Reducing Disability in Frail Older Adults

Pam: Hi everyone. I hail from Pittsburgh, Pennsylvania. I am really excited to talk to you about some topics that are not only passionate interests of mine, but topics that I think position occupational therapists in the  driver's seat promoting successful aging with older adults.

Frailty: Why Care?

An occupational therapist named Veronique Provencher and colleagues published an article in 2012 in the Australian Occupational Therapy Journal exploring why frailty is a concept that is underutilized and undercapitalized by occupational therapy practitioners because it is an important topic. Frailty is something that is frequently experienced by many older adults. Frailty increases older adults' risks for what we call adverse events. Often, adverse events are what bring these clients to us. They are things such as a fall, hospitalization, a nursing home placement, mortality, and something we are going to talk a lot more about today, the idea of disability. In addition to the fact that it is common in older adults and makes them more likely to have adverse events, frailty is also extremely expensive. There is a significant body of research on this topic, and what has been demonstrated is approximately 50% of acute care services, that occur in the United States, are in older adults who are frail. Frail older adults account for about 80% of all home and community-based services that are provided in our country, and it has been estimated that approximately 90% of residents in skilled nursing facilities are frail. Clearly, it is an important topic for this population and for our practice. 

Frailty vs. "frailty"

I like to differentiate frailty with a lowercase f or an uppercase F. The concept of frailty has really evolved over time. We used to call the population over 85 frail. We also called people who were dependent or sick frail. There is still a lot of gray in how to define frailty, but frailty has gone from a lowercase f to what I call this capital F. We now think about it as a syndrome.

I want you to think about the word vulnerability. A person, who is frail, is less likely to be able to tolerate stressful events. For example, if an older adult gets pneumonia, they may end up in the hospital, whereas a 21 year old or 25 year old who gets pneumonia, may not end up in the hospital. I also think about extreme temperature, cold, and heat. This is a vulnerable population who may not recover from being exposed to extreme temperatures, but a more hearty or robust population can withstand those types of stressors without having an adverse event. This idea of frailty is now taking on a more significant concept based on vulnerability. When we look at the literature, it is confusing because people use the word frail to mean a lot of things. For example, Bill Mann, an occupational therapy researcher, published research on promoting aging in place for frail older adults. His inclusion criteria was based on referrals from area agencies. Frailty was anyone was referred from an area agency on aging. That is a very different concept than looking for a specific population of people who have certain characteristics. Systematic reviews that have been completed on the topic of frailty have found that out of 47 studies on frail older adults, only three of those studies used a standardized criteria to determine whether someone is frail. I share this with you because today we are going to talk about some standardized approaches to be able to identify who is frail in the population versus someone that has some limitations but is not necessarily on that frail end of the spectrum.

Defining Frailty

As I mentioned, there has been a lot of discussion about what frailty means and who is frail, and there have been several international consensus panels that have been brought together to be able to come up with some common ground. Some of those have been Rodriguez and Manas and colleagues in 2013, Morley and colleagues in 2013, and Ferrucci and colleagues in 2004. There is an extensive list of references in the handout if you would like to follow up on these. From these international consensus panels, they came up with a set of items that should be consistent when we, as healthcare professionals, define frailty.

• A clinical syndrome
• Not disability
• Increased vulnerability in which minimal stress can cause functional impairment
• Potentially reversible or attenuated with intervention
• Important to detect as soon as possible
• General Frailty vs. Physical Frailty

The first one is that frailty is not a disease, but it is considered to be a clinical syndrome. In that regard, it is a combination of things that present challenges to people. It is not the same thing as disability, and we will spend more time on that. The consensus panels agree that frailty is manifested in increased vulnerability in which minimal stress can cause functional impairment. The consensus panel agrees that frailty is potentially reversible. Again, a key factor for occupational therapy practitioners is that frailty can at least be attenuated with intervention. The panel also agrees that it is important to detect frailty as soon as possible, and lastly, that there is a difference between general frailty and physical frailty. We will talk about those two conceptual approaches that have evolved out of the literature next.

Frailty: Two Conceptual Approaches

There are two ways to think about and measure frailty: the Frailty Phenotype and the Frailty Index. The Frailty Phenotype came about from a national cardiovascular health study. The health study looked at the cardiovascular system, but they detected that there were some characteristics of folks that increased their vulnerability more than other people that were also in the study. From that, Linda Fried and colleagues, in 2001, defined what they called the Frailty Phenotype. The Frailty Phenotype is reflective of this physical sense of frailty. The Frailty Phenotype includes several conditions.

It includes unintentional weight loss, and that is typically defined as a 10 pound loss in the past year that they did not want to lose, self-reported exhaustion, weakness, slow walking speed, and low physical activity. Weakness is typically defined through grip strength, and it typically reflects the lowest 20th percentile of people for gender and weight. Slow walking speed is defined as also being in the lowest 20th percentile of people in terms of speed. Exhaustion is based on self-report, and physical activity is also in that lowest 20th percentile. We are looking at people who fall on the very low end of each of the categories.

