If you were to survey the admitting diagnoses among elderly inpatients at Vancouver General Hospital, an astounding majority of them would be listed as “frailty” or “failure to thrive”. These terms do nothing to tell the story of why the patient is in the hospital, other than hint towards the fact that something (or many things) is preventing the community dwelling senior from managing at home. There is no consistently accepted definition of frailty in the literature, but most medical professionals agree that it is associated with a decreased ability to recover from stressors (such as acute illness) and an increased vulnerability to poor health outcomes in general (Fried, L. et al., 2001). Frailty (which I use here as synonymous with failure to thrive) in senior citizens is an issue that is best addressed by considering multiple levels of health influence, which I will do using the social ecological model.
Figure 1: Clinical Frailty Scale- used commonly to assess level of frailty in seniors
(Rockwood et al., 2005)
The social ecological model explains health related behaviour as being the cumulative result of factors occurring at five different levels: intrapersonal, interpersonal, institutional/organizational, community, and public policy (Golden, S. & Earp, J., 2012).The five factors can be thought of as nested structures, with the individual (in this case the elderly person) at the center. Importantly, and as is evident in the example of frailty, these levels do not exist in isolation but interact and influence each other (Golden, S. & Earp, J., 2012). This model allows for the consideration of how the individual interacts with their environment, and how social determinants of health influence outcomes.
Figure 2: social ecological model of health
In their editorial, Morley, J., Perry, H., & Miller, D. (2002) identify four major causes of frailty: muscle wasting/sarcopenia, atherosclerosis, cognitive decline, and poor nutrition. Each of these factors relate to numerous potential intrapersonal factors (factors unique to that individual including knowledge, biology/genetics, and life history). For example, several genetic factors have been identified that are involved in the maintenance of muscle mass, potentially influencing the development of sarcopenia (Morley, J. et al., 2002). However, low levels of physical activity (another intrinsic factor) is believed to be the overwhelming cause of muscle wasting in elderly (Morley, J. et al., 2002). Female gender, advanced age, having less than high school education and lower level of wealth/income are also implicated in increasing the risk of frailty (Fried, L. et al., 2001). Although frailty is more common amongst individuals with multiple comorbidities, it can be experienced in the absence of any chronic conditions (Adja, K. et al., 2020).
The next level to consider are the interpersonal relationships affecting the elderly person’s ability to cope in the community. A big component of my job as a physiotherapist working with in patients is assessing whether a patient is safe to return home, and what supports are needed to mitigate risk. In my experience, individuals with a supportive family are much less likely to have “failed discharges” and repeat admissions with failure to thrive. The importance of social support in the prevention of frailty is supported in the literature.
In their study, Woo, J., Goggins, W., Sham, A. and Ho, S. (2005) found that lower frailty scores were correlated with more frequent contact with relatives as well as with the total number of close relatives. This was echoed by Andrew, M. et al. (2018) who posed that more supportive social structures act as compensatory mechanisms for individuals experiencing a decline in their functional status. An individual who may otherwise be at risk of frailty due to untreated medical conditions (if they are unable to get to doctor's appointments or if they forget to take prescribed medications for example) are at lower risk if they have family members who are able to take them to appointments or monitor their prescriptions. Interpersonal relationships and social support networks have also been implicated in malnutrition (one of the key intrapersonal factors referred to above). Socially isolated individuals are more likely to be apathetic about food and meal preparation, resulting in poorer dietary intake (Evans, C., 2005).
Figure 3. Informal caregiving
(Canadian Institute for Health Information, 2014). Note: Copyright 2015 by CIHI
Although typically no longer affected by things like employment conditions, the level of organizational/institutional factors still apply to this population. Of course, individuals who reside in facilities such as long-term care or assisted living are affected by the policies and regulations within their facility, but I will focus here on seniors in the community. For those who have supportive families involved in their care, they are indirectly affected by the policies of their family member’s employers. Many people who are assisting their aging parents with their care (and thus decreasing their risk of frailty) are juggling this with the demands of a full-time job (Andrew, M. et al., 2028). Workplaces with policies such as flexible work hours or that allow for special leave to care for ailing family members can determine whether an at-risk senior is able to receive the support and assistance that they need. Another example of an organizational factor is the paucity of education on pain management in geriatric populations in medical schools, resulting in the under-treatment of pain in this population(Adja, K. et al., 2008). As I observe daily at the hospital: presence of pain or poorly controlled pain results in reduced mobility and muscle wasting.
Community factors play significant roles in determining frailty status. For example, rural seniors have a higher mortality rate and higher rates of frailty when compared to their urban counterparts (Song, X., 2007). There is a definite disparity in the availability of home care services in rural and remote settings (Andrew, M. et al., 2007) as well as fewer healthcare services in general, which I suspect is a contributing factor. In addition to geographical location (urban versus rural) the design or environment of a community is also important. For many seniors, walking is a main form of exercise as well as a means of transportation. Areas with poorly maintained sidewalks, excessive noise pollution, or lack of park benches or public washrooms all have the effect of decreasing physical activity in seniors, which, as stated above, is a major cause of sarcopenia (Jones, S., 2016). The design and accessibility of public transportation can also be a barrier, potentially making it more difficult to attend doctor’s appointments or visit family members. Even public parks can help combat frailty as they provide greater opportunities for exercise and social interactions (Jones, S., 2016). For those without family nearby, relationships and interactions within community or religious groups are an important mitigator of frailty (Woo, J. et al., 2005) but this depends on the seniors ability to physically access these groups. Community business composition in terms of the accessibility and affordability of neighbourhood grocery stores also impacts frailty by influencing nutrition options(Evans, C., 2005).
