BACKGROUND/STATEMENT OF PROBLEM

A.  Presentation and prevalence

1. Frailty is characterized by physical factors such as low physical activity, decreased muscle strength, and unintentional weight loss, as well as cognitive, emotional, social, and spiritual aspects.
2. Between 25% and 50% of people older than 85 years are estimated to be frail with an estimate of 10.7% reported in noninstitutionalized, community-dwelling older adults.
3. Decline in multiple systems affects the normal complex adaptive behavior that is essential to health.
4. Primary frailty occurs in the absence of significant overt disease, whereas secondary frailty is associated with known advanced disease.
5. Frailty can potentially be prevented or treated with specific modalities, such as exercise, protein-calorie supplementation, vitamin D, and reduction of polypharmacy.
6. In the hospitalized older adult, the clinical presentation of frailty often includes nonspecific symptoms, and gait and balance impairment with potential falls, delirium, and functional abilities that vary from day to day.

B.  Etiology and epidemiology

1. Risk factors include (a) chronic diseases; (b) physiological impairments, such as activation of inflammation and coagulation systems; (c) anemia; (d) atherosclerosis; (e) autonomic dysfunction; (f) hormonal abnormalities; (g) obesity; (h) hypovitaminosis D in men; and (i) environmental characteristics.
2. 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.

C.  Pathophysiology

1. The pathophysiology of frailty is considered to be multifaceted, and it reflects a consequence of cumulative decline in many physiological systems during a lifetime.
2. Contributors to frailty include sarcopenia, a proinflammatory state, anemia, deficiencies in anabolic hormones, excess exposure to cortisol, insulin resistance, compromised or altered immune function, micronutrient deficiencies, and oxidative stress.

D.  Outcomes of frailty

1. Frail older adults are at high risk for disability, falls, institutionalization, hospitalization, and mortality.
2. Frailty increases risk of MACCE.
3. Frailty independently predicts postoperative complications, length of stay, discharge to a skilled or assisted-living facility in older surgical patients, and mortality.
4. Psychosocial factors that increase the likelihood of adverse outcomes include anxiety, as well as low sense of well-being, sense of control, social activities, and home/neighborhood satisfaction.

E.  Frailty models

1. The frailty phenotype proposed by Fried et al. includes five dimensions: unintentional weight loss, exhaustion, muscle weakness, slowness while walking, and low levels of activity.
2. The cumulative deficit model views frailty as the combined effect of individual symptoms (e.g., low mood); signs (e.g., tremor); and abnormal laboratory values, disease states, and disabilities (collectively referred to as deficits).

ASSESSMENT OF FRAILTY

A.  Single markers of frailty

1. 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 (women), less than 30 kg (men).
2. Walking speed is measured over 6 m, with or without the use of a walking aid. Slow walking speed is defined as unable to walk 6 m in 30 seconds.

B.  Phenotypic frailty indices

1. The frailty phenotype, with its five indicators, is commonly used to identify frailty. Those with three or more of the five factors are considered as frail, those with one or two factors as prefrail, and those with no factors as not frail or robust older adults.
2. The SOF Index (Study of Osteoporotic Fractures frailty scale) defines frailty as two or more of weight loss (5% loss either intentional or unintentional over the past year) and self-report of low energy and low mobility (unable to rise from a chair five times).
3. The FRAIL Index classifies frailty as three or more of fatigue (self-report), resistance (unable to rise from a chair five times), ambulation (slow walking speed), illnesses (greater than or equal to five illnesses on CCI), and loss of weight of 5% or more in the past year.
4. The CHS Index defines frailty as three or more of shrinking (unintentional weight loss of 4.5 kg or more in the last 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).

