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TIME TO ADDRESS “FRAILTY CREEPAGE” IN THE CANADIAN HEALTHCARE SYSTEM

J. Young

J Frailty Aging 2018;7(4):206-207

CITATION:
J. Young (2018): Time to address “frailty creepage” in the Canadian healthcare system. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2018.28

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IMPLEMENTING FRAILTY MEASURES IN THE CANADIAN HEALTHCARE SYSTEM

D.B. Rolfson, G.A. Heckman, S.M. Bagshaw, D. Robertson, J.P. Hirdes, On behalf of Canadian Frailty Network

J Frailty Aging 2018;7(4):208-216

Canadian healthcare is changing to include individuals living with frailty, but frailty must be better operationalized and better framed by sound data standards and policy. Frailty results from deficit accumulation in multiple body systems, with exaggerated vulnerability to external stressors. A growing consensus on defining frailty sets the stage for consensus on operationalization and widespread implementation in care settings. Frailty measurement is not yet integrated into daily clinical practice in Canada. Here, we will present how this integration might occur. We hope to demonstrate that implementation must appeal to inter-professional practice needs in different settings or circumstances. In some settings, methods for frailty case finding are expected to evolve as deemed to be most appropriate to the front-line users. In this “hands-off” approach, care providers, supported by emerging knowledge translation on frailty operationalization, would be informed by their setting and local practices to establish patterns of ad hoc case finding and component definition of frailty. This more nimble case finding strategy would be opportunistic, and would appeal to expert clinicians and self-directed teams who emphasize an individualized health care experience for their patients. In other settings, we can shape frailty case finding by building care algorithms around existing standardized practices and data repositories, leading to a systematic application of frailty measures and a more coordinated process of component definition and care protocols. Here, recommended instruments and data standards must be endorsed by health networks locally, provincially and nationally. The interRAI suite of assessment instruments has pan-Canadian standards in place and its pervasiveness makes it the most obvious starting point, especially in home care and long-term care. We anticipate the evolution of an integrated model informed by stakeholders and settings, where policy makers focus on system supports for frailty case finding, while front-line clinicians use case finding strategies to pinpoint and act on key frailty components.

CITATION:
D.B. Rolfson ; G.A. Heckman ; S.M. Bagshaw ; D. Robertson ; J.P. Hirdes ; On behalf of Canadian Frailty Network (2018): Implementing Frailty Measures in the Canadian Healthcare System. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2018.29

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SOCIAL AND SOCIETAL IMPLICATIONS OF FRAILTY, INCLUDING IMPACT ON CANADIAN HEALTHCARE SYSTEMS

M.K. Andrew, S. Dupuis-Blanchard, C. Maxwell, A. Giguere, J. Keefe, K. Rockwood, P. St. John, On behalf of Canadian Frailty Network

J Frailty Aging 2018;7(4):217-223

Frailty has many social and societal implications. Social circumstances are key both as contributors to frail older adults’ health outcomes and as practical facilitators or barriers to intervention and supports. Frailty also has important societal implications for health systems and social care policy. In this discussion paper, we use a social ecology framework to consider the social and societal implications and impact of frailty at each level, from the individual, through relationships with family and friend caregivers, institutions, health systems, neighborhoods and communities, to society at large. We conclude by arguing that attention to these issues at a policy level is critical. We identify three target actions: 1) Social dimensions of frailty should be systematically considered when frailty is assessed. 2) Action is needed at the level of policies and programs to improve support for caregivers. 3) Policy review across all portfolios will benefit from a social frailty lens.

CITATION:
M.K. Andrew ; S. Dupuis-Blanchard ; C. Maxwell ; A. Giguere ; J. Keefe ; K. Rockwood ; P. St. John ; On behalf of Canadian Frailty Network (2018): Social and societal implications of frailty, including impact on Canadian healthcare systems. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2018.30

