|Year : 2016 | Volume
| Issue : 2 | Page : 101-106
Visiting a “frail elderly”: A review on model of care and treatment strategies
Tarun Rao, Vishakha Jain, AP Jain
Department of Medicine, MGIMS, Wardha, Maharashtra, India
|Date of Web Publication||31-Aug-2016|
Department of Medicine, MGIMS, Sevagram, Wardha - 442 102, Maharashtra
Source of Support: None, Conflict of Interest: None
Frail elderly are those who have less than normal physiological reserve which predisposes them to more severe adverse outcomes following a stressor compared to normal. As the number of elderly is increasing worldwide, there is increase in the problem of frailty. Frailty is a dynamic state in the sense that if interventions are directed to correct the state of frailty, then an elderly starts to shift toward normal side and if not then deteriorated even more. When it comes to managing a frail elderly, then the place of care can be patientfs home as well as health care facility. Comprehensive geriatric assessment and program for all.-inclusive care for the elderly are the concepts that advocate multidisciplinary approach for the management of frail elderly. There is increasing evidence in favor of the management of these patients at their home and delaying the transfer to health care facility till these patients cannot be managed at home. Apart from the specific treatment of the acute illness and the underlying chronic illness, there are other interventions cum life style modification which can help in improving a frail state. These includes increasing content of whey protein, essential amino acids in the diet, combination of resistance and endurance exercises, Vitamin D supplementation, and pharmacotherapy such as testosterone, ghrelin, and growth hormone.
Keywords: Comprehensive care, frail elderly, model of care, program for all.-inclusive care for the elderly
|How to cite this article:|
Rao T, Jain V, Jain A P. Visiting a “frail elderly”: A review on model of care and treatment strategies. J Mahatma Gandhi Inst Med Sci 2016;21:101-6
|How to cite this URL:|
Rao T, Jain V, Jain A P. Visiting a “frail elderly”: A review on model of care and treatment strategies. J Mahatma Gandhi Inst Med Sci [serial online] 2016 [cited 2020 Jul 15];21:101-6. Available from: http://www.jmgims.co.in/text.asp?2016/21/2/101/189542
| Introduction|| |
As the age advances, the body systems start to show a decline in function. This decline is usually a gradual one because the physiologic reserve depletes gradually. But in some individuals, especially during stress, the body function deteriorates more rapidly and profoundly. These elderly are referred to as “frail.” The concept of “frail elderly” is not new, but is becoming clinically and socially more important with increasing number of elderly in the population, so the importance to understand and manage these elderly increases. The numbers speak for themselves as elderly population all over the world is expected to increase to 2 billion by 2050. The importance of knowing and recognizing frailty lies in the fact that frail elderly respond quite differently to disease process as well as to the treatment of various ailments that they suffer with. Dynamic nature of frailty can help predict adverse health events and hence intervention focused on its determinants can prevent disability. The reversible nature of frailty makes it a concept necessary to recall when interventions are planned.
| Comprehensive Geriatric Assessment and Program for All-Inclusive Care for the Elderly|| |
Apart from old age, multiple chronic diseases along with the lack of social support impose great challenges for those managing frail patients. Hence, an interdisciplinary team-based approach is needed for managing frail elderly. Frailty management approach can be either individual clinician (usually a primary care clinician or a geriatrician) managing a patient or a more intensive multidisciplinary program, also known as a comprehensive geriatric assessment (CGA).
Comprehensive geriatric assessment
Marjory Warren of United Kingdom in 1946 while caring for neglected and bedridden elderly proposed a comprehensive assessment of elderly prior to their placement in chronic hospital or nursing-home facilities. CGA is defined as a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail elderly in order to develop a coordinated plan to maximize overall health with aging. CGA includes the assessment as well as management of elderly population and the process starts with the referral by a physician who came in first contact with the patient. CGA has its utility and implication in various settings such as hospital geriatric units, Chronic Care Model for ill and impaired adults, and program for all-inclusive care for the elderly (PACE).,
CGA team includes physician, nurse, and social worker and when appropriate, draws upon an extended team of physical and occupational therapists, nutritionists, pharmacists, psychiatrists, psychologists, dentists, audiologists, podiatrists, and opticians. The level of care can be various like at home, outpatient or inpatient, and acute care units.
The multidisciplinary team of CGA work to achieve the following goals:
- To improve physical and psychological function
- To optimize medication prescription and use
- To decrease nursing home placement, hospitalization, mortality risk
- To improve patient satisfaction.
