Backgrounder: The Concept of “Frailty” and How it Can Help Reform our Health System
The Canadian population is rapidly aging as the Baby Boomer generation heads into retirement. By 2030, almost one in four Canadians will be over the age of 65. Canadians are also living longer than ever, but how well they live while aging remains a concern.
Individuals do not age according to a pre-existing timetable; rather there are many social issues that contribute to a person’s health as they age. Some individuals at age 80 can be healthier than others at age 65.
It is important, as our population ages, to be able to track health and not just treat people because of their chronological age. The concept of “frailty” helps with this.
Frailty is defined as a “state of increased vulnerability, with reduced physical reserve and loss of function across multiple body systems.” Frailty predicts death, heightened vulnerability, institutionalization and a reduced quality of life. Although it can refer to patients of any age, it is most commonly used in referring to older adults.
People can suffer from many conditions or functional losses from frailty, including slower walking speed, weight and muscle loss, fatigue, decline of grip strength, decline of physical activity and memory loss. Individuals with many impairments, in a more vulnerable state, and at a greater risk of dying are considered frail, while those at a lower risk are said to be fit.
Frailty exists on a continuum, so that there are many individuals who live at various degrees in between the extremes of frailty and fitness.
How prevalent is frailty in Canada?
Over one million Canadians living in the community are estimated to be frail, while another 1.4 million are considered pre-frail. As people age, they become more at risk for frailty. As women outlive men, they are at greater risk for frailty as they become older, although studies have shown they have fewer adverse outcomes as a result of living with frailty.
There are also geographic differences in the prevalence of frailty of older adults living in the community, with Saskatchewan, Nova Scotia, New Brunswick, Ontario and the territories, having higher rates, while BC and Quebec have the lowest rates. The cause of these geographic differences is not known, but could be due to different age profiles within provinces, varying access to home care or fewer residential care communities for older adults.
Many tools for measuring and detecting frailty have been created – and some of the tools, such as the Clinical Frailty Scale, Frailty Index and Edmonton Frail Scale have been developed and validated in Canada. Different measures are used in different settings, depending on needs. For example, the interRAI suite of assessment instruments is available for individuals in homecare and long-term care, while the CSHA Frailty Index is better used for research and policy applications. Measuring for frailty is currently not widely used in hospital settings, which is a gap in practice.
Screening for frailty
Screening for frailty can help older adults in different ways. It can be easier to identify those who are frail or at risk for frailty through screening and then more appropriate health and/or social care can be provided and at an earlier time. There is, however, no consensus on exactly who needs to be screened for frailty. This still needs to be determined.
Various tools can be used to screen for frailty. Existing electronic medical databases could be searched by building algorithms to detect frailty cases or there are simple screening tools that can be used by front-line caregivers as well. The setting and personal needs of the individual will help dictate which tools are best.
What are the risks with screening for frailty?
Risks of screening for frailty must also be considered. One of these is a risk of the medicalization of social issues. By putting the focus on medical issues instead of the social issues that may cause them — the social determinants of health — there is a risk of focusing on the individual at the expense of addressing upstream causes. Income and wealth disparity, housing and social isolation, for example, are all factors that have been shown to influence health.
There is also a risk of stigmatizing those assessed as frail. Labelling a person as frail could negatively change their own perceptions of their health and ultimately lead them to question their independence. Others could also view those assessed as frail in a more negative way.
Frailty is also a dynamic process that can change over time and being assessed as frail at one time may not mean that a person remains frail.
There are also ethical concerns when assessing for frailty. There is a risk of frailty being used as a reason to deny care and this denial could become the norm. On the other hand, there is also the risk of frail individuals being harmed by aggressive, life-sustaining treatments when healthcare workers are not well informed about frailty.
Making informed decisions about those assessed as frail is of serious concern. Frail individuals may not be given all the information or assistance they need to make decisions for themselves because their healthcare providers do not have a good understanding of frailty. What is needed is shared or supported decision making in these cases, where frail persons are aware of their choices for care and can opt for less invasive procedures.
Finally, frail individuals are often excluded from clinical research trials because of a lack of understanding of frailty, but at the same time they are some of the largest consumers of health care resources. Yet, including them appropriately and ethically is also a challenge. More research needs to be conducted on how to improve outcomes for those who are frail.
Beyond ethical concerns, there are also legal concerns. When an individual is assessed as frail, this could lead to a false assumption of legal capacity or incapacity. A person’s capacity, in the legal sense, needs to be looked at not as an absolute and ongoing state, but instead, reframed as relative or changeable due to any given situation. This variable state is a result of the complex relationship between a person’s physical and cognitive issues, along with their social supports and circumstances.
Canadian law ensures that actual “needs, circumstances and capacities” of individuals take precedence over age or stereotypes. However, a diagnosis of frailty may also be used to limit, withhold or deny care to frail individuals, as well as increase their loss of independence in decision-making. More evidence-based research on frailty is needed to determine the needs, circumstances and capacity of frail older adults to provide more clarity on shared decision making.
What impacts frailty?
Social and societal issues impact frailty a great deal. A person’s social networks, living situations (especially rural or urban), social isolation or engagement and a person’s social position (socioeconomic status, education, perceived income adequacy) contribute to a person’s degree of frailty. Lower social position, especially education and income, strongly equates to frailty. Personal attitudes towards health also play a role in frailty. How a person views his or her own health can either advance or reduce frailty levels.
Healthcare providers need a comprehensive, organized understanding of social circumstances, available resources and supports to help frail individuals. As with frailty itself, this is complex as social issues and frailty are often linked to many factors and can operate in both directions (positive and negative). Many older adults have been exposed to these social issues over numerous years by the time frailty takes hold.
