The Frail Hospitalized Older Adult   27  

Stewart M. Bond, Rebecca Bolton, and Marie Boltz

OVERVIEW

Frailty is a multidimensional geriatric syndrome characterized by multisystem dysregulation and decreased physiological reserve. The interaction of these biological abnormalities (including inflammation) results in an increased vulnerability to stressors and adverse health outcomes (Clegg, Young, Iliffe, Rikkert, & Rockwood, 2013; Song, Mitnitski, & Rockwood, 2010). Frailty is characterized by diminished strength, endurance, and reduced physiological function that increases an individual’s risk for dependence on caregivers and/or death. A longitudinal study conducted among community-dwelling older adults found that the course of disability closely mirrored the prevalence of hospital admission, indicating that aggressive measures are needed to prevent complications in frail older adults during hospitalization (Gill, Gahbauer, Han, & Allore, 2015). Nurses play a central role in the detection of frailty and in providing timely interventions to prevent complications in those who are frail, both during hospitalization and the transition to the postacute setting.

BACKGROUND AND STATEMENT OF PROBLEM

Presentation and Prevalence

Frail older adults exhibit three or more of the following characteristics: low physical activity, muscle weakness, slowed performance, fatigue or poor endurance, and unintentional weight loss (Fried et al., 2001). Between 25% and 50% of people older than 85 years are estimated to be frail (Song et al., 2010) with prevalence estimates of 7% to 16% reported in noninstitutionalized, community-dwelling older adults (Fried et al., 2001). Declines in physiological reserves and resilience are the essence of being frail (Fedarko, 2011). The development of frailty involves declines in energy production, energy usage, and repair systems in the body, resulting in declines in the function of many different physiological systems (Bandeen-Roche et al., 2006). This decline in multiple systems affects the normal, complex adaptive behavior that is essential to health (Fried et al., 2009). Frail individuals are significantly more likely to have cognitive decline, memory decline, and sarcopenia than nonfrail older adults (Nishiguchi et al., 2014).

Primary frailty occurs in the absence of significant overt disease, whereas secondary frailty is associated with known advanced disease. Although many frail older adults have chronic medical conditions and may have disability when frailty is detected, in the Cardiovascular Health Study (CHS), 63% of frail patients had no impairment in activities of daily living (ADL) and 32% had none or only one of nine chronic diseases (Fried et al., 2001). Persons with secondary frailty may have worse prognoses than those with primary frailty, as suggested by a study in which patients with diabetes, cancer, heart failure, and lung disease showed worse 4-year survival independent of features such as low weight and decreased walking (Lee, Lindquist, Segal, & Covinsky, 2006). Frailty can potentially be prevented or treated with specific modalities, such as exercise, protein-calorie supplementation, vitamin D, and reduction of polypharmacy (Morley et al., 2013). In the hospitalized older adult, the clinical presentation of frailty often includes nonspecific symptoms (e.g., extreme fatigue, unexplained weight loss, and frequent infections), and gait and balance impairment with potential falls, delirium, and functional abilities that vary day to day (Parker, Fadayevatan, & Lee, 2006).

Etiology and Epidemiology

A number of risk factors have been identified for frailty, including (a) chronic diseases, such as cardiovascular disease, diabetes, chronic kidney disease, depression, and cognitive impairment (Fried, Ferrucci, Darer, Williamson, & Anderson, 2004); (b) physiological impairments, such as activation of inflammation and coagulation systems (Walston et al., 2002); (c) anemia (Chaves et al., 2005; Roy, 2011); (d) atherosclerosis (Chaves et al., 2008); (e) autonomic dysfunction, (Varadhan et al., 2009); (f) hormonal abnormalities (Cappola, Xue, & Fried, 2009); (g) obesity (Blaum, Xue, Michelon, Semba, & Fried, 2005); (h) hypovitaminosis D in men (Shardell et al., 2009); and (i) environmental factors within the living space and the neighborhood (Xue, Fried, Glass, Laffan, & Chaves, 2008). The occurrence of frailty increases incrementally with advancing age, and is more common in older women than men and among those of lower socioeconomic status (Fried et al., 2004).

