Monday, 12 December 2016

Untangling the skein of frailty to leave the maze of disability. From detection to prevention

Marco Inzitari

Following on from Ariadne’s thread which was extended across the concepts of aging, complexity and disability, I will build this new contribution on my previous post entitled “Frail, cracked or broken?”. In that post, I defined as "frail" a person with apparent good health and overall functions but with concomitant alterations of different organs and systems, often sub-clinical, that increase the vulnerability to progress towards disability in case of injuries of a different nature (clinical, such as illness, or social, such as widowhood, etc). The main goal of the detection of frailty is prevention, because frailty and disability are reversible.

In this new post, I will try to move towards the exit of the maze, although this may be an even more complex task than Theseus’ challenge. The metaphor of frailty and, more generally, of aging as a "Minoan" maze, is not accidental: it’s a complex phenomenon where multiple systems and organs begin to be simultaneously altered, different pathologies appear and drug treatments are added. The social situation of the person and their environment can represent added elements of frailty. Besides coexisting, all these factors are interacting, determining an intricate tangle of threads of different colours that are really hard to discern. It’s as if the aging tended towards entropy, just like too many electric cables tend to become entangled. Given this complexity, it’s hopeless to pull a single thread and expect the skein to untangle. This is why "magic" recipes such as an alleged "pill" to combat aging, have failed so far. If we want different results we need a focus shift when looking at the classic "risk factor - disease - treatment".

The strategy of the Australian study Frailty Intervention Trial (FIT) looks like an interesting way out. FIT, whom I have been following since the first methodological 2008 article, raises an "a la carte" approach with a multi-domain or multi-lever intervention, as if we were simultaneously pulling various threads based on a preliminary analysis of each skein. Detection is based on the concept of frailty of the Cardiovascular Health Study which focuses on physical performance and nutritional status which is made operational in the valuation of 5 domains: unintended weight loss, slow walking, weakness, fatigue and low physical activity. The evaluation of these domains, conducted by a nurse or physiotherapist can tailor the intervention, basically by combining for example nutritional supplementation and exercise adjusted to deficits and psychological interventions for those who expressed fatigability, (that can be, not only physical but also psychological) with the discussion of the case in a inter-disciplinary team (a physiotherapist who coordinates, a geriatrician, a physiatrist, a nurse and a nutritionist).

FIT’s good results have been published in different articles over the past two years and show a reduction in the number of frail people per year and a stabilization of physical performance and mobility, which worsens in the control group. An improvement of disability and quality of life goes unnoticed possibly due to the relatively short time of intervention or monitoring. Interestingly enough, the authors also demonstrate the achievement of functional goals set by the individual, in a person-centred approach. Finally, a complex estimation of the value of intervention, based mainly on the use of health and social services, estimates the investment needed to reverse a case of frailty and suggests that it’s cost-effective.

In summary:
  • We must focus on the detection of frailty in the community through a strategy that includes a validated, simple and practical screening, plus a deeper appreciation of the basic deficits 
  • We must implement multi-domains strategies, addressing the deficits based on frailty and basing interventions on established evidence, such as physical exercise.
  • A person-centred evaluation based on health outcomes and of good value (improved performance against reverse investment) solidly supports these interventions so that we can move on and study how to scale them.

As always we’re left with the problems of implementing such programs and finding resources to do it. In this regard we have previously proposed disruptive interventions, which unfortunately cannot be generalized. Anyway, we must try to be creative and follow this direction contextualizing the interventions in our environment where resources are not lacking. On the plus side, I must highlight the interest of the Society of Family and Community Medicine CAMFiC in the subject, with a recent CAAPS monograph which recommends cooperation between family physicians and geriatricians, and is supported in this project by the Program for Prevention and Care Chronicity (PPAC).

We will continue our thread, trying to find our way out of the maze of disability and complexity, in theory first as hopefully in practice as well.

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