Listening for the Music

Frailty occurs when multiple physiological systems become dysregulated and the dysfunction exceeds the threshold for homeostasis. Fried refers to this as a transition from a homeostatic symphony to cacophony. From this perspective, the sounds of frailty are not melodious; and we know they are accompanied by increased risk for adverse outcomes. 

Frailty models explain the underlying dysregulations present in a clinical state, following a period of time in a preclinical state, and are manifested as individual deficits. As deficits accumulate frailty increases, furthering the degree of risk and reducing the remaining resilience and robustness. Understanding the concept of preclinical to clinical deficit development is central to applying frailty to the development of care plans. Deficits develop as systems become less efficient as the result of chronic illnesses. Knowing what deficits are likely to occur as a result of a specific disease can trigger vigilance to anticipate the deficit and be proactive to prevent or mitigate its impact. Likewise, when we know what deficit might occur we can develop care plans to accommodate both the deficit and the context, degree of frailty, framing recovery or rehabilitation. Mitigating and/or managing frailty is supported by care plans framed by frailty and aligned with patient goals and priorities. 

Deficit-Driven Care Plans

Frailty measurement at Patient Pattern is guided by the deficit accumulation model and is beneficial for identifying the degree of risk present and the likelihood of an adverse response to the next acute stressor. While this is valuable information for providing high-quality care to a vulnerable population, there is more benefit to measuring frailty than just risk assessment. According to Rockwood, frailty evaluations should be coupled with care planning to prevent worsening of frailty and to achieve better health. There is great reward for our patients when our clinical management reverses or slows the impact of a specific deficit.

A Word About Deficits and Assets

Deficits represent the areas of decline, the things that are not working well and have the potential to increase dependence on others. The more deficits that are present, the higher the Frailty Risk Index will be.  Assets refer to strengths and approaches with the potential of increasing independence. Balancing deficits and assets involves a holistic, interdisciplinary assessment of the patient and care plans that bridge the gap between vulnerabilities and strengths.

One Patient’s Success from One Dedicated Team and One Prehabilitation Stay 

Bill was a 50-year-old, retired hospital worker, recovering from lumbar spinal fusion and awaiting cervical spine fusion. He also was morbidly obese, had COPD, and was chronically depressed and in pain. His Frailty Risk Score was 51%, an end-of-life level, and he had just been told by his surgeon that he was not a candidate for more surgery unless some dramatic changes were made. So he came to us for “prehab” before surgery and we planned our approach to his care framed by frailty deficits and supported by his assets.

Bill’s Deficits Bill’s Assets
Obesity, shortness of breath, pain, depression, high frailty Index, recent surgery Dedicated interdisciplinary team, supportive wife, involved adult children, history of previous recoveries
Deficit-Based Care Planning: 

  • Dietary involved with dieting guidance and education
  • Respiratory therapist and pharmacist modified medications and therapy
  • Pain assessment led to significant change in analgesics to manage pain better
  • Depression medications reviewed by pharmacist and clinician and changes made
  • High frailty made recovery more difficult and advance care planning more important
  • Post-op care provided according to surgeon orders

Bill’s wife and children were included in the care planning, and their support increased his resilience and willingness to cooperate with the care plan.

 

The Rest of the Story – The Sound of Music for Bill

With four weeks of prehabilitation, each deficit improved. Bill lost 10 pounds and reduced his Frailty Risk Score by 20%. His mood improved as his pain was better managed. Best of all, he was cleared for spinal fusion surgery, returned to us for rehabilitation, and is now enjoying a more comfortable and independent life.

For more information on deficit-based care planning for frail patients please contact us at patientpattern.com. Our frailty experts would love to talk with you about how you can plan for better outcomes and quality of life for your patients.