Identifying, staging and managing frailty provides both community, and primary and acute care health care teams the opportunity to implement targeted interventions to halt, slow or reverse health declines including frailty and to construct goal-oriented, patient-centred individualized care.
Knowing that a person lives with frailty informs care teams that this person is at an increased risk of serious adverse health outcomes and how frailty will impact a person’s outcomes and provide a way to frame difficult situations.
Identifying and staging frailty using the most widely used (and best validated in the acute context) assessment tool, the Clinical Frailty Scale (CFS) will enable care teams to target the complex adult population at highest risk of adverse health outcomes and hospital-related complications such as falls, delirium, loss of functional autonomy, prolonged stays, nursing home placement and death.
The CFS is a one-page pocket-card tool that shows clip art of a person at certain degrees of frailty in their life.
The first image is a person upright and running (a CFS score of 1 or very fit) to show that they are vital and energetic. Each succeeding picture shows someone who is a little less well and a little less functional. Ultimately, the person is lying flat in a bed and total dependent in their activities of daily living (a CFS score of 8 or very severely frail) and then sitting in a chair (a CFS score of 9 or terminally ill for a person whose life expectancy is less than six months but shows no other signs of frailty). Each picture in the nine-point scale also has a few sentences describing what a person with that frailty level might be like or might be able to do at that level of frailty.
The Clinical Frailty Scale is not a questionnaire. Grading the degree of frailty requires clinical judgement that is based, in part, on screening criteria (PFFS, FI, CFS-FAST, CFS-SELF) and then considers degrees of fitness and frailty.
It’s all about the BASELINE—what the person’s state of health was like before they were ill (roughly two weeks prior).
The CFS is:
When considering management options, it is important to recognize that patients diagnosed with frailty vary in their presentation and treatment needs. Clinical judgment is critical when choosing a treatment option. Some older adults may not be capable of initiating or completing certain treatments, and in certain situations, the risk of treatment may outweigh the benefit. In the severe stages of frailty, palliative care options may be appropriate to discuss.
Management of patients who live with frailty must be individualized, i.e. tailored to their goals of care and life expectancy. Mobility and balance exercises may be suitable for patients who are less frail. Palliative care and symptom control typically are appropriate with very severe frailty. It is crucial that we understand frailty as the key to care plans and not as a polite way to limit care.
People who live with very severe frailty at baseline (about two weeks prior to becoming acutely ill) are near their end of life. Extensive data, including from intensive care, that most people who lived even with moderate frailty before they became ill will be alive one year after admission. The critical issues are how they will function and in what cognitive state. There is no point in blaming all adverse outcomes on their baseline frailty, and ignoring the harm of not mobilizing people early, or not paying attention to nutrition, pain, sleep, function, continence, social engagement, and medications. Even more important are their desires and the capacity of their family and community support to get them home. For most, their relevant “goal of care” is not what cardiopulmonary rituals to perform should they die. Instead, individualized care plans require us to know what they were like at baseline, how close to that they need to be to get home, and what needs to be done to achieve that outcome.
This must be done quickly. Most of you will know of the golden hour of trauma: the time when prompt action is crucial and much more likely to be effective. Fewer have heard of the golden 72 hours of acute elder care. Too often the only concern for mobilizing patients comes on day three, with the default being “consult physio”. We must do better than that.
The care plan goals for everyone should be:
For patients with just one thing wrong, that is reasonably straightforward. When people have multiple, interacting medical and social problems, management is more complicated. Having complex needs is not their fault, nor not of their families. It is not up to patients to get sick on our terms. It is up to us to treat them on their terms. This won’t happen without effort, skill and care. That’s what care planning is trying to achieve.