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ETHICAL AND LEGAL IMPLICATIONS OF FRAILTY SCREENING

L. Reid, W. Lahey, B. Livingstone, M. McNally, On behalf of Canadian Frailty Network

J Frailty Aging 2018;7(4):224-232

Goals of screening for frailty include (a) promoting healthy aging, (b) addressing frailty with preventive and targeted interventions, (c) better aligning social and medical responses to frailty with the needs of frail older adults and (d) preventing harms to frail older adults from excessive and inappropriate medical interventions that are insensitive to the implications of frailty. However, the medicalization of frailty and outcomes of the screening process also risk harming frail older adults and their autonomy through stereotyping and by legitimizing denial of care. This risk of harm gives rise to ethical and legal questions and considerations that this paper addresses. Frailty screening that is ethically defensible will situate and support healthcare that is consistent with people’s needs, circumstances and capacity to benefit from the care provided. We also call for an informed consent process that incorporates supported or shared decision making in order to protect the autonomy of frail older adults.

CITATION:
L. Reid ; W. Lahey ; B. Livingstone ; M. McNally ; On behalf of Canadian Frailty Network (2018): Ethical and Legal Implications of Frailty Screening. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2018.31

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POLICY AND ECONOMIC CONSIDERATIONS FOR FRAILTY SCREENING IN THE CANADIAN HEALTHCARE SYSTEM

K. Grimes, J. Kitts, B. Tholl, C. Samuelson-Kiraly, J.I. Mitchell, On behalf of Canadian Frailty Network

J Frailty Aging 2018;7(4):233-239

Canada faces significant policy and economic challenges related to healthcare for frail older adults. Annual per capita healthcare costs for people over age 65 are five times those for people under 65. Flat economic growth and an aging workforce decrease tax revenue, which funds 70% of health spending. Governments are shifting policy to enhance person-centered care and shifting spending from hospitals to primary and community care. Recognizing that frailty and evidence-based frailty screening can contribute directly to reform initiatives, what are the policy and economic considerations, both nationally and internationally, around frailty screening that will benefit patients, families and/or the wider health system? Based on key informant interviews, we present recommendations for approaching policy and economic challenges in frailty through the following healthcare policy instruments: financing, funding, legislation, regulation, technology, interdisciplinary care, person-centered service and health promotion.

CITATION:
K. Grimes ; J. Kitts ; B. Tholl ; C. Samuelson-Kiraly ; J.I. Mitchell ; On behalf of Canadian Frailty Network (2018): Policy and Economic Considerations for Frailty Screening in the Canadian Healthcare System. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2018.32

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IMPROVING END-OF-LIFE CARE AND ADVANCE CARE PLANNING FOR FRAIL OLDER ADULTS IN CANADA

J. Downar, P. Moorhouse, R. Goldman, D. Grossman, S. Sinha, T. Sussman, S. Kaasalainen, S. MacDonald, A. Moser, J.J. You, On behalf of Canadian Frailty Network

J Frailty Aging 2018;7(4):240-246

We present five Key Concepts that describe priorities for improving end-of-life care for frail older adults in Canada, and recommendations based on each Key Concept. Key Concept #1: Our end-of-life care system is focused on cancer, not frailty. Key Concept #2: We need better strategies to systematically identify frail older adults who would benefit from a palliative approach. Key Concept #3: The majority of palliative and end-of-life care will be, and should be, provided by clinicians who are not palliative care specialists. Key Concept #4: Organizational change and innovative funding models could deliver far better end-of-life care to frail individuals for less than we are currently spending. Key Concept #5: Improving the quality and quantity of advance care planning for frail older adults could reduce unwanted intensive care and costs at the end of life, and improve the experience for individuals and family members alike.

CITATION:
J. Downar ; P. Moorhouse ; R. Goldman ; D. Grossman ; S. Sinha ; T. Sussman ; S. Kaasalainen ; S. MacDonald ; A. Moser ; J.J. You ; On behalf of Canadian Frailty Network (2018): Improving End-of-Life Care and Advance Care Planning for Frail Older Adults in Canada. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2018.33

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NUTRITIONAL INTERVENTION IN SARCOPENIA: REPORT FROM THE INTERNATIONAL CONFERENCE ON FRAILTY AND SARCOPENIA RESEARCH TASK FORCE

