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“Frailty is everyone’s business, and recognizing it improves outcomes and helps people live well longer,” said William Mills, MD, BrightSpring Health Services’ senior vice president of medical services, during Frailty: Why It Is Important, How to Identify It, and Programs to Help, a 2023 Clinical Impact Symposium webinar.
Addressing frailty is essential on many fronts. As Mills said, “Evidence shows that age, frailty, chronic disease load, and ADL dependency are predictive of mortality, hospitalization, and total cost.” At the same time, severe frailty is associated a five-fold higher risk of death at one year.
Frailty not only needs to be on your radar; you need a methodical, team-based, person-centered system to address this. The following are 7 elements your efforts should include:
Mills noted that frailty generally is “a clinically recognizable state in which the ability of older people to cope with everyday or acute stressors is compromised by an increased vulnerability brought by age- associated declines in physiological reserve and function across multiple organ systems.” He added that the most commonly used definition is the “frailty phenotype,” which consists of five physical components: weight loss, weakness, exhaustion, slowness, and low physical activity level.
Individuals aren’t likely to report that they are getting frail or weak. Instead, they may say things like: “The stairs are getting so hard to climb;” “Since my wife died, I just open a can of soup for dinner;” “I’ve lived here 40 years, and no other place will seem like home;” “I’m having more trouble getting around;” and “I’ve had a couple of falls – not too bad, though.” Family and team members need to be alert for signs that a patient is experiencing increasing frailty or frailty-related issues.
Mills said, “A clinical frailty tool should be quick, inexpensive, reliable, and easy to use in clinical settings because the identification of frail older people at risk is an important initial step potentially leading to appropriate preventive or treatment interventions and ultimately to higher quality care for this vulnerable population.” He noted that FRAIL scale is a simple questionnaire consisting of five yes or no questions addressing fatigue, resistance (inability to climb stairs), ambulation (inability to walk a certain distance), Illnesses (more than five comorbidities) and weight loss.
This scale, he said, has been shown to be able to predict mortality and incident ADL and IADL disabilities among community-dwelling older people in recent meta-analysis studies.” Other potentially useful instruments include the Clinical Frailty Scale, Edmonton Frail Scale, INTER-FRAIL Prisma-7, Sherbrooke Postal Questionnaire, Short Physical Performance Battery, and Study of Osteoporotic Fractures Index.
Mills said, “An exciting project we have worked on involves a claims-based assessment to detect frailty. This is a unique opportunity to identify patients who may need specific interventions and provide them with those services.”
This should include resistance training, aerobic exercise training, balance training, and flexibility training. Mills and Renee Lach-Sharon, PT, MS, CPHQ, manager of therapy clinical and quality services at Rehab Without Walls NeuroSolutions, who also spoke at the webinar, talked about a new BrightSpring exercise program adapted from a program at the University of Otago in New Zealand. “The Otago program initially focused on falls prevention and found it useful in this regard. It has shown that even in higher risk populations, it was able to reduce falls by 35%, and it improved things like mobility and hand grip strength. We are looking at using it with very old adults who have multiple risk factors such as arthritis and deconditioning,” said Lach-Sharon.
This involves an individually tailored, home-based balance and strength falls prevention program delivered by a physical therapists and available via home health. Lach-Sharon stressed that intensity is key to the success of this program. This means sessions three days a week for each category of exercise, with a rest day between exercising in the same category. “We are looking to roll this out in the home health environment. Each visit would be about 45-60 minutes, then we would conduct follow-up calls to check in. This is key to the success of the program, as we are trying to make this a lifestyle change,” said Mills, adding, “One goal is to get these individuals into community-based exercise programs for socialization. This makes a tremendous difference in compliance.”
This should include the use of your frailty assessment tool as well as measurements of gait speed, 30-second chair rise, and balance (4-stage balance test: stand with feet side by side, place instep of one foot so it is touching the big toe of the other foot, place one foot in front of the other – heel touching toe, and stand on one foot). Mills noted that, according to research, “The inability to stand on one leg for 10 seconds in mid to later life is linked to a near doubling in the risk of death from any cause within the next 10 years.”
Ideally, a good frailty program should be led by a trained physical therapist. BrightSpring is rolling out a national program currently. After starting the program led by physical therapy, leveraging technology, including efforts such as exercise videos and remote therapeutic monitoring can be useful as well. Make effective use of non- skilled staff and caregivers. For instance, consider using a standardized assessment tool to enable caregivers to address social determinants of health. “It is important to provide structure, clinical assessments and support between visits to assess frailty, falls risk, etc.,” Mills said, adding, “Make sure you provide a system for patients to get access to medications and maximize compliance with medication regimens.”
By assessing and addressing frailty, providers can manage patient proactively, instead of reactively. “We think an exercise prescription will be an innovative and exciting way to positively impact frail elders,” Mills said.