Clinical Utility of Identifying Frailty

The clinical utility of identifying frailty is related to the fact that frailty is strongly associated with increased health care service use [12]. Initially a concept in the geriatric literature, frailty has now been explored in both the community and hospital settings. Frailty has been recognised as a risk factor for adverse events in both community populations [13] and older people admitted to hospital [14]. Specialist hospital services such as surgery [15], hip fractures [16] and oncology [17] have now begun to recognise frailty as an important predictor of mortality and morbidity. In high risk healthcare settings such as care homes, there are very high levels of frailty [18]. As the population ages and healthcare systems begin to adjust to a different demand, then frailty can be used as an important construct to guide changes in healthcare resources [19].

The clinical significance of frailty lies in the consequences of acute illness on a frail person. Older people with frailty are common users of emergency departments because frailty may predispose them to acute illness due to reduced physiological reserve [20]. Acute illness in a frail adult often presents atypically (differently than in younger adults) and this has given rise to the frailty syndromes of delirium, falls, immobility and susceptibility to drug side effects [21]. Heightened awareness and identification of frailty in clinical practice can then allow implementation of geriatric medicine focussed management as well as specific interventions which will be discussed later. In practice, acute illness in a frail person results in a disproportionate change in a frail person’s functional ability when faced with a relatively minor physiological stressor, associated with a prolonged recovery time or early tipping point [22]. This is illustrated in Fig. 9.2 [23].

The identification of frailty as part of routine medical practice has been advocated with the development of a number of screening tools to allow clinicians to

Vulnerability of frail older people to a sudden change in functional ability after a minor illness

Fig. 9.2 Vulnerability of frail older people to a sudden change in functional ability after a minor illness. The upper line represents a fit older individual who, after a minor stressor event such as an infection, has a small deterioration in function and then returns to full function. The lower line represents a frail older individual who, after a similar stressor event, undergoes a larger deterioration, which may manifest as functional dependency, and who fails to return to previous function over a longer recovery period. The horizontal dashed line represents the threshold between independence and dependence. Reprinted from The Lancet, Vol.381, Clegg, A; Young, J; Iliffe, S; Rikkert, Mo; Rockwood, K. Frailty in Elderly People, 752-767, Copyright (2013), with permission from Elsevier rapidly assess frailty [24]. The best described of these is the PRISMA-7 questionnaire, a short self-reported questionnaire, which is recommended as the most appropriate screening tool by the British Geriatrics Society [25]. This allows rapid identification of frailty and has reasonable diagnostic test accuracy with a sensitivity of 83 % and a specificity of 83 % when compared to a comprehensive geriatric assessment identifying frailty by the Fried phenotype [26]. A simple functional test, such as a timed walk or timed get up and go test has also been suggested as a good screening tool for frailty [26].

Clinical operationalisation of the deficit accumulation model of frailty has been seen with the Rockwood Clinical Frailty Scale [3], as well as a frailty indices based on routine laboratory tests [27], biomarkers of ageing [28] and routinely collected primary healthcare data [29]. All these scales accurately predict the risk of adverse events such as mortality or new institutionalisation.

Comprehensive Geriatric Assessment (CGA) is a multidisciplinary, multidimensional assessment, led by geriatricians [30]. CGA is designed as both a diagnostic tool and a tool to develop treatment plans. The key objective of CGA is to diagnose specific geriatric conditions. CGA involves the detailed assessment of the patient by a geriatrician, physiotherapist, occupational therapist, social worker and others professionals. This includes physical examination, medical history, and functional assessments of the patient as well as assessment of their home environment and psychosocial support. The information from these assessments form the management plan which involves specific treatment goals that are patient and carer focused. The primary aims of CGA are to improve both physical and psychological health, reduce or shorten hospital stay, reduce institutionalisation and improve quality of life [31]. A meta-analysis of CGA in hospitals in 2011 identified 22 randomised trials with a total of 10,315 older patients included. This reported that older patients receiving CGA in hospital increased the chance of being alive or in their own home at six months by 25 % (OR 1.25 95 % CI 1.11-1.42; P < 0.001) [32].

CGA also improves outcomes in other settings such as stroke medicine [33], hip fracture management [34], surgical care [35], care homes [36] and oncology [37]. However, to date there is no direct evidence that CGA prevents or improves frailty, only the consequences of frailty. Research investigating the improvement of frailty with CGA is challenging due to various methodological issues [38].

 
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