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Geriatric Medicine Picture

Not just another F-word: Why Frailty Matters in Medicine

Jay Kataria, MSc Candidate (Neuroscience)

On March 12th, the Department of Medicine and Translational Medicine had the pleasure of hosting Dr. Leah Nemiroff, a staff Geriatrician and Assistant Professor in the Division of Geriatric Medicine at Queen’s University. Dr. Nemiroff introduced the topic of frailty, emphasizing it’s not just another “F-word” and why it matters in medicine.

 

The concept of clinical frailty was extensively discussed during Dr. Nemiroff’s presentation. It can generally be described as, “A medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiological function that increases an individual’s vulnerability for developing increased dependency and/or death.”1 Often times in practice, it may be difficult to provide optimal care when feeling frustrated, but Dr. Nemiroff provided us with a quote from Dr. Rockford that keeps her motivated, “Knowledge is the best remedy for the frustration that we feel.”

 

The field of geriatrics is much needed in Canada; however, we may be facing a shortage as the country’s population is aging and there are only about 304 geriatricians present.2 This field is particularly complex as individual differences matter more as people age and everyone is heterogeneous in their mortality risk. What adds to the complexity is the predisposing factors individuals are introduced to throughout their life. In general, the more predisposing factors one is introduced to means the fewer precipitating factors are needed to become frail.

 

It is as important to identify and grade frailty as it is to understand it. Dr. Nemiroff introduced the frailty phenotype, first proposed by Fried and Watson. The Fried frailty phenotype, including five components interlinked to form a cycle of frailty: weakness, slowness, exhaustion, low activity and weight loss, operationalizes frailty.3 In addition, Dr. Nemiroff spoke about the Clinical Frailty Scale, emphasizing the importance of quantifying frailty. The Clinical Frailty Scale ranges from one to nine, including classifications such as “very fit, vulnerable, moderately frail, and terminally ill.”4 It is important to characterize one on how frail they are as practice and treatment can be tailored towards their score. However, it is important to note that this is a baseline measurement and should be taken two weeks before an illness. If this score is taken after a surgery or during an illness, it will alter the actual score of frailty.

 

It is well understood that a person can progress through the stages of frailty, however an interesting question that was brought up is if it’s possible to become less frail. Dr. Nemiroff mentioned that if one is in the very early stages of frailty, reversal and prevention is possible using preventative interventions such as exercise and proper nutrition. A staggering statistic mentioned by Dr. Nemiroff is that patients in hospital care units are told or required to do around 40 minutes of physical activity a day, including seated exercises. This may be reasonable for patients with physical disabilities, however Dr. Nemiroff advocates for physical activity and exercise to prevent and treat frailty. The topic of polypharmacy, taking over five medications without evidence-based reasoning, is important to consider when looking at personalized treatment options.5 Dr. Nemiroff discussed the positive changes she’s seen when removing unneeded medications from a patient’s treatment plan.

 

Finally, Dr. Nemiroff went over outcomes of frail patients after ICU. She mentioned a critical study done in the field by Bagshaw et al., finding frail patients were older, more likely to be female, and had more comorbidities and greater functional dependence than those who were not frail.6 Compared to nonfrail survivors, frail survivors were more likely to become functionally dependent, had a lower quality of life and were more often readmitted to hospital.6

 

During our post-Grand Round discussion, we discussed if biomarkers may be used to better describe frailty. There are certain biomarkers that may be linked to scores on the Clinical Frailty Scale, however individuals are different, meaning they may have different biomarkers. In addition, we discussed the importance of having a conversation about frailty early on to combat stigma surrounding aging. Understanding that patients’ views on frailty is critical to provide optimal care.

 

Finally, when asked about making the right career choice, Dr. Nemiroff gave us some meaningful advice. From her personal experience; pivoting from studying long-finned pilot whales to practicing geriatric medicine, she explained that career paths can often change, and we should be our own person.

 

It was a pleasure hosting Dr. Nemiroff at Grand Rounds. On behalf of the Department of Medicine and the TMED 801 class, we thank you for giving us insight into your world of geriatric medicine.