Figure 4. Frailty Matters
(Canadian Frailty Network, nd)
Finally, public policy must also be considered as a final “big picture” factor influencing failure to thrive in seniors. Federal legislation impacts seniors directly by determining how much money an individual can receive from the Canada Pension Plan, for example. Another way that the federal government impacts the economic status of seniors is by choosing to not pursue a publicly funded pharma-care program as an extension to the Canada Health Act. Evans, C. (2005) found that out-of-pocket cost of prescription medications correlated with incidence of malnutrition in seniors, many of whom are on fixed incomes. The federal government can also indirectly affect the level of social support or assistance available to seniors at risk of frailty through things like tax credits or caregiver benefits, allowing family members to support their loved ones (Herbert, P. et al., 2011).Governments also have power to influence frailty via employment legislation or by offering corporate tax breaks to companies that provide support for employees that are caring for their aging parents (Herbert, P. et al., 2011). Another realm of consideration is the value that society assigns to paid caregivers. Health Care Aides are paid notoriously low wages given the physical labour required for the job and their elevated risk of injury, and it is often seen as an undesired industry as a result (Andrew, M. et al., 2018). This has the effect of making it hard to fill care aide positions, decreasing the support available for seniors in the home (Andrew, M. et al., 2018).
A common limitation of public health initiatives is that they often target only one social ecological level, with most interventions targeting intrapersonal factors (Golden, S. & Earp, J., 2012). I argue that to truly impact the number of patients arriving at a hospital with a frailty diagnosis, we need to intervene at higher levels such as public policy and community factors. Encouraging someone to get enough physical activity is useless if the person has no safe place to walk in their neighbourhood. Similarly, encouraging an elderly person to eat healthy does not help if the person cannot afford their prescription medications without sacrificing their ability to purchase healthy foods. To be truly effective, I believe that interventions should target multiple levels of the ecological model, with coordination and cooperation between levels of government, non-profit agencies and community businesses.
Figure 5. Frailty: Every step matters
(Archibald, M., 2019)
References
Adja, K. Y. C., Lenzi, J., Sezgin, D., O’Caoimh, R., Morini, M., Damiani, G., Buja, A., & Fantini, M. P. (2020). The importance of taking a patient-centered, community-based approach to preventing and managing frailty: A public health perspective. Frontiers in Public Health, 8. https://doi.org/10.3389/fpubh.2020.599170
Andrew, M. K. , Dupuis-Blanchard, S., Maxwell, C., Giguere, A., Keefe, J., Rockwood, K., & st. John, P. (2018). Social and societal implications of frailty, including impact on Canadian healthcare systems. The Journal of Frailty & Aging , 7, 217–223 https://doi.org/10.14283/jfa.2018.30
Archibald, M. (2019) Frailty: every step matters [image]. Centre of Research Excellence for Frailty and Healthy Aging. https://health.adelaide.edu.au/cre-frailty/
Canadian Frailty Network. (nd). Frailty Matters [image]. Canadian Frailty Network website. https://www.cfn-nce.ca/frailty-matters/#1574890408921-bde36ff7-f581
Canadian Institute for Health Information. (2015). How Canada compares: Results from the commonwealth fund 2014 international health policy survey of older adults [image]. https://www.mcmasterforum.org/docs/default-source/product-documents/citizen-briefs/strengthening-care-frail-older-adults-cb.pdf?sfvrsn=c35f55d5_2
Evans, C. (2005). Malnutrition in the elderly: A multifactorial failure to thrive. The Permanente Journal, 9(3), 38-41. https://doi.org/10.7812/TPP/05-056
Fried, L. P., Tangen, C. M., Walston, J., Newman, A. B., Hirsch, C., Gottdiener, J., Seeman, T., Tracy, R., Kop, W. J., Burke, G., & McBurnie, M. A. (2001). Frailty in older adults: Evidence for a phenotype. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 56(3), 146-157. https://doi.org/10.1093/gerona/56.3.M146
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Hebert, P. C., Coutts, J., Stanbrook, M., Macdonald, N., & Flegel, K. (2011). A federal plan to address seniors’ health and well-being. Canadian Medical Association Journal, 183(5), 531. https://doi.org/10.1503/cmaj.110318
Jones, S. E. (2016). Ageing and the city: making urban spaces work for older people. HelpAge International. https://itdpdotorg.wpengine.com/wp-content/uploads/2017/02/Ageing-and-City-Low-Res.pdf
Morley, J. E., Perry, H. M., & Miller, D. K. (2002). Editorial: Something about frailty. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 57(11),698-704. https://doi.org/10.1093/gerona/57.11.M698
Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, Mitnitski A. (2005) A global clinical measure of fitness and frailty in elderly people [image]. CMAJ, 173(5):489-95. https://doi.org/10.1503/cmaj.050051
Song, X., MacKnight, C., Latta, R., Mitnitski, A. B., & Rockwood, K. (2007). Frailty and survival of rural and urban seniors: Results from the Canadian Study of Health and Aging. Aging Clinical and Experimental Research, 19(2), 145-153. https://doi.org/10.1007/BF03324681
Woo, J., Goggins, W., Sham, A., & Ho, S. C. (2005). Social determinants of frailty. Gerontology, 51(6), 402–408. https://doi.org/10.1159/000088705
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