The lack of a systematic way to assess frailty in older people – and therefore to treat them appropriately – prompted Hawke’s Bay geriatrician Dr Tim Frendin and colleagues to develop the Assessment of Robustness in Ageing (ARIA) tool.
'Our system struggles with generic recommendations for treating older people because there is such heterogeneity of health state for the average 85-year-old. A blanket recommendation may be appropriate for half and inappropriate for the others.
'I think trying to flesh out a person’s degree and type of frailty becomes critically important and, up until now, no method of quantifying frailty has been incorporated into routine clinical practice.'
An ARIA assessment generally takes 10 to 15 minutes to complete. It plots a person’s performance in 12 domains – including cognition, mood, continence, medication and disease burden, sight and hearing, mobility and falls – against the measures of robust; vulnerable; mild-moderate impairment; and moderate to severe impairment. The result is a ‘robustness dashboard’ (best likened to the concept of reserve or resilience) that identifies potential further areas of assessment or intervention. It also encourages conversations between the older person and their family and health professionals about the impacts of further interventions and what the best choices might be for them.
Dr Frendin says frailty is a concept not particularly well articulated in medical literature.
'Frailty is a clinical vulnerability towards the end of life as a result of physiologic wind-down with susceptibility to adverse events in health care. And quite possibly decreasing potential to benefit from interventions. Whereas the literature on frailty focuses more on the increased likelihood of complications, hospitalisations, mortality, length of stay and increasing dependency.
'It is a state of life we all go through if we live long enough. A bit like infancy but at the other end of life. Everyone who reaches 95 is frail. We’re actually programmed to wind down as we approach our potential lifespan, and if most of us attain that, unfortunately the price you pay towards the end is increasing frailty. Older people often understand their limitations, but medicine tends to act otherwise. If frailty is part of the human condition, we need to have tools that better recognise this and allow us to de-medicalise it.'
In Dr Frendin’s view, one of the most important measures of frailty is increasing dependency.
'Early on there is the potential for intervention, and some things are reversible, but beyond a certain point that changes. As you get frailer, you need more and more help to get through each day; you can correlate frailty to increasing levels of dependency according to how much help the person needs. A mild frailty is needing help with things like housework or shopping, but then you need personal cares and then go into a rest home – each of those is a significant increase in dependency and frailty.'
He says expectations about what medicine can achieve are high, but the reality is, as you get frailer, the likelihood of responding positively to interventions diminishes.
'We don’t do ourselves justice by increasingly doing more for people in frail states and not putting enough weight on the likelihood of bad outcomes. If you are able to recognise more specifically the sort of frailty a person has, you can have better conversations with them about future care, and can help them make better decisions. Having a better understanding of frailty also lets us treat and care for people more consistently.
'Having a person’s degree of frailty documented allows you to tease out which components have contributed to their picture of frailty. This may allow you to identify that they are on too many medications, they may be depressed, they may be falling a lot, or be badly nourished. Each of those things becomes a target for potential improvement.'
He says the ARIA assessment is also a great prompt to have open conversations with an older person and their family.
'You can put the map in front of them and start to have a conversation about how they’re not as robust as they used to be. People say ‘yes, I get it, this really is me, and I can accept that the future may be a bit different from what I’d thought’. This may lead to a more realistic understanding of what the outcome could be from intervention.
'It’s a way of trying to map the progress of declining function and capability, and increasing dependency. At some point it will become clear that ‘x’ intervention is not in that person’s best interest. And you can have the conversation with them as to why ‘x’ five or ten years ago may have been appropriate, but now it’s not. It gives you a standardised map of what an older person’s total health state is like.'
He says ARIA contains concepts common to both the Choosing Wisely campaign and the advance care planning programme.
'It’s about understanding a person’s specific needs – what interventions and treatments might be best for them. Sometimes that might mean not doing certain tests or interventions, or not undertaking any further treatment at all. And having that discussion with them, so they can make really informed choices about their own care.'
The ARIA tool is currently undergoing further testing and is not yet widely used. Dr Frendin is interested to discuss the tool with others working with older people, and can be contacted on Tim.Frendin@hawkesbaydhb.govt.nz.