Assessing frailty
How screening for frailty helps
Our current health system is fragmented, with everyone gathering different information relevant to frailty, using different assessment tools, and reporting information in different ways. Reliably evaluating care, health outcomes and healthcare resource utilization by frail people is close to impossible. Frailty in older adults is under-recognized, under-documented and under-coded in data from medical encounters, hospital discharge summaries and death certificates.
“If we assess frail, older people well and treat underlying causes of deterioration, there is great potential to make them less dependent, less immobile, less fearful and less confused – and in turn, less reliant on care.” – Innovation Partnership on Active and Healthy Aging
Identifying frailty is important in providing clinical care. The presence of frail, poorer health and multiple conditions often result in older patients at higher risk of dying, even after a successful medical procedure. Identifying these conditions when counselling patients on their prognosis following a procedure is helpful. For example, a patient at moderate risk for long-term worse outcomes may decide against a procedure if they know the incremental risk from associated frailty and related health challenges. Or, a person at high risk may be a better candidate if they are not frail and have good functional status. Assessment of frailty may reclassify individuals to new and clinically meaningful risk categories. Identifying frailty can also prompt more comprehensive geriatric evaluation and interventions that improve functional status – and possibly reverse deteriorating conditions and restore an older patient to non-frail status.
Implementing standardized ways to determine frailty will support comparisons between jurisdictions and identify variations in care, outcomes and healthcare resource utilization. This can increase value from healthcare resources by avoiding underuse and overuse of care by frail people.
No care setting in Canada currently identifies and assesses frailty as standard clinical practice.
In community settings, frailty predicts future hospitalization, worsened quality of life, and loss of ability to carry out activities of daily living. Routinely identifying frailty offers opportunities for targeted care, including applying clinical practice guidelines and tools specific for frailty.
In primary healthcare, such as family practices, identifying those living with frailty is a proactive approach. It can improve their understanding of their overall health and engage them and their families in making decisions with their healthcare provider about preventive strategies and medical or surgical treatments. Most people living with frailty live in the community, so strengthening primary healthcare for adults living with frailty is crucial to help them age in their preferred setting. It also offers them access to appropriate community resources when needed.
In nursing homes, almost all residents are frail or are pre-frail. Enhancing or preserving their quality of care and quality of life is the dominant goal, keeping in mind their own goals of care and wishes about death and dying. Assessing their degree of frailty may support more appropriate care plans, including approaches to medication use and advance planning for palliative care.
In the emergency department, screening acutely-ill, high-risk older adults for frailty can alter the trajectory of care in the hospital and after their discharge. Given the hectic workflow of the emergency department, though, screening requires brief, valid and reliable tools that support further assessment and guide options for treatment.
Frailty screening in different care settings can be mass screening of large populations or case finding (opportunistic screening) of individuals who consult health services for another reason. Although mass screening is advocated by some organizations, it remains controversial. Organizations such as the British Geriatrics Society advocate case finding.Both approaches have merit. CFN has consulted with its stakeholders, network members and frailty experts, and advocates case finding. All older adults who come into contact with the healthcare system and who meet pre-specified criteria should be assessed for frailty.
Simple and effective tools to assess frailty are readily available and can be part of routine healthcare. Often, tools commonly used to measure frailty are also useful to identify possible treatments that can prevent, slow or significantly delay negative outcomes. This can help older adults to stay in their homes and communities and to be as functional as possible for as long as possible.
The following video was created by Dr. Susan Lane, a Care of the Elderly Family Physician working with the North East Specialized Geriatrics Centre, with support from the Northern Ontario Academic Medical Association. It gives an overview of how frailty assessment can help improve outcomes for hospitalized older adults: