Roberta Heale, Associate Editor EBN, @robertaheale @EBNursingBMJ
The harsh winters in Canada where I live, have me thinking about the difficulties of living on your own as you age, particularly for those who are frail. A recent commentary of an article on the risk of fractures related to frailty 1,2 as well as a recent blog about addressing frailty in prisons 3 demonstrate that I’m not alone in my interest in frailty as a priority concept in caring for aging persons. As a complex phenomenon, and not a definitive diagnosis, frailty can be overlooked in favour of focus on individual issues. Not only that, but strategies to mitigate the impact of frailty may be missed.
Just what is frailty? People are frail if they are assessed as having at least three of the following characteristics: low physical activity, unintentional weight loss, slowed performance, muscle weakness, or fatigue and poor endurance. 4 These characteristics alone don’t deem a person to be frail, rather an accumulation of changes toward decline moves a person to “a state of vulnerability to poor resolution of homeostasis following a stress.”5In other words, a declining overall physical state means that eventually, even minor stressors such as a fall can take a large physical toll on a person who may never regain their previous health status.
When frailty is included as a variable, studies demonstrate alarming statistics. In a 10 year prospective study of older people living in their homes, the condition most likely to lead to death was frailty (27.9%) ahead of organ failure, cancer, and dementia.4 Frailty is a dynamic process, which typically worsens, rather than improves, over time. The greater the level of frailty, the higher the risk of disability, falls, hospital admissions, long term care admissions and death.5
Efforts have been made toward assessment of the level of frailty of an individual. Such things as the timed-up-and-go test (TUGT) which is a standardized measure of gait speed and hand grip strength as well as The Edmonton Frail Scale, which includes the TUGT, but adds a test for cognitive impairment, are some examples.5 Assessing for frailty is important in the care of older people living at home. It’s ideal to assess and plan before a hospitalization event, however, comprehensive geriatric assessments for patients in hospital have benefits, leading to a higher likelihood of returning home, and lower likelihood of cognitive or functional decline. 5
Interventions to slow the progression of frailty and to mitigate its effects are practical and focused in common sense. First and foremost, exercise is essential for all persons, regardless of age. Exercise that is tailored to the needs and abilities of the individual, improves the workings of the brain, endocrine, immune and skeletal muscle systems. Exercise has been proven over and over again, to improve mobility and functional status.4 Attention to the nutritional status of an older person is another important intervention, particularly since an older person may not eat enough protein to maintain muscle mass and their weight. 4
Given the potentially devastating consequences of frailty and the relatively simple measures to slow its progression and impact, assessment for frailty should be as ubiquitous in healthcare as taking a blood pressure. Nurses, at the forefront of healthcare, are in an ideal position to assess for frailty and implement strategies to mitigate the negative outcomes.
- Kojima, G. (2017). Frailty significantly increases the risk of fractures among middle-aged and older people http://ebn.bmj.com/content/20/4/119
- Chen KW, Chang SF, Lin PL. Frailty as a predictor of future fracture in older adults: a systematic review and meta-analysis. Worldviews Evid Based Nurs2017;14:282–93.
- Waldegrave, K. (Nov 6, 2017). A vulnerable population—assessing and managing frailty in older prisoners. https://blogs.bmj.com/ebn/2017/11/06/a-vulnerable-population-the-health-care-needs-of-older-prisoners/
- Torpy, J;Cassio, L. & Glass. R. (2006). Frailty in older adults. JAMA.296(18):2280. doi:10.1001/jama.296.18.2280. https://jamanetwork.com/journals/jama/fullarticle/204046
- Clegg, A., Young, J., Iliffe, S., Olde Rikkert, M. & Rockwood, K. (2013). Frailty in elderly people Lancet, 381(9868): 752–762. DOI: http://dx.doi.org/10.1016/S0140-6736(12)62167-9 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4098658/