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Nursing Standard of Practice Protocol: Frailty and its Implications for Care

Lazelle E Benefield, PhD, RN, FAAN, Rachel L. Higbee, BSN, RN

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. These protocols were revised and tested in NICHE hospitals. The text is available here.

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

Overview
Background
Definitions
Screening Tools/Assessment
Nursing Care Strategies
Outcomes
References

Overview

Frailty is prevalent in older people and involves a progressive physiological decline of multiple body systems. (Espinoza & Walston, 2005)
Caring for frail older adults is difficult and challenging because they have an increased burden of symptoms, are medically complex, and often have increased social needs. (Espinoza & Walston, 2005)
Frailty is a strong predictor of several negative outcomes including disabilities, institutionalization, and mortality. (van Iersel & Rikkert, 2006) Frailty has also been linked to acute illness, falls, and increased vulnerability. (Espinoza & Walston, 2005)
The identification of frailty in its early stage is important because interventions may potentially prevent, or delay the clinical consequences of frailty. (Bartali et al., 2006)
Nurses are in a position to assess for frailty and begin interventions to prevent functional decline and improve or maintain functional independence. (Espinoza & Walston, 2005)
Interventions are directed to 1) exercise including resistance, strength, physical movement (gait and balance) training, and lingual exercise 2) nutritional maintenance and/or supplementation, 3) maintenance of oral health, 4) environmental modifications, and 5) family and professional caregiver education. The goal of intervention is to minimize further weight loss, loss of muscle mass and strength, and reduce fall risk factors to help maintain a state of homeostasis. (Fried, Ferrucci, Darer, Williamson, & Anderson, 2004)

Background

"Successful aging is defined as a low risk of disease and disease-related disability, high mental and physical function, and active engagement with life." (Kahn, 2002) However, once organ reserve decreases, the body’s ability to restore homeostasis is diminished.(Fries, 1980) Therefore, due to chronic and/or acute diseases, physiological decline that occurs during the aging process and a dysregulation of body systems, frailty may occur. (Cohen, 2000)

The terms frailty, disability, and comorbidity interrelate and over-lap. Frailty is often confused with disability and/or comorbidity. Frailty is the manifestation of changes in the physiological state of a person and the inability to maintain homeostasis. Comorbidity refers to the occurrence of two or more distinguishably different disease processes in a person. Disability relates to the inability to carry out activities of daily living. (Fried, Ferrucci, Darer, Williamson, & Anderson, 2004)
Disability can arise from dysfunction of a single system or from many systems, but frailty always implies multisystem dysfunction. Disability need not be associated with instability, whereas frailty necessarily is. (Rockwood, Hogan, & MacKnight, 2000)

Definitions

Frailty is defined as "a state of high vulnerability for adverse health outcomes, including disability, dependency, falls, need for long-term care, and mortality." (Fried, Ferrucci, Darer, Williamson, & Anderson, 2004)
Frailty includes both physical and functional decline (Fisher, 2005) and is commonly used to describe older persons at increased risk for morbidity and mortality. (Morley, Kim, Haren, Kevorkian, & Banks, 2005)
Frailty typically involves alteration in multiple, not individual, body systems. (Fried, Ferrucci, Darer, Williamson, & Anderson, 2004)
Frailty is a syndrome associated with reduced functional reserve, impairment in multiple physiological systems, and reduced ability to regain physiological homeostasis. (Bartali et al., 2006)

Screening Tools/Assessment

Frailty is recognized by a constellation of signs and symptoms including weight loss, fatigue, muscle weakness, slow or unsteady gait declines in activity. (Walston et al., 2002)
Screening for frailty and assessing levels of frailty in older adults can identify those most vulnerable and assist in targeting nursing interventions.
Fried's Phenotype for Frailty offers an initial screening tool.(Fried et al., 2001) The screening tool for frailty in older adults has been adapted from her work. See original article:
Frailty in Older Adults: Evidence for a Phenotype
The presence of three or more components identifies a person as being frail. Scoring is as follows: 0 = robust, 1-2 = intermediate or pre-frail, and =3 = frail. Components include:

Shrinking: unintentional weight loss of 10 pounds or more in the past year.
Exhaustion: lack of energy or vigor, or the presence of fatigue and tiredness.
Strength: loss of physical robustness, skeletal muscle soundness.
Slowness: a lethargic, unsteady, and unbalanced gait.
Low physical activity: inactivity or sedentariness.
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Nursing Care Strategies

Frailty can be thought of as a dynamic balance between assets which help maintain a person’s independence and deficits which threatens a person’s self-sufficiency or functional capacity.(Rockwood, Fox, Stolee, Robertson, & Beattie, 1994) Therefore, managing frailty involves maintaining the balance between assets and deficits. Care strategies are aimed at maintaining this homeostatic balance. Frailty is a complex problem; therefore multiple interventions are necessary to preserve this balance.

