ABSTRACT
Aging of the population is characterised by a marked increase
in the number of subjects aged eighty years or more (the oldest
old). In this group frailty is extremely common. Frailty is a
recently identified condition, resulting from a severely impaired
homeostatic reserve that puts the elderly at highest risk for
adverse health outcomes, including dependency, institutionalisation
and death, following even trivial events. Geriatric medicine proposes
an original methodology for the management of frail elderly subjects,
the so-called “comprehensive geriatric assessment”
(CGA), and a model of long-term care, which have been shown to
reduce the risk of hospitalisation and nursing home admission,
with a parallel decrease in the expenses and an improvement of
the patient’s quality of life. The effectiveness of the
long-term care system depends on:
1) the availability of all the services that are necessary for
the frail elderly, both in the hospital and in the community;
2) the presence of a coordinating team, the comprehensive geriatric
assessment team, that develops and implements the individualised
treatment plans, identifies the most appropriate setting for each
patient and verifies the outcomes of the interventions;
3) the use of common comprehensive geriatric assessment instruments
in all the settings;
4) the gerontological and geriatric education and training of
all the health care and social professionals.
The history of medicine is marked by the constant onset of new
clinical entities, which are given a name that precedes research
designed to build knowledge on their real nature. Typical recent
examples are NASH (Non-Alcoholic Steato-Hepatitis) and AIDS (Acquired
Immunodeficiency Syndrome). Today, due to the quick population
aging process, which has been taking place since the mid-20th
century, the one who attracts the attention of healthcare service
and facility workers is the frail elderly person, a clinical entity
who has been identified and described by geriatric medicine in
the past 15-20 years.
Frailty affects a significant percentage of the elderly population,
especially the oldest old, with a considerable impact on our "welfare"
system due to the great need to find solutions to meet the demand
for social and healthcare, which patients who suffer from this
condition require and will increasingly ask in the future.
On the basis of statements made by the most authoritative members
in the world of geriatric medicine, the frail elderly person is
a geriatric patient. It is in fact on this patient that geriatric
medicine has built a heritage of scientific knowledge, processed
a targeted assessment method - the so-called comprehensive geriatric
assessment - and proposed and experimented with suitable healthcare
models.
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Fig.
1 Fig. 1. An "extreme" case
of a frail elderly person: "… patients who
have been historically ignored by traditional medicine as
numerically irrelevant and professionally unrewarding because
incurable and "difficult" to handle through healthcare
and social care facilities, also because they are often
disturbing …" (Senin U., 1999).
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To
the question as to "What is the typical geriatric
patient?", the Editor of Textbook of Principles
of Geriatric Medicine and Gerontology, responds "Think
of your oldest, sickest, most complicated and frail patient
…. He or, more frequently, she often presnts with
multiple disabilities covert as well as overt. Thus while
signs and symptoms might suggest, for example, pneumonia
as in the younger patient, limited physiologic reserves
in multiple
systems may lead to complications vastly reducing the remaining
life span of the patients…. Often also presents atypically…."
(1999). (Fig. 1).
Analogously, Linda Fried, director of the Centre on Aging
at John's Hopkins Universityin Baltimore (USA) states: "The
identification, evaluation, and treatment of frail older
adults is a cornerstone of the practice of geriatric medicine."
(2001). |
And lastly Morley, Director of the Department of Geriatrics, St.
Louis University (USA), adds: "Geriatrics finds its greatest
expression in the management of the frail because it is this individual
who most escapes the attention of the specialist in internal medicine
and other specialists". (2002)
On the other hand these patients have been historically ignored
by traditional medicine because they were numerically irrelevant
till recent times and especially because they were neither "scientifically"
interesting nor professionally rewarding since they were in practice
incurable, "disturbing" and difficult for social and
healthcare facilities to manage.
Though there is no unanimous agreement on its definition, the
expert clinician can recognise the frail elderly person. Hazzard
writes (2004) "… a man, or more often a woman,
who lives on a razor’s edge, balanced between maintaining
his independence and the risk of a tragic cascade of pathological
events, disablement and complications, which only too often prove
to be irreversible, is one of the most complex problems physicians
and all healthcare professional figures have to face… It
is a great challenge as the coexistence of multiple chronic and
progressive diseases is the rule, while simple problems, which
are spontaneously solved or which are easily treated, are the
exception… besides, these mutually interacting diseases
appear in an atypical or non specific manner, thus "darkening"
all attempts to formulate a precise diagnosis…… These
are individuals, whose reduced functional reserve and limited
recovery capacity increase the risk of weight loss, malnutrition,
dehydration and adverse reactions to drugs and to medical and
surgical interventions… The complex network of all these
factors’ interactions is frequently the cause of the onset
of one or more geriatric syndromes, which probably, more than
any other element mark geriatrics as a medical specialisation:
confusion, falls and fractures, urinary incontinence, depression
and dementia, to mention only a few".
