Assessing and Addressing Frailty- Research leads the way to compassionate care for the frail

The Pictorial Fit-Frail Scale was developed as a more practical approach to identifying frailty compared to previous scales.
The Pictorial Fit-Frail Scale was developed as a more practical approach to identifying frailty compared to previous scales.

Frailty is a compromised state of health that leaves a person vulnerable to sudden and serious declines. In Canada, one quarter of the people over 65 and half those over the age of 85 are frail. Frailty poses an immense challenge to individuals, families, the health system and society. NSHA researchers are measuring and tracking frailty to provide more sensitive, effective care.

Researchers at NSHA and Dalhousie University are global leaders in defining the concept of frailty. They’ve developed tools for quantifying frailty that are now used in Canada, the United Kingdom, the United States, China and other parts of the world.

“The frailty index captures the complete picture of a person’s health,” notes Dr. Kenneth Rockwood, NSHA-Dalhousie geriatrician and professor who, with mathematician Dr. Arnold Mitniski, pioneered the frailty index. “It shows how multiple health problems add up to various degrees of frailty. From there, people can make informed decisions about their health care.”

As Dr. Rockwood explains, frail individuals do not respond to standard treatments the same as more robust people do. Surgeries, drugs and combinations of multiple drugs (polypharmacy) can lead to complications and loss of function, and even independence, for the frail.

Researchers at NSHA are adapting and applying the frailty index and other locally developed assessment tools. They want to ensure frailty is identified and properly addressed—whether it’s showing up in a visit to the family doctor, an ambulance call, a geriatric day hospital, or the intensive care unit.

Measuring and tracking frailty has also revealed that steady decline is not the only trajectory. “We’re finding that certain aspects of frailty can be reversed,” Dr. Rockwood says. “Our research shows that reducing polypharmacy and improving mobility are two of the most powerful ways to boost resilience and achieve better outcomes.”

Pictorial fit-to-frail scale provides a “picture of health”

Patients and their families can literally see where they sit on the continuum from fit to frail, when they work through a pictorial scale being tested in geriatric clinics at the Halifax Infirmary and St. Martha’s Regional Hospital in Antigonish. Dr. Olga Theou and colleagues developed the scale, with funding from Nova Scotia Health Research Foundation, and are testing its usability and accuracy now with support from the NSHA Research Fund and the Canadian Frailty Network.

“The visual nature of the scale cuts through barriers of language and literacy, while giving a clear view of a person’s health status,” says Dr. Theou. “This is an enormous aid in planning for care and supports at home. We ultimately hope it will be used in all corners of the health care system.”

In case of emergency, assess frailty

A trip to emergency can be distressing, even dangerous, for a frail person. “Emergency departments are set up to respond to acute crises… staff are not typically trained how to assess frailty, and frail patients may be at risk for dehydration or delirium,” notes Dr. Stacy Ackroyd, a longtime emergency medicine researcher who’s evaluating ways to improve the well-being of frail elderly people during their time in emergency.

Getting a handle on a person’s degree of frailty before or when they arrive at the emergency department is an important step to providing more appropriate care. “We’ve adapted the clinical frailty scale so patients or family members can fill in the information on a tablet,” says Dr. Judah Goldstein, research coordinator for Emergency Health Services (EHS). “We’re testing the feasibility of this tool and educating staff so frailty becomes an important consideration not only in the triage process but throughout the person’s visit to emergency.”

Safeguarding the frailest of the frail

Frail people are overrepresented in the intensive care unit, where 30 per cent of patients over age 50 are frail. NSHA-Dalhousie geriatrician Dr. Sam Searle is studying how a frail person’s health status changes when a health crisis comes along, how this is affected by a stay in the ICU and if and how well they are able to recover their health, function and independence after discharge.

“We’ve found that one of the most important predictors of a person’s recovery is their mobility during their stay in the ICU,” Dr. Searle notes. “So now we’ve involved physiotherapists in assessing patients’ mobility—in addition to helping them move—as part of our study.”

Ultimately, Dr. Searle wants to ensure that ICU staff, patients and family members understand how frailty affects a person’s response to interventions—in such a precarious state, even an IV can cause problems. “Standard ICU protocols may not always be safe for frail patients,” he explains. “Everyone involved needs to understand the potential consequences of interventions, so patients and families can make informed decisions.”

Dr. Karthik Tennankore, meanwhile, is exploring the implications of frailty in patients on the waitlist for a kidney transplant. “We need to know more about how frailty affects the health of patients who are waiting for a kidney,” notes the NSHA-Dalhousie nephrologist. “We’re identifying sophisticated ways to make our assessments more objective to better inform how we prioritize patients on the wait list.”

Frailty Portal: doorway to intervention upstream

Researchers, decision makers, providers and patient advisors have created the Frailty Portal to help family doctors and other primary care providers identify and address emerging signs of frailty in their patients. “Our goal is to help providers work more proactively with their frail patients,” says Dr. Tara Sampalli, NSHA’s director of research and innovation in primary health care. “By educating patients about frailty, providers can help patients make more informed health care decisions and prevent many crisis situations.”