Effective interventions for frailty
Current thinking states that physical (exercise), nutritional or cognitive interventions may help — or a mix of these. Exercise-based interventions have already shown some positive effects. More research is needed on ways to prevent or treat frailty.
Restructuring healthcare systems to effectively address frailty
The current Canadian healthcare system is not set up to respond well to frailty. There has been a push towards greater specialization which responds to only one health issue at a time. As frailty is a complex condition, healthcare professionals need to work together to effectively manage this complexity. A person-centred care plan will help frail individuals remain independent. Decisions need to be made collaboratively with input from clinicians, patients, caregivers and support persons. Further training, support and having better systems to refer frail individuals to specific care and treatments will also help healthcare providers.
Responding to frailty in different settings
As frail older adults live in various settings, it is important to look at each setting to see how best to respond to frailty. Many frail individuals (over one million) still live in their homes in the community. For these people, age-friendly policies and programs are helpful.
The age-friendly community movement is growing and many Canadian cities and towns have adopted strategies to support all older adults, not just those who are frail. Certain programs are particularly helpful to frail individuals, including those that help with home maintenance, transportation, loneliness and social isolation.
Within the healthcare system, family doctors are perfectly placed to identify frailty, but it can often be overlooked due to frailty’s gradual onset and progression and by attributing changes to the normal aging process.
When frail individuals are in acute care in hospitals, they often have poor outcomes. Many frail individuals who are hospitalized, end up with worse function levels and are no longer able to return home.
Frailty screening could help with more accurate prognostication and better follow-up after admission to hospital. As an example, in critical care units (ICU), 33 per cent of patients in one Alberta study were found to be frail. They were more likely to stay longer in hospital, suffer from adverse events and were twice as likely to die in hospital than non-frail ICU patients. When they were discharged, they were less likely to return home, as they were more likely to develop new conditions or need further hospital stays. All of this led to a poorer quality of life.
Many older adults in assisted living are considered frail, but there are many gradients of frailty within this setting. Those living in long-term care facilities can be considered very frail. Staff in these facilities could be trained to identify social vulnerability and isolation, which would provide a better understanding of the role of social vulnerability in frailty.
Many individuals with advanced frailty would benefit from the palliative care system. However, the facilities and services for this system were set up with cancer in mind, not frailty. A better way to systematically identify frail older adults who might benefit from palliative care is needed, as is training for the provision of palliative care for non-cancer diagnoses. Better experiences for frail individuals and their families will let them focus on advance care planning, which would avoid intensive and unwanted care and medical costs at end of life.
Information on frailty and its impacts needs to be available to people within and beyond the healthcare sector. Researchers, healthcare providers, administrators, policy makers, decision makers, social care organizations and older adults and their families all need access to this information.
Future of frailty research
There is much work to be done with regard to frailty, starting with a common language to define it. Consensus is needed on which assessment tools to use, when and where, as well as who should be responsible for conducting it. More research on evidence-based interventions for frail individuals is also necessary. Interdisciplinary, person-centred, team-based care is needed to address the complexities of frailty while at the same time respecting a person’s autonomy. Discussions on how to fund the integration of frailty assessments and interventions into mainstream healthcare and social care settings need to occur, as well as evaluations on how efforts at dealing with frailty are working.
Why is it important to consider “frailty”?
Providing more education and support for frailty can ensure that frail patients are considered first and foremost when considering care options and that older adults can be better informed when making decisions about their care. It can also help people with medical decision-making at the end of life. It is always best to involve older adults in their own care planning, as this will ensure their goals and values are always respected.
Frailty can also be reduced or delayed, which can improve quality of life. Conducting assessments along with interventions, such as exercise, wellness plans, coaching, and/or community engagement, can improve a person’s quality and enjoyment of life. Individuals can also delay frailty by participating in healthy behaviours, such as eating fruits and vegetables daily, avoiding excessive alcohol and smoking and exercising regularly.
Family and friends who act as caregivers are also impacted. As the Baby Boomers age, they find themselves caring for increasingly frail parents with few supports. Some studies indicate that they are more likely to put limits around their caregiving and expect social care networks to support them.
With better strategies to deal with frailty, costs to the healthcare system can potentially be reduced, as it is known that the bulk of healthcare funds are spent at the end of life. As an example, Mount Sinai Hospital has reported savings of $6.7 million in avoidable costs in 2014 through a program focusing on frailty.
Our podcasts on Frailty
Kenneth Rockwood, How can we overcome an ageist healthcare system?
John Muscedere, How improving healthcare for the frail elderly can also cut costs
Our commentaries/op-eds on Frailty
Our position papers and briefs on frailty
Time to Address “Frailty Creepage” in the Canadian Healthcare System. Supplement to The Journal of Frailty and Aging, Vol 7, Number 4, 2018.
We Can’t Address What We Don’t Measure Consistently: Building Consensus on Frailty in Canada — National Institute on Aging/Canadian Frailty Network, 2018
A National Seniors Strategy needs to account for complexity in the aging process – article by Russell Williams, CFN Board Chair, in May 2018 issue of Policy magazine
Ensuring a more equitable healthcare system: addressing the needs of Canada’s frail elderly — CFN 2017 Federal Pre-Budget Submission
Screening for Frailty in Canada’s Health Care System: A Time for Action. Canadian Journal on Aging. 2016 Sept; 35(3):281-297. doi: 10.1017/S0714980816000301. Epub 2016 May 23.