Category Archives: frailty

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How might we further detail the identity of frailty?

The current future direction, and indeed past, of “frailty”, for both service provision and research at least, are both intimately linked with the angle of perspective you decide to choose.

“Anekāntavāda” (Sanskrit: अनेकान्तवाद, “many-sidedness”) refers to the Jain doctrine about metaphysical truths that emerged in ancient India; it states that the ‘ultimate truth and reality’ is complex, has multiple aspects (https://en.wikipedia.org/wiki/Anekantavada).

The Jain texts explain the anekāntvāda concept using the parable of blind men and elephant, in a manner similar to those found in both Buddhist and Hindu texts about limits of perception and the importance of complete context.

A famous parable has several Indian variations, but broadly goes as follows:

A group of blind men heard that a strange animal, called an elephant, had been brought to the town, but none of them were aware of its shape and form. They then tried to deduce its form from some preliminary investigations. In the case of the first person, whose hand landed on the trunk, said “This being is like a thick snake”. For another one whose hand reached its ear, it seemed like a kind of fan. As for another person, whose hand was upon its leg, said, the elephant is a pillar like a tree-trunk. The blind man who placed his hand upon its side said, “elephant is a wall”….”

The ‘ultimate truth and reality’ in frailty are sometimes difficult to see, when processes, procedures and policies appear to be so dominant in the discourse.

Part of the drive to wanting to ‘do something’ about frailty, as for dementia, is that there appears to be so much to stake in terms of exposure to risk of increased morbidity and mortality. As for dementia, the rationale has been to hope to intervene in a more timely way, with more accurate timely diagnoses. Frailty could learn lessons here from other fields such as dementia.

Artificial intelligence (AI) is a field of computer science that aims to mimic human thought processes, learning capacity, and knowledge storage. AI techniques have been applied, for example, in cardiovascular medicine to explore novel genotypes and phenotypes in existing diseases, improve the quality of patient care, enable cost-effectiveness, and reduce readmission and mortality rates.

Precision medicine is a new paradigm that combines diagnostic, imaging, and analytical tools to produce accurate diagnoses and therapeutic interventions tailored to the individual patient. This approach stands in contrast to the traditional “one size fits all” concept, according to which researchers develop disease treatments and preventions for an “average” patient without considering individual differences.

If frailty is viewed as a number of different symptom clusters, involving heterogeneity, a ‘swiss army knife’ approach to managing frailty might, in fact, reap dividends.  The “one size fits all” concept has led to many ineffective or inappropriate approaches across health and social care, especially for disease such as dementia and cancer, where comorbidity is the norm rather than the exception.

Psychiatric diseases are very heterogeneous both in clinical manifestation and aetiology, and many care of the elderly conditions are heterogeneous likewise. With the growing interest in personalised medicine, it becomes even more important not only to classify or diagnose someone as a patient with a certain disorder, its treatment needs a more precise definition of the underlying biology, since different biological origins of the same disease may require (very) different treatments.

There are different lines of thinking about what frailty is, and a broad consensus has indeed emerged. Frailty might, nonetheless, benefit from a more sophisticated approach to its identification, which takes on board how the person who is frail is just part of a wider ecosystem which brings with it its own factors encouraging vulnerability or resilience. The recent alternative interpretation (a “network approach”) is gaining some support. It suggests that a stressor causes symptoms that activate other symptoms, in a circular, self-reinforcing way.

This theory moves away from disorders being traditionally conceptualised as categorical or dimensional models. For example, while the clinical specialism of psychiatry has shifted its focus to a more biological approach, social factors still have an important role in crosscultural diagnosis, psychiatric disorders relating to social deprivation, rehabilitation and enabling social inclusion. The degree to which society is willing to accept people with various issues and problems has an obvious impact on their quality of life. An alternative representation of the long-term course of Crohn’s disease complications has introduced the notion of the “rolling phenotype”.

As is commonly observed in clinical practice, this definition allows progression to a more severe phenotype (stricturing, penetrating) but also, regression to a less severe behaviour (inflammatory, or remission) over time.  This might be especially fruitful in models of frailty, where a unilateral accumulation of deficits is often left unchallenged, despite various research and service improvement iniatives to provide effective ‘interventions’ for frailty.

Schizophrenia and dementia as complex syndromes are well recognised. Taking schizophrenia, similar to positive and negative symptoms, the three ’syndromes’ or clusters of symptoms appear to represent independent or semi-independent dimensions of psychopathology that frequently coexist in individuals with schizophrenia. Mental health is not the only place where clusters of symptoms occur. Physical symptoms are likely to occur in clusters that may be associated with adverse outcome in patients with heart failure (HF).