Monitor for signs and symptoms of frailty (see phenotype of frailty above) and refer to primary care provider (PCP) as needed. In partnership with PCP, assess and diagnose underlying causative factors.

Differentiate primary frailty and secondary frailty. Primary frailty has no underlying, pathological causative factors, whereas secondary frailty originates from underlying, pathological causative factors. (Fried, Ferrucci, Darer, Williamson, & Anderson, 2004)
Interventions center on 1) exercise including resistance, strength, physical movement (gait and balance) training, and lingual exercise 2) nutritional maintenance and/or supplement, 3) maintenance of oral health, 4) environmental modifications and, 5) family and professional caregiver education (See Figure 1). The goal of intervention is to minimize further weight loss, loss of muscle mass and strength, and reduce fall risk factors to help maintain a state of homeostasis.(Fried, Ferrucci, Darer, Williamson, & Anderson, 2004)
Exercise training and reinforcement includes both resistance exercise training and aerobic exercise training.(Carr, Flood, Steger-May, Schechtman, & Binder, 2006)
Resistance training includes weight lifting or weight bearing exercises of the large skeletal muscle groups to increase lean body mass and improve strength, exercise tolerance and walking speed.(Fiatarone et al., 1994)
Tai chi is a slow and gentle exercise regime that involves both physical movement and meditation to improve balance and gait.(Adler & Roberts, 2006)
Lingual exercises include isometric exercise of compressing an air filled bulb between tongue and hard palate to enhance the swallowing mechanism.(Robbins et al., 2005)
Nutritional supplements include adding supplementation during and between meals along with supplements of essential vitamins and minerals. Protein supplementation assists in maintaining muscle mass.(Torpy, Lynm, & Glass, 2006) This may also include prescriptive medications used to increase appetite.(Fiatarone et al., 1994) A mini nutritional exam is available for additional nutritional assessment. See:
Try This Issue 9 - Assessing Nutrition in Older Adults
Socialization during meal times includes incorporating family-style meal times and company during meals rather than eating in isolation.(Milne, Avenell, & Potter, 2006)
Maintenance of adequate oral hygiene includes brushing and flossing at least two times per day, limiting intake of simple sugars such as soda and candy, and ensuring dental exams at least once a year. (Macentee, MI, 2006)
Environmental assessment of home or living area includes addressing safety issues and reducing task demand.

Implement strategies to decrease fall risk. ("A Tool Kit to Prevent Senior Falls", 2006)
Modify the living environment to enhance opportunities for independence and self-reliance. These interventions include grab bars, walk in showers with shower seats, counter and cabinet height adjustments, wide doorways, contrasting colors of counters, floors, walls, and dishes, non-slip surfaces, ramps, proper lighting, and emergency call systems. (Crews, DE, Zavotka, S, 2006)

Educate family and caregivers regarding the dynamics of frailty and teach care strategies listed above to maintain homeostasis. Instruct family and caregivers to contact PCP if decline is noted.

Outcomes

Extend the older adult’s length of time in relative independence and delay problems such as falls, injuries and susceptibility to acute illness, which lead to disability, and placement in care facilities

Older adult will demonstrate:
Extended length of time in relative independence in their preferred home or care setting
Maintain a safe level of ADL and ambulation
Make necessary adaptations to maintain safety and independence including assistive devices and environmental modifications.
Provider will:
Assess, identify, and manage older adults susceptible to or experiencing frailty
Document and communicate the elder's functional capacity, interventions used, and outcomes
Maintain competence in preventive and restorative strategies for preserving independence and function
Teach older adult and family caregiver(s) assessment and intervention strategies to preserve function and reduce task demand in the preferred home or care setting
Institution/Agencies will demonstrate:
Environments that reflect universal design sensitive to older adult needs
Increase in assessment of frailty in all care settings
Prompt and accurate referral for evaluation of frailty
Decrease in morbidity and mortality rates associated with functional decline
Increase in prevalence of patients who leave hospital care facility or professional homecare with baseline or improved functional status
Increase in early utilization of rehabilitative services (occupational and physical therapy)
Support of institutional policies programs that promote function e.g. caregiver educational efforts and walking programs
Evidence of continued interdisciplinary assessments and evaluation of care

References

Adler, P. A., & Roberts, B. L. (2006). The use of Tai Chi to improve health in older adults. Orthopaedic Nursing, 25(2), 122-126.

