A Coming of Age Story
The history of Geriatric Medicine is a rich and interesting story, and it’s worth noting that frailty has been there from the start. The history of geriatrics actually dates back to Hippocrates and Cicero. Fast forward to 1909, when Ignatz Nascher coined the phrase “geriatrics”. Then, by 1914, he published the first American textbook in Geriatric Medicine.
Dr. John Brocklehurst edited the first comprehensive medical textbook on geriatric medicine in 1973. The text focused on all aspects relevant to caring for older people with multiple chronic illnesses that impact multiple systems simultaneously, creating a state of frailty and vulnerability or risk. In 1973, this was referred to as “clinical complexity”, calling for an interdisciplinary approach to care based in assessment and case management.
Assessing Clinical Complexity by Measuring Frailty
These landmarks set the stage for research into frailty; and according to a world-renowned expert in frailty, the notion of frailty has evolved for more than 15 years. Even though frailty remains without a consensus-based definition, experts agree that it reflects a state of increased vulnerability to adverse outcomes for people of the same chronological age. Since 2001, frailty has been explained from two divergent approaches –one based on common characteristics creating a Phenotypic Model of frailty and the other that calculates frailty on the basis of the number of deficits as a ratio of the number of things that could go wrong, thus creating a Deficit Accumulation Model of frailty.
While many frailty measurement tools have been developed and implemented, these two are the most commonly used and researched models. In spite of their differences in approach to frailty they have much in common and continue to benefit our understanding of frailty.
Screening for Frailty When Measurement is Unavailable
Screening for the presence of frailty has also led to the development of many tools best suited for bedside or clinic use. The “Clinical Frailty Scale” (CFS) is a frequently cited, widely validated, frailty screening tool. It has been in use since the 1990s and in 2020 a CFS version 2.0 was introduced. The idea behind the original CFS was to bring together information on the health deficits that accumulate over time with their impact on higher order functions that define overall health. The health deficits occur because chronic illnesses impact function and cognition. Of course, the higher order (executive) functions — such as looking after oneself, thinking and doing what one pleases, interacting with others, or moving about without falling – are affected too. Bringing both metrics of health status together helps clinicians to understand the older adult’s current baseline status and anticipates the continued decline in executive function.
Since frailty is more of a focus in USA healthcare today many specialties have adapted existing tools or created new versions to make routine care safer for those at risk. Many of these screening tools are best suited to a specific population and when implemented provide the basis for care planning to address the specific area of risk.
Frailty Meet COVID-19
Until recently, the Clinical Frailty Scale was used to guide decisions based on the degree of frailty. Care Plans benefitted when frailty framed interventions and goals. Then, the COVID-19 pandemic brought a new use for the frailty screen; and in March 2020 the NICE guidelines recommended its use for determining which clinically complex patients would do best with aggressive acute care and those who would likely be harmed because of their degree of frailty.
As uncomfortable as this guidance was and still is, the protocol in the pandemic hot spots is to acknowledge that rationing of care may become necessary in a public health emergency and criteria is needed to make appropriate decisions. Hence, many providers, unfamiliar with frailty, are being called upon to screen for its presence. The Rockwood article CFS version 2.0 was written to support clinicians called on to make this assessment and frame discussions surrounding decision-making for frail patients.
Measuring frailty is best implemented as a means of communicating meaningful information to inform care plans that move our patients towards their goals. When the interdisciplinary team speaks the same frailty language, everyone shares in moving the patient toward the goal. This can mitigate and manage frailty because it is tied to the patient’s physiological ability and their priorities of care.
If you are new to frailty screening and measurement, please visit us at patientpattern.com. We have tools and resources to get you started and answer all your questions.
To get a better sense of how to evaluate frailty, click here to begin a 10-minute Frailty Risk Assessment.