Frailty

Frailty refers to a condition in which older people have multiple, usually interacting, medical and social problems. Such states, with multiplicity and interaction of problems, are complex. Complexity has many consequences, each of which can make the care of a frail older person more challenging. These consequences include complexity of care, making it impossible to do just one thing at once. Every intervention has effects that go beyond the one intended.

Perhaps the most challenging consequence of this complexity is that when frail elderly people become acutely ill, they do not develop the symptoms usually associated with their illness. Emmer Freeman, 84, prepares to board the van that will take her home after a day at the Alexandrian Brothers Health System facility in St. Louis. The van is part of the All-Inclusive Care for the Elderly (PACE) program, which is designed to keep frail senior citizens in their own homes for as long as possible. (AP photo by James A. Finley.) Instead, they develop more nonspecific symptoms, such as delirium or falling. This can challenge health care professionals who are typically trained to recognize illness by the characteristic way in which patients describe their complaints. Eliciting these complaints is known as taking a history, and history-taking skills are taught to be as precise as possible, so that many health care professionals come to expect their patients to describe symptoms that specifically fit particular diagnoses. For example, a fit elderly person who develops pneumonia is likely to complain of a fever, cough, shaking chills, and shortness of breath. By contrast, a frail older person who develops pneumonia is more likely to become confused suddenly, or to fall, or simply to take to bed. Symptoms such as these are less specific, and to a health care professional without special training in how illnesses present in older people who are frail, the apparent vagueness of their complaints can be frustrating. The exact mechanism by which so many diseases of older people can present in a nonspecific way is not clear, but it likely reflects the high level of integration of organ systems required to perform such apparently simple, but actually complex, functions such as staying upright, walking about, or being mentally focused.

When an elderly person is frail, their individual organ systems usually are compromised to such an extent that new, additional impairment in one organ system—such as pneumonia, representing an infectious/immunologic impairment that compromises the respiratory system—has effects on other organ systems (such as regulation of blood pressure, or maintenance of alertness and attention). Those caring for frail elderly people must therefore be aware that attention should be paid to problems in several organ systems at once. In consequence, a systematic approach is essential. In addition, the phenomenon of compromise of many organ systems, even if they are not actually failing, increases the likelihood of poor health outcomes when people with such problems become acutely ill. The phenomenon of difficulty in regulating and integrating organ systems to maintain their balance (known as homeostasis) has been referred to as homeostenosis. The phenomenon of multiple system impairment is also referred to as allostatic loading.

Another consequence of frailty is that it alters both how drugs are handled by the body, and how even stable drug levels affect the body. In both cases the result usually is to increase the effect of the drug, so that, frequently, lower than the usual adult doses of most drugs are required. Special vigilance must be taken when prescribing a new medication to an older person who is frail.

A related consequence of multiple medical problems is that frail older people tend to see several different physicians, each specializing in one of the particular problems affecting the older person who is frail. Under these circumstances, the provision of medical care can be fragmented. There often is a need for physicians who can coordinate the overall plan of care.

Another consequence of multiple medical problems is that frail elderly people tend to be on many medications. Sometimes these drugs can interact to produce side effects that themselves require treatment. This problem, known as polypharmacy, is particularly important because the more drugs that a person takes, the higher the chance that they will have an adverse drug reaction.

When older people are frail, they are likely to need assistance to perform daily activities required to remain in the community, such as cooking, shopping, or using the telephone. Special care must be taken to maximize function in these areas, or to provide support should help be needed. Maximizing the function of a frail older person is often the special responsibility of physical and occupational therapists.

People who are frail may also require help with more personal aspects of daily care, such as grooming, toileting, dressing, or even eating. When such dependence occurs, an older person cannot live in the community without a caregiver. This caregiver becomes an essential part of the health picture for those providing health services. How the caregiver feels about their caring role, and how their own health is being affected by having to provide care, become important concerns for both the patient and the health care team. Within a health care team, this aspect is often addressed by a social worker.

The care of older people who are frail requires the specialized skills of many health care professionals. While they each apply their own skills, they face the challenge of doing so in a way that complements the others, and which conforms to the needs and wishes of the patients.