Despite the importance of early recognition of worsening symptoms in HF management, the impact of physical symptoms on adverse outcome has been relatively under-explored in the context of symptom clusters. For example, the “weary and the dyspneic” symptom clusters predicted cardiac rehospitalisation and cardiac mortality, respectively. Patient education for self-monitoring of symptoms should focus on symptom clusters rather than single symptom. Targeting management to the right people, the idea behind realistic medicine, is not a new idea. It has been called various things elsewhere, such as “Choosing Wisely” in the United States and “Slow Medicine” in Italy. They all grow from the same root—reduce unnecessary treatment, address unacceptable variation, and deliver more appropriate, personalised care.

 

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A need to frame the narrative of ‘frailty’ more clearly?

At the time of writing, the newspapers are full of sentences blaming ‘old, frail people’ for getting ill and attending hospitals en masse.

Take for example the recent example of “a patient who was evicted from a hospital under a court order after spending more than two years in a bed has insisted that he did not want to stay there.”

The Guardian article (2017) continues:

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The most famous modern definition of health was created during a Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Indeed, this definition has not been amended since 1948.

In response to this, the Lancet opined (2009, p.781) that: “The obstacles to a minimum quantity of health seem so huge and so complex that it is almost impossible for a single doctor to have any influence on their effects.” The Lancet concluded instead that ‘health is an ability to adapt’, and may be that frailty simply represents poor health, or an inability to adapt.

Back in 2005, Rockwood argued on frailty:

Frailty is common and especially a focus for geriatricians, but there is no consensus on its definition beyond that it arises from many factors, and is a state of vulnerability. This paper proposes that a successful definition of frailty must also identify clinically recognisable degrees of frailty, be susceptible to animal modelling and demonstrate predictive validity as its highest standard of validation.” (p.432)

Clinical studies have shown that frailty can be quantified in a number of different ways. One clinical measure of frailty that has been used in many recent studies is known as a “frailty index” (FI), sometimes also referred to as a “deficit index”; a FI can be created by counting the accumulation of deficits in health, such as clinical signs, symptoms, diseases, laboratory and radiographic abnormalities (Parks et al., 2001). An alternative perspective is provided by the “Fried phenotypic definition of frailty”, developed by Fried and co-workers based on data from the Cardiovascular Health Survey (Fried et al., 2001). This proposes five items: weight loss, exhaustion, weakness, slow walking speed and low levels of physical activity. Experience from the dementia field has shown that, if one concentrates on deficits all the time, it is very difficult to convey the notion that ‘it is possible to live well with dementia’.

I feel that there needs to be now a coherent open discussion, including patients of all ages, as to what they think about the word ‘frailty’, if correctly applied to them. For example, some disabled people who use wheelchairs embarrassing and stigmatising (it is for example difficult to hail a cab in London if you’re sitting in a wheelchair); but others find their presence of a wheelchair profoundly empowering. The irony of seeking a definition of frailty is that it was supposed to provide objective criteria to help guide the identification of patients whose diverse needs needing tackling, when previously the rule of thumb had been “you recognise it when you see it”. In my experience, many people newly diagnosed with dementia report that people are surprised they do not look as if they have dementia. A person with severe muscle wasting might appear obviously frail, but frailty might not visibly obvious.

It is therefore, perhaps, worth going to the first paragraph of Goffman on stigma (1963) (p.1):

The Greeks, who were apparently strong on visual aids, originated the term stigma to refer to bodily signs designed to expose something unusual and bad about the moral status of the signifier. The signs were cut or burnt into the body and advertised that the bearer was a slave, a criminal, or a traitor — a blemished person, ritually polluted, to be avoided, especially in public places. Later, in Christian times, two layers of metaphor were added to the term: the first referred to bodily signs of holy grace that took the form of eruptive blossoms on the skin; the second, a medical allusion to this religious allusion, referred to bodily signs of physical disorder. Today the term is widely used in something like the original literal sense, but is applied more to the disgrace itself than to the bodily evidence of it.”

A failure to engage in this wider dialogue of what living with frailty means, I think, “risks confusion, alienation and a failure to connect with the very people who most stand to benefit from targeted services”(as correctly pointed out by Nicholson, Gordon and Tinker, 2016).

Luna Dolezal (2015) recently expanded on the insights of Aaron Lazare’s 1987 article ‘Shame and Humiliation in the Medical Encounter’ where it is argued that patients ‘often see their diseases and ailments as defects, inadequacies or personal shortcomings’. Donezal continues, ‘that visits to doctors and medical professionals involve potentially humiliating physical and psychological exposure.’ This is a perceptive observation, as a clinician labelling someone as ‘frail’ and then not offering anything to help, might be seen of little benefit, other than doshing up stigma in large quantities. Strikingly, Dolezal concluded that ‘shame can be exacerbated or even incited by physicians through judgment and as a result of the power imbalance inherent to the physician-patient dynamic, compounded by the contemporary tendency to moralise about ‘lifestyle’ illnesses.’ And therein possibly lies the greatest danger of offering the diagnosis of frailty; the subconscious feeling that the diagnostic label might be of more benefit to commissioners planning services, exercising power over patients, than patients themselves.