F. Landi, C. Sieber, R.A. Fielding, Y. Rolland, J. Guralnik, and the ICFSR Task Force

J Frailty Aging 2018;7(4):247-252

Research suggests that poor nutrition is an underlying cause of sarcopenia and frailty, and that dietary interventions may prevent or treat age-related loss of muscle mass and strength. In February 2018, the International Conference on Frailty and Sarcopenia Research Task Force explored the current status of research on nutritional interventions for sarcopenia as well as gaps in knowledge, including whether nutritional supplements must be combined with physical activity, and the role of nutritional intervention in sarcopenic obese individuals. The lack of consistency across trials in terms of target populations, assessments, health-care settings, control groups, and choice of outcomes has made it difficult to draw meaningful conclusions from recent studies. The Task Force recommended large randomized controlled trials in heterogeneous, real-world populations to enable sub-group analysis. The field also needs to reach consensus on what outcomes are most meaningful and what represents clinically meaningful change.

CITATION:
F. Landi ; C. Sieber ; R.A. Fielding ; Y. Rolland ; J. Guralnik ; and the ICFSR Task Force (2018): Nutritional Intervention in Sarcopenia: Report from the International Conference on Frailty and Sarcopenia Research Task Force. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2018.26

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ASSOCIATION BETWEEN HIGH LEVELS OF PARATHYROID HORMONE AND FRAILTY: THE NEPEAN OSTEOPOROSIS AND FRAILTY (NOF) STUDY

L. Murthy, P. Dreyer, P. Suriyaarachchi, F. Gomez, C.L. Curcio, D. Boersma, G, Duque

J Frailty Aging 2018;7(4):253-257

Background: Frailty is associated with poor outcomes hence identification of risks factors is pivotal. Since the independent role of parathyroid hormone (PTH) in frailty remains unexplored, we aimed to determine this in a population of older individuals with a history of falling. Design: Cross-sectional study. Setting: Falls and Fracture Clinic, Nepean Hospital (Penrith, Australia). Participants: 692 subjects (mean age=79, 65% women) assessed between 2009-2015. Measurements: Assessment included clinical examination, mood, nutrition, grip strength, gait velocity, bone densitometry and posturography. Chemistry included serum PTH, calcium, vitamin D (25(OH)D3), creatinine and albumin. Normocalcemic subjects were divided into 4 groups: (1) Normal: 25(OH)D3 >50nmol/L and PTH between 1.6-6.8pmol/L; (2) PTH responsive: low 25(OH)D3 (<50nmol/L) and high PTH (>6.8pmol/L); (3) PTH unresponsive: low 25(OH)D3 and normal PTH; (4) Hyper PTH (>6.8pmol/L) with normal 25(OH)D3. Frailty was defined using Fried’s criteria. Difference between the groups was assessed using one-way ANOVA and X2 analysis. Multinomial logistic regression evaluated the association between the groups and the number of Fried’s criteria adjusted for age, BMI, renal function, 25(OH)D3 levels, and albumin. Results: 22.6% subjects had high PTH levels (>6.8pmol/L). All subjects in the high PTH groups had significantly lower grip strength, gait velocity, limits of stability, and higher BMI. The PTH responsive group had a higher risk of pre-frailty (β=3.8, 95% CI = 3.42 - 5.22, p< 0.01) and frailty (β=8.26, 95% CI = 2.8-16.1, p<0.01). The risk of frailty was also higher in the Hyper PTH group (β=2.3, 95% CI = 1.74-4.32, p<0.01). Conclusion: We have reported an independent association of high PTH levels with high number of falls and with the clinical components of physical frailty in community dwelling older persons. Our results suggest a possible role of PTH in frailty that deserves further exploration.

CITATION:
L. Murthy ; P. Dreyer ; P. Suriyaarachchi ; F. Gomez ; C.L. Curcio ; D. Boersma ; G, Duque (2018): Association between High Levels of Parathyroid Hormone and Frailty: The Nepean Osteoporosis and Frailty (NOF) Study. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2018.22

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THE ROLE OF ULTRASOUND AS A DIAGNOSTIC TOOL FOR SARCOPENIA

H.J. Stringer, D. Wilson

J Frailty Aging 2018;7(4):258-261

Sarcopenia is the progressive loss of skeletal mass and strength, particularly in older adults, with consequent reduction in function and independence. Changing population demographics, have resulted in increased prevalence of sarcopenia and this is associated with a considerable economic burden. Whilst simple, effective, non-intrusive management of this condition exists, no routine diagnosis takes place either in the UK or in many other countries, partly due to an absence of pragmatic clinical diagnostic tools to support the early identification of the syndrome. This position paper aims to provide a short overview proposing the potential case for developing ultrasound as a new and alternative diagnostic tool for identifying sarcopenia.

