Mrs. Singh is 85, has dementia, diabetes, hypertension, and arthritis. She has a hard time walking and remembering who came for dinner the night before, but she still remembers the names of her children.
Her endocrinologist prescribed two medications to control her diabetes, and a cardiologist put her on four other pills to reduce her chances of a heart attack. One of the diabetes medications made her stomach upset so the family doctor prescribed a pill to reduce stomach acid. A couple of the medications had a side effect of constipation, so she started taking a laxative pill. All told, she is taking nine medications a day. One morning, she gets up and feels dizzy, has a fall and is taken to the emergency department.
She doesn’t have a fracture, but is badly bruised and is started on six more pills a day for her pain. By the time she leaves the hospital, Mrs. Singh is on 15 medications per day and feels terrible. Does this sound familiar?
Mrs. Singh is frail. Frailty is defined as a “multidimensional syndrome of loss of reserves (energy, physical, ability, cognition, health) that gives rise to vulnerability.” The weighted prevalence of frailty in seniors above 80 is about 30% and given the growth in this age group, both in hospital and community settings, we are all likely to see many more frail people. With the baby boomers’ advancing frailty, it is imperative that health systems develop physicians’ ability to screen for and understand frailty, including how medications affect frailty.
This is important because frailty, far more than age, is associated with a poor response to treatment, poor prognosis, and poor restoration of function. Frailty is associated with longer length of stay in hospital, greater risk of delirium, admission to residential care, and death. Additionally, many of the rules based on scientific evidence that guide our practice in medicine don’t apply to frail seniors. And when we do apply these guidelines to frail patients, our treatment recommendations may cause them substantial harm.
Furthermore, unless patients and families understand the limited prognosis for frailty, they lack the information to make informed decisions about their care. There is now good evidence that as lifespan becomes more limited, we cannot assume treatment decisions to prolong life trump, more immediate quality of life considerations.
Frailty assessment in seniors needs to become the “fifth vital sign.” While few studies have directly measured physicians’ ability to detect frailty, the common use of statins in frail nursing home populations and physicians’ failure to identify those with a limited prognosis when the diagnosis isn’t cancer, has been well described. Obvious cases of frailty are easy to detect, but more subtle functional deficits, especially when dementia is present, require careful digging that includes gathering collateral information and using standardized screening tools.
What will it take to shift the culture so that all clinicians acquire competency in detecting and understanding frailty? More exposure to geriatrics may be one strategy. Through such exposure, learners can have an opportunity to assess for frailty (including dementia assessment), quantify its presence, and better understand why and how frailty matters.
However, despite over a decade of medical education policy advocacy for more exposure to geriatrics, most medicine and surgical specialty training programs do not consider geriatrics a mandatory rotation. In family medicine pediatrics and obstetrics rotations in family medicine are universally compulsory, while geriatrics remains an elective in many training programs. While the number of residency positions in geriatrics has increased, some programs in Canada remain under-enrolled with a perception that these disciplines are poorly remunerated and stressful.
The fast paced “rescue and fix” approach of hospital settings in which physicians receive most of their undergraduate and post graduate training, the marriage of technology with life extension at all costs, the false sense that doing something is always better than doing nothing, and the slow response time of medical education policy to adapt to an aging population, have conspired to create a culture that is blind to frailty.
Physician competence in frailty screening cannot be an elective proposition. It’s time for a culture shift – if not now, then when?