Pathophysiology

The pathophysiology of frailty is multifaceted. In addition to sarcopenia (Ferrucci, Penninx, & Volpato, 2002), a proinflammatory state that is present in cardiovascular disease, diabetes mellitus, renal insufficiency, and other diseases (Walston et al., 2002) are believed to contribute to frailty. Anemia (Chaves et al., 2005; Roy, 2011), deficiencies in anabolic hormones (e.g., androgens and growth hormone; Cappola et al., 2009), excess exposure to cortisol (Varadhan et al., 2008), insulin resistance (Barzilay et al., 2007), compromised altered immune function (Wang et al., 2010; Yao, Li, & Leng, 2011), micronutrient deficiencies, and oxidative stress (Semba et al., 2007) are also each individually associated with a higher likelihood of frailty. Thus, frailty is a consequence of cumulative decline in many physiological systems during a lifetime rather than the presence of a measurable disease state.

Outcomes Associated With Frailty

Frail older adults are at high risk of major adverse health outcomes, including disability, falls, institutionalization, hospitalization, and mortality (Fried et al., 2001; Lahousse et al., 2014). Frailty, cognitive impairment, and functional status were markers of perceived risk for negative outcomes (e.g., institutionalization, hospitalization, and death) in frail older adults (O’Caoimh et al., 2014). In older surgical patients, frailty independently predicts postoperative complications, length of stay, discharge to a skilled or assisted-living facility, and mortality (Afilalo et al., 2010; Lee, Buth, Martin, Yip, & Hirsch, 2010; Makary et al., 2010; Sundermann et al., 2011). A systematic review conducted by Sepehri et al. (2014) examined the relationship between objective frailty assessments and postoperative outcomes. Frailty, defined using multiple criteria, had a strong positive relationship with the risk of major adverse cardiac and cerebrovascular events (MACCE; odds ratio, 4.89; 95% CI [1.64, 14.60]). The authors concluded that further study is needed to determine which components of frailty are most predictive of negative postoperative outcomes before integration in risk prediction scores (Sepehri et al., 2014). In a study of older adults admitted to a Geriatric Evaluation and Management Unit (GEMU) in Australia, Dent, Chapman, Howell, Piantadosi, and Visvanathan (2014) found that psychosocial factors modify the association of frailty with adverse outcomes. Frail patients had an increased likelihood of 12-month mortality, discharge to a higher level of care, longer length of stay, and 1-month emergency rehospitalization. Psychosocial factors that increased the likelihood of adverse outcomes included anxiety, and low ratings for well-being, sense of control, social activities, and home/neighborhood satisfaction.

TABLE 27.1

The Phenotype Model: Indicators of Frailty and Measures

Frailty Models

Frailty models are underpinned by biological principles of causality and are offered to predict the clinical course and response to treatment (Bell, 2010). The two main emerging models of frailty are the phenotype model (Fried et al., 2001) and the cumulative deficit model (Rockwood et al., 2005).

The frailty phenotype proposed by Fried et al. (2001) includes five dimensions: unintentional weight loss, exhaustion, muscle weakness, slowness while walking, and low levels of activity (Table 27.1). A criticism of this model is that cognitive impairment, a highly prevalent condition associated with functional decline and disability, is not included as part of the phenotype (Rothman, Leo-Summers, & Gill, 2008). In addition, it may be difficult to use this model in hospitalized older adults whose clinical presentation may be altered by the acute illness or injury.

The cumulative deficit model views frailty as the combined effect of individual symptoms (e.g., low mood), signs (e.g., tremor), abnormal laboratory values, disease states, and disabilities (collectively referred to as deficits). This model supports the idea of reduced homoeostatic reserve, as no one deficit causes frailty but it is the accumulation of deficits that contribute to risk. Frailty, then, is viewed as a gradable syndrome (Rockwood & Mitnitski, Skoog, 2008).

ASSESSMENT OF THE PROBLEM

The International Frailty Consensus Group recommends that all individuals with significant weight loss (greater than or equal to 5%) resulting from chronic disease should be screened for frailty (Morley et al., 2013). Although many methods have been proposed in academic trials, a universally accepted screening tool for frailty in acute admissions does not exist.