CITATION:
H.J. Stringer ; D. Wilson (2018): The role of ultrasound as a diagnostic tool for sarcopenia. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2018.24

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SINGLE PHYSICAL PERFORMANCE MEASURES CANNOT IDENTIFY GERIATRIC OUTPATIENTS WITH SARCOPENIA

S.M.L.M. Looijaard, S.J. Oudbier, E.M. Reijnierse, G.J. Blauw, C.G.M. Meskers, A.B. Maier

J Frailty Aging 2018;7(4):262-267

Background: Sarcopenia is highly prevalent in the older population and is associated with several adverse health outcomes. Equipment to measure muscle mass and muscle strength to diagnose sarcopenia is often unavailable in clinical practice due to the related expenses while an easy physical performance measure to identify individuals who could potentially have sarcopenia is lacking. Objectives: This study aimed to assess the association between physical performance measures and definitions of sarcopenia in a clinically relevant population of geriatric outpatients. Design, setting and participants: A cross-sectional study was conducted, consisting of 140 community-dwelling older adults that were referred to a geriatric outpatient clinic. No exclusion criteria were applied. Measurements: Physical performance measures included balance tests (side-by-side, semi-tandem and tandem test with eyes open and -closed), four-meter walk test, timed up and go test, chair stand test, handgrip strength and two subjective questions on mobility. Direct segmental multi-frequency bioelectrical impedance analysis was used to measure muscle mass. Five commonly used definitions of sarcopenia were applied. Diagnostic accuracy was determined by sensitivity, specificity and area under the curve.Results: Physical performance measures, i.e. side-by-side test, tandem test, chair stand test and handgrip strength, were associated with at least one definition of sarcopenia. Diagnostic accuracy of these physical performance measures was poor. Conclusions: Single physical performance measures could not identify older individuals with sarcopenia, according to five different definitions of sarcopenia.

CITATION:
S.M.L.M. Looijaard ; S.J. Oudbier ; E.M. Reijnierse ; G.J. Blauw ; C.G.M. Meskers ; A.B. Maier (2018): Single physical performance measures cannot identify geriatric outpatients with sarcopenia. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2018.19

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OLDER ADULTS’ PERCEPTIONS OF THE BUILT ENVIRONMENT AND ASSOCIATIONS WITH FRAILTY: A FEASIBILITY AND ACCEPTABILITY STUDY

B. Arakawa Martins, H. Barrie, J. Dollard, N. Mahajan, R. Visvanathan

J Frailty Aging 2018;7(4):268-271

It is essential to evaluate frail older adults understanding and execution of survey tools to improve data quality and accurate representation in research. The study tested the feasibility and acceptability of a survey that assesses various measures of functional status in frail older people. The study evaluated: 1) recruitment rate; 2) time to complete questionnaires and difficulties encountered; and 3) acceptability by participants. Validated tools including: FRAIL Scale, EuroQoL 5D-5L, Charlson’s Comorbidities Index, Baecke’s Physical Activity Questionnaire, Life-Space Assessment, Katz and Lawton ADL and NEWS Walkability Scale were assessed. Twenty-five older patients (63% recruitment rate) of a post-acute restorative program (residential Transition Care Program) in Adelaide, South Australia were interviewed. Although not statistically different, time to complete the overall questionnaire differed between robust, pre-frail and frail participants. Overall, the survey was considered acceptable and feasible, with consideration with NEWS and Life-Space assessment regarding length, phrasing and layout.

CITATION:
B. Arakawa Martins ; H. Barrie ; J. Dollard ; N. Mahajan ; R. Visvanathan (2018): Older adults’ perceptions of the built environment and associations with frailty: a feasibility and acceptability study. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2018.23

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