 

References:

 

1) Morley, J., Vellas, B., Abellan van Kan, G., Anker, S., Bauer, J., & Bernabei, R. et al. (2013). Frailty Consensus: A Call to Action. Journal Of The American Medical Directors Association14(6), 392-397. doi: 10.1016/j.jamda.2013.03.022

2) (2020). Retrieved 15 March 2020, from https://www.cma.ca/sites/default/files/pdf/Physician%20Data/02-physicia…

3) Fried, L., Tangen, C., Walston, J., Newman, A., Hirsch, C., & Gottdiener, J. et al. (2001). Frailty in Older Adults: Evidence for a Phenotype. The Journals Of Gerontology Series A: Biological Sciences And Medical Sciences56(3), M146-M157. doi: 10.1093/gerona/56.3.m146

4) Rockwood, K. (2005). A global clinical measure of fitness and frailty in elderly people. Canadian Medical Association Journal173(5), 489-495. doi: 10.1503/cmaj.050051

Comments

Name
Daniel Rivera

Fri, 03/20/2020 - 09:23

Hi Jay,
Thanks for the summary. You summarized that there are only about 304 geriatricians in Canada, despite an aging population. I found this to be interesting as it could post a potential problem as these aging individuals start to require more complex care. Dr. Nemiroff also said, in regards to her choice of specialty, that it sought out by people who are aware that it would be a good fit for them, or that the specialty/medicine selects for the individual (i.e. they are led to this specialty, where they turn out to be quite the good fit). Nonetheless, the number of specialist remain relatively low in Canada - do you think that, perhaps instead of perturbing whatever process is in place to match doctors with geriatrics, expanding geriatric care teams to include additional specialized nurses/nurse practitioners or allied care professionals might help manage this shortage?

Name
Daniel Rivera

Name
Matthew James

Mon, 03/23/2020 - 09:45

In reply to by Anonymous (not verified)

Great question Daniel. I think like so many of our critically strained medical specialties, having an increased involvement of other allied health care professionals is important. I think Geriatrics is definitely a place where this needs to be implemented in a timely manner with the increased burden on the health care system as life expectancy increases, and many baby boomers begin to retire.

Name
Matthew James

Hi Jay, Daniel and Matthew.
I agree with Matthew, in response to Daniel's question, that it is imperative to involved allied health professionals in the care of not only geriatrics, but across all medical specialties. This will take a substantial amount of burden off of physicians, especially in specialties where physician personnel is important, and allow allied health professionals to contribute within their scope of practice. Each allied health profession has a very well defined scope of practice that will lend well to all areas of geriatric care, and may be more readily accessible in a timely manner (e.g. allied health professionals will be able to respond to matters that may not require a physician and thus, frees up the constrained amount of physician personnel available). Coming from a allied health background in Kinesiology, I am always an advocate for involving AHPs into the circle of care, and breaking the paradigm that care can only be provided by physicians.

Name
Quentin Tsang

Hi all,

Thanks for the reply! I agree with both Matthew and Quentin, involving other healthcare professionals into the circle of care for these patients will definitely lighten the burden on primary geriatric physicians. Not only will the burden be lightened, but it is also beneficial including expert opinions from a variety of healthcare professionals to provide optimal care.

Jay

Name
Jay Kataria

Name
Edwin Ocran

Tue, 03/24/2020 - 11:26

Great summary Jay. Dr. Nemiroff's presentation and the ensuing discussions have given me a deeper insight into the field of geriatrics and the many challenges that geriatricians face on a daily basis while managing frail patients with complex comorbidities. An aspect of the discussion that was striking was the depth of social issues that were associated with the care of patients such as caregiver fatigue and the relative lack of resources to support in this area. I was wondering what others' thoughts are on this considering, as Dr. Nemiroff put it, there are so many other issues in our environment competing for the very limited resources available.

Name
Edwin Ocran

Hello Edwin,

Thanks for your comment! I too was intrigued by the fact that social issues often come along with the care of patients. These issues are often undermined by the general public, making them more complicated to resolve. One of the reasons social issues may be undermined because it's hard to understand exactly what it's like being a caregiver to someone who isn't one. That being said, it is important having empathy in the field of geriatrics. Addressing these issues, whether it be through speaking with caregivers or providing information on pamphlets, would be beneficial.

Jay

Name
Jay Kataria

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