Bartali, B., Frongillo, E. A., Bandinelli, S., Lauretani, F., Semba, R. D., Fried, L. P., et al. (2006). Low nutrient intake is an essential component of frailty in older persons. Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 61(6), 589-593.

Carr, D. B., Flood, K., Steger-May, K., Schechtman, K. B., & Binder, E. F. (2006). Characteristics of frail older adult drivers. Journal of the American Geriatrics Society, 54(7), 1125-1129.

Cohen, H. J. (2000). In search of the underlying mechanisms of frailty. Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 55(12), M706-708.

Crews DE. Zavotka S. Aging, disability, and frailty: implications for universal design. Journal of Physiological Anthropology. 25(1):113-8, 2006 Jan

Espinoza, S., & Walston, J. D. (2005). Frailty in older adults: insights and interventions. Cleveland Clinic Journal of Medicine, 72(12), 1105-1112.

Fiatarone, M. A., O'Neill, E. F., Ryan, N. D., Clements, K. M., Solares, G. R., Nelson, M. E., et al. (1994). Exercise training and nutritional supplementation for physical frailty in very elderly people.[see comment]. New England Journal of Medicine, 330(25), 1769-1775.

Fisher, A. L. (2005). Just what defines frailty? Journal of the American Geriatrics Society, 53(12), 2229-2230.

Fried, L. P., Ferrucci, L., Darer, J., Williamson, J. D., & Anderson, G. (2004). Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 59(3), 255-263.

Fried, L. P., Tangen, C. M., Walston, J., Newman, A. B., Hirsch, C., Gottdiener, J., et al. (2001). Frailty in Older Adults: Evidence for a Phenotype. J Gerontol A Biol Sci Med Sci, 56(3), M146-157.

Fries, J. F. (1980). Aging, natural death, and the compression of morbidity. New England Journal of Medicine, 303(3), 130-135.

Kahn, R. L. (2002). On "Successful aging and well-being: self-rated compared with Rowe and Kahn". Gerontologist, 42(6), 725-726.

Milne, A. C., Avenell, A., & Potter, J. (2006). Improved food intake in frail older people. BMJ, 332(7551), 1165-1166.

Morley, J. E., Kim, M. J., Haren, M. T., Kevorkian, R., & Banks, W. A. (2005). Frailty and the aging male. Aging Male, 8(3-4), 135-140.

Robbins, J., Gangnon, R. E., Theis, S. M., Kays, S. A., Hewitt, A. L., & Hind, J. A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatrics Society, 53(9), 1483-1489.

Rockwood, K., Fox, R. A., Stolee, P., Robertson, D., & Beattie, B. L. (1994). Frailty in elderly people: an evolving concept. CMAJ Canadian Medical Association Journal, 150(4), 489-495.

Rockwood, K., Hogan, D. B., & MacKnight, C. (2000). Conceptualisation and measurement of frailty in elderly people. Drugs & Aging, 17(4), 295-302.

A Tool Kit to Prevent Senior Falls (2006). Retrieved September 3, 2006, from http://www.cdc.gov/ncipc/pub-res/toolkit/toolkit.htm

Torpy, J. M., Lynm, C., & Glass, R. M. (2006). JAMA patient page. Frailty in older adults. JAMA, 296(18), 2280.

van Iersel, M. B., & Rikkert, M. G. M. O. (2006). Frailty criteria give heterogeneous results when applied in clinical practice. Journal of the American Geriatrics Society, 54(4), 728-729.

Walston, J., McBurnie, M. A., Newman, A., Tracy, R. P., Kop, W. J., Hirsch, C. H., et al. (2002). Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities: results from the Cardiovascular Health Study. Archives of Internal Medicine, 162(20), 2333-2341.

Last updated - April 2007

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