But arguably, on a positive note, we have come a some way already. Gillick defined frail elderly people as “old debilitated individuals who cannot survive without substantial help from others,” emphasising the social consequences of frailty (Gillick, 1989).

I feel stigma and frailty do deserve discussion, although a MEDLINE search for “frailty” and “stigma” will only elicit four results. Stigma is a process that has been conceptualised as being initiated by the identification and labelling of difference that links to a stereotype with negative characteristics and the labelling that distinguishes a ‘them and us’ separation (see Gray, 2002; Link and Phelan, 2001, 2006). However, that the relationship between stigma and frailty is extremely under-researched does not mean that the issue is not significant. It might be that the NHS actively tries to case-find people who are frail, but there are genuine ethical issues here. Anyway, research on help-seeking behaviour in a totally different context, that of young people’s mental illness, has paid particular attention to the confidentiality of healthcare, young people’s knowledge about services, and how accessible they are, but such factors do not fully explain the very low rates of consultation among young people who are mentally unwell (Zwaanswijk et al., 2003). Recent published work has indicated help-seeking by mentally unwell young people may be improved by interventions that address both their lack of factual information about mental illness, and those which reduce their strong negative emotional reactions towards people with mental illness (Rose et al., 2007). This merits a coherent analysis of how much people of a certain age understand by the word ‘frail’, if frailty awareness is poor, a decision has to be made as to whether as a society we need to invest in some kind of frailty awareness.

A genuine question persists as to whether patients who are deemed a frail share much in common. As Rockwood (2002) points out, “criterion validity” exists when a new definition or test correctly classifies people according to a referent outcome, In the case of frailty, Rockwood concludes is strongly linked with vulnerability, so one means of testing the criterion validity of a definition of frailty would be to assess its ability to predict adverse outcomes, such as prolonged hospital stays, or falls. So, from a clinical perspective, the diagnostic label is useful. On the other hand, the now classic “Frailty: Language and Perceptions” report prepared by BritainThinks on behalf of Age UK and the British Geriatrics Society June 2015 report found that older people they spoke to did not identify with the term ‘frail’. Indeed, the report explicitly states on p.10 that: “Older people consulted in this research have a strong aversion to the term frail’; it is not part of their vocabulary when they talk about themselves and their lives… This aversion seems to be driven by synonymous associations between ‘frailty’ and very severe physical (and mental) limitations.” The report continues (p.11): “These strong negative associations meant that the word ‘frailty’ was understood to mean an irreversible state that some older people enter into in the very final stages of their lives.”

Of course, not all people with mild forms of frailty progress to a state of severe disability. That is precisely why we need to have a discussion of ways to make people less susceptible to ‘shocks’, for example nutritional manipulations for brain health, particularly as pre-rehabilitation pre general surgery to avoid delirium, or medication to build up bone strength to mitigate against osteoporosis and severe fractures.  The BGS/Age UK report is not an isolated finding. A recent qualitative study of 29 older people aged 66–98 years found that ‘most participants actively resented the identity’, even those whocould be classified as frail using objective criteria (Warmoth et al., 2016). The authors report from verbatim transcripts that people labelled by others as ‘old and frail’ contributed to the development of a frailty id entity by encouraging confirmation of it, including a loss of interest in participating in social and physical activities, poor physical health and increased stigmatisation.

In clinical lingo, labelling is an inevitable part of the diagnostic procedure (see ‘labelling theory’ described by Becker (1963)). Diagnosis is often dependent on the proposed or actual disposition of the case and becomes more accurate when treatment procedures are available and tested. This is indeed true for clinical frailty, but sociologically labelling might have some negative connotations. In that sense labelling means the attachment of a deviant tag or status to an individual whose behaviour does not appear normal to the identifier of the problem (Rowitz, 1981).  From the mental illness literature, where receiving a label has been investigated extensively, it appears that there are mixed reactions to receiving a diagnosis. Warner and colleagues (1989) have revealed that ‘label acceptors’ manifested better overall functioning than ‘label rejecters’.  Alternatively, individuals may resist stigma and have a strong sense of group identity and empowerment (Watson et al., 2007).

Vellenga and Christenson (1994) in their research have emphasised the extent of the turmoil clients have in apprehending their diagnosis and their need to cope with the deep losses evoked by it, in order to feel more reconciled with it. On the other hand, studies also show people who are out with their mental illness experience less self-stigma and great quality of life (Corrigan et al., 2010). In this light, advocates believe that strategic disclosure might be taught to people to manage self- stigma (Corrigan et al., 2013). The persistent effects of stigmatisation have also been previously reported. For instance, in a longitudinal study of men with mental illness, Link and colleagues (1997) found that the pervasive effects of stigma remained apparently unaffected by treatment benefits despite of major improvements on symptoms and functioning described by the participants’ one-year after entering into treatment.