From an operational perspective the frail elderly person is generally
old or very old and suffers from multiple chronic diseases. Clinically
unstable and frequently disabled, he often presents social and
economic problems, especially solitude and poverty. (Figure
2).
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| Fig.
2 Frail elderly: the domains of frailty. |
THE EPIDEMIOLOGICAL DIMENSION
The prevalence of frail patients in the elderly population varies
depending on the criteria used. In a longitudinal study conducted
in the United States on a sample of about 5,000 patients aged
over 60 years living in their homes, (Cardiovascular Health Study
1989), 7% proved "frail" with an incidence
of 7% at three years (excluding those suffering from Parkinson’s
disease, mental deterioration and depression). These patients
presented a significantly higher risk of mortality, falls, hospitalisation
and disablement than the “non frail”. (Figure
3)
The same study revealed that the prevalence increased exponentially
in older patients involving 3% of individuals aged between 65
and 70 years and 26% between 85 and 89 years with a greater incidence
in women than in men (7% vercascata. sus 5%).
According to the American Medical Association about 40% of people
aged over 80 are carriers of frailty, just as the great majority
of 1.6 million elderly individuals hospitalised in nursing homes
in the United States is frail.
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| Fig.
3 Risk of adverse events in the frail elderly compared
to the non frail at the close of three years of longitudinal
observation. (Fried LP. 2001) |
PHYSIOPATHOLOGY OF FRAILTY
Frailty is the final result of a process of accelerated
psychophysical decline, which tends to progress once triggered.
Many experts agree on the fact that frailty is the expression
of the body’s
extreme homeostatic precariousness due to the concurrent impairment
of more than one anatomical and functional system when aging effects
are associated with damage resulting from an inadequate lifestyle
and diseases in progress or suffered during a lifetime. (Figure
4)
These are the reasons why the frail elderly person is a patient
who is characterised by inability to react effectively to events
which disturb his already precarious balance, such as for example
unusually high environmental temperature, worsening of chronic
diseases, the moderate onset of a serious disease, a physically
and psychologically traumatic event, a diagnostic procedure that
is either inconsistent or conducted without due caution and an
inappropriate therapeutic intervention.
Naturally a greater degree of frailty involves a greater risk
that even the most trivial factors will trigger a chain of events
in the short term with a catastrophic outcome (the so-called "decom-risulterebpensation
cascade"). (Figure 5).
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| Fig.
4 Intrinsic and extrinsic factors of frailty. |
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Fig.
5 Decompensation cascade in the frail elderly.
*LUT: urinary tract infections |
Causes of Frailty
Today a reduction in muscular mass (sarcopaenia) that significantly
impairs physiological functions is considered a central triggering
factor of frailty. (Figure 6)
It has in fact been proved that very evident sarcopaenia is associated
with reduced muscular strength, power and resistance; reduced
basal metabolism and increased adipose mass; accelerated loss
of bone mass; postural instability; and lower thermoregulation
capacity. These trends increase the risk of functional decline,
falls, fractures, hypothermia, hyperthermia and cardiovascular
disease.
Frailty also causes progressive dysregulation in some neuroendocrine
systems with impairment especially of the following ones: hypothalamic-pituitaryadrenal
axis, whose altered functionality involves a chronic increase
in blood cholesterol followed by a gradual resistance to insulin,
reduced immune defences, hippocampal neurodegeneration, to which
the increased muscle catabolism, cardiovascular risk and risk
of infection must be traced, and mental deterioration;
the sympathetic system, whose increased basal activity contributes
towards the increase in blood cholesterol;
anabolizing hormones – especially sexual ones, GH and DHEAS
- whose reduction accelerates the loss of muscular and bone mass.
The immune system too could be involved since certain studies
have documented a greater vulnerability towards infections and
higher inflammation indexes expressed by an increase in cytokines
such as IL-6 and TNF-a in the frail elderly, compared to the non
frail group. On the basis of this data a recently introduced theory
stated that a chronic proinflammatory state is at the root of
frailty and the accelerated muscular catabolism, increased stimulation
of the adrenal-cortical axis and an increased synthesis of corticotropin
releasing factor (CRF), which is a powerful anorexigenic agent,
can be partly traced to it.
Other biological mechanisms would however be involved in causing
frailty since this condition is often also characterised by the
presence of anaemia, low albumin, total protein and blood cholesterol
levels and other signs of protein caloric malnutrition, higher
levels of plasma osmolarity and high levels of D-dimer, which
is an indicator of fibrinolysis and inappropriate activation of
coagulation.
