Frailty in the Elderly

Rationale

Frailty applies to some older adults who have varying degrees of weight loss and/or malnutrition, cognitive impairment, multiple medical comorbidities, decreased mobility, and/or psychosocial stressors, leading to decreased function (e.g., activities of daily living). A multidisciplinary approach in the form of a comprehensive geriatric assessment has been shown to decrease morbidity and maintain or improve function.

Causal Conditions

(list not exhaustive)

Often multifactorial, including

1. Environmental/social (e.g., isolation, poverty, elder abuse, neglect)
2. Medical disease (including hazards of hospitalization, atypical presentations)
3. Medications
4. Malnutrition (e.g., decreased intake, malabsorption, dysphagia)
5. Psychiatric (e.g., cognitive impairment secondary to acute or chronic medical conditions, mental health issues such as depression or psychosis)
6. Changes in visual acuity
7. Changes in auditory acuity
8. Decreased mobility (e.g., falls)

Key Objectives

Given a frail elderly patient, the candidate will diagnose the cause, severity, and complications, will conduct an assessment of function and cognition, and will initiate an appropriate management plan that demonstrates an awareness of the importance of a multidisciplinary approach.

Enabling Objectives

Given a frail elderly patient, the candidate will

1. obtain and interpret critical clinical findings, including those derived from
   1. a complete psychosocial history (e.g., social supports, financial status);
   2. diagnosing symptoms of medical disease, weight loss, and malnutrition;
   3. a comprehensive medication history;
   4. screening for elder abuse and neglect;
   5. assessing the effect of symptoms on activities of daily living;
   6. assessing physical examination findings (e.g., malnutrition, stasis ulcers);
   7. assessing mental status examination and cognitive function test results using a validated scale; and
   8. validating their frailty index score;
2. construct an appropriate plan for further investigation that is supported by the history and physical examination findings; and
3. construct an effective initial multifactorial management plan, including but not limited to
   1. consultations (with medical specialists and other health professionals) or referral to rehabilitation;
   2. nonpharmacological approaches to nutrition;
   3. pharmacological/medical management, including
      1. recommend interventions to target causes of morbidity;
      2. outlining changes to medications to improve symptoms and minimize adverse effects (appropriate deprescribing, and avoiding prescribing cascades);
      3. referral where indicated to rehabilitation and/or geriatric medicine;
   4. community support services, including
      1. listing services available to support elders in the community (e.g., home care services);
      2. referring the patient for counseling about financial concerns or abuse, if required;
   5. advanced care planning;
   6. recognition of psychosocial and spiritual needs; and
   7. providing support for family members.