Program for all-inclusive care for the elderly
Acts through an interdisciplinary team approach and was designed in 1997 with the goals to improve function, overcome environmental challenges, and keep older adults living in their communities by preventing institutionalization. PACE aims at providing health care, as minimum as possible in hospital setting through the promotion of day care centers. The interdisciplinary team includes a geriatrician, nurses, physical and occupational therapists, and social workers. Services provided include home nursing, physical and occupational therapy, transportation, aide service, and adult day care. Patients who enter the program receive complete long-term care and are followed until the end of their lives, even if they eventually require placement in an assisted-living facility or nursing home. The health care cost is lower with PACE as compared with traditional fee-for-service care.
| Settings for Care of Frail Elderly|| |
One physician/one patient visit approach
This approach refers to the usual medical care in which a physician manages a patient. Adding to the this, Ganz et al. have proposed the following inclusion criteria in the care of frail elderly:
- Accessibility to community resources for housing, health promotion, and caregiver support
- Co-management involving physician and nurse or physician assistant
- Facilities including the following: Adjustable height tables, clearance for wheelchair maneuvering, microphones/headsets for hearing impaired, adjustable walker
- Staff education for communicating with frail elderly
- Team discussion for managing complicated patients
- Support personnel (nurses, social workers) with specialized gerontology training
- Full integration of electronic communications and information technology
- Block scheduling.
Block scheduling refers to giving appointment to several patient for a time period rather than allotting a fixed number of minutes to every patient. For example, scheduling an hour for three patients rather than allotting a specific duration say 20 min to each of them. This is particularly helpful for “frails” who are likely to come late due to dependence on others for issues such as transportation.
| Hospital Care|| |
The hospital environment is much different from anyone's home environment, and this difference can be a source of significant morbidity for a frail elderly. Along with the so called alien hospital environment, medications, immobility, and acute illness can result into devastating outcomes for these vulnerable elderly. The decline in the level of function and self-care independence that occurs during hospitalization often persists after discharge. With hospitalization, risk for institutionalization and reduction in the quality of life increases. A prospective cohort study conducted in Connecticut found that frail individuals had a seven time (35% vs. 7%) more risk of progressing from no disability to mild disability within 1 month of hospitalization, compared to nonfrail patients.
| Acute Care for Elders|| |
Specific gerontology intervention to manage acutely ill hospitalized elderly can alter in-hospital course among frail patients. Acute care for elders (ACE) deals with and aims to prevent functional decline and improve functional independence following decline. The interventions include a specially designed home-like environment; patient-centered medical care that focuses on the prevention of disability; and comprehensive discharge planning and management. A randomized controlled trial, which studied 1531 elderly aged seventy and older, found that ACE decreased the likelihood of activity of daily living decline or nursing home placement both at hospital discharge and at 12 months without an increase in hospital length of stay or hospital costs.
| Tailoring Individual Care|| |
Prevention of diseases should start at younger age as in the older patients, possibility or value of primary and secondary prevention is less; hence leading to greater stress over tertiary prevention. Above 85 years of age, conventional screening tests are unlikely to be of significant benefit. With the deterioration along the frailty spectrum, it is important to tailor medical care to the needs of these vulnerable elderly while keeping the individual's values and goals in mind. Breast cancer screening, smoking cessation, hypertension treatment, and vaccination for infectious diseases are among the most firmly proven and well-accepted specific preventive strategies. Physical exercise has also been shown to have promising change, especially for frail elderly. Frequent reminders in the form of summary table of recommendations or flow sheets may be valuable in helping the physician carry out prevention and screening programs. For frail elderly, the geriatrician should appropriately treat known chronic diseases, manage intermittent acute illness and events, and assure age-appropriate screening measures and preventive care.
Aggressive screening or intervention for nonlife threatening conditions may result in serious complications. Procedures or hospitalizations may bring about unnecessary burden and decreased quality of life to a patient who is already at great risk of morbidity and mortality. Hence, approach should be properly planned and care of a frail elderly should always be individualized.
| Strategies for Treatment of Frail Elderly|| |
Treatment of acute illness
Treatment of acute illness that the elderly is suffering with is important as if acute disease process is not taken care of then these elderly with a poor physiological reserve will deteriorate very rapidly. For the management of an elderly with acute illness, principles similar to the management of other elderly patients with similar illness are followed along with special address to the state of “frailty.” In the present review, the focus is upon the issues which are routinely not considered primary when it comes to the management of ill frail elderly.