The latter condition has proved to be associated with a higher
risk of functional decline and mortality in the elderly.
There is a basic conviction that the elderly reach this condition
after a long course, which comprises progressive phases and results
from the negative synergy of many factors - inflammatory, metabolic,
endocrine, functional, psychological, etc. – which enhance
the loss of homeostatic skills in various organs and systems due
to aging, especially in the great integrating systems (immune
and psychoneuroendocrine), thus leading individuals towards a
condition of increasing vulnerability.
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Fig.
6 Sarcopaenia and frailty: the pathogenetic processes
involved.
CV: cardiovascular
CNTF: ciliary neurotrophic factor;
INF: interferon |
CLINICAL FRAILTY
An analysis of literature on frailty thus characterises the condition
from a clinical perspective: high susceptibility to develop acute
diseases, which are expressed by atypical clinical pictures (mental
confusion, postural instability and falls);
reduced motor skills and immobility due to serious asthenia and
adynamia that are not entirely justified by the diseases present;
rapid fluctuations in health even during the same day with a remarkable
tendency to develop complications (decompensation cascade) (Figure
5);
high risk of iatrogenic problems and adverse events;
slow recovery capacity, which is almost always only partial;
constant request for medical interventions,
frequent and repeated hospitalisations and the need for continuative
care; high risk of mortality.
Considering these patients’ high complexity, extreme instability
and vulnerability, their management requires a solid gerontological
culture, extensive clinical expertise combined with "common
sense" and long standing experience, but the "motivational"
aspect must play an essential role. These are patients, whose
only possibility of obtaining a significant outcome is entrusted
to the systematic application of the evaluation method, principles
and interventions typical of geriatric medicine and the presence
of an integrated specifically designed and organised hospital
and territorial network of facilities and services.
THE ITALIAN HEALTHCARE FRAMEWORK
The current social and healthcare organisation is the
expression of a society, which had many healthcare requirements
mainly arising from acute infectious diseases that decimated infant
and young adult populations. Chronic diseases, when present, were
only a short-term issue and the disabled were basically registered
disabled ex-servicemen and registered disabled civilians. The
elderly population and especially the oldest old were numerically
irrelevant and their life expectation was short when they fell
ill. Hence its inadequacy towards chronically ill, unstable, disabled
and frail elderly individuals.
The general practitioner, who bears the greatest responsibility
concerning healthcare. and responds to these patients’ needs
both when they are "confined" to their homes and when
they are admitted to nursing homes, lacks adequate preparation.
The hospital, which is in practice still the reference healthcare
facility and which is not designed and created from an architectural,
organisational and functional perspective to welcome this type
of patients, is undergoing a gradual modification in its role,
which increasingly focuses on treating severe cases (i.e. the
DRG system). This trend is leading hospitals to avoid patients
who need longterm care and whose problems have a "low"
clinical complexity. They are inappropriately defined as such
as they do not require expensive technologies. Though territorial
services are the most appropriate proposal for healthcare issues
related to chronic diseases, disablement and frailty, they have
considerable deficiencies and are often not personalised. (Table
1)
| Table 1
Background Features of Continuative Care (CC) Services
1.They must not be "second class"
- No to starting and accrediting services only for economic
reasons (saving);
- No to a low quality offer based on the principle: "something
is better than nothing".
2. They must be able to reach specific goals
- Suitable architectural, organizational and functional
features;
"Safe" placing in a system of integrated services.
3. They must meet strict quality control regulations
- Proven skill to reach the goals.
4. Rates must be related to real costs
- User type;
- Treatment complexity and duration.
5. Operators must be specially trained in gerontology and
geriatrics. |
There is plenty of evidence concerning the extent of this organization’s
inadequacy: the fact that families carry about 80% of the healthcare
load;
the so-called phenomenon of carers of the elderly, which by now
counts an amazing number of elderly individuals who are not self-sufficient
and are thus cared for at home by carers who lack all training.
Besides the latter are generally from other countries, hence difficulties
concerning mutual adjustment due to a different language and culture
(Figure 7);
institutions and homes for the aged, which were initially designed
to provide hospitality to the needy and poor elderly people who
were alone in the world in their last moments, have become real
"mini-hospitals", a concentrate of chronic diseases,
disablement and psychophysical pain without adjusting structural,
organisational and functional features to the different types
of guests.
The so-called "difficult discharge" or the "blocked
beds" phenomenon further stresses the current system’s
total inadequacy. This problem, which is steadily and speedily
growing, expresses hospitals’ impossibility to speedily
discharge patients due to a lack of suitable territorial services.
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Fig.