In contrast to the Frailty Phenotype, the Frailty Index was created by Ken Rockwood and colleagues. Instead of looking at just physical features, it really explores many more deficits. The Frailty Index defines someone as being at risk for frailty as a result of what we call accumulation of multiple deficits. That includes things like your social environment, psychosocial status, cognitive status, and not just the physical features that a person may be experiencing. Today, I am going to share with you assessment tools and intervention strategies based on these two approaches. 

The Frailty Phenotype

The Frailty Phenotype focuses on physical frailty. As you can imagine, and by looking at the criteria, it is pretty easy to quantify. Many of these areas are things that we already assess as part of our typical occupational therapy evaluation. I am going to convince you today that frailty and disability are not the same thing, but what we know is that disability is a potential result of frailty, and the Frailty Phenotype expresses that. There is an expectation that if someone is frail based on their physical characteristics, that there is a high likelihood of disability and opportunity for OT intervention. The Frailty Phenotype is frequently used in clinical practice and research.

Here are three studies that are pretty significant. Chan and colleagues (2012) looked at a randomized control trial where they provided exercise and nutrition to frail older adults, while their control group received problem solving therapy. They found that people were less frail as a result of their intervention. Fairhall and colleagues (2008) conducted a randomized control trial, and they were able to demonstrate that setting goals with clients plus engaging them in an exercise program reduced disability significantly more than usual care for a frail group of older adults. Ken Ottenbacher, an occupational therapist, has done a lot of work in examining frailty and trying to understand some of the characteristics. His work has mostly been descriptive studies looking at Mexican-Americans. He wanted to see what quantifies frailty for that population. 

The Frailty Index

The Frailty Index, as I suggested earlier, is a much more comprehensive focus. The original Frailty Index was based off of a comprehensive geriatric assessment. It was a physician or a physician group gathering as much information that they could about a client and looking at potential factors. Using this method, The Frailty Index is a little bit difficult to measure. You look at the number of health deficits that an individual has divided by the total number of health deficits considered. In the original comprehensive geriatric assessment, the researchers examined 80 items. We may look at 80 items through a chart review or through an interview, but it is likely that we do not have that many different components that we examine when we are working with clients. The other tricky part is that unlike the Frailty Phenotype, which does not measure disability to determine whether someone has frailty, disability can be a component in The Frailty Index. The Frailty Index has had more limited use in research and practice than the Frailty Phenotype. This is likely because of the increased time and burden that may be needed to complete the Frailty Index. As an occupational therapy practitioner, I think the Frailty Index aligns better with the viewpoint of an occupational therapist, the use of The Occupational Profile, and uses a top down approach. It considers more things than just physical functioning to determine whether someone is frail.

Frailty vs. Frailty-Related Disability

Just because someone is frail does not mean they are disabled, have occupational performance limitations, or activity limitations. Conversely, if someone is disabled, this does not mean that they are necessarily frail. The literature suggests that they are related, but they are distinct conditions. This is cool because if I can help someone be less frail, then I could also, as an occupational therapist, help someone be less disabled. I have two opportunities to approach this client and help to increase their wellbeing. Again, these are distinct conditions, but they are likely to co-occur and to overlap. Sometimes, one may mask the other. For example, we may determine that someone has a lot of significant difficulty with occupational performance, and we automatically conclude that they are frail. Or, we focus on their occupational performance issues, and we neglect to realize that they are frail. What we do know about frailty and frailty-related disability is that there is no linear path. Frailty may lead to disability, disability may lead to frailty, they may coexist, and initially they may occur together. If you are looking for a simple solution with frailty and frailty-related disability, you might miss opportunities to be able to intervene for both of these conditions. It is estimated that 1/4 of older adults, who are frail, do not yet have disability. Disability is a difficulty or inability to perform daily activities that are important and necessary to that person. There is a whole population of people who are at risk, or perhaps likely to become disabled, because of their frailty. Occupational therapy practitioners can provide services to delay that transition. Both frailty and frailty-related disability provide distinct intervention opportunities that we will talk about later. How frequently do you look at your clients and consider whether they are frail, and do you adjust your treatment plan accordingly? Do you treat clients who are frail differently than clients who are not frail? I hope the answer is yes, but it may be no, and that is why you are probably on this continuing education workshop today. By understanding these two terms and how you can approach them will give you more opportunity to justify your intervention plan, strategies, and the services that you provide for your clients.

Disability

I like to use the word disability. I am a practitioner, an educator, and a researcher. In the world outside of occupational therapy, the word occupation is not as readily found as the word disability. Disability, in healthcare literature, is the idea of difficulty or dependency. If you are talking to someone about disability, make sure you are talking about the same thing. It is the difficulty or dependency with carrying out activities that are essential for independent living, including essential roles. It includes tasks that are needed for self-care and living independently in the home. Disability is also the difficulty or dependency in carrying out desired activities that are important to one's quality of life. In other words, we call these occupations, but we have to be able to use both our lingo and the lingo of the world to be able to help people understand the distinct things that we do. Remember, these are not just activities that are essential to independent living, but we also are well equipped to help people with their essential roles, like a wife, grandmother, or a volunteer. Disability really goes beyond being able to dress myself and being able to get on and off the toilet. We are really good at keeping people alive, but we are not really good, as a society, of keeping people well. The definition of disability allows us to think about wellbeing and what makes value in living every day. I think occupational therapists are distinctly trained to be able to address this.