How to identify and treat frailty in older adults

Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Lisa Price, MD, board certified in internal medicine and geriatrics and has expertise in managed care, electronic health records, quality improvement and geriatrics. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

The U.S. healthcare system is struggling to address the healthcare needs of country’s growing elderly population, which increases by one person every eight seconds.

Lisa Price, MDFortunately, the U.S. Centers for Medicare and Medicaid Services have taken some steps to meet the increasing needs of older adults, such as calling for quality care metrics and creating codes to reimburse physicians for managing care transitions and complex chronic conditions.

More from Dr. Price: Can PACE by the answer to the scarce lack of geriatricians in the U.S.?

In the larger sense, pay for quality care is an admirable pursuit when applied at a health system level.  However, when applied specifically to older adults, pursuit of certain quality metrics may actually do more harm than good by encouraging care that is not beneficial to frail seniors. In addition, physicians who primarily care for a geriatric population may be inadvertently penalized for failing to meet the metrics in a patient population where such interventions are not within their goals of care. 

Failure to recognize frailty and frailty-related conditions may lead to some unintended consequences.

Treating Frailty in Older Adults

Pre-frailty and frailty is an example of an elder care issue that, when identified and treated, may negatively impact quality metrics for the simple reasons that older adults don’t respond as well to treatment as younger cohorts.

Although there is no gold standard for the diagnosis of frailty, it is generally considered to be a geriatric syndrome with a decline in physiologic reserves, leaving a person less able to adapt to stressors such as trauma or an acute illness.

As in most geriatric syndromes, there are many factors contributing to frailty: age, comorbidities, and environmental and psychosocial factors. This leads to its presentation as a spectrum from pre-frailty to failure-to-thrive. Frailty’s presence is increasingly associated with poor outcomes and increased mortality in older adults.

Next: How to get ahead of pre-frailty

There are a variety of tools to help identify frailty, and its prevalence varies depending on the tool used.  A 2009 study published in the Journal of the American Geriatric Society of 765 community-dwelling seniors in the Boston area identified 18.7% to 38.8% as pre-frail and 4.2% to 10% as frail, depending on the frailty index used and the presence of pre-frailty and frailty predicted falls, ED visits and hospitalizations.

More from Dr. Price: Lost in translation: the physician-caregiver relationship

One of the tools this research used was the Study of Osteoporotic Fractures (SOF) Frailty Tool.  SOF can be performed quickly by a provider or office staff.  Frailty is defined as the presence of two of the following three:

·       Weight loss of 5% in the past year

·       Inability to rise from a chair five times without the use of arms

·       A response of “no” to the question, “Do you feel full of energy?”

Another tool that can be done simply with an interview is the FRAIL scale. A “yes” response to two or more questions indicates pre-frailty and “yes” to three or more indicates frailty.

·       Fatigue: Are you fatigued?

·       Resistance: Can you climb a flight of stairs?

·       Ambulation: Can you walk one block?

·       Illnesses: Greater than five.

·       Loss of Weight: Greater than 5%.

Get ahead of pre-frailty

With the Silver Tsunami breaking on shores around the world, getting ahead of pre-frailty is important to ensure our senior population ages as successfully as possible. Prevention is the first step in slowing pre-frailty. Although most physicians don’t have specific frailty prevention training, they can take steps to promote exercise among older adults, which has been shown to slow frailty.

Next: Additional ways to prevent and treat frailty

Daily exercise is an excellent first step in slowing the onset of pre-frailty. Just as younger adults can benefit from regular exercise to reduce their risk of diseases such as heart disease and diabetes, already-frail older adults were able to build muscle and lessen the chance of falls and stave off frailty.

The Journal of American Medical Association found weight training among a small group of nursing home residents aged 90 and older had a positive effect by building muscle and improving mobility. Another study published in the Journal of the American Geriatrics Society showed an almost 48% reduction in the risk of falls after a group of older adults participated in a Tai Chi class.

There are additional ways to prevent and treat frailty, many of which are simple and can be implemented at home by an older adult’s caregiver with a little help from a physician. These include:

·       Eating and drinking well, including following a Mediterranean diet;

·       Developing an exercise program for seniors, including balancing exercises and strength training;

·       Reviewing a senior’s list of medications to ensure all are needed, as some contribute to frailty or worsen frailty due to side effects; and

·       Taking note of a senior’s decline in appetite, movement or physical activity, as well as assessing whether a senior is feeling fatigued and weak. 

Frailty, when it is identified, should become part of the treatment plan.  Goals of care are increasingly important, as the benefits and risks of medications and interventions are less clear and risks greater. With the answers to a few quick questions, and the addition of more exercise and better nutrition, impending frailty can be identified and managed.

Lisa Price, M.D. is Chief Medical Officer at Denver-based InnovAge, a provider of health and wellness services for older adults in California, Colorado and New Mexico. Dr. Price was a private practice geriatrician for 11 years, and then attended on the Acute Care of the Elderly (ACE) service and taught Quality Improvement at the University of Colorado. Dr. Price is Board Certified in Internal Medicine and Geriatrics, and has expertise in managed care, electronic health records and quality improvement. http://MyInnovAge.org.