2020; Volume 21, No 5, May

Featured Story

Palliative Care and Frailty

By Claudia Burlá, MD, PhD, IAHPC Board Member

Frailty is a common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among older adults. It is related to the overall health state of a person, which is determined by the number of medical conditions he or she presents. Considering the rapid ageing of the population around the world, more and more health practitioners will have to manage this complex condition.

Typical of frailty is a decline of physiologic reserve. This results in greater risk of poor health outcomes, including falls, delirium, and functional decline, leading to hospitalization and death. Studies have shown a clear association between frailty and health care costs and use. It is an emerging global health burden with major implications for clinical practice and public health. Because frailty is progressive and irreversible, there is a clear indication for the provision of palliative or end-of-life care.

Risk factors for frailty

All older adults are at risk of developing frailty, particularly the old-old group of individuals aged 80 and over. The risk is higher in women than in men (interestingly, however, women appear to be more resilient — at any given age or level of frailty their mortality rates are lower), and among those with comorbid conditions, low socioeconomic status, poor diet, and sedentary lifestyle. In addition, some chronic conditions have a particularly high frailty burden, and having multiple chronic conditions increases overall vulnerability. Because people age differently, they tolerate the burden of disease differently.

Effective interventions

The evidence shows that physical exercise and nutrition are the most effective interventions for frailty. Researchers have also observed a difference in the effectiveness of interventions according to gender. Sarcopenia, low physical activity, and functional impairment are more prevalent in older women, who may benefit more from exercises than men, whereas men reap more benefits from nutrition interventions than women.

How to assess frailty

The Fried phenotype scale¹ is the best recognized tool to assess frailty, which is defined as the presence of three of more of the following: unintentional weight loss of more than 4.5 kg (10 lbs) over a year; weakness (grip strength); self-reported exhaustion; low physical activity; and slowed gait speed. Other markers of frailty include sarcopenia, being underweight, inability to perform activities of daily living or instrumental activities of daily living, depression, and impaired cognition. Quantifying the degree of frailty permits health care practitioners to identify futile interventions that will not alleviate symptoms and could worsen cognition and function. Any intervention should aim to minimize symptoms and morbid conditions.

The trajectory is known

The trajectory of frailty is well known, and every practitioner who cares for older people should be familiar with this syndrome and its consequences. There is a progressive functional decline over the years preceding death, with a slight acceleration of this decline as death approaches. Therefore, it is challenging to identify the onset of the terminal phase of the disease. Considering the particular needs of frail patients and the high burden of symptoms, palliative care should be introduced early on, at the moment of diagnosis.

Symptom relief during Covid-19

Evidence from the Covid-19 pandemic clearly shows that preexisting chronic conditions are correlated with more severe infection symptoms, which reflects underlying physical and/or cognitive frailty. If a geriatrician is the key practitioner managing older individuals, palliative care skills are essential to provide the necessary symptom relief interventions at home as much as possible, resorting to hospital care only when distressing symptoms become overwhelming, given that hospitals face a shortage of beds due to extremely high demand.

Reference

1. Fried LP, Tangen, CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, et al. Frailty in Older Adults: Evidence for a phenotype. J Gerontol 2001; 56(3): M146-M157.

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