Frailty

Tools and resources to assist health care providers with routinely identifying, documenting and communicating frailty in patient care settings.

Overall Impact

Frailty In The System

Our health care system is generally set up for addressing one health issue at a time, using a standard approach to care derived from studies where patients generally have only one, or few, health issues.  This model doesn't work well for frailty.  People who are frail often have multiple, chronic progressive health issues, and multiple competing causes for symptoms and mortality.  Fixing one health issue using the “standard of care” approach may make other health issues, or overall function, worse (Mallery & Moorhouse, 2011).

Frailty Characteristics by Care Sector

An increasing prevalence of frailty may help to explain several trends you’ve been seeing in your work such as long waits for surgeries and other procedures, falls, adverse drug reactions, delirium, etc.

  • Care needs exceeding available supports
  • Challenges with allowing dignity of risk
  • Caregiver stress
  • Increasing caregiver frailty
  • High numbers of patients who are designated ALC (Alternative Level of Care) or waiting for services/housing in the community
  • Code census
  • Pressure sores
  • Delirium
  • Long stays; frequent readmissions
  • Patient flow challenges due to complex patient needs
  • Need for complex decision making during health crisis
  • Challenges providing effective symptom control or end of life care
  • Patients having difficulty getting to appointments (e.g. missed appointments or house call requests)
  • Challenges in providing/coordinating care when multiple health issues are involved (e.g. time, wait lists for specialist appointments, conflicting priorities of single system illnesses)
  • Challenges in matching patient needs with remuneration structure
  • Polypharmacy

Our Strategy

The NSHA Frailty Strategy was developed with a focus on:

  • Creating a shared understanding and measurement of frailty 
  • Aligning frailty initiatives across all care sectors
  • Improving the patient care experience across all care sectors by using a frailty lens to guide care
  • Improving transitions between care sectors for frail patients through communicating frailty specific care needs

Optimize experience in frailty

The strategy recognizes that frailty touches a broad range of people — pre-frail/frail persons, family and friend caregivers, family members, providers (physicians, nurse practitioners, pharmacists, allied health care professionals, paramedics, etc.), and the community sector (private facilities, services and businesses, housing authorities, legal community, community groups and organizations, church/faith communities, Government, academic institutions).

We want to meet people experiencing frailty where they are at, empower them with knowledge about frailty, and offer appropriate supports and timely care. This will involve embracing difficult realities. The strategy acknowledges the need for supports and approaches to care that are designed to be flexible and to travel through transitions in health with persons experiencing frailty. This requires everyone working together - patients, families, family and friend caregivers, and health care providers.

These six areas will guide current and future initiatives:

  • Understanding - Build a culture where frailty is recognized, understood and acknowledged as a key determinant of health
  • Engagement - Involve stakeholders* in ongoing dialogue about experiences with frailty. Strengthen partnerships and ensure a collective effort in supporting persons experiencing frailty**
  • Care - Ensure optimal care planning and delivery for all persons experiencing frailty
  • Evaluation, Research & Knowledge Implementation - Seek and use leading practices, evidence and experiential learning to respond and adapt to emerging information and ensure knowledge is implemented into frailty care practices
  • Information Management and Technology - Use information technology (IT) and management (IM) structures to identify, assess, plan care and support persons experiencing frailty and inform the health care system of the contributors to frailty, its impact and outcomes of care
  • Governance - Establish a leadership structure to guide the FS, ensure initiatives are aligned, establish shared measurement structures, build momentum, advance care practices, advocate for policy, mobilize resources and ensure sustainability of frailty initiatives across sectors

* Stakeholders include persons living with frailty, families, family and friend caregivers, providers, community organizations, businesses, government and academic institutions .
** Persons experiencing frailty includes patients, clients, family and friend caregivers.

Achieving Our Vision

The term "frailty" exists in the public domain. It has many connotations, including unflattering ones. In order to achieve the vision guiding our strategy, all NSHA Staff & Physicians must share a common understanding of what it means to be frail. From there, we will be better positioned to promote its medical meaning within our care settings.

10 Key Aspects of Frailty

  1. Frailty can be reliably measured.
  2. Frailty levels are established using baseline descriptors – that is, a particular level describes a person’s vulnerability while that person is at their usual/baseline ability (often in the couple of weeks before they became acutely ill). Patients are generally not at their baseline during acute illness. For example:
    • You would not diagnose dementia when a patient is in the throes of delirium
    • You would not use a person’s mobility while rehabilitating from a fracture as an indicator of their usual mobility
  3. After recovering from an acute illness, a person may achieve at a new baseline and would therefore have a new frailty level.
  4. Frailty is more useful than chronological age at predicting outcomes. For example, a person who is 65 may be more frail and at risk than a person who is 85.
  5. Frailty is partially a result of delivery of effective, chronic care (i.e. when people survive longer, they accumulate more health issues).
  6. When a person is frail, survival and recovery often bring about more advanced frailty over time.
  7. A person’s social circumstances impact their experience and outcomes at any level of frailty.
  8. Dementia is a common and important driver of frailty.
  9. There is optimism that frailty can be reversed and research into this continues. Research is also pointing in the direction of providing multiple ways to support or take care of aspects of frailty.
  10. There is no cure for frailty, but some interventions can improve a person’s experience and may even reverse frailty when it is mild.

Reference:

Mallery, L. H., & Moorhouse, P. (2011). Respecting frailty. Journal of Medical Ethics, 37(2), 126-128. https://jme.bmj.com/content/37/2/126.long