C.  Multidimensional indices

1. A frailty index can be constructed using different numbers and types of health deficits.
2. The DI is 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.
3. The FI-CGA comprises 52 items covering the following: cognition, mood, motivation, health attitude, communication, strength, mobility, continence, nutrition, instrumental and basic ADL, sleep, medical problems, and medications.
4. The FI-CD includes 50 multidimensional health-related deficits largely obtained from patients’ CGAs.
5. SHERPA dimensions include age, falls in the previous year before hospitalization, Mini-Mental State Exam (first 21 questions), perception of health, and IADL.
6. The MPI components include ADL, IADL, mental status, nutrition, pressure ulcer risk assessment, number of medications, and living status.
7. The nine-point Clinical Frailty Scale is easy to use and classifies frailty status on a range from very fit to terminally ill. The scale has been shown to be valid and reliable, highly correlated (r = 0.80) with the frailty index.
8. The five-item FRAIL scale is another tool used to screen for frailty and the risk for disability.

CARE OF THE HOSPITALIZED FRAIL OLDER ADULT

A.  Multifaceted plans of care: require multidisciplinary collaboration

1. Evaluate need for nutritional supplements, including fortified food and supplements of essential vitamins and minerals mass.
2. Ensure oral assessment and adequate oral hygiene.
3. Promote self-care, continence, mobility, and cognitive stimulation; avoid restraints.
4. Avoid indwelling urinary catheters.
5. Implement strategies to decrease fall risk.

B.  Involvement of patient and family in decision-making

1. Establish clear goals of care based on patient preferences and needs.
2. For patients with advanced frailty, offer palliative care focused on relief of discomfort and enhancement of quality of life.
3. Whenever possible, combine discharge planning and discharge support (postacute follow-up).
4. Plan to prevent future disability: (a) exercise, including resistance, strength, physical movement (gait and balance) training, and lingual exercise; (b) nutritional maintenance and/or supplement; (c) maintenance of oral health; (d) environmental modifications; and (e) family and professional caregiver education.

C.  Referral to postacute services is warranted to address rehabilitative needs, dental care, assistive services, social engagement, and environmental home safety.

D.  Communication to the postacute provider details the treatment of acute problems as well as supportive measures to promote functional recovery.

E.  Family and caregiver education is needed to address the need for use of medications, nutritional approaches, oral health, promotion of socialization, and engagement in physical activity.

EVALUATION/EXPECTED OUTCOMES

A.  Patient outcomes

1. Improved functional and nutritional outcomes
2. Delirium detection, avoidance, and abatement
3. Prevention of complications: falls, delirium, pressure ulcers, adverse drug events
4. Less hospital readmissions and decreased length of stay

B.  Clinician outcomes

1. Assessment, identification, and management of older adults susceptible to or experiencing frailty
2. Documentation and communication of the patient’s functional and cognitive capacity, interventions used, and outcomes
3. Competence in preventive and restorative strategies for preserving independence and function
4. Educate older adult and family caregiver(s) on intervention strategies to preserve function and reduce task demand in the preferred home or care setting.

C.  Organizational outcomes

1. Assessment of frailty as indicated
2. Prompt and accurate referral for evaluation of frailty
3. Increase in prevalence of patients who leave the hospital care facility or professional home care with baseline or improved functional status
4. Support of institutional policies and programs that promote function, for example, caregiver educational efforts and walking programs
5. Evidence of continued interdisciplinary assessments and evaluation of care
6. Environmental approaches that support function and comfort

ABBREVIATIONS

ADL            Activities of daily living

CCI              Charlson Comorbidity Index

CHS             Cardiovascular Health Study

DI                Cumulative Deficit Index

FI-CD          Frailty Index of Cumulative Deficits

FI-CGA       Frailty Index based on a comprehensive geriatric assessment

FRAIL        Fatigue, Resistance, Ambulation, Illnesses, and Loss of Weight scale

IADL           Instrumental activities of daily living

MACCE      Major adverse cardiac and cerebrovascular events

MPI             Multidimensional Prognostic Index

SHERPA     Score Hospitalier d’Evaluation du Risque de Perte d’Autonomie

SOF             Study of Osteoporotic Fractures

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 31:   Bond, S. (2021) The Frail Hospitalized Older Adult.   In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 563-575).   New York: Springer.