Frailty is not a Label. Using frailty status to initiate or change healthcare decisions

Our current healthcare system focusses on labelling people with different conditions. We use these labels to guide clinical decisions. This person has diabetes, she has heart disease, my aunt was just diagnosed with dementia. These labels hold value. They have a certain power over us. We even use them to label ourselves.

Have you ever heard someone say the following phrases?
I’m a diabetic
I’m a cancer-survivor.

They become engrained in our identity. For these people, they now identify with their condition.

The population as a whole, and in Canada, is aging. Now is the first time ever that persons over 60 outnumber those under 18. This trend is expected to continue for the next several decades. Because of that, there has been increased attention into the appropriate models of care for our older citizens.

This has created an interesting discussion. As we get older, more things happen in our life and we become increasingly… complicated. Normal aspects of aging mean that we lose a bit of our resiliency. We don’t bounce back the same way as we once did. It also increases the odds that we get diagnosed with different health conditions. Age is a risk factor for many diseases. What we have been learning is that often the REASONS why these chronic health conditions come up, are overlapping. The same underlying risk factors exist and it just depends which organ shows the issue first.

Because Canadians who are older tend to be more medically complex, this has given rise to the term “clinical geriatric syndromes” or CGS. A CGS is a condition that arises from a plethora of different signs and symptoms. Examples of a CGS are dementia, sarcopenia, urinary incontinence and frailty.

Frailty is the term I want to focus on today.

When I use the term frail, I feel like we can all conjure up the image of what a frail older person looks like. They’re often sad, thin, pale, older, and gaunt looking. They just look sick. You look at that person and think … frailty.

But what does it mean when we label a person as frail?

Flip the script. Imagine you went into hospital with a sudden infection and couldn’t eat for several weeks. You’ve lost a lot of weight; you are pale and look generally sickly. How would you feel being called frail?

Would you feel stigmatized?
How would you feel particularly GOOD about your current condition?
Would that be a label you would want associated with you?
Do you think it would affect your care?

I read a fascinating editorial on the clinical utility of labelling a person as frail. Frailty by definition means a “person who is vulnerable to external stressors”. It corresponds to a lack of resiliency. Sometimes also termed “failure to thrive” as we often can label premies who aren’t growing at expected rates.

Researchers and clinicians have tried to screen individuals for level of frailty because we have evidence to show that persons who are frail tend to do worse health-wise. People who are frail tend to have more falls, land in hospital more often, need more help with care, and even have a higher chance of death than people without frailty.

Seems like something we should know about a person, right?
Knowing a person’s frailty status only changed their clinical outcomes by 3-8%! That means that we are doing something wrong.

 VS 

Using frailty as information to GUIDE clinical decisions

We know that if we work to improve some of the signs and symptoms of frailty as well as optimize a person’s medical care, frailty can improve and in some cases even reverse. This is the good news. The bad news is if we don’t use the information given to us by screening for frailty. In our world of information overload, sometimes frailty algorithms can just become another data point that we track on a spreadsheet instead of letting the fact that a person has been flagged with signs of frailty create a different care pathway.

The research world has focused so much on the proper screening and instruments needed to identify frailty, now it is time to USE some of these tools to change healthcare decisions. These decisions can happen at the bedside, in regards to need for follow up, referrals to different providers to optimize care or from a big picture, use population-level frailty indicators to make healthcare spending decisions.

When you are given a Labels in healthcare, a course of care is initiated

It triggers an action when you are told you have diabetes! New medications are started. More frequent check ins may be needed. Annual blood work to assess kidney function may be indicated. A referral to see a registered dietician may be made.

What happens when you identify as person as frail?

 

References: 

Cesari, Matteo. Frailty and sarcopenia: From theory to clinical implementation and public health relevance

Clegg.  Frailty in Elderly People

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Christina Prevett

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