Frailty and Health Care Directives

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1. What is Frailty?

Most Elderly people are ‘Well Elderly” and not frail.  However an increasing minority of elderly people become frail as they age. Frailty  refers to a state of health that increases our vulnerability . People who are frail have a number of characteristics:

  • Impaired organ function, immune systems and “homeostatic reserve’ . Loss of muscle and Bone Mass. This means that we have difficulty compensating for an illness or an injury
  • Multiple chronic diseases such as congestive heart failure, hypertension, diabetes, chronic lung diseases, arthritis etc
  • Syndromes such as memory impairment, problems with walking,  falls , weakness and incontinence
  • Dependency in household management and personal care such as bathing and dressing
  • Higher vulnerability to adverse effects from medications,  acute illness  or injury


2. What is the Risk of Frailty

People who are frail are at higher risk of

  • Complications of an acute illness.  A younger person may have minor burning when they have a bladder infection.  A frail person with the same condition may present with confusion and falls
  • Complications from an injury. Frail people may be more likely to break a bone with a fall or have a hematoma. Pain from a minor injury may cause immobility and further weakness
  • Complications from hospitalization.  These include increased confusion, delirium, depression, diarrhea, bladder  and respiratory infections, falls, deconditioning and further weakness and  death
  • Loss of independence and moving from their home to assisted living or a nursing home  if they don’t recover quickly from an illness or injury


3.  Can Frailty  be Prevented?

There is some research to suggest that  a healthy lifestyle may delay the onset of frailty to very old age. Some measures include:

  • Regular Exercise including simply walking for 30-45 minutes per day
  • Maintaining an ideal body weight and restricting excess calories. There is some evidence to suggest that olive oil and a Mediterranean Diet may promote health
  • Not smoking
  • Drinking in moderation
  • Early  treatment of chronic diseases that affect blood vessels such as high blood pressure and high cholesterol
  • Staying mentally active and engaged


4. What Can I do if I become Frail?

  • See your doctor to review all of your conditions and medications. You may no longer need all your drugs and may need different ones. Speak to your doctor before taking over-the counter (OTC) medications. Commonly used OTC medications can cause severe side effects eg. ibuprofen may cause stomach bleeding and kidney problems and Gravol may cause confusion and bladder problems
  • Consider getting an Interdisciplinary Geriatric Assessment particularly if this is new in onset or causing syndromes such as falls, weakness or memory problems
  • Exercise regularly, maintain an optimal diet, stop smoking and reduce your alcohol consumption
  • Speak to your family and doctor about your health priorities and health care wishes. This is called a Health Directive


5.  What is a Health Directive?

A Health Directive may include the following:

  •  A statement about your priorities including freedom from disabling symptoms, maintaining your independence and function, desired place of residence, wishes to prolong your life as long as possible or not
  • Delegation of health care decision to someone you trust. This person would be come your “Health Representative”
  • Your wishes about Cardiopulmonary Resuscitation (CPR).  CPR is done when someone has a cardiac arrest and no longer has a pulse or breathing spontaneously.  This leads to brain death in a few minutes. A cardiac arrest usually occurs after a catastrophic event like a heart attack or stroke. Recent research indicates that less than 6% of people are alive and neurologically intact if they have a cardiac arrest out of hospital despite optimal response times from paramedics. Similarly, less than 10% of people survive  3 months neurologically intact after being resuscitated in a hospital.  These numbers are probably lower for frail people. Many of the survivors are brain damaged and cannot return to their homes –  thereby requiring nursing home care.  It is important that paramedics or hospital personnel know your wishes or they may be obligated to perform CPR under law. Therefore, if  you do not want CPR, complete a form that you can keep on your fridge door in clear view of paramedics that are called. Give this form to your doctor, family members and health representatives
  • Your  feelings about hospitalization. You may wish to have your acute illness treated at home recognizing there is a risk that you may get worse or die. This is something that may also occur in a hospital setting. Hospital care poses risks for frail elderly people. Let your doctor and family know if you have strong feelings for or against hospitalization and what conditions would be acceptable for transfer (e.g. a broken hip)
  • Your wishes for life support if you were unable to communicate. An example may be a stroke with little hope of recovery.  It is best to state specific interventions rather than using an umbrella term like “no heroic measures”.  Important considerations for all these interventions are: 
    • What is the purpose of the intervention: delay death, improve comfort, improve function,  allow me to remain in my home
    • What is my life expectancy?
    • What are my wishes regarding prolonging my life
    • Will these interventions restore me to my baseline function or increase my dependency and suffering
    • What are the risks of these interventions?
    • How uncomfortable are these interventions?

Examples of Medical Interventions are:

  • Mechanical ventilation if you cannot breath
  • Intravenous (IV) Hydration – if you could not drink
  • Feeding tubes into your stomach thru your nose (NG) or an incision in your stomach (PEG) if you couldn’t swallow
  • IV  or any antibiotic treatment if you had a life threatening infection
  • Transfusions
  • Surgical procedures
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