Reduced muscle mass hastens the development of frailty among elderly. Decrease in muscle mass occurs with decreasing weight. Loss in weight is usually preceded by anorexia which can predict adverse outcome such as mortality. Nutrition can be assessed by tools such as mini nutritional assessment – a thirty-item scale  or simplified nutrition assessment questionnaire – a four-question scale, validated for community, and institutions for anorexia. The loss of muscle mass results from imbalance in protein intake and protein degradation. The protein requirement of healthy adult is 0.83 g/day and that of an elderly is 0.89 g/day and this further increases to as high as 1.3 g/day in acute conditions such as hospitalization., Increased intake of amino acids through the supplementation can improve protein synthesis. Vegetable proteins are inferior to animal proteins as diet rich in vegetable proteins result in lower inhibition of protein breakdown in muscle compared to diet rich in animal proteins. The concept of fast and slow proteins has a significant relevance in the management of frail elderly. Fast proteins, e.g., whey protein are those proteins which are rapidly absorbed after intake and they appear in the blood faster and at the same time the amount of these proteins is higher in blood following absorption compared to the slow proteins. Hence, fast proteins enhance muscle anabolism. Presence of essential amino acids helps in improving muscle anabolism and supplementation of nonessential amino acids do not have a significant impact over muscle anabolism. It is recommended to take a large amount of amino acids in a single meal rather than the same amount divided in several meals over the day as this strategy is better in improving muscle mass. Timing of the intake of essential amino acids in relation to resistance exercise is important, as essential amino acids taken just prior to resistance exercise are better in improving the muscle mass compared to their intake at a distant time from exercise time.
Vitamin D deficiency is a frequent problem in elderly resulting in proximal muscle weakness; hence, it is recommended to supplement Vitamin D to those with 25 hydroxy Vitamin D level <100 nmol/L. Supplementation of 800 IU of Vitamin D for 2–12 months results into significant improvement in lower limb weakness, and it also results in decreased risk of falls by 19% in the elderly.
Inactivity leads to decrease in muscle mass and strength. Among elderly aged >60 years, there occurs gradual decrease in muscle mass, it is 2 kg/decade in males and 1 kg/decade in females. Confinement to bed results in rapid loss of 1.5 kg over 10 days of lean mass mainly in lower extremities. Resistance exercises increase muscle mass in frail elderly. Muscle strength improves with a few days of starting resistance exercise but muscle mass take 6–8 weeks to improve. According to American Heart Association, an elderly is required to perform 1 set of 8–12 repetitions and 10–15 repetitions at reduced level of resistance. Resistance exercise should be performed 2–3 times/weeks with 8–10 different exercises each time. Endurance training is also helpful in improving muscle strength and mass but not as much as resistance exercises. Endurance exercises such as walking, jogging, and swimming increase the maximum oxygen consumption, and hence decreases fatigue and elderly generally have better compliance with endurance exercises. Resistance and endurance exercises improves insulin resistance and its anabolic effect, especially in the presence of amino acids. Combination of resistance and endurance exercises is the best approach to improve the compliance, oxygen consumption, muscle mass, and strength.
It is suggested that as the age declines testosterone level decreases so is the muscle mass and strength. Testosterone administration improves muscle mass in hypogonadal males but similar effect among community dwelling males could not be demonstrated through studies., But routine administration of testosterone to frail elderly cannot be done as it can result into serious cardiovascular side effects. Selective androgen receptor modulators may be a potential alternative as they lack the side effect profile of testosterone.
Growth hormone supplementation has not been found to increase in muscle mass or strength even in combination with resistance exercises. However, recent findings suggest that combined growth hormone and testosterone results into increase in lean mass by up to 7.5 kg and muscle strength by 30%.
Ghrelin, a peptide hormone produced by stomach in response to fasting, is being assessed with promising effect to reduce wasting. Tibolone, a steroid with estrogenic, progestogenic, and androgenic activity, has been found to have positive effect although controversial on functional performance due to its beneficial effect on fat mass.
A recently discovered member of transforming growth factor beta family is expressed in skeletal muscles and inhibits its growth. Hence, drugs that can antagonize myostatin can help prevent sarcopenia and hence help in improving frailty. A report has mentioned that recombinant human antibodies to myostatin tested in healthy postmenopausal women could increase the lean body mass by 2.5% after 15 days of treatment.
Acute care for elders inhibitors
Those elderly who use ACE inhibitors as antihypertensive are likely to have better lower limb mass and are likely to perform better on 6 min walking test than those taking other antihypertensive.
Although recently proposed by a panel of experts for the prevention and management of sarcopenia, some trials have reported increase in lean mass after 3 months of treatment with creatine. However, other trials have failed to demonstrate any increase in lean mass with creatine.
| Conclusion|| |
As the number of elderly increase, those affected with frailty is likely to grow. Importantly, frail state is dynamic and if intervened appropriately can be reversed also. This emphasizes the role of appropriate and timely recognition of this problem and directed intervention to manage this. Hence a well structured model of care to meet the multiple needs of “Frail” is likely to have a positive impact over this population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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