comprehensive geriatric assessment is also iterative, meaning that assessment of the patient is ongoing and continually revisited. Comprehensive geriatric assessment has been shown to improve outcomes in frail older adults, whether initiated in the community or in a hospital setting. Meta-analysis of 22 randomized controlled trials found that frail older patients who received comprehensive geriatric assessment during a hospitalization were more likely to return home, were less likely to experience cognitive or functional deterioration, and had lower in-hospital mortality compared to patients who did not receive comprehensive geriatric assessment as inpatients.20 Additionally, when comprehensive geriatric assessment is delivered in the community, patients experience fewer falls and have an increased likelihood of continuing to live at home.21,22

Goals of Care
Finally, any discussion of geriatric care should include goals of care. As in all patients, but especially in geriatric patients, the overall mission is to avoid premature morbidity and mortality while also maintaining a good quality of life. However, the risk-to-benefit ratio of medical interventions for frail older adults can be quite different from that of other patient groups. Providers should discuss with these patients their wishes regarding aggressiveness of care for ongoing medical issues, measures of screening and prevention, and possibly end-of-life care. Current screening and prevention guidelines suggest that the utility of conventional screening tests after age 75 may be limited, but ultimately care must be individualized to the patient.23 A combination of individualized and shared decision-making with the patient can ensure that care continues to be provided in a manner that is appropriate and concordant with the patient’s wishes.24

In summary, frailty is a prevalent syndrome within the rapidly growing geriatric population, and its presence in a patient merits special consideration for that patient’s care. The benefits of exercise interventions, comprehensive geriatric assessment, and goals of care conversations are well established. It is important to remember that frailty is a unique entity and synonymous with neither disease nor disability. As such, it is our mission as providers to ensure the vitality of our older patients for years to come.

By Jessica K Qiu, 3rd year medical student at NYU School of Medicine

Peer reviewed by Nina Blachman, MD, Geriatrics, NYU Langone Health

Image courtesy of Wikimedia Commons


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