Recognising older frail patients near the end of life: What next?

Cardona, Magnolia; Lewis, Ebony; Suman, Sanjay Kumar; Haywood, Cilla; Williams, Marcella; Brousseau, Audrey-Anne; Greenaway, Sally; Hillman, Ken; Dent, Elsa

doi:10.1016/j.ejim.2017.09.026

Cited by 38 publications

(45 citation statements)

References 90 publications

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“…While triaging frail dying people to other services may lead to reduction in acute care costs, in practice, a sense of equity in healthcare and a duty to be honest about poor prognosis are the ethical responses to the escalating problem of high and unrealistic demand for services to prolong life in the absence of benefit. 28 There is evidence of physical training strategies to slow its progression and minimize the complications of frailty such as poor functional outcomes and death. Multidisciplinary teams can play a part in providing active or comfort care based on need.…”

Section: Discussionmentioning

confidence: 99%

“…When frailty becomes more advanced, palliative care can help facilitate a good death involving attention to the physical, psychosocial, and spiritual aspects of patient care aligned with patient's informed goals of care. 28 It is the responsibility of all clinicians both in the community and hospital settings to screen for frailty and associated risk of death among older patients. There needs to be systems of care, especially in the community setting so once frailty is identified, practitioners consult older patients on their personal values, guide the establishment of realistic goals, and refer them to the most appropriate care pathway.…”

Section: Discussionmentioning

confidence: 99%

“…There needs to be systems of care, especially in the community setting so once frailty is identified, practitioners consult older patients on their personal values, guide the establishment of realistic goals, and refer them to the most appropriate care pathway. 28 When people are so frail that they cannot withstand interventions that can cause significant injury, such as surgery or chemotherapy, then appropriate end-of-life care should focus on maintaining their highest-order functions. 29 That is the reason that palliative care, developed initially to provide holistic and timely symptom-based care for patients with noncurable cancer, should also be available and offered to patients with nonmalignant, life-limiting diseases.…”

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Aging, Fragility and Palliative Care: Challenges of an Emerging Context

Jlc¹,

Souza²,

Ral³

et al. 2018

HPMIJ

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Background: It is common, the difficulty among health professionals to recognize the frailty syndrome, multisystemic disease responsible for the physical, cognitive and functional weakness of the elderly. The undervaluation of the general state of the elderly in the clinical routine and the lack of an accurate identification tool result in a late diagnosis. Thus, frail elderly people are subjected to aggressive and nonbeneficial interventions that impair the remaining quality of life due to the suffering caused by iatrogeny. Objective: To study the application of palliative care in the approach to this nonmalignant but life-limiting syndrome, emphasizing the importance of the systematic evaluation of the fragile elderly and the main tools to do so. Conclusion: Although there is no ''gold standard'' tool in the evaluation of the elderly's fragility, palliative care promotes, through various analytical methods, the survival of the elderly patient, preserving not only their physical integrity, but also their cognitive, emotional, spiritual values and social insertion.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Aging, Fragility and Palliative Care: Challenges of an Emerging Context

Jlc¹,

Souza²,

Ral³

et al. 2018

HPMIJ

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“…It has been mooted that identification of frailty might trigger advance care planning discussions . While it is clear that the relative risk of mortality is significantly increased by frailty, the absolute risk is more helpful for clinician and patient decision‐making.…”

Section: Frailty and Goals Of Carementioning

confidence: 99%

“…It has been mooted that identification of frailty might trigger advance care planning discussions. 29 While it is clear that the relative risk of mortality is significantly increased by frailty, the absolute risk is more helpful for clinician and patient decision-making. In a study including almost 1 million older community living older people in the UK who had a FI generated from their primary care electronic medical record (electronic frailty index (eFI)), 3% were identified as severely frail (eFI > 0.36) and 12% moderately frail (eFI 0.24-0.36).…”

Section: Frailty and Goals Of Carementioning

confidence: 99%

Management of frail older people with acute illness

Mudge

Hubbard

2019

Internal Medicine Journal

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Frailty status is intrinsically related to every aspect of older patients’ hospital journeys: the way in which they present to hospital, their health status at admission, vulnerability to complications in hospital and rate of recovery after an acute insult. In younger people, hospitalisation is usually the result of a serious illness or injury, such as sepsis or major trauma. Management can be underpinned by evidence‐based algorithms relating to the precipitating insult and recovery usually follows a predictable trajectory. In older people who are frail, on the other hand, admission to hospital may be triggered by an illness that may seem minor, such as a viral infection, which causes a geriatric syndrome. A fall or delirium with no major precipitant should be considered an indicator of frailty. Promptly recognising the acute illness and the increased risk for hospital‐associated complications is essential for providing safe systems of care for frail older people. Early consideration of health assets and engagement of families and community services can have an important role in successful recovery during and beyond the hospital stay. Effective decision‐making about clinical interventions can benefit from explicit assessment of frailty status and consideration of patient priorities.

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Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management

Dent

Morley

Cruz-Jentoft

et al. 2019

The Journal of nutrition, health and aging

617

536

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Objective: The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults. Methods: These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care. Recommendations for Screening and Assessment: The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation). Recommendations for Management: A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multicomponent physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.

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Recognising older frail patients near the end of life: What next?

Cited by 38 publications

References 90 publications

Aging, Fragility and Palliative Care: Challenges of an Emerging Context

Aging, Fragility and Palliative Care: Challenges of an Emerging Context

Management of frail older people with acute illness

Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management

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