At ANZSPM16 one topic up for discussion will be the palliative care and frailty in older people. If you are interested in knowing a bit more about this then read on.
From my perspective there are a few things to consider on the topic of frailty. First is what does frailty mean to clinicians and researchers? Among geriatricians there is a common quip that frailty is like pornography – you know it when you see it but it is hard to define. Most clinicians I know seem to have a clear and reasonably shared sense of what the term means, but how do you define it? There have been multiple attempts to try and produce a rigorous definition which are notable in their similarities and differences. Fried has championed a view of frailty as a physical syndrome with 5 easily testable elements. Frailty in this sense is a related but distinct problem from functional decline or co-morbidity and may be a phenotype with correlates to physiological and molecular changes. Rockwood by comparison has described a multi-domain model which describes accumulated deficits expressed by physical illness, disability and mental changes. Interestingly there is some evidence to say that there is cross over with different models, and some experts would say these approaches are trying to describe the same thing from different directions. An important extra thing here is to note that some advocate seeing frailty as a continuum of risk and descriptions of pre-frail or vulnerable states also exist. Vulnerability assessment is used with increasing frequency in assessments of older people with cancer, and has also been used in palliative populations.
A second important thing for us is what does frailty mean to those who have it? All of the descriptions already cited have prognostic significance in those studies, particularly around the risk of death or hospitalisation. Frailty is also a risk factor for co-morbid illnesses, Frailty is also thought to have relevance to trajectories of change in health though the predictability of this is debated. Frailty may also effect the experience of persons with advanced illness and therefore their needs, their concerns, and their goals. This overall suggests that people who are frail may need to be considered as a different population from others with palliative needs.
How palliative care can or should support people with these issues is an ongoing question, and hopefully one that we will be well informed about at ANZSPM 16.
Michael
palliverse.com 
Thank you, Michael, for posting these interesting ideas. For me, my patients who are frail struggle with so many aspects of their life. Everything is an effort. On top of that is a sense of a loss of a previous robust life, and a more heightened sense of their mortality. As well, there is the fear that their life becomes one long drawn out phase. Many of my patients tell me that they aren’t afraid of dying, but, when it is to occur, for death to occur quickly (“I want to die in my sleep.”)
The challenge, as a GP, is to let go of the standard medical model of treatment. Too often, drugs are prescribed when they are not needed. Health parameters are set as if they are 30 year olds. For example, all of the patients in the RACFs have to have a range given for their observations when I often think that doing these observations is not going to be beneficial for these patients.
As for a definition of frailty, it sounds like a repeat of the pre-eclampsia saga of the late 1980s. At that time, experts decided that there should be a new term for pre-eclampsia as it wasn’t “scientific” enough. But after a several years and disagreements about the various other definitions proposed, it was agreed to stick to “pre-eclampsia” because everyone knew what you were talking about!
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Thanks for another great post. I have never seen frailty and pornography used in the same sentence prior to this!
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