Frailty in Elderly Can Be Proactively Managed: An Expert Interview With Renee Roberts, MSN, RN, NP-C

Laurie Barclay, MD

October 21, 2008

October 21, 2008 — Editor's note: The concept of frailty has recently emerged as a crucial facet of the care of older adults. This clinical syndrome can include loss of muscle mass, generalized weakness, and poor endurance, often resulting in adverse outcomes, such as hospitalization, decline in functioning, and even death. Nurse practitioners are uniquely positioned to proactively identify frailty and to help determine whether it can be reversed or stabilized.

To find out more about the role of nurse practitioners in helping to reduce complications and healthcare costs of frailty in the elderly, Medscape interviewed Renee Roberts, MSN, RN, NP-C, about her presentation at the National Conference of Gerontological Nurse Practitioners (NCGNP), held from September 25 to 27 in St Louis, Missouri. Ms. Roberts, a board-certified adult nurse practitioner, is a clinical team leader of Evercare Georgia and a member of the National Black Nurses Association, the American Academy of Nurse Practitioners, the National Conference of Gerontological Nurse Practitioners, the American Geriatric Society, and the Georgia Medical Directors Association. She is also a board member of the Atlanta Black Nurses Association and a 2007–2008 American Health Insurance Plans Fellow.

Medscape: How widespread is frailty in the elderly, and what are its causes or underlying mechanisms?

Ms. Roberts: Researchers estimate that 3% to 7% of 65- to 75-year-olds are frail, as are about 20% of those older than 80 years. This proportion reaches a third for those in their 90s. Life expectancy today is around 78 years, unlike in 1900, when it was 47 years. As you can see, individuals are living longer with long-term or chronic illnesses. By 2020, 20% of the population, or an estimated 12 million people, will be older than 65 years. If you think that is astonishing, by 2050, 80 million people will be older than 65 years. With this shift in demographics, the problem of frailty will only escalate.

According to Dr. Linda Fried, an expert in this area, "frailty is a stage of age-related physiologic vulnerability, resulting from impaired homeostatic reserve and a reduced capacity of the organism to withstand stress." It is also characterized as a syndrome that involves a progressive physiologic decline of multiple body systems. Before the age of 75, individuals have efficient reserves to tolerate stressors or to maintain homeostasis. After the age of 75, individuals need compensation around diminishing reserves to preserve function and well being.

The presence of 3 or more of the following elements identifies an individual as being frail: weakness, as measured by grip strength; unintentional weight loss of 10 pounds or more in a year; slow gait or walking speed; low levels of physical activity; and general feeling of exhaustion or poor endurance. Sarcopenia, osteopenia, malnutrition, and depression are also common among frail older adults.

Medscape: What are the consequences of frailty in the elderly in terms of medical complications and healthcare costs?

Ms. Roberts: Frailty can occur after an acute event or as the end stage of a chronic condition, such as atherosclerosis, infection, cancer, depression, or other long-term illnesses. It is a predictor of negative outcomes or adverse health outcomes, including disabilities, institutionalization, falls, dependency, injuries, acute illnesses, hospitalizations, and mortality. Once frailty is established, and if measures are not implemented to slow down or prevent its progression, there is often a rapid decline toward death. It is important to rehabilitate these individuals early to minimize the harmful effects on illness and on their physical functioning.

According to the Medical Expenditure Panel Survey of 2001, healthcare spending more than doubles for people with chronic illnesses and activity limitations. This can lead to inappropriate hospitalizations and emergency department transfers of frail individuals. The cost to manage and care for these older adults is steadily increasing, which continues to stress our current healthcare system.

Medscape: What can be done to identify and reduce risk factors for development of frailty?

Ms. Roberts: There is clearly an opportunity for nurse practitioners to deliver quality care, improve health outcomes, and provide cost-effective care for frail individuals. In nursing homes and in community settings, nurse practitioners can proactively identify early changes in conditions to reduce risk factors and determine reversibility or stabilization potential in the development of frailty, which is of paramount importance and could save our nation money. Nurse practitioners are skilled at identifying and stratifying elderly at risk for frailty. This includes those without advanced-care plans, and those with cognitive and functional declines, behavioral problems, depression, weight loss, recurrent infections, inappropriate hospitalizations and emergency-department visits, polypharmacy, dysphagia, falls, chronic diseases, and exacerbations. Intervening early in these conditions would help reduce risk factors for the development of frailty.

Medscape: What role should nurse practitioners play in preventing, diagnosing, and managing frailty?

Ms. Roberts: It is important for nurse practitioners to design a plan of care that is highly individualized and to coordinate services that will ensure successful implementation. This includes providing evidence-based interventions while preventing, diagnosing, and managing frailty. Treating any underlying disease processes or any medical condition that can cause frailty must be the first consideration. This includes recognizing and treating depression, which is undertreated in the elderly population.

Nurse practitioners, when developing a clinical pathway and plan of care for frailty, understand specific health–illness trajectories, and they know that not everything can be reversed. This is important when determining goals and priorities of care, which can include comfort, function, and longevity.

It is important that this individualized plan of care be established on the basis of a comprehensive advanced-care plan and communicated to all providers. Successful intervention includes identifying early changes in conditions, being proactive with prompt assessment and treatment, educating patients and caregivers about key triggers of decline, and developing contingency plans for possible complications. Barriers should be identified and addressed appropriately. Care should be provided in the least invasive manner and least intensive setting.

Preventative strategies and supportive services include medication management, balance, gait, strength and exercise training, depression recognition and management, pain assessment and management, management of undernutrition, immunizations, fall prevention and injury control, and environmental safety assessment and management.

In preventing frailty, food intake should be maintained with a balanced diet that includes protein, fruits, vegetables, fiber, and fluids. Resistance exercises build muscle and help to reduce joint stiffness and pain. There is evidence that tai chi can reverse the cycle, restoring balance in the community setting.

Avoiding isolation and keeping the mind active as long as possible is important for older adults. Socializing, playing games, reading, and working on crossword puzzles are great ways to maintain mental sharpness.

Medscape: Describe the take-home message and clinical implications of your research regarding frailty in the elderly.

Ms. Roberts: The syndrome of frailty in the elderly can be challenging for clinicians because it is often subtle or asymptomatic. THe degree to which these individuals — whether robust, highly independent, vulnerable, or frail — respond to medical treatment or stressors during an acute event or at the end stage of a chronic condition makes some more vulnerable to poor or adverse health outcomes than others.

Reversing, preventing, and slowing down the adverse effects of frailty takes a multidisciplinary team approach. Proactively identifying frailty and intervening early can make a difference in the outcomes of these individuals. I cannot stress this enough.

Medscape: What new data presented at NCGNP most captured your attention regarding frailty in the elderly, and how are these findings likely to affect management?

Ms. Roberts: Many of the causes of frailty are treatable and even reversible with early identification and a comprehensive treatment plan, but there may be a point where a palliative-care approach is appropriate for frailty. We must take the whole-person approach to function, independence, comfort, and quality of life.

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