Single Markers of Frailty

Grip strength and walking speed are commonly used single measures of frailty. Grip strength is evaluated as the maximum of three attempts of the dominant hand using a handheld dynamometer: low grip strength is less than 18 kg in women and less than 30 kg in men (Fairhall et al., 2008). Walking speed is measured over 6 m, with or without the use of a walking aid. Slow walking speed is defined as an inability to walk 6 m in less than or equal to 30 seconds (Smith, 1994).

Phenotypic Frailty Indices

The frailty phenotype (Fried et al., 2001), with its five indicators described earlier, is commonly used to identify frailty. Older adults with three or more of the five factors are considered to be frail, those with one or two factors as prefrail, and those without any factors as robust or not frail. Table 27.1 describes the measures associated with each indicator.

The SOF (Study of Osteoporotic Fractures) Index defines frailty as two or more of the following: weight loss (5% loss either intentional or unintentional over the past year), self-report of low energy and low mobility (unable to rise from a chair five times; Ensrud et al., 2008). The CHS Index defines frailty as three or more of the following: shrinking (unintentional weight loss of more than or equal to 4.5 kg in the past year), weakness (low grip strength), exhaustion (self-report), slowness, and low physical activity (low walking speed, defined as unable to walk 6 m in 30 seconds; Fried et al., 2001).

Multidimensional Indices

Frailty, conceptualized as an accumulation of deficits, can be assessed using a frailty index (Rockwood & Mitnitski, 2007). A frailty index allows one to quantify frailty or vulnerability resulting from multiple, interacting health-related problems (i.e., individuals with more accumulated deficits are more likely to be frail). A frailty index demonstrated greater discriminatory ability for people with moderate and severe frailty than that shown by the categorical phenotype model—a finding that has been validated independently (Kulminski et al., 2008).

A frailty index can be constructed using different numbers and types of health deficits (Searle, Mitnitski, Gahbauer, Gill, & Rockwood, 2008). It is recommended that a frailty index include at least 30 to 40 deficits to enhance its precision. Typically, the index includes information that is gathered in routine health assessments or health surveys. To score the frailty index, the deficits that are present are summed and divided by the total number of deficits on the index. Kulminski et al. (2008) created a Cumulative Deficit Index (DI) based on a set of 48 deficits, including multiple chronic medical conditions, health attitudes, symptoms, functional impairments, ADL, depression and other mental health problems, eyesight/hearing difficulties, and social support. Hubbard et al. (2011) used a frailty index based on a comprehensive geriatric assessment (FI-CGA) in conjunction with balance and mobility to assess illness and recovery in older hospitalized patients. The FI-CGA comprised 52 items covering the following: cognition, mood, motivation, health attitude, communication, strength, mobility, continence, nutrition, instrumental and basic ADL, sleep, medical problems, and medications. Similarly, Dent et al. (2014) developed and used the Frailty Index of Cumulative Deficits (FI-CD) to predict outcomes in patients admitted to a geriatric evaluation and management unit. The FI-CD included 50 multidimensional health-related deficits that were largely obtained from patients’ CGAs.

SHERPA (Score Hospitalier d’Evaluation du Risque de Perte d’Autonomie) dimensions include age, falls in the previous year before hospitalization, Mini-Mental State Exam (first 21 questions), perception of health, and instrumental activities of daily living (IADL). Scores are summed and frailty is defined as scores greater than 6 out of 11.5, consistent with the category of high risk for functional decline during hospitalization (Cornette et al., 2006).

The Multidimensional Prognostic Index (MPI) is based on a CGA and includes the following components: ADL, IADL, mental status, comorbidity, nutrition, pressure ulcer risk assessment, medication number, and living status. Problems for each component are classified as: major (1 point), minor (0.5 point), and none (0 point). Scores were summed, divided by eight, and scores greater than 0.66 are graded as frailty (Pilotto et al., 2008).

