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GPAC: Guidelines and Protocols Advisory Committee Frailty in Older Adults – Early Identification and Management Effective Date: October 1, 2008 Summary | Flow Sheet | Patient Guide | Full Guideline in PDF Recommendations and TopicsScopeThis guideline addresses the early identification of patients who are at risk for frailty and the management of patients aged 65 years or older who are identified as frail. Over a series of planned office visits, this guideline will facilitate enhanced individualized planning for patients who are frail or at risk for frailty, and implementation of patient-centred strategies to prevent further functional decline, particularly during transitions in care. Elements of Care
Care SummaryThis guideline focuses on the development of a Care Plan. The Care Plan is individually developed and addresses modifiable biological and psychosocial factors while integrating individual disease factors that impede the health goals of patients. The recommended approach to care incorporates patient-centred preferences and tolerance for intervention and support. The approach is grounded in the philosophy that frailty may be prevented or delayed and that patients can improve their function and quality of life through rehabilitation.1  Identification of Frail Patients and Patients at Risk for FrailtyEach visit provides an opportunity to engage the patient in individualized care planning, and to identify any follow-up needs.2 Older adults may share a number of non-specific concerns that could lead the physician to think about their older patients as frail or at risk for frailty, such as:3-6
Once a patient is identified as frail, or at risk for frailty, it is recommended that the Canadian Study on Health and Aging (CSHA) Clinical Frailty Scale7be used to categorize the needs of the patient. The scale is based largely on a person’s function for Basic and Instrumental Activities of Daily Living (ADL and IADL). Further AssessmentPatients with identified frailty (CSHA Scale, Level 4 and above) require additional assessment in order to support the development or refinement of a Care Plan (see Appendix A for a sample Seniors Assessment Tool). Ideally, the physician and other health professionals will work collaboratively to complete assessments, in order to create one comprehensive Care Plan that is used by the patient and all health professionals involved in the patient’s care. For example, if community case managers have completed their comprehensive initial assessment using the Minimal Data Set-Home Care8, a list of identified problem areas generated by that assessment could help to further inform the physician assessment and Care Plan. In addition to the collection of information on underlying chronic conditions, some practical areas to pursue in assessing older adult patients are noted below. 9-12Observed changes in these areas constitute early warning signs of frailty (CSHA Frailty Scale Level 4), while a combination of impairments may signal progression toward frailty (CSHA Frailty Scale Levels 5-7):
(see GPAC Cognitive Impairment in the Elderly Guideline to access the Geriatric Depression Scale [GDS] and the Standardized Mini Mental State Exam [SMMSE]) Collaborative Goal SettingIt is important to have a shared understanding of desired care with the patient and family/caregiver.1 One approach is to combine the physician’s problem list with the patient and family/caregiver concerns and preferences for care:
Collaborative goal setting will inform the development and implementation of a functional Care Plan. Development and Implementation of a Care PlanThe Care Plan (see sample, Appendix B) is generated from these collaborative goals. Develop a Care Plan by first noting the most bothersome complaint, as voiced by the patient, and proceed with consideration for:
In this complex population of older adults, it is recommended that the Care Plan also include:
Sharing Care Plan Documents with Patients Communication for coordination and continuity of care is particularly important with older adult patients.20 Key management information should be made available at transitions of care to other providers including medical specialists, as well as emergency room staff and acute care practitioners. The Care Plan, including advance care planning documentation, could be given to the patient (and/or family/caregivers) to carry as they become involved with other care providers and as they transition across care settings. The patient could also carry a copy of the Medication Review (includes medication list paired with medical problem list). Monitoring, Follow-up and Re-evaluationA scheduled Care Plan review should include input from the patient, family/caregiver(s), and other involved health care providers. The review should be undertaken as scheduled, at the request of the patient, or when there is a transition (planned or unplanned), such as:
RationaleWhile many older adults living in British Columbia are robust and active, some older adults who are frail, or at risk for frailty, have a limited capacity to respond to stresses and are at significant risk of morbidity or death. A prudent response is to identify older adults in our population who are frail, or at risk for frailty, and take steps to reduce or manage the risks associated with frailty.1,5,21-23 A common approach to assessment is needed that would enable physicians:
Information collected during assessment visits will inform the development of a Care Plan – an essential tool for capturing key medication information, patient/provider goals and patient preferences for care. To help facilitate shared understanding within a multi-disciplinary approach, the Care Plan could be given to the patient (and/or family/caregivers) to carry as they become involved with other care providers and as they transition across care settings. References
Provincial Resources
Office Practice and Redesign Resources
This guideline is based on scientific evidence current as of the Effective Date. This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission. AppendicesAppendix A - Seniors Assessment Tool Appendix B - Sample Care Plan Template Appendix C - Medication Review Appendix D - Advance Care Planning The principles of the Guidelines and Protocols Advisory Committee are to:
DisclaimerThe Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems. PDF Format Some documents on this Web site are in PDF format and require a PDF reader. If you do not have Adobe Acrobat Reader Version 7.0 or the most recent version of another PDF reader, you can download Adobe Acrobat Reader by clicking on the 'Get Adobe Reader' icon.
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