7
The exponential growth of the phenomenon of carers for the
elderly in our country (from "Repubblica", 2005). |
GERIATRIC MEDICINE’S HEALTHCARE PROPOSAL
The healthcare method geriatric medicine proposes for
such a complex patient as the frail elderly person is essentially
based on three elements:
comprehensive overall assessment;
team work;
continuative care.
Comprehensive Geriatric Assessment (CGA)
This method’s validity and effectiveness have been proved
by many controlled clinical studies on whose basis Guidelines
have been drafted by a committee of dell’Asexperts as per
the Ministry of Health’s proposal.
CGA or Comprehensive Geriatric Assessment is an original method,
which is considered as geriatric medicine’s technological
tool "..., which enables to identify and explain the
many problems of the elderly, assess their limitations and resources,
define their need for care and process a programme for overall
care and targeted interventions…".
It makes use of many tests and scales, which have been specially
processed and validated for the elderly patient. When it is applied
to the same patient at regular intervals and not only when a problem
appears, CGA can:
identify elderly individuals who risk frailty or who are already
frail; enable early detection of problems that are often misdiagnosed,
thus enabling the implementation of appropriate preventive and
therapeutic strategies;
assess the healthcare plan’s effectiveness. Many studies
have been conducted in different healthcare settings – hospitals
for serious cases, assisted long-term hospitalisation and homecare
– which have proved the method’s effectiveness. Overall
results, which have been assessed by meta-analysis, currently
suggest that CGA applied to patient management leads to clear
advantages both in terms of reduced mortality rates and especially
of quality of life.
Team Work
This method is based on the fact that CGA cannot be conducted
irrespective of collaboration between many professional figures.
Effective team work requires the following:
clear intervention goals that are common to all operators;
goals, which focus on the well-being of the elderly;
team members must have an equal degree of professional authoritativeness
and they must be recognised specific competences;
all members must freely state their opinion with equal dignity;
team members must be satisfied, motivated and develop a strong
sense of belonging and a constructive attitude;
an effective communication model between all team members. It
must be ensured by using the appropriate tools (i.e. an interdisciplinary
clinical report) and strategies for the management of contrasting
opinions.
Continuative Care
The proposed model of care for the frail elderly is Continuative
Care (CC), which is designed to provide answers that are constant,
global and flexible in time. It is in fact the only model that
can really take care of patients for whom sporadic and/or specialist
interventions are entirely inadequate or rather pointless.
Besides responding in a qualitatively adequate manner to these
patients’ requirements, this model has also proved to be
economically advantageous as it reduces unnecessary hospitalisation,
the so-called difficult hospital discharge phenomenon (or blocked
beds) and, subsequently, the cost of hospital care, which influences
health expenditure more than
all other items.
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Fig.
8 The "network" model for continuative
care of the elderly chronic, disabled and frail patient.
MMG: general medicine physician; ADI: integrated homecare;
RSA: assisted longterm
hospitalisation; UVG: geriatric assessment team; CGA: comprehensive
geriatric assessment |
Figure 8 specifies services and facilities,
which form CC organised as a "network" model.
The following points are essential for CC to reach its goals:
all hospital and territorial services and facilities should adopt
the same working method, which should be CGA;
all services and facilities should be functionally linked also
by an IT network;
there should be an operational team appointed to process plans
for personalised care, to send patients to facilities and services
envisaged by the network system and to check that the set goals
are reached. This team, which is called Geriatric Assessment Unit
(UVG), comprises a geriatrician, a social worker and a geriatric
nurse who are assisted by a specialist in general medicine and
other professional figures depending on the various problems and
individual needs.
CONCLUSIONS
Population aging has involved a deep change in the need
for care due to a considerable increase in chronically sick and
disabled individuals and to a new emerging patient category, the
so-called frail elderly who are characterised by extreme clinical
instability and have a high risk of rapid decline in health and
in the level of functional autonomy.
The current social and sanitary model cannot provide these individuals
with an adequate response. Hence the need felt by all industrialised
countries, which are experiencing the same demographical transition
as Italy, for a new model designed to provide continuative longterm
care by implementing a network of facilities and services that
are functionally integrated among them.
The operational method required to ensure this network’s
correct functioning is the so-called geriatric CGA, which has
been validated by many studies.
Some of these studies have also been conducted in our country.
Unfortunately though this model of Continuative Care of the frail
elderly is envisaged by the latest national health plans and by
many regional health plans, to date it has been implemented only
partly and in a limited manner due to budget limitations and especially
due to a lack of "mentality-culture" concerning the
population’s weaker category.
Umberto Senin
Director of the Institute of Gerontology and
Geriatrics - Department of Clinical and Experimental
Medicine, University of Perugia.