Two tools are efficient for use in the busy acute care setting. The nine-point Clinical Frailty Scale is easy to use and classifies frailty status on a range from very fit to terminally ill (Dalhouse University, n.d.). The scale has shown to be valid and reliable, and highly correlated (r = 0.80) with the Frailty Index (Rockwood et al., 2005). The five-item FRAIL scale (Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight) is another tool used to screen for frailty and the risk for disability (Abellan van Kan et al., 2008). The tool inquires about whether patients are fatigued, are unable to climb a flight of stairs or walk one block, have more than five illnesses, and lost more than 5% of body weight in the past year. Three or more positive items indicate frailty.

Care of the Hospitalized Frail Older Adult

The older adult who demonstrates characteristics of frailty requires a multifaceted approach to address the potential for or actual presence of the hazards of hospitalizations. In addition to the increased predisposition to deep vein thrombosis and adverse medication effects, frail individuals are at increased risk for worsening functional status, delirium, falls, nosocomial infections, malnutrition, dehydration, immobilization, and decubitus ulcers while in the hospital (Boockvar & Meier, 2006).

Nutritional supplements, including fortified foods and essential vitamins and minerals, may be necessary (Torpy, Lynm, & Glass, 2006). Randomized controlled trials showed oral nutritional supplements during acute illness and recovery was associated with reduced non-elective hospital readmissions (Bergstrom, 2007) and in patients recovering from hip fracture, a decreased hospital length of stay (Myint et al., 2013). Ongoing oral assessment and adequate oral hygiene are standard care. Exercise and promotion of physical activity has demonstrated a decrease in length of stay and an increased likelihood of being discharged to home (de Morton, Keating, & Jeffs, 2007). Strategies to mitigate fall risk should be implemented without restricting physical activity. Nursing processes that emphasize promotion of physical and cognitive activity, nonpharmacological approaches to behavioral manifestations of distress, the avoidance of both physical restraint and the use of indwelling urinary catheters are key elements of care and may potentially benefit frail older people, particularly those with dementia or at high risk of delirium (Parker et al., 2006).

It is critical to mobilize these interventions in tandem to address the clinical complexity of the frail older adult. Multidisciplinary collaboration with physicians, dietitians, rehabilitation therapists, and social workers will facilitate these interventions. Evidence-based approaches to prevent, detect, and manage the syndromes associated with frailty are described in detail in various chapters throughout this book.

Discussions of goals of care and advance care planning are routinely indicated when the frail older person is hospitalized (Boockvar & Meier, 2006). For patients with advanced frailty, palliative care focused on relief of discomfort and enhancement of quality of life is highly appropriate. Studies suggest that patients with serious end-stage conditions, such as cancer, end-stage kidney disease, or neurodegenerative disease, have the following priorities for treatment: symptom management, measures to optimize quality of life, sense of control, minimized burden on family, and promoting relationships with loved ones (Singer, Martin, & Kelner, 1999; Steinhauser et al., 2000).

Current evidence indicates that hospital discharge planning for frail older people can be improved if interventions address family inclusion and education, communication between health care workers and family, interdisciplinary communication and ongoing support after discharge (Bauer, Fitzgerald, Haesler, & Manfrin, 2009). Interventions that combine discharge planning and discharge support (i.e., postacute health monitoring and teaching) tend to have the greatest effects (Mistiaen, Francke, & Poot, 2007). In addition to the traditional approaches that include coordination and teaching related to the management and follow-up of the acute admitting problem, discharge planning of the frail older adult requires attention to preventing future disability (Clegg et al., 2013; Parker et al., 2006). Transitional planning requires additional foci: (a) exercise, including resistance, strength, physical movement (gait and balance) training, and lingual exercise; (b) nutritional maintenance and/or supplementation; (c) maintenance of oral health; (d) environmental modifications and; (e) family and professional caregiver education (Benefield & Higbee, 2013)