The ideal for someone who has been newly diagnosed by a clinician as being frail is to be offered some mechanism of having your ‘health assets’ improved so that you are in a better state of wellbeing, able to withstand slippage into a state of illbeing.

A health asset is defined thus.

A health asset is any factor or resource which enhances the ability of individuals, communities and populations to maintain and sustain health and wellbeing and to help to reduce health inequalities. These assets can operate at the level of the individual, family or community and population as protective and promoting factors to buffer against life’s stresses” (Morgan and Ziglio, 2007; p.18).

Assets can therefore be described as the collective resources which individuals and communities have at their disposal, which protect against negative health outcomes and promote health status. These assets can be social, financial, physical, environmental, or human resources, for example employment, education, and supportive social networks (Harrison et al., 2004). Although assets can include material resources – land, buildings and income in public health, more typically, the primary focus is on valuing individual and collective psycho-social attributes, including self-esteem, confidence, “intangible assets” such as knowledge, skills, wisdom and culture, and key features of social capital: social networks and reciprocity, mutual aid (Friedl, 2012). There is currently a growing interest in the UK in asset-based approaches that identify and mobilise the assets of individuals, communities and organisations to enhance individual and community capabilities and address health inequalities (Public Health England and NHS England, 2015).  Recent legislation, viz the Care Act 2014, requires local authorities to ‘consider the person’s own strengths and capabilities, and what support might be available from their wider support network or within the community to help’ in considering ‘what else other or alongside the provision of care and support might assist the person in meeting the outcomes they want to achieve’ (SCIE, 2015).

Salutogenesis is the underpinning theory, that is understanding how positive health is created and how people stay well even when faced with stressful events or adverse circumstances (Lindström and Eriksson, 2005). It is very surprising that there has been little discussion of frailty, which is intimately defined through the poor response to stress, through the assets prism. A recent review indicated that individual health assets are associated with improved outcomes of functional decline, mortality, new need for residential care and readmission in hospitalised older adults (Gregorevic et al., 2016). The importance of assets, however, has been previously very clearly recognised in the literature. Rockwood and colleagues (1994) have perceptively captured the essence of frailty, and added the important controlling principle of precarious balance easily perturbed. When assets clearly outweigh deficits, the patient is not frail and in the absence of serious acute illness would be expected to live independently in the community. Conversely, where deficits clearly outweigh assets then the patient is more likely to be in institutional long-term care or, at least, require substantial community long-term care.

frailty pic

 

Fig 1. Assets v deficits, redrawn from Rockwood et al., 1994.

 

The comprehensive geriatric assessment, pivotal in the management of frailty, is in an unique position to assess both assets and deficits. CGA is defined as a multidimensional, interdisciplinary diagnostic process focused on determining the medical, psychological, and functional capabilities of a frail elderly person to develop a coordinated and integrated plan for treatment and long-term follow-up (e.g. Rubenstein et al., 1991). The jewel in the assets vs. deficits crown, not just viewing frailty through a deficits or phenotype lens, is that it enables the clinician to build up a picture of individual resilience. Individual resilience, the capacity to do well in the face of adversity, is promoted by long-term relationships in the family, neighbourhood and schools, alongside secure parenting, educational progress, satisfying work and support for self-esteem (Rippon and Hopkins, 2015).

The concept of resilience, the tendency to remain well or “bounce back” in the face of adversity, is not new (Jain et al., 2014). In recent decades, a robust literature has framed resilience as a psychological construct, referring to adaptive attitudes and behaviours that allow one to remain psychologically sound, or even thrive, after being exposed to stressful life events (Whitson et al., 2016).  Due to the nature of stigma, it is unlikely that patients or service users will bring it directly to the attention of professionals (Howe, Tickle and Brown, 2014).  Therefore, arguably, professionals should specifically ask about experiences of stigma, the extent of social networks, self-image and ‘new’ identity post-diagnosis (Byrne, 2000). I feel that it is also important to not lose sight of an assets perspective on frailty. Allowing people to view themselves as ‘taking back control of their frailty’ through such a perspective might mitigate successfully against stigma, poor self-confidence and poor self-management. Frailty can lead to disability, but not always – and even then, control is still fundamental to living with disability. Disability is a situation, caused by social conditions, which requires for its elimination that disabled people should, with the advice and help of others, assume control over their own lives, and that professionals, experts and others who seek to help must be committed to promoting such control by disabled people (Campbell, 2002).

 

References

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