Referral to postacute services is warranted to address rehabilitative needs, dental care, assistive support, and social engagement. Alerting the postacute provider to the degree and nature of the older adult’s frailty status is critical to promote a smooth transition and prepare for care in the postacute setting. An important priority is modifying the living environment to enhance opportunities for independence and self-reliance. These interventions include grab bars; walk-in showers with shower seats; counter and cabinet height adjustments; wide doors and hallways; contrasting colors of counters, floors, walls, and dishes; nonslip surfaces; ramps; proper lighting; and emergency call systems (Crews & Zavotka, 2006). Physical therapy should include both resistance and aerobic exercise training (Carr, Flood, Steger-May, Schechtman, & Binder, 2006). Resistance training involves weight-lifting or weight-bearing exercises of the large skeletal muscle groups to increase lean body mass and improve strength, exercise tolerance, and walking speed (Fiatarone et al., 1994). After the older adult’s condition stabilizes, a recommendation for tai chi may be considered. Tai chi is a slow and gentle exercise regimen that involves both physical movement and meditation to improve balance and gait (Adler & Roberts, 2006). Additionally, lingual exercises (i.e., isometric exercises compressing an air-filled bulb between the tongue and hard palate) may help to enhance swallowing (Robbins et al., 2005).

When a frail older adult is transferred to the nursing home, details of the treatment of the acute problem as well as supportive measures to promote functional recovery need to be communicated. Family and caregiver education are needed to address the need for use of medications, nutritional approaches, oral health, promotion of socialization, and engagement in physical activity.

CASE STUDY

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Ms. T is an 88-year-old woman who was admitted to the medical unit after being brought to the emergency room from the assisted-living facility where she resides. Her admitting diagnosis is acute change in mental status. Her other medical problems include Alzheimer’s disease, a history of falls, and atrial fibrillation. The emergency department reports that Ms. T has a low-grade fever and an area of consolidation in the right lower lobe. Her lab values indicate dehydration and an elevated international normalized ratio (INR). Her medications before admission included donepezil hydrochloride/Aricept, Coumadin, and Risperdal. After spending 6 hours in the emergency department because of high patient volume and demands there, Ms. T is restless and irritable on transfer to the medical unit. Her daughter, who has her power of attorney, reports that Ms. T was admitted to the assisted-living facility 6 months ago after she lost 20 pounds over several months and began to require assistance with medications, bathing, and dressing.

Ms. T’s physical examination reveals a small, disheveled woman with an anxious appearance. An intravenous (IV) line is running; she is receiving hydration and antibiotics. The IV site is “camouflaged” and secured for comfort. Her oral mucosa is dry and dentition is fair (a few missing teeth). Ms. T is oriented to person and place but has difficulty with the Clock Draw test and can recall only one of three words. She is able to respond to a two-step verbal command. Her heart rate is 80 with an irregularly, irregular rhythm. She is able to rise from the chair very slowly with maximum help and states she is “too tired” and “too weak” to walk. Ms. T’s balance is poor, as she sways back onto the bed, when assisted to stand. Her motor strength is diminished in all extremities; range of motion is intact. Her body mass index is 18. Ms. T’s unintended weight loss, exhaustion, muscle weakness, and low activity levels are consistent with a frailty state.

The initial plan of care developed with the input of Ms. T and her daughter includes:

  Evaluation with the geriatric consultation service with a plan to secure physical therapy consultation, nutritional evaluation, and discussion of treatment goals and advance directives

  A fall-prevention plan, including an adjustable height low bed and a room close to the nurses’ station

  Careful monitoring of her INR is warranted especially with the addition of new medications

  Diligent oral care

  Careful monitoring of food and fluid intake; follow-up with the dietitian to provide dietary supplements and address food preferences

  Ongoing monitoring for delirium and implementation of nonpharmacological delirium prevention strategies

  Avoiding physical and chemical restraints

  Encouraging her daughter to bring in a few familiar items from home

  A plan for family visits/frequent presence at the bedside

  Assistance to a chair for meals and a commode for elimination. Range of motion and self-care during bathing are encouraged. Follow-up needed with physical therapy to develop a plan for ambulation, including the assistive device, as soon as possible.

  Discuss with the assisted-living facility staff the supports and resources available at discharge, including the need for postacute rehabilitation, nutritional support and monitoring, and therapeutic activities that provide social engagement, cognitive stimulation, and physical activity.

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